The popularity of TV shows such as A&E’s Hoarders,TLC’s Hoarding: buried alive,and Planet Green’s Gutted has increased public awareness of problems caused by hoarding. Seventy-five communities across the United States have coordinated hoarding task forces that include therapists, social workers, police, fire departments, and child protective services, and that number is rising quickly.1 Therefore, psychiatrists likely will be encountering growing numbers of hoarders and their families seeking treatment.
Hoarding behavior
Affecting 2% to 5% of the population, compulsive hoarding is persistent difficulty parting with possessions—even useless items or those of limited value—that results in cluttered personal surroundings and impaired functioning.2 Hoarders may be threatened with eviction or the possibility of losing custody of their children.1 Hoarding can create fire hazards, fall risks, and unsanitary environments.3
Causes
Hoarding behavior usually is a result of fear of losing items that may be needed later or making the “wrong” decision about what should be kept or discarded.4Symptoms generally start at age 12 or 13, begin interfering with daily functioning in the mid-30s, and increase in severity with age.2 Clutter can accumulate with or without excessive acquisition of goods, through buying, collecting, or stealing.2Hoarding often is ego-syntonic, and many patients do not believe their behaviors are problematic.3
A new diagnosis?
Hoarding often is associated with obsessive-compulsive disorder (OCD), and DSM-IV-TR lists hoarding behavior as a criterion for obsessive-compulsive personality disorder. However, hoarding behavior has been observed in other neuropsychiatric disorders, including schizophrenia, depression, social phobia, dementia, eating disorders, brain injury, and mental retardation, and in nonclinical populations.3,4
Most research has focused on the connections between hoarding and OCD, but genetics, brain lesions, neuroimaging, and neuropsychological studies suggest that “hoarding disorder” should be a separate entity in DSM-5.2A proposed set of diagnostic criteria states that the hoarding behavior not be restricted to the symptoms of another mental disorder.2 For example, the behavior is not caused by intrusive or recurrent thoughts from OCD or secondary to apathy in depression. The proposed criteria specify if the hoarding is associated with excessive acquisition of items, as well as how much insight the patient has into his or her problem.2
Treatment
Because hoarding behavior frequently is ego-syntonic, patients may be brought in by family members or friends. Treatment should begin with a thorough neuropsychiatric evaluation to determine the etiology of the behavior, such as another axis I disorder.4Assess the amount of clutter, types of items saved, usability of living and work spaces, potential health and safety hazards, beliefs about possessions, information processing deficits, avoidance behaviors, insight, motivation for treatment, social and occupational functioning, and activities of daily living.4
Studies of selective serotonin reuptake inhibitors and cognitive-behavioral therapy (CBT) in OCD patients with hoarding symptoms have produced mixed results.4 In some cases, paroxetine monotherapy, specialized CBT protocols, and combined treatments have proven effective.4 Studies examining those treatments’ efficacy for hoarding in the absence of OCD are underway. Whichever strategy is employed, it is important to involve family members or friends in treatment2 and to identify other available resources, such as community hoarding task forces.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.