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Compulsive Hoarding Compulsive hoarding 12 Current VOL. 4, NO. 3 / MARCH 2005 p SYCHIATRY Current p SYCHIATRY Unclutter lives and homes by breaking anxiety’s grip Fear about making ‘wrong’ decisions ompulsive hoarding behavior is considered notoriously difficult to may underlie hoarders’ pathologic Ctreat, but targeting its characteristic symptoms saving and collecting behaviors. with medication and psychotherapy can be suc- cessful. This article provides a guide for the psy- Here’s a strategy to help them chiatrist—alone or with a cognitive-behavioral therapist—to diagnose compulsive hoarding syn- drome and help patients overcome the anxieties Jamie Feusner, MD that fuel its symptoms. Psychobiology research fellow and staff psychiatrist OCD Intensive Treatment Program Anxiety Disorders Clinic WHAT IS COMPULSIVE HOARDING? Hoarders acquire and are unable to discard items Sanjaya Saxena, MD that others consider of little use or value.1 They Associate professor in residence and director, most often save newspapers, magazines, old cloth- Obsessive-Compulsive Disorder Research Program Associate director, Anxiety Disorders Program ing, bags, books, mail, notes, and lists. Hoarding and saving behaviors occur in nonclinical popula- Department of psychiatry and biobehavioral sciences tions and with other neuropsychiatric disorders— David Geffen School of Medicine schizophrenia, dementia, eating disorders, mental University of California, Los Angeles retardation—but are most often found in persons with obsessive-compulsive disorder (OCD). OCD is a heterogeneous clinical entity with several major symptom domains:2,3 • aggressive, sexual, and religious obsessions with checking compulsions © Scott Eklund/Seattle Post-Intelligencer VOL. 4, NO. 3 / MARCH 2005 13 Hoarding • symmetry/order obsessions with Box ordering, arranging, and repeating What causes compulsive hoarding? compulsions Genetics. Compulsive hoarding may have a different pattern • contamination obsessions with of inheritance and comorbidity than other OCD symptom factors. washing and cleaning compul- Hoarding/saving symptoms show a recessive inheritance pattern, sions whereas aggressive/checking and symmetry/order symptoms • hoarding and saving symptoms. show a dominant pattern.9 The hoarding phenotype has been Among OCD patients, 18% to 42% significantly associated with genetic markers on chromosomes have hoarding and saving compul- 4, 5, and 17.14 In other studies: sions.4,5 Hoarding and saving can be • Among 20 OCD patients with prominent hoarding, 84% had part of a broader clinical syndrome first-degree relatives with hoarding behaviors and only 37% that includes indecisiveness, perfec- 11 had first-degree relatives who met DSM-IV criteria for OCD. tionism, procrastination, difficulty • Among 126 OCD patients, social phobia, personality disorders, organizing tasks, and avoiding routine and pathologic grooming disorders were more common in daily activities.6,7 The 1 to 2 million hoarders than in nonhoarders. Hoarding and tics were more Americans whose most prominent common in first-degree relatives of hoarders than in those and distressing OCD symptom is of nonhoarders.12 hoarding and saving and who show Neurobiology. Using positron emission tomography (PET) brain these other associated symptoms are imaging, our group13 compared glucose metabolism in patients considered to have “compulsive with compulsive hoarding syndrome with that of nonhoarding hoarding syndrome.”7,8 Evidence sug- OCD patients and normal controls. Compulsive hoarders had gests that this syndrome may be a neu- unique brain activity, with significantly lower metabolism: robiologically distinct OCD variant • in the posterior cingulate gyrus and occipital cortex than (Box).9-16 controls • in the dorsal anterior cingulate gyrus (AC) and thalamus than ASSESSMENT AND nonhoarding OCD patients. TREATMENT PLANNING Hoarding severity was significantly correlated with lower To manage compulsive hoarding activity in the dorsal AC across all OCD patients. syndrome, begin with a thorough neuropsychiatric evaluation: Discussion. Genetic and neurobiologic data suggest that • Rule out primary psychotic disor- compulsive hoarding syndrome may be a neurobiologically distinct variant of OCD14 and may help explain its clinical ders, dementia, and other cogni- symptoms and poor treatment response. Low AC activity may tive impairments and neurologic mediate compulsive hoarders’ decision-making and attentional disorders. problems, whereas low posterior cingulate activity may be • Rule out primary major depres- responsible for visuospatial and memory deficits. Moreover: sion, as clutter and self-neglect may • lower pretreatment AC activity has been strongly associated be caused by amotivation, low with poor response to antidepressants15 energy, or hopelessness. • Determine if the patient has OCD. • lower posterior cingulate gyrus activity correlates with poorer After making a compulsive hoard- response to fluvoxamine in patients with OCD.16 ing diagnosis (Table 1),6 visit the patient’s home or view photographs 14 Current VOL. 4, NO. 3 / MARCH 2005 p SYCHIATRY Current p SYCHIATRY to assess his or her environment and behaviors Table 1 (Table 2, page 16). Proposed criteria to diagnose Amount of clutter. Living areas may be so cluttered obsessive-compulsive hoarding* that sleeping in a bed, sitting on chairs, or prepar- ing food on a kitchen counter are impossible. How Patient acquires and fails to discard a large much of the home is cluttered? How much floor number of possessions that appear useless and counter space is usable? Are rooms unusable or of limited value or inaccessible because of clutter? Can the patient Clutter prevents patient from using living use the laundry, prepare food in the kitchen, use or work spaces for activities for which they the shower, toilet, etc.? were designed Health or safety hazards. Huge piles of papers can Hoarding behavior causes significant be a fire hazard. Clutter may be blocking the exits. distress or functional impairment Collected items may extend beyond patients’ * Proposed by Frost and Hartl, reference 6. homes to their cars, garages, storage lockers, and even storage areas owned by friends and family. Beliefs about possessions. Compulsive hoarders Many hoarders also report marked distractibility often have distorted feelings about their possessions. and inattention, jumping from one task to the next They may over-buy or impulsively purchase items without completing any of them. Their communi- they feel have emotional or monetary value. They cation style is often as cluttered and disorganized may consider the items extensions of themselves as their homes, with tangential, circumstantial, and suffer grief-like loss when discarding things.7 and over-inclusive descriptions. Some collect free items—flyers, coupons, Avoidance behaviors are a hallmark of the com- newspapers, discarded goods—hoping to save pulsive hoarding syndrome. To avoid deciding to money or be prepared “just in case” the item is ever discard items, they put them in a box, garage, needed. This may represent unattainable expecta- rented storage facility, etc. They may also avoid tions of perfection, needing to maintain prepared- routine decision-making tasks that could lead to ness for every possible contingency. Hoarders often making a mistake. believe they have poor memory and have cata- Daily functioning. Hoarders may take a long time strophic fears of what might happen if they forget to do even small chores, such as taking an hour to something. Thus, their desire to keep their posses- pay one bill. An inordinate amount of time may be sions in sight is strong.17 spent “churning”—moving items from one pile to Information processing deficits. Because of anxi- another but never discarding any item or establish- eties about making mistakes, most hoarders have ing a consistent system or organization. great difficulty making decisions.18 It is easier to not Medication compliance. Compulsive hoarders decide than to suffer the consequences of a often forget to take medications or take them at “wrong” decision. To gauge this behavior, ask inappropriate times. They may lose their medica- patients how long routine decisions take them and tions in the clutter. which decisions they procrastinate or avoid. Insight. Hoarders often have little awareness of how Compulsive hoarders often have trouble cate- their behavior and clutter affect their lives.19 They gorizing possessions;6,7 because every item feels minimize the clutter in their homes and its health unique, they create a special category for each one and safety risks. Insight can fluctuate over time and and resist storing items together. needs to be assessed repeatedly during treatment. continued VOL. 4, NO. 3 / MARCH 2005 15 Hoarding Table 2 Assessing a patient with compulsive hoarding symptoms Domain Useful questions or strategies Amount of clutter Visit home and/or see pictures Hazards relating to clutter Ask: What precautions do you take to reduce risk of fire? Have you ever had a problem with rodent or insect infestation as a result of the clutter? Have neighbors complained about the risks of fire or infestation that the clutter might impose on their homes? Beliefs about loss of possessions Ask: What is the worst thing that would happen if you threw this item away? If you did not have this, what do you think would happen? Information-processing deficits Ask: How long do routine decisions take you? Which decisions do you procrastinate or avoid? Decision-making and organizational skills Ask:
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