What Am I Going to Do with all This Stuff? By Fugen Neziroglu, PhD on 2/11/19 - 12:52 PM

“I’ve always had trouble throwing things away. Magazines, newspapers, old clothes. What if I need them one day? I don’t want to risk throwing something out that might be valuable. The large piles of stuff in our house keep growing so it’s difficult to move around and sit or eat together as a family.”

“My husband is upset and embarrassed, and we get into horrible fights. I’m scared when he threatens to leave me. My children won’t invite friends over, and I feel guilty that the clutter makes them cry. But I get so anxious when I try to throw anything away. I don’t know what’s wrong with me, and I don’t know what to do.”

These statements are typical of clients with whom I have worked who suffer from what the DSM-5 calls Hoarding Disorder (300.5), a variant of Obsessive-Compulsive Disorder. Hoarding is a disorder that may be present on its own or as a symptom of another disorder. The other disorders most often associated with hoarding are obsessive-compulsive personality disorder (OCPD), obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and depression. Less frequently hoarding may also be associated with an eating disorder, pica (eating non-food materials), Prader-Willi syndrome (a genetic disorder), psychosis or dementia.

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These clients have extreme difficulty parting with common everyday objects such as magazines, newspapers, used cups, household supplies, foodstuffs and various forms of waste material. They may also compulsively acquire and then accumulate other items and commodities including clothing, mechanical parts, toiletries, CDs, DVDs and toys. There really is no limit, and each hoarder and the objects they hoard are unique.
Hoarding is not the same as collecting, as collectors tend to look for specific items and often organize and display them in well-maintained settings. Collectors also express a sense of pride about their possessions, enthusiastically talk about them, feel satisfied when adding to their collection(s), and can budget their time and money.

Individuals with hoarding disorder often experience severe distress at the thought of getting rid of their possessions. This results in their homes filling with clutter that disrupts their and others’ ability to use and, when severe, navigate living and working spaces. Individuals may engage in hoarding behavior for sentimental reasons. They not only feel, but deeply and intractably believe, that an item is unique, irreplaceable, or serves as a reminder of a cherished memory. Others attribute their hoarding behavior to instrumental reasons, clinging to the belief that one day these items will be useful. The psychological and physical burdens of hoarding may lead to unhealthy and dangerous living conditions, as hoarders are often reluctant to allow people into their homes to clear safe paths, remove contaminated or dirty items or to fix broken heating systems and appliances. Unlivable conditions such as these can lead to divorce, eviction, or loss of child custody.

Hoarding typically develops over the course of many years, sometimes beginning at a very young age and continuing throughout an individual’s life. Generally, in individuals living alone, the hoarding tends to develop more quickly and intensely than for those living with others. However, significant time must generally pass before the hoarder’s condition becomes very severe and impairing. It is the secretive and insidiously progressive exacerbation of the disorder that prevents those on the outside from immediately recognizing the hoarder’s issues and symptoms, and from facilitating the required intervention for the hoarder.

My work in hoarding arose through my interest in OCD, when a man once came to see me, reporting extreme concern for his children who didn’t have a bed to sleep on as the home was in disarray. The father was prominent in the community and was therefore expected to regularly invite guests to his home, which he was never able to do. Meeting the children was terribly sad as I learned firsthand about their isolation and the conditions in which they were living. My heart truly went out to the children and my memories of those interactions drove my future desire to treat and research hoarding. Upon meeting the wife who was the hoarder, it was evident that she was very socially presentable and an active member of the community. If you had met her outside of her home without knowledge of her home’s condition and clutter, you would’ve had no indication that she was a hoarder. This is very typical of most hoarders, and sadly perpetuates the hoarder’s resistance to treatment.

Many hoarders ultimately agree to seek therapy in order to avoid eviction or other negative consequences. When clinical intervention has been facilitated, which is often coordinated by those in the life of the hoarder, cognitive-behavioral therapy (CBT) has been demonstrated to have good efficacy. In such cases, it may be appropriate for the therapist to first specifically focus on helping the patient achieve greater insight into their personal situation, symptom severity, and necessity for change. Successful treatment is much more likely to be achieved and continued when the patient maintains awareness in these areas, and seriously engages in their intervention work.

Hoarders who are not determined to develop and exercise coping skills often don’t sufficiently engage in treatment to the point where they achieve long-lasting and sustainable progress, rendering them vulnerable to resuming their hoarding behavior. When CBT protocol intervention is appropriate, it focuses on four domains: information processing, emotional attachment to possessions, beliefs about possessions, and behavioral avoidance. The therapist will perform techniques such as cognitive restructuring and exposure therapy in order to challenge the patient’s beliefs about maintaining their possessions and the strong sentimental value placed on the hoarded belongings. Furthermore, the therapist will engage the patient in talking about commonly avoided and experienced situations related to hoarding that are intended to provoke anxiety, while allowing for the development of more adaptive coping techniques.

It is long and hard work to help the hoarder emotionally and cognitively disabuse themselves of their attachment to the things with which they’ve surrounded themselves, but quite rewarding to all impacted when the symptoms relent, and the stuff recedes from their lives.  

File under: The Art of Psychotherapy