By Lori L. Riddle-Walker, MFT
Compulsive hoarding can be defined as behavior leading to an over-accumulation of possessions that negatively impacts life. There are multiple issues that come together to create hoarding. It has a poor prognosis and can cause extreme distress for the sufferer as well as family and friends. Hoarding can create safety hazards, interfere with the ability to complete daily tasks, cause financial and legal problems, social isolation, and relational difficulties.
Hoarding is not solely a psychological problem that can be addressed by challenging thoughts and belief, addressing early learning patterns, or working through difficult emotions. It has genetic and biological underpinnings that cannot be ignored. It is a very complex illness where multiple vulnerability factors and information processing deficits converge to create a painful and debilitating disorder. A relationship has been established between hoarding and obsessive compulsive disorder, and it is often comorbid with social phobia, depression, attention deficit hyperactivity disorder, impulse control disorders, and personality problems (Stekette, 2007, p. 5-8 ).
Psychosocial contributors to hoarding can include family rules and values, early associations, learning, and various forms of behavioral reinforcement. These will not be discussed here. Rather, we will look at genetic and biological vulnerability factors that impact brain function. These will include mental health concerns such as obsessive compulsive disorder, depression, or trauma, as well as other medical concerns that limit mobility or cause fatigue. Later we will look at deficits that impair information processing, then consider the role of compulsive acquiring. This article will show the complex interaction between brain function, the environment, physiological illness and hoarding symptoms.
Vulnerability Factors that Involve Brain Function
Obsessive compulsive disorder (OCD) is diagnosed in the presents of obsessions, compulsions or both. Examples of obsessive thoughts contributing to hoarding include: one’s environment must be perfect; one must not make mistakes; one must not waste; everything must be used for a purpose. Compulsions may include things like detailed and perfectionistic ordering, arranging, or organizing to the point of overwhelm and shut down; excessive recycling; and attempting to find the perfect home for any possessions that are being parted with, no matter how much time or energy is involved. A large percentage of hoarders also have other symptoms of OCD.
The cause of OCD is not clearly understood. However, OCD has been shown to be genetically predisposed (Chansky, 2000, p. 30). Gene expression or activation in general can be an internal process or may be impacted by the environment. Factors that have been shown to activate gene expression include psychoactive drugs or chemicals, stress hormones, thyroid hormones, and sex hormones (Preston, 2005, p. 34). The interplay between the genetic predisposition to OCD and environmental factors is being researched extensively. Anecdotal stories and observations from this author’s practice include OCD onset after LSD use, puberty, trauma, strep infection (PANDAS), and severe stressors. Traumatic brain injury (TBI) has also been show to trigger OCD symptoms which have been correlated with brain lesions in inhibitory brain structures (Grados, 2003, p. 7).
The areas of the brain implicated in OCD are the prefrontal cortex, hypothalamus, amygdala, cingulate, and basal ganglia. The prefrontal cortex has been specifically implicated in hoarding due to its function in behavioral monitoring and organization of complex information processing. It is also associated with impulse control (Preston, 2005, p. 37; An, 2009, p. 318-331). The cingulate is part of the autonomic pathway which controls response to external and internal stimuli as part of the fight or flight response to emergencies. The basal ganglia inhibits unwanted movement patterns and speech and is more likely associated with other obsessive compulsive spectrum disorders.
Depression is a vulnerability factor for hoarding due to its impact on motivation, energy levels, ability to concentrate, memory, anxiety level, and sleep. These factors then impact general functioning. At times depression can be a reaction to grief, loss, rejection, or other psychological factors but often there is biochemical dysfunction.
Some common drugs that can cause depression are high blood pressure medicine, corticosteroids and other hormones, anti-parkinson drugs, anti-anxiety drugs, birth control pills and alcohol.
The prefrontal cortex, hypothalamus, amygdala, and hippocampus have been implicated in depression. The hypothalamus in particular plays a large part in common symptoms of depression since it regulates the autonomic nervous system, sleep-cycles, hunger, sex drive, and also influences the immune system (Preston, 2005, p. 37). The link is clear since common symptoms of biological depression include sleep disturbance, appetite disturbance, fatigue, decreased sex drive, restlessness or psychomotor slowing, impaired concentration, forgetfulness, and inability to experience pleasure (Preston, 2009, p.6).
Causes of depression that can be linked to the hypothalamus include: hypothyroidism which is attributed to 5-10% of major depressions; difficulties in menopause; post-partum hormonal changes; and premenstrual syndrome (Preston, 2009, p. 3-4).
Post traumatic stress disorder (PTSD)
PTSD is classified as an anxiety disorder and can result from many types of trauma including early deprivation and loss, either physical or psychological. Sometimes early loss or deprivation can contribute to the onset of hoarding behaviors. Secondary loss of possessions for hoarders during “clean-outs” may create additional trauma that reinforces the need to hold on even tighter. At times late onset of hoarding can be precipitated by trauma (Stekette, 2007, p. 7). The brain structures implicated in anxiety disorders include the hypothalamus, amygdala, and cingulate. The amygdala can be responsible for intense emotions and “elicits and controls aggression” and “primitive threat appraisal” (Preston, 2005, p. 37). It “integrates information from the senses and from within the body with past experiences.” (Woolsey, 2008, p. 220)
General medical conditions
Any medical condition that impacts overall functioning can be a vulnerability factor for hoarding. An example of this would by post concussion syndrome which impacts the hippocampus and can last for up to a year after a minor head trauma. Symptoms include headaches, dizziness, fatigue, irritability, anxiety, insomnia, loss of concentration and memory, noise and light sensitivity. If other vulnerability factors are present, any medical condition may be enough to tip the scales and minor problems with discarding and clutter can become more severe.
Information Processing Difficulties Due to Brain Function
Attention Deficit Disorder (ADHD) has been shown to contribute to hoarding and clutter problems with common symptoms being difficulty paying attention to details, being easily distracted by irrelevant stimuli, difficulty performing tasks that require concentration, frequent shifts from one uncompleted activity to another, procrastination, disorganized work habits, forgetfulness in daily activities, frequent shifts in conversation, not listening to others, not keeping one’s mind on conversations, and restlessness. Both the prefrontal cortex, discussed previously, and the brain stem, specifically the reticular system, are implicated in ADHD. The reticular system is the stimulus filter or gate (Preston, 2005, p. 37). If irrelevant stimuli are not filtered, information overload can be responsible for difficulty managing tasks and possessions.
Memory problems also can contribute to hoarding and clutter because frequently items are left in view so they are not forgotten or duplicates of items are purchase due to difficulty finding them. “The hippocampus processes experience into memories and is involved in the recall of spatial locations.” (The Brain Atlas, 2008, p. 218) Various learning disabilities can also contribute to clutter, disorganization, and time management problems.
Hoarding worsens with age possibly due to cognitive decline and memory loss (Dudley, 2007). Cognitive decline can be caused by dementia and other confusional states linked to dysfunction of the cortex. The cause of dementia includes disease, infection, stroke, head injury, drugs, and nutritional deficiencies.
Frequently those that hoard also compulsively acquire. Common methods of acquiring include buying from stores, yard sales, the internet, picking up discarded items, and more infrequently stealing (Stekette, 2007, p., 168). Compulsive acquiring is considered an impulse control disorder and indicates pathology in the prefrontal cortex and amygdala (both discussed previously), as well as the septum. The septum is the emotional and stimulus gate and contains the pleasure centers (Preston, 2005, p. 37). Often acquiring is done to alter negative mood states, decrease anxiety, or relieve tension and can be treated similarly to other addictive behavior.
In conclusion it is clear that brain function is an important element in understanding compulsive hoarding, and is a part of vulnerability factors such as OCD, depression, and trauma. Information processing difficulties stemming from ADHD, learning disabilities, or cognitive decline are also linked to brain function. Additionally, as we have noted, brain function plays a role in compulsive acquiring. Treating hoarding is a complex task that must include medical evaluation, psychiatric evaluation, compensatory skill building, exposure therapy, as well as addressing distorted thoughts and beliefs, facing issues of grief, loss, trauma, and increasing social support.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
An, S. K., Mataix-Cols, D., Lawrence, N. S., Wooderson, S., Giampietro, V., Speckens, A., Brammer, M. J., Phillips, M. L., (2009). To discard or not to discard: The neural bases of hoarding symptoms in obsessive-compulsive disorder. Molecular Psychiatry, 14, 3, 318-331.
Chansky, T., (2000). Freeing your child from obsessive-compulsive disorder. New York, NY: Three Rivers Press.
Dudley, D., (2007). Conquering clutter. AARP Magazine, 1, 2.
Grados, M., (2003). Obsessive-compulsive disorder after traumatic brain injury. International Review of Psychiatry, 15, 4, 350-358.
Preston, J., Johnson, J., (2009). Clinical psychopharmacology made ridiculously simple (6 ed.). Miami, FL: MedMaster Inc.
Preston, J., O’Neal, J. O., Talaga, M., (2005). Handbook of clinical psychopharmacology for therapists (45th ed.). Oakland, CA: New Harbinger publications, Inc.
Steketee, G., Frost, R., (2007). Compulsive Hoarding and Acquiring, Therapist Guide. New York, NY: Oxford University Press.
Woolsey, T., Hanaway, J., Mokhtar, G., (2008). The brain atlas (3rd ed.). Hoboken, NJ: John Wiley & Sons, Inc.