Chapter 23 HOARDING: CLINICAL ASPECTS AND TREATMENT STRATEGIES

Chapter 23 HOARDING: CLINICAL ASPECTS AND TREATMENT STRATEGIES
Randy O. Frost, Ph.D., Gail S. Steketee, Ph.D.
[Find biographic information at the end of this document.]
This document is Chapter 23 from the following book:
OBSESSIVE-COMPULSIVE DISORDERS
Practical Management
Third Edition (1998)
Michael A. Jenike, M.D., Lee Baer, Ph.D., William E. Minichiello, Ed.D., editors
HOARDING SYMPTOMS AND FEATURES
Hoarding behavior is most commonly associated with the collection and storage of food items among rodents,
small animals, and birds.[1] Among these creatures, food hoarding is a normal part of the life cycle and can be
stimulated in predictable ways.[2-4] Although non-food hoarding occurs in some nonhuman species, the
phenomenon is unusual and not well studied.[5,6] The relationship between nonhuman and human hoarding
is uncertain, although Smith[7] has suggested some similarities. Virtually no research exists on the hoarding of
food in humans and, until recently, only clinical descriptions of non-food hoarding among humans could be
found. Hoarding behavior has been observed in a variety of disorders, including anorexia nervosa[8], organic
mental disorders[9], psychotic disorders[10], obsessive-compulsive personality disorder (OCPD)[11], and
mental retardation.[12] However, the majority of research links hoarding to obsessive-compulsive disorder
(OCD).
Definition of Hoarding
Although it is widely recognized as a symptom of OCD, hoarding is not described in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV)[11] in this context. DSM-IV presents hoarding in the context
of OCPD in which it is defined as the inability to discard worthless or worn-out things, even though they have
no sentimental value. Hoarding is defined in the same way on the Yale-Brown Obsessive-Compulsive Scale
Checklist (Y-BOCS).[13] Until recently, little attention has been given to this type of compulsion in the
research literature, despite the fact that it appears difficult to treat.[14]
Because both the DSM-IV and Y-BOCS definitions of hoarding appear inadequate, Frost and Gross[15]
proposed a refined definition of hoarding as, "the acquisition of and failure to discard possessions which
appear to be useless or of limited value" (p.367). Several features of this definition are noteworthy.
The definition of hoarding includes acquisition[15-17] because most hoarders actively acquire possessions. We
have found that hoarders often buy extra possessions "just in case" they might need them in the future.[15]
For example, one of our study participants bought and kept more than 30 bottles of shampoo; if her hoard fell
below that number, she felt compelled to buy more. Another participant had rooms full of "gifts" that she had
purchased over several decades. She did not know to whom she would give them, but they were "good buys"
that she couldn't pass up. A third had accumulated an entire room full of unworn clothing with the sales tags
still attached.
The absence of sentimentality as an exclusion criterion is a second feature of this definition. Although both
DSM-IV and the Y-BOCS suggest that hoarding involves only non-sentimental saving, several studies dispute
this assumption. For example, Furby found that ordinary people save possessions for either instrumental
reasons (i.e., because they have a need for them) or for sentimental reasons (because they are emotionally
attached to them).[18] These are the most frequent reasons for saving among hoarders as well.[15] Clinical
observations have consistently described hoarding as, in part, an overemotional attachment to
possessions.[8,15,19,20] Further, hoarders develop a greater emotional attachment to their possessions than
non-hoarders,[16] and these emotional reasons are part of why they hoard .[15] Indeed, this feature appeared
so prominently among our study participants, that we made it a major component of our cognitive-behavioral
model of hoarding (see following paragraphs, and Frost and Hartl).[21]
One difficulty with our proposed definition is that it does not distinguish between hoarding as a behavior and
hoarding as a clinical symptom. That is, how much does one have to hoard to constitute a symptom of OCD?
In one of our first hoarding studies, we placed an ad in the local newspaper asking for "pack rats" or "chronic
savers" to participate in our research, and we received more than 100 calls. Although all these people
considered themselves hoarders, our home visits found that many did not have a clinical problem associated
with their hoarding. In our subsequent research, we found that the reasons for saving possessions and the
types of things saved by hoarders were no different than those of non-hoarders.[15] Hoarders endorsed the
same reasons for saving described by Furby[18] as reasons for saving in the general population. We also asked
self-identified hoarders and control subjects to rate 80 possessions on the extent to which they saved each
one.[15] (The 80-possession list was generated in an earlier investigation of frequently saved things, such as
clothes, magazines, and bags, as well as less frequently saved items, such as old appliances, flower pots, and
shoe laces.) From this list, we ranked items in each group and calculated a Spearman Rank Order correlation.
The correlation between the groups was high (rho = 0.79, p <0.001), suggesting that hoarders save the same
kinds of things as non-hoarders, but in larger quantities.
To clarify the distinction between clinical and non-clinical levels of hoarding, Frost and Hartl[21] proposed a
three-part definition of clinical hoarding: (1) the acquisition of and failure to discard, a large number of
possessions that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to
preclude activities for which those spaces were designed; and (3) significant distress or impairment in
functioning caused by the hoarding. This definition ties the notion of hoarding to clutter, which is the most
common associated functional deficit.
Hoarding, Obsessive-Compulsive Disorder, and Obsessive-Compulsive Personality Disorder
Is hoarding a characteristic of OCD, OCPD, or both? Because hoarding is one of the diagnostic criteria for
OCPD, it is reasonable to assume that it would be correlated with other OCPD diagnostic criteria and with
global measures of OCPD. To test this hypothesis, Frost and Gross[15] administered a self-report measure of
hoarding; measures of other OCPD characteristics such as perfectionism, excessive job involvement,
restricted affect, rigidity, generosity, and authoritarianism; and a global measure of OCPD to a sample of
college students. We found that hoarding was not correlated with a general measure of OCPD, nor was it
correlated in the predicted direction with most of the specific OCPD characteristics (the only predicted
significant relationship being between hoarding and perfectionism). In a follow-up study, Frost, et al.[17]
examined hoarding, perfectionism, and general OCPD traits in a group of self-identified hoarders compared
with community volunteers matched for age and gender. Although hoarders scored significantly higher on
hoarding scale scores and perfectionism, they did not significantly differ from community members on the
global measure of OCPD.
A number of studies have attempted to measure the covariation of OCPD symptoms,[22] but only one of
these has attempted to objectively measure hoarding behavior. Heatherington and Brackbill[23] told a group
of children that they could keep any rocks put into their box from a pile in the experimental room. Rocks
were selected based on the assumption that they were "transitional objects" representing money or feces.
The number of rocks they kept was the operational definition of hoarding. The number of rocks taken and
kept was correlated with other tests of parsimony. Unfortunately, no attempt was made to independently
verify the reliability or validity of this measure of hoarding. The findings from our studies, plus the scant
evidence on the covariation of hoarding and other OCPD characteristics, lead us to question whether
hoarding is truly a symptom of OCPD.
Is hoarding a symptom of OCD? If so, it should be correlated with other measures of OCD. Frost and
Gross[15] found that a hoarding scale was significantly correlated with nearly all sub-scales from three
different measures of OC symptoms among college students and a community sample. They also found that
self-identified hoarders had significantly higher scores on nearly all OCD sub-scales compared with a group of
matched controls. Subsequently, Frost, et al.[17] found that the hoarding scale was significantly correlated
with the Y-BOCS total score in a sample of college women. Further, when participants in this study were
divided into subclinical compulsives and non-compulsives based on their scores on an obsessive-compulsive
inventory, the subclinical compulsives more frequently identified hoarding as a target symptom on the YBOCS than non-compulsives.
In another study, we compared the Y-BOCS scores of a sample of self-identified and screened hoarders to a
matched control group. The mean Y-BOCS total score for the hoarding group was significantly higher than
that of the matched controls. (The mean Y-BOCS total for the hoarding group was 16.5, which indicated a
clinical OCD severity in this undiagnosed population.) These findings strongly suggest that hoarding is closely
associated with OCD symptomatology.
Associated Features of Hoarding
Prevalence estimates of hoarding symptoms in OCD patients range widely. Rasmussen and Eisen[24]
reported that 18% of 200 adult OCD patients had hoarding compulsions. Rapoport[25] found that 11% of 70
children with OCD had hoarding symptoms, and in a later study, it was reported that 42% (10 of 24) of
children with OCD had hoarding as a pronounced symptom.[26] However, because no definition of hoarding
was provided in these studies, the findings are somewhat unclear. We used the Y-BOCS Checklist and found
endorsement of hoarding obsessions in 31% and hoarding compulsions in 26% of 39 outpatients in treatment
for OCD.[17] Thus, it appears that hoarding symptoms typically occur in one quarter to one third of OCD
patients. No studies have documented the frequency with which hoarding is a primary symptom.
Greenberg[19] suggested that the onset of problematic hoarding occurs in the patient's early twenties.
However, this estimate was based on only four patients, two of whom reported hoarding symptoms in
childhood. Among 32 hoarders, Frost and Gross[15] noted that 66% recalled hoarding behavior in childhood
and an additional 25% reported onset in the teens or early twenties. A significantly greater number of
hoarders reported excessive saving among first-degree relatives (84%) than did non-hoarders (54%).
Interestingly, the hoarding patients were more often unmarried compared with non-hoarders in this study –
similar to findings from other OCD populations.[14] Nothing is known about the gender ratio of compulsive
hoarding, although Frost and Gross[15] found no gender differences on hoarding scale scores.
Although little research exists on the symptom of hoarding, the nature of acquisition tendencies was once a
popular topic in psychology. William James[28] believed acquisitiveness was an instinct commonly found in the
general population. Other early theorists incorporated hoarding into theories of psychopathology. Fromm[27]
described hoarding as one aspect of character, a way in which people related to the world around them. He
described a "hoarding orientation" which represents one type of "nonproductive character" in which security
depends on acquiring and saving things. For Freud,[29] the hoarding of money reflected the parsimony
component of the anal triad. Jones[30] elaborated on Freud's notion of hoarding by including the hoarding of
other possessions. Bender and Schilder[31] suggested that hoarding in children is a precursor to the
development of obsessions. Likewise, Adams[32] described it as a background characteristic from which
OCD develops. Other psychoanalytic writers (e.g., Salzman[33]) suggested that hoarding develops from
perfectionistic strivings to gain control over the environment. To achieve perfect control, the hoarder must
not throw out anything that might be needed in the future. Thus, because one cannot be certain of exactly
what might be needed in the future, the safest course of action is to save everything. In a slightly different
vein, Rapoport[25] suggested that hoarding is a "fixed-action pattern" (p.280) resulting from evolutionary
development. Similar to nesting in animals, this behavior is innate and released by certain hormonal changes.
Despite the longevity of some of these theories, they have failed to generate research that supports or refutes
them and have failed to generate treatment programs directed at compulsive hoarding. Prior to 1993, most of
the available information on hoarding came from case studies. Greenberg[19] described four cases of
compulsive hoarding. In each case, despite debilitating symptoms, patients strongly resisted changing the
hoarding behavior, and attempts by family members to discard possessions were met with intense anger and
threats of violence. Frankenburg[8] described an anorexic patient who hoarded "bits of paper and Styrofoam,
toothpaste tube caps, screws, and nails (p.57)." As with other hoarding patients, she had plans to use each of
these possessions, and consistent with Fromm's[27] observation, she felt "safe" only when she was
surrounded by her possessions.
*****
A COGNITIVE-BEHAVIORAL MODEL OF COMPULSIVE HOARDING
Based on our recent research using non-clinical samples,[15-17] on interviews of people suffering from this
condition,[15] and on attempts to change hoarding behavior,[34] we propose a cognitive-behavioral model of
compulsive hoarding[21] as a guide for future research and treatment. It is a preliminary model, in that many
of the features are hypotheses that are, as yet, untested. The model is phenomenologic in nature, in that it
outlines a number of experiential and behavioral features associated with hoarding. We make no assumptions
about how these features develop, but hypothesize how they are related to each other and to hoarding
behavior.
In this model, we view hoarding as a multifaceted problem that stems from four types of deficits or difficulties:
(1) information-processing deficits; (2) problems with emotional attachments to possessions; (3) behavioral
avoidance; and (4) erroneous or distorted beliefs about the nature or importance of possessions. These
deficits or difficulties overlap in significant ways. Each of these facets is discussed together with the pertinent
research in the following paragraphs.
Information-Processing Deficits
Deficits in information processing in compulsive hoarding encompass three general and overlapping cognitive
functions: (1) decision making; (2) categorization/organization; and (3) memory. These deficits appear to be
general, because they are not limited to saving or hoarding. These functions are closely related to one another
and can be difficult to separate.
Decision Making
The clinical literature suggests that indecisiveness is a hallmark of compulsive hoarding. Case descriptions
typically note the difficulty these people have in making general decisions,[20,35] not merely decisions about
what to save and what to throw away. In studies of college students, community volunteers, and selfidentified hoarders, we have found substantial correlations between general indecisiveness (unrelated to
hoarding) and measures of compulsive hoarding.[15,36] Deciding what to wear in the morning, what to order
at a restaurant, and what task to perform next are all troublesome decisions for compulsive hoarders. Warren
and Ostrom[20] suggested that the indecisiveness shown by compulsive hoarders may be a way of avoiding
mistakes. Consistent with this hypothesis, we found hoarding to be correlated with the perfectionistic
concern over making mistakes.[15] As with the findings regarding indecisiveness, this relationship existed in
student, community, and self-identified hoarder samples. Perhaps hoarding is an avoidance behavior closely
related to indecisiveness and perfectionism[15] (i.e., saving a possession allows the hoarder to avoid the
decision required to throw it away , thereby avoiding the worry that a mistake has been made). The general
indecisiveness displayed by compulsive hoarders forms the backdrop for specific difficulties in deciding
whether or not to save a possession, and if saved, where to put it.
Categorization/Organization
Another information-processing deficit that may be related to compulsive hoarding is categorizing and
organizing information. Reed[37] has suggested and other investigators[38-41] have found support for the
hypothesis that obsessionals have more complex concepts. They define category boundaries so narrowly that
few items fit within them, a feature labeled underinclusion, and thus many categories are required to classify
personal possessions. This has several implications for compulsive hoarders. First, each possession may be
seen as belonging to its own category (i.e., so unique that nothing else is like it and nothing can substitute for
it). Such a view makes it difficult to discard anything. Second, because each possession is unique and complex,
it is impossible to decide that a class of objects (e.g., old newspapers) is unimportant and can be discarded
without closely examining each one. All important aspects of each possession must be examined before
discarding. Third, because each possession is unique, it cannot be categorized with similar objects, and thus
there is no way to organize possessions.
An example of this phenomenon can be seen in the arrangement of a hoarder's books. The hoarder begins to
read a book but must stop to do something else. The book cannot be returned to the shelf because it is now
in a different category – books being actively read. It is placed on the coffee table. Next, a cookbook is
consulted for dinner and it too cannot be returned to the shelf because it is being used. It is deposited on the
back of the couch. The dictionary used next cannot be reshelved, lest the person forget the word he looked
up. This process is repeated until there are books everywhere, none of which can be returned to its shelf
because they are all different in their own category. Their new position in the room has meaning because
each position represents a different category, and an idiosyncratic sort of organization exists, but the ultimate
result is clutter and chaos.
The finite amount of space available means that possessions must be piled on top of one another until there
are large mounds of unrelated objects. From this chaos, a sort of temporal organization emerges. The
hoarder may have a sense of where things are placed based on when they entered the pile. Hoarders trying
to sort through a pile often pick up a possession and, not being sure what to do with it say, "I'll set it here for
now" placing it somewhere nearby. This is repeated until the piles are so large and numerous that they begin
merging (or collapsing) into one large pile. With each new attempt to organize and discard, everything in the
pile is examined and moved to the new pile or repositioned in the old pile. The end result is that the pile has
been "churned" but no real progress has been made.
Another organizational problem is the mixing of important and unimportant possessions. A typical pile
contains everything from paychecks to gum wrappers. We have observed that hoarders have trouble
determining the relative importance of possessions, because when a possession is picked up and examined, its
value increases. Whatever is "in sight" becomes more important. Judgments about discarding or organizing
that are based on the value of a possession are thus difficult to make. When being examined by the hoarder,
everything seems "very important." In the treatment of hoarding, we recommend the creation of a small
number of categories into which objects from a hoarding pile can be placed (e.g., save, discard, to go through
later). One of our participants created a fourth category, an "immediate-to-go-through" box. In it she placed
possessions from a pile on her couch that she deemed essential to go through right away (i.e., before our next
session). At the next session she had not gone through the box and could not remember what was in it, so
she created another category she called "immediate-immediate-to-go-through." This box contained the same
sorts of things that went into the immediate to-go-through box, but these seemed even more important. The
only difference between the objects in these two boxes was that she had handled one group of items more
recently and they had therefore become more important to her.
The mixing of important and unimportant objects in a hoarding pile creates complications when trying to
excavate the pile. The hoarder's wish to closely review everything before discarding it has some basis in
reality. For example, some of our research participants found envelopes full of cash (up to $100) among
decades-old newspapers. Such occurrences reinforce the hoarder's belief that he must carefully scrutinize
everything before discarding it.
Memory
Some evidence suggests that OCD patients and non-clinical compulsive checkers suffer from subtle memory
deficits.[42-44] In addition, OCD patients and non-clinical checkers show less confidence in their
memories.[44,45] Similar memory problems have been observed with compulsive hoarders.[21] Frost and
HartI[21] suggested that two aspects of memory are salient: (1) confidence in memory and (2) beliefs about
the importance of remembering or recording information. For example, one of our participants saved
newspapers because she was convinced she would not remember the information they contained. Saving the
newspapers allowed her to feel that she still retained the information, even though she could not remember
it. Frost and Longo[46] recently examined several hypotheses regarding memory functioning in compulsive
boarders. Participants scoring high or low on the hoarding scale were given the Wechsler Memory ScaleRevised and a measure of the extent to which they would rely on (have confidence in) their memory. The
findings failed to reveal any actual memory deficits, but did reveal significantly lower confidence in memory
among hoarders.
Beliefs about memory have been hypothesized to influence memory processes themselves (e.g.,
Andersson[47]). In the case of hoarding, these beliefs may be important determinants of saving behavior. In
addition to believing that things must be saved lest they be forgotten, hoarders also seem to believe that if an
object is out of sight, it will be forgotten. The concern reported by one of our participants about using a filing
system was, "If I put it with this stuff [into a filing system], I won't remember it!" This suggests that visual cuing
is an important memory aid for compulsive hoarders, and this element may explain why hoarders create piles
of objects in living areas and why things in sight take on greater value. Difficulties like these suggest that
hoarding is a problem not only of saving, but also of organizing possessions.
Why hoarders believe it is important to remember everything is unclear. It may be that they believe the
negative consequences of not remembering are more likely and more severe than do non-hoarders. The high
levels of perfectionism seen among compulsive hoarders[15] may be partly responsible for these beliefs.
Perhaps forgetting is interpreted as a mistake or failure that provokes distress. Lack of confidence in memory
among compulsive hoarders may manifest itself in checking rituals. The extent to which the hoarding or
checking is the primary symptom may be difficult to determine. Further research on the relationship between
checking and hoarding is necessary to sort out these questions.
Emotional Attachment Problems
We have already noted that hoarded items are saved for both nonsentimental and sentimental reasons. Case
studies and anecdotal reports of compulsive hoarding frequently note extreme emotional attachments to
possessions.[8,19,20,34] From these accounts, it appears that many hoarders see their possessions as
extensions of themselves. When other people touch or move them, the hoarder feels violated.[16]
Several empirical studies also have demonstrated the extent to which possessions are saved for sentimental
reasons. Frost and Gross[15] found that hoarders reported more sentimental saving than non-hoarders, and
greater emotional attachment to possessions. In a subsequent study, Frost, et al.[16] found evidence for two
types of excessive emotional attachment to possessions among compulsive hoarders: sentimental and
security-based. In the former, possessions serve as meaningful reminders of important past events. They
become extensions of the self not to be discarded without careful consideration, because getting rid of such a
possession feels like the loss of a close friend. Possessions also provide a source of comfort and security,
signaling a safe environment (see Fromm[27]).[48,49] For example, after a particularly stressful day, one
hoarder remarked, "I just want to go home and gather my treasures around me." The thought of throwing
away these possessions violates this feeling of safety. In a test of these emotional attachment hypotheses,
Frost, et al.[16] found that among both college student and community samples, hoarding severity was
correlated with a measure of sentimental attachment to possessions and the extent to which possessions
provided emotional comfort.
Such attachment also appears to occur among hoarders when they are acquiring new possessions. Buying
objects seems to provide hoarders with some degree of comfort, even if the items are frivolous. The
relationship between compulsive hoarding and compulsive shopping is unclear, although such a relationship
has been hypothesized.[21]
Behavioral Avoidance
A third prominent feature of compulsive hoarding is behavioral avoidance. Saving possessions allows the
hoarder to avoid the loss of objects that may be needed someday, that may be of use to others, or that are
aesthetically pleasing. Hoarding also prevents emotional upset associated with discarding (losing) possessions
with sentimental or safety signal value. Although it is clear that these situations are avoided, it is still not
entirely clear why. Perhaps the significant variable here is the fear of losing something that is not entirely
tangible. Hoarders who save newspapers, for instance, fear losing not so much the paper itself or the stories
that they have read, but information that may be there. O'Connor and Robillard[50] described people with
OCD as creating a fiction ("I may be contaminated") and trying to bend the real world to match the fiction
(trying to wash away germs that are not there). This idea is applicable here. Hoarders may manufacture an
idea that something very important is embodied in this possession. With newspapers, it may be information.
With junk mail, it may be opportunities. Used envelopes may represent a part of their life. Saving these things
means avoiding such losses. Likewise, excessive buying of unneeded items may seem to prevent the loss of a
good bargain. Relatedly, one of our research participants noted that imagining all the newspapers that are
published in the world made her very uncomfortable because of all the information that is lost to her forever.
In addition, hoarders save to avoid decision making – a difficult and unpleasant chore – perhaps because of
their excessive concern over mistakes.[15] The overly complex concepts of compulsive hoarders require
consideration of many details and for some extensive checking and reading rituals. Simply saving the item
avoids this time-consuming and onerous process. In some instances, decision making is more troublesome
than actually discarding the possession. On several occasions, we have observed patients with very high
anxiety in anticipation of making a decision to discard something, but once the decision is made, the anxiety
subsides quickly and thoughts about the object itself play a very small role.
As mentioned earlier hoarding involves not only the inability to discard objects of limited value, but also a
problem in organizing possessions. Without a workable organizational scheme, decisions about where to put
things are problematic, especially when coupled with fears of losing information, opportunities, or parts of
oneself. Putting everything in a pile to be sorted later avoids this problem, and leaving things in sight avoids the
worry that they will be forgotten if they are filed away. Unfortunately, however, the creation of an effective
filing system may not resolve fears of loss, as in the case of one client who still reported feeling that filed
papers were lost to her despite her newfound ability to locate them using her organizing scheme.
Beliefs About the Nature of Possessions
Underlying many hoarding behaviors is a set of beliefs about the nature and meaning of possessions. Many of
these beliefs are experienced by patients with other OCD symptoms (see Chapter 18), but in patients with
hoarding tendencies, they have a specific connection to possessions. Several of these beliefs have already been
mentioned: (1) beliefs about the necessity of perfection and excessive concern over mistakes; (2) beliefs about
responsibility; (3) beliefs about control over possessions; (4) beliefs about emotional attachments to
possessions; and (5) beliefs about memory. Each of these beliefs is related to an overestimation of catastrophe
or loss. Distorted beliefs about the probability and severity of negative consequences if possessions are
discarded or placed out of sight may be a key feature connecting these distorted thoughts. For example,
beliefs about memory and the usefulness of keeping important things in sight also appear to influence hoarding
behavior. Other types of beliefs are discussed in the following paragraphs.
Perfectionism
As mentioned previously, compulsive hoarders score higher on measures of perfectionism, especially concern
over mistakes.[15] It also has been suggested that hoarders have a fundamental belief that perfection is not
only possible, but expected.[21] For example, Frost and Hartl[21] described a woman who reported two
concerns when trying to discard newspapers. First, she was concerned that she had not read them
thoroughly, and second, she couldn't remember what she had read. She believed that it was possible to read
the paper and remember everything "perfectly." Failure to do so seemed a catastrophe. Saving the
newspapers allowed her to continue the fiction (erroneous belief) that perfect paper reading was possible and
to avoid the failure associated with not reading the paper perfectly.
Need for Control
Frost, et al.[16] found hoarding to be associated with an exaggerated need for control over possessions.
Hoarders were less willing to share possessions with others or to have others touch or use their possessions.
Unauthorized touching or moving of possessions can prompt extreme anger among compulsive hoarders.[9]
This need for control may be associated with other features. For instance, if someone else touches a
possession, it may remove some of the safety signal value of the possession, similar to an object becoming
contaminated. Because possessions are often believed to be extensions of the self, it may seem to the hoarder
that he is personally being violated when someone touches his things. This feature has obvious implications for
treatment, which will be discussed shortly.
Responsibility
Beliefs about the nature of responsibility toward possessions also may play a role in the development and
maintenance of hoarding behavior Frost, et al.[16] reported that hoarders felt more responsible for preparing
to meet future needs than did non-hoarders. This behavior also was reflected in the fact that hoarders carry
more "just-in-case" items in their pockets, purses, and cars than do non-hoarders.[15] If they can imagine a
situation in which an object they possess (or could possess) can be used, hoarders appear to feel responsible
for attaining and saving that object in case that situation arises.
A second type of responsibility is for the proper care and use of possessions. Discarding a possession that still
has a use – even a remote one – leads hoarders to feel guilty about waste. Frost, et al.[16] found that
hoarders reported these thoughts more frequently than did non-hoarders. Specifically, thoughts such as,
"Ownership carries with it a responsibility to use a possession properly," "I must take precautions to protect
my possessions from harm," and "I feel guilty if I don't use something for a long time," were reported more
frequently by hoarders than by non-hoarders.
Emotional Comfort
In addition to these beliefs, a fourth set of beliefs has to do with beliefs about emotional comfort. Beliefs such
as, "Without my possessions, I will be vulnerable," "Throwing something away means losing a part of my life,"
and "My possessions provide me with emotional comfort," characterize compulsive hoarders[16] and
undoubtedly make discarding possessions more difficult.
TREATMENT FOR COMPULSIVE HOARDING
At present, very little information is available about the treatment outcomes of patients with hoarding
problems. Most single-case and anecdotal reports[9,19] have been descriptive rather than treatment oriented, noting a tendency among hoarders to be disinterested in changing their behaviors. Occasionally,
treatment outcome studies of patients with OCD have made passing reference to the difficulty in treatment
of hoarding[14] or to refusal, dropout, or treatment failure of those patients with hoarding symptoms.[55]
However, Baer[53] and Foa and Wilson[54] anecdotally described cases of women with hoarding symptoms
who made substantial progress in reducing these symptoms by using a behavioral program of gradual
exposure to discarding.
Based on an early version of our hoarding model, Frost and Hartl[34] developed a preliminary treatment
strategy and applied it in a single case study, using a multiple-baseline design.
Case I
A 53-year-old woman had suffered from compulsive hoarding since childhood. She had one drug trial – a
serotonin reuptake inhibitor (SRI) with limited success – and side effects resulted in discontinuation. Her
hoarding behavior was so severe that no room in her house could be used in any normal way. Because her
kitchen table was covered, her family ate with their plates on their laps. Several rooms had only small
pathways, with possessions piled halfway to the ceiling everywhere else.
Our treatment strategy had three main components. The first of these was training in decision making and
organizational skills for the management of possessions. For many hoarders, the idea of trying to discard
possessions is too frightening, but being more organized and decisive is a goal they will agree to and strive to
achieve. In this case, decision-making training involved category creation and moving designated possessions
to storage with a goal of creating uncluttered living space. This training was performed in the context of
weekly excavation sessions with homework between sessions. The second component was exposure to
discarding and the associated experiences that saving things allowed her to avoid (i.e., decision making,
emotional upset, etc.). Cognitive restructuring of hoarding-related beliefs was the third component of the
treatment. Excavation sessions provided an in vivo context for cognitive restructuring of beliefs related to
saving behaviors (i.e., perfectionism, responsibility, control over possessions, memory, and emotional
attachment to possessions).
Treatment progressed with each room being completed before moving to the next. Within each excavation
session, a four-step process was used, which included identifying a target area to work on, creating a small
number of categories into which possessions were placed, excavation of the area, and physical moving of the
items in each category to their proper destination. To assess the severity of hoarding, we calculated two
clutter ratios (CRs) for each room in the house before treatment and again when each room was excavated.
Floor CRs were calculated by dividing the square footage of floor space that was cluttered by the square
footage of total floor space not occupied by furniture. Furniture CRs were calculated by dividing the square
footage of cluttered furniture tops by the total square footage of furniture tops minus decorative items. To
gain some perspective on normal CRs, a small pilot study was undertaken in which CRs of four non-hoarding
individuals were calculated. The mean CRs from this sample for both floor and furniture tops were less than
0.05.
At pretest, this patient's floor CRs ranged from 0.23 to 0.78 with a mean of 0.54. Furniture CRs ranged from
0.53 to 1.0 with a mean of 0.85. Over 18 months and 35 sessions, seven rooms were excavated. When each
room was excavated, the CRs declined substantially. Immediately after excavation, the mean CR for floors for
all seven rooms was 0.02 and for furniture tops it was 0.05 – ratios that were quite normal. The CRs of rooms
completed early in the treatment were maintained throughout the 18 months.
The results of this case study indicate that it is possible to significantly alter severe hoarding behavior using a
framework consistent with the cognitive-behavioral model outlined earlier. Based on this model of hoarding
and the results of this case study, we have generated a treatment program for compulsive hoarding.[54] We
are in the process of refining and testing the intervention, which can be administered either by an individual
therapist treating a patient in the home or in a group format supplemented with a paraprofessional helper
holding excavation sessions in the patient's home. The treatment assumes that the therapist is familiar with
this cognitive-behavioral model of compulsive hoarding, and that the patient accepts the basic goals and
procedures of treatment. Outlined below are the assessment procedures, treatment goals, treatment rules, a
description of the excavation sessions, and a brief overview of cognitive restructuring.
Assessment
A great deal of information about the patient's hoarding behavior is essential for designing this treatment
program. Much of this information can be gathered from initial interviews. The types of information needed
include the following:
# What types of possessions are saved?
# What are the reasons for saving each type of possession?
# Where are saved items kept? Is there some form of organization?
# What is the actual amount of clutter? Spaces in the house should be evaluated in terms of their usability.
Note parts of the house that are unusable because of clutter.
# Are family members involved? How does the problem affect relationships with family or friends?
# How are items acquired? Note how new items enter the house and where they go when they do.
# Does the patient have decision-making problems? A careful analysis of the nature and extent of decisionmaking problems and the creation of effective decision-making strategies are crucial.
# What avoidance behaviors are evident? A careful analysis of all of the things that are avoided by saving is
necessary.
# How much anxiety or discomfort regarding hoarding is experienced during a typical day and during
attempts to organize and discard possessions? This information is critical for setting up excavation
sessions and hierarchies for discarding, and for determining the course of habituation to discarding.
# What is the patient's hoarding history and previous treatment? Circumstances surrounding the onset of
hoarding and the results of previous attempts at treatment for the problem behavior may be helpful.
In addition to this information, standardized assessments also are useful. The Y-BOCS provides an overall
index of severity of the problem. We recommend the use of a modified Y-BOCS in which the clinician
inquires about the hoarding symptoms rather than all OCD symptoms. We also have developed a Hoarding
Severity Scale and a Hoarding Cognitions Inventory to provide additional information on the severity and
range of thoughts and beliefs associated with hoarding. (These scales are available from the authors.)
Psychomatic data supporting the reliability and validity of these measures are pending.
Finally, a behavioral assessment of hoarding severity is necessary. As noted earlier, we have used CRs to
provide baseline information about the severity of the hoarding problem and to track the progress during
treatment. As described earlier, two clutter ratios are useful, one for floor space and one for furniture tops.
Photographs or videotapes of rooms also can help in the calculation of these ratios after the initial room
measurements are made.
Treatment Goals
A careful discussion of concrete goals is essential prior to beginning treatment. Most severe hoarders are
reluctant to enter a treatment program in which the only goal is to discard the possessions they have spent
their lives collecting. Thus, in this treatment program, the discarding of possessions is a lesser goal at the
outset of treatment and gains importance as it becomes apparent to the patient that the most important goals
cannot be reached without discarding. The first and primary goal of this treatment program is the creation of
uncluttered living space. The most troublesome aspect of compulsive hoarding is that clutter interferes with
the ability to use interior living spaces. Most people who suffer from compulsive hoarding can readily agree to
such a goal. Even if no change occurs in the acquisition and saving by a hoarding patient, if he is able to
maintain uncluttered living spaces in his home, the treatment will have been useful.
A related goal is to increase the appropriate use of space. Severe hoarders may not have used most parts of
their houses for years. Establishing a regular pattern of use will facilitate the maintenance of a clutter-free
house. For instance, patients must learn to use the kitchen table for food preparation or sit-down meals. If it is
not used in this way, the table may once again become a space to store hoarded objects.
To excavate and maintain an uncluttered home, it is necessary for a hoarder to improve decision-making skills,
and to develop an organizational plan for the home. The strategy we have adopted is to create with the patient
a small number of categories for each type of possession. Then all possessions are placed into one of these
categories. Each category has a designated location once excavation is performed. For example, because most
compulsive hoarders have difficulty with books, we often begin with books and require that every book in a
room go into one of three categories: (1) sell or donate; (2) store; and (3) display. The sell-or-donate books
are placed in a box and moved to a designated location out of the main living area. The books to be stored are
also placed in a box, labeled, and placed in a designated storage location. Books to display are put on a
bookshelf. If the display category is larger than the bookshelf, the extra books are treated like books to store,
but are labeled "display" so they may be readily identified when bookshelf space becomes available. Limiting
the number of categories makes these first decisions easier and the organizational plan clear. Other types of
possessions usually require more elaborate filing systems (e.g., letters, documents, etc.).
Discarding unneeded possessions is a more difficult goal. Most hoarders recognize that they must be more
selective about what they keep, but fear they will lose control over what is saved and what is discarded. This
is especially problematic in cases in which family members have discarded some possessions against the
patient's wishes. In this treatment, we emphasize that the volume of possessions does not matter. What
matters instead is that appropriate living space exists in the home. In their efforts to achieve the first several
goals, hoarders begin to change their perspective about how much they "need" to keep. One strategy we
have found helpful is asking hoarders to think about the clutter in their house as a loss of control. Then, we
request that they think about "temporarily suspending" their normal saving behavior to gain control over the
clutter. This allows them to view the discarding of possessions as serving a greater purpose (i.e., giving them a
sense of control over the hoarding). As the patient gains some experience at discarding, the prospect of
discarding unneeded possessions becomes a more palatable therapeutic goal.
Reducing the accumulation of new possessions is a necessary goal of this treatment. Because many hoarding
patients engage in compulsive shopping or trash picking in an effort to accumulate new possessions, it is
important to understand the value that these possessions have for the hoarder. Understanding the
instrumental or sentimental value of each type of acquisition enables the therapist to design specific exposure
and response prevention (ERP) strategies as well as cognitive interventions. If the patient accumulates
possessions from certain places (e.g., tag sales, dumpsters), the therapist can accompany the patient to these
sites, identify desired items, and stay until the patient habituates to the feeling of "needing" to acquire the
possession. It is important to emphasize the distinction between objective need and the feeling of need. If a
patient can learn this distinction, managing the "feeling" of need may be easier.
Familiarizing patients with the nature of OCD hoarding and the model on which this treatment is based helps
them develop confidence in their ability to tolerate the discomfort associated with hoarding. Education
regarding OCD hoarding also gives patients a sense of optimism and empowerment. Finally, developing skill of
self-instruction and cognitive correction of faulty thinking about saving possessions is an essential part of this
treatment. The exact nature of these skills and suggestions for developing them are presented in the following
paragraphs.
Treatment Rules
The history of interpersonal relationships for someone with a hoarding problem is invariably intertwined with
the relationships they have with their possessions. Most hoarders have had family or friends attempt to "help"
them with their hoarding problem and actively resist this help because they usually involve offers to make
decisions about what to save and to do the discarding for the hoarder. In considering treatment, the hoarder
often has only these negative experiences of "helpers" on which to reflect. To make the treatment and the
therapist's role clear, specifically defined rules of behavior for the therapist are necessary. Likewise, to make
the importance of the procedures clear, a defined set of rules for the patient to follow is necessary. We
propose the following six treatment rules.
1. The therapist may not touch or throw away anything without explicit permission. Knowing that the therapist
will not touch a possession without permission helps to develop trust and confidence in a cooperative patienttherapist relationship. This is not an easy rule to follow. The impulse to pick things up and discard or organize
them is strong when the goal is to remove clutter. However, if the rule is violated, the trust between the
therapist and patient also will be violated. There may be some exceptions to this rule if the patient has
contamination fears or obsessions about others disturbing their possessions. In this case, a change in the rule
should be negotiated and the rationale for doing so should be clear to both patient and therapist.
2. All decisions regarding saving, discarding, and organizing are made by the patient. Because part of the problem
of compulsive hoarding has to do with inability to make decisions of this sort, making decisions for these
patients will not help. Indeed, one of the goals for the treatment is to teach the patient how to make
decisions.
3. Any possession touched by the patient during an excavation session should be placed in a final location. The
excavation sessions should enable the patient to learn the most efficient way of organizing and discarding to
prevent behaviors that have led to the clutter problem. One of the most prominent of these is "churning." We
use the Only handle It Once (OHIO) rule: Whenever a possession is picked up, it cannot go back onto the
pile. It must go into one of the categories generated prior to the excavation (or in some cases, a new
category).
4. Categories for possessions must be established before handling them. Before each excavation session, a small
number of categories must be established by the patient and therapist. This is essential for the development
of efficient decision making and organization of possessions.
5. Treatment should proceed systematically. Like the excavation sessions themselves, it is important that the
treatment sequences be systematic and well organized, so the patient will know what needs to be done and
when. Many hoarders spend hours trying to organize and discard with little success, because their efforts are
unfocused and produce little visible benefit. They may spend 30 minutes in one room and 30 minutes in
another room and in the end see no progress. Thus, it is important that treatment should focus on one area
or room until it is complete before moving to the next. More easily categorized objects (e.g., books) should
be first, and should progress to more difficult ones (documents). Focus first on spaces in which progress will
be readily observable and have the most desired functional effect for the patient (e.g., able to eat comfortably
or sit in favorite chair).
6. Flexible and creative strategies are to be applied as needed to make steady progress. There will invariably be
unforeseen problems in trying to excavate a house full of possessions. It may be necessary, for instance, to
temporarily redefine some areas of the home as storage rather than living space, until more actual storage
space becomes available later in the treatment.
Excavation Sessions
Before beginning the first excavation session, the patient should understand the model of hoarding and the
objectives of the treatment. The excavation sessions are designed to create in vivo opportunities for the
patient and therapist to encounter each of the problems outlined in the model. These sessions have clear-cut
steps to help the patient structure similar excavation homework between sessions. Such structure helps the
patient avoid some of the difficulties encountered in previous attempts to clear the house. The specific steps
for each excavation session are outlined in the following list.
#
#
#
#
#
#
#
#
#
Step 1. Select a target area (e.g., kitchen table).
Step 2. Assess types of possessions in the target area.
Step 3. Determine hierarchy of items within target area.
Step 4. Select type of possession with which to begin.
Step 5. Create categories and a filing system for this possession type.
Step 6. Begin excavating.
Step 7. Continue until target area is clear.
Step 8. Plan for appropriate use of cleared space.
Step 9. Plan for preventing new clutter to this area.
Cognitive Restructuring
During excavation sessions, there is ample time to explore the belief systems underlying hoarding behavior.
The therapist should encourage the patient to verbalize thoughts and feelings when excavating to understand
specific decision-making problems and erroneous beliefs regarding saving and discarding. A "stream of
consciousness" instruction facilitates this process. It is important to help the patient recognize his
characteristic thought processes and develop ways of challenging these beliefs. The most common themes
encountered are perfectionism, responsibility, control, emotional attachment, and beliefs about memory. A
variety of techniques are useful here to challenge these thoughts and the excessive value placed on
possessions. These cognitive techniques are described elsewhere[52] (see Chapter 18).
During these sessions, it is important that the therapist not express disappointment or negative feedback
regarding decisions made by the patient. Such expressions are likely to increase shame and disappointment
and decrease motivation. It also is important not to engage in extended arguments with the patient about a
decision to save something. A Socratic approach that encourages the patient to question his or her reason for
saving something is preferable. These instances also may provide opportunities to remind patients of the goals
in treatment, especially the need to create usable living spaces and to establish decision-making rules and
categories for saving.
Behavioral experiments to test the patient's beliefs and reactions also are helpful in the process of cognitive
restructuring. Most hoarders show excessive attachment to possessions that have little instrumental value and
are not reminders of special times. They believe they will not be able to tolerate discarding such a possession.
A behavioral experiment to test this hypothesis by discarding such an item reveals not only the strength of this
feeling, but also the amount of time it takes to habituate to a decision to discard such a possession. The
outcome of such an experiment also will clearly show the patient that his or her "feeling" of being unable to
stand it is inaccurate.
SUMMARY
Obsessive-compulsive hoarding is a little-studied phenomenon. This chapter reviews the existing literature on
this topic, presents a cognitive-behavioral model of compulsive hoarding, and outlines a treatment program
for this problem. The literature review suggests a change in the definition of compulsive hoarding most
commonly used so as not to exclude possessions saved for sentimental reasons. Compulsive hoarding was
defined here as having three parts: (1) the acquisition of and failure to discard, a large number of possessions
that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to preclude activities
for which those spaces were designed; and (3) significant distress or impairment in function caused by the
hoarding. The cognitive-behavioral model of compulsive hoarding emphasizes four major factors: (1)
information-processing deficits; (2) problems with emotional attachments to possessions; (3) behavioral
avoidance; and (4) erroneous or distorted beliefs about the nature or importance of possessions. The
individual and group treatment program outlined emphasizes the creation of uncluttered living space, the
appropriate use of uncluttered space, improvement in decision-making skills, and the creation of an
organizational plan for possessions. As treatment progresses, more emphasis is placed on discarding and
reducing accumulation. The treatment is conducted in the context of highly structured excavation sessions
during which exposure and cognitive restructuring can take place.
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http://www.ocfoundation.org/1005/m600a_001.htm
About Dr. Randy Frost, Ph.D.
Randy Frost received his Ph.D. in clinical psychology from the University of Kansas in 1977, and is currently
the Harold Edward and Elsa Siipola Israel Professor of Psychology at Smith College. He has published
extensively on obsessive-compulsive disorder and Compulsive Hoarding. Together with Dr. Gail Steketee, he
has developed a treatment program for Compulsive Hoarding. This work has been funded by the Obsessive
Compulsive Foundation and the National Institute of Mental Health. He has also served as consultant to
several communities in setting up task forces to deal with the problem of Compulsive Hoarding.
About Dr. Gail Steketee, Ph.D.
Gail Steketee, Ph.D. is a professor at the Boston University School of Social Work where she chairs the
Clinical Practice department. She received her master's in social work (MSS) and her Ph.D. from Bryn Mawr
Graduate School of Social Work and Social Research. She has conducted a variety of research studies on the
psychopathology and treatment of obsessive compulsive disorder, recently focusing on familial factors that
influence treatment, on cognitive therapy for OCD and on the psychopathology and treatment of Compulsive
Hoarding. She has been principal investigator or co-investigator of NIMH-funded studies on family aspects of
OCD, cognitive therapy for OCD and a current project with Dr. Randy Frost and Dr. David Tolin on
development of cognitive and behavioral treatment for Compulsive Hoarding. She co-chairs an international
research group, the Obsessive Compulsive Cognitions Working Group (OCCWG), dedicated to the study of
cognitive aspects of OCD. She has published numerous articles, chapters and books on OCD and related
disorders, including When Once is Not Enough (New Harbinger), Treatment for Obsessive Compulsive Disorder
(Guilford), Overcoming Obsessive Compulsive Disorder (New Harbinger) and with Dr. Randy Frost, Cognitive
Approaches to Obsessive Compulsive Disorder: Theory, Assessment and Treatment (Elsevier).