Many of us may have trouble organizing the daily accumulation of clutter, but a paralyzing inability to throw away possessions can belie a potentially debilitating mental condition known as hoarding disorder.
Hoarding disorder (HD) is considered related to – but distinct from – the more familiar obsessive-compulsive disorder (OCD). It is also believed to be up to twice as common as OCD, and somewhat more difficult to treat. The American Psychiatric Association estimates that 3 to 5 percent of the population may have a pathological difficulty discarding items.
Though friends and family often want to help an afflicted person “get organized,” a big spring cleaning won’t treat the disorder because HD is rooted in abnormal brain functioning, not laziness.
Sanjaya Saxena, MD, director of the Obsessive-Compulsive Disorders Clinic at UC San Diego Health, offers insights on HD and how to help loved ones.
Question: What distinguishes a person with HD from a packrat?
Answer: Like many common mental disorders, symptoms of HD are on a continuum with normative behaviors. It is normal to save items with sentimental value or utility, but people with HD save many more items, experience much more distress with discarding possessions or deciding which items to keep or toss. To avoid these decisions, more items are left to accumulate. Excessive acquisition of items is also common. As with all psychiatric disorders, we only diagnose HD when the symptoms of hoarding, saving, acquisition and clutter cause clinically significant distress or impairment in a person’s social, occupational, financial or health-related functioning. Impairment may also include an inability to maintain a safe living environment.
Q: How is HD treated?
A: There are two main types of treatment: specialized cognitive-behavioral therapy (CBT) and medication. During CBT, individuals practice throwing away unnecessary possessions. Gradually, they learn to discard things with less distress, as their exaggerated perceived need or desire to save possessions diminishes. CBT also helps extinguish fears of no longer having items that might be useful later. Our
hoarding treatment approach also teaches skills such as organization, decision-making and relaxation. For many people, certain antidepressant medications are effective and result in more rapid improvement. We are also now testing novel medications for HD in our program.
Q: How successful is treatment?
A: In clinical studies, medications and specialized CBT each have resulted in significant improvement in 60 to 70 percent of patients treated. The combination of CBT and medications appears to work better than either treatment alone.
Q: How early in life does HD appear and what are the earliest signs of a problem?
A: The average age of first symptom onset is 12-13 years of age. The earliest symptoms usually are indecisiveness and difficulty discarding possessions. Excessive acquisition and clutter usually appear next. Unfortunately, most people don’t recognize the problem for many years, until the clutter becomes severe.
Q: Are there things parents can do to reduce the severity of a child’s HD?
A: If a child displays persistent HD symptoms, parents should have the child evaluated by a clinician with experience diagnosing and treating HD. Only treatment can reduce the severity of the disorder. If left untreated, the condition usually worsens over time.
Q: What can family or friends do to help a person who may have HD?
A: Family and friends should encourage the person to get an appropriate evaluation, diagnosis and treatment by a qualified clinician.
Q: What do we know about the brains of hoarders vs. non-hoarders?
A: Brain imaging studies have shown that compared with non-hoarding people without any psychiatric disorder, people with HD have abnormal activity in specific brain areas, including the anterior cingulate cortex (ACC), ventromedial prefrontal cortex and limbic structures. HD patients have abnormally low baseline activity in the ACC at rest, but they have increased activation of that brain area and nearby cortical areas during symptom-provoking tasks. The ACC is a brain area critical for focused attention, motivation, decision-making, choosing between multiple conflicting options and regulating emotion. Dysfunction in the ACC may underlie both the symptoms and information processing problems commonly experienced by people with HD.
Care at UC San Diego Health
Psychiatry and Behavioral Health