Hoarding: Where Does It Belong?

James Claiborn, Ph.D.

Northeast Occupational Exchange
Portland, Maine

Hoarding is defined as the acquisition and failure to dispose of large quantities of items, which are of little use or value (Frost & Gross, 2003). Typically, the hoarded material takes up space and makes parts of the home unusable for their intended purposes. Hoarding often creates situations that are considered dangerous or unsafe by local government officials responsible for the health and safety of the community (i.e., public health officials, fire officials). The diagnostic status of compulsive hoarding is uncertain. Hoarding is a problem often seen in people with obsessive-compulsive disorder (OCD). It can be associated with any number of other disorders including schizophrenia, dementia, anorexia, depression and even the so called Diogenes syndrome (Rosenthal, Steilan, Wagner & Berkman, 1999; Seedat & Stein, 2002). This article will address two questions regarding the diagnostic status of hoarding. Is it part of OCD and is hoarding an impulse control disorder?

Is hoarding part of OCD?

One of the most confusing diagnostic question is whether hoarding is part of OCD or obsessive-compulsive personality disorder (OCPD). Hoarding is common among people with OCD. The estimates of frequency vary widely, but a reasonable estimate is that 20 to 30% of individuals diagnosed with OCD have hoarding symptoms (Frost, Krause & Steketee, 1996). Hoarding symptoms appear earlier, and people with OCD who hoard tend to have more severe OCD symptoms than general clinical samples of OCD patients. People who hoard also have higher rates of personality disorders, social phobia, and pathological grooming behaviors such as skin picking (Frost, Krause & Steketee, 1996; Samuels et al., 2002). Although it appears that most individuals who hoard probably can be diagnosed as having OCD, hoarding is not included in the diagnostic criteria for OCD (Coles, Frost, Heimberg & Steketee, 2003). Hoarding is described as one of the diagnostic criteria for OCPD. It is questionable, however, whether hoarding should be seen as an indicator of OCPD, OCD, or both.

Psychoanalytic theory holds that OCD is on a spectrum with OCPD. It represents anal eroticism. According to this model, in milder forms an individual would have the traits seen in OCPD. More severe pathology would present as OCD (Baer & Jenike, 1998). If this were an accurate account, then everyone who has OCD should also have strong OCPD traits. However, this is not the case. Furthermore, many of the traits of OCPD show up in otherwise anxious individuals who do not have OCD. In fact, among OCD patients with personality disorders, other personality disorders are as common as, or more common, than OCPD (Baer & Jenike, 1998).

Despite the fact that psychoanalytic theory is no longer seen as a viable explanation for OCD, the diagnostic criteria for OCPD were established based on the psychoanalytic notion of anal fixation. One of these is the inability to discard useless items with no sentimental value. This criterion was added in DSM-IIIR. It seems to have been based on the erroneous belief that possessions have no sentimental value for people who hoard them. Recent scientific evidence contradicts this view. In fact, people with hoarding problems seem to suffer from a hypersentimental attachment to possessions (Frost, Hartl, Christian, & Williams, 1995; Winsberg, Cassic & Koran, 1997).

Research examining personality traits of people who hoard has repeatedly failed to find them to have more characteristics of OCPD than non-hoarding OCD patients or other anxiety disorder patients, with the exception of perfectionism and a tendency to get lost in details (Coles et al., 2003; Frost & Gross, 1993; Frost, Steketee, Williams & Warren, 2000). These traits do not discriminate OCPD from other disorders. Perfectionism has been shown to be strongly associated with or even a central feature of OCD. It is typically seen in other anxiety disorders such as social phobia and panic (Antony, Purdon, Huta, & Swinson, 1998; Frost & Steketee, 1997). Work on the neuropsycholoogy of OCD suggests that the tendency to get lost in the details is actually typical of OCD in general (Savage, 1998). Thsi probably correlates with the severity of the OCD. The tendency to get lost in details would fit with the hypothesized information processing deficit in compulsive hoarding (Frost & Hartl, 1996). Because other than these characteristics the average OCD patient does not show a preponderance of OCPD traits, and because hoarding individuals with OCD are not more likely to have other traits of OCPD. It is questionable whether hoarding should be a diagnostic criteria for OCPD.

Hoarding is often thought of as a symptom of OCD. However, there are several ways in which it is distinct. With hoarding it is difficult to identify an intrusive thought that is typical of other obsessive symptoms. Also, hoarding does not respond as well to treatments that are effective for other OCD symptoms (see Steketee & Frost, 2003). Furthermore, recently researchers have attempted to identify subtypes of OCD based on the types of obsessions and compulsions experienced. This research has consistently found hoarding to fall into a separate cluster (Calamari, Wiegartz & Janeck, 1999; Summerfeldt, Richter, Antony & Swinson, 1999). Hoarding and tics also show up more commonly in the families of people who hoard than those of other OCD patients. This might suggest a separate genotype (Samuels et al., 2002; Stein et al., 1999). It could be that OCD hoarding represents a separate disorder that might explain the poor response to treatments (Saxena et al., 2002). Another possibility is that hoarding is one of a spectrum of disorders related to OCD but somehow distinct (Stein, Seedat, & Potocknk, 1999). Investigators have suggested a wide range of disorders as part of this spectrum including hypochondriasis, eating disorders, and many more.

Is hoarding an impulse control disorder rather than OCD?

Among the spectrum of disorders thought to be related to OCD are the impulse control disorders. These disorders are characterized by the failure to control the impulse to engage in harmful behavior, for example "compulsive gambling," kleptomania, etc. The excessive acquisition of new possessions that characterizes compulsive hoarding fits this characterization. This behavior mimics what is usually called "compulsive shopping." Although not officially recognized as a disorder in DSM-IV, compulsive shopping is often considered an Impulse Control Disorder and resembles or is co-morbid with other OCD spectrum disorders (Koran, 1999). Hoarding individuals may purchase excessively, or may acquire excessive amounts of free items, or may pick from others' trash. In a study of the relationship between gambling and OCD, Frost, Meagher, and Riskind (2001) found those who engage in heavy purchase of lottery and scratch tickets tended to have more obsessions, compulsions and avoidance behaviors. The heavy gamblers showed more hoarding symptoms and compulsive buying. This suggests that the problems are interrelated. It suggests that OCD, including hoarding, presents with features in common with these impulse control disorders. This might suggest that OCD hoarding may fit as an impulse control disorder as well as a form of OCD. The implication for treatment is that strategies that work for both OCD and impulse control disorders must be considered.

Summary

Compulsive hoarding has enough in common with other forms of OCD to be classified as a variation of this disorder with some features of impulse control disorders. This particular variety of OCD is common and can be severe and quite difficult to treat. Ultimately, research may clarify questions about differences in neurobiology or genetics of varieties of OCD and tell us where hoarding best fits.