Compulsive hoarding: Unclutter lives and homes by breaking anxiety’s grip
Fear about making ‘wrong’ decisions may underlie hoarders’ pathologic saving and collecting behaviors. Here’s a strategy to help them
Information processing deficits. Because of anxieties about making mistakes, most hoarders have great difficulty making decisions.18 It is easier to not decide than to suffer the consequences of a “wrong” decision. To gauge this behavior, ask patients how long routine decisions take them and which decisions they procrastinate or avoid.
Compulsive hoarders often have trouble categorizing possessions;6,7 because every item feels unique, they create a special category for each one and resist storing items together.
Table 1
Proposed criteria to diagnose obsessive-compulsive hoarding*
| Patient acquires and fails to discard a large number of possessions that appear useless or of limited value |
| Clutter prevents patient from using living or work spaces for activities for which they were designed |
| Hoarding behavior causes significant distress or functional impairment |
| * Proposed by Frost and Hartl, reference 6. |
Avoidance behaviors are a hallmark of the compulsive hoarding syndrome. To avoid deciding to discard items, they put them in a box, garage, rented storage facility, etc. They may also avoid routine decision-making tasks that could lead to making a mistake.
Daily functioning. Hoarders may take a long time to do even small chores, such as taking an hour to pay one bill. An inordinate amount of time may be spent “churning”—moving items from one pile to another but never discarding any item or establishing a consistent system or organization.
Medication compliance. Compulsive hoarders often forget to take medications or take them at inappropriate times. They may lose their medications in the clutter.
Insight. Hoarders often have little awareness of how their behavior and clutter affect their lives.19 They minimize the clutter in their homes and its health and safety risks. Insight can fluctuate over time and needs to be assessed repeatedly during treatment.
Table 2
Assessing a patient with compulsive hoarding symptoms
| Domain | Useful questions or strategies |
|---|---|
| Amount of clutter | Visit home and/or see pictures |
| Hazards relating to clutter | Ask: What precautions do you take to reduce risk of fire? Have you ever had a problem with rodent or insect infestation as a result of the clutter? Have neighbors complained about the risks of fire or infestation that the clutter might impose on their homes? |
| Beliefs about loss of possessions | Ask: What is the worst thing that would happen if you threw this item away? If you did not have this, what do you think would happen? |
| Information-processing deficits | Ask: How long do routine decisions take you? Which decisions do you procrastinate or avoid? |
| Decision-making and organizational skills | Ask: How do you pay and store your bills? |
| Avoidance behaviors | Ask: Do you avoid other things (sorting mail, returning calls, doing dishes, or paying bills, rent, or taxes)? |
| Daily functioning | Ask: Do you get everything done that you want to do? Are you often late? Do you have difficulty starting or finishing tasks? Describe a typical day. |
| Insight | Ask: Do you think this amount of clutter is normal? Do you think having this clutter has caused problems in your life? |
| Motivation for treatment | Ask: What brings you into therapy now? Do you think you have a problem with excessive hoarding/saving? If it was not for your family, would you come for help? |
| Social and occupational functioning | Ask: How has your clutter affected your personal relationships? When was the last time you had someone come to your home? What prevents you from working right now? Are you working to your full potential? |
| Support from friends and family | Ask: What does your family say about your clutter? Do your friends or family understand what is going on? |
| Treatment compliance | Ask: How long does it typically take before you renew your prescriptions when you run out of medications? |
Cognitive behavioral therapy for compulsive hoarding
| Treatment sequence | Methods and goals |
|---|---|
| Educate patient about hoarding | Help improve insight and motivation |
| Set up treatment | With patient, select target area of clutter |
| Assess items together, creating a hierarchy of least to most difficult areas to sort and items to discard | |
| Create realistic categories and a storage system | |
| Begin discarding | Patient must decide to keep or discard each item and permanently remove it from pile |
| Patient must store saved items appropriately | |
| Continue until area is clear, then move to next area | |
| Plan and implement appropriate use of space | |
| Stop incoming clutter | Cancel subscriptions |
| Address compulsive buying and acquisition | |
| Provide organization training | Organize possessions, time, tasks, etc. |
| Prevent relapse | Replace hoarding with healthier behaviors to prevent clutter from re-accumulating |
| Source: Adapted from reference 23. | |
