When keeping stuff gets out of hand

Content provided by the Faculty of the Harvard Medical School

When keeping stuff gets out of hand

"Waste not, want not" is a useful rule to live by; it's not a license to hoard.

We've all been encouraged to keep essentials on hand for the future. But some people take this to an extreme, acquiring and accumulating objects of dubious value (to others) and in such large and disorderly quantities that their living space is filled and normal use of the home becomes dangerous or impossible.

The problem, known as compulsive hoarding, is a prominent and distressing symptom in up to 20% of people with obsessive-compulsive disorder (OCD). It can also occur in people with schizophrenia, dementia, eating disorders, head injuries, and certain personality disorders. Hoarding can even become a problem for a person with no psychiatric illness and no psychiatric history. Many hoarders are elderly, unmarried, socially isolated women.

A common object of hoarding is paper — vast piles of it — including old newspapers, magazines, books, mail, and lists. The accumulated clutter may leave no space to cook or sleep comfortably. Worse, people are occasionally burned when papers catch fire, or crushed beneath shifting piles of junk.

What's behind compulsive hoarding?

Psychologists at Smith College and Boston University have identified a pattern of distorted thinking and emotional difficulties common to hoarders. These include:

• Indecisiveness and fear of making mistakes. Never deciding to throw anything out and constantly buying things "just in case" seems to them, albeit wrongly, to be a way to avoid never making a wrong decision or having regrets.

• Difficulty categorizing. Someone who has a hard time sorting objects, such as office supplies, into categories, can find it difficult to decide which drawer something belongs in. If differentiating between valuable and worthless items is also difficult, keeping old supermarket flyers may seem to make as much sense as keeping last year's tax return.

• Concerns about memory. A hoarder may doubt the reliability of her memory (usually for no good reason) and therefore avoid putting things away for fear of not being able to find them again. Thus, dresser drawers remain empty while clothes pile up all around. Newspapers and magazines are saved to be sure that any bit of news or information that might be needed later on will be available.

• Emotional attachment to objects. A hoarder often comes to see beauty and value in clutter — and develops a sentimental attachment to it. This heightens her enthusiasm for acquiring things and reluctance to discard them.

• Need for control. The hoarder usually doesn't want anyone else to make decisions about her possessions, so it can be difficult for the hoarder's family to help.

It's unclear where compulsive hoarding comes from, but research shows that it isn't correlated with material or emotional deprivation earlier in life.

In a 2004 study in the American Journal of Psychiatry, brain scans on compulsive hoarders revealed lower levels of activity in a specific brain area, the cingulate gyrus, when compared with control subjects or people with OCD who did not hoard. The cingulate gyrus is associated with decision-making, motivation, and spatial orientation; its lessened activity might help explain several of the common features of hoarding.

An escalating problem

Over the years, compulsive hoarding takes an increasing emotional, financial, and sometimes physical toll on family members. The home becomes unsafe. The stove may be piled with junk and hallways blocked. Accumulated dust and mold may trigger asthma and other allergic reactions. Guests are not allowed.

"Family members are much more likely to seek help than the hoarder. Hoarders are reluctant to change. And they are usually upset about their hoarding only if people are putting lots of pressure on them to change," says Dr. Michael Jenike, professor of psychiatry at Harvard Medical School.

Not all family interventions help. Extra storage units may simply be filled up, and the family's insistence on hiring a professional cleaner is often resisted.

"Some relatives or friends try to strong-arm people into getting rid of hoarded stuff, and that often ends disastrously, creating lifelong resentments. You need someone to negotiate for you," says Jenike. "In some cases, a person isn't going to deal with this until the board of health gets involved."

Treating hoarding

What to do? A lot depends on whether the hoarder wants to change. A motivated person with mild compulsive hoarding may be able to use a self-help program or work with a professional organizer. But most hoarders need professional therapeutic help. Treatment can be difficult and lengthy and may require several approaches.

First, it's important to find a good physician, mental health professional, or neurologist who can determine whether the hoarder has any underlying or contributing conditions and treat those as well as the hoarding itself. For example, someone with untreated attention deficit disorder may not be able to focus long enough to make headway in clutter removal.

There are no specific anti-hoarding medications. Drugs that are used to treat OCD may help, especially selective serotonin reuptake inhibitor (SSRI) antidepressants or tricyclic antidepressants. However, compulsive hoarding often doesn't respond to these medications. Some small studies have shown that among subjects with OCD who are treated with SSRIs, those who also have hoarding symptoms are less likely to be helped by SSRIs than those who do not. However, these drugs may be useful in treating the other anxiety disorders or depression that may co-exist with hoarding.

Changing thoughts, behaviors

Traditional cognitive behavioral therapy hasn't worked well either, often because the patients don't see hoarding as a problem and are reluctant to participate. Researchers are working on modifications of cognitive behavioral therapy to help compulsive hoarders identify and confront distorted thinking or beliefs, bolster organizational skills, and cope with (and gradually lessen) anxiety about discarding or organizing possessions.

Therapy generally takes several months and may involve home visits as well as in-office sessions. Therapist and patient may use photographs to help monitor progress at home, or work together sorting boxes of items. Researchers at Boston University and the Hartford Hospital in Connecticut have designed a behavioral therapy program specifically for hoarding. It is being tested in a randomized controlled trial as of early 2006.

Collector or hoarder?

Many people have collections that can occupy a great deal of home space and leisure time. But they differ from hoarders in specific and important ways. For example, collectors usually enjoy showing off the objects they collect. Hoarders, on the other hand, are often embarrassed about all the things they've accumulated and may go out of their way to prevent others from seeing their living spaces — such as meeting for coffee elsewhere rather than inviting someone in. See the chart "Distinguishing between collectors and hoarders" for more examples.

Last updated:	September 05, 2008