Evidence-Based Reviews

Compulsive hoarding: Unclutter lives and homes by breaking anxiety’s grip

Current Psychiatry. 2005 March;4(3):12-26

References

1. Frost R, Gross R. The hoarding of possessions. Behav Res Ther 1993;31:367-81.

2. Leckman J, Grice D, Boardman J, et al. Symptoms of obsessive-compulsive disorder. Am J Psychiatry 1997;154:911-17.

3. Leckman J, Zhang H, Alsobrook J, Pauls D. Symptom dimensions in obsessive-compulsive disorder: toward quantitative phenotypes. Am J Med Genet 2001;105(1):28-30.

4. Hanna G. Demographic and clinical features of obsessive-compulsive disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1995;34(1):19-27.

5. Rasmussen S, Eisen J. The epidemiology and clinical features of obsessive-compulsive disorder. Psychiatr Clin North Am 1992;15(4):743-58.

6. Frost R, Hartl T. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther 1996;34:341-50.

7. Steketee G, Frost R. Compulsive hoarding: current status of the research. Clin Psychol Rev 2003;23:905-27.

8. Saxena S, Maidment K, Vapnik T, et al. Obsessive-compulsive hoarding: symptom severity and response to multi-modal treatment. J Clin Psychiatry 2002;63:21-7.

9. Leckman JF, Pauls DL, Zhang H, etal. and the Tourette Syndrome Association International Consortium for Genetics. Obsessive-compulsive symptom dimensions in affected sibling pairs diagnosed with Gilles de la Tourette Syndrome. Am J Med Genet 2003;116B:60-8.

10. Zhang H, Leckman JF, Pauls DL, etal. and the Tourette Syndrome Association International Consortium for Genetics. Genome-wide scan of hoarding in sib pairs in which both sibs have Gilles de la Tourette syndrome. Am J Hum Genet 2002;70:896-904.

11. Winsberg M, Cassic K, Koran L. Hoarding in obsessive-compulsive disorder: a report of 20 cases. J Clin Psychiatry 1999;60:591-7.

12. Samuels J, Bienvenu OJ, 3rd, Riddle MA, et al. Hoarding in obsessive compulsive disorder: results from a case-control study. Behav Res Ther 2002;40(5):517-28.

13. Saxena S, Brody A, Maidment K, et al. Cerebral glucose metabolism in obsessive-compulsive hoarding. Am J Psychiatry 2004;161:1038-48.

14. Black D, Monahan P, Gable J, et al. Hoarding and treatment response in non-depressed subjects with obsessive-compulsive disorder. J Clin Psychiatry 1998;59:420-5.

15. Mayberg H, Brannan S, Mahurin R, et al. Cingulate function in depression: a potential predictor of treatment response. Neuroreport 1997;8(4):1057-61.

16. Rauch S, Shin L, Dougherty D, et al. Predictors of fluvoxamine response in contamination-related obsessive-compulsive disorder: a PET symptom provocation study. Neuropsychopharmacol 2002;27(5):782-91.

17. Hartl T, Frost R, Allen G, et al. Actual and perceived memory deficits in individuals with compulsive hoarding. Depress Anxiety 2004;20:59-69.

18. Frost R, Krause M, Steketee G. Hoarding and obsessive-compulsive symptoms. Behav Modif 1996;20:116-32.

19. Steketee G, Frost R, Kim H-J. Hoarding by elderly people. Health Soc Work 2001;26:176-84.

20. Frost RO, Steketee G, Williams LF, Warren R. Mood, personality disorder symptoms, and disability in obsessive compulsive hoarders: a comparison with clinical and non-clinical controls. Behav Res Ther 2000;38:1071-81.

21. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry 1989;46(11):1006-11.

22. Frost RO, Steketee G, Grisham J. Measurement of compulsive hoarding: saving inventory-revised. Behav Res Ther 2004;42(10):1163-82.

23. Saxena S, Maidment K. Treatment of compulsive hoarding. J Clin Psychol 2004;60(11):1143-54.

24. Mataix-Cols D, Marks IM, Greist JH, et al. Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychother Psychosom 2002;71(5):255-62.

25. Abramowitz JS, Franklin ME, Schwartz SA, Furr JM. Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. J Consult Clin Psychol 2003;71(6):1049-57.

26. Steketee G, Frost RO, Wincze J, et al. Group and individual treatment of compulsive hoarding: a pilot study. Behav Cognit Psychother 2000;28:259-68.

27. Mataix-Cols D, Rauch S, Manzo P, Jenike M. Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. Am J Psychiatry 1999;156:1409-16.

28. Greist JH, Jefferson JW, Kobak KA, et al. Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis. Arch Gen Psychiatry 1995;52(1):53-60.

29. Pallanti S, Hollander E, Goodman WK. A qualitative analysis of nonresponse: management of treatment-refractory obsessive-compulsive disorder. J Clin Psychiatry 2004;65(suppl 14):6-10.

30. McDougle C, Goodman W, Leckman J, et al. Haloperidol addition in fluvoxamine-refractory obsessive-compulsive disorder: a double-blind, placebo-controlled study in patients with and without tics. Arch Gen Psychiatry 1994;51:302-8.

²⁰

Motivation. Like insight, motivation can fluctuate over time. Patients usually must work tremendously hard to adhere to treatment. To support these efforts, we periodically review with patients compulsive hoarding’s negative effects and the activities they would enjoy—such as improved relationships, greater work capacity, hobbies—if overcoming this behavior allowed them more time and space.

Rating scales. The symptom checklist of the Yale-Brown Obsessive-Compulsive Scale (YBOCS)²¹ contains two items for hoarding obsessions and compulsions but none for avoidance behaviors, which are prominent with compulsive hoarding. The Saving Inventory-Revised²² is a validated, 23-item self-report measure of clutter, difficulty discarding, and excessive acquisition, which distinguishes compulsive hoarders, nonhoarding OCD patients, and normal controls.

TREATMENT

The compulsive hoarder’s problems will not be solved by someone else throwing away or organizing his or her possessions. These actions often anger patients, who see them as intrusive and a loss of control.

In our experience, family members’ attempts to intervene can disrupt relationships and worsen hoarders’ social withdrawal. “Taking over” also does not help the patient create a sustainable system for keeping clutter-free.

Algorithm

Medication treatment for compulsive hoarding*

Start with SSRIs, as for nonhoarding OCD (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)	High doses and 12-week trials Some compulsive hoarders will respond well to SSRIs Other OCD symptoms usually improve as well Comorbid depression and other anxiety symptoms may respond If ineffective, may need to do 3 or 4 full trials of different SSRIs, clomipramine, or venlafaxine
Treat comorbid conditions	Mood disorders, other anxiety disorders, ADHD, psychotic disorders, etc.
Use adjunctive medications if SSRIs give only partial response	Atypical antipsychotics (risperidone, olanzapine, quetiapine) Stimulants Mood stabilizers (for comorbid bipolar disorder, cyclothymia, or impulsivity)
* Combine medication treatment with cognitive-behavioral therapy
SSRI: selective serotonin reuptake inhibitor
OCD: obsessive-compulsive disorder
ADHD: attention-deficit/hyperactivity disorder

We find that combining cognitive-behavioral therapy (CBT) and medication is optimal treatment for compulsive hoarding,²³ although no controlled studies have compared this combination with each treatment alone. One controlled trial²⁴ and three uncontrolled trials^8,25,26 have shown some benefit of CBT for compulsive hoarding, although with poorer response and higher dropout rates than for nonhoarding OCD patients.

Psychotherapy. Exposure and response prevention (ERP) focuses on preventing incoming clutter, discarding, organizing, and relapse prevention (Table 3).²³ Start treatment by explaining compulsive hoarding syndrome to patients as having problems with information processing, obsessional anxiety, and avoiding decisions.

Preventing incoming clutter. Before you focus on discarding, patients must stop incoming clutter; otherwise, it will come in as fast as it goes out. We ask patients to keep a daily log of every item they acquire or buy to build their awareness of what triggers their behavior.

Discarding. To desensitize over time, we repeatedly expose patients to the anxiety, sadness, or anger they feel when discarding items and making decisions. We encourage them to provoke their anxiety by throwing away as many items as possible, keeping only necessary items.

We support ERP with cognitive restructuring, prompting patients to reframe their obsessive fears about losing something necessary or valuable. By thinking through the consequences of discarding their clutter, they challenge their erroneous beliefs that dire consequences will occur.

Organizing. When patients decide they must keep an item, ask them to immediately identify a specific place and deadline to store it. After an area is cleared, patients must keep it clear and use it for its intended purpose. Most patients need training in time management, scheduling, and prioritizing.

Relapse prevention. Replace hoarding behaviors with more-adaptive, healthy behaviors. Teach patients to create a realistic schedule that includes time for chores, eating and sleeping, CBT homework, and recreation. Treatment goals are to:

extinguish obsessional fears and compulsive saving behaviors
teach lasting organizational and decision-making skills, thereby reducing relapse risk.

Practical matters. Sorting and discarding a houseful of clutter takes time, although the patient does this primarily as homework. To control costs and your time commitment, consider collaborating with a CBT therapist trained in working with compulsive hoarders. Use your sessions with the patient to create hierarchies, go over assignments, do brief exposures, and monitor drug therapy.

Medications. No controlled studies have examined whether any medications are effective for compulsive hoarding syndrome. The treatment strategies and algorithm described here are based on our clinical experience, controlled trials of OCD patients, and limited OCD studies secondarily examining hoarders’ specific treatment responses.

Selective serotonin reuptake inhibitors (SSRIs) may be less effective for compulsive hoarding than for other compulsive behaviors.^14,27 Nevertheless, SSRIs may help alleviate hoarders’ core symptoms, other OCD symptoms, depression, and anxiety. For hoarding treatment to be effective, comorbid disorders must be treated and stabilized.