The two books available about Compulsive Hoarding:
Overcoming Compulsive Hoarding
"Buried in Treasures"
HOARDING: CLINICAL ASPECTS AND TREATMENT
STRATEGIES
Randy 0. Frost, Ph.D., Gail S. Steketee, Ph.D.
HOARDING SYMPTOMS AND FEATURES
Hoarding behavior is most commonly associated with the collection and
storage of food items among rodents, small animals, and birds.[1]
Among these creatures, food hoarding is a normal part of the life
cycle and can be stimulated in predictable ways.[2-4] Although
nonfood hoarding occurs in some nonhuman species, the phenomenon is
unusual and not well studied.[5,6] The relationship between nonhuman and
human hoarding is uncertain, although Smith[7] has suggested some
similarities. Virtually no research exists on the hoarding of food in humans and,
until recently, only clinical descriptions of nonfood hoarding among humans could
be found. Hoarding behavior has been observed in a variety of disorders,
including anorexia nervosa[8], organic mental disorders[9], psychotic
disorders[10],
obsessive-compulsive personality disorder (OCPD)[11], and mental
retardation.[12] However, the majority of research links hoarding
to obsessive-compulsive disorder (OCD).
Definition of Hoarding
Although it is widely recognized as a symptom of OCD, hoarding is
not described in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV)[11] in this context. DSM-IV presents hoarding in
the context of OCPD in which it is defined as the inability to
discard worthless or worn-out things, even though they have no
sentimental value. Hoarding is defined in the same way on the
Yale-Brown Obsessive-Compulsive Scale Checklist (Y-BOCS).[13] Until
recently, little attention has been given to this type of compulsion
in the research literature, despite the fact that it appears
difficult to treat.[14]
Because both the DSM-IV and Y-BOCS definitions of hoarding appear
inadequate, Frost and Gross[15] proposed a refined definition of
hoarding as, "the acquisition of and failure to discard possessions
which appear to be useless or of limited value" (p.367). Several
features of this definition are noteworthy.
The definition of hoarding includes acquisition[15-17] because most
hoarders actively acquire possessions. We have found that hoarders
often buy extra possessions "just in case" they might need them in
the future.[15] For example, one of our study participants bought and
kept more than 30 bottles of shampoo; if her hoard fell below that
number, she felt compelled to buy more. Another participant had rooms
full of "gifts" that she had purchased over several decades. She did
not know to whom she would give them, but they were "good buys" that she
couldn't pass up. A third had accumulated an entire room full of unworn clothing
with the sales tags still attached.
The absence of sentimentality as an exclusion criterion is a second
feature of this definition. Although both DSM-IV and the Y-BOCS
suggest that hoarding involves only nonsentimental saving, several
studies dispute this assumption. For example, Furby found that
ordinary people save possessions for either instrumental reasons
(i.e., because they have a need for them) or for sentimental reasons
(because they are emotionally attached to them).[18] These are the
most frequent reasons for saving among hoarders as well.[15]
Clinical observations have consistently described hoarding as, in
part, an overemotional attachment to possessions.[8,15,19,20]
Further, hoarders develop a greater emotional attachment to their
possessions than nonhoarders,[16] and these emotional reasons are
part of why they hoard .[15] Indeed, this feature appeared so
prominently among our study participants, that we made it a major
component of our cognitive-behavioral model of hoarding (see
following paragraphs, and Frost and Hartl).[21]
One difficulty with our proposed definition is that it does not
distinguish between hoarding as a behavior and hoarding as a
clinical symptom. That is, how much does one have to hoard to
constitute a symptom of OCD? In one of our first hoarding studies, we
placed an ad in the local newspaper asking for "packrats" or "chronic
savers" to participate in our research, and we received more than 100
calls. Although all these people considered themselves hoarders, our
home visits found that many did not have a clinical problem
associated with their hoarding. In our subsequent research, we found
that the reasons for saving possessions and the types of things saved
by hoarders were no different than those of nonhoaders.[15] Hoarders
endorsed the same reasons for saving described by Furby[18] as
reasons for saving in the general population. We also asked
self-identified hoarders and control subjects to rate 80 possessions
on the extent to which they saved each one.[15] (The 80-possession
list was generated in an earlier investigation of frequently saved
things, such as clothes, magazines, and bags, as well as less
frequently saved items, such as old appliances, flower pots, and
shoe laces.) From this list, we ranked items in each group and
calculated a Spearman Rank Order correlation. The correlation between
the groups was high (rho = 0.79, p <0.001), suggesting that hoarders
save the same kinds of things as nonhoarders, but in larger
quantities.
To clarify the distinction between clinical and nonclinical levels
of hoarding, Frost and Hartl[21] proposed a three-part definition of
clinical hoarding: (1) the acquisition of and failure to discard, a
large number of possessions that appear to be useless or of limited
value; (2) living spaces sufficiently cluttered so as to preclude
activities for which those spaces were designed; and (3) significant
distress or impairment in functioning caused by the hoarding. This
definition ties the notion of hoarding to clutter, which is the most
common associated functional deficit.
Hoarding, Obsessive-Compulsive Disorder, and Obsessive-Compulsive
Personality Disorder
Is hoarding a characteristic of OCD, OCPD, or both? Because hoarding
is one of the diagnostic criteria for OCPD, it is reasonable to
assume that it would be correlated with other OCPD diagnostic
criteria and with global measures of OCPD. To test this hypothesis,
Frost and Gross[15] administered a self-report measure of hoarding;
measures of other OCPD characteristics such as perfectionism,
excessive job involvement, restricted affect, rigidity, generosity,
and authoritarianism; and a global measure of OCPD to a sample of
college students. We found that hoarding was not correlated with a
general measure of OCPD, nor was it correlated in the predicted
direction with most of the specific OCPD characteristics (the only
predicted significant relationship being between hoarding and
perfectionism). In a follow-up study, Frost, et al[17] examined
hoarding, perfectionism, and general OCPD traits in a group of
self-identified hoarders compared with community volunteers matched
for age and gender. Although hoarders scored significantly higher on
hoarding scale scores and perfectionism, they did not significantly
differ from community members on the global measure of OCPD.
A number of studies have attempted to measure the covariation of
OCPD symptoms,[22] but only one of these has attempted to objectively
measure hoarding behavior. Heatherington and Brackbill[23] told a group of
children that they could keep any rocks put into their box from a pile in the
experimental room. Rocks were selected based on the assumption that they
were "transitional objects" representing money or feces. The number of rocks
they kept was the operational definition of hoarding. The number of rocks taken
and kept was correlated with other tests of parsimony. Unfortunately, no
attempt was made to independently verify the reliability or validity of this
measure of hoarding. The findings from our studies, plus the scant evidence on
the covariation of hoarding and other OCPD
characteristics, lead us to question whether hoarding is truly a
symptom of OCPD.
Is hoarding a symptom of OCD? If so, it should be correlated with
other measures of OCD. Frost and Gross[15] found that a hoarding
scale was significantly correlated with nearly all subscales from
three different measures of OC symptoms among college students and a
community sample. They also found that self-identified hoarders had
significantly higher scores on nearly all OCD subscales compared
with a group of matched controls. Subsequently, Frost, et al[17]
found that the hoarding scale was significantly correlated with the
Y-BOCS total score in a sample of college women. Further, when
participants in this study were divided into subclinical compulsives
and noncompulsives based on their scores on an obsessive-compulsive
inventory, the subclinical compulsives more frequently identified
hoarding as a target symptom on the Y-BOCS than noncompulsives.
In another study, we compared the Y-BOCS scores of a sample of
self-identified and screened hoarders to a matched control group.
The mean Y-BOCS total score for the hoarding group was significantly
higher than that of the matched controls. (The mean Y-BOCS total for
the hoarding group was 16.5, which indicated a clinical OCD severity
in this undiagnosed population.) These findings strongly suggest
that hoarding is closely associated with OCD symptomatology.
Associated Features of Hoarding
Prevalence estimates of hoarding symptoms in OCD patients range
widely. Rasmussen and Eisen[24] reported that 18% of 200 adult OCD
patients had hoarding compulsions. Rapoport[25] found that 11% of 70
children with OCD had hoarding symptoms, and in a later study, it was
reported that 42% (10 of 24) of children with OCD had hoarding as a
pronounced symptom.[26] However, because no definition of hoarding
was provided in these studies, the findings are somewhat unclear. We
used the Y-BOCS Checklist and found endorsement of hoarding
obsessions in 31% and hoarding compulsions in 26% of 39 outpatients
in treatment for OCD.[17] Thus, it appears that hoarding symptoms
typically occur in one quarter to one third of OCD patients. No
studies have documented the frequency with which hoarding is a
primary symptom.
Greenberg[19] suggested that the onset of problematic hoarding occurs
in the patient's early twenties. However, this estimate was based on
only four patients, two of whom reported hoarding symptoms in
childhood. Among 32 hoarders, Frost and Gross[15] noted that 66%
recalled hoarding behavior in childhood and an additional 25%
reported onset in the teens or early twenties. A significantly
greater number of hoarders reported excessive saving among
first-degree relatives (84%) than did nonhoarders (54%).
Interestingly, the hoarding patients were more often unmarried
compared with nonhoarders in this study--similar to findings from
other OCD populations.[14] Nothing is known about the gender ratio
of compulsive hoarding, although Frost and Gross[15] found no gender
differences on hoarding scale scores.
Although little research exists on the symptom of hoarding, the
nature of acquisition tendencies was once a popular topic in
psychology. William James[28] believed acquisitiveness was an
instinct commonly found in the general population. Other early
theorists incorporated hoarding into theories of psychopathology.
Fromm[27] described hoarding as one aspect of character, a way in
which people related to the world around them. He described a"hoarding orientation' which represents one type of "nonproductive
character" in which security depends on acquiring and saving things.
For Freud,[29] the hoarding of money reflected the parsimony
component of the anal triad. Jones[30] elaborated on Freud's notion
of hoarding by including the hoarding of other possessions. Bender
and Schilder[31] suggested that hoarding in children is a precursor
to the development of obsessions. Likewise, Adams[32] described it
as a background characteristic from which OCD develops. Other
psychoanalytic writers (e.g., Salzman[33]) suggested that hoarding
develops from perfectionistic strivings to gain control over the
environment. To achieve perfect control, the hoarder must not throw
out anything that might be needed in the future. Thus, because one
cannot be certain of exactly what might be needed in the future, the
safest course of action is to save everything. In a slightly
different vein, Rapoport[25] suggested that hoarding is a"fixed-action pattern" (p.280) resulting from evolutionary
development. Similar to nesting in animals, this behavior is innate
and released by certain hormonal changes.
Despite the longevity of some of these theories, they have failed to
generate research that supports or refutes them and have failed to
generate treatment programs directed at compulsive hoarding. Prior
to 1993, most of the available information on hoarding came from case
studies. Greenberg[19] described four cases of compulsive hoarding.
In each case, despite debilitating symptoms, patients strongly
resisted changing the hoarding behavior, and attempts by family
members to discard possessions were met with intense anger and
threats of violence. Frankenburg[8] described an anorexic patient
who hoarded "bits of paper and Styrofoam, toothpaste tube caps,
screws, and nails (p.57)." As with other hoarding patients, she had
plans to use each of these possessions, and consistent with
Fromm's[27] observation, she felt "safe" only when she was surrounded
by her possessions.
* * * * *
A COGNITIVE-BEHAVIORAL MODEL OF COMPULSIVE HOARDING
Based on our recent research using nonclinical samples,[15-17] on
interviews of people suffering from this condition,[15] and on
attempts to change hoarding behavior,[34] we propose a
cognitive-behavioral model of compulsive hoarding[21] as a guide for
future research and treatment. It is a preliminary model, in that
many of the features are hypotheses that are, as yet, untested. The
model is phenomenologic in nature, in that it outlines a number of
experiential and behavioral features associated with hoarding. We
make no assumptions about how these features develop, but hypothesize
how they are related to each other and to hoarding behavior.
In this model, we view hoarding as a multifaceted problem that stems
from four types of deficits or difficulties: (1)
information-processing deficits; (2) problems with emotional
attachments to possessions; (3) behavioral avoidance; and (4)
erroneous or distorted beliefs about the nature or importance of
possessions. These deficits or difficulties overlap in significant
ways. Each of these facets is discussed together with the pertinent
research in the following paragraphs.
Information-Processing Deficits
Deficits in information processing in compulsive hoarding encompass
three general and overlapping cognitive functions:
(1) decision
making;
(2) categorization/organization; and
(3) memory.
These
deficits appear to be general, because they are not limited to
saving or hoarding. These functions are closely related to one
another and can be difficult to separate.
Decision Making
The clinical literature suggests that indecisiveness is a hallmark of
compulsive hoarding. Case descriptions typically note the difficulty
these people have in making general decisions,[20,35] not merely
decisions about what to save and what to throw away. In studies of
college students, community volunteers, and self-identified hoarders,
we have found substantial correlations between general indecisiveness
(unrelated to hoarding) and measures of compulsive hoarding.[15,36]
Deciding what to wear in the morning, what to order at a restaurant,
and what task to perform next are all troublesome decisions for
compulsive hoarders. Warren and Ostrom[20] suggested that the
indecisiveness shown by compulsive hoarders may be a way of avoiding
mistakes. Consistent with this hypothesis, we found hoarding to be
correlated with the perfectionistic concern over making mistakes.[15]
As with the findings regarding indecisiveness, this relationship
existed in student, community, and self-identified hoarder samples.
Perhaps hoarding is an avoidance behavior closely related to
indecisiveness and perfectionism[15] (i.e., saving a possession
allows the hoarder to avoid the decision required to throw it away ,
thereby avoiding the worry that a mistake has been made). The general
indecisiveness displayed by compulsive hoarders forms the backdrop
for specific difficulties in deciding whether or not to save a
possession, and if saved, where to put it.
Categorization/Organization
Another information-processing deficit that may be related to
compulsive hoarding is categorizing and organizing information.
Reed[37] has suggested and other investigators[38-41] have found
support for the hypothesis that obsessionals have more complex
concepts. They define category boundaries so narrowly that few items
fit within them, a feature labeled underinclusion, and thus many
categories are required to classify personal possessions. This has
several implications for compulsive hoarders. First, each possession
may be seen as belonging to its own category (i.e., so unique that
nothing else is like it and nothing can substitute for it). Such a
view makes it difficult to discard anything. Second, because each
possession is unique and complex, it is impossible to decide that a
class of objects (e.g., old newspapers) is unimportant and can be
discarded without closely examining each one. All important aspects
of each possession must be examined before discarding. Third,
because each possession is unique, it cannot be categorized with
similar objects, and thus there is no way to organize possessions.
An example of this phenomenon can be seen in the arrangement of a
hoarder's books. The hoarder begins to read a book but must stop to
do something else. The book cannot be returned to the shelf because
it is now in a different category--books being actively read. It is
placed on the coffee table. Next, a cookbook is consulted for dinner
and it too cannot be returned to the shelf because it is being used.
It is deposited on the back of the couch. The dictionary used next
cannot be reshelved, lest the person forget the word he looked up.
This process is repeated until there are books everywhere, none of
which can be returned to its shelf because they are all different in
their own category. Their new position in the room has meaning
because each position represents a different category, and an
idiosyncratic sort of organization exists, but the ultimate result is
clutter and chaos.
The finite amount of space available means that possessions must be
piled on top of one another until there are large mounds of
unrelated objects. From this chaos, a sort of temporal organization
emerges. The hoarder may have a sense of where things are placed
based on when they entered the pile. Hoarders trying to sort through
a pile often pick up a possession and, not being sure what to do with
it say, "I'll set it here for now' placing it somewhere nearby. This
is repeated until the piles are so large and numerous that they begin
merging (or collapsing) into one large pile. With each new attempt to
organize and discard, everything in the pile is examined and moved to
the new pile or repositioned in the old pile. The end result is that
the pile has been "churned" but no real progress has been made.
Another organizational problem is the mixing of important and
unimportant possessions. A typical pile contains everything from
paychecks to gum wrappers. We have observed that hoarders have
trouble determining the relative importance of possessions, because
when a possession is picked up and examined, its value increases.
Whatever is "in sight" becomes more important. Judgments about
discarding or organizing that are based on the value of a possession
are thus difficult to make. When being examined by the hoarder,
everything seems "very important." In the treatment of hoarding, we
recommend the creation of a small number of categories into which
objects from a hoarding pile can be placed (e.g., save, discard, to
go through later). One of our participants created a fourth category,
an " immediate to-go-through" box. In it she placed possessions from
a pile on her couch that she deemed essential to go through right
away (i.e., before our next session). At the next session she had not
gone through the box and could not remember what was in it, so she
created another category she called "immediate-immediate
to-go-through." This box contained the same sorts of things that went
into the immediate to-go-through box, but these seemed even more
important. The only difference between the objects in these two boxes
was that she had handled one group of items more recently and they
had therefore become more important to her.
The mixing of important and unimportant objects in a hoarding pile
creates complications when trying to excavate the pile. The hoarder's
wish to closely review everything before discarding it has some basis
in reality. For example, some of our research participants found
envelopes full of cash (up to $100) among decades-old newspapers.
Such occurrences reinforce the hoarder's belief that he must
carefully scrutinize everything before discarding it.
Memory
Some evidence suggests that OCD patients and nonclinical compulsive
checkers suffer from subtle memory deficits.[42-44] In addition, OCD
patients and nonclinical checkers show less confidence in their
memories.[44,45] Similar memory problems have been observed with
compulsive hoarders.[21] Frost and HartI[21] suggested that two
aspects of memory are salient: (1) confidence in memory and (2)
beliefs about the importance of remembering or recording information.
For example, one of our participants saved newspapers because she was
convinced she would not remember the information they contained.
Saving the newspapers allowed her to feel that she still retained
the information, even though she could not remember it. Frost and
Longo[46] recently examined several hypotheses regarding memory
functioning in compulsive boarders. Participants scoring high or low
on the hoarding scale were given the Wechsler Memory Scale-Revised
and a measure of the extent to which they would rely on (have
confidence in) their memory. The findings failed to reveal any actual
memory deficits, but did reveal significantly lower confidence in
memory among hoarders.
Beliefs about memory have been hypothesized to influence memory
processes themselves (e.g., Andersson[47]). In the case of hoarding,
these beliefs may be important determinants of saving behavior. In
addition to believing that things must be saved lest they be
forgotten, hoarders also seem to believe that if an object is out of
sight, it will be forgotten. The concern reported by one of our
participants about using a filing system was, "If I put it with this
stuff [into a filing system], I won't remember it!" This suggests
that visual cueing is an important memory aid for compulsive
hoarders, and this element may explain why hoarders create piles of
objects in living areas and why things in sight take on greater
value. Difficulties like these suggest that hoarding is a problem
not only of saving, but also of organizing possessions.
Why hoarders believe it is important to remember everything is
unclear. It may be that they believe the negative consequences of not
remembering are more likely and more severe than do nonhoarders. The
high levels of perfectionism seen among compulsive hoarders[15] may
be partly responsible for these beliefs. Perhaps forgetting is
interpreted as a mistake or failure that provokes distress. Lack of
confidence in memory among compulsive hoarders may manifest itself in
checking rituals. The extent to which the hoarding or checking is the
primary symptom may be difficult to determine. Further research on
the relationship between checking and hoarding is necessary to sort
out these questions.
Emotional Attachment Problems
We have already noted that hoarded items are saved for both
nonsentimental and sentimental reasons. Case studies and anecdotal
reports of compulsive hoarding frequently note extreme emotional
attachments to possessions.[8,19,20,34] From these accounts, it
appears that many hoarders see their possessions as extensions of
themselves. When other people touch or move them, the hoarder feels
violated.[16]
Several empirical studies also have demonstrated the extent to which
possessions are saved for sentimental reasons. Frost and Gross[15]
found that hoarders reported more sentimental saving than
nonhoarders, and greater emotional attachment to possessions. In a
subsequent study, Frost, et al[16] found evidence for two types of
excessive emotional attachment to possessions among compulsive
hoarders: sentimental and security-based. In the former, possessions
serve as meaningful reminders of important past events. They become
extensions of the self not to be discarded without careful
consideration, because getting rid of such a possession feels like
the loss of a close friend. Possessions also provide a source of
comfort and security, signaling a safe environment (see
Fromm[27]).[48,49] For example, after a particularly stressful day,
one hoarder remarked, "I just want to go home and gather my treasures
around me." The thought of throwing away these possessions violates
this feeling of safety. In a test of these emotional attachment
hypotheses, Frost, et al[16] found that among both college student
and community samples, hoarding severity was correlated with a
measure of sentimental attachment to possessions and the extent to
which possessions provided emotional comfort.
Such attachment also appears to occur among hoarders when they are
acquiring new possessions. Buying objects seems to provide hoarders
with some degree of comfort, even if the items are frivolous. The
relationship between compulsive hoarding and compulsive shopping is
unclear, although such a relationship has been hypothesized.[21]
Behavioral Avoidance
A third prominent feature of compulsive hoarding is behavioral
avoidance. Saving possessions allows the hoarder to avoid the loss of
objects that may be needed someday, that may be of use to others, or
that are aesthetically pleasing. Hoarding also prevents emotional
upset associated with discarding (losing) possessions with
sentimental or safety signal value. Although it is clear that these
situations are avoided, it is still not entirely clear why. Perhaps
the significant variable here is the fear of losing something that is
not entirely tangible. Hoarders who save newspapers, for instance,
fear losing not so much the paper itself or the stories that they
have read, but information that may be there. O'Connor and
Robillard[50] described people with OCD as creating a fiction ("I
may be contaminated") and trying to bend the real world to match the
fiction (trying to wash away germs that are not there). This idea is
applicable here. Hoarders may manufacture an idea that something very
important is embodied in this possession. With newspapers, it may be
information. With junk mail, it may be opportunities. Used envelopes
may represent a part of their life. Saving these things means
avoiding such losses. Likewise, excessive buying of unneeded items
may seem to prevent the loss of a good bargain. Relatedly, one of our
research participants noted that imagining all the newspapers that
are published in the world made her very uncomfortable because of all
the information that is lost to her forever.
In addition, hoarders save to avoid decision making--a difficult and
unpleasant chore--perhaps because of their excessive concern over
mistakes.[15] The overly complex concepts of compulsive hoarders
require consideration of many details and for some extensive checking
and reading rituals. Simply saving the item avoids this
time-consuming and onerous process. In some instances, decision
making is more troublesome than actually discarding the possession.
On several occasions, we have observed patients with very high
anxiety in anticipation of making a decision to discard something,
but once the decision is made, the anxiety subsides quickly and
thoughts about the object itself play a very small role.
As mentioned earlier hoarding involves not only the inability to
discard objects of limited value, but also a problem in organizing
possessions. Without a workable organizational scheme, decisions
about where to put things are problematic, especially when coupled
with fears of losing information, opportunities, or parts of oneself.
Putting everything in a pile to be sorted later avoids this problem,
and leaving things in sight avoids the worry that they will be
forgotten if they are filed away. Unfortunately, however, the
creation of an effective filing system may not resolve fears of loss,
as in the case of one client who still reported feeling that filed
papers were lost to her despite her newfound ability to locate them
using her organizing scheme.
Beliefs About the Nature of Possessions
Underlying many hoarding behaviors is a set of beliefs about the
nature and meaning of possessions. Many of these beliefs are
experienced by patients with other OCD symptoms (see Chapter 18), but
in patients with hoarding tendencies, they have a specific connection
to possessions. Several of these beliefs have already been mentioned:
(1) beliefs about the necessity of perfection and excessive concern
over mistakes;
(2) beliefs about responsibility;
(3) beliefs about
control over possessions;
(4) beliefs about emotional attachments to
possessions; and
(5) beliefs about memory.
Each of these beliefs is
related to an overestimation of catastrophe or loss. Distorted
beliefs about the probability and severity of negative consequences
if possessions are discarded or placed out of sight may be a key
feature connecting these distorted thoughts. For example, beliefs
about memory and the usefulness of keeping important things in sight
also appear to influence hoarding behavior. Other types of beliefs
are discussed in the following paragraphs.
Perfectionism
As mentioned previously, compulsive hoarders score higher on measures
of perfectionism, especially concern over mistakes.[15] It also has
been suggested that hoarders have a fundamental belief that
perfection is not only possible, but expected.[21] For example,
Frost and Hartl[21] described a woman who reported two concerns when
trying to discard newspapers. First, she was concerned that she had
not read them thoroughly, and second, she couldn't remember what she
had read. She believed that it was possible to read the paper and
remember everything "perfectly." Failure to do so seemed a
catastrophe. Saving the newspapers allowed her to continue the
fiction (erroneous belief) that perfect paper reading was possible
and to avoid the failure associated with not reading the paper
perfectly.
Need for Control
Frost, et al[16] found hoarding to be associated with an exaggerated
need for control over possessions. Hoarders were less willing to
share possessions with others or to have others touch or use their
possessions. Unauthorized touching or moving of possessions can
prompt extreme anger among compulsive hoarders.[9] This need for
control may be associated with other features. For instance, if
someone else touches a possession, it may remove some of the safety
signal value of the possession, similar to an object becoming
contaminated. Because possessions are often believed to be
extensions of the self, it may seem to the hoarder that he is
personally being violated when someone touches his things. This
feature has obvious implications for treatment, which will be
discussed shortly.
Responsibility
Beliefs about the nature of responsibility toward possessions also
may play a role in the development and maintenance of hoarding
behavior Frost, et al[16] reported that hoarders felt more
responsible for preparing to meet future needs than did nonhoarders.
This behavior also was reflected in the fact that hoarders carry more"just-in-case" items in their pockets, purses, and cars than do
nonhoarders.[15] If they can imagine a situation in which an object
they possess (or could possess) can be used, hoarders appear to feel
responsible for attaining and saving that object in case that
situation arises.
A second type of responsibility is for the proper care and use of
possessions. Discarding a possession that still has a use--even a
remote one--leads hoarders to feel guilty about waste. Frost, et
al[16] found that hoarders reported these thoughts more frequently
than did nonhoarders. Specifically, thoughts such as, "Ownership
carries with it a responsibility to use a possession properly," "I
must take precautions to protect my possessions from harm," and "I
feel guilty if I don't use something for a long time," were reported
more frequently by hoarders than by nonhoarders.
Emotional Comfort
In addition to these beliefs, a fourth set of beliefs has to do with
beliefs about emotional comfort. Beliefs such as, "Without my
possessions, I will be vulnerable," "Throwing something away means
losing a part of my life," and "My possessions provide me with
emotional comfort," characterize compulsive hoarders[16] and
undoubtedly make discarding possessions more difficult.
TREATMENT FOR COMPULSIVE HOARDING
At present, very little information is available about the treatment
outcomes of patients with hoarding problems. Most single-case and
anecdotal reports[9,19] have been descriptive rather than treatment
-oriented, noting a tendency among hoarders to be disinterested in
changing their behaviors. Occasionally, treatment outcome studies of
patients with OCD have made passing reference to the difficulty in
treatment of hoarding[14] or to refusal, dropout, or treatment
failure of those patients with hoarding symptoms.[55] However,
Baer[53] and Foa and Wilson[54] anecdotally described cases of women
with hoarding symptoms who made substantial progress in reducing
these symptoms by using a behavioral program of gradual exposure to
discarding.
Based on an early version of our hoarding model, Frost and Hartl[34]
developed a preliminary treatment strategy and applied it in a single
case study, using a multiple-baseline design.
Case I
A 53-year-old woman had suffered from compulsive hoarding since
childhood. She had one drug trial--a serotonin reuptake
inhibitor (SRI) with limited success--and side effects resulted
in discontinuation. Her hoarding behavior was so severe that no
room in her house could be used in any normal way. Because her
kitchen table was covered, her family ate with their plates on
their laps. Several rooms had only small pathways, with
possessions piled halfway to the ceiling everywhere else.
Our treatment strategy had three main components. The first of
these was training in decision making and organizational skills
for the management of possessions. For many hoarders, the idea
of trying to discard possessions is too frightening, but being
more organized and decisive is a goal they will agree to and
strive to achieve. In this case, decision-making training
involved category creation and moving designated possessions to
storage with a goal of creating uncluttered living space. This
training was performed in the context of weekly excavation
sessions with homework between sessions. The second component was
exposure to discarding and the associated experiences that saving
things allowed her to avoid (i.e., decision making, emotional
upset, etc.). Cognitive restructuring of hoarding-related beliefs
was the third component of the treatment. Excavation sessions
provided an in vivo context for cognitive restructuring of
beliefs related to saving behaviors (i.e.; perfectionism,
responsibility, control over possessions, memory, and emotional
attachment to possessions).
Treatment progressed with each room being completed before moving
to the next. Within each excavation session, a four-step process
was used, which included identifying a target area to work on,
creating a small number of categories into which possessions
were placed, excavation of the area, and physical moving of the
items in each category to their proper destination. To assess
the severity of hoarding, we calculated two clutter ratios (CRs)
for each room in the house before treatment and again when each
room was excavated. Floor CRs were calculated by dividing the
square footage of floor space that was cluttered by the square
footage of total floor space not occupied by furniture. Furniture
CRs were calculated by dividing the square footage of cluttered
furniture tops by the total square footage of furniture tops
minus decorative items. To gain some perspective on normal CRs, a
small pilot study was undertaken in which CRs of four nonhoarding
individuals were calculated. The mean CRs from this sample for
both floor and furniture tops were less than 0.05.
At pretest, this patient's floor CRs ranged from 0.23 to 0.78
with a mean of 0.54. Furniture CRs ranged from 0.53 to 1.0 with a
mean of 0.85. Over 18 months and 35 sessions, seven rooms were
excavated. When each room was excavated, the CRs declined
substantially. Immediately after excavation, the mean CR for
floors for all seven rooms was 0.02 and for furniture tops it
was 0.05--ratios that were quite normal. The CRs of rooms
completed early in the treatment were maintained throughout the
18 months.
The results of this case study indicate that it is possible to
significantly alter severe hoarding behavior using a framework
consistent with the cognitive-behavioral model outlined earlier.
Based on this model of hoarding and the results of this case study,
we have generated a treatment program for compulsive hoarding.[54]
We are in the process of refining and testing the intervention, which
can be administered either by an individual therapist treating a
patient in the home or in a group format supplemented with a
paraprofessional helper holding excavation sessions in the patient's
home. The treatment assumes that the therapist is familiar with this
cognitive-behavioral model of compulsive hoarding, and that the
patient accepts the basic goals and procedures of treatment.
Outlined below are the assessment procedures, treatment goals,
treatment rules, a description of the excavation sessions, and a
brief overview of cognitive restructuring.
Assessment
A great deal of information about the patient's hoarding behavior is
essential for designing this treatment program. Much of this
information can be gathered from initial interviews. The types of
information needed include the following:
* What types of possessions are saved?
* What are the reasons for saving each type of possession?
* Where are saved items kept? Is there some form of organization?
* What is the actual amount of clutter? Spaces in the house should
be evaluated in terms of their usability. Note parts of the
house that are unusable because of clutter.
* Are family members involved? How does the problem affect
relationships with family or friends?
* How are items acquired? Note how new items enter the house and
where they go when they do.
* Does the patient have decision-making problems? A careful
analysis of the nature and extent of decision-making problems
and the creation of effective decision-making strategies are
crucial.
* What avoidance behaviors are evident? A careful analysis of all
of the things that are avoided by saving is necessary.
* How much anxiety or discomfort regarding hoarding is experienced
during a typical day and during attempts to organize and discard
possessions? This information is critical for setting up
excavation sessions and hierarchies for discarding, and for
determining the course of habituation to discarding.
* What is the patient's hoarding history and previous treatment?
Circumstances surrounding the onset of hoarding and the results
of previous attempts at treatment for the problem behavior may
be helpful.
In addition to this information, standardized assessments also are
useful. The Y-BOCS provides an overall index of severity of the
problem. We recommend the use of a modified Y-BOCS in which the
clinician inquires about the hoarding symptoms rather than all OCD
symptoms. We also have developed a Hoarding Severity Scale and a
Hoarding Cognitions Inventory to provide additional information on
the severity and range of thoughts and beliefs associated with
hoarding. (These scales are available from the authors.)
Psychomatic data supporting the reliability and validity of these
measures are pending.
Finally, a behavioral assessment of hoarding severity is necessary.
As noted earlier, we have used CRs to provide baseline information
about the severity of the hoarding problem and to track the progress
during treatment. As described earlier, two clutter ratios are
useful, one for floor space and one for furniture tops. Photographs
or videotapes of rooms also can help in the calculation of these
ratios after the initial room measurements are made.
Treatment Goals
A careful discussion of concrete goals is essential prior to
beginning treatment. Most severe hoarders are reluctant to enter a
treatment program in which the only goal is to discard the
possessions they have spent their lives collecting. Thus, in this
treatment program, the discarding of possessions is a lesser goal at
the outset of treatment and gains importance as it becomes apparent
to the patient that the most important goals cannot be reached
without discarding. The first and primary goal of this treatment
program is the *creation of uncluttered living space*. The most
troublesome aspect of compulsive hoarding is that clutter interferes
with the ability to use interior living spaces. Most people who
suffer from compulsive hoarding can readily agree to such a goal.
Even if no change occurs in the acquisition and saving by a hoarding
patient, if he is able to maintain uncluttered living spaces in his
home, the treatment will have been useful.
A related goal is to *increase the appropriate use of space*. Severe
hoarders may not have used most parts of their houses for years.
Establishing a regular pattern of use will facilitate the
maintenance of a clutter-free house. For instance, patients must
learn to use the kitchen table for food preparation or sit-down
meals. If it is not used in this way, the table may once again become
a space to store hoarded objects.
To excavate and maintain an uncluttered home, it is necessary for a
hoarder to *improve decision-making skills*, and to *develop an
organizational plan* for the home. The strategy we have adopted is
to create with the patient a small number of categories for each type
of possession. Then all possessions are placed into one of these
categories. Each category has a designated location once excavation
is performed. For example, because most compulsive hoaders have
difficulty with books, we often begin with books and require that
every book in a room go into one of three categories: (1) sell or
donate; (2) store; and (3) display. The sell-or-donate books are
placed in a box and moved to a designated location out of the main
living area. The books to be stored are also placed in a box,
labelled, and placed in a designated storage location. Books to
display are put on a bookshelf. If the display category is larger
than the bookshelf, the extra books are treated like books to store,
but are labelled "display" so they may be readily identified when
bookshelf space becomes available. Limiting the number of categories
makes these first decisions easier and the organizational plan
clear. Other types of possessions usually require more elaborate
filing systems (e.g., letters, documents, etc.).
*Discarding unneeded possessions* is a more difficult goal. Most
hoarders recognize that they must be more selective about what they
keep, but fear they will lose control over what is saved and what is
discarded. This is especially problematic in cases in which family
members have discarded some possessions against the patient's wishes.
In this treatment, we emphasize that the volume of possessions does
not matter. What matters instead is that appropriate living space
exists in the home. In their efforts to achieve the first several
goals, hoarders begin to change their perspective about how much they"need" to keep. One strategy we have found helpful is asking hoarders
to think about the clutter in their house as a loss of control. Then,
we request that they think about "temporarily suspending" their
normal saving behavior to gain control over the clutter. This allows
them to view the discarding of possessions as serving a greater
purpose (i.e., giving them a sense of control over the hoarding). As
the patient gains some experience at discarding, the prospect of
discarding unneeded possessions becomes a more palatable therapeutic
goal.
*Reducing the accumulation of new possessions* is a necessary goal
of this treatment. Because many hoarding patients engage in
compulsive shopping or trash picking in an effort to accumulate new
possessions, it is important to understand the value that these
possessions have for the hoarder. Understanding the instrumental or
sentimental value of each type of acquisition enables the therapist
to design specific exposure and response prevention (ERP) strategies
as well as cognitive interventions. If the patient accumulates
possessions from certain places (e.g., tag sales, dumpsters), the
therapist can accompany the patient to these sites, identify desired
items, and stay until the patient habituates to the feeling of"needing" to acquire the possession. It is important to emphasize the
distinction between objective need and the feeling of need. If a
patient can learn this distinction, managing the "feeling" of need
may be easier.
Familiarizing patients with the nature of OCD hoarding and the model
on which this treatment is based helps them develop confidence in
their ability to tolerate the discomfort associated with hoarding.
Education regarding OCD hoarding also gives patients a sense of
optimism and empowerment. Finally, *developing skill of
self-instruction and cognitive correction* of faulty thinking about
saving possessions is an essential part of this treatment. The exact
nature of these skills and suggestions for developing them are
presented in the following paragraphs.
Treatment Rules
The history of interpersonal relationships for someone with a
hoarding problem is invariably intertwined with the relationships
they have with their possessions. Most hoarders have had family or
friends attempt to "help" them with their hoarding problem and
actively resist this help because they usually involve offers to make
decisions about what to save and to do the discarding for the
hoarder. In considering treatment, the hoarder often has only these
negative experiences of "helpers" on which to reflect. To make the
treatment and the therapist's role clear, specifically defined rules
of behavior for the therapist are necessary. Likewise, to make the
importance of the procedures clear, a defined set of rules for the
patient to follow is necessary. We propose the following six
treatment rules.
1. *The therapist may not touch or throw away anything without
explicit permission*. Knowing that the therapist will not touch a
possession without permission helps to develop trust and confidence
in a cooperative patient-therapist relationship. This is not an easy
rule to follow. The impulse to pick things up and discard or
organize them is strong when the goal is to remove clutter. However,
if the rule is violated, the trust between the therapist and patient
also will be violated. There may be some exceptions to this rule if
the patient has contamination fears or obsessions about others
disturbing their possessions. In this case, a change in the rule
should be negotiated and the rationale for doing so should be clear
to both patient and therapist.
2. *All decisions regarding saving, discarding, and organizing are
made by the patient*. Because part of the problem of compulsive
hoarding has to do with inability to make decisions of this sort,
making decisions for these patients will not help. Indeed, one of
the goals for the treatment is to teach the patient how to make
decisions.
3. *Any possession touched by the patient during an excavation
session should be placed in a final location*. The excavation
sessions should enable the patient to learn the most efficient way of
organizing and discarding to prevent behaviors that have led to the
clutter problem. One of the most prominent of these is "churning."
We use the Only handle It Once (OHIO) rule: Whenever a possession is
picked up, it cannot go back onto the pile. It must go into one of
the categories generated prior to the excavation (or in some cases, a
new category).
4. *Categories for possessions must be established before handling
them*. Before each excavation session, a small number of categories
must be established by the patient and therapist. This is essential
for the development of efficient decision making and organization of
possessions.
5. *Treatment should proceed systematically*. Like the excavation
sessions themselves, it is important that the treatment sequences be
systematic and well organized, so the patient will know what needs
to be done and when. Many hoarders spend hours trying to organize and
discard with little success, because their efforts are unfocused and
produce little visible benefit. They may spend 30 minutes in one room
and 30 minutes in another room and in the end see no progress. Thus,
it is important that treatment should focus on one area or room until
it is complete before moving to the next. More easily categorized
objects (e.g., books) should be first, and should progress to more
difficult ones (documents). Focus first on spaces in which progress
will be readily observable and have the most desired functional
effect for the patient (e.g., able to eat comfortably or sit in
favorite chair).
6. *Flexible and creative strategies are to be applied as needed to
make steady progress*. There will invariably be unforeseen problems
in trying to excavate a house full of possessions. It may be
necessary, for instance, to temporarily redefine some areas of the
home as storage rather than living space, until more actual storage
space becomes available later in the treatment.
Excavation Sessions
Before beginning the first excavation session, the patient should
understand the model of hoarding and the objectives of the treatment.
The excavation sessions are designed to create in vivo opportunities
for the patient and therapist to encounter each of the problems
outlined in the model. These sessions have clear-cut steps to help
the patient structure similar excavation homework between sessions.
Such structure helps the patient avoid some of the difficulties
encountered in previous attempts to clear the house. The specific
steps for each excavation session are outlined in the following list.
--Step 1. Select a target area (e.g., kitchen table).
--Step 2. Assess types of possessions in the target area.
--Step 3. Determine hierarchy of items within target area.
--Step 4. Select type of possession with which to begin.
--Step 5. Create categories and a filing system for this possession type.
--Step 6. Begin excavating.
--Step 7. Continue until target area is clear.
--Step 8. Plan for appropriate use of cleared space.
--Step 9. Plan for preventing new clutter to this area.
Cognitive Restructuring
During excavation sessions, there is ample time to explore the belief
systems underlying hoarding behavior. The therapist should encourage
the patient to verbalize thoughts and feelings when excavating to
understand specific decision-making problems and erroneous beliefs
regarding saving and discarding. A "stream of consciousness"
instruction facilitates this process. It is important to help the
patient recognize his characteristic thought processes and develop
ways of challenging these beliefs. The most common themes encountered
are perfectionism, responsibility, control, emotional attachment, and
beliefs about memory. A variety of techniques are useful here to
challenge these thoughts and the excessive value placed on
possessions. These cognitive techniques are described elsewhere[52]
(see Chapter 18).
During these sessions, it is important that the therapist not
express disappointment or negative feedback regarding decisions made
by the patient. Such expressions are likely to increase shame and
disappointment and decrease motivation. It also is important not to
engage in extended arguments with the patient about a decision to
save something. A Socratic approach that encourages the patient to
question his or her reason for saving something is preferable. These
instances also may provide opportunities to remind patients of the
goals in treatment, especially the need to create usable living
spaces and to establish decision-making rules and categories for
saving.
Behavioral experiments to test the patient's beliefs and reactions
also are helpful in the process of cognitive restructuring. Most
hoarders show excessive attachment to possessions that have little
instrumental value and are not reminders of special times. They
believe they will not be able to tolerate discarding such a
possession. A behavioral experiment to test this hypothesis by
discarding such an item reveals not only the strength of this
feeling, but also the amount of time it takes to habituate to a
decision to discard such a possession. The outcome of such an
experiment also will clearly show the patient that his or her"feeling" of being unable to stand it is inaccurate.
SUMMARY
Obsessive-compulsive hoarding is a little-studied phenomenon. This
chapter reviews the existing literature on this topic, presents a
cognitive-behavioral model of compulsive hoarding, and outlines a
treatment program for this problem. The literature review suggests a
change in the definition of compulsive hoarding most commonly used so
as not to exclude possessions saved for sentimental reasons.
Compulsive hoarding was defined here as having three parts:
(1) the
acquisition of and failure to discard, a large number of possessions
that appear to be useless or of limited value;
(2) living spaces
sufficiently cluttered so as to preclude activities for which those
spaces were designed; and
(3) significant distress or impairment in
function caused by the hoarding.
The cognitive-behavioral model of
compulsive hoarding emphasizes four major factors:
(1)
information-processing deficits;
(2) problems with emotional
attachments to possessions;
(3) behavioral avoidance; and
(4)
erroneous or distorted beliefs about the nature or importance of
possessions.
The individual and group treatment program outlined
emphasizes the creation of uncluttered living space, the appropriate
use of uncluttered space, improvement in decision-making skills, and
the creation of an organizational plan for possessions. As treatment
progresses, more emphasis is placed on discarding and reducing
accumulation. The treatment is conducted in the context of highly
structured excavation sessions during which exposure and cognitive
restructuring can take place.
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OBSESSIVE-COMPULSIVE DISORDERS
Practical Management
Third Edition (1998)
Michael A. Jenike, M.D.
Director, Obsessive-Compulsive Disorders
Clinic and Research Unit
Massachusetts General Hospital
Professor of Psychiatry, Harvard Medical School,
Boston, Massachusetts
Lee Baer; Ph.D.
Director, Psychological Research
Obsessive-Compulsive Disorders Clinic and Research Unit
Massachusetts General Hospital
Associate Professor of Psychology
Department of Psychology, Harvard Medical School
Boston, Massachusetts
William E. Minichiello, Ed.D.
Director, Psychological Clinical Services, Behavior Therapist
Obsessive-Compulsive Disorders Clinic and Research Unit
Massachusetts General Hospital
Assistant Professor of Psychology, Department of Psychiatry
Harvard Medical School, Boston, Massachusetts |
