588228 research-article2015

APY0010.1177/1039856215588228Australasian Psychiatry 23(4)Snowdon

Australasian

Psychiatry

Anxiety

Accumulating too much stuff: what is hoarding and what is not?

Australasian Psychiatry 2015, Vol 23(4) 354­–357 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856215588228 apy.sagepub.com

John Snowdon  Clinical Professor, Sydney Medical School, Old Age Psychiatrist, Sydney Local Health District, Concord Hospital, Sydney, NSW, Australia

Abstract Objective: This paper considers the meaning of the terms hoarding, collecting and accumulation, with a focus on what is abnormal and what is not. Conclusions: Hoarding is an adaptive behaviour. When hoarding is excessive and interferes with people’s lives, it is a disorder. A central feature of hoarding disorder is accumulation of items due to unwillingness to discard them. This must be distinguished from abnormal accumulation of material caused by poor motivation or unawareness concerning the need to discard. Keywords:  hoarding, accumulation, collecting, squalor

E

xcessive hoarding is as undesirable and potentially harmful as excessive appetites, though the threshold between normality and excess is ill defined. Recent statements in psychology and psychiatric texts have implied that all hoarding of any degree is a disorder. This needs to be questioned.

Normal hoarding A cogent dictionary definition of ‘hoarding’ is ‘storing for future use’. Synonyms for the word ‘hoard’ include squirrel away, stockpile, amass, accumulate, store, and save up.1 Hoarding, when within acceptable limits, can be regarded as a variant of normal behaviour. The most common reasons for hoarding items are the following: (1) sentimental value attached to items. Keeping them helps preserve memories. Seeing them provides reminders of people, events, successes, experiences, etc.; (2) Potential value or utility of the items (‘I might need it one day’); (3) Their aesthetic or intrinsic value (‘For me, this is beautiful/fascinating. It makes me feel proud/ good’). There is a subtle semantic difference between the words ‘hoarding’ and ‘collecting’. Squirrels gather/collect nuts and then hoard them. People who acquire and then

squirrel away a range of memorabilia without causing themselves or others distress manifest ‘normal’ hoarding behaviour. Some hoarders accumulate items tidily; others collect and store items in disorganised, unsorted agglomerations. Unless their hoarding interferes with activities of living (their own or someone else’s), or causes significant distress or functional impairment,2 it should not be regarded as pathological. Saving and hoarding can be described as adaptive, controlled and normal, providing the hoard has not become excessive or messy in relation to its surroundings. Hoarding, like other human behaviours, is observed to vary along a continuum from normal/acceptable to abnormal/excessive. Location of the threshold between normal and abnormal will be affected by the attitudes of the observer and by the constraints imposed by the hoarder’s living circumstances.

Normal collecting Accumulating objects of a related type (such as stamps, paper-weights, objets d’art, antiques) is commonly referred to as collecting. Such collecting can prove a wise investment and might be encouraged, providing it does Corresponding author: John Snowdon, Clinical Professor, Sydney Medical School, Old Age Psychiatrist, Sydney Local Health District, Concord Hospital, Sydney, NSW 2139, Australia. Email: [email protected]

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not obstruct activities of daily living within a shared home. Collectors selectively accumulate objects, classifying and meaningfully arranging them, whereas those who accumulate in less organised ways could be called non-selective accumulators.

The hoarder actively acquires these possessions.7 The person then determinedly keeps or retains material that has come into their possession (delivered or obtained free or at a cost), resisting pressure from others to discard or dispose of it.

Commonly, collectors aim to collect ‘sets’ of similar but non-identical items, such as national coinage of identical face value but different date. Over 50% of young schoolchildren have ‘collections’ and many of them maintain them into adulthood.3 About 30% of adults are said to manifest ‘normative and benign’ collecting behaviour; Nordsletten et al.4 recruited a self-identified but probably atypical sample of these in London. A study of a truly representative sample of ‘normal’ collectors would be useful.

Non-purposeful accumulation

Some individuals accumulate personally relevant and meaningful items such as letters, theatre programmes, certificates, and invitations. They are retained rather than collected, and are stored for their sentimental value or potential later interest. Such items do indeed prove useful to historians (as shown by various biographies and accounts of war-time experiences).

Abnormal (pathological) hoarding If someone hoards excessively, resisting attempts by others to enforce rules to avert the dangers of excessive clutter, the behaviour can be called ‘abnormal (pathological) hoarding’. Some call it ‘compulsive hoarding’: the person has an irresistible urge to retain acquired items even when there seem to be overwhelming reasons for discarding at least some. However, in more than 80% of such cases the hoarding is not associated with (other) manifestations of obsessive-compulsive disorder (OCD).5 Maier6 posited that, in many cases, so-called compulsive hoarding is really an impulse-control deficit, not a compulsion. When accumulation of items results in encroachment on living areas so that usual activities (food preparation, washing, toileting, socialising) are constrained, the acquiring behaviour leads to functional impairment. Discarding or rearrangement of items, and cessation of further acquisition, might postpone increases in functional impairment – but compulsive hoarders show inability to comply. Moving to a bigger home or renting storage space provides only temporary respite: the increased space soon gets filled. Compulsive hoarding was defined2 as the following: (1) the acquisition of and failure to discard a large number of possessions that appear to be useless or of limited value; with (2) living spaces so cluttered that activities for which they were designed are precluded; and (3) significant distress or impairment caused by the hoarding.

Prior to development of criteria for ‘compulsive hoarding’, the term ‘hoarding’ was used somewhat loosely in medical journal publications, referring to material or item amassment even when it was not done purposely. Clark et al.8 reported that several of their 30 inpatients with Diogenes syndrome ‘hoarded useless rubbish (syllogomania) – newspapers, tins, bottles, and rags, often in bundles and sacks’. Snowdon,9 presenting a series of 83 people who lived in very unclean dwellings, stated that ‘marked hoarding was a feature of most cases’, with items ‘piled high’ in 36 cases. A majority showed evidence of impaired memory, two-fifths were heavy drinkers and one-third had delusions and/or hallucinations. With hindsight, the word ‘accumulation’ should have replaced ‘hoarding’: commonly, the items had piled up because of inability or lack of motivation to discard, rather than resistance to discarding, and most of the occupants were not distressed in spite of the restrictions on their ability to function. Most had mental disorders. Although Kim et al.10 described 62 people as ‘hoarders’, it seems likely that some at least were passive (‘organic’) accumulators. A majority (77%) were diagnosed as having mental disorders and denied the problematic nature of their ‘hoarding’. A number refused entry to service providers. Although not stated, it seems that resistance to discarding was less of a problem than resistance to intrusion by people with ideas different to their own. Hwang et al.11 reported that the prevalence of ‘hoarding’ (defined as repeatedly collecting mostly useless or unneeded objects) among inpatients with dementia was 22.6%. These reports exemplify studies where some or a majority of the participants would not have fulfilled criteria for compulsive hoarding, let alone those for a Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnosis of hoarding disorder (HD). Maier6 referred to stereotypic and ritualistic behaviours in cases of dementia and chronic schizophrenia, where acquisition is ‘just motor activity without clear intention or aim’. He favoured the term ‘collectionism’ to describe this ‘grasping’ behaviour. In the absence of good evidence of purposeful acquisition and then resistance to discarding, the term ‘accumulation’ is preferable to ‘hoarding’ as a descriptor. Most of the widely quoted studies of the prevalence of hoarding have not reported whether cases of passive or ‘organic’ accumulation might have been included among those diagnosed as compulsively hoarding. Table 1 lists highlights differences between collecting, controlled hoarding, pathological hoarding and nonpurposeful accumulation. These are behaviours, not diagnoses. 355

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Australasian Psychiatry 23(4)

Table 1.  Comparison of the features of collecting, hoarding and accumulation Normal collecting

Controlled hoarding

Pathological hoarding

Non-purposeful (‘organic’) accumulation

Selective. Cohesive theme. One or a few categories. Planned, organised collecting. Not usually excessive. Orderly display of collected items. Not distressing unless costly. Little or no social impairment; collecting enhances social life. No significant functional or work impairment.

Somewhat selective. One or a few categories. Purposeful, but relatively unplanned. Not excessive. Items commonly stored in a disorganised way. Not distressing.

Non-selective. Lots of different categories. Purposeful, but with lack of planning or focus. Excessive. Disorganised clutter.

Non-selective.

Can become excessive. Unorganised.

Distress is very common.

Can become distressing.

Little or no social impairment.

Considerable social impairment/withdrawal.

Social life may be affected.

No functional or work impairment.

Occupational + functional impairment common.

May result in functional impairment.

HD versus ‘organic’ accumulation Plans to develop a new version of the DSM-512 allowed an opportunity to seek diagnostic clarity regarding cases of excessive item accumulation, some of which may be classifiable as pathological/abnormal hoarding, and some as non-purposeful. Discussions led to the creation of HD as a new diagnostic category in the DSM-5 manual.12 Evidence was available to differentiate it from OCD,13 from conditions where hoarding is attributable to other DSM-listed disorders, and from ‘normal’ hoarding. Arising from the earlier definition of compulsive hoarding, DSM-5’s criteria include (1) difficulty in discarding due to (2) a perceived need to save, (3) resultant excessive clutter, interfering with use of living areas, and (4) consequent impairment in functioning and distress. Importantly, there is also a requirement that the hoarding not be attributable to another medical condition or better accounted for by the symptoms of another DSM-5 disorder such as schizophrenia, dementia or autism. The validity and acceptability of the criteria were found to be good.14 The prevalence of HD has been reported to be 1.6%.15 Mataix-Cols et al.16 listed phenomenological differences between cases fulfilling criteria for HD and ‘organic’ cases in which excessive acquisition and accumulating are attributable to more recently sustained or developing brain changes. The latter include individuals with chronic schizophrenia, and drug or alcohol addiction. People with HD hoard, whereas people with neurodegenerative brain changes may accumulate – commonly not purposefully. Some of the ‘organic’ patients seem able to discard their possessions easily or do not care if others discard them, whereas others are resistant to discarding;17 some (but not all) have little interest in these items and never use them. The accumulation of food, often

Unplanned.

decaying, is comparatively frequent in ‘organic’ cases, but not in HD. Personality change, apathy and lack of insight, with neuropsychological dysfunction suggestive of frontal lobe damage, is common in ‘organic’ cases, in contrast to HD. In cases where HD criteria are fulfilled, insight ranges along a continuum from good/fair to absent or delusional.18 A minority of people with HD live in squalor, whereas ‘organic’ over-accumulators commonly live in very disorganised and unclean dwellings. Reasons for identifying differences between HD and accumulation attributable to brain pathology, and distinguishing them from psychiatric conditions such as OCD that are not usually regarded as organic (in spite of demonstrated brain changes on neuroimaging), are the following: (1) to ensure that epidemiological reports about hoarding clarify whether they are referring to cases that fulfil criteria for HD. Studies of the prevalence of ‘organic accumulation’, and of hoarding attributable to other DSM-5 psychiatric disorders, are also desirable; (2) that studies of how best to treat HD, and of how best to manage cases of organic or mental disorder where accumulation is a major problem, need to ensure differentiation of one from the other.

Conclusions Some people tend to discard possessions more than others, but they are not necessarily more ‘normal’ than the others. Hoarding may be viewed as an adaptive behaviour. When it interferes with people’s lives, it can be called a disorder. If excessive hoarding is not attributable

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to an organic or psychiatric disorder (other than HD), it is appropriate to examine whether the criteria for HD are fulfilled. Where items, material or rubbish have piled up because of lack of ability or motivation to discard, rather than because of determined resistance to discarding, the word ‘accumulation’ is preferable to ‘hoarding’.

7. Frost RO, Steketee G and Williams L. Hoarding: A community health problem. Health Soc Care Community 2000; 8: 229–234. 8. Clark AN, Mankikar GD and Gray I. Diogenes syndrome. A clinical study of gross neglect in old age. Lancet 1975; 1: 366–368. 9. Snowdon J. Uncleanliness among persons seen by community health workers. Hosp Community Psychiatry 1987; 38: 491–494. 10. Kim HJ, Steketee G and Frost RO. Hoarding by elderly people. Health Soc Work 2001; 26: 176–184.

Disclosure The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.

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11. Hwang JP, Tsai SJ, Yang CH, et al. Hoarding behaviour in dementia. A preliminary report. Am J Geriatr Psychiatry 1998; 6: 285–289. 12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing, 2013. 13. Grisham JR, Brown TA, Liverant GI, et al. The distinctiveness of compulsive hoarding from obsessive-compulsive disorder. J Anxiety Disord 2005; 19: 767–779. 14. Mataix-Cols D, Fernández de la Cruz L, Nakao T, et al. Testing the validity and acceptability of the diagnostic criteria for hoarding disorder: A DSM-5 survey. Psychol Med 2011; 41: 2475–2484. 15. Nordsletten AE, Reichenberg A, Hatch SL, et al. Epidemiology of hoarding disorder. Br J Psychiatry 2013; 203: 445–452. 16. Mataix-Cols D, Pertusa A and Snowdon J. Neuropsychological and neural correlates of hoarding: A practice-friendly review. J Clin Psychol 2011; 67: 467–476. 17. Anderson SA, Damasio H and Damasio R. A neural basis for collecting behaviour. Brain 2005; 128: 201–212. 18. Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: A new diagnosis for DSMV? Depress Anxiety 2010; 27: 556–572.

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Accumulating too much stuff: what is hoarding and what is not?

This paper considers the meaning of the terms hoarding, collecting and accumulation, with a focus on what is abnormal and what is not...
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