Evidence-Based Reviews

Compulsive hoarding: Unclutter lives and homes by breaking anxiety’s grip

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Fear about making ‘wrong’ decisions may underlie hoarders’ pathologic saving and collecting behaviors. Here’s a strategy to help them


 

References

Compulsive hoarding behavior is considered notoriously difficult to treat, but targeting its characteristic symptoms with medication and psychotherapy can be successful. This article provides a guide for the psychiatrist—alone or with a cognitive-behavioral therapist—to diagnose compulsive hoarding syndrome and help patients overcome the anxieties that fuel its symptoms.

WHAT IS COMPULSIVE HOARDING?

Hoarders acquire and are unable to discard items that others consider of little use or value.1 They most often save newspapers, magazines, old clothing, bags, books, mail, notes, and lists. Hoarding and saving behaviors occur in nonclinical populations and with other neuropsychiatric disorders—schizophrenia, dementia, eating disorders, mental retardation—but are most often found in persons with obsessive-compulsive disorder (OCD).

OCD is a heterogeneous clinical entity with several major symptom domains:2,3

  • aggressive, sexual, and religious obsessions with checking compulsions
  • symmetry/order obsessions with ordering, arranging, and repeating compulsions
  • contamination obsessions with washing and cleaning compulsions
  • hoarding and saving symptoms.
Box
What causes compulsive hoarding?

Genetics. Compulsive hoarding may have a different pattern of inheritance and comorbidity than other OCD symptom factors. Hoarding/saving symptoms show a recessive inheritance pattern, whereas aggressive/checking and symmetry/order symptoms show a dominant pattern.9 The hoarding phenotype has been significantly associated with genetic markers on chromosomes 4, 5, and 17.14 In other studies:

  • Among 20 OCD patients with prominent hoarding, 84% had first-degree relatives with hoarding behaviors and only 37% had first-degree relatives who met DSM-IV criteria for OCD.11
  • Among 126 OCD patients, social phobia, personality disorders, and pathologic grooming disorders were more common in hoarders than in nonhoarders. Hoarding and tics were more common in first-degree relatives of hoarders than in those of nonhoarders.12

Neurobiology. Using positron emission tomography (PET) brain imaging, our group13 compared glucose metabolism in patients with compulsive hoarding syndrome with that of nonhoarding OCD patients and normal controls. Compulsive hoarders had unique brain activity, with significantly lower metabolism:

  • in the posterior cingulate gyrus and occipital cortex than controls
  • in the dorsal anterior cingulate gyrus (AC) and thalamus than nonhoarding OCD patients.

Hoarding severity was significantly correlated with lower activity in the dorsal AC across all OCD patients.

Discussion. Genetic and neurobiologic data suggest that compulsive hoarding syndrome may be a neurobiologically distinct variant of OCD14 and may help explain its clinical symptoms and poor treatment response. Low AC activity may mediate compulsive hoarders’ decision-making and attentional problems, whereas low posterior cingulate activity may be responsible for visuospatial and memory deficits. Moreover:

  • lower pretreatment AC activity has been strongly associated with poor response to antidepressants15
  • lower posterior cingulate gyrus activity correlates with poorer response to fluvoxamine in patients with OCD.16
Among OCD patients, 18% to 42% have hoarding and saving compulsions.4,5 Hoarding and saving can be part of a broader clinical syndrome that includes indecisiveness, perfectionism, procrastination, difficulty organizing tasks, and avoiding routine daily activities.6,7 The 1 to 2 million Americans whose most prominent and distressing OCD symptom is hoarding and saving and who show these other associated symptoms are considered to have “compulsive hoarding syndrome.”7,8 Evidence suggests that this syndrome may be a neurobiologically distinct OCD variant (Box).9-16

ASSESSMENT AND TREATMENT PLANNING

To manage compulsive hoarding syndrome, begin with a thorough neuropsychiatric evaluation:

  • Rule out primary psychotic disorders, dementia, and other cognitive impairments and neurologic disorders.
  • Rule out primary major depression, as clutter and self-neglect may be caused by amotivation, low energy, or hopelessness.
  • Determine if the patient has OCD.
After making a compulsive hoarding diagnosis (Table 1),6 visit the patient’s home or view photographs to assess his or her environment and behaviors (Table 2).

Amount of clutter. Living areas may be so cluttered that sleeping in a bed, sitting on chairs, or preparing food on a kitchen counter are impossible. How much of the home is cluttered? How much floor and counter space is usable? Are rooms unusable or inaccessible because of clutter? Can the patient use the laundry, prepare food in the kitchen, use the shower, toilet, etc.?

Health or safety hazards. Huge piles of papers can be a fire hazard. Clutter may be blocking the exits. Collected items may extend beyond patients’ homes to their cars, garages, storage lockers, and even storage areas owned by friends and family.

Beliefs about possessions. Compulsive hoarders often have distorted feelings about their possessions. They may over-buy or impulsively purchase items they feel have emotional or monetary value. They may consider the items extensions of themselves and suffer grief-like loss when discarding things.7

Some collect free items—flyers, coupons, newspapers, discarded goods—hoping to save money or be prepared “just in case” the item is ever needed. This may represent unattainable expectations of perfection, needing to maintain preparedness for every possible contingency. Hoarders often believe they have poor memory and have catastrophic fears of what might happen if they forget something. Thus, their desire to keep their possessions in sight is strong.17

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