Obsessive-Compulsive Disorder and Hoarding

What is Obsessive-Compulsive Disorder (OCD)?

Although previously considered an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR), in the most recent edition, the DSM-V, Obsessive Compulsive Disorder is now in the category of Obsessive-Compulsive and Related Disorders. This new category not only includes Obsessive Compulsive Disorder (OCD) but also includes Hoarding Disorder. OCD is characterized by either intrusive images or thoughts which are unwanted (obsessions) or particular repetitive behaviors or intentional thoughts (compulsions). Both obsessions and compulsions may be present, but both do not need to be present in order to meet criteria for OCD. Obsessions cause significant distress to the individual and may prompt avoidance behaviors, as well. Compulsions are not typical reassurance-seeking behaviors, because compulsions tend to take up significant amounts of the individual's time and interfere with functioning in multiple areas of the individual's life. Often compulsions develop as a means to alleviate or neutralize obsessions. Despite a possible awareness that the obsessions are not logical and possible knowledge of the interference in daily routine or time consumed by compulsive behaviors,  individuals who meet criteria for OCD may find the obsessions impossible to ignore and may find safety or comfort in these compulsive behaviors.

Common obsessions include:

  • Fear of contamination or germs
  • Religious doubt or fear of divine punishment (i.e., Scrupulosity)
  • Fear of harming self or others (Note: The individual likely does not actually want to harm anyone. Rather, the distress is caused by the fear that they might harm others or themselves, despite a lack of evidence for this possibility).  
  • Fear of harm coming to others
  • Intrusive sexual thoughts or urges
  • Fear of losing control or behaving aggressively

Common compulsions include:

  • Washing (e.g. excessive hand washing, bathing, or cleaning)
  • Repeated checking (locks, windows, stove, etc.)
  • Repetition of thoughts or behaviors
  • Counting (e.g. counting objects or steps, counting to a specific number, arranging objects in groups of two’s or three’s)
  • Avoidance
  • Praying
  • Reassurance-seeking

Please note that these behaviors are typically excessive and present in the individual as a powerful need. If unable to complete these behaviors, the individual may feel heightened anxiety.

What is Hoarding?

One study by Frost (1996) estimated that about one-third of persons with Obsessive-Compulsive Disorder also show compulsive hoarding behaviors. Compulsive Hoarding is characterized by the excessive accumulation of items, particularly items without apparent value or use, and/or the feeling of being unable to discard items. Any attempt to do so causes intense amounts of anxiety and panic. Hoarding, as a disorder, is distinguished from general clutter by its interference with normal levels of functioning. The homes of persons with hoarding disorder are excessively cluttered, with little space for movement. They may present fire hazards or increase the risk of tripping and falling, particularly for older adults, among whom the disorder presents more often (Ayers, Saxena, Golshan, & Wetherell, 2010). Likewise, such constriction of movement in the home of an older adult poses additional safety concerns, as an injury sustained during a fall can have severely disabling or otherwise fatal consequences.

This clutter also prevents cleaning, which can promote unsanitary living conditions due to the accumulation of trash and food, or the inability to address problems such as the growth of mold which may not be seen. Conditions such as these increase the likelihood of physical illness, which can be particularly worrisome for older adults. Hoarding may also prevent the performing of everyday activities such as cooking. In such circumstances, an older adult may be considered as experiencing “self-neglect,” the most reported form of elder abuse in which a person over the age of 60 “lives alone and doesn't properly take care of him/herself. There are often added problems of declining health isolation, [such as] Alzheimer's disease or dementia, or drug and alcohol dependency” (Berkshire District Attorney, 2016).

The clutter may cause strain on interpersonal relationships within the home, as it causes stress and negatively impacts others' lives. Sketee, Frost, and Kim (2001) note that persons who compulsively hoard frequently lack insight into the extremity of the symptoms, are often resistant to treatment, and do not seek treatment until the intervention of friends and family. This is a particular concern because social isolation is also common in persons who hoard, especially in older adults.

What Causes OCD?

Obsessive-compulsive disorder frequently appears between the ages of nine and 12, though it may also initially emerge in the twenties or into middle age. There is no one known cause for OCD, though there are a few hypotheses which explain the symptoms. Rachman (1997) explains that the obsessions in OCD are so persistent and distressing because of thought-action fusion. This means that persons with the disorder believe their thoughts to be incredibly significant, to the point that the thoughts seem to be capable of increasing the likelihood that a negative event will occur. The performance of the compulsion feels as though it is the only way to negate the power of these thoughts. As with people who do not have the disorder, any attempt to intentionally suppress the thoughts and focus on something else only increases the frequency and urgency of the thoughts.

Neuroscientific explanations for the disorder exist as well. Parts of the brain which appear to be over-active in persons with OCD are those involved in decision-making, concentration, and impulse control. This over-activity may result in rumination over the potential consequences of a situation, as well as obsessions and anxiety about particular thoughts and emotions. Other parts of the brain which affect judgment about when to start and stop behaviors appear also to be affected, resulting in strong impulses to repeat thoughts and actions.

Scientists have also found a relationship between traumatic life events and OCD or hoarding symptoms. The areas of the brain affected by depression, trauma, and OCD disorders overlap as do the symptoms of these disorders, which may contribute to this relationship (Huppert et al, 2004). While it remains unclear whether or not traumatic life events make it more likely for someone to develop OCD or hoarding, individuals who have experienced trauma and have a diagnosis of OCD or hoarding tend to experience more severe symptoms (Cromer, Schmidt, & Murphy, 2007).   

What causes Compulsive Hoarding?

Compulsive hoarding may appear in childhood or adolescence but often shows up later in life than OCD symptoms, becoming severe around middle age. These symptoms tend to become more intense with time; over forty percent of hoarding-related complaints to authorities have been found to be related to older adults (Sketee, Frost, & Kim, 2001). In this population, hoarding behaviors frequently co-occur with and are exacerbated by, dementia.

Hoarding has also been shown to have similar causes to OCD. For instance, it is related to distorted evaluations of importance. Individuals who compulsively hoard view objects as intensely emotionally important, and may report feeling as though the objects are seen as a part of the self, and therefore cannot be thrown away (Weaver, n.d.). Hoarding behavior also appears to be affected by areas of the brain involved in decision-making and organization and has been linked to the disruption in areas of the brain related to memory, possibly affecting both organizational skills and the evaluation of objects.

In both of these disorders, avoidance encourages the behavior through a process called negative reinforcement. In negative reinforcement, the performance of a certain behavior leads to something unpleasant being removed, which encourages the individual to repeat the behavior to continue to avoid distress. In persons with anxiety, the anxiety causes distress, but avoidance – whether through avoidance of a situation or object, as in OCD, or avoidance of the removal and organization of objects in hoarding – temporarily alleviates the anxiety. The individual is therefore reinforced by the avoidance behavior and does not develop positive coping skills for the underlying anxiety. This cycle can lead to worsening of OCD and hoarding symptoms as the individual continues to avoid the source of the anxiety and the anxiety continues to grow.

Treatment of OCD and Hoarding Disorder

Obsessive-compulsive and related disorders, including OCD and hoarding disorder, are most commonly treated using Cognitive-Behavioral Therapy (CBT) or psychopharmacology, as best practices. CBT targets both the thoughts and actions of the individual which are symptomatic of the disorder and aims to empower the individual to develop more realistic thoughts and behavioral responses to situations or stimuli which trigger their symptoms.

In the treatment of OCD, the form of CBT most often used is Exposure and Response Prevention, which targets the negative reinforcement discussed above. This takes place in several steps. First, the client and clinician together develop a hierarchy of stimuli and situations, from least to most distressing, to which the client will be exposed. The client and therapist then move through this list together, with the client generally directing the speed. The client is exposed to the situations and prevented from performing compulsions and avoidance behaviors that alleviate their distressing thoughts or impulses, for increasing periods of time. As the individual spends time exposed to the stimulus without the feared consequences of removing their neutralizing compulsions, they experience a gradual decrease of the anxiety symptoms, known as habituation. As the individual's level of anxiety decreases when presented with a stressful situation, the individual feels less need to perform compulsions in order to cope.

In the treatment of hoarding, CBT focuses on helping an individual develop organization and decision-making skills, as well as reducing anxiety around de-cluttering. Because of the distressing nature of learning to get rid of objects which may have no obvious use or value to others but hold strong personal value, it is very important for the individual to have support from others– this may include support groups, friends, and family. However, the support of a professional who is trained to help persons who hoard has been shown to be effective and often necessary to prevent recurrence of compulsive hoarding. Various services to partially or completely clear out a home are available, and regular cleaning services may be put in place after the initial cleaning, particularly to help older adults or others who would still find cleaning difficult when the home is de-cluttered.

Each of these disorders may also be treated using medications, typically Selective Serotonin Reuptake Inhibitors (SSRIs). Although SSRIs are typically used as medication for depression, they have demonstrated efficacy in the treatment of OCD at higher doses in adults (Bloch, McGuire, Landeros-Weisenberg, Leckman, & Pittenger, 2010). These medications affect the serotonin levels in the brain, which is believed to be effective because of the role of serotonin in decision making and executive functioning, particularly in the areas of the brain implicated in OCD and hoarding disorders.

Familial and social support for those with OCD and/or hoarding disorder is very important to treatment. Friends and family members of people with OCD and/or hoarding disorder should also remember to pay attention to and take care of themselves while their loved ones are receiving treatment. Simply being aware of the possible signs of these disorders and reaching out to family members or friends in a non-judgmental manner, to let them know that they are cared about, can be an important gesture in helping people with these disorders seek treatment and feel safer and supported throughout it.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. L. (2010). Age at onset and clinical features of late life compulsive hoarding. International Journal of Geriatric Psychiatry, 25(2), 142. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083761/

Baer, L. (2001). The imp of the mind.

Berkshire District Attorney (2016). Elder abuse. Retrieved from http://www.mass.gov/berkshireda/crime-awareness-and-prevention/elder-abuse/elder-abuse.html

Bloch, M.H., McGuire, J., Landeros-Weisenberger, A., Leckman, J.F., & Pittenger, C. (2010). Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder. Molecular Psychiatry 15, 850–855. https://www.nature.com/articles/mp200950 

Chok, J. (2008, December). The neuropsychology of obsessive-compulsive disorder. Lecture given in the Obsessive-Compulsive Disorder Institute staff meeting, Mclean Hospital, Belmont, MA.

Claiborn, J. (2006). Hoarding—A successful compulsion. http://drclaiborn.info/hoarding.html

Claiborn, J. (n.d.). Hoarding: Where Does It Belong?

Cromer, K.R., Schmidt, N.B., & Murphy, D.L. (2007). Do traumatic events influence the clinical expression of compulsive hoarding? Behaviour Research and Therapy, 45(11), 

2581-2592. https://doi.org/10.1016/j.brat.2007.06.005

Demitri, M. (2006). Medications for obsessive-compulsive disorder. psychcentral.com/lib/2006/medications-for-obsessive-compulsive-disorder

Frost, R.O.; Hartl, T.L. (1996). A cognitive-behavioral model of compulsive hoarding. Behavior Research and Therapy, 34 (4), 341-50. http://ac.els-cdn.com/0005796795000712/1-s2.0-0005796795000712-main.pdf?_tid=a2b9846a-566d-11e5-9483-00000aacb35d&acdnat=1441746638_aa51a5206b4ed2f41f82ea4e054abf9b

Goodman, H. (2006). What causes obsessive-compulsive disorder (ocd)? psychcentral.com/lib/2006/what-causes-obsessive-compulsive-disorder

Huppert, J.D., Mosera, J.S., Gershunyb, B.S, Riggsa, D.S, Spokasa, M., Filipa, J., Hajcaka, G., Parkerd, H.A., Baere, L., Foaa, E.B. (2003). The relationship between obsessive-compulsive and posttraumatic stress symptoms in clinical and non-clinical samples. Anxiety Disorders, 19(2005), 127–136. doi:10.1016/j.janxdis.2004.01.001 

Janeck, A. & Calamari J. (1999). Thought suppression in obsessive-compulsive disorder. Cognitive Therapy and Research 23, 497-509.

Jenike, M. (n.d.). Obsessive-compulsive disorder. www.beatcfsandfms.org/references/OCD.html

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Maidment, K. (n.d). Compulsive Hoarding Syndrome - An Introduction. UCLA OCD Intensive Treatment Program. jhampton.pbworks.com/f/hoarding2.docx

Martin, A., Purdon, C., & Summerfeldt, L. (2007). Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond.

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Obsessive Compulsive Foundation Compulsive Hoarding Website -  https://hoarding.iocdf.org/

Rachman S. (1997). A cognitive theory of obsessions. Behavioral Research Theory, 35, 793–802. http://homepage.psy.utexas.edu/Homepage/Class/Psy394Q/Behavior%20Therapy%20Class/Assigned%20Readings/OCD/Rachman97.pdf

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Resource Organizations » OCD and Hoarding

In Massachusetts

Organizations with hotlines

National Alliance on Mental Illness (NAMI)- Massachusettes

1-800-370-9085

(617)-580-8541

The National Alliance on Mental Illness maintains a helpline for information on mental illnesses and referrals to local groups. The local self-help groups have support and advocacy components and offer education and information about community services for diverse communities comprising of LGBTQ individuals, veterans, active duty military members, teens, young adults, older adults and families. Local chapters can be found through the main website. For information about the Alliance's affiliates and activities in MA, contact NAMI Massachusetts. NAMI is a great resource for individuals, families, and loved ones facing mental illness and the accompanying challenges. 

Organizations without hotlines

Children of Hoarders: Massachusetts

COH provides helpful links to help a family member who hoards. These include links to therapists, professional organizers, cleaning companies, and applicable laws and regulations. The website also has information about hoarding support groups and family support groups.

International OCD Foundation for Kids

617-973-5801

Mission: "Let's work together to improve the lives of everyone affected by OCD"

Based in Boston, Masschusetts, the International OCD Foundation website offers learning opportunities, a thorough resource directory providing information on therapists, clinics, treatment programs, support groups, and organizations specializing in helping kids with OCD and related disorders in your area, and a list of upcoming events to join in building awareness for kids with OCD.

International OCD Foundation Hoarding Center

617-973-5801

Email: info@iocdf.org

The IOCDF Hoarding Center is designed to provide the most up-to-date and accurate information about hoarding and its treatment. The Center has five goals, which includes educating the general public about hoarding, Facilitating education and training of human service personnel including mental health, social services, public health and housing as well as police and fire officials, supporting research into the causes of and effective treatments for hoarding, improving access to resources for those with hoarding disorder and their families, as well as clinicians and service personnel, and advocating and lobbying for public policy change as it affects people who hoard, their families and community members.

Mass Housing Hoarding Resources

800-882-1154 (Toll-Free)

617-854-1000

Email: rentalsupport@masshousing.com

The Mass Housing organization provides a comprehensive list of organizations and resources to help address hoarding. This website includes information about hoarding, how to assess it, best practices in trying to help someone struggling with hoarding, and local resources both for the person who is hoarding as well as family members who are being impacted.

Massachusetts Department of Mental Health

617-626-8000

TTY: 617-727-9842

The Department of Mental Health, as the State Mental Health Authority, assures and provides access to services and supports to meet the mental health needs of individuals of all ages, enabling them to live, work and participate in their communities. This critical mission is accomplished by working in partnership with other state agencies, individuals, families, providers and communities.

OCD Massachusetts: An Official Affiliate of the International OCD Foundation

(617) 855-8623

Email: info@ocdmassachusetts.org

Founded in 1995, OCD Massachusetts is a non-profit affiliate of the International OCD Foundation (IOCDF). OCD Massachusetts is a locally based group made up of people with Obsessive Compulsive Disorder (OCD) and related disorders, as well as their families, friends, professionals and others. Their website contains helpful information on OCD, it's treatment, and communicating with insurance companies. This website also offers information on local events and resources in Massachusetts, including potential providers and support groups, research studies in the area focused on OCD,  lectures, and OCD awareness week. 

Outside Massachusetts

Anxiety and Depression Association of America (ADAA)

240-485-1001

Email: information@adaa.org

The Anxiety and Depression Association of America (ADAA) - formerly The Anxiety Disorders Association of America - is a nonprofit organization whose mission is to promote the prevention, treatment and cure of anxiety disorders and to improve the lives of all people who suffer from them. ADAA is dedicated to informing the public, health care professionals, and media that anxiety disorders are real, serious, and treatable. ADAA promotes professional and public awareness of anxiety and related disorders (such as PTSD, OCD, panic disorder, social anxiety) and their impact on people's lives. The organization also links people who need treatment with the health care professionals who provide it. The ADAA website also provides listings of anxiety disorder support groups offered across the United States.

AnxietyBC

(604) 620-0744

AnxietyBC contains a wealth of information to help people learn about and practice effective strategies to manage anxiety on their own, at their own pace. All content is grounded in scientific research and developed by professionals who specialize in helping people with anxiety.

Children of Hoarders: National

Children of Hoarders, Inc is a not-for profit organization made up of volunteer Children of Hoarders (COH), dedicated to increasing awareness and understanding of the unique challenges facing children of hoarders while helping them to support themselves and each other. COH, Inc provides extensive resources on what hoarding looks like, various types, suggestions and available support for not only children worried about family members hoarding but also spouses or other loved ones. The website also provides opportunities to connect with others impacted by hoarding through online groups and forums.

Geriatric Mental Health Foundation

(703) 556-9222

Email: web@GMHFonline.org

The Geriatric Mental Health Foundation was established by the American Association for Geriatric Psychiatry to raise awareness of psychiatric and mental health disorders affecting the elderly, eliminate the stigma of mental illness and treatment, promote healthy aging strategies, and increase access to quality mental health care for the elderly. Explore the site for mental health information for older adults and their families, to find a geriatric psychiatrist, for news of Foundation programs and events, and much more.

Mental Health America

Toll-Free: 800-969-6642

Office: 703-684-7722

TTY: 800-433-5959

Mental Health America (formerly known as the National Mental Health Association) is the country's leading nonprofit dedicated to helping ALL people live mentally healthier lives. With more than 320 affiliates nationwide, they represent a growing movement of Americans who promote mental wellness for the health and well-being of the nation -- everyday and in times of crisis.

The Brain and Behavior Research Foundation

Main Line: 646-681-4888

Toll Free: 800-829-8289

Email: info@bbrfoundation.org

The Brain and Behavior Research Foundation (formerly NARSAD, the National Alliance for Research on Schizophrenia and Depression) is committed to alleviating the suffering of mental illness by awarding grants that will lead to advances and breakthroughs in scientific research. The BBR Foundation offers news on the research it funds as well as information (documents and videos) about these and other disorders in children and adults. It also provides guidance and resources for families coping with a child or parent with mental illness.

Worry Wise Kids

This site was launched because of the urgent need to address the growing needs of our children to be equipped to cope with and overcome the stress, worry and anxieties in their life. Our mission is to improve the quality of life for anxious children and their families by providing parents, educators and mental health professionals with comprehensive, user-friendly information on the full range of anxiety disorders. Because children may be secretive about their worries and suffer in silence, our goal is to help adults who care about kids to be on the lookout for red flags. We offer information about treatment options, kid-friendly explanations for the mechanisms that create and maintain anxiety, parenting do's and don'ts, how to handle school issues and more.