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

Compulsive hoarding behavior is considered notoriously difficult to treat, but targeting its characteristic symptoms with medication and psychotherapy can be successful. This article provides a guide for the psychiatrist—alone or with a cognitive-behavioral therapist—to diagnose compulsive hoarding syndrome and help patients overcome the anxieties that fuel its symptoms.

WHAT IS COMPULSIVE HOARDING?

Hoarders acquire and are unable to discard items that others consider of little use or value.¹ They most often save newspapers, magazines, old clothing, bags, books, mail, notes, and lists. Hoarding and saving behaviors occur in nonclinical populations and with other neuropsychiatric disorders—schizophrenia, dementia, eating disorders, mental retardation—but are most often found in persons with obsessive-compulsive disorder (OCD).

OCD is a heterogeneous clinical entity with several major symptom domains:^2,3

• aggressive, sexual, and religious obsessions with checking compulsions
  
• symmetry/order obsessions with ordering, arranging, and repeating compulsions
  
• contamination obsessions with washing and cleaning compulsions
  
• hoarding and saving symptoms.
  

Box

Among OCD patients, 18% to 42% have hoarding and saving compulsions.^4,5 Hoarding and saving can be part of a broader clinical syndrome that includes indecisiveness, perfectionism, procrastination, difficulty organizing tasks, and avoiding routine daily activities.^6,7 The 1 to 2 million Americans whose most prominent and distressing OCD symptom is hoarding and saving and who show these other associated symptoms are considered to have “compulsive hoarding syndrome.”^7,8 Evidence suggests that this syndrome may be a neurobiologically distinct OCD variant (Box).^9-16

ASSESSMENT AND TREATMENT PLANNING

To manage compulsive hoarding syndrome, begin with a thorough neuropsychiatric evaluation:

• Rule out primary psychotic disorders, dementia, and other cognitive impairments and neurologic disorders.
  
• Rule out primary major depression, as clutter and self-neglect may be caused by amotivation, low energy, or hopelessness.
  
• Determine if the patient has OCD.
  

After making a compulsive hoarding diagnosis (Table 1),⁶ visit the patient’s home or view photographs to assess his or her environment and behaviors (Table 2).

Amount of clutter. Living areas may be so cluttered that sleeping in a bed, sitting on chairs, or preparing food on a kitchen counter are impossible. How much of the home is cluttered? How much floor and counter space is usable? Are rooms unusable or inaccessible because of clutter? Can the patient use the laundry, prepare food in the kitchen, use the shower, toilet, etc.?

Health or safety hazards. Huge piles of papers can be a fire hazard. Clutter may be blocking the exits. Collected items may extend beyond patients’ homes to their cars, garages, storage lockers, and even storage areas owned by friends and family.

Beliefs about possessions. Compulsive hoarders often have distorted feelings about their possessions. They may over-buy or impulsively purchase items they feel have emotional or monetary value. They may consider the items extensions of themselves and suffer grief-like loss when discarding things.⁷

Some collect free items—flyers, coupons, newspapers, discarded goods—hoping to save money or be prepared “just in case” the item is ever needed. This may represent unattainable expectations of perfection, needing to maintain preparedness for every possible contingency. Hoarders often believe they have poor memory and have catastrophic fears of what might happen if they forget something. Thus, their desire to keep their possessions in sight is strong.¹⁷

 

Information processing deficits. Because of anxieties about making mistakes, most hoarders have great difficulty making decisions.¹⁸ It is easier to not decide than to suffer the consequences of a “wrong” decision. To gauge this behavior, ask patients how long routine decisions take them and which decisions they procrastinate or avoid.

Compulsive hoarders often have trouble categorizing possessions;^6,7 because every item feels unique, they create a special category for each one and resist storing items together.

Table 1

Proposed criteria to diagnose obsessive-compulsive hoarding*

Patient acquires and fails to discard a large number of possessions that appear useless or of limited value
Clutter prevents patient from using living or work spaces for activities for which they were designed
Hoarding behavior causes significant distress or functional impairment
* Proposed by Frost and Hartl, reference 6.

Many hoarders also report marked distractibility and inattention, jumping from one task to the next without completing any of them. Their communication style is often as cluttered and disorganized as their homes, with tangential, circumstantial, and over-inclusive descriptions.

Avoidance behaviors are a hallmark of the compulsive hoarding syndrome. To avoid deciding to discard items, they put them in a box, garage, rented storage facility, etc. They may also avoid routine decision-making tasks that could lead to making a mistake.

Daily functioning. Hoarders may take a long time to do even small chores, such as taking an hour to pay one bill. An inordinate amount of time may be spent “churning”—moving items from one pile to another but never discarding any item or establishing a consistent system or organization.

Medication compliance. Compulsive hoarders often forget to take medications or take them at inappropriate times. They may lose their medications in the clutter.

Insight. Hoarders often have little awareness of how their behavior and clutter affect their lives.¹⁹ They minimize the clutter in their homes and its health and safety risks. Insight can fluctuate over time and needs to be assessed repeatedly during treatment.

Table 2

Assessing a patient with compulsive hoarding symptoms

Domain	Useful questions or strategies
Amount of clutter	Visit home and/or see pictures
Hazards relating to clutter	Ask: What precautions do you take to reduce risk of fire? Have you ever had a problem with rodent or insect infestation as a result of the clutter? Have neighbors complained about the risks of fire or infestation that the clutter might impose on their homes?
Beliefs about loss of possessions	Ask: What is the worst thing that would happen if you threw this item away? If you did not have this, what do you think would happen?
Information-processing deficits	Ask: How long do routine decisions take you? Which decisions do you procrastinate or avoid?
Decision-making and organizational skills	Ask: How do you pay and store your bills?
Avoidance behaviors	Ask: Do you avoid other things (sorting mail, returning calls, doing dishes, or paying bills, rent, or taxes)?
Daily functioning	Ask: Do you get everything done that you want to do? Are you often late? Do you have difficulty starting or finishing tasks? Describe a typical day.
Insight	Ask: Do you think this amount of clutter is normal? Do you think having this clutter has caused problems in your life?
Motivation for treatment	Ask: What brings you into therapy now? Do you think you have a problem with excessive hoarding/saving? If it was not for your family, would you come for help?
Social and occupational functioning	Ask: How has your clutter affected your personal relationships? When was the last time you had someone come to your home? What prevents you from working right now? Are you working to your full potential?
Support from friends and family	Ask: What does your family say about your clutter? Do your friends or family understand what is going on?
Treatment compliance	Ask: How long does it typically take before you renew your prescriptions when you run out of medications?

Table 3

Cognitive behavioral therapy for compulsive hoarding

Treatment sequence	Methods and goals
Educate patient about hoarding	Help improve insight and motivation
Set up treatment	With patient, select target area of clutter
	Assess items together, creating a hierarchy of least to most difficult areas to sort and items to discard
	Create realistic categories and a storage system
Begin discarding	Patient must decide to keep or discard each item and permanently remove it from pile
	Patient must store saved items appropriately
	Continue until area is clear, then move to next area
Plan and implement appropriate use of space
Stop incoming clutter	Cancel subscriptions
	Address compulsive buying and acquisition
Provide organization training	Organize possessions, time, tasks, etc.
Prevent relapse	Replace hoarding with healthier behaviors to prevent clutter from re-accumulating
Source: Adapted from reference 23.

Social and occupational functioning. Many compulsive hoarders have very little family or social support. They frequently are too embarrassed by their clutter to have people come to their homes, sometimes for years. The syndrome frequently impairs work performance.

 

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.

 

Several studies of SSRI use in OCD patients have shown modest improvements in compulsive hoarders:

• In a descriptive study of patients with compulsive hoarding, 1 of 18 (6%) patients had a “marked” response to at least one SSRI trial. The others showed a partial response,¹⁷ with YBOCS scores decreasing by at least 25% in approximately 50% of this group.
  
• When 17 OCD patients with hoarding symptoms were treated with paroxetine, CBT, or placebo, 18% responded to active treatment. Response was defined as a 40% reduction on YBOCS scores and “very much” or “much” improved on the Clinical Global Impression Scale (CGI).¹⁴
  

Based on these findings and our clinical experience, an effective approach to treating compulsive hoarding with medications—as with other OCD patients—is to start with SSRIs²⁸ (Algorithm). If adequate SSRI trials fail to improve a patient’s hoarding/saving symptoms, adjunctive medications can be added.

Atypical antipsychotics may be effective for OCD symptoms that do not respond adequately to SSRIs.²⁹ Conventional antipsychotics are also effective adjuncts to SSRIs—particularly for patients with coexisting tic or psychotic disorders³⁰—but consider the potential for extrapyramidal side effects and tardive dyskinesia.

We find that stimulants help some compulsive hoarders, particularly those with comorbid ADHD, other attentional problems, low motivation, or lethargy. Mood stabilizers are necessary to treat comorbid bipolar disorder, cyclothymia, and impulsivity.

Related resources

• Saxena S, Maidment K. Treatment of compulsive hoarding. J Clin Psychol 2004;60(11):1143-54.
  
• UCLA OCD Intensive Treatment Program. For information on research studies contact Karron Maidment (310) 794-7305 or visit www.mentalhealth.ucla.edu/projects/anxiety/ocdintensivetreatment.htm.
  
• Compulsive hoarding project. Institute of Living Anxiety Disorders Center, Hartford Hospital. http://instituteofliving.org/adc/compulsive_hoarding.htm
  
• Obsessive Compulsive Foundation compulsive hoarding Web site. http://www.ocfoundation.org/1005/index.html
  
• Neziroglu F, Bubrick J, Yaryura-Tobias JA. Overcoming compulsive hoarding. Oakland, CA: New Harbinger Publications, 2004.
  

Drug brand names

• Citalopram • Celexa
  
• Clomipramine • Anafranil
  
• Escitalopram • Lexapro
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Olanzapine • Zyprexa
  
• Paroxetine • Paxil
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Sertraline • Zoloft
  
• Venlafaxine • Effexor
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Compulsive hoarding behavior is considered notoriously difficult to treat, but targeting its characteristic symptoms with medication and psychotherapy can be successful. This article provides a guide for the psychiatrist—alone or with a cognitive-behavioral therapist—to diagnose compulsive hoarding syndrome and help patients overcome the anxieties that fuel its symptoms.

WHAT IS COMPULSIVE HOARDING?

Hoarders acquire and are unable to discard items that others consider of little use or value.¹ They most often save newspapers, magazines, old clothing, bags, books, mail, notes, and lists. Hoarding and saving behaviors occur in nonclinical populations and with other neuropsychiatric disorders—schizophrenia, dementia, eating disorders, mental retardation—but are most often found in persons with obsessive-compulsive disorder (OCD).

OCD is a heterogeneous clinical entity with several major symptom domains:^2,3

• aggressive, sexual, and religious obsessions with checking compulsions
  
• symmetry/order obsessions with ordering, arranging, and repeating compulsions
  
• contamination obsessions with washing and cleaning compulsions
  
• hoarding and saving symptoms.
  

Box

Among OCD patients, 18% to 42% have hoarding and saving compulsions.^4,5 Hoarding and saving can be part of a broader clinical syndrome that includes indecisiveness, perfectionism, procrastination, difficulty organizing tasks, and avoiding routine daily activities.^6,7 The 1 to 2 million Americans whose most prominent and distressing OCD symptom is hoarding and saving and who show these other associated symptoms are considered to have “compulsive hoarding syndrome.”^7,8 Evidence suggests that this syndrome may be a neurobiologically distinct OCD variant (Box).^9-16

ASSESSMENT AND TREATMENT PLANNING

To manage compulsive hoarding syndrome, begin with a thorough neuropsychiatric evaluation:

• Rule out primary psychotic disorders, dementia, and other cognitive impairments and neurologic disorders.
  
• Rule out primary major depression, as clutter and self-neglect may be caused by amotivation, low energy, or hopelessness.
  
• Determine if the patient has OCD.
  

After making a compulsive hoarding diagnosis (Table 1),⁶ visit the patient’s home or view photographs to assess his or her environment and behaviors (Table 2).

Amount of clutter. Living areas may be so cluttered that sleeping in a bed, sitting on chairs, or preparing food on a kitchen counter are impossible. How much of the home is cluttered? How much floor and counter space is usable? Are rooms unusable or inaccessible because of clutter? Can the patient use the laundry, prepare food in the kitchen, use the shower, toilet, etc.?

Health or safety hazards. Huge piles of papers can be a fire hazard. Clutter may be blocking the exits. Collected items may extend beyond patients’ homes to their cars, garages, storage lockers, and even storage areas owned by friends and family.

Beliefs about possessions. Compulsive hoarders often have distorted feelings about their possessions. They may over-buy or impulsively purchase items they feel have emotional or monetary value. They may consider the items extensions of themselves and suffer grief-like loss when discarding things.⁷

Some collect free items—flyers, coupons, newspapers, discarded goods—hoping to save money or be prepared “just in case” the item is ever needed. This may represent unattainable expectations of perfection, needing to maintain preparedness for every possible contingency. Hoarders often believe they have poor memory and have catastrophic fears of what might happen if they forget something. Thus, their desire to keep their possessions in sight is strong.¹⁷

 

Information processing deficits. Because of anxieties about making mistakes, most hoarders have great difficulty making decisions.¹⁸ It is easier to not decide than to suffer the consequences of a “wrong” decision. To gauge this behavior, ask patients how long routine decisions take them and which decisions they procrastinate or avoid.

Compulsive hoarders often have trouble categorizing possessions;^6,7 because every item feels unique, they create a special category for each one and resist storing items together.

Table 1

Proposed criteria to diagnose obsessive-compulsive hoarding*

Patient acquires and fails to discard a large number of possessions that appear useless or of limited value
Clutter prevents patient from using living or work spaces for activities for which they were designed
Hoarding behavior causes significant distress or functional impairment
* Proposed by Frost and Hartl, reference 6.

Many hoarders also report marked distractibility and inattention, jumping from one task to the next without completing any of them. Their communication style is often as cluttered and disorganized as their homes, with tangential, circumstantial, and over-inclusive descriptions.

Avoidance behaviors are a hallmark of the compulsive hoarding syndrome. To avoid deciding to discard items, they put them in a box, garage, rented storage facility, etc. They may also avoid routine decision-making tasks that could lead to making a mistake.

Daily functioning. Hoarders may take a long time to do even small chores, such as taking an hour to pay one bill. An inordinate amount of time may be spent “churning”—moving items from one pile to another but never discarding any item or establishing a consistent system or organization.

Medication compliance. Compulsive hoarders often forget to take medications or take them at inappropriate times. They may lose their medications in the clutter.

Insight. Hoarders often have little awareness of how their behavior and clutter affect their lives.¹⁹ They minimize the clutter in their homes and its health and safety risks. Insight can fluctuate over time and needs to be assessed repeatedly during treatment.

Table 2

Assessing a patient with compulsive hoarding symptoms

Domain	Useful questions or strategies
Amount of clutter	Visit home and/or see pictures
Hazards relating to clutter	Ask: What precautions do you take to reduce risk of fire? Have you ever had a problem with rodent or insect infestation as a result of the clutter? Have neighbors complained about the risks of fire or infestation that the clutter might impose on their homes?
Beliefs about loss of possessions	Ask: What is the worst thing that would happen if you threw this item away? If you did not have this, what do you think would happen?
Information-processing deficits	Ask: How long do routine decisions take you? Which decisions do you procrastinate or avoid?
Decision-making and organizational skills	Ask: How do you pay and store your bills?
Avoidance behaviors	Ask: Do you avoid other things (sorting mail, returning calls, doing dishes, or paying bills, rent, or taxes)?
Daily functioning	Ask: Do you get everything done that you want to do? Are you often late? Do you have difficulty starting or finishing tasks? Describe a typical day.
Insight	Ask: Do you think this amount of clutter is normal? Do you think having this clutter has caused problems in your life?
Motivation for treatment	Ask: What brings you into therapy now? Do you think you have a problem with excessive hoarding/saving? If it was not for your family, would you come for help?
Social and occupational functioning	Ask: How has your clutter affected your personal relationships? When was the last time you had someone come to your home? What prevents you from working right now? Are you working to your full potential?
Support from friends and family	Ask: What does your family say about your clutter? Do your friends or family understand what is going on?
Treatment compliance	Ask: How long does it typically take before you renew your prescriptions when you run out of medications?

Table 3

Cognitive behavioral therapy for compulsive hoarding

Treatment sequence	Methods and goals
Educate patient about hoarding	Help improve insight and motivation
Set up treatment	With patient, select target area of clutter
	Assess items together, creating a hierarchy of least to most difficult areas to sort and items to discard
	Create realistic categories and a storage system
Begin discarding	Patient must decide to keep or discard each item and permanently remove it from pile
	Patient must store saved items appropriately
	Continue until area is clear, then move to next area
Plan and implement appropriate use of space
Stop incoming clutter	Cancel subscriptions
	Address compulsive buying and acquisition
Provide organization training	Organize possessions, time, tasks, etc.
Prevent relapse	Replace hoarding with healthier behaviors to prevent clutter from re-accumulating
Source: Adapted from reference 23.

Social and occupational functioning. Many compulsive hoarders have very little family or social support. They frequently are too embarrassed by their clutter to have people come to their homes, sometimes for years. The syndrome frequently impairs work performance.

 

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.

 

Several studies of SSRI use in OCD patients have shown modest improvements in compulsive hoarders:

• In a descriptive study of patients with compulsive hoarding, 1 of 18 (6%) patients had a “marked” response to at least one SSRI trial. The others showed a partial response,¹⁷ with YBOCS scores decreasing by at least 25% in approximately 50% of this group.
  
• When 17 OCD patients with hoarding symptoms were treated with paroxetine, CBT, or placebo, 18% responded to active treatment. Response was defined as a 40% reduction on YBOCS scores and “very much” or “much” improved on the Clinical Global Impression Scale (CGI).¹⁴
  

Based on these findings and our clinical experience, an effective approach to treating compulsive hoarding with medications—as with other OCD patients—is to start with SSRIs²⁸ (Algorithm). If adequate SSRI trials fail to improve a patient’s hoarding/saving symptoms, adjunctive medications can be added.

Atypical antipsychotics may be effective for OCD symptoms that do not respond adequately to SSRIs.²⁹ Conventional antipsychotics are also effective adjuncts to SSRIs—particularly for patients with coexisting tic or psychotic disorders³⁰—but consider the potential for extrapyramidal side effects and tardive dyskinesia.

We find that stimulants help some compulsive hoarders, particularly those with comorbid ADHD, other attentional problems, low motivation, or lethargy. Mood stabilizers are necessary to treat comorbid bipolar disorder, cyclothymia, and impulsivity.

Related resources

• Saxena S, Maidment K. Treatment of compulsive hoarding. J Clin Psychol 2004;60(11):1143-54.
  
• UCLA OCD Intensive Treatment Program. For information on research studies contact Karron Maidment (310) 794-7305 or visit www.mentalhealth.ucla.edu/projects/anxiety/ocdintensivetreatment.htm.
  
• Compulsive hoarding project. Institute of Living Anxiety Disorders Center, Hartford Hospital. http://instituteofliving.org/adc/compulsive_hoarding.htm
  
• Obsessive Compulsive Foundation compulsive hoarding Web site. http://www.ocfoundation.org/1005/index.html
  
• Neziroglu F, Bubrick J, Yaryura-Tobias JA. Overcoming compulsive hoarding. Oakland, CA: New Harbinger Publications, 2004.
  

Drug brand names

• Citalopram • Celexa
  
• Clomipramine • Anafranil
  
• Escitalopram • Lexapro
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Olanzapine • Zyprexa
  
• Paroxetine • Paxil
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Sertraline • Zoloft
  
• Venlafaxine • Effexor
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Compulsive hoarding behavior is considered notoriously difficult to treat, but targeting its characteristic symptoms with medication and psychotherapy can be successful. This article provides a guide for the psychiatrist—alone or with a cognitive-behavioral therapist—to diagnose compulsive hoarding syndrome and help patients overcome the anxieties that fuel its symptoms.

WHAT IS COMPULSIVE HOARDING?

Hoarders acquire and are unable to discard items that others consider of little use or value.¹ They most often save newspapers, magazines, old clothing, bags, books, mail, notes, and lists. Hoarding and saving behaviors occur in nonclinical populations and with other neuropsychiatric disorders—schizophrenia, dementia, eating disorders, mental retardation—but are most often found in persons with obsessive-compulsive disorder (OCD).

OCD is a heterogeneous clinical entity with several major symptom domains:^2,3

• aggressive, sexual, and religious obsessions with checking compulsions
  
• symmetry/order obsessions with ordering, arranging, and repeating compulsions
  
• contamination obsessions with washing and cleaning compulsions
  
• hoarding and saving symptoms.
  

Box

Among OCD patients, 18% to 42% have hoarding and saving compulsions.^4,5 Hoarding and saving can be part of a broader clinical syndrome that includes indecisiveness, perfectionism, procrastination, difficulty organizing tasks, and avoiding routine daily activities.^6,7 The 1 to 2 million Americans whose most prominent and distressing OCD symptom is hoarding and saving and who show these other associated symptoms are considered to have “compulsive hoarding syndrome.”^7,8 Evidence suggests that this syndrome may be a neurobiologically distinct OCD variant (Box).^9-16

ASSESSMENT AND TREATMENT PLANNING

To manage compulsive hoarding syndrome, begin with a thorough neuropsychiatric evaluation:

• Rule out primary psychotic disorders, dementia, and other cognitive impairments and neurologic disorders.
  
• Rule out primary major depression, as clutter and self-neglect may be caused by amotivation, low energy, or hopelessness.
  
• Determine if the patient has OCD.
  

After making a compulsive hoarding diagnosis (Table 1),⁶ visit the patient’s home or view photographs to assess his or her environment and behaviors (Table 2).

Amount of clutter. Living areas may be so cluttered that sleeping in a bed, sitting on chairs, or preparing food on a kitchen counter are impossible. How much of the home is cluttered? How much floor and counter space is usable? Are rooms unusable or inaccessible because of clutter? Can the patient use the laundry, prepare food in the kitchen, use the shower, toilet, etc.?

Health or safety hazards. Huge piles of papers can be a fire hazard. Clutter may be blocking the exits. Collected items may extend beyond patients’ homes to their cars, garages, storage lockers, and even storage areas owned by friends and family.

Beliefs about possessions. Compulsive hoarders often have distorted feelings about their possessions. They may over-buy or impulsively purchase items they feel have emotional or monetary value. They may consider the items extensions of themselves and suffer grief-like loss when discarding things.⁷

Some collect free items—flyers, coupons, newspapers, discarded goods—hoping to save money or be prepared “just in case” the item is ever needed. This may represent unattainable expectations of perfection, needing to maintain preparedness for every possible contingency. Hoarders often believe they have poor memory and have catastrophic fears of what might happen if they forget something. Thus, their desire to keep their possessions in sight is strong.¹⁷

 

Information processing deficits. Because of anxieties about making mistakes, most hoarders have great difficulty making decisions.¹⁸ It is easier to not decide than to suffer the consequences of a “wrong” decision. To gauge this behavior, ask patients how long routine decisions take them and which decisions they procrastinate or avoid.

Compulsive hoarders often have trouble categorizing possessions;^6,7 because every item feels unique, they create a special category for each one and resist storing items together.

Table 1

Proposed criteria to diagnose obsessive-compulsive hoarding*

Patient acquires and fails to discard a large number of possessions that appear useless or of limited value
Clutter prevents patient from using living or work spaces for activities for which they were designed
Hoarding behavior causes significant distress or functional impairment
* Proposed by Frost and Hartl, reference 6.

Many hoarders also report marked distractibility and inattention, jumping from one task to the next without completing any of them. Their communication style is often as cluttered and disorganized as their homes, with tangential, circumstantial, and over-inclusive descriptions.

Avoidance behaviors are a hallmark of the compulsive hoarding syndrome. To avoid deciding to discard items, they put them in a box, garage, rented storage facility, etc. They may also avoid routine decision-making tasks that could lead to making a mistake.

Daily functioning. Hoarders may take a long time to do even small chores, such as taking an hour to pay one bill. An inordinate amount of time may be spent “churning”—moving items from one pile to another but never discarding any item or establishing a consistent system or organization.

Medication compliance. Compulsive hoarders often forget to take medications or take them at inappropriate times. They may lose their medications in the clutter.

Insight. Hoarders often have little awareness of how their behavior and clutter affect their lives.¹⁹ They minimize the clutter in their homes and its health and safety risks. Insight can fluctuate over time and needs to be assessed repeatedly during treatment.

Table 2

Assessing a patient with compulsive hoarding symptoms

Domain	Useful questions or strategies
Amount of clutter	Visit home and/or see pictures
Hazards relating to clutter	Ask: What precautions do you take to reduce risk of fire? Have you ever had a problem with rodent or insect infestation as a result of the clutter? Have neighbors complained about the risks of fire or infestation that the clutter might impose on their homes?
Beliefs about loss of possessions	Ask: What is the worst thing that would happen if you threw this item away? If you did not have this, what do you think would happen?
Information-processing deficits	Ask: How long do routine decisions take you? Which decisions do you procrastinate or avoid?
Decision-making and organizational skills	Ask: How do you pay and store your bills?
Avoidance behaviors	Ask: Do you avoid other things (sorting mail, returning calls, doing dishes, or paying bills, rent, or taxes)?
Daily functioning	Ask: Do you get everything done that you want to do? Are you often late? Do you have difficulty starting or finishing tasks? Describe a typical day.
Insight	Ask: Do you think this amount of clutter is normal? Do you think having this clutter has caused problems in your life?
Motivation for treatment	Ask: What brings you into therapy now? Do you think you have a problem with excessive hoarding/saving? If it was not for your family, would you come for help?
Social and occupational functioning	Ask: How has your clutter affected your personal relationships? When was the last time you had someone come to your home? What prevents you from working right now? Are you working to your full potential?
Support from friends and family	Ask: What does your family say about your clutter? Do your friends or family understand what is going on?
Treatment compliance	Ask: How long does it typically take before you renew your prescriptions when you run out of medications?

Table 3

Cognitive behavioral therapy for compulsive hoarding

Treatment sequence	Methods and goals
Educate patient about hoarding	Help improve insight and motivation
Set up treatment	With patient, select target area of clutter
	Assess items together, creating a hierarchy of least to most difficult areas to sort and items to discard
	Create realistic categories and a storage system
Begin discarding	Patient must decide to keep or discard each item and permanently remove it from pile
	Patient must store saved items appropriately
	Continue until area is clear, then move to next area
Plan and implement appropriate use of space
Stop incoming clutter	Cancel subscriptions
	Address compulsive buying and acquisition
Provide organization training	Organize possessions, time, tasks, etc.
Prevent relapse	Replace hoarding with healthier behaviors to prevent clutter from re-accumulating
Source: Adapted from reference 23.

Social and occupational functioning. Many compulsive hoarders have very little family or social support. They frequently are too embarrassed by their clutter to have people come to their homes, sometimes for years. The syndrome frequently impairs work performance.

 

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.

 

Several studies of SSRI use in OCD patients have shown modest improvements in compulsive hoarders:

• In a descriptive study of patients with compulsive hoarding, 1 of 18 (6%) patients had a “marked” response to at least one SSRI trial. The others showed a partial response,¹⁷ with YBOCS scores decreasing by at least 25% in approximately 50% of this group.
  
• When 17 OCD patients with hoarding symptoms were treated with paroxetine, CBT, or placebo, 18% responded to active treatment. Response was defined as a 40% reduction on YBOCS scores and “very much” or “much” improved on the Clinical Global Impression Scale (CGI).¹⁴
  

Based on these findings and our clinical experience, an effective approach to treating compulsive hoarding with medications—as with other OCD patients—is to start with SSRIs²⁸ (Algorithm). If adequate SSRI trials fail to improve a patient’s hoarding/saving symptoms, adjunctive medications can be added.

Atypical antipsychotics may be effective for OCD symptoms that do not respond adequately to SSRIs.²⁹ Conventional antipsychotics are also effective adjuncts to SSRIs—particularly for patients with coexisting tic or psychotic disorders³⁰—but consider the potential for extrapyramidal side effects and tardive dyskinesia.

We find that stimulants help some compulsive hoarders, particularly those with comorbid ADHD, other attentional problems, low motivation, or lethargy. Mood stabilizers are necessary to treat comorbid bipolar disorder, cyclothymia, and impulsivity.

Related resources

• Saxena S, Maidment K. Treatment of compulsive hoarding. J Clin Psychol 2004;60(11):1143-54.
  
• UCLA OCD Intensive Treatment Program. For information on research studies contact Karron Maidment (310) 794-7305 or visit www.mentalhealth.ucla.edu/projects/anxiety/ocdintensivetreatment.htm.
  
• Compulsive hoarding project. Institute of Living Anxiety Disorders Center, Hartford Hospital. http://instituteofliving.org/adc/compulsive_hoarding.htm
  
• Obsessive Compulsive Foundation compulsive hoarding Web site. http://www.ocfoundation.org/1005/index.html
  
• Neziroglu F, Bubrick J, Yaryura-Tobias JA. Overcoming compulsive hoarding. Oakland, CA: New Harbinger Publications, 2004.
  

Drug brand names

• Citalopram • Celexa
  
• Clomipramine • Anafranil
  
• Escitalopram • Lexapro
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Olanzapine • Zyprexa
  
• Paroxetine • Paxil
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Sertraline • Zoloft
  
• Venlafaxine • Effexor
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.