The tall order of the hoarding disorder

A complex psychiatric disorder, hoarding can affect one’s quality of life and interpersonal relationships, warns Dr Alok Kulkarni

Asha, a homemaker in her thirties, had accumulated a lot of clutter in her home. She had started to save items that had little use for her. These included mundane things such as very old newspapers, torn bags, and ill-fitting clothes. She had persistent difficulties in discarding these items. There was no space in her home to store these items, and yet she continued to hoard them. This led to frequent tiffs with her family members. After much coaxing, she agreed to see a mental health professional who diagnosed her with a complex neuropsychiatric disorder called hoarding disorder.

Hoarding disorder (HD) is a complex psychiatric disorder that was included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V). Individuals meeting the diagnostic criteria for hoarding disorder experience persistent difficulty discarding or parting with possessions due to a perceived need to save the items; there is distress associated with discarding them. HD has its origins in the psychoanalytical descriptions of the ‘anal’ character. Hoarding runs in families. Heritability (a measure of how well differences in people’s genes account for differences in their traits) is between 36 and 50% and the remaining variance is attributable to non-shared environmental factors.

Specific genes implicated in HD are yet to be identified. Some unique environmental risk factors such as traumatic life events have previously been implicated, but it is unclear how such exposures contribute to the onset or exacerbation of HD. Anecdotal links between maternal deprivation, childhood poverty and hoarding have received no research
support. HD shares features with emotional, impulse control, and neurodevelopmental disorders such as ADHD. It is very likely that genetic and environmental influences will be partially shared with related conditions such as OCD, body dysmorphic disorder, hair-pulling disorder, and skin-picking disorder.

Clinical features

The landmark feature of HD is a persistent difficulty with discarding or
parting possessions. The most commonly saved items include newspapers, old clothing, bags, books, and paperwork. Discarding difficulties are generally motivated by the perceived utility or aesthetic value of the items, a strong sentimental attachment to the possessions, the fear of losing important information, a desire to avoid being wasteful, or a combination of these factors. The prospect of discarding or parting with possessions causes substantial distress to the individual. These difficulties result in the disorganised accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use. Frequently, the clutter extends beyond the person’s actual home, with the accumulation of possessions taking place in garages, gardens, vehicles, and even workplaces. Some individuals may pay for private storage spaces or ask family members or friends to keep items in their homes.

In severe cases, hoarding can put individuals at risk for fire, falling, poor sanitation, and other health risks. Quality of life is severely impaired and individuals with HD have strained interpersonal relationships. Legal proceedings ranging from forced clearings to evictions may also be seen. A diagnosis of HD can only be made after ruling out other medical conditions. Differential diagnoses include traumatic brain injury, cerebrovascular disease, CNS infections such as herpes simplex encephalitis, and neurogenetic conditions such as Prader-Willi syndrome. Hoarding may also be seen secondary to neurosurgical intervention for brain tumours or epilepsy. HD is not diagnosed if the accumulation of objects is judged to be a direct consequence of a neurodevelopmental disorder such as autism spectrum disorder or intellectual disability. Hoarding can also be a direct consequence of a neurodegenerative disorder such as Alzheimer’s disease or frontotemporal lobar degeneration (FTLD).

Interventions

The intervention that has the strongest evidence base for HD is a multi-component psychological treatment that is based on a cognitive behavioural model. This involves motivational interviewing to address ambivalence about therapy, educating about hoarding, exposure to sorting, discarding, and not acquiring; and cognitive strategies to facilitate these aforementioned interventions.

(The author is a mental wellness expert.)