Compulsive hoarding: etiology, pathophysiology, clinical presentation, and treatment interventions

Compulsive hoarding is a disorder that is characterized by an inability discarding items that to most people appear to have little or no value. This inability to throw things away results in an accumulation of clutter that often leads to an inability to use living areas and workspaces for their intended functions. Moreover, the clutter can lead to potential serious health conditions and to safety risks of the hoarder or others.

In order for a person to meet criteria to qualify for a diagnosis of compulsive hoarding the person must experience significant personal distress and/or impairment in their functioning due to their hoarding behaviors. More often it is the impairment in functioning that qualifies someone for a diagnosis as the hoarding behavior serves to reduce anxiety in the person associated with discarding items. Several types of functional impairment seen in hoarders include: health or fire hazards due to clutter or waste in the case of pet hoarders; inability to have guests due to clutter; infestations of insects, rodents, etc.; inability to eat or make food; inability to find important possessions; and interpersonal conflicts caused by the clutter. Not all hoarding behaviors qualify as compulsive hoarding and hoarding may be a symptom of another psychiatric diagnosis (American Psychiatric Association [APA], 2000).

Compulsive hoarding behaviors often have a dramatic impact on the lives of the hoarders as well as family members and friends. Ambivalence by the hoarder is common and family members are often dismayed at the seemingly lack of concern the hoarder has for their obviously dysfunctional behavior. This often leads to alienation from friends and family and other hard feelings. It is often a family member or friend that initiates some form of treatment and not the hoarder. Families, children, and friends can be destroyed by the complications associated with the hoarder not to mention the potential health hazards that may occur. On other hand this ambivalence can also result in family members colluding with the hoarder's illness which makes treatment even more difficult to initiate (Tolin, Fitch, Frost, & Steketee, 2001).

Compulsive hoarding is not currently considered to be a distinct form of mental illness. Traditionally a diagnosis of compulsive hoarding has been viewed as a subtype of Obsessive Compulsive Disorder (OCD). The DSM-IV-TR (The Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria were was published in 1994 with the text amendments updated in 2000. The current criteria list compulsive hoarding as a subtype of OCD and does not list hoarding behaviors in the diagnostic criterion of OCD (APA, 2000). Nonetheless, this may change when the DSM-V is released as Hoarding Disorder (compulsive hoarding) is expected to be defined as a discrete disorder. The reason for the change is that a good deal of the research on compulsive hoarding has investigated the relationship between OCD and hoarding. This research has raised some doubts about the OCD connection to hoarding because while some hoarding behaviors respond to treatments used for OCD many of these behaviors do not. Even in cases where a patient has other symptoms of OCD and qualifies for an OCD diagnosis, the hoarding behaviors may not respond to the standard OCD treatments (Sadock & Sadock, 2007). However, currently the diagnosis of compulsive hoarding is subsumed as a subtype of OCD.

There appears to be a genetic component to both OCD and compulsive hoarding (Sadock & Sadock, 2007) and there also appears to be a link between abnormal brain development and/or lesions in the brain. Cases of compulsive hoarding have been observed to can begin after brain damage has occurred such as a stroke, a brain injury, a brain infection, or even following some types of brain surgery (Sadock & Sadock, 2007). PET brain imaging (positron emission tomography) has demonstrated different cerebral glucose metabolism patterns for OCD hoarders compared to non-hoarding OCD patients. These differences are most observable in the dorsal anterior cingulate gyrus (Saxena et al., 2004). This part of the brain is believed to be responsible for attention, decision making, and other aspects of judgment. Studies have also found that lesions to the frontal lobes are associated with emotional disturbances and difficulties with judgment, whereas lesions to the right medial prefrontal cortex appear to be associated with compulsive hoarding (Sadock & Sadock, 2007). Thus, it appears that frontal cortex involvement, particularly medial frontal cortex involvement is associated with compulsive hoarding (Sadock & Sadock, 2007; Saxena, 2004).