Compulsive Hoarding: Current Status of the Research
Gail Steketee[1], Ph.D, and Randy Frost[2], Ph.D
[1] Boston University, Boston, MA
&
[2] Smith College, Northampton, MA
Abstract
This article reviews the literature on compulsive hoarding, including the definition and manifestations of the problem. There is a conceptual model for understanding hoarding behavior. This model addresses information-processing deficits (e.g., attention, organization, memory, decision making), beliefs about and emotional attachments to possessions, and distress and avoidance. Research regarding the diagnostic categorization of hoarding, its course and phenomenology, and evidence to support the model is presented. The limited research on treatment provides evidence that current serotonergic medications for OCD are largely ineffective for treating hoarding. Cognitive and behavioral treatments, especially those focused on deficits identified in the model, have some utility. Recommendations for further research on the psychopathology and treatment of hoarding are provided.
This article was originally published in the Clinical Psychology Review, 609, G. Steketee and R.O. Frost, pp. 1-22, 2003, with permission from Elsevier.
The problem of compulsive hoarding has emerged as an important unresolved challenge in understanding and treating obsessive-compulsive disorder (OCD). The behavior can result in serious and even life-threatening pathology (Frost, Steketee, & Williams, 2000a). The severity appears to increase with age (Steketee, Frost & Kim, 2001; Grisham, Frost, Steketee, Kim, & Hood, in preparation). Findings that hoarding is a consistent predictor of treatment dropout, failure or worse outcome following pharmacological and behavioral treatments for OCD (e.g., Black, Monahan, et al., 1998; Mataix-Cols et al., 1999, 2002; Winsberg, Cassic, & Koran, 1999) has led Christensen and Greist (2001) to call for including compulsive hoarding as an indicator of poor prognosis in the treatment of OCD. They need more research on the nature of this problem. Several laboratories, including our own, have begun to conduct such research. This review summarizes findings regarding the psychopathology of compulsive hoarding in the context of a model of components underlying the condition. The research raises several questions regarding the classification and phenomenology of the problem. In addition, the limited information about treatment for compulsive hoarding is reviewed with an eye toward determining promising next steps for research. This review is intended to spur such research.
Definition and Severity of Compulsive Hoarding
Saxena and Maidment (personal communication, 2002) have suggested the term "compulsive-hoarding syndrome" to characterize the condition described here. This is because of the multifarious nature of the deficits that characterize it and because it is not formally recognized as a diagnosis. Early anecdotal descriptions (Frankenberg, 1984; Greenberg, 1987; Greenberg, Witzum, & Levy, 1990) included information about collecting and the inability to discard. None attempted to verify the accounts or provide a clear definition of the problem. Frost and Hartl (1996) provided the first systematic definition, identifying three characteristics: "(1) the acquisition of, and failure to discard a large number of possessions that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and (3) significant distress or impairment in functioning caused by the hoarding." (p. 341). This definition distinguished hoarding from the collecting of objects generally considered interesting and valuable.
The first symptom, acquisition, has been examined previously only in the context of compulsive buying. This is considered an impulse control disorder (Black, Repertinger, Gaffney, & Gabel, 1998). Buying has also been found to play a major role in compulsive hoarding. Also a somewhat broader acquisition problem that includes acquiring free things (e.g., newspapers, advertisements, promotional give-aways, discarded items) (Frost & Gross, 1993; Frost, et al., 1998). The failure to discard worthless or worn-out objects has been linked to beliefs about their instrumental and emotional value. It is suggested that possessions are imbued with importance far in excess of their true value (Frost, Hartl, Christian, & Williams, 1995). These behaviors are generally not considered pathological unless accompanied by extreme clutter. In severe hoarding cases, clutter prevents the normal use of space to accomplish basic activities. Such activities as cooking, cleaning, moving through the house, and even sleeping. The interference with these functions makes hoarding a dangerous problem. It puts people at risk for fire, falling (especially elderly people), poor sanitation, and health risks (Damecour & Charron, 1998; Frost et al., 2000a; Steketee, Frost, & Kim, 2001; Thomas, 1997). This feature of compulsive hoarding appears to be associated with more than just the volume of possessions saved. Clutter in the homes of people with hoarding problems is extremely disorganized. Valuable objects (and sometimes money) are commonly mixed in with trash (Frost & Hartl, 1996; Frost & Steketee, 1998). Even in cases where the volume of possessions is not large, considerable dysfunction results from the gross disorganization.
The covariation among the three proposed symptoms of hoarding compulsive acquisition, difficulty discarding, clutter and resulting distress and impairment has received limited study. Recent work on the psychometric properties of a questionnaire designed to measure these and related components (Frost, Steketee, & Grisham, in press) indicated that difficulty discarding, acquisition, and clutter were significantly correlated in a large sample of compulsive hoarders. Acquisition was significantly associated with clutter and discarding, whereas discarding and clutter were more strongly correlated. The association of hoarding with impairment was reported by Frost, Steketee, Williams, and Warren (2000). They observed more family, work and social disability among OCD patients with compulsive hoarding.This was compared to OCD and anxiety clinic patients without this problem. The degree of disruption in this sample was moderate. Those seeking treatment for hoarding who lived with family members, discord over the problem was reported as substantial to severe (Steketee et al., 2000). Research to date regarding the nature and relationship among defining features of compulsive hoarding is suggestive but far from definitive.
Diagnostic Aspects of Compulsive Hoarding:
Links to OCD and Impulse Control Disorders
Several years of research on this problem make clear that fundamental questions about the nature of compulsive hoarding have not yet been answered. For example, is hoarding merely a symptom associated with various conditions/disorders (such as OCD, compulsive buying) or should it be considered a syndrome or disorder that merits separate classification? Are acquiring and saving activities driven by positive emotional states, as evident in substance abuse and impulse control disorders, or on avoidance of discomfort as is observed in anxiety and mood disorders? Evidence pertinent to these and related questions are discussed below.
A further concern is whether clinically severe hoarding is part of a dimensional or categorical construct. This is a symptom or a disorder in its own right. Hoarding is common in nonclinical as well as treatment seeking populations. The nature of the behavior and that its correlates are similar in these groups (Frost & Gross, 1993; Frost et al., 1995; 1998; 2000) suggest a dimensional view. Hoarding is often considered a subtype of OCD (Christensen & Greist, 2001; Winsberg et al., 1999), arguing for a diagnostic construct. This is not merely an esoteric question. If hoarding is taxonic, analogue studies have limited value for understanding this pathology. Evidence of taxonic versus dimensional structure sheds light on etiological models of compulsive hoarding (e.g., genetic vs. environmental basis).
Although hoarding has been associated with a variety of disorders researchers have focused most on the link between hoarding and OCD. Studies of OCD clinic samples indicate frequencies of hoarding in 18% to 33% of adults (Frost, Krause, & Steketee, 1996; Rasmussen & Eisen, 1989; Samuels et al., 2002; Sobin et al., 2000), and Saxena et al. (2002). Hording is reported to be the primary symptom in 11% of their large OCD sample. However, the use of less than satisfactory measures of hoarding limits the utility of these figures.
Among student samples, we observed significant correlations between measures of hoarding and OCD symptoms assessed by self-report and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) interview (Frost & Gross, 1993; Frost et al., 1996). Students who scored high on a measure of OCD that did not include items pertinent to hoarding were more likely to identify hoarding compulsions on the Y-BOCS checklist than those who scored low on OCD symptoms (Frost et al., 1996). Among community samples nonclinical/nonstudent and self identified hoarders, scores on an early measure of hoarding were positively correlated with OCD symptoms. For both student and community samples, Padua Inventory subscales of checking and doubting (Frost & Gross, 1993) and impaired mental control (Frost et al., 1998) were most highly correlated with hoarding. The latter subscale reflect excessive concerns about responsibility and decision-making difficulties observed in hoarding.
Comparisons of people who self-identified with hoarding problems and nonclinical controls revealed elevations of OCD symptoms among people who hoard. Hoarding participants scored higher on three self-report measures of OCD symptoms (Frost & Gross, 1993). As well as on Y-BOCS subscales and items pertinent to avoidance, indecisiveness, responsibility and doubt (Frost et al., 1996). The mean Y-BOCS total score of 16.5 for this community-solicited sample suggested that a substantial number were above the severity range (score of 16). This was often used as a cutoff for treatment studies of OCD. To determine whether these differences in Y-BOCS scores might be due to hoarding items on the Y-BOCS, Frost and Gross compared the number of non-hoarding symptoms endorsed on the checklist and included on the target symptom list. Hoarding subjects endorsed significantly more non-hoarding symptoms, and included more target symptoms than non-hoarding subjects. Community hoarding samples reported more symptoms of OCD and experienced them as more severe and distressing. This suggested a link between OCD and hoarding.
Among clinical samples selected via the Y-BOCS checklist and a screening interview (Frost et al., 2000b), OCD participants with and without hoarding symptoms did not differ in severity of OCD symptoms. According to the Y-BOCS and Padua Inventory, and both groups scored higher than anxious patients and controls. Patients with hoarding did not differ from the non-hoarding ones on the number of OCD symptoms reported on the Y-BOCS checklist. Studies using the Y-BOCS to examine the association between hoarding and OCD suffer from a problem of overlapping symptoms. Typically, one of the symptoms being rated for severity is hoarding. To correct this problem, Frost et al. (2003) removed the hoarding items from the Y-BOCS checklist and administered a self-report version of the scale to a sample of 70 people suffering from hoarding problems and to a community control group. Those with hoarding symptoms, the modified Y-BOCS showed small but significant correlations with the acquisition and discarding subscales (rs = .24 to .29) on a measure of hoarding symptoms. It was not correlated with a subscale measuring clutter. OCD is more closely linked to compulsive acquisition and saving, rather than clutter. This may be a consequence rather than a causal feature of the syndrome. Also noteworthy in this sample is the absence of significant OCD symptoms. The Y-BOCS scores were below 5 in 33% of the sample of 70 hoarding participants.
Although most researchers presume that hoarding is a symptom of OCD, this remains open to debate. An association with OCD is suggested by the excessive doubting, checking and reassurance seeking when trying to discard possessions that appear related to compulsive rituals (Rasmussen & Eisen, 1989; 1992). The moderate correlations of hoarding and OCD symptoms, and the frequency and severity of other OCD symptoms among people with hoarding problems (Frost & Gross, 1993; Frost et al., 1996; Frost et al., 2000b; Samuels et al., 2002) support an association. Clinical observations indicate that a substantial number of those with hoarding display no other OCD symptoms. Whether hoarding in these individuals represents a mono-symptomatic obsessive compulsive disorder or a separate, sometimes co-occurring disorder is not clear Unfortunately, the issue is not resolved by findings in four of five recent studies that hoarding emerges as an independent subtype of OCD symptoms (Calamari, Wiegartz, & Janeck, 1999; Leckman et al., 1997; Mataix-Cols et al., 1999; Summerfeldt et al., 1999; but see Baer, 1994). The ego syntonic nature of hoarding symptoms and lack of insight contrasts with typical OCD symptoms. The co-occurrence of hoarding with other disorders like dementia (Hwang et al., 1998) raises questions about its inclusion as an OCD symptom. Furthermore, treatments demonstrated effective for other OCD subtypes have produced little or no effect on hoarding symptoms (see below; Black, Monahan, et al., 1998; Mataix-Cols et al., 1999; 2002; Saxena et al., 2002; Winsberg et al., 1999).
Complicating the diagnostic picture is the fact that compulsive acquisition evident in hoarding consists in part of compulsive buying, an impulse control disorder (McElroy, Keck, & Phillips, 1995). Impulse control disorders (ICDs) have been linked to OCD and to other anxiety disorders in a variety of studies (Black & Moyer, 1998; McElroy, Keck, Pope, Smith, & Strakowski, 1994; Schlosser, Black, Repertinger, & Freet, 1994). This has led to speculation of a compulsive-impulsive spectrum (McElroy et al., 1995). The observed ego-syntonic nature of some features of hoarding suggests an association, and several empirical investigations have connected hoarding and ICDs. We have found high levels of compulsive buying, as well as compulsive acquisition of free things in compulsive hoarders (Frost et al., 1998). and high levels of hoarding symptoms among compulsive buyers (Frost et al., 2002). Some research suggests that beliefs about possessions and about buying are similar to beliefs of those with compulsive hoarding (Kyrios, Frost, & Steketee, 2002). Samuels et al. (2002) reported a greater frequency of trichotillomania and skin picking, in both ICDs, among OCD patients with hoarding compared to non-hoarding OCD patients. Also, Frost, Meagher and Riskind (2001) found higher levels of hoarding symptoms among a sample of compulsive gamblers.
An association between kleptomania, an impulse control disorder, and compulsive buying has been proposed (Fishbain, 1994). This is despite the fact that data on this question are very limited (Christenson et al., 1994). Several of our hoarding clients have described shoplifting and related behaviors. No studies have addressed the prevalence of kleptomania in compulsive hoarding. Perhaps compulsive hoarding is part of a broader category of disorders that are psychopathologies of acquisition. This includes hoarding, buying, and kleptomania.
The findings suggest a diagnostic overlap between compulsive hoarding, OCD and ICDs. Unfortunately, clarity regarding the association of hoarding and OCD is obscured by studies that have seriously flawed methodologically. These flaws are small samples of compulsive hoarders, recruitment strategies that bias selection toward those who have both hoarding and other OCD symptoms, absence of formal diagnostic interviews for OCD, and inadequate measures of hoarding symptoms. Information about compulsive hoarding and ICDs is too limited to draw conclusions. Epidemiological studies of the prevalence of compulsive hoarding in the community and its co-occurrence with OCD and ICD symptoms are needed to establish whether hoarding should be viewed as a subtype of OCD, an ICD, or an independent syndrome.
Comorbidity Associated with Compulsive Hoarding
Hoarding behavior has been reported in a variety of Axis I disorders including schizophrenia (Luchins et al., 1992), organic mental disorders (Greenberg, Witztum, & Levy, 1990), eating disorders (Frankenberg, 1984), brain injury (Eslinger & Damasio, 1985), and various forms of dementia (Finkel et al., 1997; Hwang et al., 1998). Hoarding is considered one of eight symptoms of obsessive-compulsive personality disorder (OCPD) (APA, 1994). Research has yet to address the frequency of hoarding with and without these conditions. And whether hoarding behavior differs according to the presence or absence of comorbid conditions.
Also associated with compulsive hoarding are social phobia and depression. Using a formal diagnostic interview (ADIS), five of seven hoarding patients in a treatment study were comorbid for social phobia. Five had diagnoses of major depression (Steketee et al., 2000). Frost et al. (2000) determined that among OCD samples, those with compulsive hoarding experienced significantly more anxiety than non-hoarding subjects. This was despite comparable scores for severity of OCD symptoms. Samuels et al. (2002) found a significantly higher frequency of social phobia among hoarders compared to non-hoarders in a sample of 126 patients with OCD. Findings of isolation and limited social networks among elders who hoard support this association (Steketee, Frost, & Kim, 2001). Anecdotal (Greenberg, 1987; Shafran & Tallis, 1996) and empirical accounts (Frost et al., 2000; Samuels et al., 2002) suggest a high frequency of depression in people who suffer from compulsive hoarding. Frost et al. (2000b) reported significantly higher depression scores among OCD hoarders compared to OCD non-hoarders. Samuels et al. (2002) found a higher frequency of diagnosed brief depression (as well as hypomania) among OCD hoarders versus OCD non-hoarders. The compulsive buying component of hoarding may be associated with mania in bipolar disorder.
Although hoarding is a diagnostic feature of obsessive-compulsive personality disorder (OCPD), research regarding the association between these conditions is equivocal. Winsberg et al. (1999) reported that only 15% of clients presented with compulsive hoarding were diagnosed with OCPD. Though the hoarding participants had more Axis II symptoms generally. Samuels et al. (2002) found more PD diagnoses among hoarding versus non-hoarding OCD participants for most of cluster B (dramatic), but not for cluster A (odd) and only for OCPD in cluster C (anxious). Studying symptom subtypes among 75 OCD cases, Mataix-Cols et al. (2000) observed that hoarding was associated with more personality disorders, specifically OCPD, avoidant, dependent, and paranoid personality disorders. Seedat and Stein (2002) reported lifetime diagnoses of OCPD (N = 9), avoidant (N = 3), and dependent (N = 1) personality disorders among a sample of 15 hoarding subjects. Only two subjects having no personality disorder. These findings suggest that OCPD is only one of several personality disorders that might be observed among hoarders.
Studies of self reported personality traits produced mixed findings. Frost et al. (1996) failed to find differences between hoarding participants and non-hoarding controls on OCPD traits. A study comparing OCD hoarding and non-hoarding participants to anxiety and community controls showed more PD traits among hoarders than anxious or community controls on all of cluster B, and most of clusters A and C (Frost et al., 2000b). Only on dependent and schizotypal traits did the hoarding OCD sample differ from non-hoarding subjects. Frost and Gross (1993) found no correlation between scores on a hoarding scale and the OCPD subscale of the MCMI. Perfectionism and indecisiveness were significantly related to hoarding severity (see also Frost et al., 1996).
In general, these studies suggest that hoarding is associated with a variety of Axis I disorders and negative personality traits. The specific disorders involved are not consistent across studies. Reliance on checklist items from the Y-BOCS to assess hoarding (except Frost et al.), and on small samples reduces confidence in the findings. This is especially true for infrequently represented Axis I diagnoses and personality traits. No investigations have examined the presence of hoarding symptoms in large samples of those with other non-OCD Axis I diagnoses. Needed to fully understand the phenomenology of compulsive hoarding is a large scale study that employs formal diagnostic procedures in community and clinical samples. These samples are not pre-selected for the presence of particular diagnoses (e.g., OCD).
Prevalence, Course and Features Associated with Compulsive Hoarding
Formal prevalence estimates for compulsive hoarding are not available. Frost et al. (2000a) reported that hoarding-related complaints to public health departments occurred in 26 per 100,000 over 5 years. This figure undoubtedly seriously underestimates the frequency of compulsive hoarding. Many with this problem have never had a public complaint filed against them. Using figures from studies of OCD in which hoarding co-occurred in approximately 25% of cases and the OCD lifetime prevalence rate is estimated at 1-2%. This is a rough estimate of how lifetime hoarding frequency would be 4 per 1000. This is an underestimate since this figure includes only those with an OCD diagnosis.
Existing case reports suggest that compulsive hoarding runs a chronic and unchanging course. Greenberg (1987) suggested that onset occurred in the early 20s. A study of 32 "pack rats or chronic savers" from the community (aged 17 to 73) indicated that age of onset for saving occurred most often in childhood or early adolescence (Frost & Gross, 1993). Samuels et al. (2002) reported that among a group of OCD patients whose symptoms included hoarding, onset of OCD symptoms occurred at age 10. It is not clear whether hoarding symptoms began then. A recent study of retrospective assessment of onset and course using a timeline to facilitate accurate recall indicates that mild levels of hoarding symptoms began around age 18. They did not achieve moderate levels until 8 years later (Grisham, Frost, Steketee, Kim, & Hood, 2003). Extreme levels of hoarding typically occurred a decade later at about age 35. Acquisition problems had slightly later onset than clutter or difficulty discarding. The course of symptoms tended to be chronic, with few individuals reporting improvement between onset and the development of extreme symptoms. However the degree of variability over time was unclear.
With regard to familial features, Frost and Gross (1993) noted that more than three-quarters of a community sample of hoarders reported having at least one "pack rat" among first degree relatives. Other studies have Sfound higher frequencies of hoarding in the families of people who hoard (Samuels et al., 2002; Winsberg et al., 1999). These findings suggest that it may be important to determine whether some features that lead to compulsive saving are transmitted genetically. One striking finding from several studies is the low rate of marriage among compulsive hoarders from community and clinical samples (e.g., Frost & Gross, 1993; Samuels et al., 2002; Steketee et al., 2001). This is consistent with Fromm's (1947) description of those with a "hoarding orientation" as withdrawn and remote from others. This may relate to findings of greater social anxiety and schizotypy among compulsive hoarders (Frost et al., 2000b; Samuels et al., 2002; Steketee et al., 2000).
Limited recognition (insight) of the severity and impairment caused by hoarding behavior is a problem that is particularly troublesome for family members and service providers (Frost, Steketee, Youngren, & Mallya, 1999). Research and case reports indicate that many do not consider their hoarding behavior unreasonable (e.g., Frost & Gross, 1993; Frost et al., 2000a; Hogstel, 1993; Thomas, 1997). Evidence of limited insight is found in lower ratings of insight on the Y-BOCS compared to non-hoarders (Frost et al., 1996). The delayed recognition of a hoarding problem at least a decade after onset is common (Grisham et al., 2003). Social service providers reported that most elderly clients with serious hoarding showed little insight into their problem. This wasS despite the absence of observable cognitive impairment, and that this interfered with provision of needed services to address clutter and health-related complications (Steketee et al., 2001). Despite the general consensus that hoarding is often accompanied by poor insight, research using more detailed standardized measures of insight is needed.
Model of Compulsive Hoarding
According to a cognitive behavioral model of compulsive hoarding, the manifestations of hoarding (acquisition, saving, clutter) result from basic deficits or problems. These are in (a) information processing, (b) beliefs about and attachments to possessions, and (c) emotional distress and avoidance behaviors that develop as a result (Frost & Hartl, 1996; Frost & Steketee, 1998; Hartl & Frost, 1999; Steketee et al., 2000).
Information processing deficits. The cognitive processing problems thought to be associated with hoarding include attention, categorization, memory, and the use of information to draw conclusions and make decisions. A series of studies have provided evidence supporting these hypotheses. Anecdotal observations during individual and group treatments (e.g., Steketee et al., 2000) suggest difficulties staying focused on sorting tasks. this occurs even when the therapist is present. Some empirical support comes from Duffany, Hartl, Allen, Steketee and Frost's (2003) study comparing members of a clutter self-help group who exhibited problems with acquisition, discarding and clutter to a community control sample on measures of attentional focus and cognitive failure (Duffany et al., 2003). The hoarding group had significantly higher scores on measures of adult attention deficit hyperactivity disorder (ADHD), childhood symptoms of ADHD, and current cognitive failures in perception, memory and motor function. These findings help explain organizing problems and clutter observed in hoarding. But better laboratory tests of attentional capacity are needed to confirm these hypotheses.
People with hoarding problems suffer from an underinclusive cognitive style with respect to categorization. That is, each possession must be set apart to reflect its special importance. Such a style obviously complicates the organizing of possessions because of too many categories. To study this issue, Wincze, Steketee and Frost (2001) compared 21 hoarders, 21 OCD non-hoarders, and 21 non-psychiatric controls on three categorization tasks. In a classification task involving a variety of ordinary objects, hoarders took significantly more time, created more piles, and reported more anxiety than non-psychiatric controls. They took more time than OCD controls but only for the classification of personal possessions. This suggests that classifying personal objects may be especially problematic for those with hoarding.
With regard to possible memory deficits, Hartl et al. (2001) examined memory performance, memory confidence and memory beliefs in severe hoarders compared to non-clinical controls matched for age, gender and handedness. People with problematic hoarding recalled less information on delayed recall in the Rey-Osterrieth Complex Figure Test (RCFT) and the California Verbal Learning Test (CVLT). They used less effective organizational strategies on the RCFT. Hoarders also reported significantly less confidence in their memory, more concern about the catastrophic consequences of forgetting, and a stronger desire to keep possessions in sight so they would not be forgotten. Differences in confidence in memory were not accounted for by differences in actual memory performance. In previous research, OCD patients showed problems with encoding and organizational strategies that mediate their nonverbal memory impairment (Savage et al., 1999). Decision making problems have also been observed in hoarding samples, but only on self-report measures (Frost & Gross, 1993; Frost & Shows, 1993; Steketee et al., in press). These findings are suggestive and call for more detailed analyses of attention, memory, categorization and decision making using laboratory and experimental procedures. While the information-processing deficits appear to be characteristic of people with hoarding problems, we suspect they are most closely associated with clutter and disorganization rather than acquisition or difficulty discarding. To date no research has been conducted to determine whether this is true.
Beliefs about and emotional attachment to possessions. Prominent among the phenomena associated with compulsive hoarding is the remarkable attachment to possessions. Although DSM-IV specifies that in OCPD items are kept for nonsentimental reasons, findings from a number of investigations make clear that hoarding is associated with strong emotional responses to possessions (Cermele, Melendez-Pallitto, & Pandina, 2001; Frost & Gross, 1993; Frost et al., 1995). These certain beliefs about possessions are hypothesized to lead some individuals to acquire or save indiscriminately to avoid emotional upset and/or prevent negative outcomes (Frost & Hartl, 1996; Frost & Steketee, 1998).
Steketee et al. (in press) used a self-report scale to identify four cognitive/emotional features that characterize the experience of attempting to discard possessions. They are emotional attachment, memory-related concerns, desire for control, and responsibility. Emotional attachment to possessions encompasses beliefs about the emotional comfort provided by objects, fears of losing something important, and feelings of loss of self or identity. Memory related concerns refers to beliefs that possessions are needed as reminders. Desire for control over possessions reflects a wish to restrict others from touching, borrowing or moving one's possessions. Responsibility refers to the sense of proprietary obligation toward possessions and people who may need them. These constructs are closely associated with hoarding behavior, even after controlling for other psychopathology.
In a laboratory study to identify beliefs associated with hoarding, student and clinical hoarding participants imagined they had purchased a newspaper. They kept it for a week, and read some but not all of it (Frost et al., 1998). In deciding whether to keep the newspaper, subjects rated the likelihood of 18 thoughts. Half of these were about reasons to save it (e.g., losing something important) and half about reasons to discard it (e.g., reduce clutter). Both the student and clinical samples endorsed more reasons to save than to discard. This suggests that an information bias during decision-making favors considering the benefits of saving and the costs of discarding but not the reverse. A further experimental study (Kim, Frost, Steketee, Tarkoff, & Hood, 2003) examined the emotional responses of students and a clinical sample of compulsive hoarders. This study examined receiving and keeping a small object (key chain) for one week. In both groups, those with significant hoarding symptoms showed stronger and more durable emotional attachment to the object than non-hoarders.
Resistance to treatment and poor treatment response appear to be closely tied to beliefs and emotional attachments to possessions (Frost & Steketee, 1999). It is unlikely that effective treatments will be developed without first understanding these phenomena. The affective attachment to possessions is related to elevated levels of depression and anxiety observed among people with hoarding problems (Coles, Frost, Heimberg, & Steketee, 2003; Frost et al., 2000). Perhaps also found related to positive emotions, among compulsive buyers (Christensen et al., 1994). The next steps are to examine how these beliefs and attachments pertain to acquisition, difficulty discarding, and clutter. This is to determine which beliefs influence actual discarding and attempts to resist acquiring possessions. Careful study of these features will provide important avenues for designing treatment interventions.
Distress and avoidance. We have hypothesized that information processing problems, beliefs and attachments to possessions cause people to experience distress at the thought of not acquiring or discarding a possession. This leads them to avoid these behaviors. Some investigators have suggested that hoarding differs from other OCD symptoms. Obsessive thoughts and distress do not drive the compulsive behavior (Black et al., 1998; Miguel et al., 1997; Seedat & Stein, 2002). Hoarding beliefs and emotional attachments play a role similar to obsessive thoughts. They only occur in certain circumstances (i.e., they are not intrusive as are obsessions) and are not experienced as nonsensical. These thoughts occur upon seeing or imagining an item not yet owned but deemed valuable (compulsive acquisition) and upon considering removing a possession. Compulsive acquisition and hoarding are conceptualized as avoidance behaviors. This is to avoid feelings of anxiety and grief/loss (see below) provoked by these thoughts and beliefs.
Avoidance behaviors extend to avoiding making decisions about possessions. We have observed many situations in which people do not tolerate the distress associated with making a decision about a possession. This involves (e.g., where to put it, whether it was needed), presumably produced by information-processing problems and beliefs (e.g., making a mistake, being unable to find it again), and avoided the problem by setting it aside. Experimental research clarifying this aspect of hoarding will help in developing appropriate treatments.
A further difference between hoarding and other forms of OCD are in the nature of the emotions experienced. While compulsive hoarding is associated with considerable anxiety (Frost et al., 2000b), many people report grief like feelings of loss in response to discarding or not acquiring possessions (Frost & Hartl, 1996; Frost & Steketee, 1998). This type of emotional response accords with the intense initial attachments to possessions (positive emotions) experienced during the acquiring process (Kim et al., 2003). Only one study has studied processes during actual discarding in a sample of compulsive hoarding participants (Frost et al., 1998). To understand the nature of the thoughts, beliefs, emotions and avoidance behaviors associated with hoarding, more detailed experimental studies are needed.
Assessment
Many studies of hoarding have relied on the two Y-BOCS checklist items. This pertains to hoarding obsessions and hoarding compulsions (Baer, 1994; Calamari, Wiegartz, & Janeck, 1999; Leckman et al., 1997; Mataix-Cols et al., 1999; Summerfeldt et al., 1999). The usefulness of these items is questionable. It is not clear how a hoarding obsession is defined. Especially since hoarding thoughts/beliefs appear to be different from typical obsessions. There are no established criteria for determining the presence or absence of hoarding obsessions or compulsions. Hoarding severity ranges from mild to severe. Exactly when hoarding is present is unclear, especially given the ego-syntonic nature of the symptoms for many people. The two checklist items do not capture the multiple facets of hoarding behavior. This includes acquisition, clutter and difficulty discarding.
The hoarding subscale of the Obsessive Compulsive Inventory improves upon the YBOCS items (OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998) but has flaws. While the other six subscales of the OCI showed good discriminate validity, the three-item hoarding subscale did not. This leads the authors to conclude that "the hoarding items do not adequately distinguish pathological hoarding from ordinary collecting, and this subscale requires revision" (p. 212). A recent study showed the OCI hoarding subscale correlated moderately with the Saving Inventory-Revised (see below). Correlations were slightly higher than those for the other OCI subscales (Coles et al., 2003).
Frost and Gross (1993) reported the first attempt to measure hoarding systematically using a 22 item self report hoarding scale, later expanded to 24 items (Frost et al., 1998). It assessed a range of symptoms (discarding, emotions, decision making, sentimental attachments). It had excellent internal reliability and demonstrated construct, convergent, discriminant and known-groups validity (Frost et al., 2000b). This measure was sensitive to non pathological levels of hoarding (Frost & Gross, 1993). It correlated with predicted variables in student, community, and clinical samples (Frost et al., 1995; 1996; 1998). It had several flaws, including the lack of items about acquisition, the confounding of beliefs with behavioral symptoms, overly specific items with limited relevance, and inadequate assessment of severe symptoms associated with clinically significant pathology.
Two measures have been developed and tested more recently to assess separately the severity of hoarding symptoms. It is based on the formal definition and the cognitive and emotional aspects of the problem. The Saving Inventory-Revised (SI-R; Frost et al., in press) used five-point anchored scales, initially for 26 items. They were later reduced to 23 items following factor analysis based on a moderately large sample of people suffering from compulsive hoarding. Observed factors matched hypothesized domains of hoarding behavior. They were compulsive acquisition, difficulty discarding, and cluttered living spaces. Factor analysis in a large student sample generated the same three factors. There was a weaker one reflecting distress and interference (Coles et al., 2003). The three subscales demonstrated good internal and test-retest reliability (Frost et al., 2003). This included significantly discriminated OCD patients with and without hoarding symptoms, as well as clinical samples from community controls. Convergent validity was evident in the higher correlations of subscale scores with hoarding beliefs than with measures of mood or other OCD symptoms. The observer ratings of clutter during a home visit were highly correlated with SI-R subscales, especially clutter. The SI-R appears to be a reliable and valid self-report measure of hoarding symptoms that improves substantially upon other scales.
The 24-item Saving Cognitions Inventory (SCI; Steketee et al., in press) measures hoarding beliefs and emotional reactions. Factor analysis of this scale yielded four dimensions labeled emotional attachment, memory concerns, desire for control and responsibility for possessions. Subscales derived from these factors showed good internal consistency, known groups validity, and convergent and discriminant validity. Three of the four SCI scales independently predicted hoarding symptoms after controlling for age, moodstate, OCD symptoms, and other OCD related cognitive variables.
These self report measures are important advances. The interview-based assessment strategies are essential to render the diagnostic process comparable to that of other psychiatric disorders (DiNardo et al., 1994). It provides multiple methods of assessment. Our home visits have revealed a tendency among self-identified compulsive hoarders to incorrectly estimate the severity of their symptoms. Some have underestimated and others overestimated symptom severity (Steketee, de Nobel, & Frost, 2002). This raises serious concern about the validity of self report and interview measures. This calls for additional observational or pictorial assessment strategies that we have begun to implement.
Treatments for Hoarding
Existing treatments demonstrated effective for OCD have shown little benefit for compulsive hoarding. Several suggestions have been offered to explain this phenomenon. Ball, Baer and Otto (1996) concluded that hoarding patients are under represented in the treatment outcome literature. This is in part because they frequently refuse treatment. This may be due to poor insight, making development of effective treatments difficult. Baer (1994) noted that patients with hoarding behaviors were more difficult to treat because they did not habituate easily to exposure. Kozak and Foa (1997) suggested that hoarders display perfectionistic behaviors and magical ideas about discarding. This interferes with usual behavioral treatments for OCD. Most reports agree that treatment of hoarding is problematic. A review of published findings is given below. It explains reasons for failure and examination of interventions that have produced promising outcomes.
Case Studies
In contrast to the usual pattern of case studies reporting successful outcomes with new treatment methods, hoarding case reports provides negative predictions about treatment refusal and poor outcome. Poor insight, the absence of resistance to hoarding behavior, treatment refusal or drop out, and lack of cooperation during treatment were evident in 15 cases described in the literature (Damecour & Charron, 1998; Fitzgerald, 1997; Greenberg, 1987; Greenberg et al., 1990). Two cases reported by Vostanis and Dean (1992) displayed an absence of concern about hoarding behavior accompanied by gross self-neglect. Failure characterized case reports of hoarding clients who actively sought treatment and received behavior therapy (Shafran & Tallis, 1996). Especially those with symptoms of self-neglect (Drummond, Turner, & Reid, 1996). These reports did not include detailed outcome assessments. However, the uniformity of the negative outcomes with regard to motivation and benefits from usual treatments is remarkable.
Medication and Combined Treatment Trials
In research studies with larger samples, medication and combination treatments have fared poorly in ameliorating compulsive hoarding. Black et al. (1998) treated 38 non-depressed OCD patients. 17 of whom had hoarding problems, with paroxetine (n=20), cognitive behavior therapy (CBT) for OCD (n=10), or placebo (n=8). Only 18% of those who reported hoarding symptoms on the Y-BOCS checklist, responded to treatment. This was compared to a 67% response rate among non-hoarders. They concluded that the presence of hoarding symptoms predicted a poor treatment response. How many of those with hoarding symptoms received the three types of treatments was not reported. Black (personal communication, 2002) has indicated that these were distributed approximately evenly among hoarders and non-hoarders. This suggests that both medications and CBT were ineffective.
Mataix-Cols et al. (1999) reported similar findings using a somewhat different methodology for 150 OCD patients treated with serotonergic reuptake inhibitors (SRIs). This was across six placebo-controlled medication trials. They sought to determine whether symptom features based on a factor analysis of the Y-BOCS checklist predicted outcomes on the Y-BOCS and the NIMH OC scale after controlling for baseline severity. Only the hoarding symptom dimension was associated with negative outcomes. This accounted for 36% of the variance in Y-BOCS outcomes. And 18% for NIMH OC scale scores. Like Black and colleagues, Mataix-Cols et al. concluded that hoarding predicted poorer response to SRIs and required alternative treatments.
Mataix-Cols et al. (2002) examined predictors of compliance and response to behavior therapy and relaxation treatments for 153 randomized OCD participants. Patients received computer-guided exposure and response prevention (BT-Steps, n = 45), a similar treatment guided by a therapist (n = 48) or audio-taped relaxation instructions (n = 60). Hoarding compulsions were over-represented in the sample due to a media broadcast at the time of recruitment. Of the 52 participants who scored high on the hoarding factor, 27% dropped out prematurely. This compared to only 12% of those without hoarding symptoms. A regression analysis confirmed that high scores on hoarding significantly predicted early discontinuation. Hoarding tended to predict poorer response to these treatments among the 78 patients who completed at least one session. Of 20 patients with hoarding symptoms, only 25% responded with at least a 40% gain on Y-BOCS scores compared to 48% of those without hoarding (p=.10). The percentage of goals completed for three consecutive exposure sessions in the BT steps treatment was 0% for hoarding. This was compared to 39% for cleaning rituals and 19% for checking rituals. In describing the BT-Steps program, Christensen and Greist's (2001) concluded that compulsive hoarders displayed poor insight, low motivation, and passive resistance to treatment. She noted that many of these patients were pressured into treatment by significant others.
Winsberg et al. (1999) observed disappointing outcomes following SSRI treatments. This sometimes accompanied CBT, in a detailed report of 20 patients with hoarding symptoms. Seven of these people were also diagnosed with compulsive buying. All patients also had other OCD symptoms. Because of this, some of the improvement on the Y-BOCS (see below) may have been due to changes in other non-hoarding OCD symptoms. Of 18 patients who received adequate trials of SSRI treatments, often several trials, 50% improved by at least 25% on the Y-BOCS. But only one patient showed a marked response. Mean Y-BOCS scores for the sample was reduced from 24.8 to 17.6 at the time of the interview, a moderate change of 7.2 points. Nine of the 20 patients (eight of them also on SRIs) received a CBT intervention. These patients were treated with 10 to 30 half-hour sessions held weekly or every other week. Outcomes specifically due to CBT could not be determined. Thiswas due to its non-standardized format and accompanying medications. These nine patients benefited somewhat more than for those treated with medications alone. Three improved markedly and six showed partial benefits. None were rated as having little change as occurred frequently after SRI trials.
The studies described indicate that poor outcome for hoarding was common for both serotonergic medications and behavioral treatments. An exception is evident in unpublished findings by Abramowitz, Franklin and Foa (2001). They examined the effects of treatment by standard exposure and response prevention on subtypes of OCD symptoms. In contrast to other reports, they did not find worse outcomes for their 13 patients with hoarding problems compared to those with other types of symptoms. This was due to the intensive nature of the behavioral intervention given daily over a period of three weeks. The use of the Y-BOCS to assess treatment gains obscures specific outcomes for hoarding symptoms in patients who have other OCD complaints.
Treatments based on the Cognitive Behavioral Model of Compulsive Hoarding
Treatments based on the cognitive behavioral model of compulsive hoarding described above (Frost & Hartl, 1996; Frost & Steketee, 1998) have fared somewhat better. But evidence is still scant. Hartl and Frost (1999) applied a treatment based on this model. It was a single case experimental design with a 53-year-old woman with a long standing hoarding problem exacerbated by contamination fears. Her treatment exemplifies specialized CBT for hoarding behavior used in subsequent studies. This client had failed to benefit from serotonergic medication. Also attempts to clean the house herself by taking time off from work and hiring a helper failed. Therapy consisted of training in decision making and categorizing possessions, exposure to discarding, and cognitive restructuring. These three components were combined in weekly two-hour "decluttering" sessions. This was followed by detailed homework assignments to practice techniques. The client made all decisions about the placement and disposition (save or discard) of her possessions. The two therapists who visited her home avoided making decisions for her or touching any of her things unless given explicit permission. Their role was to assist in the development of decision-making skills. They provided feedback regarding normal saving behaviors, and helped her identify and challenge distorted thinking.
Treatment progressed room by room. As the client selected a specific target area, she decided what type of possession to sort first, and determined item disposition (recycle, discard, save, store for later review). She determined the final location for all saved items. More emphasis was placed on decision-making and organizing possessions than on discarding them. The client developed a comprehensive filing system to practice categorizing skills. This improved access to important papers. She was exposed to making decisions, to emotional distress at discarding, and to putting things out of sight (provoking fears about memory and loss). During the process, she reported her thoughts and feelings to facilitate examination and restructuring of hoarding beliefs during exposure.
Treatment outcome was assessed with self-report measures of hoarding, decision making and OCD symptoms. A multiple baseline design served to evaluate reduction of clutter. This was based on a ratio of cluttered space to total surface area for floors and furniture. After 24 sessions during nine months, hoarding symptoms decreased by 24%, indecisiveness by 18% and non-hoarding OCD symptoms (contamination) by 31%. After 18 months clutter ratios in all targeted rooms reduced from .54 before treatment to .02 after treatment. This was for floor clutter and from .85 to .05 for furniture clutter. The clutter was entirely eliminated in the targeted rooms. Whereas the clutter ratio in a control room (untreated) remained unchanged throughout the study. Thus, targeting specific hoarding deficits was successful. The benefits occurred despite the presence of contamination fears and cleaning rituals. Although these complicated her efforts, they did not prevent progress. She improved as her hoarding behavior decreased. The fluctuation in the client's level of motivation and compliance with homework assignments proved a recurrent problem. Especially later in treatment, and may have been responsible for the lengthy labor-intensive treatment.
Frost and Hunt (2000) applied an updated version of this hoarding treatment protocol to a 63 year old woman who lived in a three family home. She had filled all three apartments. She was highly motivated to achieve a goal of selling her home. Treatment focused on the apartment in which she lived. A much shorter 12 week treatment relied on pictures of the rooms in her home. They were used to structure the organizing and discarding homework. During individual sessions, the client and therapist identified objects in the pictures. They recorded whether they should be saved or discarded and where each item should be placed during homework. Post-treatment photographs reflected a substantial reduction in clutter. An independent observer rated pictures on usability, navigation, and organization using five point scale. Improvement was evident in these areas, as well as in self-rated acquisition (67% improvement) and clutter (33% improvement). Gains persisted for three months at which time the client cleared and sold her home, achieving her main therapeutic goal.
In a third case, Cermele et al. (2001) employed similar methods in an intensive format to treat a 72 year old woman with a 10 year history of hoarding. This was due in part to compulsive buying of "bargains" and inability to discard items because of emotional attachments and feelings of loss. Treatment meant establishing a trusting relationship and detailed planning for an intensive "dehoarding" intervention. This was done with a team of three therapists and a case manager. A 52% reduction in clutter was achieved. After a one-day program, the client was able to continue working on the remaining clutter with assistance from her case manager. Gains were sustained at the six month follow up. These case studies indicate that the amount of time and preparation needed to accomplish substantial reduction of clutter ranges widely with individuals with hoarding problems. In contrast to case studies reported earlier in which most clients refused, dropped out or failed to benefit. The treatments described in these three cases were carefully planned and scheduled. This included a variety of strategies directly focused on hoarding symptoms.
Only two other studies, both uncontrolled, have described larger scale treatment efforts. Steketee, Frost, Wincze, Greene, and Douglass (2000) reported positive but modest outcomes. This was after 15 sessions of treatment during 20 weeks for seven clients with hoarding problems. Six clients were treated with group therapy plus individual home visits and one received individual home visits using a revised version of the CBT applied by Hartl and Frost (1999). Five clients were taking SSRI's but had experienced no relief of their hoarding symptoms. None had received prior behavior therapy. Mean scores on a Y-BOCS scale modified to assess only hoarding showed modest improvement from 22.3 at pretest to 18.7 (16% improvement) after 15 sessions. On self-ratings, excessive acquisition showed the most improvement (47%), followed by increased recognition of irrational reasons for saving (37%), organization (31%) and decision making (30%). Slowest to improve was clutter (18%). For three clients who continued to receive individual treatment twice monthly for a full year, Y-BOCS hoarding scores decreased from 20.2 to 14.7 (27%). Improvement in self-rated target symptoms was also greater for continuers: 66% for acquisition; 58% for recognition of irrational reasons for saving; 52% for organization; 48% for decision making; and 30% for clutter. Motivation problems may have limited the effectiveness of the treatment protocol.
Using similar procedures, Saxena et al. (2002) reported significant improvement in a sample of 20 OCD patients. They described compulsive hoarding as their primary symptom. Along with a large group of 170 OCD patients without hoarding problems, the hoarding patients received a six-week daily multimodal therapy. It included SSRI medications, CBT and psychosocial rehabilitation in a partial hospitalization program. Treatment based on Hartl and Frost's (1999) model included goal setting, education, developing a hierarchy for target areas, exposure and cognitive restructuring, responsibility, doubts about memory, and emotional attachment. Medications included SRIs and augmentation drugs in some cases. Y-BOCS scores reduced from means of 30.4 at pretest to 19.9 after treatment. The 10.6 point reduction for hoarders was less than the 13.4 point improvement for non-hoarders (p<.02). This was nonetheless impressive in light of the poor response reported in previous studies of medication outcomes. Substantial improvement in mood and functioning was comparable for hoarding and non-hoarding patients. This study confirmed that hoarders responded less well to medication and psychological treatment than patients with other types of OCD symptoms. Together with the Steketee et al. study, it suggests that CBT methods targeted specifically at hoarding behavior can lead to substantial change.
These research findings suggest that serotonergic medications and behavior therapy via E&RP are less helpful for hoarding symptoms than for other types of OCD symptoms. Medications have not been formally tested among those with primary hoarding problems (for example, by random assignment to medication and placebo). Likewise, studies of CBT methods are uncontrolled. Thus, firm conclusions about either type of intervention are premature. The limited utility of SSRIs and psychotherapy in several investigations argues for the need to study alternative treatments. CBT designed to address idiosyncratic problems associated with compulsive hoarding appears to be a promising alternative. A weakness in the existing studies is that measures of outcome were not specific to hoarding symptoms. It is therefore difficult to know how much gain was due to improvement in non-hoarding OCD symptoms. Reliable and accurate measures of clutter, acquiring behavior, and difficulty discarding are needed to clarify the true effectiveness of hoarding treatments. Formal tests with large samples of clients recruited for hoarding as their primary problem, regardless of OCD symptoms, are needed to determine the effects of specialized CBT for hoarding symptoms.
Treatment of Compulsive Buying
Since compulsive acquisition is an integral part of the hoarding syndrome, studies of treatments for compulsive buying have relevance for compulsive hoarding. Few studies exist. McElroy and colleagues (1991) reported on three cases of compulsive shopping treated with fluoxetine, buproprion or nortriptyline. All demonstrated partial or complete remission of urges to shop in response to these medications. Koran, Bullock, Hartston, Elliott, and D'Andrea (2002) found a 71% response rate in an intent-to-treat sample of 24 compulsive buyers using citalopram. Black, Monahan, and Gabel (1997) reported success with fluvoxamine. In two recent placebo controlled studies, neither Ninan et al. (2000) nor Black, Gabel, Hansen, and Schlosser (2000) found fluvoxamine more effective than the placebo. Thus, the medications tried so far for buying behavior have shown little or uncertain promise.
No studies of the effects of psychotherapy have been published. McElroy et al (1994) reported that only nine patients in their sample of 20 compulsive buyers reported having received supportive or insight-oriented therapy for the problem. Of nine, only two experienced any benefit from the treatment. Research by Steketee et al. (2000) indicated that CBT interventions similar to those described by Lejoyeux et al. (1996) and Bernik et al. (1996) directed at compulsive acquiring were moderately effective in reducing acquisition and buying behaviors. Ongoing efforts to identify cognitive behavioral strategies for treating compulsive buying are underway. They use methods similar to the ones we have piloted for acquisition problems in compulsive hoarding (Brazer, 2000; Burgard & Mitchell, 2000). Perhaps specialized components of treatments for acquisition in compulsive hoarding will prove applicable to compulsive buying.
Addressing Insight and Motivational Problems in Compulsive Hoarding
Several researchers have noted the lack of insight and ego-syntonic nature of hoarding symptoms and the resulting resistance to treatment (Christensen & Greist, 2001; Steketee et al., 2001). Ball et al. (1996) suggested that people with hoarding symptoms have a greater tendency to refuse or drop out of treatment. Mataix-Cols et al. (2002) provided supporting evidence that hoarding patients were more likely to terminate treatment prematurely compared to OCD patients without hoarding problems. Communication with health department officials (Frost et al., 2000a) suggests that many people with hoarding problems refuse treatment unless pressured to do so (see also Steketee et al., 2000).
Even during treatment, motivation levels among people with hoarding problems is low. In a successful treatment of hoarding, Hartl and Frost (1999) noted the waxing and waning of motivation to work on the problem. Steketee et al. (2000) reported difficulty getting clients to complete homework assignments. Christensen and Greist (2001) described passive resistance to treatment among hoarding clients who expressed an intention to work on their problem. They made little real effort to do so. The compelling conclusion from these and other accounts (see Frost & Steketee, 1998, 1999) is that motivation for change in this population is ambivalent at best. Research on the use of motivational interviewing for hoarding problems using Miller and Rollnick's (2002) methods seems warranted. Particularly in view of Maltby, Tolin and Diefenbach's (2002) successful use of these methods for OCD. We are presently engaged in developing and testing such procedures in treatments for hoarding behaviors.
Future Directions
Research on compulsive hoarding has increased substantially in recent years Still it remains a nascent field with much research to be done. Among these are the need to establish the diagnostic status of compulsive hoarding with regard to seemingly related conditions. These are OCD, attention-deficit disorders, impulse control disorders and perhaps also psychosis and dementia. This is in view of the limited insight and sometimes severe manifestations of hoarding in conjunction with squalor. Research on large samples is needed to determine common comorbid conditions (these are social phobia, major depression) and personality features and their effects on hoarding symptoms and severity. In the course of this research accurate methods of assessment of the disorder are extremely important. These must be multimodal and preferably based on visual inspection, given the observable behavioral effects of hoarding. Ideally, this would include diagnostic interview methods, self report, behavioral observation in the home (or other relevant sites), standardized photographic methods, and family members' report when available. Although self report methods have shown promise (Frost, Steketee, & Grisham, in press), much work remains to be done regarding standardizing and testing other methods.
Research on the psychopathology of hoarding has helped define the components of this problem. Yet, little is known about age and reasons for onset, family history, course of this disorder, and insight into the problem. Only a limited number of laboratory studies have been conducted examining cognitive, emotional, and behavioral features of compulsive hoarding. We recommend study of behavior and reported thoughts and emotions during actual discarding and non-acquiring tasks. Neuropsychological laboratory tasks should be implemented to study information-processing features such as attention, memory, and cognitive integration hypothesized to be central to the problem of hoarding.
Determining the best methods of treatment for hoarding is a compelling need. Modest success has been achieved with the use of specialized interventions based directly on a model of the psychopathology of compulsive hoarding (see Frost & Steketee, 1998; 1999; Frost, Steketee, & Greene, in press). These include comprehensive assessment, education, practice in decision making and organizing, exposure to non-acquisition and discarding, and cognitive restructuring. These are directed at the major manifestations of hoarding: disorganization, compulsive acquisition, and difficulty discarding. We recommend including motivational treatments and relapse prevention methods to consolidate gains over time. It appears that after motivational problems are addressed, treatment should focus first on organizing, rather than discarding. This is to avoid asking clients to discard valued possessions before adequate trust in the therapist and confidence in treatment benefits are developed. Compulsive acquisition requires cognitive restructuring and exposure techniques to help clients gain control over acquisition problems. Difficulty discarding can be addressed via cognitive interventions to reduce problematic beliefs and systematic exposures. Future research should test this comprehensive intervention program in relation to control and comparison treatments, and examine potential predictors of outcome.
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