Jean* is a 54-year-old single mother of three adult children who no longer live at home, but Jean’s no empty nester: She shares her home with six dogs, seven birds, and 15 cats. Family conversations invariably turn to Jean’s other “collections”: magazines and newspapers, outdated computers and computer hardware (eight computers, 15 unusable printers, and at least 25 unused keyboards), and a closet of items in need of repair (vases, figurines, kitchen gadgets, and furniture).

Family members discourage Jean from “rescuing” more animals. Family, friends, and neighbors complain about the hair, excrement, and general chaos resulting from so many animals. People are concerned about health and safety hazards that the animals create.

Visits to Jean’s home are awkward; it is necessary to move magazines and newspapers to find a place to sit. Computers and other hardware cover the furniture and floor, impairing movement through the house. The family describes Jean as a “pack rat.” They find it impossible to use most rooms in the house efficiently because of the clutter and poor sanitary conditions.

When asked about her behavior, Jean says she needs to save all the items for future use and intends to repair the broken items. She maintains she needs ready access to the valuable information found in the newspapers and magazines and is providing a service to the community by rescuing animals. When her children offer to clean or straighten up her home, Jean becomes highly agitated. She fears that parts of her collection will be lost.

Jean vows to reorganize her treasures, but reorganization usually leads to further hoarding and more clutter. Jean is a compulsive hoarder.

Nurses can make a difference in the lives of people like Jean by understanding the neurological deficits and psychological conflicts compulsive hoarders experience and the safety hazards hoarding may present and by knowing the nursing interventions that are most likely to be effective.

What’s behind compulsive hoarding?

Compulsive hoarding is being studied as a distinct pattern of behaviors that may or may not be part of another psychiatric disorder.¹ Hoarding is most often associated with obsessive-compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and compulsive behaviors.^1,2

The inability to discard useless items is one diagnostic criterion for obsessive-compulsive personality disorder (OCPD), a condition in which perfectionism and attention to details, rules, and organization become a pervasive and maladaptive way of coping.² Hoarding has also been considered a symptom of an impulse-control disorder (ICD), such as compulsive shopping or gambling,¹ but despite different theories about compulsive hoarding, it currently remains a symptom, or symptom cluster, rather than a distinct diagnosis.^1,3

While the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) does not list compulsive hoarding as a distinct diagnosis, generally agreed upon criteria provide defining features for the disorder. Some researchers use a cognitive-behavioral model to explain compulsive hoarding. From this model have emerged three defining features or behaviors:⁴

• The compulsive hoarder seeks to acquire and fails to discard a large number of possessions that appear to be useless or of no value.
• The compulsive hoarder’s living spaces are sufficiently cluttered to preclude the activity for which the spaces were designed (e.g., cooking, cleaning, sleeping).
• The compulsive hoarding causes the person significant distress or impairment of functioning.

The symptoms of a compulsive hoarder can be summarized as problems with acquisition, trouble discarding, and accumulation of clutter.¹ Acquisition includes acquiring more items than needed through behaviors such as compulsive shopping or a preoccupation with accumulating free things. Hoarding by definition includes trouble discarding items. This behavioral symptom seems to be related to cognitive problems in sorting and decision-making — and to unusual emotional attachment to possessions that leads to increased anxiety when the person is faced with discarding valued items.^1,5 Acquisition and failure to discard result in clutter, functional impairment, and distress, if not for the person accumulating the clutter, then for those close to the person.

Who hoards?

OCD, with which compulsive hoarding is most often identified, occurs equally in men and women, with men more often having a childhood onset.² About one-third of OCD patients are estimated to have compulsive hoarding as a primary symptom.³ One researcher found compulsive hoarding twice as common among men than women diagnosed with OCD.⁶
Nurses who have worked with the elderly often witness hoarding behaviors, particularly when dementia is present. Data on animal hoarding, a type of hoarding in which symptoms are usually more severe, suggest that compulsive hoarders tend to be older adults, living a solitary existence.¹ Animal hoarding has been more commonly found in women.⁷

Compulsive hoarders exhibit personality traits that include a tendency to get lost in details and at the same time to be perfectionists.³ A genetic vulnerability appears to exist. One study found that 84% of people with compulsive hoarding as a primary symptom reported that at least one first-degree relative also had significant hoarding behaviors.⁵ In addition to being seen with OCD, personality disorders, and impulse-control disorders, compulsive hoarding is seen with depression, dementia, social phobia, anorexia nervosa, schizophrenia, and brain injuries.^2,3,5 Researchers are also investigating the relationship of hoarding behaviors to trauma and attention deficit hyperactivity disorder (ADHD).⁸

Most research on compulsive hoarding has been conducted on people with OCD.^1,9 Brain imaging has shown a particular pattern of brain activity (or lack thereof) in OCD patients who are compulsive hoarders.⁹ These people had less activity in the part of the brain known as the cingulate gyrus compared to OCD patients who were not hoarders and a control group of normal subjects.⁹ The cingulate gyrus communicates with both the limbic system (emotional center) of the brain and the neocortex, which controls higher-level thinking. When activity is reduced in the cingulate gyrus, a person has problems with attention, motivation, problem-solving, and decision-making, as well as in assigning emotional meaning to stimuli.^5,9 In other words, the person with compulsive hoarding has difficulty with both emotional and cognitive functioning. Because of the functional patterns seen with brain imaging and the treatment resistance seen with compulsive hoarding, some researchers are beginning to argue for a separate diagnosis of “compulsive hoarding syndrome” or a definition of compulsive hoarding as a distinct subset of OCD.^1,3,9

The drive for compulsive hoarding differs from that of people with OCD. In general, the person with OCD compulsively engages in behaviors to reduce anxiety.² The compulsive hoarder is driven by intrusive thoughts about not having something that might be needed or be valuable, not being able to remember something, or wasting something.^3,4 In addition, the person with OCD has insight into the irrationality of the obsessive thoughts and compulsive actions,² while most people who demonstrate compulsive hoarding have no such insight, nor do they see hoarding as a problem.1 However, both OCD patients and people who hoard experience anxiety if their behaviors are interrupted or prohibited.^1,2

Hoarding dangers

From a healthcare perspective, compulsive hoarding creates concerns about physical safety, the loss of important items (medications, medical supplies, medical records), fire danger, and sanitation.⁹ In addition, compulsive hoarders tend to be solitary and fail to seek healthcare because of embarrassment or a failure to recognize that a problem exists.¹ Failure to seek healthcare — particularly by people with comorbid physical conditions such as heart failure or diabetes — could lead to devastating consequences. Comorbid psychiatric conditions, such as depression or schizophrenia, could be exacerbated and be equally dangerous.

Compulsive hoarders may be brought to the attention of the healthcare community by law enforcement or another public agency such as adult protective services, code enforcement, or animal control. Treatment often requires collaboration between the affected person, family, and an interagency treatment team.

Animal hoarding has been investigated as a particular, often more serious, type of hoarding and poses more human health and sanitation risks than other types of hoarding.^1,7,10 It often receives more media coverage, as well, and may be the type of hoarding best known to the public. Animal hoarding is frequently found in conjunction with other kinds of hoarding such as hoarding trash and newspapers.^7,10 Besides excrement and other contamination, it is not uncommon to find dead animals in the homes of these hoarders.10 Animal hoarders have poorer treatment outcomes than people who hoarded possessions only.¹⁰

Overcoming compulsive hoarding

Early detection and intervention can alter the progressive decline that generally ensues with compulsive hoarders.¹¹ Because the profile, functional disability, and cognitive interpretation for compulsive hoarding differ from those of OCD, OCPD, and ICD, a different treatment approach is required.

Cognitive-behavioral therapy geared to the cognitive distortions and problematic behaviors has shown the most success in treating compulsive hoarding.^1,4 Hoarding is remarkably resistant to medications such as the SSRIs (e.g., paroxetine [Paxil] and sertraline hydrochloride [Zoloft]) and to treatments typically used to treat OCD.^1,5 While hoarding does not respond as well to medications as OCD and other anxiety disorders, medications are often needed to treat comorbid conditions such as depression, psychosis, social phobia, and dementia. Medication may also prove useful in treating cognitive distortions and anxiety symptoms. For these reasons, medications may serve to make cognitive-behavioral therapy more effective.⁵ A new direction in treatment may involve the cholinesterase inhibitors such as donepezil hydrochloride (Aricept), used in treating memory problems, and stimulant meditations used to improve attention in ADD/ADHD.^5,9

Some interesting research has investigated the role of memory problems or perceived memory problems. People who hoard don’t trust their memory and worry about forgetting things, or forgetting where their possessions are, and prefer to have their belongings in sight.¹² They also have difficulties categorizing items (especially personal belongings) and trouble making decisions.¹³ Some of the most effective treatment is intensive and focuses first on building a trusting relationship with the person, then focusing on decision-making and organizing skills. Only as treatment progresses is discarding of items approached.¹ Some hoarders are more easily able to choose items to discard from photographs of a room.¹ Before and after photos help the person see progress. More successful treatment also involves homework assignments and ongoing practice in using newly learned skills.¹

Compassionate care

Nurses can organize care around the understanding that the person who is a compulsive hoarder has difficulty processing information and assigning emotional value to stimuli. Nurses can also recognize the anxiety the person is experiencing. This anxiety is often a reflection of the fear of losing or running out of an item that might be needed later. The nurse can also realize that people with hoarding symptoms experience distress when discarding items. This distress is created as the person must decide between what he or she feels are conflicting options (e.g., save for future security or discard for health and safety). Irrational fears of disaster may also be associated with discarding.^1,5

Treatment should directly involve the person in a nonconfrontational manner that allows him or her to explore the hoarding behavior.¹⁴ Nurses and other healthcare providers can demonstrate respect for the person and his or her possessions while seeking solutions to the functional impairment, safety hazards, and social isolation resulting from the hoarding behavior. Care and support can be provided while evaluating the person’s specific hoarding behavior concerns.¹¹ Behavioral change will be slow, and the person may be expected to relapse. Obviously, interventions should not be forced, as forced change may precipitate anxiety or anger — and possibly rage or delusions.^11,14

Compulsive hoarding is a unique set of symptoms seen in about a third of people with obsessive-compulsive disorder and comorbid with a variety of other diagnoses. New information about unique aspects of pure hoarding continues to raise the possibility of a separate disorder.^1,3 Treatment is slow and relapse frequent. However, reports of intensive skills training with decision-making practice in the context of a trusting relationship offer hope for future progress in treatment.^1,14

Nurses can also provide accurate information to the public about compulsive hoarding and plan interventions that address the cognitive and emotional sources of the symptoms while respecting the person.

*Composite patient