Refining the diagnostic boundaries of compulsive hoarding: A critical review

doi:10.1016/j.cpr.2010.01.007

Clinical Psychology Review

Volume 30, Issue 4, June 2010, Pages 371-386

https://doi.org/10.1016/j.cpr.2010.01.007 Get rights and content

Abstract

Like most human behaviors, saving and collecting possessions can range from totally normal and adaptive to excessive or pathological. Hoarding, or compulsive hoarding, are some of the more commonly used terms to refer to this excessive form of collectionism. Hoarding is highly prevalent and, when severe, it is associated with substantial functional disability and represents a great burden for the sufferers, their families, and society in general. It is generally considered difficult to treat. Hoarding can occur in the context of a variety of neurological and psychiatric conditions. Although it has frequently been considered a symptom (or symptom dimension) of obsessive–compulsive disorder, and is listed as one of the diagnostic criteria for obsessive–compulsive personality disorder, its diagnostic boundaries are still a matter of debate. Recent data suggest that compulsive hoarding can also be a standalone problem. Growing evidence from epidemiological, phenomenological, neurobiological, and treatment studies suggests that compulsive hoarding may be best classified as a discrete disorder with its own diagnostic criteria.

Section snippets

Phenomenology

The hallmark of hoarding is the difficulty discarding or letting go of possessions. Close inspection of the nature of items collected has revealed that hoarding individuals collect and save many different kinds of items, often filling their homes with recently purchased items that never leave their original packaging. Such objects are often mixed with trash and are frequently mistaken as worthless. For most hoarding individuals, the nature of the items saved and the reasons they give for doing

Epidemiology

Recent studies suggest that hoarding is much more frequent in the population than previously thought (see Table 1). In the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of US adults, 14% of participants had lifetime prevalence of hoarding symptoms (Ruscio, Stein, Chiu, & Kessler, 2008). However, the parallel European study, which used a similar instrument to the NCS-R (see footnote in Table 1), found a much lower lifetime prevalence of hoarding (2.6%).

Assessment of compulsive hoarding

Measures of hoarding have evolved with the changing understanding of the hoarding phenomenon. The earliest measure, the Y-BOCS Symptom Checklist (Goodman et al., 1989), contains two relevant items — hoarding obsessions and compulsions. Unfortunately, these items convey no information about the dimensions of hoarding or about their severity. At best, the Y-BOCS Symptom Checklist items are an indicator of hoarding. The Dimensional Yale-Brown Obsessive Compulsive Scale (Rosario-Campos et al., 2006

Pharmacological treatment

Studies assessing the efficacy of serotonin reuptake inhibitors (SRIs) in OCD patients with compulsive hoarding symptoms have produced mixed results (see Table 2). Although some studies have found that OCD patients with hoarding symptoms respond worse to SRIs than nonhoarding OCD patients (e.g., Black et al., 1998, Mataix-Cols et al., 1999, Salomoni et al., 2009, Stein et al., 2008, Winsberg et al., 1999), others found no differences between these groups (e.g., Alonso et al., 2001, Erzegovesi

Discussion

Clinically significant compulsive hoarding occurs in up to 5% of the population, twice the rate of OCD and almost four times the rate of disorders such as bipolar disorder and schizophrenia, and can vary from mild to life threatening. The personal and pubic health consequences of compulsive hoarding are substantial and it is generally considered difficult to treat. Much remains to be done in order to understand the causes and develop cost-effective interventions for this problem. In our view, a

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Benefits of Planning as an emotion regulation strategy in obsessions and compulsions (OC): Implication of the perfectionism level in the Planning-OC relationship
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Obsessions and compulsions are characteristics of obsessive and compulsive (OC) disorders and are present to various extents in the population. Such symptoms were associated with difficulties in regulating the emotions triggered by the obsessions, which induce compulsions and use of maladaptive emotion regulation (ER) strategies. The present work gives an overview of the use of different ER strategies in all-comers presenting various levels of OC symptoms, with a focus onto the benefits of “Planning”, an adaptive ER strategy that shares common backgrounds with several obsessions, such as perfectionism, which was also explored. University students (N = 248) completed online questionnaires. The findings confirmed a positive relationship between OC symptoms and difficulties in ER and use of maladaptive ER strategies. Planning was negatively correlated with OC symptoms while perfectionism was positively associated with both OC symptoms and the use of Planning, which lowers the beneficial prospects of Planning implementation in sub-clinical obsessive-compulsive disorders (OCD). Hoarding not being associated with perfectionism, this particular symptom could however directly benefit from Planning. Altogether, this study highlights the importance of considering individualities in the efficiency of different ER strategies and provides potential benefits of Planning, a strategy that is likely to help alleviating OC symptoms, and particularly that of hoarding.
Early life stress in adults with hoarding disorder: A mixed methods study
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Traumatic life events are common among individuals with hoarding disorder (HD), though rates of posttraumatic stress disorder are no higher than in other groups. HD symptoms typically begin to appear in mid-childhood, and early life stress (ELS) is a known associated feature of negative mental health outcomes. The specifics of this relationship are still unclear.
We obtained Early Life Stress Questionnaire (ELSQ) responses from 35 participants with HD, 22 participants with obsessive-compulsive disorder (OCD), and 23 non-clinical control participants. We combined these quantitative data with qualitative interviews exploring what role ELS experiences play in HD.
Per the ELSQ, individuals with HD reported significantly more ELS events than the non-clinical control participants. In qualitative interviews, HD participants described the ELS events that were most impactful in shaping their relationship to material possessions; these events tended to be long in duration and elicited feelings of scarcity of emotional support. Participants described relying on possessions in place of relationships and viewed possessions as potential sources of connection to peers.
Our qualitative and quantitative results build on the cognitive behavioral model of HD, emphasizing early experiences of prolonged stress or scarcity of emotional support as a key contributing vulnerability factor. Specific differences are consistent with earlier research that people with HD experience absence of early warmth. They further suggest that screening for ELS experiences is important when working with individuals with HD, and that HD treatments may benefit from increased focus on social and emotional connection building.
Hoarding
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Hoarding disorder (HD) is considered an obsessive–compulsive spectrum disorder with key features of difficulty parting with possessions due to strong urges to save and/or distress about discarding. The saving leads to substantial clutter in the home that prevents use of spaces for their intended purpose and leads to impairment in functioning. Acquiring behaviors and low insight are common accompaniments. Standard cognitive and behavioral treatment and pharmacotherapy used to treat OCD are less effective for people with hoarding problems. A cognitive and behavioral theoretical model of hoarding that is supported by research evidence has led to a specialized cognitive and behavioral treatment for hoarding that yields moderate benefits. Treatment can be delivered individually, in groups, in self-help group workshops, or virtually with similar outcomes. Limited insight and low motivation are obstacles for some people with HD. Animal, attachment, and genetic models are under development and likely to expand understanding of this complex problem. Subgroups including children, older adults and non-treatment seeking adults with hoarding disorder require additional research and specialized treatment approaches, including community-based interventions that reduce public health and safety effects of severe hoarding.
Toward a biopsychosocial model of hoarding disorder
2023, Journal of Obsessive-Compulsive and Related Disorders
The present paper aims to elaborate on the original cognitive-behavioral model of hoarding disorder (HD; Frost & Hartl, 1996) by incorporating the results of recent research on biological and psychological contributors to HD. According to the proposed model, HD is characterized by several vulnerability factors that are thought to increase the likelihood that HD will develop, including genetic predisposition, abnormalities of brain structure, environmental factors such as traumatic life experiences, neuroticism, and impairments of cognitive function. Superimposed on these vulnerability factors is a biphasic abnormality of central and peripheral nervous system activity; at rest, or when doing completing symptom-irrelevant tasks, individuals with HD show blunted activity in brain regions that make up the salience network, including anterior cingulate cortex and insula. This blunted reactivity is further demonstrated through diminished error-related negativity (ERN) and decreased physiological arousal during error trials. However, when individuals with HD make decisions about possessions, they show relative hyperactivation of the salience network (and other brain regions), with accompanying indecisiveness, negative affect, exaggerated ERN, increased physiological arousal, and activation of maladaptive beliefs about, and attachment to, possessions. These factors lead to acquiring and saving behaviors, which are subsequently reinforced through emotion modification.
Identifying psychiatric and neurological comorbidities associated with hoarding disorder through network analysis
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Citation Excerpt :
Less is known about neurological comorbidities, although hoarding behaviors are common in dementia (Hwang et al., 1998; Mitchell et al., 2019). For example, between 22% and 28% of patients with dementia display hoarding behavior (Hwang et al., 1998; Mitchell et al., 2019) and individuals with HD often exhibit mild cognitive impairments (Mackin et al., 2016; Mitchell et al., 2019; Pertusa et al., 2010). Similarly, approximately 12% of those with Parkinson's disease display excessive hoarding (O'Sullivan et al., 2010), while 15% with focal brain lesions have abnormal collecting behaviors (Anderson et al., 2005).
The relationships between hoarding disorder (HD) and other neurological and psychiatric disorders remain largely unknown. Although psychiatric burden in those with HD is high, less is known about neurological disorders. Furthermore, which disorders are primarily associated with HD vs which can be better explained via a relationship with another disorder has not been determined. To address these questions, we examined comorbidity patterns of psychiatric and neurological disorders in a large online registry of adults using network analyses.
We first examined psychiatric comorbidity among 252 participants completing clinician administered psychiatric assessments. Using the Brain Health Registry (BHR) (N = 15,978), we next analyzed prevalence of self-reported neurological and psychiatric disorders among participants with no/minimal hoarding, subclinical hoarding, and clinically significant hoarding and used network analyses to identify direct and indirect relationships between HD and the assessed psychiatric and neurological disorders.
The most prevalent comorbidity in clinically assessed participants with HD was major depressive disorder (MDD, 62%), followed by generalized anxiety disorder (GAD, 32%). Network analyses in the BHR indicated that the strongest direct relationships with HD were attention-deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), and obsessive-compulsive disorder (OCD). The relationships between HD and neurological disorders, including mild cognitive impairment, were weak or non-existent after controlling for other disorders.
ADHD, MDD, and OCD form a triad of psychiatric disorders directly associated with HD. Despite their high comorbidity rates, the associations among anxiety disorders and HD were weak or indirect.
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With the cost of data storage approaching near zero, an individual can acquire, share, and store digital content (i.e., emails, images, videos, and documents) more than ever before. This behavior is exacerbated by the availability, affordability, and usability of modern technological devices like smart mobile phones, wearables, the rapid proliferation of social media and communication apps, and the intensification of digitized business and/or personal interactions. As a result, there is an increased propensity to acquire and accumulate substantial amounts of digital content. Employing the theoretical foundations of the attachment theory and the hoarding disorder, this study argues that the characteristics such as difficulty of discarding digital content, digital clutter, and frequent excessive acquisition of digital content demonstrate the signs of digital hoarding. By conducting a survey using 846 respondents and conducting a multigroup analysis, this study provides confirmatory evidence on digital hoarding and its association to anxiety. As such, this study contributes to the dark side of technology use and introduces a new concept called digital hoarding to information systems research.

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Refining the diagnostic boundaries of compulsive hoarding: A critical review

Abstract

Section snippets

Phenomenology

Epidemiology

Assessment of compulsive hoarding

Pharmacological treatment

Discussion

Behaviour Research and Therapy

Psychiatry Research

Lancet

Lancet

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Psychiatric Research

Behavior Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of anxiety disorders

Psychiatry Research

Journal of Anxiety Disorders

Behaviour Research and Therapy

Behaviour Research and Therapy

Encephale

Behaviour Research and Therapy

Biological Psychiatry

American Journal of Geriatric Psychiatry

Brain Research

Behaviour Research and Therapy

Schizophrenia Research

Journal of the American Academy of Child and Adolescent Psychiatry

Comprehensive Psychiatry

Behaviour Research and Therapy

Clinical Psychology Review

Symptom presentation and outcome of cognitive-behavioral therapy for obsessive–compulsive disorder

Journal of Consulting and Clinical Psychology

Aredictive study of obsessive-compulsive disorder response to clomipramine

Journal of Clinical Psychopharmacology

Genetic susceptibility to obsessive–compulsive hoarding: the contribution of neurotrophic tyrosine kinase receptor type 3 gene

Genes, Brain and Behavior

Long-term follow-up and predictors of clinical outcome in obsessive–compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy

Journal of Clinical Psychiatry

Diagnostic and statistical manual of mental disorders: DSM-IV-TR

To discard or not to discard: The neural basis of hoarding symptoms in obsessive–compulsive disorder

Molecular Psychiatry

A neural basis for collecting behaviour in humans

Brain

Structure of diagnostic and statistical manual of mental disorders, fourth edition criteria for obsessive–compulsive personality disorder in patients with binge eating disorder

Canadian journal of psychiatry

Children who are cruel to animals: A review of research and implications for developmental psychopathology

Anthrozoos: A Multidisciplinary Journal of The Interactions of People & Animals

Childhood cruelty to animals: Assessing cruelty dimensions and motivations

Anthrozoos: A Multidisciplinary Journal of The Interactions of People & Animals

An autistic dimension: A proposed subtype of obsessive–compulsive disorder

Autism

Hoarding and treatment response in 38 nondepressed subjects with obsessive–compulsive disorder

Journal of Clinical Psychiatry

Meta-analysis of the symptom structure of obsessive–compulsive disorder

American Journal of Psychiatry

The challenge of obsessive–compulsive disorder hoarding

Primary Psychiatry

The Temperament and Character Inventory (TCI): A guide to its development and use

Factor analysis of the Yale-Brown Obsessive Compulsive Scale in a family study of obsessive-compulsive disorder

Depression and Anxiety

Hoarding: A symptom, not a syndrome

Journal of Clinical Psychiatry

Insight and alexithymia in adult outpatients with obsessive-compulsive disorder

European Archives of Psychiatry and Clinical Neuroscience

Obsessions and compulsions in Prader–Willi syndrome

Journal of Child Psychology and Psychiatry

Clarifying the convergence between obsessive compulsive personality disorder criteria and obsessive compulsive disorder

Journal of Personality Disorders