05.09.12

Hoarding Made a Hit TV Show. Now It’s Becoming a Sickness in the DSM.

For the first time in psychiatric history, you could be diagnosed for burying yourself in stuff.

There is something about hoarding that people find hard to resist. Just ask the ardent fan base of TLC’s hit reality show Buried Alive. The show takes you inside the homes of hoarders and captures the drama that invariably ensues when specialists arrive to intervene in the unthinkable collecting of stuff. Stuff piled on every surface. Stuff blocking doorways, piled up to ceilings, immobilizing entire rooms.

Watching this show, it’s not hard to understand why, for the first time in psychiatric history, hoarding is poised to become an official mental disorder.

The newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)—the handbook of American psychiatry—is due out next year, and hoarding is likely to be among the newest additions. For the last week, the American Psychiatric Association (APA), which publishes the text, has been unveiling its final rounds of recommended changes. Earlier this week, Katharine Phillips, the chair of the APA's Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group said that hoarding is “highly likely” to make it past the last stages of deliberation and into the final version of DSM V.

So who will get this label? Think of Miss Havisham. Think of the legendary Collyer brothers who died in their New York apartment when the piles of books and papers and musical instruments they’d saved for years collapsed around them, trapping them inside a labyrinth of stuff, where they starved to death.

They are pack rats extraordinaire—people who, to put it in clinical terms, have so much clutter that they can no longer use their living space for the purpose of living. Hoarders find it impossible to discard possessions, and, in most cases, find it equally impossible to resist acquiring new objects.

Yet, despite epidemiological studies showing that 2 percent to 5 percent of the population has a hoarding problem—not a small number—research on the condition is still relatively new, dating back only to the early 1990s. Until now, the prevailing clinical assumption has held that hoarding is a member of the obsessive-compulsive disorder family. That assumption came from an apparent similarity between hoarding behaviors and behaviors associated with OCD. To researchers the excessive acquisitiveness exhibited by many hoarders looked like a kind of ritualized compulsion, and the distress hoarders can exhibit when possessions are moved or thrown away seemed rooted in the same kind of obsession with order that often comes with obsessive-compulsive disorder.

In clinical terms, a hoarder is a person who has so much clutter that he can no longer use his living space for the purpose of living.

But Phillips says that new evidence “suggests that hoarding behavior is not the same as OCD.” “[W]hen you separate it out, it’s clearly different,” says Randy Frost, the author of Stuff and a professor of psychology at Smith College. “In OCD, we have these obsessions, intrusive thoughts that are nonsensical but cause the person great distress. But in hoarding, there are no real obsessions. There are attractions to objects—it’s more about a positive valence, whereas in OCD, the intrusive thoughts are always experienced as depressing, distressing, or somehow anxiety provoking.”

Frost, who has been studying hoarding since the early 1990s, believes hoarding exists on a continuum that we all find ourselves on.

In hoarders, he says, “the emotional attachments to objects are much more powerful than the attachments most of us have with our possessions ... Possessions have a magical quality for all of us. And by magical quality, what I mean is that the meaning an object has frequently goes well beyond the physical characteristics.” But with hoarders, “the beliefs about possessions are much more rigid and intense.”

The purpose of appointing hoarding its own diagnostic status is, in large part, to encourage hoarding-specific treatments. Until now, many clinicians have relied on the cognitive behavioral methods designed for OCD to treat hoarders. This type of therapy aims to challenge obsessive thought patterns and ritualized compulsions. But as treatments for hoarders, they’ve proven largely ineffective— further proof of the essentially distinct nature of these two conditions.

Frost acknowledges that the newer treatment methods, specifically created for hoarding, are still works in process. Techniques include teaching people how to control the urge to acquire by taking them on “non-shopping trips” where they come into contact with a desired object but resist the impulse to buy it.

“One of the frequent beliefs people have is that they won’t be able to tolerate the distress they will experience without the object,” Frost says. “They fear how they’ll feel and fear that that bad feeling will go on forever.”

If those beliefs can be pried loose just a bit, Frost says, the possessions might eventually follow.