Causes of Hoarding
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Course and Causes of Hoarding
Hoarding usually begins early in life, though onset can vary greatly. It can occur in children, and we have seen it as young as 3-years old. For young children, hoarding may look different because parents control what children can buy and the level of clutter in their rooms. More apparent in children are extremely intense attachments to objects and the tendency to personify things, applying human-like characteristics to objects. In addition, children who hoard seem to have more difficulty recognizing hoarding behavior as a problem.
The typical age of onset for hoarding behavior (though not hoarding disorder) is around age 13. At that time the behavior is usually mild and would not be considered a disorder. Hoarding typically progresses to become a moderate problem in the 20’s and 30’s, and a severe problem in the 40’s and 50’s. Onset appears to be earlier in women than in men, though hoarding occurs more frequently in men than in women. Late onset of hoarding (after age 40) is rare and seems to occur in people who have mild hoarding to begin with and suffer a loss of some kind. Most people who hoard describe a chronic course, while a small number describe an increasing or fluctuating one. Stressful and traumatic events are common in people who hoard and may be associated with periods of worsening symptoms. Recent epidemiological studies suggest that as many as 1 in 20 people have significant hoarding problems.
Hoarding is a complex disorder that is believed to be associated with 4 underlying characteristics. First there are certain core vulnerabilities including emotional dysregulation in the form of depression or anxiety along with family histories of hoarding and generally high levels of perfectionism. Second, people who hoard appear to have difficulties processing information. In particular, these difficulties appear as problems in attention (including ADHD-like symptoms), memory, categorization, and decision-making. The areas of the brain that control these functions roughly correspond to the brain regions that have been shown to activate differently in people who hoard. Third, people who hoard form intense emotional attachments to a wider variety of objects than do people who don’t hoard. These attachments take the form of attaching human-like qualities to inanimate objects, feeling grief at the prospect of getting rid of objects, and deriving a sense of safety from being surrounded by possessions. Fourth, people who hoard often hold beliefs about the necessity of not wasting objects or losing opportunities that are represented by objects. Additional beliefs about the necessity of saving things to facilitate memory and appreciation of the aesthetic beauty of objects contribute to the problem.For more information about the course and causes of hoarding, please see the following:Grisham, J., Frost, R.O., Steketee, G., & Hood, S. (2006). Age of onset in compulsive hoarding. Journal of Anxiety Disorders, 20, 675-786.
Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., & Mataix-Cols, D. (in press). Refining the boundaries of compulsive hoarding: a review. Clinical Psychology Review.
Plimpton, E.H., Frost, R.O., Abbey, B.C., & Dorer, W. (2009). Compulsive hoarding in children: 6 case studies. International Journal of Cognitive Therapy, 2, 88-104.
Samuels, J.F., Bienvenu, O.J., Grados, M.A. et al. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour Research and Therapy, 46, 836-844.
Steketee, G. & Frost, R.O. (2003). Compulsive hoarding: Current status of the research. Clinical Psychology Review, 23, 905-927.
Tolin, D.F., Meunier, S.A., Frost, R.O., & Steketee, G. (in press). The course of compulsive hoarding and its relationship to life events. Depression & Anxiety.
Hoarding and the Brainby David F. Tolin and the institution is the Institute of Living and Yale University School of Medicine
Compulsive hoarding is currently thought to be maintained by a pattern of maladaptive beliefs, avoidant and impulsive behavior patterns, and cognitive impairments 1-5
. From a neuropsychological perspective (in which specific brain-behavior relationships are identified) and from a neuroimaging perspective (in which specific activity in regions of the brain are localized), these impairments can be linked to abnormalities in specific brain regions associated with executive functioning, impulse control, and processing of reward value. Below, we describe impairments of brain functioning that have been detected among people who hoard.Neuropsychological Findings
People who hoard frequently report problems sustaining attention 6-8
. Neuropsychological tests show that hoarding is associated with diminished nonverbal attention, greater variability in reaction time, greater impulsivity, and poorer ability to detect target stimuli 7, 8
. Many people with hoarding problems also describe poor memory, and indicate that they keep certain possessions due to fears that they will forget relevant information or lose an important memory if they discard an object. They state that they prefer to leave objects out in the open (e.g. piling important papers on the table), rather than putting them away (e.g. in a filing cabinet) due to fear that they will forget where they placed the item or that they possess that item. Neuropsychological tests of memory functioning have revealed that hoarding individuals show impaired delayed recall (both verbal and visual), and use less effective visual recall strategies, compared to non-hoarding participants 9
. Ironically, despite these apparent memory deficits, individuals with hoarding frequently report overtaxing their existing memory capacity by relying on a memory-based approach to finding objects, rather than a category-based approach 4. In other words, individuals with compulsive hoarding attempt to organize and find items based on visual spatial recall (remembering where an item was last seen) instead of categorical recall (remembering where a certain category of item is usually placed). Difficulty discarding possessions is also thought to result, in part, from problems of executive function (higher-level cognitive functions such as decision-making and categorization). Self-reported indecisiveness has been associated with hoarding in college and community samples 10-12
. Compared to participants with OCD, hoarding participants reported greater indecisiveness on a self-report measure, and were rated by study clinicians as more indecisive 13
. Research using the Iowa Gambling Task 14
, which requires participants to sacrifice immediate rewards in order to maximize long-term gain, shows that OCD patients with hoarding symptoms perform more poorly than do OCD patients without hoarding symptoms 15
. This result was not replicated in a separate study of primary hoarding patients, however 7
. The ability to categorize possessions, a key skill in maintaining organization, also appears to be compromised in hoarding. When asked to sort their personal possessions, hoarding individuals took longer, and created more categories (with a smaller number of items per category), than did non-hoarding participants 16
Many of the impairments observed among people who hoard are commonly associated with frontal cortical regions, particularly the prefrontal cortex and anterior cingulate cortex (ACC). Case studies have reported the onset of hoarding symptoms in adulthood following insult to these regions 17, 18
. Sanjaya Saxena and colleagues 19
used positron emission tomography (PET) to examine brain activity (specifically, metabolism of glucose). Compared to non-hoarding OCD patients, hoarding patients showed lower brain activity in the ACC (Figure 1)
David Mataix-Cols and colleagues 20
took this research a step further using functional magnetic resonance imaging (fMRI), which measures brain activity by detecting blood flow in different regions of the brain. These researchers asked OCD patients (not necessarily with hoarding) and healthy controls, while in the scanner, to imagine throwing away items such as newspapers. OCD patients showed increased activation in left precentral gyrus and right orbitofrontal cortex, a region that is associated with decision-making, reward processing, and inhibition. In a second study by the same group of researchers, An et al. 21
extended these findings by comparing OCD patients (with and without hoarding) and healthy controls using the same imaginal symptom provocation task. In response to the hoarding-related (but not hoarding-unrelated) anxiety provocation, OCD patients with prominent hoarding symptoms showed greater activation in ventromedial prefrontal cortex (VMPFC) than did patients without hoarding symptoms and healthy controls (Figure 2)
My colleagues and I 22
used fMRI to examine brain activity when people who hoard make an actual (rather than imagined) decision about keeping vs. discarding possessions. We asked hoarding and non-hoarding participants to bring a bag of their mail (e.g., letters, magazines, catalogues, etc.) to the experiment. While in the scanner, participants watched the experimenter on a live video feed. The experimenter held up pieces of mail, one at a time, and the participant indicated by pressing buttons whether each piece of mail should be kept or discarded. If the item was to be discarded, the experimenter placed it into a shredder while the participant watched. Compared to non-hoarding participants, hoarding participants showed greater activity in left lateral orbitofrontal cortex (OFC) and parahippocampal gyrus (PHG) (Figure 3)
Collectively, evidence from neuropsychological testing and neuroimaging research suggests that compulsive hoarding is characterized by abnormal activity in areas of the frontal lobe such as orbitofrontal cortex, ventromedial prefrontal cortex, and anterior cingulate cortex. These abnormalities likely underlie the observed problems of neuropsychological functioning observed by several researchers, including problems with sustained attention, problems with memory, and problems of executive function. We propose that there is a direct connection between these disruptions of brain activity and the problems our hoarding patients encounter during routine decision-making. Specifically, when people with hoarding problems are asked to make a decision about whether to keep or discard possessions, they get swamped. Their attention starts to wander (I'll work on sorting my possessions as soon as I finish watching this TV show), they begin to doubt the accuracy of their memory (Did I have a need for this? I forget; better keep it in sight), they have difficulty with categorization (Should this go in the keep, discard, or recycle pile?), the process starts to feel punishing rather than rewarding (I have to grieve the loss of these possessions), and they have problems delaying gratification (Ooh, that's pretty; I must have it!). The end result for many people is that sorting, deciding, and discarding becomes such an overwhelming and unpleasant experience that they choose to avoid it altogether. References1. Frost RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther. 1996;34(4):341-350.
2. Steketee G, Frost RO. Compulsive hoarding: Current status of the research. Clin Psychol Rev. 2003;23:905-927.
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21. An SK, Mataix-Cols D, Lawrence NS, et al. To discard or not to discard: the neural basis of hoarding symptoms in obsessive-compulsive disorder. Mol Psychiatry. 2008.
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