Hoarding: A Review
Stein, Dan J., Seedat, Soraya, Potocnik, Felix, The Israel Journal of Psychiatry and Related Sciences
Abstract: Background: Hoarding is currently categorized as a symptom of both obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder. However, hoarding has also been documented in association with other psychiatric disorders, raising questions about the classification, psychobiology and treatment of these symptoms. This paper reviews the literature on hoarding. Method: A computerized literature search was done using the MEDLINE database. Relevant references were collated and were used to obtain additional literature on hoarding behavior.
Results: Although hoarding may meet DSM-IV diagnostic criteria for a compulsion, this symptom is also seen in a range of other disorders. Nevertheless, the phenomenology of hoarding remains under-researched. In addition, the psychobiology and treatment of hoarding remains relatively poorly understood, although in certain aspects there may be some overlap with the symptoms of OCD. Conclusions: Further research on the phenomenology, psychobiology and treatment of hoarding is clearly needed. A neuro-ethological view of hoarding as a spectrum symptom seen not only in OCD, but also in other disorders, may provide a useful heuristic for current clinical practice and for future empirical research.
Hoarding has been defined as the acquisition of, and failure to discard, possessions that are useless or have limited value (1). This behavior is generally conceptualized as a pathological symptom, in contrast to normal collecting. Hoarding is currently classified as a symptom of obsessive-compulsive disorder (OCD) and of obsessive-compulsive personality disorder (OCPD) (2). Nevertheless, this behavior may also be seen in a variety of other psychiatric disorders (3).
The problem of how best to classify hoarding immediately raises questions about the psychobiology and treatment of hoarding. Is hoarding best understood as a classical compulsion of OCD, and therefore seen as mediated by abnormalities of the serotonin system and prefrontal-basal ganglia circuits and viewed as best managed by serotonin reuptake inhibitors and cognitive-behavioral techniques (4)? Or should hoarding be understood using an alternative framework? In order to approach these questions, this paper reviews the phenomenology, psychobiology and treatment of hoarding.
Hoarding in OCD
Freud and the early psychoanalysts were aware that hoarding could take on the characteristics of a compulsion. Abrahams (5), for example, in his classic paper on the anal character, described a woman who was unable to throw away useless objects. When she felt compelled to throw away an object she would "trick" herself. She would attach the object (e.g., old clothes) to her back, then walk through the woods. She would "lose" the object and return home via another route so as not to encounter the object again. Presumably, this patient viewed her hoarding as excessive and unreasonable, and was sufficiently distressed by the hoarding to try and get rid of objects. If so, then this symptom would likely meet current diagnostic criteria for a compulsion.
More recently Phillips (6), in an article on the "accumulator," noted that in some patients hoarding began in response to the thought that the items might one day come in handy. However, with time the accumulation of items became an end in itself. Such patients were typically ashamed of their behavior. Once again, then, this symptom is reminiscent of compulsions which may begin in response to specific obsessions, and then develop into complex autonomous rituals.
Greenberg (7) has described four cases (2 men and 2 women) of compulsive hoarding. The patients collected a wide variety of discarded objects which they were unable to get rid of. The collections were initially ordered, but became increasingly disordered. The hoarding behaviors resulted in significant interference in occupational and social function. …