Hoarding - A Successful Compulsion

James Claiborn, Ph.D.

Northeast Occupational Exchange
Portland, Maine

Hoarding is a problem that is asked about frequently in connection with obsessive-compulsive disorder (OCD). We can define hoarding as acquiring and keeping objects to such an extent that they begin to impair the normal use of one's living space. Most of the time, non-hoarders do not think the saved objects have little or any intrinsic value. However, it is also possible that a hoarder is a collector as well. There are other disorders sometimes associated with hoarding including obsessive-compulsive personality disorder (OCPD). However, in most cases, it is likely that the individual hoarder has a variation of OCD.

People who hoard typically acquire excessive amounts of certain things and have difficulty or are unwilling to dispose of accumulated material. This leads to incoming material far exceeding outgoing material. The result is that the person's living space becomes filled with material and what would be considered normal use of much of their living space becomes impossible. Furniture may be used as a place to pile objects. Indeed, any flat surface may become a place upon which to pile things.

The most commonly hoarded items are papers. This can include papers most people would consider important, such as, tax records along with unimportant papers, such as, brochures, advertisements, junk mail, newspapers, magazines and scraps of paper with notes, shopping lists, etc. Some keep food products, broken items to be fixed, clothes, books, craft materials and leaves. In rare and extreme cases, hoarders have been known to save feces or urine. Another extreme form involves hoarding animals and the occasional story of someone living in a home with hundreds of cats or dogs often including carcasses of decaying animals are probably best understood as incidents of hoarding OCD. Much more common, however, is a description of rooms filled with piles of papers, clothes and similar items often criss-crossed by narrow paths between the piles.

The hoarder may label parts of his material as a "collection." These collections can include books, toys or other objects that may be considered valuable by many people. The hoarder may, however, believe his collection would be valued by others when this is not realistic. One hoarder had a collection of pictures of staircases. She believed her children might want them some day. Another explained that she kept newspapers because someday her grandchildren (not yet conceived) might be interested in contemporaneous coverage of events.

There is at present not enough information about how common this problem is. But judging from the number of times questions are asked about it in online support groups and the occurrence in clinical populations, it is reasonable to speculate that hoarding is actually a common problem. People with OCD are often unwilling to seek treatment at least in part because of embarrassment or shame about their disorder. Most questions about hoarding come from concerned family members rather than the individual with the problem, suggesting that hoarders are even less likely to come into treatment than others with OCD.

This reluctance to seek treatment and the difficulty in treating hoarding as a behavior lead to speculation about what is different in this population. One idea is to describe hoarding as a "successful compulsion." In OCD in general, compulsions are seen as a method to reduce anxiety or other forms of distress and, to some extent, they must work or people would not continue to engage in them. The individual with a contamination fear may wash to reduce anxiety when she believes she has been exposed to contamination. Avoidance of situations which arouse anxiety is also important in OCD. The contamination fear may lead to avoiding touching certain objects, going certain places or limiting other activity. Yet, OCD is described as an anxiety disorder in part because most people who have it have considerable anxiety in spite of their engaging in both avoidance and compulsive rituals. Many individuals with the hoarding form of OCD seem to have significantly less anxiety than the average OCD patient.

If the anxiety in OCD is generated as a result of interpretation of intrusive thoughts as described in a cognitive model, then what is driving a hoarder to hoard? Hoarders seem to have intrusive thoughts about: not having something that might be needed or valuable; not being able to remember something important; or possibly wasting something. When objects are disposed of, a hoarder may want to go to great lengths to make sure their disposal was done properly. The need to remember and the imperative not to waste or to dispose of something improperly are linked to "responsibility," a theme that runs through many OCD symptoms. The anxiety generated by the thoughts may be reduced quickly by knowing that the individual still has possession of the material. And the anxiety associated with intrusive thoughts, such as, "what if I need this and can't get it in the future," that occur when a hoarder is exposed to a new object can be quickly managed by acquisition. The anxiety is assuaged by the rationale: "If I get it now, I will have it if I ever need it." Some hoarders also report gaining some sort of comfort or pleasure from their possessions. They may indulge themselves by just looking at the things they have acquired or surrounding themselves with the piles of things that they've collected.

When the idea of a "successful compulsion" was discussed on an e-mail list of hoarders, a number of the subscribers indicated that they did think this was an apt description. They explained that they did have anxiety and that the model of a "successful compulsion" did not truly describe the experience of hoarding. Remember that in all OCD we understand compulsions to be a method for dealing with anxiety. Yet, ironically, people often report anxiety about having to engage in compulsions. Sometimes people avoid doing things because they know that they will be stuck for long periods engaged in some compulsive ritual. They may consider the ritual absurd but still feel required to do it.

One difference with hoarding is that hoarders often do not acknowledge the absurdity of the ritual. They may argue about it not being good to waste, explain that they will really read all the collected newspaper articles again or someone in the future might be interested in whatever object they are discussing. More commonly, hoarders have anxiety when their hoard is threatened in some way. A pending visit from a landlord can be terrifying. The hoarder may fear how others will react to the situation and experience shame because of how people respond to the hoard.

Some hoarders will report anxiety when they look at their own piles of clutter. This often results from concern about their things not being organized. The disorganization is the aversive part of hoarding not its interference with function. Hoarders see objects as unique so that they cannot be stored together. One hoarder described trying to organize possessions as like trying to organize snow flakes. This metaphor is telling because it illustrates how the differences rather than similarities of objects contribute to the confusion. This is known as having under-inclusive categories. Things that don't belong together cannot be stored together. The anxiety generated by thoughts of needing to organize possessions is most often dealt with by avoidance or procrastination. Sometimes, paradoxically, the desire to organize may lead to more hoarding. The hoarder may buy lots of containers in which to store his things. But due to under-inclusive categories, be unable to make use of them. Thus, the containers become part of the hoard rather than a solution.

There are two well-established treatments for OCD, serotonin reuptake blocking medications and cognitive behavioral therapy (CBT). Hoarding as a specific form of OCD does not seem to respond well to medication. One reason for this poor response may be that the medication works by reducing intensity and frequency of intrusive thoughts. This, in turn, allows the individual with OCD to engage in formal or informal behavior therapy including exposure to anxiety producing situations. Because hoarders already successfully avoid or manage much of their anxiety, the medication doesn't have a noticeable impact. Also, medication does not change the distorted value a hoarder places on his/her possessions. A lessening in valuation is necessary for a hoarder to begin to be able to dispose of his hoard. So, they do not experience any relief from medication. It may be that medication would make CBT more tolerable. But people who are not distressed by a behavior are unlikely to seek help in changing it. Finally, the individuals, who report they don't fit the model described above, are individuals who are highly motivated to change their hoarding. They are involved in a support group and committed to changing. They seem to represent a minority of hoarders for whom hoarding is no longer a "successful compulsion."