Title: Hoarding Disorder.
Author: Rawan Osama Abu Nsair.
Editor: Hala Qaryouti
Keywords: hoarding, OCD, attachment, clutter.

 

 Overview

In 1947, New York City police received an anonymous call regarding a possible death in a mansion in Harlem, New York inhabited by two brothers, Homer and Langley Collyer (2).

On arrival to the Collyer mansion, police found piles of clutter, including books, newspapers, and boxes reaching the ceiling in much of the mansion’s area, making the house traversable through maze-like tunnels hidden through the debris. After searching, Homer, 65 years, was found dead on a chair in an upstairs room, while no trace could be found of Langley. Efforts to evacuate the house continued until 130 tons of material were removed, including fourteen grand pianos, a pipe organ, an old generator, and the chassis of a Model-T Ford. (2) [figure 1]

Eighteen days later, Langley was found buried 10 feet from where his brother was found (2), crushed under debris by one of the baits he made to satisfy his fear of intrusion (3). Since his corpse was gnawed by rats, police concluded that he had died before his paralyzed brother Homer (2), leaving him to starve to death (3).

Soon after the Collyer brothers created a junk-cluttered building by hoarding objects of no value, firefighters started using the term “Collyer mansion” to describe the dangerous debris-filled sites (4). In addition, the term “The Collyer’s Syndrome” was used to describe such bizarre collecting behaviors. Nowadays, the behavior is referred to as Hoarding Disorder (HD) (5).

Hoarding Disorder is a newly-added disease in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), categorized under obsessive-compulsive and related disorders, and characterized by disorganization and the persistent inability to discard possessions regardless of their actual value. (6)

 

Epidemiology

The overall prevalence of HD is estimated to be around 2%, with the elderly being at higher risk such that prevalence among individuals over 70 years reaches up to 6%. Among the elderly, hoarding severity could be slightly higher in men than in women (7). However, prevalence rates are similar across genders (8).

It is noted that HD is more common among people who live alone, and those who are not married nor in a relationship (9). A transcultural study revealed that hoarding disorder presents with similar phenomenology across the United Kingdom, Spain, Japan, and Brazil (10).

 

Etiology and Pathophysiology

The exact etiology of hoarding disorder is still unknown. However, the numerous studies conducted revealed correlations between hoarding disorder and several factors.

A four-factor model described a mixture of information-processing deficits, emotional attachment problems, behavioral avoidance, and beliefs about the nature of possessions (11). Hoarding disorder patients show impairment in multiple cognitive domains, such as executive functioning and attention (12). In addition, decision-making deficits that accompany the disorder increase the distress patients feel, especially when obliged to choose whether to keep or discard an object (13). They also have an increased incidence of impaired visual memory, visual detection, and visual categorization (14) as well as lack of inhibition (15), which could be the reason behind the patients’ inability to resist the urge of acquiring a new object (13). Poor memory confidence is a significant correlation between inattention and excessive saving of objects (16).

Excessive acquisition and avoidance of discarding are reinforced when patients avoid the anticipated distress of making an incorrect decision to discard a given item (13). Patients with HD have difficulties identifying and describing feelings as well as unhelpful attitudes toward the emotional experience, so they use avoidance and acquisition to regulate their emotions (17).

A recent study found that there is no significant object attachment in patients with hoarding disorder (18). However, anthropomorphism (attributing human characteristics to inanimate objects) is strongly associated with hoarding symptoms such as excessive buying and obsession to acquire free items (19). In a study done to figure out beliefs and reasons for saving, the participants validated their behavior through several reasons, e.g. fear of losing important information or wasting a potentially useful object, and emotional significance (20).

Genetics also seems to play a role in the etiology of hoarding disorder, as 50% of geriatric hoarding disorder patients reported having a mother with hoarding tendencies, and over 26% reported having had a father with such tendencies (21). A twin study indicated that heritability is moderate-to-high, with about 50% of the variability in hoarding behavior attributable to genetic factors (22).

Regarding neurobiology, these patients have significantly greater grey matter in the right frontal pole (23). In addition, greater activity is found in the right dorsolateral prefrontal cortex and the anterior cingulate cortex, which could mediate the deficits in evaluation of rewards and visual processing observed in hoarding disorder patients (24).

 

DSM-5 Diagnostic Criteria (25)

1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
2. The difficulty is due to both a perceived need to save the items and distress associated with discarding them.
3. The difficulty of discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (family members, cleaners, authorities).
4. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
5. The hoarding is not attributable to another medical condition such as brain injury, cerebrovascular disease, Prader-Willi syndrome.
6. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

 After a diagnosis is established, Specify whether the disorder is:

• With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

Also, specify whether the disorder is:

• With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
• With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary.
• With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary.

 

Clinical Course

Hoarding disorder is a chronic progressive disorder, which usually has an onset in early adulthood (26). The average age for symptom onset is between 10 and 20 years, while the average age for the diagnosis of hoarding disorder was between 20 and 30 years (27), with daily-function impairment evident in the twenties, and definite impairment in the thirties (6). Therefore, it seems that severity increases as the age advances (27). However, some factors are associated with poorer treatment response, like male gender, early-onset, strong attachment to possessions, poor insight, comorbid depression/ anxiety disorders, cognitive impairment, and biological abnormality in the ventral prefrontal cortex (6).

On the individual’s level, HD has many functional consequences. Clutter interferes with basic activities like walking throughout the house, cleaning, cooking, personal hygiene, and even sleeping. About 6% of reported cases represented a serious public health hazard, since clutter accumulation puts the patients at risk of falling, fire, and poor sanitation (28), and impacts the patient’s family and neighbors. In most extreme cases it can raise legal issues, possibly due to forced evacuation (29).

A distinct entity of hoarding disorder is “animal hoarding”, in which the hoarder accumulates a large number of animals without being able to provide the minimum standards of sanitation, nutrition, and veterinary care (25). In addition, animal hoarders are associated with poorer insight and sanitary conditions compared to object hoarders (30).

 

Differential Diagnoses

First of all, hoarding disorder should be differentiated from normal collecting behaviors which result in little clutter and impairment (31) in comparison to hoarding disorder, which causes the accumulation of huge amounts of objects that disrupt the living space use (32). Moreover, normal collectors have a more selective and focused collecting behavior and are able to organize objects (32).

Hoarding behavior could be a result of many brain conditions that should be excluded before making the diagnosis, such as cerebrovascular disease, brain trauma, and central nervous system infections. Other psychiatric disorders can also cause HD, such as autism spectrum disease (ASD), dementia, schizophrenia, major depressive disorder (MDD), and obsessive-compulsive disorder (OCD) (33).

Hoarding symptoms can be a subtype of OCD or a partial symptom of obsessive-compulsive personality disorder (OCPD).  Hoarding disorder patients typically don’t show invasive and uncomfortable thoughts or images. They also have poorer insight in comparison to those with OCD. (6)

Attention-deficit/ hyperactivity disorder (ADHD) is a comorbidity present in more than 20% of HD patients (34). In fact, many studies revealed that both ADHD and hoarding disorder have a common biological background and considered inattention a core symptom in hoarding disorder (34). A large-scale study showed that 75% of hoarding disorder patients have a comorbid mood or anxiety disorder. The most common comorbid disorders are MDD, social anxiety disorder, and generalized anxiety disorder (29).

 

Treatment

Hoarding disorder is underreported, and that could be why it is unrecognized and undertreated (35). However, it is considered a treatment-resistant disease, and there are no professional guidelines for its management (29).

Psychotherapy, especially cognitive-behavioral therapy (CBT) has been proven useful when addressing the four deficits thought to be involved in the disease’s etiology (mentioned above) (29). CBT involves sorting and discarding practices. For example, the therapist asks patient to bring a box of objects to the session to provide graded exposure to discarding (36). Therapy could be offered as an individual or group CBT, as group therapy may be offered as a cost-effective alternative (16). In both methods, monthly home visits can be scheduled. CBT was found to decrease hoarding symptoms by about one-third over 20–26 weekly sessions (37).

Studies on pharmacotherapy are still premature. However, some selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, (36) and serotonin and norepinephrine reuptake inhibitors (SNRIs), such as extended-release venlafaxine, (38) have been suggested as effective treatments for hoarding symptoms. Paroxetine has shown a moderate response not tolerated in high doses, while venlafaxine was shown to achieve significant improvement within 12 weeks (38).

Researchers have conducted preclinical and clinical studies investigating the benefit of atomoxetine, a non-stimulant used to treat ADHD, for treating hoarding disorder on a small sample size in which 11 out of 12 patients completed a trial of atomoxetine at flexible-dose (40-80 mg) for 12 weeks, after which their mean UCLA Hoarding Severity Scale score decreased by 41.3%, and inattention and impulsivity symptoms showed a significant mean score reduction of 18.5% from baseline (39).

 

Digital Hoarding

With the increasing dominance and availability of technology, digital hoarding is appearing as a new term being suggested as another subtype in the literature. It describes the accumulation of digital files to the point of loss of perspective which can result in stress and disorganization. Hoarded items can range from files to applications, music, and pictures. Disorders such as OCD and physical hoarding scores are significant risk factors. (40,41)

The first reported case was of a photographer who took nearly 1000 photos per day and found difficulty discarding them due to his attachment to them and his belief that they may be of use in the future. However, contrary to his beliefs, he never used nor reviewed the photos after taking them, resulting in an accumulation so severe that the patient had 4 external hard drives to store the original pictures and another 4 as backup (40).

With the growing availability of digital media and the feasibility of storage methods, more research should be done to explore this field.

 

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