Is Hoarding A Symptom Or A Disorder? – It’s Place in the DSM-V

We have all seen it before on reality television — mound and mounds of rotten foods, unsalvageable trinkets, and even cat poop fill every nook and cranny of what was once a livable space. As we cover our mouths in disgust, we cannot help but shake our heads at the homeowners’ uncontrollable hoarding habits. Suddenly, you remember your own oddball collection of rare porcelain statues, used notebooks, or whatever your fetish of the month is and wonder: how do you know when you have crossed the line from savvy collector to obsessive hoarder? Are you suffering from a type of obsessive compulsive disorder (OCD), or even, a new hoarding disorder (HD) in itself?

The collecting of objects has always been regarded as both a benign and normative human behavior; so much so that industry has been quick to capitalize on the apparent mass appeal of this activity. Because of the ubiquitous attraction of collecting that has been garnered over the past years, researchers in the realm of academia have also developed interest in the study of its behavior. For psychologists, descriptors of collecting behavior have proliferated from the perspectives of psychodynamics, behavioral neurology, social psychology, and other fields. Although some may view object accumulation as a leisurely activity that provides psychological benefit to the participant, clinical psychologists have become more concerned in its ability to hinder normal performances. This excessive form of acquisition, or “hoarding”, carries potential to impair one’s individual, interpersonal, and occupational functioning.

Previously, hoarding has always been characterized as a dimension of OCD, whereby hoarding was regarded as a symptom rather than a distinct diagnostic entity. In the early 1900s, theoretical conceptualizations of hoarding features were defined on an idiosyncratic level by Freud; that is, they were merely viewed as behavioral characteristic peculiar to an individual or group or people. In the mid-1990s, Frost and Hartl shifted this idiosyncratic view of “compulsive hoarding behavior” into one that was defined operationally. Under this view, three specific characteristics of hoarding behavior were produced: (1) the acquisition of and failure to discard a large number of possessions that seem 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 hoarding. The purpose of developing such operational criteria was to create a mindset among the scientific community that hoarding behavior was actually pathological rather than idiosyncratic. Subsequently, this view became widely-accepted across the research and clinical communities and allowed for the first construct consistent investigations of hoarding behavior.

The view of hoarding as a symptom of OCD has begun to shift in the past few years. This was demonstrated by one descriptive study conducted by Mataix-Cols and colleagues that examined community-based participants with hoarding behaviors. When hoarding was used as the factor of inclusion in the study (rather than as an established diagnosis of OCD or OCPD), only 18% of the 217 participants met diagnostic criteria for OCD. As a result of this study and others in literature that have produced similar results, HD is currently being considered for inclusion in the upcoming 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

Under the structural definition developed by Frost and Hartl, many rewordings of HD have been developed and turned-over in the recent years to reflect the changing and growing literature on hoarding behavior. It is with these circumstances that the proposed diagnostic criteria for HD were developed for the DSM-V. The criteria, and their presenting symptoms, are listed as follows:

• Criterion A – Persistent difficulty discarding or parting with personal possessions, regardless of their actual value.
• Criterion B – The difficulty is due to strong urges to save items and/or distress associated with discarding.
• Criterion C – The symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible. If all living space is uncluttered, it is only because of the interventions of third parties (e.g. family members, cleaners, authorities).
• Criterion D – The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning (including maintaining a safe environment for self and others).
• Criterion E – The hoarding symptoms are not due to a general medical condition (e.g. brain injury, cerebrovascular disease).
• Criterion F – The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g. hoarding due to obsessions in Obsessive Compulsive Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder, and food storing in Prader–Willi Syndrome).

The understanding of hoarding and best practices for clinical treatment are quickly evolving given the increasing knowledge gains from research and clinical practice. Hopefully, with the new diagnostic criteria in place, opportunities and challenges in the care of patients who meet the diagnostic criteria of hoarding will improve in both meaningful and engaging ways.

References

American Psychiatric Association DSM-V Development (2012). Hoarding Disorder.

Anderson SW, Damasio H, & Damasio AR (2005). A neural basis for collecting behaviour in humans. Brain : a journal of neurology, 128 (Pt 1), 201-12 PMID: 15548551

Grisham JR, Norberg MM, Williams AD, Certoma SP, & Kadib R (2010). Categorization and cognitive deficits in compulsive hoarding. Behaviour research and therapy, 48 (9), 866-72 PMID: 20542489

Mataix-Cols D, Frost RO, Pertusa A, Clark LA, Saxena S, Leckman JF, Stein DJ, Matsunaga H, & Wilhelm S (2010). Hoarding disorder: a new diagnosis for DSM-V? Depression and anxiety, 27 (6), 556-72 PMID: 20336805

Subkowski P (2006). On the psychodynamics of collecting. The International journal of psycho-analysis, 87 (Pt 2), 383-401 PMID: 16581582

Image via MCarper / Shutterstock.