Hoarding: Ownership Gone Awry

Possessions have a magical quality for all of us. Our most cherished ones contain an essence that goes beyond their physical qualities, like a ticket stub from a favorite concert, a gift from a dear friend, or a piece of clothing belonging to a lost loved one. Most of us own many things of this sort, but our ownership does not interfere with our ability to live. For some people, however, ownership goes awry and possessions accumulate and clutter living spaces, making them unusable.

The severity of hoarding ranges from mild to life threatening. In a study of deaths related to house fires in Australia, fewer than half a percent of all house fires involved hoarded conditions, but those fires accounted for nearly one quarter of fire-related deaths. In other cases, people have lost custody of children because of the condition of the home. Other research has indicated that hoarding is associated with more work interruption than most other psychiatric disorders. Far from being rare, the prevalence of hoarding is greater than any of the other obsessive-compulsive and related disorders. In response to accumulating data, APA recognized hoarding disorder as an official disorder in DSM-5.

Research on hoarding began only 30 years ago but reveals that hoarding is a complex problem with lots of moving parts. There is evidence that the behavior is partly genetic. There are significant differences in the way the brain functions and information is processed in individuals with hoarding disorder as compared with healthy individuals. High levels of anxiety sensitivity and intolerance of distress characterize most people with the disorder. Comorbidities are common, especially depression and problems with attention.

Two things stand out most in people with this disorder. The living space in the home of someone with a severe hoarding problem is packed with a wide-ranging assortment of things that soar to the ceiling, with only narrow pathways for navigation. Some rooms can be navigated only by “swimming” through the clutter. In contrast to one common myth about hoarding—that saved objects are “worthless or worn out”—the vast majority of these things are potentially useful or emotionally meaningful to the person retaining them. In fact, our research has indicated that the types of things found in the homes of people with hoarding disorder are largely the same as things everyone saves—just more of them.

Also notable are the stated motivations for saving things. The motivations reveal the nature of attachments to possessions, and they are not all that different from the attachments all of us form to the things we own. They relate to our sense of identity, safety, and comfort; a sense of responsibility; and an appreciation for the aesthetic qualities of physical objects. These attachments are normative, but in people with hoarding disorder, they are experienced more intensely and seem to apply to a larger number and wider variety of objects.

When one of our research participants was asked to consider letting go of one of her 30-year-old college textbooks that she hadn’t looked at since graduating, she put it into a box to go to the local library and started to cry. She said, “I just feel like I want to die!” She couldn’t explain why. A short while later, she put a five-year-old receipt into a recycle box—more tears. “It feels like I’m losing that day in my life. And if I lose too much, there will be nothing left of me.” But it wasn’t just the distress of that fear that motivated her saving. She saved hundreds of cardboard tubes from the inside of toilet paper rolls. Discarding them seemed wasteful, and she was sure she could find someone who could use them, perhaps an art teacher. She would feel guilty and wasteful if she got rid of them. She also saved bottle caps, not because she wanted or needed them, but because she appreciated the shapes, colors, and textures. The motives for saving she displayed were not unusual, but the extent to which they applied to virtually anything that entered her home made them dysfunctional.

These objects helped to define her life. Letting go of them raised a host of questions about who she was. But are these attachments the core of hoarding or are they rationalizations to explain the behavior? These and other questions fit within a model of hoarding that emphasizes vulnerability factors, information-processing deficits, beliefs about and attachments to possessions, and the way these factors interact and reinforce hoarding behavior.

Treatment of hoarding disorder requires attention to three interrelated problems: excessive acquisition of possessions, absence of discarding or letting go of possessions, and disorganized behavior that impairs the management of daily tasks. Although excessive acquisition is not required for a diagnosis of hoarding disorder, our research indicates that the vast majority of sufferers acquire excessively. Sometimes the excessive acquisition does not show up until later in treatment when patients no longer avoid the places where acquiring is most likely to occur.

Exposure-based strategies can help patients learn to tolerate the intense urges to acquire. Getting patients to discard possessions means having them challenge their above-mentioned motivations for saving. Once possessions enter the home, they are seldom used or even noticed. Some research has shown that establishing a process by which patients must focus on an object and consider its importance in their lives can help them develop discarding skills. Research with elderly hoarding patients has indicated that cognitive rehabilitation strategies can provide significant benefits, especially with respect to managing time and important daily activities.

People with hoarding disorder are notoriously difficult to treat. Problems with motivation frequently interfere with progress. Therapists’ motivational interviewing skill makes a big difference in fostering good outcomes. Additional resources are available in many communities that involve highly structured, peer-led workshops such as the Buried in Treasures (BIT) Workshop. Outcome data from studies of BIT workshops show them to be as effective as group and individual treatments run by therapists. ■

Carolyn I. Rodriguez, M.D., Ph.D., is associate chair and associate professor and director of the Translational Therapeutics Lab in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.

Randy O. Frost, Ph.D., is the Harold Edward and Elsa Siipola Israel Professor Emeritus of Psychology at Smith College.

They are the authors of “Hoarding Disorder: A Comprehensive Clinical Guide” from APA Publishing. APA members may purchase this book at a discount.