The disorder popularized by reality television is poised to take its place as a unique diagnosis in the forthcoming DSM-V, with functional brain imaging evidence that renders it distinct from OCD.TLC
For half a century, the disorder known as "hoarding" was little more than an urban legend, best personified by the Collyer brothers. In 1947, they were found dead -- trapped and starved -- in a Manhattan apartment amid 140 tons of amassed possessions, their utilities long shut off. When they opened their doors to television cameras three years ago, hoarders secured their place in the public consciousness by reality programs that portrayed their behavior as showcasing the limits of unsettling, unsanitary deviancy. A&E's Hoarders premiered in August 2009, followed soon after by TLC's Hoarding: Buried Alive and Animal Planet's Confessions: Animal Hoarding. As popular interest grew, so, too, did the attention of the psychiatric community.
It's time for hoarding to take its rightful place as a defined mental disorder, codified by the American Psychiatric Association in its forthcoming fifth edition of the Diagnostic and Statistical Manual (DSM), which was last revised in 2000. The APA is currently conducting field trials; if approved, "hoarding disorder" (HD) will become officially diagnosable in May 2013, when the DSM-V is released.
The unofficial diagnostic criteria for HD have been circling the psychiatric community since 1996. The disorder is characterized by:
- The acquisition of and failure to discard a large number of possessions that seem to be useless or of limited values
- Living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed
- Significant distress or impairment in functioning caused by the hoarding
These symptoms of HD are estimated to occur in 2 to 5 percent of the overall population.
In the current DSM, hoarding is referred to only as a symptom of obsessive-compulsive disorder (OCD), a disease more commonly associated with the extremes of organization. The fourth edition of the DSM lists hoarding as a sign of the less serious obsessive-compulsive personality disorder and only implies that it can present in patients with typical OCD. According to a 2010 review published by the APA, though, fewer than five percent of patients with OCD count hoarding as a significant problem, while only 18 percent of people with HD have the extra symptoms necessary for a concurrent diagnosis of OCD.
OCD is best characterized by intrusive thoughts ("obsessions") that lead to compulsive behavior. People with OCD engage in its characteristic behaviors in response to these thoughts: for example, they repeatedly wash their hands because of their irrational fear of germs. It is the fear of germs, not the hand-washing, that is the basis of the disorder.
If hoarding is a true mental disorder, it is so because of its physical reality -- the out-of-control clutter can go so far as to be life-threatening. The build-up of possessions occurs relatively passively, and people with HD only experience distress when faced with the prospect of having to throw or give things away. Otherwise, they are often unperturbed by their situation. It's the people surrounding compulsive hoarders -- their families, their neighbors, their landlords -- who are more likely to be aware of and distressed by the disorder.
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Perhaps the most convincing evidence for hoarding being defined as a unique disorder -- a separate entity from OCD entirely -- comes from current research that suggests it is rooted in a brain dysfunction that occurs during the decision-making process. A new study in the Archives of General Psychiatry was the first to use fMRI scans to look at the brain functioning behind the compulsion to hoard.
The study identified subjects with distinct diagnoses of hoarding and OCD, along with a control group exhibiting neither disorder, and had them bring in papers from their homes that they had not previously sorted. The subjects were shown an image of each item on a computer screen, interspersed with similar objects that they were told belonged to the experimenters. The difference was made as clear as possible: the word "yours" would appear on the screen immediately before they were shown items belonging to them, which were surrounded by a red border. The other items were introduced by the word "ours" and were bordered in black. They were given six seconds to decide the fate of each item.