A Successful Compulsion
Hoarding is a problem that is asked about frequently in connection with Obsessive-Compulsive Disorder (OCD). We can define hoarding as acquiring and keeping objects to such an extent that it begins to impair the normal use of one’s living space. Most of the time the objects are considered of little or no value by others although commonly hoarders may also be collectors. There are other disorders sometimes associated with hoarding including obsessive-compulsive personality disorder, schizophrenia or dementia. For years, experts who studied hoarding considered hoarding to be a form of OCD. When the most recent diagnostic manual (DSM-5) was published in 2013 hoarding was described as a discrete disorder in the category of Obsessive-Compulsive and Related disorders. People who hoard typically acquire excessive amounts of some things and have difficulty or are unwilling to dispose of accumulated material. This leads to incoming material far exceeding outgoing material. The result is that the person’s living space becomes filled with material and what would be considered normal use of much of their living space becomes impossible. Furniture may be used as a place to pile objects; indeed any flat surface may become a place to pile things. The most commonly hoarded items are papers. This can include papers most people would consider important such as tax records along with unimportant papers such as brochures, advertisements, junk mail, newspapers, magazines and scraps of paper with notes, shopping lists etc. Some hoarders keep food products, broken items to be fixed, clothes, books, craft materials and leaves. In rare and extreme cases people have been known to save feces or urine. Another extreme form involves hoarding animals and the occasional story of someone living in a home with hundreds of cats or dogs often including carcasses of decaying animals are best understood as incidents of hoarding disorder or a variant of OCD. Much more common however is a description of rooms filled with piles of papers, clothes and similar items often traversed by narrow paths between the piles.
This reluctance to seek treatment and the difficulty treating hoarding as a behavior leads to speculation about what is different in this population. One idea is to describe hoarding as a successful compulsion. In OCD in general, compulsions are seen as a method to reduce anxiety or other forms of distress and to some extent they must work or people would not continue to engage in them. The individual with a contamination fear may wash to reduce anxiety when they believe they have been exposed to contamination. Avoidance of situations which arouse anxiety is also important in OCD. The contamination fear may lead to avoiding touching certain objects, going certain places or lead to other limits on activity. OCD was typically described as an anxiety disorder in part because most people who have it have considerable anxiety in spite of their engaging in both avoidance and compulsive rituals. Many individuals with the Hoarding Disorder seem to have significantly less anxiety in proportion to the severity of their disorder, than seen in individuals with OCD.
If the anxiety in OCD is generated as a result of interpretation of intrusive thoughts as described in a cognitive model, is there a comparable process in people with Hoarding Disorder? Hoarders seem to have intrusive thoughts about not having something that might be needed or valuable, not being able to remember something important or possibly wasting something. When objects are disposed of the hoarder may want to go to great lengths to make sure they are treated properly. The need to remember, not waste or dispose of properly is linked to responsibility, a theme that runs through much of OCD. The anxiety generated by the thoughts may be reduced quickly by knowing that the individual still has possession of the material. Anxiety associated with intrusive thoughts that occur when exposed to new objects such as, what if I need this and can’t get it in the future, is quickly reduced by acquisition. If I get it now I will have it if I ever need it. Some individuals with Hoarding Disorder also report gaining some sort of comfort or pleasure from their possessions. They may look at things or pull piles of things around them. The underlying thinking in OCD and Hoarding Disorder are similar but distinct.
When the idea of a successful compulsion was discussed on an email support group of self-identified hoarders, a number of the subscribers indicated that something was wrong with the description. They explained that they did have anxiety and that the model of a successful compulsion is insufficient. Remember that in OCD we understand compulsions to be a method for dealing with anxiety. Yet ironically people often report anxiety about having to engage in compulsions. Sometimes people avoid doing things because they know that they will be stuck for long periods engaged in some compulsive ritual. They may consider the ritual absurd but still feel required to do it. One difference here is that individuals with Hoarding Disorder often don’t acknowledge the absurdity of the ritual. They may argue about it not being good to waste, explain that they will really read all the collected newspaper articles again or someone in the future might be interested in the objects they hoard. More commonly individuals with Hoarding Disorder have anxiety when their hoard is threatened in some way. A pending visit from a landlord can be terrifying. The hoarder may fear others’ reaction and experience shame because of how people respond to the hoard. Some individuals will report anxiety when they look at their own piles. This often results from concern about their things not being organized. The disorganization is the aversive part of the hoard not its size or interference with function. Hoarders see objects as unique so that they can not be stored together. One individual described trying to organize possessions as like trying to organize snowflakes. This metaphor is telling because it illustrates the focus on the differences rather than similarities of objects contributes to the confusion. This is known as having under-inclusive categories. Things that don’t belong together cannot be stored together. The anxiety generated by thoughts of needing to organize possessions is most often dealt with by avoidance or procrastination. Sometimes paradoxically the desire to organize may lead to further acquisitions. The individual with Hoarding Disorder may buy lots of containers to store things in but due to under-inclusive categories but is unable to make use of them so the containers become part of the hoard rather than a solution.
There are two well-established treatments for OCD, serotonin reuptake blocking medications and cognitive behavioral therapy (CBT). Hoarding, considered a disorder related to OCD, does not seem to respond anywhere near as robustly as OCD to medication. One reason for this poor response may be that the medication works primarily by reducing anxiety by reducing intensity and frequency of intrusive thoughts. This in turn allows the individual with OCD to engage in formal or informal behavior therapy including exposure to anxiety producing situations. Since hoarders already successfully avoid or manage much of their anxiety and typically have an exaggerated sense of value or importance for their possessions, the medication doesn’t have much impact. Medication does not change the value placed in the possessions and since for most hoarders the anxiety level is already manageable they will not experience important medication effects. It may be that medication would make CBT more tolerable but people who are not distressed by a behavior are unlikely to seek help in changing it. Finally the individuals who report they don’t fit the model described are individuals who are highly motivated to change their hoarding. They are involved in a support group and committed to changing. They seem to represent a minority of hoarders for whom hoarding is no longer a successful compulsion.