The Psychology of Compulsive

Hoarding
Dr Christopher Mogan
The Anxiety Clinic, VIC
 The Psychology of
Compulsive Hoarding

Dr Christopher Mogan

NATIONAL SQUALOR CONFERENCE

Sydney, November 5-6, 2009

 Hoarding behaviours
Common to hoard stuff - keep just in case
Compulsive hoarding is more pervasive,
dominating time, space of self & others. Packed
garages, backyards, corridors, roof spaces,
rooms chaotic & unusable.
Unable to organize, discard things or prevent
clutter, high distress, hazards to health/safety.
Hoarding largely undiagnosed & untreated.

mogan@theanxietyclinic.com
 Issues in studying hoarding
Causes and phenomenology of
compulsive hoarding remains unclear -
no DSM IV criteria
Estimates of population with OCD range
from 0.6% to more than 3%. Hoarding in
the OCD population estimated at 30%+.
Hoarders seen as secretive, resistant to
treatment, undiagnosed for years; not a
diagnostic criterion for OCD, only OCPD.

mogan@theanxietyclinic.com
 Frost & Hartl (1996) defined
Compulsive Hoarding
The acquisition of and failure to
discard possessions that appear to be
useless or of limited value.
Impairment from
the degree of clutter involved making rooms
unusable for their purpose
negative effect on the personal functioning
of the hoarder - reported risks: fire(47%),
falls (38%), hygiene (35%). Nil hazards
(25%).
mogan@theanxietyclinic.com
 Hoarders & non-hoarders
think differently about things

Hoarders have specific problem appraisals:

1. Emotional attachment to objects
2. Memory for possessions and objects
3. Control of possessions and objects
4. Responsibility for possessions and
objects
mogan@theanxietyclinic.com
 Other hoarding-related
cognitions
Indecisiveness
No confidence in memory uncertainty
Need to keep things in view
Comfort from being with things
Fear of forgetting important memories
Need to be reassured about things

mogan@theanxietyclinic.com
ETIOLOGY (Causation)
Psychoanalytic approaches
Freuds construct of reactive defence against conflict
in the anal stage led Fromm to delineate a hoarding
character - remoteness, withdrawal from others.. a
controlling mode of relatedness - reduce anxiety by
control.
In Kleinian theory, the unconscious urge is to return
all that had been removed from the mother, yet brings
a un-resolvable conflict in the compulsive urge to
hold on.
Contemporary P/A theory emphasizes the loss of
adaptiveness & mental inflexibility of the hoarder in
fearing change/unpredictability
 Neurological approaches
Heuristic value based on the reported
issues with memory & organization.
Research is still developing and findings
are inconclusive even with advances in
functional & structural imaging.
Meta-memory factors suggest memory
bias based on appraisal not on deficits.
 Cognitive Behavioural
model
CBT has defined hoarding, developed
treatment on a multi-factorial model.
Information-processing deficits
memory, decision-making, categorizing
Faulty appraisal of importance of things
Disability associated with clutter, no
insight, emotional & rigid behaviours.
 Some models of Hoarding
Abnormal Psychology model - focused
Delusional Disorder e.g. odd and
bizarre reasons for keeping things
Claiming affinity with animals or special
relationship with or need for things.
Deny obvious neglect, harm & chaos;
hostile, rejecting of help.
Function well outside delusional system.
 Squalor model
Dementia and other deteriorating models
emphasize loss of self-care & organization.
Secretive, isolated, uncooperative; decayed
food, animal waste, pest infestation
Hoarder profiles emphasize 65+, single, female.
Dementia brings a sudden deterioration to any
hoarding situation
Require structure, psychiatric assessment,
protective interventions and medication
 3) Addiction model

- Total pre-occupied with hoarding focus

- denial, excuses, claims of persecution,
ignoring overall outcome of hoarding.
- Impulse control issues in compulsive
acquiring of things or animals.
- Significant comorbidities
 4) Attachment model
Emphasizes disorganized early attachment
with compromised chaotic parenting. Animal
or object as stable fixtures.
Compensatory unconditional love for & from
animals has explanatory power.
Consistent with CH where sense of self and
grief-like loss connected with things
Compulsive need to keep animals or objects
to protect them, maintain connectedness
 Obsessive Compulsive
Disorder Model
OCD associated with hoarders key FELT
RESPONSIBILITY to care for possessions
including things, animals, memories.
Harm prevention, special relationships or
other symbolic meanings.
Sense of mission whether for animals or
responsibility for things
Avoidance behaviours can reach delusional
levels
 Age of onset, course of
hoarding
Chronic and insidious course becoming
overwhelming.
Age of onset in childhood/early
adolescence: as young as 10, mild
symptoms at 17, moderate in mid-20s,
extreme by mid-30s.
Help-seeking not until 50 years and
over
 How common is hoarding
As many as 1.2 million problem
hoarders in the USA.
Estimates range from 1 in 350 or 400
people in the UK and Australia.
Number of problem hoarders possibly in
the range of 60,000 to 90,000, but no
research data available.
mogan@theanxietyclinic.com
mogan@theanxietyclinic.com
 Clutter

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Safety concerns

mogan@theanxietyclinic.com
Phenomenology of hoarding
Examined in a study of known hoarders
in comparison with clinical groups
(OCD, anxiety states) and community
controls (N= 109).
Findings consistent with overseas
research.
Hoarding phenomenology is distinct
from other clinical and control groups.
 Measuring hoarding?
Savings Inventory Revised: savings actions, time spent, emotional
responses to saving & discarding, usefulness of saving, interference
caused by saving.

Savings Cognitions Inventory: measuring beliefs associated with

possessions - need for things, why cannot throw things away, need to
control what happens, to get comfort from things.

Savings List of things kept.

Hoarding Rating Scale

Hoarding Interview
Visual Rating of Clutter

mogan@theanxietyclinic.com
 Outcomes
The cognitive, affective and information-
processing factors of CBT model
supported.
Emphasis on severity of clutter, amount
saved, and dysfunctional beliefs about
things.
Hoarders compared with other clinical
groups and community controls showed
significant difference in socio-economic
status (income).
mogan@theanxietyclinic.com
 Hoarding-related Early Devel.
Influences Inv. (Kyrios, 2005)
Isolated two factors showing hoarders had more
issues than non-hoarders:
1) Uncertainty about the self and others e.g.
I have never been able to work out peoples
reactions to me
2) Warm Family - assessing memories of warmth
and security in ones family e.g.
My early childhood featured a constant sense
of support
The warm family factor was a significant predictor
of hoarding behaviour.
www.theanxietyclinic.com 26
 Predictors of hoarding in
analyses of the data: In order

i. Perceived lack of family warmth

ii. Padua Inventory OCS
iii. Fear of Neg. Eval. Social Anxiety
iv. Possessions in View Scale
v. Beck Anxiety Inventory
vi. OCPD Personality Disorder
vii. Frost Indecisiveness Sc Fear of decision making
viii.Consequences of Forgetting Scale
 TREATING HOARDING IS
COMPLEX
Hoarders have highly-personalised reasons for
Hoarding
Hoarders have ambivalent and avoidant personality
styles
Uncertainty about self and others leads to object-
driven compensatory behaviour
Treatment interfering variables are common
Rigidity, Control, Reluctance for treatment
Fear of making decisions, control and memory and
the deep seated beliefs held by hoarders.

mogan@theanxietyclinic.com
Termination

Maintenance Relapse

Action Contemplation

Preparation

Precontemplati
on
The Wheel of Change
 Treatment of hoarding
Assessment of hoarders in their context to
determine the treatment needs.
Liaison with health & welfare agencies
complexities require collaboration.
Therapy is not quick-fix, outcomes based
on specifying goals. Harm minimization as
in drug addiction as a guide.
Treatment still being developed.
.
 Treatment
Learning of skills in managing paper items
categorizing, judging worth, challenging keeping of
everything
Increasing confidence in discarding sessions in
clinic led to systematic practices in home.
Motivation needs to be very high
Respond to positive reinforcement, sense of
achieving very specific goals

mogan@theanxietyclinic.com
 Quick fix clean-ups
Imposing controls and cleaning up
without respecting the needs of the
hoarder lead to rapid relapse and highly
reinforced resumption of hoarding.
Better to understand the personal
context, build up rapport and motivation,
by targeting small improvements.
Small goals, active collaboration.
mogan@theanxietyclinic.com
 Myths of saving need
challenging
Someone will find this useful.
I never throw anything away.
I must keep all things that recall this person.
I know exactly where everything is.
How helpful to me is this clutter and mess?
These things are my lifeI dont know why!
Throwing things away is rejecting them
Keeping a things is to accept it into my life.

mogan@theanxietyclinic.com
 Therapy tips
Skills-building is based on practice.
Discard something however small every
day- DSD
Build a relationship affirming the difficult
task of CH Try to keep them attending
therapy motivation as key to change
Set small targets - safety of self/others
Visualization of de-cluttered room
mogan@theanxietyclinic.com
 Future
Research needs financial commitment
Training of associated workers health, welfare,
community carers, state & local jurisdictions -
team approach.
Leadership for the long term research, planning
and resourcing, education, lobbying
Solution not in legislation and enforcement yet
they are essential elements, especially when risk
extend to children, elderly; and also animals.
Dr Christopher Mogan
The Anxiety Clinic
TMC Suite 6,140 Church St,
Richmond 3121
Tel 03-9420 1424
mogan@theanxietyclinic.com
mogan@theanxietyclinic.com