Types of Hoarding
OCD-based Hoarding: When is Hoarding Really OCD?
It appears that a small number of hoarding cases may be true or primary OCD where the hoarding is secondary to OCD symptoms. In other words, the hoarding behavior is driven entirely by OCD symptoms such as contamination fears or symmetry obsessions. There appear to be four things that characterize OCD-based hoarding. First, the hoarding occurs because of classic obsessions. Among the most common of these are fears of contamination (for example, objects can’t be touched because they are contaminated and thus they accumulate on the floor or wherever they are dropped), superstitious thoughts (for example, unreasonable belief that throwing something away will result in a catastrophe of some kind), feelings of incompleteness (symmetry obsessions fall in this category), or persistent avoidance of onerous compulsions (for example, not discarding to avoid endless checking before discarding can occur). Second, in OCD-based hoarding the hoarding behavior is unwanted and highly distressing and the person experiences no pleasure from it. Third, the individual shows little interest in saved items, especially not sentimental attachments or beliefs about the intrinsic value of possessions. Finally, excessive acquisition is usually not present in OCD-based hoarding. However, occasionally collecting occurs in the context of rituals associated with other OCD symptoms such as having to buy items in multiples of a certain number to ward off feared consequences, or having to acquire something because the person feels responsible for having contaminated it. In cases with these features, OCD should be the diagnosis and not hoarding.
Hoarding in Older Adulthood
There is limited research on hoarding in older adults with the majority of published articles on isolated case reports or in dementia samples. Nevertheless, it is well known that late life hoarding is a serious psychiatric and community problem that warrants considerable attention.
Onset and Course throughout the LifespanHoarding is more prevalent in older than younger age groups. Initial onset of hoarding symptoms is believed to occur in childhood or adolescence with a chronic and progressive course throughout the lifespan. There is little evidence for late onset hoarding. Hoarding severity increases with each decade of life, thus older adults experience very serious levels of hoarding. This increase in hoarding symptoms is particularly interesting given findings of decreasing prevalence of other psychiatric disorders in late life. Other than dementia, hoarding may be the only psychiatric disorder that actually increases in severity and prevalence throughout the life course.
Many elderly hoarders suffer from serious medical conditions that require consistent medication and monitoring. Unfortunately, they tend to not seek out appropriate medical care, often due to cost of care, transportation difficulties, or difficulty scheduling/keeping appointments. Older hoarders are often disorganized and have trouble following medical regimens. Most of the time, their physicians are unaware of their problem with hoarding.
Psychiatric comorbidities complicate the clinical picture of late life hoarding. Hoarding has been found in older adults without other psychiatric diagnoses. However, approximately half of older adults with hoarding suffer from other psychiatric illnesses, mainly mood and anxiety disorders. Major depression is the most common psychiatric comorbidity. In many cases, it is possible that that concurrent mood and anxiety symptoms are another consequence of hoarding.
Hoarding behaviors have been associated with dementia and appear to increase with severity of dementia. Hoarding and hiding behaviors are commonly reported in nursing home patients with dementia. It is not clear whether this behavior is a manifestation of dementia or these patients had a prior history of hoarding. Despite the fact that these behaviors look like hoarding, it is also unclear if the characteristic intense urges to save and distress from discarding are present as seen in hoarding disorder.
Hoarding is particularly dangerous for older persons, who may have physical and cognitive limitations. Basic functioning in the home is impaired which has serious consequences for older adults. One investigation found that 45% could not use their refrigerators, 42% could not use their kitchen sink, 42% could not use their bathtub, 20% could not use their bathroom sink, and 10% could not use their toilet. Further, hoarding was viewed as a physical health threat due to fires, falling, unsanitary conditions, and inability to prepare food. Not surprisingly, many suffer from great social impairment. The majority of elderly hoarders report substantial social isolation and that their living conditions have kept them from having house guests due to shame or embarrassment. Although many older hoarders are now retired, they report prior work impairment. Most live on a fixed income and suffer from financial problems due to paying for extra storage spaces, purchasing unneeded items, or housing fines. Finally, older adults are at risk for eviction and premature relocation to senior housing. Unwanted housing relocation has serious psychiatric consequences for elderly hoarders. We likely do not know the true extent of disability and quality of life impairment given the lack of research in this area.
Older adults with hoarding have likely engaged in some form of mental health treatment in their lifetime. However, their hoarding symptoms went largely undetected and untreated. The vast majority of older hoarders have never sought treatment specifically for hoarding. Due to the lack of awareness and knowledge of hoarding by the public and mental health professionals in previous decades, many older adults did not believe their symptoms could be treated. Even today, only a small percentage of older hoarders are receiving psychiatric treatment for hoarding. Reasons for not receiving treatment include lack of public awareness, cost of treatment, transportation problems, negative views of mental health treatment, low motivation, lack of insight, and lack of qualified professionals.
Studies using a specialized cognitive-behavioral therapy (CBT) approach for hoarding have demonstrated success in mid-life samples. However, the specialized CBT for hoarding may not work as well for older adults. Patients often report that the cognitive therapy “tools” and strategies are too abstract or challenging to understand. Overall, patients prefer very specific, concrete tasks and exposure treatment.
The neurocognitive profile of late life hoarding patients may explain the difference in psychotherapy response compared to younger age groups. There is burgeoning evidence that older adults with hoarding may have particular executive functioning deficits. Specific cognitive problems include deficits in flexibility, categorization, hypothesis generation, and efficiency, which may impact the utility of cognitive therapy. There is no evidence for impairment in other areas such as memory, learning, or attention. Future psychotherapy research may focus on behavioral (exposure treatment) rather than traditional cognitive therapy principles. Cognitive rehabilitation and medication treatment are also likely to be beneficial however; there is no current empirical evidence for these interventions.
by: Catherine R. Ayers, Ph.D., ABPP
For more information about hoarding in the elderly, please see the following:
Ayers, C.R., Saxena, S., Golshan, S., & Wetherell, J. L, (2009). Age at onset and clinical features of late life compulsive hoarding. International Journal of Geriatric Psychiatry, 25, 142-149.
Kim, H., Steketee, G., & Frost, R.O. (2001). Hoarding by elderly people. Health & Social Work, 26, 176-184.
Turner, K., Steketee, G. & Nauth, L. (in press). Treating elders with compulsive hoarding: A pilot program. Cognitive and Behavioral Practice.
Animal hoarding was first described as a hoarding-type problem with publication of a paper in Public Health Reports in 1999 [Patronek 1999]. The similarities between the pathological hoarding of objects with what was known in the animal welfare community for many years as “animal collecting” was described, and the term “animal hoarding” was proposed as a more accurate and consistent way of framing this problem.
When the Hoarding of Animals Research Consortium (HARC) was first formed in 1997, there had been almost no systematic research into this problem. Dealing with these cases was left almost entirely to animal shelters and animal welfare workers. There was little recognition of the human health implications of animal hoarding or the similarities to other kinds of compulsive hoarding.
Animal hoarding is more than just having a large number of animals, although numbers do need to be taken into account. The published definition of an animal hoarder [Patronek 1999] is someone who:
- Accumulates a large number of animals, and
- Fails to provide minimal standards of nutrition, sanitation, and veterinary care, and
- Fails to act on the deteriorating condition of the animals (including disease, starvation and death) or the environment (severe overcrowding and extremely unsanitary conditions), and
- Fails to act on the negative effect of the collection on their own health and well-being and that of other household members.
Taken to its inevitable conclusion, animal hoarding results in considerable animal suffering from neglect. The health and welfare of both the human and animal occupants of the home may be at risk from the accumulated clutter and squalor [HARC 2002]. The risk to the hoarder of self-neglect has also been described [Nathanson 2009]. In worst-case scenarios, the home will be so damaged from accumulated feces and urine that it is condemned as unfit for human habitation.
Animal hoarding occurs in every community, and it is estimated that there are three to five thousand cases each year in the US, involving up to 250,000 animals. There is now a searchable database of cases with descriptions of their consequences for animals, people, and communities.
Initially, due to the striking similarities between people with OCD with a hoarding compulsion and animal hoarders, we sought to understand animal hoarding as a form of OCD. Whether that is still the best model is uncertain, since the compulsive caregiving of living creatures seems to have qualitative differences with the hoarding of inanimate objects.
We are just beginning to understand how animal hoarding evolves, from both personal accounts of animal hoarders as well as those of their adult children, parents, siblings or friends. A common theme across many of these stories is a history of unstable or inconsistent parenting, trauma, neglect, or abuse during childhood. This history is also shared by people with other types of addictive behaviors, such as substance abuse. A very interesting perspective is provided in the book “Addiction as an Attachment Disorder” by Richard Flores.
The diagram below shows our current working model of how hoarding might evolve. Ultimately, hoarding is not an altruistic behavior. Animals are compulsively accumulated and cared for in order to serve deep-seated human needs. Hoarding is not legitimate rescue, sheltering, or providing sanctuary for animals.
Intervention in animal hoarding cases is almost always complex. There is no one universal solution. Each person comes in with a different history, a different set of circumstances and resources, unique medical and psychological diagnoses that may all affect what kind of intervention might work best. In 2006, an expert working group developed a preliminary typology of animal hoarders, shown in the diagram below.
From Patronek, Loar, and Nathanson, 2006 Each of these types will respond to or require different types of intervention approaches. The overwhelmed caregiver is more likely to be responsive to a more therapeutically oriented approach, whereas the exploiter hoarder will most likely require aggressive prosecution for animal cruelty in order to achieve change. The rescuer hoarder may require a bit of both.
Therapeutically oriented approach – in this model, conditions are improved by gradual downsizing and a moratorium on new animals so the number of animals present is compatible with the person’s capacity to provide care. This approach depends on establishing trust and a negotiated process for all decisions. Providing or improving the support network for the person is essential in these situations. One advantage of this approach is that it can be done much more discreetly and out of the public domain. If you think you or a family member may be at risk of becoming a hoarder, a first step would be to have a confidential conversation with a veterinarian, the department of health or social services, or the Director of the local animal shelter or SPCA to learn what options are available. Most animal welfare groups will be willing to work with a person to achieve a situation where the animals can be properly cared for and an adversarial approach is avoided. A therapeutically-oriented approach involves: 1) helping the person arrange for spay-neuter of the animals 2) providing necessary veterinary care; 3)reviewing the environmental condition and how well it meets the animals’ needs for exercise, socialization, and mental stimulation as well as basic care; and 4) finding avenues for adoption for whatever number of animals exceeds the person’s capacity for care. Some kind of on-going informal monitoring and support is also essential.
Law enforcement approach – this approach is by nature much more adversarial via enforcement of the anti-cruelty laws. In some cases, the environment is so toxic and the person so resistant to improving conditions, no other option but forcible removal is available. Each state has laws that require a caretaker or owner to provide adequate food, clean water, a sanitary environment, protection from the elements, and veterinary care to prevent suffering (eg, treating a broken leg or tumor). Because all of the rules of criminal justice and evidence collection apply, this approach is more burdensome and complex. Police will obtain a search warrant, and the animals will be taken into protective custody as the legal process unfolds. This could take months to years, and if convicted of animal cruelty, could even result in jail time for the offender. Often the media become involved, and the case is a matter of public record if charges are filed.
Each state will have its own process for enforcing the animal cruelty laws and investigating complaints. In some cases, this will be a humane society or society for the prevention of cruelty to animals (SPCA). In other cases, it may be the local police or animal control authority.
Counseling and therapy
Little is really known about which kinds of therapy work best. There are very few psychologists, counselors, or psychiatrists who have any expertise in animal hoarding. That said, it is important that the therapist have experience diagnosing and treating a wide variety of disorders, since identifying any co-morbid conditions will be important for addressing the animal hoarding. We do believe that without some kind of long-term treatment and monitoring, that the chances that the behavior will return nears 100%. Many of the principles outlined for treating compulsive object hoarders likely apply in these situations.
What is also important is that the therapist be provided information about animal hoarding and the conditions of both the animals and household that led to the referral for therapy. We have published a paper outlining some of the general issues that therapists should be aware of [Patronek & Nathanson 2009].
Arluke A, Vaca-Guzman M. Normalizing passive cruelty: The excuses and justifications of animal hoarders. Anthrozoos 2005; 18:338–357. Available here
Berry C, Patronek GJ, Lockwood R. Animal hoarding: A study of 56 case outcomes. Animal Law 2005; 11:167–194. Available here
Cassidy J, Mohr JJ. Unsolvable fear, trauma, psychopathology: theory, research, and clinical considerations related to disorganized attachment across the lifespan. Clinical Psychology: Science and Practice 2001; 8:275–298.
Flores PJ. (2004). Addiction as an attachment disorder. Jason Aronson:Lanham, MD.
Hoarding of Animals Research Consortium (HARC). Health implications of animal hoarding. Health & Social Work 2002; 27:125–132. Available here
Nathanson J. Animal Hoarding: Slipping into the darkness of comorbid animal and self-neglect. Journal of Elder Abuse & Neglect 2009; 21:307–324
Patronek GJ, Nathanson JN. A theoretical perspective to inform assessment and treatment strategies for animal hoarders. Clinical Psychology Reviews2009; 29:274–281. Available here
Patronek GJ, Loar L, Nathanson JN. (2006). Animal Hoarding: Strategies for Interdisciplinary Interventions to Help People, Animals, and Communities at Risk. Boston, MA:Hoarding of Animals Research Consortium. Available here
Patronek GJ. Hoarding of animals: an under recognized public health problem in a difficult to study population. Public Health Reports 1999; 114:82–87. Available here