Hoarding: Examining the Basics
A Look at the Symptoms and Treatment Options for this Debilitating Disorder

Fugen Neziroglu, PhD, ABBP, ADAA Professional Member
Estee Acobas, MA
Great Neck, New York  Bio-Behavioral Institute

I’ve always had trouble throwing things away.  Magazines, newspapers, old clothes… what if I need them one day and I don’t have them anymore?  I don’t want to risk throwing something out that I should have saved.  The large piles of stuff in our house keep growing and they make it difficult to move around and eat and sit together as a family.  The piles are very upsetting to my husband and my children, who are embarrassed by them and won’t invite friends over because of it.  We get into horrible fights. I feel guilty that it causes my daughter to cry and scared when my husband threatens to leave me, but I get so anxious when I try to throw any of it away… I can’t bring myself to do it.  I don’t know what’s wrong with me.  I don’t know what to do.

This story is typical of someone who suffers from compulsive hoarding. Read on to learn what hoarding is, the differences between hoarding and collecting, and how hoarding can be treated.

What is Hoarding?

Compulsive hoarding is the gathering and saving of items that have little or no value — or have some perceived value — and that a person has great difficulty discarding.

People that hoard don’t necessarily acquire items that are different than others. Rather, it is the quantity that sets them apart. Commonly hoarded items include newspapers, magazines, paper and plastic bags, cardboard boxes, photographs, household supplies, food and clothing.

Hoarding can be related to the compulsive purchasing of items (such as never passing up a bargain, however useless), the compulsive acquisition of free items (such as collecting flyers), or the compulsive search for perfect or unique items (which may not appear to others as unique, such as an old container).

Am I a Hoarder?

An individual who hoards can exhibit the following symptoms:

• Avoids throwing away possessions
• Has severe anxiety when attempting to discard possessions
• Has trouble making decisions and cannot decide what to keep, where and for how long
• Has some level of distress, including:
• Feeling overwhelmed or embarrassed by possessions
• Feeling suspicious of others touching items
• Depression
• Anxiety
• Has obsessive thoughts about possessions, including but not limited to:
• Fear of running out of an item
• Fear of needing it later
• Thoughts of checking the garbage can to ensure an item was not accidentally discarded
• May have functional impairments, such as:
• Loss of space inside the home
• Social isolation
• Family or marital discord
• Financial difficulties
• Health hazards
• Has great difficulty categorizing items
• Possessions are grossly disorganized

Hoarding may be present on its own, or a symptom of another disorder. Disorders most often associated with hoarding are Obsessive-Compulsive Personality Disorder (OCPD), Obsessive-Compulsive Disorder (OCD), Attention Deficit Hyperactivity Disorder (ADHD) and depression. Although less often, it may be associated with an eating disorder, Pica, Prader-Willi syndrome, psychosis and/or dementia (i.e. Alzheimer’s disease).  It is important that a qualified mental health professional determine why an individual is hoarding so he or she can receive appropriate treatment.

Reasons for Hoarding

Individuals who hoard do so for many reasons, including:

• belief that the item will be useful at a later date
• belief that the item has sentimental value
• belief that one cannot trust his/her own memory and needs the item as a reminder
• belief that the item was a bargain
• belief that the item is unique and can’t be replaced
• belief that the item has some value either now or potentially in the future
• inability to decide where the item goes, so it’s better just to hold on to it, and
• belief that printed material should be read cover to cover before discarding because the information may be useful in the future.

What is the Difference between Hoarding and Collecting?

Hoarding is not the same as collecting.In general, collectors have more of a sense of pride about their possessions, and experience joy in displaying their possessions and conversing about them. They keep their collection organized, feel satisfaction when adding to their collection, and budget their time and money around their possessions.

In contrast, hoarders generally experience embarrassment about their possessions, and feel uncomfortable when others see them. They have clutter, often at the expense of functional living space, feel sad or ashamed after acquiring additional items, and often experience debt, which may be extreme.

Quality of Life

• Hoarding can affect a person’s quality of life in many ways.  A lack of functional living space is a common issue, in addition to unhealthy and sometimes dangerous living conditions. Individuals who hoard often live with broken appliances, without heat and without other necessary comforts rather than allow a qualified person into their home to fix the problem. Hoarding also affects family members, and can cause anger, resentment, and depression, as well as social issues in children. Legal ramifications may include separation or divorce, eviction from an apartment/home, and even loss of child custody due to neglect. Hoarding may also become a major financial issue. 

Effective Treatment Options Are Available

Treatment options for compulsive hoarding include:

Cognitive Behavior Therapy

A modified version of cognitive behavior therapy (CBT), commonly used to treat anxiety disorders, is often used to treat hoarding. With this treatment, a mental health professional will complete a functional analysis of the individual consisting of a thorough assessment of all the environmental influences, beliefs and emotions that influence his or her hoarding behavior. The therapy addresses and attempts to alter the presence of some of these factors, and teaches people to recognize their dysfunctional thinking and replace it with more rational thoughts. Changing these thoughts and beliefs about hoarding can lead to changes in feelings and behaviors related to hoarding. For example, beliefs related to the importance of a certain collection of items (i.e., old newspapers), and beliefs that one cannot do without them can be challenged and modified to a more rational way of thinking (I do not want to throw this out, but I can do it).

Cleaning the Clutter (a part of CBT)
An integral behavioral component of CBT treatment modified for hoarders is the actual clearing of clutter. A first step is to try to temporarily suspend acquisition of new items. One method of ridding the clutter that has been effective is the three-and-a-half box technique. This involves selecting a target area to work on and completely clearing it of all items. It is strongly suggested to choose an area that is highly visible and would be most rewarding and/or will provide the most functional living space, such as a couch, the dining room table or the kitchen counter. Target areas can be broken down into more practical chunks, such as one-half of the couch at a time. Items are cleared in a systematic fashion, initially one item at a time, and are temporarily stored in one of the following designated boxes:

Save Box: For items to be saved but that do not belong in the target area

Ex: a stapler on the dining room table

Display Box: For items to be returned to the target area for permanent placement

Ex: throw blanket, if the target area is the couch

Discard/Recycle Box: For items to be thrown away or recycled. Bags can alternatively be used, and the box can be split to temporarily place items to be sold and/or donated as well.

Ex: old clothing currently not in use

To-Do-Immediately Box: The half-box; for items that are extremely important and need to be attended to immediately

Ex: an important bill that is due

After a target area is complete, everything but the save box are emptied and disposed as appropriate, and the save box is labeled with the items contained. Regular cleaning sessions are scheduled, preferably at least one thirty to forty-five minute session per day initially. It is important to take rewarding breaks and not to work in one long, continuous block. Additionally, once a target area is cleared, it should be used for its intended purpose in order to increase motivation to maintain the area. Once one target area is complete, the next one should be tackled, with a focus on both clearing the new area and maintaining previous accomplishments.

Medication
Sometimes hoarders do not respond to medications commonly used to treat anxiety disorders (for instance SSRI antidepressants), and the disorder often can be treated without medication. In some cases, however, medications can increase treatment response, such as when there are other conditions or factors present that impair a person’s ability to follow through with treatment (such as extreme anxiety, attention deficit symptoms, severe depressed mood, suicidal thoughts or thoughts of harm, OCD symptoms, alcohol/drug abuse, and hallucinations or delusions). Medications used in these cases include antidepressants (tricyclics and MAOIs), anti-psychotics, anticonvulsants, anti-anxiety agents and stimulants.

How to Help a Family Member

There is often a great deal of tension between an individual who hoards and his/her family.  The family may have difficulty understanding or tolerating the clutter since the behavior directly impacts others in the household.  There is often a loss of functional space, so the kitchen table can no longer be used for family meals or the couch is unusable, etc.  In response, family members may attempt to discard items without the hoarders’ knowledge.  This creates more anxiety, suspiciousness and possessiveness of the items being hoarded.  Family members typically urge their loved one to seek help without success.  An intervention technique that is described by Neziroglu et al. (2004) in Overcoming Compulsive Hoarding is recommended for family members who are trying to get loved ones into treatment.  This method involves having significant individuals in the life of the hoarder one by one encourage them just to seek a consultation visit with an already selected therapist who is familiar with the situation. An individual with hoarding recognizes the tension in the household and may feel a number of negative emotions, such as guilt, hopelessness, anger and/or anxiety, which can exacerbate the hoarding behavior itself.  Discussing these feelings may help the sufferer to listen to the plea of the loved ones during the intervention.

Because the entire family is often affected by hoarding, family involvement in treatment is necessary and valuable.  Psychoeducation and training for the family can decrease the household tension and allow the individual with hoarding to better address their symptoms. For example, family members are urged never to touch the hoarded items without the consent of the person hoarding. Family involvement is especially useful when someone resistant to treatment. Intervention methods are often taught to families who are faced with this situation.

If you question whether you are a hoarder, you may go to the website www.bio-behavioral.com and take a brief quiz that may be helpful to you. For help finding a therapist in your area who can treat compulsive hoarding, click here.