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Vol. LXIII, No. 2
January 21, 2011

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When Too Much Stuff Really Is Too Much
Hoarding Disorder Can Have Dangerous Ramifications

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There are probably many of us, especially in the wake of the holidays, who have homes or offices that are less neat than we’d like them to be. Maybe there are piles of papers, files or books that we put off sorting because we’ve grown accustomed to them, and they don’t interfere with our daily routines.

This tendency is common and rarely cause for concern. Unfortunately, for some people the accumulation of stuff can develop into a more advanced state of clutter, turning a few piles into roomfuls of belongings that get in the way of living life. These people suffer from hoarding.

Defined as the acquisition of, and failure to discard, a large number of possessions that invade living spaces in such a way that people can no longer live normally in them, hoarding was the subject of a recent NIMH Innovation Speaker Series lecture at the Neuroscience Center. Three visiting researchers presented what they’ve learned about the disorder and called for further study.


  Dr. Randy Frost of Smith College  
  Dr. Randy Frost of Smith College  

Dr. Randy Frost of Smith College explained just how serious and widespread the condition is. Hoarding is estimated to affect between 2 and 5 percent of the population and is more prevalent in older folks. Scientists have found that the onset of hoarding typically occurs between 11 and 15 years of age, but does not reach significant levels until later in life.

“Hoarders can collect all measure of things, and many times doorways will be blocked, windows will be blocked. Piles of papers near a stove, for instance, are a fire hazard,” he said. “This condition can be life-threatening, particularly if someone had to get out of the house quickly.”

A frequent feature of these cluttered homes, he said, is the presence of what some call “goat paths,” narrow aisles that navigate through the mountains of stuff. An inability to clean, dust and vacuum can lead family members to suffer acutely from dust and mold allergies. Local health services and family protective services can step in and remove people and pets from the home.

Most people might think the easy fix to hoarding is to have someone come in and throw everything out, but anyone who’s watched one of the popular television programs dedicated to this topic knows it’s not that simple; the people who hoard don’t often see the problem. There is resistance, denial and bargaining. The process frequently becomes emotional, with tears and anger a typical outcome.

“When others clean up after them, they feel as though they are losing things of value, even parts of themselves. One person said, ‘If I throw away too much, there will be nothing left of me,’” Frost said. “After one woman had others come into her home to clean up and throw things away, she said, ‘I feel as though I’ve been raped.’”

Dr. David Tolin, director of the Anxiety Disorders Center at the Institute of Living
Dr. David Tolin, director of the Anxiety Disorders Center at the Institute of Living
Dr. Gail Steketee, dean and professor at Boston University’s

Dr. Gail Steketee, dean and professor at Boston University’s School of Social Work

That statement may seem extreme to many unfamiliar with the disorder, but the revelation comes as little surprise to researchers working to unravel this extraordinary attachment to material things. People who hoard can, and often do, review their possessions by going through piled items (an expired flyer for a tire sale, a brochure about a resort they can’t afford to visit, a phone number jotted on the back of an envelope that lacks a name to go with it). They rarely discard anything and instead shuffle items within the pile, a process called “churning.”

While hoarding does share some traits with obsessive-compulsive disorder, the overlap isn’t exact and many people who hoard display characteristics that differ from OCD. For example, researchers have reported that while there are few differences in memory or problem-solving between hoarders and control subjects, hoarders often performed much worse on matters relating to attention span and decision-making. Another area, insight, or the subject’s self-awareness, was wildly variable.

“We can rate their insight from excellent to delusional,” said Dr. David Tolin, director of the Anxiety Disorders Center at the Institute of Living. His research suggests that there may be a neurological aspect to the condition that impairs cognitive processing, but said more study is needed.

Aside from the obvious threats to life and limb that hoarding poses, perhaps most troubling to researchers and mental health clinicians is the fact that it has yet to be formally recognized as a psychiatric condition requiring intervention. Because hoarding is mostly hidden behind closed doors, few are aware of the condition’s prevalence. Little attention has been given to the disorder until recently.

Hoarding is not currently included in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, but there is talk of adding it to the latest edition of the book. The inclusion of hoarding might open more doors to study the disorder, scientists say.

Treatments for the condition are lengthy and difficult, the scientists said.

“We face a great deal of treatment refusal and dropout, low insight into the problem and limited cooperation during treatment,” said Dr. Gail Steketee, dean and professor at Boston University’s School of Social Work who also spoke at the lecture. Frost and Steketee have written a book called Stuff: Compulsive Hoarding and the Meaning of Things as well as a clinician therapy guide and client manual. “There are a lot of non-voluntary clients who may require community intervention.”

Researchers have thus far found little help from combination therapies adapted from current OCD treatments. However, thanks to an NIMH study, it appears there is hope in using cognitive behavioral therapy (CBT), particularly when it includes specialized components designed for hoarding such as motivational interviewing, organizing and decision skills training and practice discarding and not acquiring.

“While standard therapy doesn’t work, specialized CBT makes a dent,” Steketee said. “And group treatments provide [patients] with an instant, built-in support system. The therapy turns into something they look forward to.” NIHRecord Icon

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