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From Dante to DSM-V: A Short History of Hoarding

"Here, too, I saw a nation of lost souls,
far more than were above: they strained their
chests against enormous weights, and with mad howls
rolled them at one another. Then in haste
they rolled them back, one party shouting out:
“Why do you hoard?” and the other: “Why do you waste?”
“Hoarding and squandering wasted all their light
and brought them screaming to this brawl of wraiths.
You need no words of mine to grasp their plight.”
 

From The Inferno by Dante Alighieri in J. Ciardi (translator), 1954, Rutgers University Press, p. 73-74.


The earliest reference to hoarding occurred in Dante Aligheri’s Divine Comedy, an epic poem written early in the 14th century. In the poem, Dante along with a guide had to descend through all 9 circles of Hell before they could ascend through Purgatory and then on to Paradise. The first section of the poem, The Inferno, was Dante’s account of their trip through Hell. Each circle of Hell contained assorted shades (ghosts) suffering increasingly harsh punishments. As the pair entered the 4th circle of Hell, they found two mobs at war, crashing against each other with enormous boulders they pushed with their chests. The armies formed a circle and as Plutus, the Greek God of Wealth watched, they collapsed upon each other crashing the stones against each other, only to retreat and taunt “Why do you hoard?” While the opposite mob replied, “Why do you waste?” Dante’s guide explained that these were the hoarders and wasters in life, the Avaricious and Prodigal. Their lives were spent acquiring possessions and chasing wealth, but by doing so they shielded themselves from God’s light. Now they were forever doomed to this fate. Their possessions became the heavy stones they heaved and crashed for eternity.

Other references to hoarding have appeared in literature since then. Charles Dickens’ character, Krook, in Bleak House (1862) was described as “possessed with documents” in a shop where “Everything seems to be bought and nothing sold.” Honore de Balzac’s character, Cousin Pons (1847), was a collector of “bric-a-brac.” Watson described Sherlock Holmes as having a “horror of destroying documents” resulting in stacks of papers in every corner of the room. In the 1842 Russian novel, Dead Souls, written by Nikolai Gogol, a wealthy landowner named Plyushkin displayed all the characteristics of hoarding. The local peasants called him the fisherman for his habit of “fishing” the neighborhood for “an old sole, a bit of a peasant woman’s rag, an iron nail, a piece of broken earthenware.” He collected them all in his cluttered manor. Not long after that, “Plyushkin” became slang in Russian for anyone collecting discarded, useless, or broken objects. “Plyuskin syndrome” is still used in Russian psychiatry to refer to someone with a hoarding disorder.

Early in the 20th century, ownership and acquisitiveness received some attention from psychologists. William James (1918) described acquisitiveness as something instinctual that contributed to one’s sense of identity. For James, one’s sense of self fused “me” and “mine.” In the mid 20th century, Erich Fromm suggested that acquisition was one way for people to relate to the world around them and was core to one’s character. In his theory, a “hoarding orientation” was one of four types of dysfunctional character. This orientation corresponded with a fundamental orientation to existence – “having.” The destructive orientation of “having” or avarice contrasted with the more healthy “being” orientation. At about the same time as Fromm was writing about the “hoarding orientation,” the New York City newspapers were filled with stories about the Collyer brothers who died among the junk in their Harlem brownstone. The Collyer brothers not only affected a generation of New Yorkers whose mothers admonished them to clean their rooms or end up like the unfortunate brothers, but they also inspired several novels, Marcia Davenport’s My Brother’s Keeper published in 1954, and the recent E.L. Doctorow’s Homer and Langley. It has been the stuff of theatre, and even now among New York City firemen, a hoarded home is referred to as a Collyer house.

While Freud said little about the hoarding of things, he did suggest that hoarding money developed out of fixations at the anal stage of development and was a more acceptable alternative to saving excrement. The hoarding of money reflected the parsimony dimension of the anal triad which also included orderliness and obstinancy. Other psychoanalysts expanded the definition of parsimony to include the hoarding of objects (Jones, 1912). The anal triad formed the backbone of what was an anal personality and became the basis for the diagnostic criteria for obsessive compulsive personality disorder in DSM-III. More recent analytic theorists have focused on objects to which people develop intense emotional attachments as “transitional objects” that serve as bridges in the development of independence.

Hoarding appeared in 1980 as one of 9 diagnostic criteria for obsessive compulsive personality disorder in DSM-III. As mentioned, it originated from psychoanalytic theorizing about an anal character and was associated with the notion of holding on or saving feces during toilet training (Grilo, 2004). Interestingly, the similar disorder, Anakastic Personality Disorder, as defined in the International Classification of Disease (World Health Organization, 1992) has not included hoarding as a diagnostic criterion. DSM defines OCPD hoarding as the inability “to discard worn-out or worthless objects even when they have no sentimental value” (DSM-IV-TR; p. 729). This OCPD hoarding criterion survived other changes in OCPD criteria in DSM-III-R, DSM-IV and DSM-IV-R. However, recent evidence has questioned whether it should be included within OCPD for DSM-V because various studies have shown that hoarding is not very closely associated with the other OCPD criteria and that the disorder would be more reliable if it were excluded (Pertusa et al., in press). Consequently, the DSM-V personality disorder working group has recommended removal of hoarding as a criterion for the proposed Obsessive-Compulsive Type of personality disorder in DSM-V.

Although hoarding is not listed as a current diagnostic criterion for obsessive compulsive disorder, a recommendation in the OCPD section of the DSM-IV states, “A diagnosis of obsessive-compulsive disorder should be considered especially when hoarding is extreme (e.g., accumulated stacks of worthless objects present a fire hazard and make it difficult for others to walk through the house,” p. 728). A few links with OCD can be found in the sparse literature on hoarding prior to the early 1990s. Adams (1973) observed that obsessional children tended to hoard and had parents who did so as well. He suggested that hoarding in children was a non-serious obsession, but was a risk factor for the later development of obsessive compulsive disorder. Salzman (1973) also tied hoarding to OCD, suggesting that it was closely associated with perfectionism and uncertainty, associations that have been borne out by later research. Greenberg (1987) provided the first detailed description of hoarding in two reports. In the first, four cases of hoarding were considered to be part of OCD, and in the second (1990) eight cases showed co-morbidity that varied from OCD to organic mental disorders. In addition, some prominent measures of OCD such as the early Leyton Obsessional Inventory (Cooper, 1970) and the more recent Yale-Brown Obsessive Compulsive Scale included hoarding items. Clinically, hoarding was widely considered to be a relatively rare symptom of OCD.

The first systematic study and definition of hoarding was published in 1993 by Frost and Gross. Here hoarding was defined for the first time as “the acquisition of, and failure to discard, possessions which appear to be useless or of limited value” (p. 367), a definition which is commonly used today. This study was the first to describe hoarding in a large sample of people, and it framed our earliest picture of hoarding and the phenomena associated with it. In contrast with the definition in DSM-IV, the nature of items saved in hoarding included far more than worthless or worn out things. In fact, the types of things saved closely corresponded with the types of things people without hoarding problems saved, the only difference was volume. Furthermore, the attachments to possessions appeared to include emotional ones, also inconsistent with the criterion for hoarding in obsessive compulsive personality disorder in DSM-IV. In this study, hoarding was associated with indecisiveness and perfectionism – both of which play prominent roles in theories about hoarding. The hoarding participants had many more first degree relatives who hoarded than did the non-hoarding participants. Finally, the study did not find support for the hypothesis that hoarding resulted from the experience of material deprivation early in life.

In 1996, Frost and Hartl published the first theoretical account of hoarding based on the limited empirical evidence available at that time. Their model proposed that hoarding resulted from a combination of information-processing deficits, dysfunctional beliefs about and exaggerated emotional attachments to possessions, as well as difficulty with organization. This study marked a change in the trajectory of research on hoarding. Before 1996, fewer than 10 studies had been published on the topic. By 2009, more than 20 articles per year were being published about hoarding (Mataix-Cols et al., in press). These studies have covered a wide variety of topics including phenomenology, epidemiology, genetics, brain function, treatment and co-morbidity.
Early studies helped define the symptoms of hoarding and the features associated with it. Indecisiveness, perfectionism, and attention deficit problems are some of the associated features that we now know are important for understanding hoarding, and being able to treat it successfully.

Perhaps one of the reasons for the lack of research before 1996 was the belief that hoarding was an uncommon problem. This belief has been challenged by the publication of three recent landmark studies on the prevalence of hoarding. A Johns Hopkins study found hoarding in nearly 4% of a U.S. sample and when the researchers adjusted this figure to fit population demographics, the estimated prevalence was 5.3%, making hoarding far more common than OCD. Hoarding occurred more often among men than women and increased with age. A representative sample of the German population showed a very similar prevalence rate of 4.6%, although there were no gender differences. In a UK study of over 5,000 twins, 2.3% met criteria for clinically serious hoarding and like the first U.S. study, men who hoarded outnumbered women. We do not yet have a complete picture of the prevalence of hoarding as this will depend on general agreement in the mental health professional community on exactly how to diagnose it. Nonetheless, it seems clear that hoarding is far more common than previously thought, and may well be more common than OCD.

From the earliest studies of hoarding, it has been clear that hoarding runs in families. Studies asking about family members have reported that 50 to 80% of people who hoard had first-degree relatives whom they considered “pack rats” or hoarders. In a more stringent test of the family connection, the Johns Hopkins OCD Family Study diagnosed hoarding in 12% of first-degree relatives of people who hoarded. Although lower than the self-reported frequency found in other studies, it was still significantly greater than that of relatives of people with OCD (3%). Other studies have found evidence indicating that hoarding is genetically influenced.

Our knowledge of the effects of medications for hoarding is incomplete. Early studies examining serotonin reuptake inhibitors (or SRIs) in people with OCD and hoarding suggested that medications don’t work well for hoarding. When researchers have studied OCD patients who did not respond well to medication, they found more people with hoarding symptoms in this group than in the treatment responder group. Other researchers have found that having hoarding symptoms predicts worse outcome among people who are being treated for their OCD symptoms. Still other studies have reported that when people have symptoms of hoarding, they are much less likely to respond well to medications (as few as 14%) compared to people who have other types of OCD symptoms (50-80%). However, none of these studies was really designed to study hoarding by itself, and none recruited people who had hoarding without other OCD symptoms. Only one study has solicited patients with hoarding (and not OCD) and has taken care to establish a clear diagnosis of hoarding (Saxena et al., 2007). In this study, paroxetine was just as effective for people with hoarding problems (28% responded) as for people with OCD but without hoarding (32% responded). The only caveat here is that neither group improved as much as is typically seen in the treatment of OCD with paroxetine.

A number of studies tried to treat hoarding using exposure and response prevention, the standard cognitive and behavioral treatment for OCD. This effort met with little success. Treatment in these studies focused on discarding as many things as possible in a short period of time without engaging in careful or perfectionistic inspection of the items being discarded. Like the results for medications, this treatment led to less benefit for hoarding than for other OCD symptoms. Further, people with hoarding problems more often dropped out of treatment, and they also showed very poor motivation compared to people with other forms of OCD.

Recent attempts to develop a treatment tailored to hoarding symptoms have been more successful. This treatment grew out of the cognitive-behavioral model of hoarding proposed by Frost and Hartl (1996). It includes office visits as well as in-home sessions focusing on acquisition, difficulty discarding, and disorganization. Both a pilot study of this treatment and a wait-list controlled study had generally positive outcomes. Participants showed significant improvement from before to after the therapy and those in the 12-week waitlisted group showed less change than participants who received the specialized CBT for the same period of time. After a total of 26 sessions in these two studies, 50 to 70% of patients were considered treatment responders. While there are still significant improvements to be made in the treatment of hoarding, it appears that this treatment shows considerable promise.

One of the most pressing questions about hoarding has to do with its relationship to OCD. Hoarding has long been considered a subtype of OCD and is featured in several prominent measures of OCD symptoms like the YBOCS and the Obsessive Compulsive Inventory. There are several reasons why hoarding and OCD appear to be closely linked. Many studies have demonstrated significant correlations between measures of hoarding and measures of OCD, and somewhere between 18 and 40 percent of OCD patients report significant hoarding symptoms, although generally the hoarding symptoms are not the person’s primary problem. Also, hoarding resembles OCD in several ways. The avoidance of and difficulties with discarding seem to be driven, at least in part, by fears of losing something significant (either information or emotional attachment) or being responsible for a bad outcome (e.g., behaving wastefully). These could be thought of as obsessional fears.

On the other hand, hoarding appears distinct from OCD in a number of ways. First, few hoarders experience negative, intrusive, or unwanted thoughts about hoarding, whereas this is the defining feature of OCD. Distress in hoarding seems to occur only when the person is forced to discard, and the distress is much more grief-like than the anxiety typically seen in OCD. Also, parts of the hoarding syndrome are experienced as pleasurable (e.g., acquisition), something that almost never happens in people with OCD. Another reason to question the link between hoarding and OCD is that most people who suffer from hoarding (80% or more) do not have any other OCD symptoms, and hoarding shows the smallest correlation with other OCD symptoms of any of the OCD subtypes. Neuroimaging studies, although still preliminary, suggest that different areas of the brain are involved for hoarding than for OCD. Finally, pharmacotherapy and behavior therapy for OCD do not seem to work as well for hoarding clients as for clients with other forms of OCD.

In a review commissioned by the DSM-V working group on OC Spectrum disorders, Mataix-Cols and colleagues (in press) summarized these similarities and differences and recommended that hoarding be considered a disorder distinct from OCD in DSM-V. This recommendation, together with proposed diagnostic criteria, is now under consideration by the DSM-V committee. [See article on the proposed criteria for Hoarding Disorder.]

References


Adams, P. L. (1973). Obsessive children. New York: Brunner/Mazel.
Alighieri, D. (1954). The inferno. (J. Ciardi Trans.). (pp. 73-74) Rutgers University Press.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. DC: American Psychiatric Association Washington.
Cooper, J. (1970). The Leyton obsessional inventory. Psychological Medicine, 1, 48-64.
Davenport, M. (1954). My brother’s keeper. New York: Charles Scribner.
De Balzac, H. (1847). Cousin pons. London: Penguin Classics.
Dickens, C. (1862). Bleak house. Ford G., Monod S. (Eds.), (1977). New York: W.W. Norton & Company, Inc.
Doctorow, E. L. (2009). Homer & Langley: A novel (1st ed.). New York: Random House.
Freud, S. (1908). Character and anal erotism. In Collected papers (Wol. II). London: Hogarth Press.
Fromm, E. (1947). Man for himself: An inquiry into the psychology of ethics. New York: Rinehart.
Frost, R. O., Gross, R. C. (1993). The hoarding of possessions. Behaviour Research and Therapy, 31(4), 367-381.
Frost, R. O., Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 31 (4), 341-350.
Gogol, N. (1842). Dead souls. R. Pevear, L. Volokhonsky (Trans.), (1997). New York: Vintage.
International OCD Foundation Hoarding Center