A clinician is evaluating a 45-year-old individual who lives in a home filled with stacks of old newspapers, broken appliances, and empty food containers, to the point where several rooms are unusable. The individual becomes extremely distressed when asked to discard any items. During the interview, the individual explains that they must keep the newspapers because they contain coded messages from a secret society that are essential for their safety. Based on this information, is a primary diagnosis of hoarding disorder appropriate? Explain your reasoning.

Clinical Diagnosis Scenario: Hoarding Behavior

A formal diagnosis of hoarding disorder is contingent upon the hoarding behavior not being attributable to another medical condition or being a symptom of a different disorder, such as schizophrenia.

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Hoarding disorder is characterized by a persistent difficulty in discarding or parting with possessions, regardless of their actual value. This behavior frequently results in the accumulation of items that clutter and congest the individual's living area.

Hoarding Disorder

Spielman, R. M., Jenkins, W. J., & Lovett, M. D. (2020, April 22). Psychology (2nd ed.). OpenStax. https://openstax.org/books/psychology-2e/pages/1-introduction

OpenStax Psychology (2nd ed.) Textbook

Hoarding disorder might be impacted because even though people with hoarding disorders may hoard items of little use, the need for storing necessary supplies can impact and worsen the symptoms of hoarding disorders or even OCD with hoarding symptoms.

The other side of COVID-19: Impact on hoarding

Sentimental object attachment is a psychological phenomenon that is theorized to begin early in childhood, wherein children develop an emotional attachment to a certain object as a maternal substitute. While natural maturation and independence should diminish the role these objects play in emotional security, there is a growing body of evidence exploring how and why object attachment may persist into adulthood. Little information is known about the reasons individuals experience sustainment from specific objects, but childhood object attachment is associated with favor for unique individuals, thereby subsequently influencing preferences for authentic objects in adulthood. Individuals can experience strong emotional bonds towards an object, such that if the object is lost, they can experience great emotional distress. 

Object attachment

Individuals who have a propensity towards extreme object attachment may share the tendency to collect objects with hoarding disorder, however hoarding disorder typically involves the collection of any object that leads to “the accumulation of possessions that congest and clutter active living spaces,” regardless of any monetary or sentimental significance of an object, while object attachment behavior is much more focused on a limited array of personal belongings.

Differences between hoarding disorder & object attachment behavior

Hoarding disorder (HD) is associated with severe levels of functional impairment. Individuals with HD report higher levels of disability in various daily activities compared with non-pathological collectors. As such, HD may adversely impact health-related quality of life (QoL) in psychical and psychological domains. HD is associated with decision-making impairment, deficits in basic cognitive function, emotional dysregulation & intolerance, and behavioral avoidance. Such impairments may interfere with desired goal achievements. 

Moreover, clutter may reduce usable living space, thus physically interfering with daily activities or resulting in diminished social contact. 

Symptoms include: Excessively acquiring items that are not needed, a persistent difficulty throwing out or parting with things, feeling a need to save items, being upset by the thought of discarding items, obtaining clutter to the point where rooms become unusable, a tendency toward indecisiveness, perfectionism, avoidance, procrastination, problems with planning, and organizing.

Symptoms of Hoarding Disorder 

Attachment theory proposes the idea that hoarding disorder is related with poor emotional regulation due an anxious attachment style. Individuals with this anxious attachment style may have more difficulty in caring for others, often becoming too distressed and self-focused when called upon, wherein their inability to provide care may limit support they receive in retune and so they may experience decreased empathy and impaired social relationships. Furthermore, this theory states that when an attachment figure has consistently failed to provide support, anxiously attached individuals may seek secondary attachment strategies to manage their emotional needs, including nonliving objects as a substitute for love. Attachment theory posits that an individual’s inability to engage in empathetically meaningful relationships and utilization of objects for emotional comfort is a leading role in object attachment behavior. In support of this theory, studies have found a correlation exists between that a greater tendency to experience discomfort in social situations and an anxious attachment style & greater hoarding severity

Attachment theory of hoarding disorder

Many studies reveal conflicting information regarding the associations between traumatic experiences and OCD or hoarding symptoms. Previous studies have found a plethora of information regarding differences and similarities between the trauma experiences of those with OCD and those with hoarding symptoms. It is still unclear exactly what types of traumatic events are associated with each, if any, the association between the time a traumatic event occurred and symptom development (i.e., prior to the onset or after the onset of symptoms), and how many traumatic events these individuals with these disorders have experienced or may experience in the future. A study in 2014 sought to answer these questions.

The Links between Traumatic Events and OCD and/or Hoarding Symptoms

Reference for Treatment of Hoarding Disorder 

Reference for The Comorbidities of Hoarding Disorder

Several disorders can co-occur with hoarding disorder, but depressive disorders are the most common ones. Additional disorders that can co-occur with hoarding disorder include attention-deficit/ hyperactivity disorder, impulse control disorders, obsessive-compulsive disorder, and anxiety disorders such as generalized anxiety disorder and social anxiety disorder.

The Comorbidities of Hoarding Disorder 

Treatments for hoarding disorder consist of a biopsychosocial approach that mixes using SSRIs and cognitive behavioral therapy. Other therapies include working on attachment difficulties that might be the cause of hoarding disorder, and compassion-focused therapy, which attempts to eliminate the shame of having hoarding disorder. 

Treatment of Hoarding Disorder 

A key aspect of understanding hoarding disorder involves its prevalence, which refers to how frequently the condition occurs in the general population. This epidemiological data is crucial for grasping the scope and public health significance of the disorder.

Prevalence of Hoarding Disorder

While hoarding was historically viewed as a symptom of Obsessive-Compulsive Disorder (OCD), substantial evidence now supports its classification as a separate and distinct disorder.

Distinction Between Hoarding Disorder and OCD

Diagnostic Exclusion Criteria for Hoarding Disorder

A psychologist is evaluating several individuals who accumulate a large number of possessions. Based on the defining characteristics of hoarding disorder, which of the following situations would be the strongest indicator of the condition?

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