Compulsive Hoarding

INTRODUCTION

Collecting is undertaken by all. What motivates collecting changes across the life span. In childhood, items are collected for leisure or enrichment. In adulthood, it is often for monetary reasons and in old age, the collecting of items may be for reasons of sentimentality or security. Collecting rarely leads to distress or dysfunction nor is the behaviour undertaken secretly. The acquired items are considered valuable and may be discarded with minimal anxiety.

In contrast, compulsive hoarding leads to distress and dysfunction and is undertaken secretly. The items collected are inanimate or animate, have minimal value or purpose and their disposal is resisted. Compulsive hoarding, while recognised for centuries and occurring in all cultures, has attracted little empirical inquiry despite it being disabling for the sufferer and at times becoming an issue of public health. It is not yet classified as a psychiatric disorder and is presently regarded as a form of obsessive - compulsive disorder (OCD), an illness that affects 2.5% of adults.

PHENOMENOLOGY

Compulsive hoarding is the acquisition of items that the hoarder has difficulty discarding. The hoarder is preoccupied with acquisition, has minimal insight into the purpose behind his behaviour and undertakes the hoarding in isolation. Hoarders find themselves acquiring items and while considered valuable to them, others see the acquisitions as of no value and are bewildered as to why the acquisitions occur. Hoarders lose the ability to differentiate between collecting for sentimentality, monetary or intrinsic reasons and acquire a greater number of items upon which they place significant value. Difficulty in organising the acquisitions is the norm. Efforts to re - organise the acquisitions are resisted and touching of the objects is viewed as threatening. Compulsive hoarders deny they have a problem, resist intervention and become aggressive if intervention occurs, factors that have lead to uncertainty as to the prevalence of compulsive hoarding. Evidence is suggestive, however, that compulsive hoarding may indeed be common. Moreover, it has been identified in several psychiatric and non-psychiatric illnesses as shown in Table 1. Hoarding in these illnesses may be either a specific or a non-specific symptom. Studies of adults whose primary diagnosis is OCD show that 30% have obsessions and 18% compulsions concerned with hoarding.

Compulsive hoarding is more common in females in all age groups. Childhood onset is the norm with one study showing that 66% began hoarding in childhood, 25% in their twenties and 9% after the age of twenty - four. Compulsive hoarding in the elderly may have a different etiology to earlier onset in that it may reflect pre - existing personality characteristics, symbolise relationships with loved ones who have died or be used to express denial of aging; the collection counters the process of depletion of the body: “objects do not decay but the body does”. The Greek philosopher Diogenes in the 4th century BC recognised a phenomenon in the elderly associated with hoarding that he named after himself. Those with Diogenes syndrome live in filthy conditions, show a lack of concern with their predicament, deny luxury, hoard excessively and often hoard rubbish (syllogomania).

CO-OCCURRING ILLNESSES AND IMPACT

Most who compulsively hoard have additional psychopathology. Common co-occurring illnesses include depression, dysthymia, panic disorder with agoraphobia, social phobia, attention deficit hyperactivity disorder and hypochondria. Trichotillomania, compulsive buying, pathological gambling also commonly co - occur. Significant morbidity is the norm with recent studies showing that 65% of compulsive hoarders are either single or divorced, 50% are unemployed and 25% of this group are unemployed because of their hoarding. Up to 55% experienced family conflict resulting from their condition. Visitor restriction and squalor is common and for some, there are public health issues.

While any item may be hoarded, the most common items are listed in Table 2. Most hoard multiple items. For some, the items hoarded may be similar to those saved by non - hoarders but are saved in greater quantities and the items may have a different meaning. The hoarding of animals has recently gained public attention, the hoarders collecting a large number of animals particularly cats and dogs for which they provide only poor nutritional standards. Animal hoarders justify their behaviour as stemming from an intense love of animals. They may view the animals as being surrogate children or consider that nobody else would care for them, and in the absence of their care, the animals would be euthanised.

A COGNITIVE BEHAVIOURAL MODEL

Historically, hoarding was described in psychoanalytical terms. More recently, it has been described from a cognitive behavioural perspective, which suggests that compulsive hoarders have deficits in information processing and hold faulty beliefs about the comfort and security the hoarded items may provide. Moreover, they have patterns of behavioural avoidance, the essence of which is to prevent loss of the hoard. The deficits in information processing are characterised by the hoarder having difficulties categorising, organising and processing information, i.e. deciding what is important and what is not important. Those who compulsively hoard are also often indecisive and perfectionists, excessively concerned with error. Furthermore, the hoarder often holds the belief that items hoarded must be remembered and so the items must be saved or kept in view.

The excessive pathological attachment of the hoarder to the hoard is manifested in their conviction that they may require the objects some day regardless of kind and consider the objects aesthetically pleasing, even when others may not. To protect against this loss they minimise the discarding of possessions and in so doing, avoid emotional distress that occurs in the making of decisions regarding disposal. Hoarders also overestimate the loss or catastrophise what might occur if the possessions are discarded or put out of sight. Moreover, they have a distorted view about their future needs and the degree of emotional benefit obtained from the items.

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