Hoarding in the Spotlight

Whether in reality shows, popular television series, the local news, or dinner conversations, people seem to be fascinated by hoarding—the acquisition of and failure to discard large quantities of possessions that result in extreme clutter. As a hoarding researcher, all of this attention took me somewhat by surprise because, until recently, hoarding was virtually unheard of by the general public and was a relatively understudied phenomenon in the clinical research world. In fact, prior to 1996, no operational definition of hoarding existed, and only a handful of studies in the literature dealt with it directly.¹ Hoarding patients simply were not on the radar for many people. But, considering the knowledge we have amassed about hoarding over the last 10 years, one can begin to appreciate why this syndrome has stepped into the spotlight.

One fact that we have learned is that hoarding represents a very real and much more prevalent public health burden than any of us imagined. In a recent epidemiologic investigation conducted in Germany,² we found a current population estimate of 5.8%, which mirrors findings from other studies and is far higher than the prevalence rates of schizophrenia, autism, obsessive-compulsive disorder, or panic disorder. This higher-than-expected prevalence rate is sobering to consider, particularly in light of research indicating that individuals with hoarding behaviors are more impaired in family and work domains and have greater rates of chronic and severe medical conditions than nonhoarding individuals; they also meet criteria for extensive psychiatric comorbidities and report very high rates of mental health service utilization.³

Second, the research we have conducted has also underscored the fact that hoarding is an incredibly complex and multifaceted phenomenon. We have learned that both positive (eg, joy and pleasure) and negative (eg, distress and anger) emotions, along with unique beliefs, play a role in the development of hoarding behaviors. A recent twin study found support for a substantial genetic component⁴; however, stressful or traumatic life events are also implicated in the etiology of hoarding. In addition to the primary criteria of difficulty discarding items and the accumulation of clutter, hoarding is associated with the acquisition of objects, perfectionism, indecision, procrastination, and decision-making difficulties.² Studies have revealed that not all hoarding patients endorse the excessive acquisition of objects, but, for the two-thirds of patients who do acquire possessions—whether through buying or stealing retail items or collecting free items—these behaviors are associated with greater levels of distress, general impairment, and social impairment than are difficulty discarding items, the accumulation of clutter, perfectionism, indecision, and procrastination.

The third realization we have come to is that hoarding should be considered a discrete phenomenon, separate from other disorders. Historically, hoarding was subsumed as a symptom dimension of obsessive-compulsive disorder or a criterion of obsessive-compulsive personality disorder, but now a fairly compelling case has been made that Hoarding Disorder should be added to DSM-5.¹ Hopefully, the inclusion of hoarding in the new diagnostic manual will be instrumental in opening further avenues for the investigation of hoarding. This inclusion is particularly important for the development of empirically supported treatments for this condition. As it stands, pharmacologic treatment has received limited support, and the only empirically validated psychotherapy—a form of cognitive-behavioral treatment—is both time- and labor-intensive for the patient and therapist.⁵ Therefore, although some inroads have been made toward effectively treating this disorder, much more work needs to be done to help alleviate the suffering associated with it.

For an excellent website that is geared toward providing information to patients, please visit www.ocfoundation.org/hoarding.

Financial disclosure:Dr Timpano had no relevant personal financial relationships to report.

References

1. Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010;27(6):556–572. PubMed

2. Timpano KR, Exner C, Glaesmer H, et al. The epidemiology of the proposed DSM-5 hoarding disorder: exploration of the acquisition specifier, associated features, and distress. J Clin Psychiatry. 2011;72(6):780–786. Abstract

3. Tolin DF, Frost RO, Steketee G, et al. The economic and social burden of compulsive hoarding. Psychiatry Res. 2008;160(2):200–211. PubMed

4. Iervolino AC, Perroud N, Fullana MA, et al. Prevalence and heritability of compulsive hoarding: a twin study. Am J Psychiatry. 2009;166(10):1156–1161. PubMed

5. Steketee G, Frost RO, Tolin DF, et al. Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depress Anxiety. 2010;27:476–84. PubMed​