Dr. Jennifer Patterson
Dr. Melissa Rowland
MidAmerican Psychological Institute, P.C.
Objectives
Define hoarding
 Identify different types of hoarding
 Causes of hoarding
 How hoarding evolves
 Treatment and prognosis
 How you can help

Definition of Hoarding

No consistent definition of hoarding

The term is used in different clinical and
non-clinical contexts to describe a broad
spectrum of behavioral abnormities
(Maier, 2004)
Commonly Accepted Definition
(1) The acquisition of
and failure to
discard a large
number of
possessions that
seem to be useless
or of limited value
(2) Living spaces
sufficiently cluttered
so as to preclude
activities for which
those spaces were
designed
(3) Significant distress
or impairment in
functioning caused
by the hoarding
~Frost and Hartl
Misconceptions

It is not caused by:
 Laziness
 Lack of standards
 Lack of responsibility
 Lack of intelligence
Individuals who hoard often have poor
insight regarding their behavior; others are
often more aware and bothered by the
clutter.
Misconceptions (cont.)

The stereotypic term "crazy cat lady" is
used in a pejorative sense to classify an
older, female animal hoarder and there
is no research to support such
correlation.
Misconceptions (cont.)
Hoarding and cluttering are often used
interchangeably. There are two
differences:
1. People who have clutter can
discard things more easily.
2. Their clutter does not debilitate their
lives to the same degree.

Clutter is only a symptom of the hoarding
problem
DSM-5 Hoarding Disorder
A. Persistent difficulty discarding or parting with
possessions, regardless of their actual value.
B. This difficulty is due to strong urges to save
items and/or distress associated with
discarding.
C. The difficulties discarding possessions result
in the accumulation of a large number of
possessions that congest and clutter active
living areas and substantially compromises
their intended use. If living areas are
uncluttered, it is only because of the
interventions of third parties (e.g., family
members, cleaners, authorities).
DSM-5 Hoarding Disorder (cont.)
D. The hoarding causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning (including
maintaining a safe environment for self and others).
E. The hoarding is not attributed to another medical
condition (e.g., brain injury, cerebrovascular
disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the
symptoms of another mental disorder (e.g.,
hoarding due to obsessions in ObsessiveCompulsive Disorder, decreased energy in Major
Depressive Disorder, delusions in Schizophrenia or
another Psychotic Disorder, cognitive deficits in
Dementia, restricted interests in Autism Spectrum
Disorder).
Hoarding Mentality

Scarcity Mentality
 “What if I need it?”

Frugality Mentality
 “Nothing should be wasted.”

Indecision Mentality
 “Should I get rid of this or not?”
(NSGCD, 2003)
Ordinary Hoarding

Ordinary Hoarding
 Primarily objects
 Papers
 Magazines
 Receipts
 Plastic bags
 Old news papers
OCD-based Hoarding

OCD-based
hoarding
 A small number of
hoarding cases may
be true or primary
OCD.
 Hoarding behavior is
driven entirely by
OCD symptoms such
as contamination
fears or symmetry
obsessions.
OCD-based Hoarding (cont.)
Hoarding is a response
to:

Obsessions/fears
about contamination

Superstitious thoughts

Feelings of
incompleteness
OCD-based Hoarding (cont.)

Hoarding behavior is unwanted and
highly distressing and the person
experiences no pleasure from it.

The individual shows little interest in
saved items, especially not sentimental
attachments or beliefs about the value of
possessions.
Trash Hoarding

Trash Hoarding
 Food wrappers
 Food containers
 Used paper
towels/toilet paper
 Old plastic bags
Animal Hoarding

Animal Hoarders
 Can have in excess




of 300 animals in a
home
Cats
Dogs
Birds
Rats/mice
Animal Hoarding (cont.)
Accumulation of animals to the extent
that:
 Failure to provide minimal nutrition,
sanitation and veterinary care.
 Failure to act on the deteriorating
condition of the animals or the
environment.
 Failure to act on or recognize the
negative impact of the collection on
their own health and well–being.
Animal Hoarding (cont.)

Occurs in every community, and it is estimated
that there are three to five thousand cases each
year in the US, involving up to 250,000 animals.

The most difficult to treat usually claiming to be pet
rescuers.

Where animal neglect and abuse are
suspected, also assess for child & elder
neglect and abuse if either co-reside.
(Arluke et al 2002, Patronek 2001)
Animal Hoarding (cont.)
For animal hoarders the relationship
between clutter and function can be
somewhat indirect.
 It is not always the acquired animals that
are the clutter as much as the
accumulation of animal waste and
product which renders an unhealthy
living space.

Animal Hoarding (cont.)

People who hoard animals have a deep
attachment to their pets.

Animals serve as a substitute for
human-to-human relationships.

History of interpersonal difficulties.
Animal Hoarding (cont.)
It is extremely difficult to let the pets go
despite hazardous living conditions and
pleas from family members and city
officials.
 Animal hoarders struggle to comprehend
that they are in fact neglecting their pets by
their inability to provide proper care.
 Most animal hoarders experience a
tremendous amount of grief when they lose
their animals.

Development
The age of onset for item/object
hoarding is reported to be early
adolescence.
 Whereas for animal hoarding the age of
onset is middle age or older.
 In both situations the hoarding
progresses and is chronic.

Development (Cont.)

Hoarding is a recognized MENTAL
HEALTH DISORDER.

Hoarding behavior can occur in the
context of several developmental,
neurological, and psychiatric
disorders.
Co-morbidity





Anorexia nervosa
Bipolar disorder
Dementia
Depression
Impulse control
disorders

 Such as compulsive




buying or gambling

Social phobia


Obsessivecompulsive disorder
Personality
disorders
Schizophrenia
Diogenes syndrome
Prader-Willi
syndrome
Head injury
Autism
Prevelance

1.4 to 2 million people in the United States
have compulsive hoarding syndrome
(Maidment, 2005; Collingwood, 2006).

Hoarding accompanies OCD in 25% to
40% of individuals diagnosed
(Seedat and Stein, 2002).

2-3% of the general population has OCD
and up to one-third of those diagnosed with
OCD exhibit hoarding behavior
(Cohen, 2004; Haggerty, 2006).
Causes

Social Isolation

Dementia and Alzheimer’s

Aging with mobility issues

Traumatic life events

Neurobiological/genetic factors
Causes (cont.)

Current research indicates compulsive
hoarding is associated with abnormal
brain function, particularly in a part of
the brain called the anterior cingulate
cortex (ACC). It also is inherited in
families and appears to have a strong
genetic component.
Causes (cont.)
The ACC plays a role in a number of
functions frequently impaired in
individuals who engage in compulsive
hoarding behaviors:
 focused attention
 problem solving
 motivation
 decision making
Signs of Hoarding (exterior)
Missing siding/roofing
materials
 Peeling paint/rotting
wood
 Overall poor exterior
conditions
 Odors
 Excessive exterior
storage
 Windows and shades
drawn
 Inoperable vehicles

Signs of Hoarding (interior)
Excessive storage
 Odors
 Excessive rodent and insect infestation
 Unsanitary conditions
 Poor appearance of person
 Numerous animals
 No utilities or improperly working
plumbing and electrical systems

How Hoarding Evolves
Three factors that contribute:

Amassing items at a frequent rate

Difficulty discarding items

Disorganization
Amassing Items
Frequent shopping is the most common
way that people who hoard collect
items—3 out of 4 shop too much.
 Roughly 1 in 2 people who hoard report
excessively collecting free things such
as coupons, samples, advertisements,
etc.
 Food wrappers, containers, packaging
materials also contribute to the
collection.

Difficulty Discarding Items

Throwing away

Selling

Giving away

Recycling
Common Beliefs that Maintain
the Behavior
Belief of Future Necessity
 Fear of Identity Theft
 Waste Prevention
 Informational Content
 Emotional Attachment

Disorganization
Most people with hoarding problems have
great difficulty with organizing their
possessions.
Attempts at organizing usually result in:
 hours of moving possessions from one
place to another without any effective
result.
 Accumulation of boxes, filing folders, and
categorization systems.
 Frustration and loss of hope to change.

Impact of hoarding
Self-care becomes increasing difficulty
 Fire (death or serious injury)
 Rooms: inaccessible and unusable
 Social isolation
 Structural risks develop
 Infestation creating numerous health
risks
 Risk of becoming homeless

Hoarding and the Elderly

Compulsive hoarding is known to co-exist with both
dementia and Diogenes syndrome; two conditions
that are correlated with age .

Hoarding and hiding behaviors are commonly
reported in nursing home patients with dementia.

It is not clear whether this behavior is a manifestation
of dementia or these patients had a prior history of
hoarding.

Compulsive hoarders are more likely to be socially
isolated and live alone.
Hoarding and the Elderly (cont.)

Hoarding
prescription and
OTC medicationsnot uncommon
among the elderly
(MacIsaac & Bartus
Adamson,1989)
Impact of Hoarding
on the Elderly
Particularly dangerous for older persons,
who may have physical and cognitive
limitations.
 Creates physical health threat due to
fires, falling, unsanitary conditions, and
inability to prepare food.
 Substantial social isolation due to
shame or embarrassment.

Treatment





No known ‘cure’ for compulsive hoarding
Medication has little effect on Hoarding
In home support works best
“Collaborative Intervention”
Combination of therapies/interventions
Treatment (cont.)

Treatment should focus on the following
areas:
 1) discarding
 2) organizing
 3) preventing incoming clutter
 4) introducing alternative behaviors
(Saxena & Maidment, 2004)
Prognosis



Compulsive hoarding is a chronic
illness which requires unrelenting
vigilance. Lots of resistance is
expressed.
Combined treatment (medication
and psychotherapy) is best.
Monitoring & Maintenance needed.
Motivation and Compliance fluctuate
greatly .

So often, well-intended therapists, concerned family
members, and supportive clutter coaches will
attempt to help by "getting right to business" with
removing the animals. However, this approach often
yields challenges in the long-term effectiveness of
treatment and raises several treatment noncompliance issues. Removing animals and
decreasing the compulsion to hoard are two
important outcomes in treatment but in order to get
to this goal, a framework for lasting change needs to
be established first. Without ongoing therapy and
support there is a higher risk for recidivism.
It is important to know…

Shame, guilt, and embarrassment are
emotions often associated with hoarding
behavior and because of this individuals
do not readily seek out treatment.
It's important to seek out the assistance
of a licensed therapist before going in
and removing the animals.
 Most hoarders experience anger,
resentment, and may behave defiantly
when loved ones try to help and having
a professional will lessen the impact of
these emotions.

Hoarding Interventions: What
you can do to help.
STEP: 1
1.
Assess the risk and respond
accordingly:
Risk to the resident
Risk to other residents
Risk to “responders”
2. Who else needs to assess based on
what you discover?
What you can do to help (cont.)
STEP: 2
1. Control your reactions to the sight
and smell of the unit
2. Be aware of internal reactions and
judgements – don’t voice them, stay
neutral and solution focused
3. Remember solutions are tied to
underlying causes, refer accordingly
4. Bring tools to leave with tenant
Conclusion
Clinically significant hoarding is
prevalent and generally considered
difficult to treat.
 Compulsive hoarding is an understudied
mental health issue.
 Prevention is often impossible, early
intervention strategies reduce tragic
outcomes.

Reference









Frost, R.O., & Gross, R.C. (1993). The hoarding of possessions. Behavioral Research
and Therapy, 31, 367-381.
Frost, R.O., & Hartl, T. (1996). A cognitive-behavioral model of compulsive hoarding.
Behavioral Research and Therapy, 34(4), 341-350.
Interpersonal problems and emotional intelligence in compulsive hoarding. Images
Authors: Grisham, Jessica R.1 jessicag@unsw.edu.au
Steketee, Gail2
Frost, Randy O.3 Source: Depression & Anxiety (1091-4269); 2008, Vol. 25 Issue 9,
pE63-E71, 9p, 5 Charts
Grisham, J.R., Frost, R.O., Steketee, G., Kim, H. & Hood, S. (2006). Age of onset of
compulsive hoarding. Journal of Anxiety Disorders, 20, 675-686.
Cohen, J. (2004). The danger of hoarding. USA Today; 2/19/04 [Electronic version].
Saxena, S. & Maidment, M. (2004). Treatment of compulsive hoarding. JCLP/In
Session, 60, 1143-1154.
SK, A., Mataix-Cols, D., Lawrence, N.S., Wooderson, S., Giampietro, V., Speckens, A.,
Brammer, M.J., & Phillips, M.L. (2009). To discard or not to discard: The neural basis of
hoarding symptoms in obsessive-compulsive disorder. Molecular Psychiatry, Vol. 14,
pp. 318-331