Today’s post is written by Dr. Scott Hannan, a psychologist, from the Anxiety Disorders Center. I’ve worked with Dr. Hannan twice while filming Hoarders (Gail and Kim episodes) and was hopeful that he would help me understand (and you too!) why so many mental health professionals are discussing the possibility of hoarding being it’s own, “official” diagnosis in the new Fifth Edition of the Diagnostic and Statistical Manual for Mental Disorders or DSM-V.
Below is his response.
The proposed Fifth Edition for the Diagnostic and Statistical Manual for Mental Disorders (DSM-V) is due for publication in 2013. A preliminary draft, along with newly proposed diagnoses, can be found at http://www.dsm5.org. Among the possible new diagnoses is Hoarding Disorder. Although there are diagnoses within the current DSM-IV in which the symptom of compulsive hoarding can be assessed, these diagnoses do not always present the most accurate picture of this problem. A diagnosis of Hoarding Disorder may more accurately portray this problem, enhancing public awareness, research, and treatment for this condition.
Individuals with clinically significant compulsive hoarding are most often diagnosed with Obsessive Compulsive Disorder (OCD) or Obsessive Compulsive Personality Disorder (OCPD). One of the criteria for OCPD is the inability to discard worthless or worn out objects. Research (Pertusa et al, 2008) indicates that once this criterion is removed, individuals with compulsive hoarding are no more likely to fit this diagnosis than other related groups.
In order to meet criteria for OCD, one needs to be experiencing intrusive thoughts, impulses, or images that cause emotional discomfort and/or repetitive behaviors that act to rid one of the emotional discomfort set off by the obsessions. It is recognized that some individuals with hoarding behavior do not experience obsessive thoughts and compulsions. Research (Pertusa et al., 2008) suggests that compulsive hoarding related to OCD is associated with fears of something bad happening at the loss of an item, checking rituals, fear of losing something important, and need for ordering/symmetry. Non-OCD hoarding behavior is associated with holding onto items for their emotional/intrinsic value. These individuals often become very excited at seeing their possessions or at the chance to acquire something new. The function of their behavior (acquiring, accumulating clutter) may be driven in part by positive emotions. Traditional cognitive behavioral therapy for OCD, which focuses on exposure and ritual prevention (ERP), is not typically effective for compulsive hoarding. There is growing evidence that they may be distinct diagnoses (e.g. Mataix-Cols et al., 1999; Saxena, 2007; Olatunji, et al., 2008). Treatment needs to address this difference.
Although there are cases in which a diagnosis of OCD may apply, it appears that compulsive hoarding deserves a separate category. One of the criteria for a diagnosis of Hoarding Disorder notes that the symptoms must not be better accounted for by other diagnoses, including OCD. As such, this diagnosis would clearly delineate hoarding behaviors into the appropriate diagnostic categories. Hoarding Disorder is for those individuals that have an accumulation of items, causing significant impairment in their life. The diagnosis allows a clinician to specify if there is excessive acquisition and the level of insight. This new diagnostic category will enhance understanding of the problem at the level of the individual and group. At the individual level, a diagnosis of Hoarding Disorder will inform professionals involved in their care better than a diagnosis of OCD. Traditional therapy for OCD (ERP) is not typically effective for those that would fit a diagnosis of Hoarding Disorder. This separate category would hopefully make mental health professionals aware of the need to adjust their treatment. Those with hoarding behaviors tend to have significant problems with organization, attention, and concentration. Insight into their problems may also be lacking. Cognitive behavior therapy for compulsive hoarding tends to focus on building motivation, enhancing organizational skills, and learning new ways to think about possessions. Patients are challenged to let go of items before and after acquisition.
This diagnosis will communicate to the families that this is a legitimate psychiatric problem. It is not, as some may assume, a problem of laziness or stubbornness. These individuals struggle emotionally and cognitively to reduce the clutter in their homes.
At the group level, this diagnostic category may help spur further research. Currently, researchers are already separating out OCD from Non-OCD related hoarding. This distinction may emphasize the difference for those conducting and funding research.
There are potential drawbacks to this diagnosis, as well. Some may find the term Hoarding Disorder stigmatizing. In addition, there is the potential for the misuse of the diagnosis to include individuals that engage in compulsive hoarding due to other psychiatric conditions, such as Schizophrenia, OCD, and Autism. Although there is the potential problem of misuse of the diagnosis, this is more a matter of educating professionals and the public than a reason not to include Hoarding Disorder in the DSM-V. The benefits to research and clinic work clearly outweigh the potential negatives.
Dr. Hannan’s contact information is:
Scott Hannan, Ph.D.
Staff Psychologist,
Coordinator of Clinical Services,
Anxiety Disorders Center
Phone: (860) 545-7685
Fax: (860) 545-7156
Email: shannan@harthosp.org
