Hoarding disorder affects 2.5% of the population and arises from a combination of factors, such as emotional dysregulation, information-processing deficits, unhelpful beliefs, and behavioural avoidance.
Next article in this series: Hoarding Disorder: The Items and the Impact.
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Introduction
The relatively new pathology of hoarding disorder (seen as a standalone condition since the publication of the DSM-5 in 2013) has received increasing attention in the eleven years since its recognition. This article begins a 3-part series examining what it is; its epidemiology, aetiology, and impact; how it can be assessed, and the treatments that show promise. Today we look at the basics of what hoarding disorder is, its prevalence, and the aetiology that gives rise to it.
Defining Hoarding Disorder
The DSM-5 states that hoarding disorder belongs to the disorder class of obsessive-compulsive and related disorders, or OCRD (as do body dysmorphia disorder, skin-picking disorder, and trichotillomania). The chief criteria are as follows:
- Persistent difficulty discarding or parting with possessions, regardless of their actual value. The difficulty is due to a perceived need to save the items and to the distress associated with discarding them.
- Accumulation of items. The difficulty discarding things results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.
- Significant impairment. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for oneself or others).
- Not another medical condition. The hoarding is not attributable to another medical condition, such as brain injury, cerebrovascular disease, or Prader-Willi syndrome. The hoarding must not be better explained by such conditions as decreased energy in major depressive disorder, delusions in schizophrenia, obsessions in obsessive-compulsive disorder, or cognitive defects in major neurocognitive disorder.
The clinician is asked to specify if:
- There is excessive acquisition. About 80 to 90% of individuals with hoarding disorder display the trait of excessive acquisition of items that are not needed or for which there is no available space.
- With good or fair insight. The individual recognises that hoarding-related beliefs and behaviours are problematic.
- With poor insight. The individual is mostly convinced that hoarding-related beliefs and behaviours are not problematic, despite evidence to the contrary.
- With absent insight/delusional beliefs. The individual is completely convinced that hoarding-related beliefs are not problematic, despite evidence to the contrary (SAMHSA, 2016).
Prevalence of hoarding disorder: who and how many hoard?
According to the American Psychiatric Association (2013), hoarders are more numerous than those suffering from almost any other psychological disorder of adulthood, with hoarding disorder affecting 1 out of every 25 to 50 adults. Pooled prevalence estimates in over 50,000 participants suggest an estimate of around 2.5%. The prevalence is lowest among teenagers and highest among adults over 55, where the prevalence is nearly 7% (Mathews, 2021). A recent meta-analysis of all studies published before 2019 put the age of onset at 16-17, but noted that in some cases, hoarding behaviours began as early as 6-7 years of age (Zabonski et al, 2019).
For context, hoarding disorder is more common than eating disorders, schizophrenia, autism spectrum disorder, and obsessive-compulsive disorders. It has been observed in all major inhabited continents and in many different countries and cultures. (Mathews, 2021). Studies have shown that hoarding is equally distributed between men and women, and it tends to get worse as one gets older (Postlethwaite, Kellett, & Mataix-Coles, 2019).
Aetiology: What gives rise to hoarding?
Cognitive behavioural model
Several decades ago, Frost and Hartl (1996) proposed an explanatory framework comprised of four major factors said to influence hoarding development: (1) dysregulated emotional attachment; (2) information-processing deficits; (3) unhelpful beliefs about possessions; and (4) behavioural avoidance.
Dysregulated emotional attachment
A core trait of those afflicted with hoarding disorder is that they are strongly attached to their possessions. They generally have lower capacity for emotional regulation and experience their negative emotions intensely, perceiving them as more threatening. This is not surprising when we consider that many hoarding clients report a background of emotional deprivation and experiences of traumatic loss, particularly sudden. It makes sense that an individual whose early childhood attachment bonds were either disrupted or (due to poor parenting practices) unable to be formed securely in the first place would turn to material possessions as an emotional containment mechanism. Some hoarding clients have remarked that their things give them a sense of safety, security, control, and even identity. Note how the stability of a material item is in sharp contrast to an unpredictable or sometimes withholding parent or other caregiver (Collett, 2019).
Information-processing deficits
Deficits in information processing are central to an understanding of hoarding disorder, with difficulties in concentration, categorisation, inhibitory control, flexibility of thought, planning, decision-making, and visuospatial memory being key components. There are marked similarities with the neurodiversity experienced by those with ADHD, with as many as 28% of individuals with hoarding disorder warranting a comorbid diagnosis of ADHD (the inattentive type). It seems that information-processing deficits constitute a shared vulnerability for the two disorders (Collett, 2019).
In Frost and Hartl’s model, the deficit in decision-making manifests in the indecisiveness people with hoarding troubles may experience about the likelihood of future needs. They may avoid judgment about the type of value an object has; they fear making mistakes during any attempts to discard possessions; and they tend to have doubts about whether they would be able to re-acquire an object if they needed it. Naturally, those factors together create a much lower threshold for saving due to fear of harm associated with not having a needed object and a fear of damage to possessions. Thus, just hanging onto things (that is: making no decision to discard) avoids the anticipated experience of deprivation (O’Connor, Bodryzlova, & Koszegi, 2017).
The hypothesis is that categorisation issues (an aspect of information processing) show up for persons with hoarding disorder in the challenge to decide on the number of item categories and to place a reasonable number of items in each category. Because those who hoard regard each item as “unique” and “irreplaceable” in some way, it may be difficult to lump numerous items together in a single category. This, in turn, can make sorting and discarding difficult. You can imagine the challenge for a hoarding client trying to organise their possessions into categories during a decluttering exercise: endless little piles of “one-offs” or nearly so and no overarching “big” categories, such as, say, “kitchen implements” or “decorations”.
Many people with hoarding disorder fear that they do not have a good memory, although studies have shown that their memory is not significantly different from that of age-matched non-hoarding participants; they just have lower confidence in their ability to remember (Mathews, 2021). Accordingly, such clients overestimate the importance of retaining or recording information, such as in newspapers, books, or magazines, which are felt to be too important to discard. “What if I forget? I may need the information,” they say O’Connor et al, 2017).
Unhelpful beliefs about possessions
Understandably, when material possessions are given ultra-importance, behind the strong attachment to them are numerous unrealistic and often intensely defended beliefs. A common theme here is identity, wherein the person who hoards proclaims, “Losing that would be like losing a part of myself”. Hoarding individuals sometimes take on outsized responsibility for items, such as in the stance, “If this ends up in landfill, it will be my fault.” As noted, there are themes of information loss (“How will I remember what happened on this day if I throw out the newspaper chronicling it?”). And there is the ubiquitous perceived future need (such as the fellow whose garage was overflowing with electronic bits and pieces that someone was sure to need someday).
Think for a moment about how these themes could be tied together. Dr. James Collett, at Royal Melbourne Institute of Technology, suggests that perfectionism can underlie all of them. In hoarding behaviour, perfectionism is associated with fear of making mistakes, a need to have everything exactly right, and paralysing inaction when such a client confronts both uncertainty and the scary possibility of later regret (Collett, 2019). In this regard, think about unresponsive and/or authoritarian parenting styles which tend to make any decision by the child an overwhelming prospect, with huge consequences for getting it wrong.
Behavioural avoidance
Finally in Frost and Hartl’s cognitive model is the factor of avoidance, which constitutes a form of negative reinforcement for the client. It is seen in poor motivation, lack of insight, denial, slowness, tardiness, and procrastination. Avoiding making a decision or discarding something offers the hoarding client the reward of a protective barrier against anxiety, grief (of lost possessions), regret, and uncertainty that the client would otherwise need to manage were their precious possessions to be lost. The problem with a negatively reinforced response such as avoidance is that it limits the person and engenders other problematic consequences (Collett, 2019).
Frost and Hartl’s model has been corroborated through numerous experimental and observational studies (Frost & Hartl, 2017; O’Connor et al, 2017) and has become a foundation for treatment with cognitive behavioural therapy. The model explains how and why hoarding disorder persists, but it does not explain how hoarding disorder starts. It does not address individual motivations for hoarding, and it does not examine the relationships between components of the model. Thus, O’Connor and associates have proposed a more aetiologically-based set of elements to add to the cognitive-behavioural model.
An inference-based therapy model
In an inference-based therapy model, three elements added to the above cognitive-behavioural model attempt to contribute understanding of the “inner logic of hoarders” and to address that logic in therapy: (1) poor self-identification; (2) overinvestment of those who hoard in imaginary possibilities; and (3) dissociation.
Poor self-identification
Most likely linked with the above-noted negative experience of attachment and perfectionism and rooted in familial beliefs and values – encourages the person hoarding to create an illusory, or “super-self”, wherein a person attempts to enhance their innate qualities through the collection of superfluous objects as a means of confirming that they are who they wish to be. An example of this is the would-be intellectual who acquires several times more books than he/she could ever read, or the aspiring “perfect” cook who gathers endless recipes. Objects such as the books or the recipes offer validation of the “super-self” that seems unable to be attained from other human beings, who previously have only offered negative experiences of feedback, validation, or attachment.
Overinvestment in imaginary possibilities
And subsequent beliefs in consequences occurs as the acquired objects become not only symbols and confirmation of the person’s illusory self, but acquire human-specific qualities and attributes, such as the power to keep memories, to suffer, to feel cold, to feel unsafe, to be afraid, and to yearn to be loved. Some people with hoarding disorder specifically purchase items at op shops that seemed to be unwanted by others; they just want to “give the items love”, so that they won’t “feel” unwanted, as the individuals themselves likely did growing up. Such beliefs, although erroneous, see people with hoarding disorder interacting with their possessions as a substitute for the disappointing or even non-existent interactions with the human beings of their lives.
Dissociation
The third element takes several forms. First, there is a dissociation from real life in that people who hoard check their interactions with their objects in the way that non-hoarders check the quality of their interactions with other people. Important life events always include their possessions or are closely associated with them. Dissociation occurs in another way, too. When people hoard, they stop being aware of the negative impact of their hoard or their hoarding on others, becoming divorced from the real nature and value of their objects, their genuine needs, and their “real” self and its possibilities.
When we consider that the typical age of onset of hoarding disorder is the teen years, the picture becomes even bleaker. The natural process of individuation that takes place (should take place) in adolescence is that of gaining confidence, learning who one is, and establishing one’s identity. Teens, even healthy ones, search for that confidence and identity in their possessions. However, as the years go on and possessions accumulate, those who hoard come to magically invest their things with desired characteristics. As the hoarding accelerates, possessions are imbued with a mix of real and illusory qualities, a self-sabotaging process which renders the person more isolated and their relationships more dysfunctional. The more the individual accumulates, the more isolated they become, leading to more dissociation, which in turn leads to more accumulation and investment in things: a vicious maintaining cycle (O’Connor et al, 2017) (see Figure).
Figure: Creation of “super-self” and poor self-identity through hoarding
O’Connor and associates’ therapeutic approach breaks the cycle by addressing how the super self and hoarding sabotages the person’s “real” or “authentic” self. The approach is deemed an inference-based therapy (IBT) because both the acquisition and difficulties in discarding are caused by confusion of illusory possibilities with real needs and probabilities by a type of reasoning called “inverse inference” (O’Connor et al, 2017).
There are many angles of approach to treating hoarding disorder. We discuss those in the third and final blog of this series. Suffice it to say here that hoarding is not merely being a “packrat”; the disorder goes much deeper. The next article in the series explains the type of items hoarded, the value attributed to them, and the broad impact of hoarding, including medical conditions.
Hoarding disorder training
This article was adapted from Mental Health Academy’s hoarding disorder training course, Helping Clients with Hoarding Disorder. In this 6-hour course, you’ll learn the epidemiology, aetiology, and neurobiology of hoarding disorder; how and why hoarding impacts individuals and communities; the co-morbidities of those who hoard; and how to assess and treat hoarding disorder.
Note: Mental Health Academy members can access 500+ CPD/OPD courses, including those listed above, for less than $1/day. If you are not currently a member, click here to learn more and join.
Key takeaways
- The DSM-5 has labelled hoarding a disorder on its own, not just as a symptom of another condition; its key characteristics are persistent difficulty discarding unnecessary items, excessive accumulation of possessions, and impairment in important life areas resulting from the accumulation.
- The age of onset is typically in the teenage years and the behaviours worsen over the lifespan, increasing to a prevalence of around 7% for those over 55; both sexes engage equally in it.
- A CBT-based model asserts that dysregulated emotional attachment, information-processing deficits, unhelpful beliefs about possessions, and behavioural avoidance give rise to hoarding behaviours.
- An inference-based model adds three components to the CBT one: poor self-identification; overinvestment in imaginary possibilities; and dissociation.
References
- American Psychiatric Association (APA). 2013. Diagnostic and statistical manual of mental disorders. (5th ed.). APA.
- Collett, J. (2019). Unpacking hoarding disorder. InPsych, 41(5). Australian Psychological Society. Retrieved on 25 April 2024 from: https://psychology.org.au/for-members/publications/inpsych/2019/october/unpacking-hoarding-disorder
- Frost, R.O., & Hartl, T.L. (1996). A cognitive-behavioral model of compulsive hoarding. Behavior Research and Therapy, 34, 341-350.
- Mathews, C. (2021). Recognizing and treating hoarding disorder: How much is too much? New York: W. W. Norton & Co.
- O’Connor, K.; Bodryzlova, Y.; & Koszegi, N. (2017). Etiological models of hoarding disorder. Journal of psychology and clinical psychiatry, Vol 7(5). Retrieved on 25 April 2024. DOI:10.15406/jcpcy.2017.07.00453
- Postlethwaite, A., Kellette, S., & & Mataix-Coles, D. (2019). Prevalence of hoarding disorder: A systematic review and meta-analysis. J Affect Disord, 256, 309-316. https://doi.org/10.1016/j.jad.2019.06.004
- Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.29, DSM-5 Hoarding Disorder. Retrieved on 24 April 2024 from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t29/
- Zabonski, B.A., II, Merritt, O.A., Shrack, A.P., Gayle, C., Gonzalez, M., Guerrero, L.A. et al. (2019). Hoarding: A meta-analysis of age of onset. Depress Anxiety, 36 (552-564). https://doi.org/10.1001/da.22896