Compulsive hoarding disorder [disposophobia]

In disposophobia (compulsive hoarding disorder or pathological accumulation), the subject always has great difficulty disposing of or getting rid of objects, which end up accumulating and invading the environments in which he or she lives, to the point of making them uninhabitable.

The need to acquire – without using or discarding – these possessions leads to extreme disorganization and restriction of essential activities of daily life, such as resting, eating, personal hygiene, and cleaning spaces.

In fact, those who suffer from disposophobia are driven to accumulate without restraint, even when the storage of objects prevents and/or significantly reduces the physical possibility of walking around the house. This compulsion to accumulate is accompanied by a complementary fear of disposing of one’s collections. Often the disposofobia originates from an emotional trauma, such as the loss of a loved one, a romantic disappointment, or the divorce of parents during childhood. This creates a deficiency that the compulsive hoarder tries to fill by “collecting” objects.

Disposophobia is a very complex disorder, but it can be treated with cognitive behavioral therapy.

Historical development

The emergence of evidence supporting the conceptualization of hoarding as a construct not entirely dependent on OCD has stimulated the study of its clinical features. As a result, the past two decades of research on hoarding have led to a complete revolution in the clinical conceptualization of the phenomenon.

Historically, it was considered a component of a larger disorder, obsessive-compulsive disorder. In the 1980s, it was included in DSM III as one of the diagnostic criteria for Obsessive-Compulsive Personality Disorder. With the publication of DSM IV-TR (2000), it is instead described as a component or symptom of Obsessive-Compulsive Disorder (OCD). The parable of pathological hoarding currently ends in DSM 5 (APA, 2013) with its distinction as a separate diagnostic category, included within the OCD chapter but separate from OCD. Inclusion within this chapter, however, always emphasizes and takes into account the strong association and similarities between the two clinical conditions, although the results of the body of work in this area have shown that there may also be strong associations with other clinical conditions, particularly depression and anxiety, as well as specific features of hoarding that motivate its distinction from other disorders.

Early studies of hoarding disorder – Frost’s model

The strong association between hoarding and depression, as well as other domains, was noted by Frost and colleagues in the early 1990s. Later, in 1996, the authors proposed a cognitive-behavioral model to explain hoarding based on 4 factors:

  1. Emotional processing deficits;
  2. Poor interpersonal and emotional intelligence;
  3. Avoidance;
  4. Dysfunctional beliefs about possessions.

Other research has shown that hoarding is often associated with stress or trauma, violence and separation in the individual’s history. Social and family relationships are severely diminished. There is also evidence of poor illness awareness in hoarders and egosyntonicity of symptoms.

Clinically, pathological hoarding has three components:

  • Difficulty discarding objects (Difficulty Discarging)
  • Acquisition
  • Cluttering

Disposophobia: the causes

People with hoarding disorder live with the fear of getting rid of anything they collect because they believe it might come in handy in the future or has economic or emotional value. Often, these people develop an intense emotional attachment to these objects and try to exert control over them by preventing others from touching or throwing them away. The very thought of parting with them causes anxiety and distress, so the act of disposing of the objects is never performed. This is due to the fear of making the wrong decision or the inability to let go of the objects, even if they are eventually abandoned and accumulate in a deteriorating condition around them.

Serial hoarder: the symptoms

There are signs that family members can recognize that may indicate the need to seek professional help:

  • Frequent family arguments about the clutter caused by the excessive presence of objects in the home.
  • There is an excessive tendency to hoard items.
  • Difficulties in managing household finances.
  • There is a tendency to procrastinate in rearranging things.
  • A reduction in social relationships to the point of withdrawal is observed.
  • Although the distress caused by this condition is significant for the patient, it is often family members who seek professional intervention, as they are directly affected by the effects of these behaviors.

Early intervention can prevent the deterioration of subthreshold clinical conditions, which can worsen over time and negatively affect not only the psychological well-being of the person, but also that of his or her family members.

Symptom or syndrome?

Although hoarding is often associated with obsessive-compulsive disorder (OCD), it is not specifically mentioned as a symptom of OCD in the DSM-IV-TR or ICD-10. In the DSM-IV-TR, it is listed as one of the eight diagnostic criteria for obsessive-compulsive personality disorder (OCPD). In describing the differential diagnosis between OCPD and OCD, the DSM-IV-TR states that the diagnosis of OCD should be considered, especially in cases where the clustering is extreme.

While there is little doubt that “pathological hoarding is a possible symptom of OCD, or that it is due to typical obsessive-type fears, such as the fear that throwing away objects will cause harm to oneself or others (Pertusa, Frost & Mataix-Cols, 2011), there is a body of evidence to support the idea that in most cases hoarding symptoms are not related to OCD. For example, although approximately 5-10% of OCD patients exhibit hoarding symptoms, more than 80% of patients with hoarding disorder do not exhibit other OCD symptoms (Frost, Steketee & Tolin 2012; Pertusa et al., 2008; Samuels et al., 2008). Instead (Frost et al., 2012), it appears that the most common comorbidities among cases of pathological hoarding are anxiety and depressive disorders.

Thus, hoarding is a behavior that can manifest either as a symptom (predominantly of OCD) or as a syndrome that develops over the years. According to the current literature, these two manifestations differ according to age of onset, comorbidities, and psychological context (Randy A. Sansone, MD & Lori A. Sansone, MD, 2010). As a syndrome, hoarding symptoms appear to be unrelated to OCD, tend to peak in adulthood, and may be associated with childhood difficulties, various personality traits and disorders, and alcohol abuse or dependence (Sansone & Sansone, 2010).

Also according to the DSM-V, individuals with hoarding disorder intentionally hoard their possessions. This criterion distinguishes Hoarding Disorder from other psychopathological forms in which passive hoarding is present or in which the discomfort experienced in the face of eliminating one’s possessions (e.g., in some forms of dementia) is lacking (Bernardotti, 2016) (Bernardotti, 2016).

Maier (2004) addresses this dilemma by concluding that “pathological hoarding is a complex behavior associated with different types of emotional and cognitive contexts, including obsessive-compulsive. However, while hoarding may be symptomatic of OCD, it is not exclusive to this disorder.

Compulsive hoarding and OCD: what are the differences?

From a phenomenological point of view, the fear of losing something important to the person, the fear of getting rid of things he or she feels emotionally attached to, or the fear of making a mistake about what is best to keep or throw away could be considered analogous to obsessions, while not throwing away objects, as well as some acquisition behaviors, could be likened to compulsions.

However, much research has provided evidence of important differences between compulsive hoarding and OCD.

For example, the hoarder’s thoughts related to accumulation (dysphobia) are not perceived as intrusive or unwanted; they are not repetitive, as obsessions typically are in people with OCD.

Compulsive hoarding is a passive phenomenon in which intense discomfort is experienced only when these people come to terms with the need to get rid of what they possess. The experience of acquiring things, on the other hand, is felt to be ego-syntonic, pleasurable, or otherwise reassuring.

One of the defining characteristics of individuals with disposophobia is a strong attachment to the things they own, sometimes attributing a strong sense of identity to them. Here, the scenario of having to get rid of things to which they feel very emotionally attached can be experienced as very painful by the individual. Sometimes these individuals come to believe that inanimate objects have real feelings.

The obsessive-compulsive patient, on the other hand, even in cases where he or she manifests hoarding symptomatology, is in no way concerned with the intrinsic value of the object. For example, hoarding may be the result of superstitious thoughts such as “If I throw away an object, I fear something bad will happen to a loved one.

In this case, the difficulty in getting rid of the object is not so much related to the attribution of an emotional value to it, but rather represents a protective strategy in response to intrusive thoughts of a catastrophic nature.

In contrast, the meaning attributed to the same inability to discard by patients with hoarding disorder is different. Since objects are an integral part of their personal identity, their memory, getting rid of them is tantamount to a real experience of grief. Hence the predominant emotions of grief and anger in those suffering from disposophobia.

A psychiatric entity in its own right

In recent years, the study of hoarding disorder has received increasing attention, and its nosographic characterization has been the subject of lively scientific debate.

Although this behavior has often been reported as a symptomatic manifestation of OCD, it was curiously not directly mentioned as a symptom of OCD in the DSM-IV-TR. Rather, it fell under one of the 8 criteria for obsessive-compulsive personality disorder.

So not OCD, but not a phobia either, although as mentioned above, hoarding disorder is also referred to as disposofobia (literally “fear of throwing away”). This term can be misleading because it does not provide a comprehensive picture of the clinical complexity of these patients.

The nosographic ambiguity of hoarding disorder has been resolved in DSM-5 (APA, 2013) by recognizing it as a distinct entity in the international psychiatric landscape.

This categorization may do more justice to a disorder that also exhibits precipitous features at the brain level.

Indeed, a 2012 study by Tolin and collaborators at Yale University School of Medicine, published in the Archives of General Psychiatry, showed that individuals with hoarding disorder, compared with OCD patients and normal adults, exhibit fundamental differences in both the anterior cingulate cortex, which is associated with error detection under conditions of uncertainty, and the medial and anterior insula, which is associated with risk and salience assessment of stimuli and emotionally charged decision making.

Compulsive hoarding disorder, according to the authors, seems to be characterized by a marked avoidance of decisions about possession.

The key seems to be the affective attachment to things and the importance to these patients of possessing objects that most people would not consider valuable. In these cases, objects can take over people’s lives and enslave them.

Cognitive behavioral treatment for hoarding disorder

From a therapeutic standpoint, current cognitive-behavioral treatment of hoarding disorder focuses primarily on reducing symptoms in three macro areas: disorganization, difficulty getting rid of and discarding personal items, and the tendency to acquire excess items. Specifically, treatment uses skills training aimed at strengthening problem-solving, decision-making, and organizational skills, as well as gradual exposure and cognitive restructuring of irrational beliefs related to hoarding behavior (Bernardotti, 2016).

In addition, the low level of mindfulness often associated with hoarding disorder has led to speculation about the usefulness of using motivational techniques and the support of home visits in addition to the above interventions (Steketee et al., 2010).

Associations with anxiety and depression

Approximately 75% of patients with pathological hoarding have a comorbid mood or anxiety disorder. The most common comorbid conditions are major depression, social anxiety disorder (social phobia in DSM IV-TR), and generalized anxiety disorder (Steketee et al., 2000, Frost, Steketee, Williams, and Warren, 2000, Gail Steketee & Randy Frost 2003). In general, many studies have shown that individuals with hoarding behaviors report greater symptoms of anxiety and depression, as well as poorer functioning (Frost, Steketee, Williams, & Warren, 2000; Samuels et al., 2002).

It should be noted, however, that approximately 20 percent of hoarders have symptoms that meet diagnostic criteria for OCD; this rate is significantly higher than the prevalence of the disorder in the general population (1-2 percent), suggesting that although hoarding disorder is distinct from OCD, it remains very closely related to it (Frost, Steketee, Tolin, 2011). The authors further corroborated these data by showing that within clinical samples, major depression was the most common comorbid condition among hoarders. In fact, it was diagnosed in more than half of the sample, and was much more common in hoarders than in OCD.
Although less common, generalized anxiety disorder and social phobia were also diagnosed in about a quarter of the hoarding cases, with rates similar to those in the OCD samples.

Other emotional and cognitive symptoms commonly found in hoarding groups include high levels of inattention and hyperactivity, indecisiveness, cognitive deficits, anxiety, and poor self-control. The poverty of emotional control and regulation strategies, in turn, suggests a high likelihood of using external (nonadaptive) strategies to regulate mood (Hall, Frost, Tolin, Steketee, 2013).

A study I conducted on an Italian psychiatric sample, with diagnoses mainly afferent to the anxiety and mood domains, showed the considerable prevalence of hoarding among depressive and anxiety disorders and the frequent association with a personality disorder.

Correlational analysis showed that pathological “hoarding and its components of cluttering, difficulty uncluttering, and acquisition are significantly associated with anxiety and depression, to the same or greater extent than obsessive-compulsive symptoms (Cozzi, 2014).

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