Many of us are reluctant to throw things out.
We buy. We accumulate. We collect. Eventually our attics are packed with dusty heirlooms that we rarely, if ever, look at. Eventually we’re forced to pare down and head to the Goodwill.
But not all of us.
Hoarding — or the prolonged difficulty of discarding unneeded possessions — is pervasive in our culture, affecting nearly 3% of the population. This compulsive collecting, and unwillingness to part with “stuff,” is even the subject of multiple popular television series.
We recently spoke with Andrew Guzick, PhD, an assistant professor of psychology at Baylor College of Medicine and an expert on anxiety disorders, about how growing up around hoarding behavior can affect future mental health and well-being.
How do you conceptualize hoarding behavior?
The core feature of hoarding is the inability to throw things away. This can be due to many different reasons, whether there’s a strong sentimental attachment or the belief that you will need these items one day. Compulsive buying is often involved, and inevitable clutter.
How was hoarding first conceptualized among psychiatrists and psychologists? And when did the term first enter the lexicon?
It was originally conceptualized as a difficult-to-treat subtype of obsessive-compulsive disorder (OCD). A lot of that work identifying this subgroup was going on in the late 1980s and early 1990s. There was a small but growing group of researchers demonstrating that this is fundamentally different from OCD in several ways.
In terms of the clinical presentation, the comorbidity patterns are different from those for OCD. And the course is a little bit different; We see a progressive development across the lifespan, as opposed to a clear-cut diagnosis earlier in life, as is typically seen with OCD. By the time a lot of people seek treatment, they’re often being brought in by, say, family members when they’re a little bit older. With hoarding, there is also this consistent pattern of poor treatment response across the board, whether to selective serotonin reuptake inhibitors (SSRIs) or behavioral therapy.
A lot of this work together led to advocacy for recognizing hoarding as an independent diagnosis in the DSM-5. I think official recognition by our “big book” prompted more attention to this population. Previously these patients probably would have been diagnosed with OCD, and it really isn’t appropriate to think of hoarding as purely an anxiety disorder.
Hoarding Exposure and Future Mental Health
You have a new study, published in the , looking at mental health among adult children of parents with hoarding problems. Can you tell us what inspired you to run this study, and what you found?
There were a couple of factors.
We’d seen a lot of folks with hoarding in OCD specialty clinics, so my clinical experiences with this population certainly drew me to this general area. But then, at the same time, I have this broad training in child mental health. And childhood trauma or adverse childhood experiences, which can include being around hoarding, can be a very difficult thing to live through and deal with. And here I have to give a lot of credit to Suzanne Chabaud, PhD, of the OCD Institute of Greater New Orleans, who’s one of the co-authors on the paper. She’s been beating the drum of thinking about the family and kids of people with hoarding disorders for years. My interests came from some of those experiences, but she had the good idea of really looking at this problem in a detailed way.
Prior to your paper, had there been research on the prevalence of mental illnesses such anxiety and depression in the children of people with hoarding behaviors?
That particular question was new to our paper. It was the first time anyone, to my knowledge, had looked at a validated assessment of anxiety and depression in this population.
How did you assess their symptoms and what did you find?
We asked study participants to think back on how they felt throughout their teenage years and gauged their responses with the patient health questionnaire (PHQ), a measure of mental health disorders. I should say upfront that we didn’t have a control group. But we found that among our 414 study participants, somewhere between 30% and 50% reported clinically significant anxiety or depressive symptoms, far higher than you’d expect in the normal population. So when looking back on how they were feeling as teenagers in that environment, they were struggling, and they often felt rejected by their parents.
We also found that almost 10% of participants were threatened with eviction at some point in their childhood; 15% had to live outside of their home at some point, due to the clutter; and 2% had interference from child protective services and were removed from the home.
I know you recruited patients form online forums established by the children of hoarding parents. Presumably, these are the people most affected by this phenomenon. How does this play out in people who simply like to, say, collect something? Is this a continuum of behavior, with a breaking point at which it becomes a pathology?
I think it’s safe to conceptualize collecting and hoarding as a continuum, and you’ve got to draw a line somewhere in terms of clinical significance.
Did you assess whether the children of hoarders were more likely to hoard themselves as adults?
This is our follow-up paper; we haven’t looked at it yet.
But in looking at preliminary data, the prevalence seems pretty low, actually, at least in our sample. And as you mentioned, in our study there were folks who were seeking support specifically because they grew up in a really cluttered home.
How do mental health providers typically address and treat hoarding?
To my knowledge, there are no current FDA-approved medications for hoarding, though psychiatrists will prescribe SSRIs and try to treat co-occurring problems such as depression and anxiety symptoms.
I can speak to cognitive-behavioral therapy (CBT) in a bit more detail. A number of randomized controlled trials support CBT for hoarding. I mentioned before that when we as a field treated hoarding akin to OCD and did exposure and response prevention therapy, we didn’t really target the specific features of hoarding. People didn’t do that well.
But now researchers are focusing on CBT interventions focused on discarding tasks that really address hoarding. You can create different categories for different items: Patients can either keep them, throw them out, or donate them. You can explore what thoughts or expectations are associated with these items and try to address them. Clinicians can help patients look at, say, different areas of their house and discuss what they might be willing to part with or at least parting with. You find their internal motivations for keeping things.
This sort of therapy generally takes longer than it does for, say, OCD. It can be a little bit slower, particularly if someone has a lot of stuff. And often it can involve doing home visits. In the age of Zoom this is a little bit easier because home visits aren’t always feasible.
What role does family play in managing hoarding? I imagine that including loved ones and friends in the process could be quite helpful.
Yes, absolutely. And social support, more broadly.
A colleague I worked with did a really interesting study where she looked at psychologist-delivered vs peer-delivered CBT for hoarding. They found that the biggest predictor of improved outcomes was having what they called a “clutter buddy,” which follows the Alcoholics Anonymous sponsor model. This would be somebody else struggling with the same problem who’s an accountability partner helping a patient follow through with their goals related to discarding. I think that finding underscores how important that social support is.
Any final thoughts for the Medscape audience of clinicians and researchers on how to approach hoarding?
I think there’s been a stigma — at least in psychology circles — that it’s not really treatable because of that earlier work with OCD. But on the CBT side, there’s now good reason to believe that people can live much happier lives and overcome this problem. CBT does seem to work for a lot of people with hoarding. That’s what I’d like to emphasize.