Research roundup: Hoarding

This roundup presents recent research and practical considerations related to hoarding, a subtype of obsessive compulsive disorder

By Practice Research and Policy staff

May 10, 2012—Currently considered a subtype of obsessive compulsive disorder, hoarding is characterized by three core features: the acquisition of a large number of possessions; the failure to discard a large number of possessions; and living in spaces that are sufficiently cluttered as to preclude their intended use. Many researchers have begun to explore behaviors and features that correlate with hoarding to better understand the condition, as well as make the case for classifying hoarding as a distinct disorder (i.e. hoarding disorder or compulsive hoarding).

The weighted prevalence of hoarding is approximately 5.3 percent; hoarding is twice as common in men and almost three times as common in people over the age of 55. Moreover, hoarding is disproportionately seen among low-income populations and frequently leads to hazardous conditions, impaired functioning and increased health risks. As such, there is great need for clinicians to intervene to prevent and treat this potentially devastating condition.


Frost, R. O., Steketee, G., & Tolin, D. F. (2011). Comorbidity in hoarding disorder. Depression and Anxiety, 28(10), 876-884. doi: 10.1002/da.20861

Summary

Due to varying definitions and measurement of hoarding/proposed Hoarding Disorder (HD), comorbidity rates among this population are not consistent across studies. Using well-validated measures of hoarding and the proposed diagnostic criteria for HD in DSM-5, comorbidity was compared across 217 participants with HD and 96 participants with obsessive compulsive disorder (OCD) without hoarding. Only 18.0 percent of the HD participants met the criteria for OCD and significantly more HD participants (50.7 percent) than OCD participants (33.3 percent) had a comorbid condition of major depressive disorder. Social phobia (23.5 percent) and generalized anxiety disorder (24.4 percent) were the most frequently diagnosed anxiety disorders among HD participants but these rates were not significantly different from the rates among the OCD group. HD participants were more likely than the OCD participants to have experienced a traumatic event in adult or childhood but were not more likely to be diagnosed with post-traumatic stress disorder (PTSD). Over one-quarter of the HD participants met the criteria for the inattentive subtype of attention deficit hyperactivity disorder and 78.3 percent of the HD participants had acquisition-related impulse control problems such as compulsive buying, acquiring free things or kleptomania, both significantly higher rates than the OCD participants.

Practical Implications

Findings in this study support the notion that HD is not simply a subtype of OCD but a distinct condition related to a variety of disorders. With nearly 75 percent of the HD participants meeting the criteria for a mood or anxiety disorder, clinicians may want to investigate the onset of these disorders in order to determine whether they resulted from the significant burden and impairment of HD, or if they play a role in the development of HD. Similarly, acquisition-related impulse control problems were seen among a substantial majority of the HD participants, suggesting that they may not be comorbidities but rather part of the hoarding phenotype itself. While close to 50 percent of the HD participants reported experiencing a traumatic event, only 23 percent developed PTSD. Thus, clinicians may want to examine whether hoarding served some function (for example, possessions are a source of comfort, acquisition of items distracts from traumatic events), which then buffered the experience of the traumatic event and prevented the development of PTSD. Future diagnostic assessments should utilize updated classification models and take into account these associations in order to inform treatment planning.

Frost, R. O., Tolin, D. F., Steketee, G., & Oh, M. (2011). Indecisiveness and hoarding. International Journal of Cognitive Therapy, 4(3), 253-262. doi: 10.1521/ijct.2011.4.3.253

Summary

An increasing amount of research suggests the three core features of hoarding ( excessive acquisition, difficulty discarding and clutter) are largely derived from impaired decision-making. Broadly defined as indecisiveness, this underlying characteristic of hoarding, as well as hoarding severity and onset, were assessed in a sample of 887 self-identified hoarders through a web-based survey. In order to examine potential biological and non-biological relative interactions, these constructs were also evaluated among 120 spouses and 295 adult children of the self-identified hoarders. Within the sample of self-identified hoarding participants, 75 percent met the proposed criteria for hoarding disorder and all indecisiveness measures were correlated with hoarding severity. Moreover, indecisiveness predicted each of the core features of hoarding above and beyond depression, anxiety and OCD symptoms, and indecisiveness was uniquely associated with age of onset of hoarding symptoms, with higher levels of indecisiveness associated with earlier onset. Depression accounted for unique variance in clutter, distress and interference, but not for two core features of hoarding (excessive acquisition and difficulty discarding), suggesting that depression may relate to the consequences of hoarding behavior but not its core features. As predicted, participants with hoarding were more indecisive than their adult children and spouses and the adult children reported more indecisiveness than the spouses. Unexpectedly, spouses scored significantly higher on the clutter feature of hoarding when compared to the adult children.

Practical Implications

By demonstrating that indecisiveness is uniquely associated with the onset of hoarding as well as hoarding severity this study reinforces that decision-making problems play a major role in hoarding. Incorporating decision-making skill building into hoarding treatment may prove to be an important step to increasing treatment effectiveness. Clinicians may want to consider specialized treatments that utilize motivational interviewing and cognitive restructuring techniques to directly address behavioral avoidance and decision-making. Implementing family interventions that attend to indecisiveness and hoarding tendencies among family members may also be a beneficial approach to treatment, especially since spouses may have developed behaviors that reinforce or complement the behavior of the person with HD.

Tolin, D. F., & Villavicencio, A. (2011). Inattention, but not OCD, predicts the core features of Hoarding Disorder. Behaviour Research and Therapy, 49(2), 120-125. doi: 10.1016/j.brat.2010.12.002 

Summary

The classification of Hoarding Disorder (HD) has been a topic of much debate in recent years. Although currently characterized as a type or symptom of obsessive-compulsive disorder (OCD), increasing evidence suggests HD may warrant a separate diagnostic classification. Moreover, neurocognitive ADHD symptoms, such as inattentiveness and impulsivity, has been shown to contribute to core features of HD over and above the contribution of OCD and other comorbid disorders. In hopes of clarifying the relationships between HD, OCD and ADHD symptoms, participants meeting the criteria for HD (N = 39), non-hoarding OCD (N = 26), and healthy control (N = 36) were evaluated based on standardized measures of each disorder, as well as demographic and general distress (depression, anxiety, stress) variables. Predictive models revealed that indicators of inattention, but not OCD symptoms or hyperactivity/impulsivity, were significant independent predictors of all three of the core features of hoarding.

Practical Implications

As the symptomatic issues of HD continue to be delineated, clinicians may want to carefully assess for the aforementioned neurocognitive deficits when planning treatment. In fact, the study authors recommended that these neurocognitive functions be considered in the proposed DSM-5 diagnostic criteria so clinicians will want to be familiar with these functions and any other changes to the criteria that are adopted. Problems with attention can become a major barrier to evidence-based psychosocial treatments for HD, for example the adherence to homework aspects of cognitive-behavioral therapy, and it may be necessary to improve these cognitive functions to enhance the effectiveness of treatment. Interventions typically utilized for ADHD, such as cognitive remediation, could prove to be an effective addition to treatment.   

Gilliam, C. M., Norberg, M. M., Villavicencio, A., Morrison, S., Hannan, S. E., & Tolin, D. F. (2011). Group cognitive-behavioral therapy for hoarding disorder: An open trial. Behaviour Research and Therapy, 49(11), 802-807. doi: 10.1016/j.brat.2011.08.008

Summary

Despite promising results, individual cognitive-behavioral therapy (CBT) is an intensive and costly treatment for those suffering from hoarding disorder (HD). Group CBT for HD has been found to have somewhat inferior results to individual CBT, perhaps due to the less structured interventions studied thus far. This study of 35 individuals with HD sought to gauge the effectiveness of group CBT that attempted to maintain the structured protocol successful in studies of individual CBT. Participants were enrolled in 16 or 20 sessions of group CBT and completed various assessment measures of hoarding, anxiety, depression and psychosocial functioning at pre- and post-treatment. Because home visits are challenging in real-life treatment settings, treatment in this study did not include clinician home visits, as did previous studies assessing group CBT for HD. Significant improvements in hoarding symptoms, as well as depression, anxiety and quality of life indicators, were found among participants pre- to post-treatment. These results were comparable to studies of individual CBT and superior to previous group CBT studies.

Practical Implications

Some elements of traditional treatment for HD, such as monthly home visits and non-acquiring shopping sessions, are less feasible for clinicians to undertake in real-life community settings, yet the need for treatment for this population is essential. This study outlines an alternative to these treatment components by demonstrating the effectiveness of group CBT for hoarding that reflects a similar protocol to individual CBT, without clinician home visits. Clinicians may want to consider adopting a similar structured protocol in a group setting, which includes stringent rules and close monitoring of attendance, punctuality and homework compliance.

Saxena, S., Ayers, C. R., Maidment, K. M., Vapnik, T., Wetherell, J. L., & Bystritsky, A. (2011). Quality of life and functional impairment in compulsive hoarding. Journal of Psychiatric Research, 45(4), 475-480. doi: 10.1016/j.jpsychires.2010.08.007 

Summary

In addition to excessive emotional attachments to possessions and unsanitary living environments, compulsive hoarding has been linked to poor global functioning and considerable disability. Yet few studies have investigated subjective and objective quality of life (QOL) in samples of individuals with compulsive hoarding behavior. In order to shed light on this crucial aspect of treatment, 34 people who compulsively hoard were compared to 137 non-hoarding OCD patients in an intensive outpatient setting. Compulsive hoarders were significantly older and had lower pre-treatment Global Assessment of Functioning Scale (GAF) scores than non-hoarding patients. Anxiety and depression scores did not differ between groups and therefore did not account for the lower GAF scores in compulsive hoarders. Controlling for age, subjects with compulsive hoarding reported significantly lower satisfaction with safety and living arrangements and higher victimization rates than non-hoarding OCD subjects. More specific item analyses revealed that those who hoard felt less safe in the streets of their neighborhood and less satisfied with the protection they had against being robbed or attacked. Moreover, approximately 9 percent of those who hoard had been the victims of violent crime and 23 percent had been victims of non-violent crime, compared to 4 percent and 15 percent in the non-hoarding group, respectively. Other QOL factors, such as occupational and financial issues, did not differ between groups.

Practical Implications

Many of the QOL issues examined in this study are not typical targets of traditional psychotherapy and pharmacotherapy for those suffering from compulsive hoarding. The phenomenon that individuals who compulsively hoard fear and experience crime more than others may be an important element for clinicians to address in treatment. Previous reports have found that some individuals reported that their hoarding initially developed as a result of a break-in and that a history of victimization may contribute to paranoid beliefs about possession security. Only about 15 percent of the participants in each group were employed at the time of the study, which may explain why there were no financial or occupational differences between the groups. Behavioral and educational treatment components to improve individual’s protection from crime, as well as occupational and vocational rehabilitation, may be a beneficial way to obtain a higher level of functioning for those who compulsively hoard.