Hoarding Disorder in Older Adults: Signs, Causes, and Impact

What is Hoarding Disorder?

According to the American Psychiatric Association (APA), hoarding is when one has difficulty getting rid of possessions, regardless of their actual value. Parting with these items causes significant distress, which is why they choose to keep it. This behavior typically stems from a profound emotional attachment to the item or a belief that they have to be saved for the future. Hoarding used to be a symptom of Obsessive-Compulsive Disorder (OCD) and not a standalone condition. This changed, however, in May 2013, when the APA updated the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), officially recognizing hoarding disorder as a distinct condition.

It is crucial to note that hoarding is not a pleasant experience, as accumulating possessions can force a person to live in a state of disarray, disorganization, and unsanitary conditions. Different piles can fill the house, clogging open surfaces and rendering living spaces inhospitable or unsustainable. In turn, this can make it difficult for people to form social relationships and invite others to their homes. It can also make it much more challenging for them to get rid of the items they have hoarded, especially if they already formed deep emotional connections with the objects. Consequently, living in cluttered environments is the most visible hallmark of the disorder. A person can hoard any item, and there tends to not be a theme associated with the objects.

Globally, 2.6% of the population hoards items, with the majority being over 60 years old. Hoarding is often comorbid with other psychological conditions, such as anxiety, depression, Attention-Deficit/Hyperactivity Disorder (ADHD), and OCD. There are no gender differences in hoarding, meaning its prevalence rate is equal between women and men. It often emerges as early as adolescence (i.e., 15-19 years old) and gets progressively more severe with age.

Consequences and Health Complications

Compulsive hoarding can cause significant dangers and health risks for those with the condition and their loved ones. For example, if the household is cluttered, this can pose safety risks and become a fire hazard. It can also make it difficult for people to move and walk around in the home, potentially making it hard to not trip. Considering the fact that the majority of hoarding cases are with older adults, these environments are even more dangerous, as falling is a major cause for hospitalizations, further health complications (e.g., broken hips), and even death.

As mentioned earlier, hoarding can strain social connections. Embarrassment over the clutter or sheer lack of space often prevents individuals from inviting guests to their homes, leading them to avoid social situations and become increasingly secluded. Hoarding can also make it difficult for the person to carry out daily tasks, such as cooking or bathing. These challenges closely mirror symptoms of depression and anxiety, which can be further exacerbated if no action is taken to help mitigate the situation. As a result, the person can experience high rates of social isolation and loneliness, which are common features expressed by older adults, especially those with cognitive decline. Ultimately, the more withdrawn individuals become, the more they may hoard as a form of perceived comfort and safety.

Usually, hoarding can get so severe that individuals are unable to make the decision and carry out the plan to remove the items and declutter their home. Instead, intervention from family members, cleaners, or the authorities becomes necessary to help with the situation. When this happens, conflict can sprout between the person hoarding and those telling them that this is an issue. The thought of parting and getting rid of items causes a lot of distress for the person, as the emotional attachment to the items becomes so strong that it forms part of their identity. Therefore, suggesting that the item be removed can be debilitating for the individual and may cause them to feel intense waves of anxiety, depression, and even grief for what the object represented to them. Even though it is challenging, objective and compassionate intervention is vital. If no solution gets put in place, the person can experience further complications, such as legal issues (e.g., evictions). When children, pets, or other dependents share the home, hoarding can be quite a health concern, not just for the person with the condition but for those who depend on and live with them. Furthermore, finding important documents and being punctual can be quite difficult for people with the condition, as they may frequently misplace items lost in the clutter. Consequently, they can experience more stress and lower rates of quality of life.

Characteristics, Signs, and Symptoms

Due to hoarding’s connection with OCD, ADHD, anxiety, and depression, a person with the disorder often shares similar traits. Common symptoms associated with hoarding disorder include perfectionism, indecisiveness, disorganization, distractibility, and procrastination. For that reason, we know that hoarding disorder is associated with deficits in the brain areas responsible for the following: planning, problem-solving, visuospatial learning and memory, sustained attention, working memory, and organization. Hoarding is so intertwined with OCD that it is estimated that one in four people with OCD will be compulsive hoarders. To be diagnosed with hoarding disorder, a person would need to see a psychologist. The psychologist would assess them by asking how the hoarding is interfering with their lives and affecting their daily functioning, along with how difficult it is for them to part with objects. They would also have their patients complete questionnaires and self-reported surveys to determine how severe the symptoms are. The hoarding would need to cause the person significant distress and impair their mental well-being. That is why it is important for the public to be aware of how serious this condition is and not consider it something as trivial as “collecting.”

Unknown Cause

Currently, we do not know the cause of hoarding disorder. Because hoarding disorder remains a relatively new focus in clinical research, it is a hot topic right now with many mental health professionals investigating its neurobiology. Similar to other mental health conditions, we are examining how nature and nurture contribute to its onset and development. Simply put, scientists are analyzing the relationship among genetics, the environments we were raised in, and our brain state as contributing factors to the disorder.

Researchers have recently noticed a trend where, if one has a relative who has hoarding disorder, they are more likely to have the condition. In other words, there is a strong family connection for hoarders. Traumatic life events are another significant contributor, as those who experienced abuse/neglect, the death of a loved one, or a natural disaster are more likely to hoard objects in the future. If they were abused or abandoned, a person may hoard to feel a sense of control and autonomy over a situation in which they were previously vulnerable and exploited. In turn, hoarding can help to counteract and alleviate those feelings of instability and perceived threats. If an item reminds an individual of a good memory, they may hoard it to relive those events, especially in cases of grief. For example, if an older adult has a perfume that reminds them of their younger years, they may hoard the bottle and never spray the scent since it gives them a sense of security they are missing. Even if the perfume is empty, the person may still keep the bottle since they have grown so attached to it and the nostalgia it carries.

Attachment Theory

Proposed by John Bowlby in 1958, attachment theory suggests that people develop attachments from their environment and their relationship with their caregivers, primarily their mothers, reflecting the maternal focus common in mid-twentieth-century psychology. He explained how these attachments are innate and necessary for our survival and protection from predators. Simply put, Bowlby explained how having secure attachments gives species an evolutionary advantage to their prosperity and propagation in response to natural selection. In the 1970s, Mary Ainsworth, a student of Bowlby’s, later expanded upon his theory through her Strange Situation experiment. There, she analyzed children’s responses to being in the presence of a stranger, not having their mothers present, and their reaction to their mothers’ return; this final part was called the “reunion.” Depending on how the child reacted when their mother returned, psychologists could identify the child’s attachment style. Together, Bowlby and Ainsworth’s work helped the psychological community develop the following four attachment styles: secure, anxious-ambivalent, avoidant, and disorganized.

Video clip of Ainsworth’s experiment, which features Lisa, a 14 month old placed under mild stress in an unfamiliar situation

Secure Attachments

Secure attachments are when a child forms a healthy relationship with their caregivers, whereas the remaining three are insecure attachment styles. Those with secure attachments are less likely to develop hoarding disorder, as they are comfortable with throwing things away and not being dependent on material items for their own emotional regulation, happiness, and satisfaction. Ultimately, people with this attachment style are able to accurately identify an object as unusable without the urge to hoard.

Anxious-ambivalent Attachments

Anxious-ambivalent attachments are characterized by clinginess and fear of letting things go. People with this attachment style are afraid of abandonment and often rely on others and objects for emotional regulation and support, seeking the sense of security and stability that they lack. In turn, they may hoard material objects to fill the void created by their insecure attachment.

Avoidant Attachments

Avoidant attachments involve people distancing themselves from others and not forming lasting relationships due to a fear of being hurt, disappointed, or abandoned. If they experience too much emotional closeness with others, they may appear dismissive or ignore the situation as a whole. This attachment forms when, as children, they were deprived of emotional support and their emotional needs were not met. Those with avoidant attachments may hoard as a substitute for the lack of social relationships they have. In other words, instead of receiving connection from people, they receive it from objects they are attached to and that bring them happiness.

Disorganized Attachments

Disorganized attachments have confusing and unstable relationships with others, stemming from a chaotic upbringing, often with caregivers who provided them with inconsistent forms of affection and attention. Their hoarding symptoms may be more severe and disorganized due to their extreme emotional dysregulation. For that reason, it is important that caregivers are aware that their parenting styles fundamentally shape the way their children perceive the world. Childhood abuse has lasting impacts into adulthood and shapes how we view material items and form lasting connections with our peers.

Some researchers believe that those with insecure attachments engage in anthropomorphism, which is when one gives human-like characteristics to inanimate objects. It is speculated that people do this to make up for the lack of relationships they had in their youth or what they are missing in the present day. Again, that is why it is difficult for those with hoarding disorder to throw these objects away, as it feels as though they are discarding a piece of themselves or are losing a loved one. This is no easy feat to maneuver and does not go away overnight, highlighting the importance of treatment options.

Treatment

Because hoarding disorder typically emerges early in life and worsens over time, early diagnosis is important. Prolonging a diagnosis and treatment can exacerbate symptoms and make it difficult to part with hoarded items. One form of psychotherapy treatment is cognitive behavioral therapy (CBT). CBT teaches patients how to discard items with less stress and learn techniques on how to be more organized, relaxed, and better at decision-making. It would also instruct them on how to resist the urge to hoard, establish better coping mechanisms, and improve their social abilities. Although CBT is effective, many patients still report being clinically impaired by their hoarding symptoms. In these situations, patients may be referred to see a psychiatrist. There are presently no medications prescribed to solely treat hoarding disorder. For that reason, patients are generally prescribed antidepressants and/or anti-anxiety medication.

Takeaway Message

If you or your loved one suspects you have hoarding disorder, please remember you are not alone. Know that you deserve to form healthy attachments and enjoy items without the need to hoard. Consider available treatments out there that are meant to assist you and provide you with better coping strategies. Hoarding still remains poorly understood by both the mental health community and the public, which perpetuates a great deal of misinformation and judgement. You can help to make that change by seeking mental health treatment and educating others about the reality of the disorder.

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