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Awareness of obsessive compulsive disorder (OCD) has increased tremendously over recent years, but there’s one lesser-known condition that can be a symptom of OCD that affects more than three million Americans: it’s called hoarding, or compulsive hoarding syndrome.

Hoarding is the excessive collecting of items, along with the inability to discard them. It often creates such cramped living conditions that homes may be filled to capacity with only narrow pathways winding through stacks of clutter. Interestingly, not all people who hoard have other OCD symptoms and researchers are working hard to understand hoarding as a mental health problem. To help spread awareness about hoarding and the help available to treat it, the A&E Television Network produces a real-life program called Hoarders.

Hoarders is a real-life, unscripted look inside the lives of people whose inability to part with their belongings is so out of control that they are on the verge of a personal crisis. They may encounter losing their home, custody of their children, divorce, incarceration. In a fly-on-the-wall format, the program captures the drama as experts work to put each on the road to recovery.

But, according to experts, cleaning is just the first step in the treatment of hoarding. Recovery is just as difficult as overcoming an addiction. Many people find it daunting and disturbing to discard even the most insignificant item – a cardboard toilet paper roll, old keys, even food products. In fact, most find the pain of giving up possessions, that they won’t let the cleaning crew proceed. For other hoarders, professional help and an organizer's guidance give them the strength to recover. At the end of each episode of Hoarders, viewers find out who has been able to keep their hoarding behavior at bay and who, despite help, is still lost inside this painful disease.

Clinical psychologist Suzanne Chabaud, Ph.D., works with families featured on the television program to help them understand hoarding and get on the road to recovery. She talks with BHC today* for an insightful look at hoarding.

 BHC: Dr. Chabaud, as a clinical psychologist, you’ve treated more than 400 patients with OCD, and so for those in our audience who don’t quite understand what hoarding is, can you give us an overview of the different sorts of hoarding and what causes it?

SC: Yes, hoarding is considered now to be compulsive in nature and we’re trying to differentiate it from OCD in general obsessive compulsive disorders. There’s a fairly large percentage of people who have OCD who do hoard, but also there’s a percentage of people who hoard who do not have an obsessive compulsive disorder. So we’re trying to really understand what the disorder is, and as it stands right now, we view compulsive hoarding as an acquisition of objects and the failure to discard those objects.

Objects are defined very generally, as it can vary from information that a person might want, such as in written material, to boxes, to animals, to clothes. But regardless, we use the word object to refer to anything that a person acquires and that they fear letting go of those objects. So over the course of a persons life history, there’s a greater acquisition, or keeping of objects, and a failure to let them go.

What happens is that over time, their living space becomes very cluttered to the point that they have difficulty moving about their environment. This can cause a great risk to them in terms of health, in terms of safety. Also we see that because the home becomes filled with objects that the person’s social life diminishes. Over time, there’s a decrease in their ability to connect with other people because they’re over connected with what exists in their home, the objects that they have collected.

The people who are important to them in their life at some point really do not want to enter that living space, so they become disconnected even from their most intimate relationships. If they are living with other people, other family members, those family members tend to either get absorbed in the illness or they distance themselves from the illness.

We have seen even in the A&E show Hoarders that one of the adolescent boys was actually living in the garage because he could no longer tolerate living in the home. Also as part of the compulsive hoarding is that there is some significant distress in the hoarder. Now, does the distress come form the pressure that they’re receiving from the external environment to get rid of their things, or does it come from the fact that they’re living in a cluttered space? Both are true, and I’ll get more into that later.

Often though, people become comfortable in their clutter and their senses become numb over time, so they don’t really see how bad the situation really is. Often, people who have compulsive hoarding at it’s most severe stage lack insight into their disorder. They don’t see how bad it really is, which makes them much more reticent to get help because they don’t believe that they really need help.

If a person has more insight into their disorder and feels that they cannot control what is happening in their lives, this causes distress. If they have pressure from family members about what is happening, this also causes distress. Another symptom of compulsive hoarding that is very common is that the objects that they acquire because they are of limited value to other people but are overvalued by the hoarder, they start developing a fear that they don’t have all of the objects that they collected. So while they’re trying to reassure themselves that those objects still exists, they will go through a process that’s called churning. That is where they are moving through the objects in their environment, moving them about, looking at them, sometimes because they cannot find something, so the objects in their house become increasingly more disorganized. It’s a sea of objects in which they cannot find what they really want. Interestingly on the show Hoarders I’ve observed that despite the fact that there is a sea of objects that seem to be totally disorganized, they can sometimes find the smallest object. So, interestingly, even though there’s anxiety about not finding things, because they do go look through their objects often, they do know where some are. So you see that problem in memory and some respect, but also excellent memory for small details and other respects.

BHC: Dr. Chabaud, let me interject this quick question. What if what the hoarder collects involves food or other things that decompose? How does that effect them when those things start being unusable? Do they still have the need to keep them?

SC: In every extreme case of hoarding that I have witnessed, there’s an over collection of biological objects which can include food, mostly includes food, but can also include some of their own parts of their body: it could be feces, it could be urine, it could be animal waste, and all of this is in the environment decomposing and creating very poor air quality.

I’ve also noticed if I go into a home in which there is a severe hoarder, I can barely tolerate the air, but they seem to tolerate it quite well. They do often have some kind of breathing problems, but they don’t realize how noxious the environment really is and that’s what we call sort of a ‘sensory dulling’ that takes place with the hoarder in it’s extreme case. You do have to be aware that there are real hazards that occur when hoarding is at it’s extreme level and these hazards are not only because of the air quality, it’s also because there’s also a fire hazard. There’s hazards caused by their ability to move around in their environment: piles of objects could fall on them, they could trip, this is particularly of concern with seniors and hoarding of course becomes progressively worse over time and the older a person gets the more at risk they become.

BHC: Doctor, for those who are patients who are still in the working years, do you find that it often impacts their ability to be productive outside of the home?

SC: That definitely can occur where they’re less productive outside, but I’ve also seen the case where people can be highly functional in a work situation and then enter their other world when they come home. I think that you have to keep in mind that the more that this illness progresses, the more confused a person becomes in their cognitive functioning. So it seems to me that the cognitive components of hoarding, such as the ability to make decisions, the ability to discriminate objects in terms of it’s value, seems to be anchored in their personal world in the outside world.

I have seen people be able to organize their office extremely well because they have a designated purpose, they have a clear map of what is required of them and it can be an over rehearsed function that occurs overtime so that work environment actually could be okay for them. But we have to keep in mind that when compulsive hoarding becomes severe, there are other symptoms that can occur and usually do, such as depression. And when a person becomes depressed, naturally they’re not going to function as well outside of the home.

BHC: When you mention that there’s often co-occurring situations like depression or anxiety, let me just ask a question regarding health insurance coverage. When somebody either through a family intervention or a self referral comes to you for help with hoarding, is it something that their insurance company will cover, is it recognized as a mental health problem?

SC: There is no diagnosis for hoarding at this point in time. What we have tended to do is diagnosis it as a form of an obsessive compulsive illness and that is covered by insurance. The research data is ahead of the diagnostic manuals. A current diagnostic manual actually includes hoarding as a symptom of an obsessive compulsive personality disorder and that is not usually covered by insurance, personality disorders are not usually covered. Now we’re realizing that in fact this is more than a personality disorder, that in fact it, is a real clinical disorder in and of itself. It likely can be just differentiated from an obsessive compulsive disorder and maybe it’s own unique disorder that likely would be covered by insurance because it is a real health condition.

BHC: So for those who don’t completely understand hoarding (I think a lot of us over time might collect thing, such as clothes that we’ve had since high school or children’s toys that we needed to get rid of. I think our mindset is, “One Saturday, I’m going to get to that and get rid of it. But I believe if I’m understanding what you’ve been saying is that people who have an obsessive disorder related to hoarding actually intend to keep them forever because they value them, is that correct?

SC: That’s correct. And I will in a minute go over some of the features that we do see in hoarding and overvaluing objects for a number of reasons is primary to the condition. So you may avoid taking care of some of your responsibilities because you’re too busy, but it’s not because you overvalue the objects. That’s a big difference. And so there’s avoidance because you don’t have time, or your life is too busy, this is not what’s happening with hoarding. Hoarding is caused by a real problem that exists in how you value objects, how you make decisions, how you categorize objects, your attention, your ability to attend to the objects and to the world around you. So there may be some real attentional deficits. There’s like we said the belief that objects are more important that they really are to most people and usually there is an emotional attachment to many of the objects that they do have. So you may not be attached to the clothes that you don’t put away, but they are attached to those clothes.

First of all, I’d like to just say that the research is suggesting that obsessive compulsive hoarding, or what we call now is a compulsive hoarding disorder, that’s now the most accepted term, probably is related to OCD. But there’s more to it than just OCD.

We do know that hoarding now is seen as connected. There’s a fairly large percentage. About 18-42 percent of people who have OCD have hoarding as a symptom, and also there’s a strong correlation between hoarding and what we seen in young children who have another type of OCD, which is an over focus on how things are organized, it’s a disorder of exactness in a sense. There’s a type of OCD that young children may have where everything has to be put in an exact place they like to look at their objects, count their objects they want everything to be even.

So here we have a type of perfectionism in children that’s another category of OCD and this type of OCD later in life seems to be correlated with hoarding. So now we’re confused because we’re saying, ‘Well, people who hoard don’t seem to do this, they don’t seem to organize objects, they don’t seem to be able to make those decisions about them.

What I’m thinking, and a lot of people are thinking, is that the system becomes overloaded. If when your young, the fact that everything has to be put in an exact category and as your getting older, you cannot do that because your categories become smaller and smaller, because you’re a perfectionist now, it’s not just that you have bathroom towels, but now you have to have towels for every occasion, every season. You have towels that have sentimental value, you have heavy towels, light weighted towels, Eventually, there are so many categories of towels that you don’t know how to organize them anymore. You just can’t put all of your towels in one drawer because it violates something inside of yourself.

So what could be very minute categories, just become a mass of objects, there are so many different categories that in some sense everything becomes the same. Everything becomes overvalued and you cannot actually operate within that system anymore of objects. Later what we’re seeing is that because of this that people get stuck, they don’t know how to proceed. They’re of course overly invested in the objects around them and they want to function in that world but as they start working on one small section of objects in their house they get distracted and why do they get distracted ? It’s possible because they have an attention deficit disorder but it’s also possible that any single object they have has so many connections to other things that are important to them, not only their own personal experiences but to multiple categories of importance that then they start pre-associating internally, they move from one thought to another, to another, to another, to another and they become sort of paralyzed in the process.

This is when they feel so overwhelmed. I believe that they cannot make decisions anymore, and this kind of paralysis eventually will lead to a feeling of being overwhelmed and depressed, incapable. We see, over time, a gradual decrease in self esteem. So all of the things that they really might have been good at earlier in their life, now becomes the functions that they are worse at. It’s also important that it’s not just about information processing, it’s not just about decision making, categorization and attention, but we also see that some very important categories for them are how important is the object to them emotionally.

So it’s not only about that this object represents a time in their life or a person that they valued, that kind of sentimental emotional attachment, but it also can be even thought of as part of themselves, so if they let go of the object, it feels like they are losing a part of who they are.

If we go into a home that’s completely cluttered, we feel that how could they feel comfortable in that environment? Well, if many of the objects represent something significant in your life or view as part of who you are, your self becomes extended beyond the confines of your body and now your whole self in some sense becomes the world in which you live. So naturally if someone goes in and says we’re taking away all of this stuff, there’s an experience of extreme violation really at a very core level, like your taking away part of who I am and so the hoarder can feel very emotionally violated by aggressive attempts to go in a take away their belongings.

In addition to this emotional attachment, there’s a distorted belief about just the importance of a single object. So there’s the idea that this object may be useful. For instance, at some point to somebody and so if I throw away this object ,I could be interfering with it’s use later by someone and what if it’s very important and I don’t take the responsibility to keep that for future use. So there’s this over exaggeration of a sense of responsibility for holding onto objects that most people would think are replaceable or you can get it elsewhere.

You don’t have to save that in your home in order to have access to it. There are other ways. But along with this exaggerated belief about the importance of any particular object comes this exaggerated sense of responsibility for maintaining those objects in their home. In addition to the information processing and the emotional attachment to object and distorted belief there’s an avoidance and avoidance is that, “I just can’t make decisions about this, I can’t deal with this, so I’m not going to think about it anymore.” And so in the treatment, we’re really trying to get people to take a look at their direct relation with a particular object to approach it, to go through the feelings that they need to go through about that object and to discuss that and then really work on teaching them, maybe stills that they already had, but much earlier in their life. It’s reminding them of skills that they have and refreshing those skills. Now they can become decision makers again.

*Article originally appeared on www.BehavioralHealthCentral.com on Feb. 1, 2010.

Related News Stories

• Chicago Tribune Mary Schmich column: Hoarding is not entertaining [Chicago Tribune]
• Animal hoarding an illness ending in heartbreak [Duluth News Tribune, Minn.]
• Reports outline obsessive compulsive disorder study findings from F. Jimenezponce and colleagues
• Data on obsessive compulsive disorder epidemiology published by researchers at University of Pennsylvania, Department of Psychology
   

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