Hoarding Disorder: Diagnostics, Traits, and OCD Distinctions

Introduction: Hoarding and the DSM

Hoarding is a problem that the DSM has generally classified under obsessive-compulsive disorder (OCD). However, it is very likely that a future edition of the DSM will classify hoarding as a separate disorder. This is something for which clinicians and others have hoped for some time, because hoarding and OCD have important differences. In addition, while many hoarders display tendencies associated with OCD, not all people who have OCD are hoarders. The two really should be separated, so that it is possible to diagnose one or the other and differentiate them properly.

In order to differentiate them, however, it is vital to understand the diagnostic status of hoarding and the traits and behaviors used to conclude that someone has a hoarding disorder. A clear distinction must be drawn between OCD and hoarding, and the traits used to identify hoarding behavior must also be discussed.

OCD vs. Hoarding

People who hoard do exhibit a form of OCD-related behavior, but many people who have OCD display behaviors that are completely unrelated to hoarding. Because of that, the two disorders are not the same. However, some similar traits — such as a desire to have control over one's surroundings — are found in both disorders, and they can certainly coexist in the same person (Tolin & Villavicencio, 2011; Tolin et al., 2011). For many years, psychiatrists and psychologists placed hoarding under the umbrella of OCD, because the person who hoarded items was fixated on a behavior and repeated it compulsively. He or she had an obsession with keeping everything, or a compulsion to purchase more and more things — encompassing both the obsessive and compulsive dimensions of OCD. This made it easy to classify hoarders as obsessive-compulsive.

As more was learned about hoarding, however, it became clear that there was much more to the disorder than whether a person kept items instead of discarding them, or purchased things that were not needed. There were often deep-seated reasons for the accumulation of what most people would consider garbage, and everyone's reasons for collecting things were different (Tolin & Villavicencio, 2011). Some people hoarded because they had very little as children; others did it to maintain control over at least one area of their lives; and still others could not easily articulate or explain why they did it (Tolin et al., 2011). Regardless of why a hoarder began keeping everything rather than discarding unnecessary items, treatment was necessary. When hoarding was considered part of OCD, standard OCD treatment was applied. Now that the DSM is moving toward classifying hoarding separately, there is a much greater chance that treatments will be more appropriate to the actual problem — and that can result in better outcomes for anyone who struggles with hoarding.

Inability to Discard Possessions

The ability to discard items that are no longer needed or wanted is something most people take for granted. They can dispose of such items easily — either by throwing them away or donating them to charity. Hoarders, however, do not have this ability (Anderson, Damasio, & Damasio, 2005). They may be able to throw out what they consider actual trash, but the definition of trash itself is the problem. In the mind of a hoarder, there is no real reason to discard anything. What if it is needed later? What if it can be repaired, repurposed, or completed? They hold onto the promise of what an item might become in the future (Tolin et al., 2011). More often than not, the item has no real future use, but the hoarder does not see it that way. He or she sees potential — and one does not throw away potential.

The ability to discard can be developed over time, but only with appropriate therapy. One of the clearest indicators of this problem is the state of the hoarder's home. Is it full of clutter? Is there trash that has not been removed for months or even years? If so, the ability to discard may be severely impaired — and that is something that can be improved upon. It may take considerable time for a hoarder to develop the ability to discard, given the deep-seated need not to throw anything away that might hold some value (Anderson, Damasio, & Damasio, 2005). Eventually, even items of essentially no value are kept, and the hoarder stops discarding anything at all. This can harm family life, endanger pets, and pose a physical danger to the hoarder, who may be buried under shifting boxes or trip and fall over piles of items on the floor (Tolin et al., 2008).

Conclusion

As this paper demonstrates, there are many issues faced by those who are diagnosed — or should be diagnosed — as hoarders. There are some similarities between hoarders and those who have OCD, but there are also differences that have been discounted or ignored by the DSM in the past. Correcting this classification can lead to more accurate diagnoses and more appropriate treatment criteria — both for those who hoard and for those who have OCD without any hoarding component. The problem was not with hoarding as a phenomenon, but with its having been grouped under a broader category that did not fully capture it. Now that the distinctions have been established, more people can be helped in ways that are truly appropriate to their disorder, rather than being fitted into the closest available category that does not quite match their actual experience.

References

Anderson, S. W., Damasio, H., & Damasio, A. R. (2005). A neural basis for collecting behaviour in humans. Brain, 128, 201–212.

Frost, R., & Gross, R. (1993). The hoarding of possessions. Behaviour Research and Therapy, 31, 367–382.

Saxena, S., Ayers, C. R., Maidment, K. M., Vapnik, T., Wetherell, J., & Bystritsky, A. (2011). Quality of life and functional impairment in compulsive hoarding. Journal of Psychiatric Research, 45, 475–480.

Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27(5), 476–484.

Tolin, D. F., Frost, R. O., Steketee, G., Gray, K. D., & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160, 200–221.

Tolin, D. F., & Villavicencio, A. (2011). Inattention, but not OCD, predicts the core features of hoarding disorder. Behaviour Research and Therapy, 49, 120–125.

Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2011). Hoarding among patients seeking treatment for anxiety disorders. Journal of Anxiety Disorders, 25, 43–48.