Hoarding: Obsessive Symptom or Syndrome?

| February 15, 2010 | 0 Comments

by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base.

Psychiatry (Edgemont) 2010;7(2):24–27

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Disclaimer: The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Abstract

Through media depictions, the public is becoming increasingly aware of the phenomenon of hoarding. Hoarding refers to the excessive acquisition of relatively worthless items, which eventually results in the compromise of living space and/or the daily activities of affected individuals. As a symptom, hoarding is relatively common in a significant minority of individuals with obsessive-compulsive disorder. In the context of obsessive-compulsive disorder, symptoms typically emerge in the teens through the early 20s. However, hoarding also appears to exist as a distinct syndrome, which is characterized by late onset, childhood adversity, various Axis II traits, and a history of alcohol misuse. While the explicit position of hoarding in the psychiatric nomenclature remains undetermined, this behavior is likely to surface in both psychiatric and primary care settings.

Key words: hoarding, Diogenes Syndrome, obsessive-compulsive disorder

Introduction

Hoarding is a phenomenon that is increasingly being discussed in the media. As an example, a recent newspaper article described a 52-year-old man in Cincinnati, Ohio, who was placed on probation by the court system for hoarding-related violations of the health code.[1] He reportedly collected tools, electronics, and various odds-and-ends, with the alleged intent to fix and sell the items at flea markets. Because of the extensive clutter both inside and outside his home, local authorities developed concerns about the potential for health and fire hazards, and charged him.

In response to more frequent homeowner situations like these, one Cincinnati judge is now requiring mental health treatment for severe hoarders as a condition of probation.[1] To underscore the environmental and health risks of hoarding, a number of communities have established task forces on hoarding including Orange County (California), Marin County (California), the city of Newton (Massachusetts), Fairfax County (Virginia), and San Francisco (California).[2] Hoarding-plagued actress Delta Burke, of the television series Designing Women, has candidly acknowledged that, at one point, she rented 27 storage units to amass her belongings.[3]

Hoarding has also been a topic on The Oprah Winfrey Show.[4] In this edition of The Interface, we discuss hoarding—symptom versus syndrome—which not only affects individuals and families, but also communities.

Hoarding: A Working Definition

Hoarding is characterized by the following: 1) the excessive acquisition and collection of relatively worthless objects and possessions and 2) a resulting compromise of the immediate living space because of the amount of material collected. Affected individuals have strong urges to collect and save items as well as difficulty in discarding them.[5] The collected objects typically consist of seemingly worthless items (i.e., objects of no genuine value to others),[6] such as printed materials (e.g., newspapers, magazines, junk mail)[7] as well as notes, lists, receipts, and old clothes.[8] Hoarding does not entail a specific amount of clutter, but rather clutter that functionally interferes with the normal use of living space (e.g., clutter that impedes the ability to cook, clean, sleep, and/or move through the dwelling). Because of the cordons of clutter, inhabitants of such dwellings may be at a higher risk for falls, fires, sanitation difficulties, and health risks.[9] While hoarding is not a specific diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), this behavior has seemingly been conceptualized as both a symptom as well as a syndrome. As a symptom, hoarding has been observed as an associated feature in obsessive-compulsive disorder (OCD), yet hoarding is not a specifically identified behavior for OCD in the DSM. As a syndrome, hoarding appears unrelated to OCD and is more likely to affect older age groups.

Collecting versus hoarding. Hoarding is not the same phenomenon as collecting, which is the systematic acquisition of specific types of objects (e.g., stamps, coins, posters, DVD movies) that are kept and maintained in designated places.[10] As a methodical activity, the purpose of collecting is to organize and categorize a series of objects, not to just hoard them. Unlike hoarding, the items are frequently valued by other collectors, as well.

Hoarding: Different Contexts

In general, hoarding appears to emerge during two broad life periods—youth and late adulthood. During youth, hoarding is commonly present in conjunction with OCD. In the aged, hoarding is usually not associated with OCD. In addition to these differences in onset, there appear to be a number of psychological divergences between these two presentations of hoarding as well.

Hoarding onset in youth. Hoarding has long been an associated symptom of OCD and is encountered in 18 to 33 percent of such patients.[9] In a large sample of hoarders with comorbid OCD (N= 235), Samuels et al[11] determined a mean age-of-onset of 14.4 years as well as high rates of mood disorders (e.g., 68% with major depression) and anxiety disorders (e.g., 45% with social phobia, 42% with generalized anxiety disorder, 38% with specific phobia). In this sample, the most frequent comorbid Axis II disorder was obsessive-compulsive personality disorder (22%).

Winsberg et al[12] also described a cohort of hoarders with comorbid OCD (N=20). In this sample, the mean age-of-onset for hoarding behavior was 20 years. Among these participants, 84 percent reported a family history of hoarding, 80 percent grew up in a household with a hoarder, and a number of participants disclosed comorbid psychiatric syndromes such as major depression (40%), obsessive-compulsive personality disorder (the only Axis II disorder reported, 15%), and impulsive behaviors (e.g., compulsive shopping, 35%; pathological gambling, 10%).

In terms of adjunctive psychological features, in comparison to hoarders without OCD, research indicates that hoarders with OCD tend to acquire bizarre items, demonstrate comorbid obsessions and compulsions related to hoarding, and experience checking rituals.[13] In addition, hoarders with OCD symptoms commonly demonstrate a negative affect.[14]

Hoarding in old age. A second general group of hoarders appears to develop symptoms in late adulthood. First reported in a 1975 Lancet article, Clark et al15 described a pattern of “serious self-neglect in the elderly,” which they labeled with the moniker Diogenes Syndrome. In their original description, Clark et al15 emphasized the behavior of “syllogomania”—the hoarding of rubbish—as well as “dirty untidy” homes and a “shameless filthy” appearance. In their case review, affected individuals frequently presented for medical care because of falls or physical collapse. While most were well known to social services, few accepted intervention. The authors suggested that this syndrome may be a reaction in late life to stress within the context of a certain type of personality.

While empirical data for this older subgroup of hoarders are limited, in a community study (N=27), the only one of its kind, Samuels et al[16] found that no participant exhibited comorbid OCD. As expected, researchers found an increasing prevalence of hoarding with increasing age, with hoarding being three times more likely in the oldest compared to the youngest age group.[16] Associated psychiatric characteristics in this sample included high rates of lifetime alcohol dependence (52%), several personality disorder traits (e.g., in order of frequency—obsessive-compulsive, avoidant, paranoid, schizotypal, antisocial personalities), and a history of childhood adversity (e.g., a parent with psychiatric symptoms, a lack of physical security, excessive physical discipline in childhood). Some of these characteristics appear to echo the findings originally described in Diogenes Syndrome, including the presence of personality factors as well as psychosocial stressors. Indeed, old age has been a repeated epidemiological theme in this subtype of hoarding,[7,17,18] with Saxena[19] stressing the importance of an early versus late-onset dichotomy.[19] Research also suggests that this subgroup may have lower levels of anxiety, worry, stress, and negative affect.[12]

Symptom versus Syndrome

It appears that hoarding manifests in at least two distinct contexts. In the context of OCD, hoarding may be described as a symptom. In the context of the elderly, hoarding may represent a possible syndrome. Maier[20] sums up this definitional dilemma by concluding that hoarding is a complex behavior that is associated with different types of emotional phenomena, including OCD.[20] Thus, while hoarding may symptomatically emerge in OCD, it is not exclusive to OCD. Likewise, some authors propose that hoarding warrants its own designation and associated diagnostic criteria as a defined syndrome.[21,22]

To summarize the preceding findings, hoarding may be a symptom—one that is commonly encountered in OCD—or a syndrome. As a symptom, hoarding demonstrates an early age-of-onset, an association with adjunctive obsessions and compulsions, and frequent comorbidity with mood and anxiety disorders. As a possible syndrome, hoarding symptoms appear unrelated to OCD; tend to culminate in old age; and may be associated with childhood adversity, various personality disorder traits, and alcohol dependence (Table 1). Again, hoarding as a syndrome shares a number of features with Diogenes Syndrome.

Conclusions

Hoarding is a behavior that may manifest either as a symptom (most commonly in OCD) or as a possible syndrome that develops with age. According to the available literature, these two manifestations differ with regard to the time of onset, Axis I and II comorbidities, and psychological contexts. There are likely to be other notable differences that warrant further research. Determining and defining the differences between these two variations of hoarding will undoubtedly promote diagnostically “cleaner” empirical studies as well as more effective approaches to treatment—both pharmacological and psychological. Such advances in our understanding of hoarding will be highly relevant for both psychiatric and primary care clinicians.

References

1. Cornwell C. Mental health experts look at compulsive hoarding. http://dailygleaner.canadaeast.com/liveit/article/527673. Accessed on April 7, 2009.
2. Hoarding task forces. http://search.msn.com/results.aspx?q=hoarding+task+force&form=QBRE. Accessed on April 7, 2009.
3. Delta Burke opens up about depression, hoarding. http://www.usatoday.com/life/people/2008-02-21-delta-burke_N.htm. Accessed on April 13, 2090.
4. Compulsive hoarding. The Oprah Winfrey Show. May 06, 2005. http://www.oprah.com/slideshow/oprahshow/oprahshow2_ss_20050506/6Accessed on April 7, 2009.
5. Saxena S. Neurobiology and treatment of compulsive hoarding. CNS Spectr. 2008;13:29–36.
6. Saxena S, Maidment KM. Treatment of compulsive hoarding. J Clin Psychol. 2004;60:1143–1154.
7. Murdock SJ. Conceptualizing hoarding behavior among elderly women: a mixed-methods approach. Diss Abstr Int. 2008;68:3151A.
8. Winsberg ME, Cassic KS, Koran LM. Hoarding in obsessive-compulsive disorder: a report of 20 cases. J Clin Psychiatry. 1999;60:591–597.
9. Steketee G, Frost R. Compulsive hoarding: current status of the research. Clin Psychol Rev. 2003;23:905–927.
10. Lahera G, Saiz-Gonzalez D, Martin-Ballesteros E, et al. Differential diagnosis of hoarding behaviors. Actas Esp Psiquiatr. 2006;34:403–407.
11. Samuels JF, Bienvenu OJ 3rd, Pinto A, et al. Hoarding in obsessive-compulsive disorder: results from the OCD Collaborative Genetics Study. Behav Res Ther. 2007;45:673–686.
12. Winsberg ME, Cassic KS, Koran LM. Hoarding in obsessive-compulsive disorder: a report of 20 cases. J Clin Psychiatry. 1999;60:591–597.
13. Pertusa A, Fullana MA, Singh S, et al. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? Am J Psychiatry. 2008;165:1289–1298.
14. Wu KD, Watson D. Hoarding and its relation to obsessive-compulsive disorder. Behav Res Ther. 2005;43:897–921.
15. Clark AN, Mankikar GD, Gray I. Diogenes syndrome. A clinical study of gross neglect in old age. Lancet. 1975;1:366–368.
16. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther. 2008;46:836–844.
17. Marx MS, Cohen-Mansfield J. Hoarding behavior in the elderly: a comparison between community-dwelling persons and nursing home residents. Int Psychogeriatr. 2003;15:289–306.
18. Kim HJ, Steketee G, Frost RO. Hoarding by elderly people. Health Soc Work. 2001;26:176–184.
19. Saxena S. Is compulsive hoarding a genetically and neurobiologically discrete syndrome? Implications for diagnostic classification. Am J Psychiatry. 2007;164:380–384.
20. Maier T. On phenomenology and classification of hoarding: a review. Acta Psychiatr Scand. 2004;110:323–337.
21. Grisham JR, Brown TA, Liverant GI, Campbell-Sills L. The distinctiveness of compulsive hoarding from obsessive-compulsive disorder. J Anxiety Disord. 2005;19:767–779.
22. Saxena S. Recent advances in hoarding. Curr Psychiatry Rep. 2008;10:297–303.

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Category: Impulse Control Disorders, Past Articles, Primary Care, Psychiatry, The Interface

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