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Compulsive Hoarding and Substance Abuse

For many years, individuals who displayed compulsive hoarding behaviors were diagnosed with a variant of obsessive-compulsive disorder (OCD) that included the obsession not to discard certain items and resulting compulsions to save items that were generally useless and would be considered rubbish by most standards.

However, the extensive research on both OCD and compulsive hoarding resulted in the designation of hoarding disorder being recognized as a separate but related disorder to OCD. Current diagnostic specifications allow individuals to be diagnosed with OCD and hoarding behaviors, to just be diagnosed with a hoarding disorder, or to be diagnosed with both OCD and hoarding disorder, depending on the individual’s overall presentation.

Hoarding Disorder

treatment_needsThe behaviors associated with having a formal diagnosis of hoarding disorder are such that the obsessions and compulsions are focused only at hoarding behaviors and not on other behaviors. Individuals with this disorder have extreme difficulty parting with possessions regardless of how valuable or invaluable they may be, and feel extreme distress whenever they are faced with discarding possessions. This results in the accumulation of clutter and garbage in their dwellings that significantly affects their ability to function as well as their activities with others in their lives. These behaviors are not better explained by the presence of some medical condition (e.g., a brain injury), the symptoms of some other psychological disorder (e.g., OCD or depression), or as a result of a substance use disorder (however, these individuals may have co-occurring substance use disorders).

People diagnosed with hoarding disorder may have insight regarding their situation and find it to be distressing, or they may have no insight into the problems that this condition causes. They may even be delusional regarding their hoarding behavior, such that even when very concrete evidence that their hoarding behaviors are dangerous is present, such as having a fire, these individuals still insist that their behaviors are not problematic.

The overall prevalence of hoarding disorder appears to range between 2 percent and 6 percent. This disorder affects both males and females; however, different samples indicate different prevalence rates for both. Some epidemiological studies indicate a higher prevalence of this disorder in males, whereas clinical samples nearly always report a significantly greater prevalence in females. This may be related to differential rates of males and females seeking treatment for this disorder.

Hoarding appears to be nearly three times more prevalent in older adults (age 55-94 years) compared to younger adults (age 34-44 years). It is uncertain if mild cognitive problems or factors associated with the development of early dementia in these individuals explain such a relationship. There appears to be a strong genetic association with the development of hoarding behaviors; however, the disorder is believed to result from a combination of both genetic and environmental issues.

Comorbid Disorders

According to clinical data nearly three-quarters of individuals diagnosed with hoarding disorder have comorbid (co-occurring) depression or anxiety disorders. The most common comorbid anxiety disorders are social anxiety disorder and generalized anxiety disorder. In addition, nearly 20 percent of individuals diagnosed with hoarding disorder also meet the diagnosis for OCD.

In large research studies investigating comorbidities of OCD and hoarding disorder with other psychiatric disorders, it appears that the incidence of individuals diagnosed with just hoarding disorder and a substance use disorder is relatively low; however, individuals who have comorbid depression or other anxiety disorders and hoarding disorder may be at higher risk to develop substance use disorders. Thus, it appears that the overall level of symptom severity in individuals with hoarding disorders contributes significantly to the risk to develop a substance use disorder as opposed to a definitive and significant relationship between hoarding behaviors and substance abuse. Individuals diagnosed with major depression, anxiety disorders, and OCD will be at significant risk to develop substance use disorders.

Hoarding Disorder Treatment

According to the Oxford Handbook of Hoarding and Acquiring, the treatment of hoarding disorder is similar to the treatment protocols for OCD.

There are medications that can be used to address some of the symptoms of hoarding disorder, such as depression and anxiety (e.g., antidepressant medications such as selective serotonin reuptake inhibitors and anxiolytic medications); however, medications are more effective when they are accompanied by behavioral interventions and therapy. Behavioral interventions typically utilize the principles of Cognitive Behavioral Therapy, such as response prevention, which induce the anxiety associated with the hoarding behavior in the individual and then teach them to avoid engaging in their compulsion (hoarding) while the same time using techniques learned in treatment, such as relaxation, anxiety reduction, stress reduction, etc. Treatment also involves cognitive restructuring of their beliefs and actually disposing of many of their possessions.
People diagnosed with comorbid hoarding disorder and other conditions, such as depression, other anxiety disorders, OCD, and/or substance use disorders, require more intensive treatment regimes to address their symptoms. Often, these approaches include aspects of integrated therapy.

These programs utilize a multidimensional approach to treat the overall issues associated with the person and to assist them in becoming as functional as possible. The level of autonomy that can be achieved varies from case to case, and the treatment team continually assesses the individual to determine their progress and capability of autonomous functioning. Because many individuals with hoarding disorder are older and suffer from other physical ailments, complete autonomy may not be possible for many people. It is important to get family members involved in the treatment of these individuals, so they receive as much support and assistance as possible.

An integrated treatment program is an ongoing program that should be designed to provide assistance and support to the individual over their lifetime. This includes arranging medical care and even placement in group homes if this is the necessary. Individuals who do not receive integrated treatment and long-term supervision for their hoarding disorder are at a high risk for relapse and a return to hoarding behaviors that can be potentially unhealthy and even dangerous.

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