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Diagnosing Hoarding

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Hoarding and DSM V

As mentioned, hoarding is being considered for inclusion in DSM V as a distinct disorder called “Hoarding Disorder”. While there are several ways in which hoarding resembles OCD, there are also a host of ways in which it appears quite distinct. This article briefly outlines these and describes the proposed DSM-V diagnostic criteria for hoarding. In addition, this article provides a description of those cases that can be considered OCD-based hoarding. That is, the hoarding behavior is a part of OCD rather than Hoarding Disorder.

The phenomenology associated with hoarding bears some resemblance to that of OCD. For example, the avoidance of and difficulties with discarding appear to be driven by fears of losing important information, losing objects of emotional significance or making serious mistakes. These are akin to obsessional fears. Similar to concerns about symmetry, hoarding is often associated with distress whenever other people touch or move one’s possessions. In fact, a number of studies have found stronger relationships between hoarding and symmetry obsessions and arranging compulsions than with any other forms of OCD. Finally, a number of studies have reported significant correlations between hoarding and OCD symptoms, suggesting a close association.

On the other hand, there are quite a few differences in the features of hoarding and OCD. Thoughts associated with hoarding are not intrusive in the same way as for OCD, nor are they repetitive, distressing, or unpleasant in the manner that obsessions are experienced. There is usually no ritualistic quality associated with hoarding behaviors. Failure to discard possessions is more of an absence of (passive) behavior than an active attempt to neutralize unwanted thoughts, images or impulses. In many ways, hoarding thoughts are more like preoccupations than obsessions. Further, the distress associated with getting rid of possessions in hoarding is likely to be experienced in the form of grief or anger as much as anxiety. In contrast, people with OCD more commonly experience anxiety, although guilt is found in both hoarding and OCD. Hoarding symptoms are more likely to be “ego syntonic”, meaning that the person considers hoarding to be normal behavior, whereas OCD symptoms are commonly considered “ego dystonic” or inconsistent with one’s normal behavior and sense of self. Finally, hoarding is often associated with positive and even euphoric experiences, feelings that are almost unknown in response to OCD symptoms.

Hoarding Disorder:
Because of the distinctiveness of hoarding symptoms, the DSM-V diagnostic work group on OCD has recommended that hoarding be included in DSM-V. However, the committee is still examining the evidence to determine whether to include “hoarding disorder” in the main part of the manual or in an appendix for further research. The proposed diagnostic criteria are:

A. Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding.

B. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings (e.g., office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g., family members, authorities) to keep these areas free of possessions.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

D. The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease).

E. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, lack of motivation in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autistic Disorder, food storing in Prader-Willi Syndrome).

Specify if: 
With Excessive Acquisition: If symptoms are accompanied by excessive collecting or buying or stealing of items that are not needed or for which there is no available space.

Specify whether hoarding beliefs and behaviors are currently characterized by:
Good or fair insight: Recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

Poor insight: Mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Delusional: Completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

OCD-based Hoarding:
It appears that a small number of hoarding cases may be true OCD where the hoarding is being driven by prototypical OCD symptoms such as contamination fears or symmetry obsessions. There appear to be four things that characterize OCD-based hoarding. First, the hoarding appears to be driven by classic obsessions. Among the most common of these are fears of contamination (e.g., objects can’t be touched because they are contaminated and thus they accumulate on the floor or wherever they are dropped), superstitious thoughts (e.g., unreasonable belief that throwing something away will result in a catastrophe of some kind), feelings of incompleteness (symmetry obsessions fall in this category), or persistent avoidance of onerous compulsions (e.g., not discarding in order to avoid endless checking routines that are necessary before discarding can occur). Second, in OCD-based hoarding the hoarding behavior is unwanted and highly distressing and the individual experiences no pleasure from it. Third, the individual shows no interest in saved items, especially not sentimental attachments or beliefs about the intrinsic value of possessions. Finally, excessive acquisition is usually not present in OCD-based hoarding, although occasionally excessive collecting can occur in the context of rituals associated with other OCD symptoms such as having to buy items in multiples of a certain number, or having to acquire something because the individual is responsible for contaminating it.
 

Cluttering, collecting, and hoarding


Three behaviors characterize hoarding: acquiring too many possessions, difficulty discarding or getting rid of them when they are no longer useful or needed, and difficulty organizing possessions. When these behaviors lead to enough clutter and disorganization to affect someone’s health or safety, or they lead to significant distress, then hoarding becomes a “disorder”. Simply collecting or owning lots of things does not qualify as hoarding. A major feature of hoarding is the large amount of disorganized clutter that creates chaos in the home. Rooms can no longer be used as they were intended, moving through the home is challenging, exits are blocked, and life inside the home becomes difficult.
In contrast to people with hoarding problems, collectors typically keep their possessions well-organized, and each item differs from other items to form interesting and often valuable groupings. Further, an important purpose of collecting is to display the items to others who appreciate them. People who hoard are seldom able to accomplish such goals.
While clutter is the most easily visible marker of hoarding, a home can be cluttered for a variety of reasons. Only when the clutter results from excessive acquisition and difficulty getting rid of things does it constitute hoarding. Also, having cluttered storage areas such as basements and attics does not make someone a hoarder. Only when the clutter impinges on the living areas of the home, or when it creates other problems like the financial strain of paying for storage areas, can it be considered hoarding.

While people who hoard may appear to save only trash or things of no real value, in fact, most people who hoard save almost everything. Often this includes things that have been purchased but never removed from their original wrappings. The most frequent items saved are clothes and newspapers. Other commonly hoarded items include containers, junk mail, books and craft items.

People who hoard have a variety of reasons for doing so. The most frequent motive for hoarding is to avoid wasting things that might have value. Often people who hoard believe that an object could still be usable or might be of interest or value to someone else. Considering whether to discard it leads them to feel guilty about wasting it. ”If I save it”, reasons the hoarder, “I might not ever need it but at least I am prepared in case I do.”

The second most frequent motive for saving is a fear of losing important information. Many hoarders describe themselves as information junkies who save newspapers, magazines, brochures, and other information-laden papers. They keep large quantities of newspapers and magazines so when they have time, they will be able to read and digest all the useful information they imagine to be there. Each newspaper contains a wealth of opportunities, and discarding it means losing those opportunities. For most such people, having the information at hand seems crucial, whereas knowing that the information exists on the internet or in a library does little to help them get rid of their often out-of-date papers. Hoarders are often intelligent and curious people for whom the physical presence of information is almost an addiction.

A third motive for saving is the emotional meaning of objects. This takes many forms, including the sentimental association of things with important persons, places, or events, something almost everyone experiences, just not to the same degree. Another frequent form of emotional attachment concerns the incorporation of objects as part of the hoarder’s identity—in this case, getting rid of a possession feels like losing part of oneself. For some people who hoard possessions offer a sense of comfort and security.

Finally, some people hoard because they appreciate the aesthetic appeal of objects, especially their shape, color, and texture. Many people who hoard describe themselves as artists or craftspeople who save things to further their art. In fact, many are very creative with their hands. Unfortunately, however, having too many supplies gets in the way of living, and the art projects never get done.

The homes of people who hoard are typically filled with objects whose value is apparent to them, even though it may not be to others. Occasionally, however, the clutter consists of things that hold little interest or attachment. In these cases, the hoarding is most likely a result of another obsessive compulsive symptom as described in the section on
 Hoarding and DSM-V.

For more information about Cluttering, Collecting, and Hoarding, please see the following:

Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., & Mataix-Cols, D. (in press). Refining the boundaries of compulsive hoarding: a review. Clinical Psychology Review.

Steketee, G. & Frost, R.O. (2003). Compulsive hoarding: Current status of the research. Clinical Psychology Review, 23, 905-927.
International OCD Foundation Hoarding Center