HoardingmWhat Does it Mean?

Yuval Melamed, Henry Szor, Yoram Barak, and Avner Elizur

Collecting is a normal phenomenon, in contrast with pathological collecting, or hoarding. Is hoarding a

different phenomenon, or an extreme aspect existing on the same spectrum of behavior? How may these phenomena be understood when they are part of

everyone's repertoire on one hand, but may be symp- tomatic of a grave disturbance on the other hand. An overview and a discussion of hoarding are presented. Copyright© 1998by W.B. Sounders Company

C OLLECTING IS A NORMAL phenomenon commonly found in children, but also in

adults. Most children collect stamps, dolls, paper wrappers, or greeting cards. It is regarded as an enriching activity, which serves as a good leisure- time habit. The items collected are organized and orderly, placed in boxes, albums, drawers, etc. 1

Some authors regard collections as a form of transitional object 2 that helps the child transfer his involvement from his internal world to the external world.

Adults usually collect articles with monetary value. The habit demands time, but it may become an alternative to social life or a defense against loneliness.

Freud considered collecting, orderliness, and inability to part with useless articles as indications of anal character)

The fourth century B.C.E. Greek philosopher, Diogenes, prescribed a constricted and reclusive life, advocating a monastic, modest existence of asceticism, endurance, self-sufficiency, and accep- tance of poverty in the struggle against the hedonis- tic way of life existing at that time in Greece. "Diogenes' syndrome ''4,5 was the name given to such behavior when it accompanied the gradual deterioration in hygiene and social activity that comes with age. This designation, which is not appropriate to the description of pathological hoard- ing, illustrates the difficulty of defining the limit between normal and pathological behavior.

When a university student maintains notebooks from first grade, does this mean that he is pathologi- cally hoarding, unable to separate from things no longer useful, or that he has a sentimental affinity with the past? The phenomenon could be consid-

From the Yehuda Abarbanel Mental Health Center, Bat Yam, Israel.

Address reprint requests to Yuval Melamed, M.D., Yehuda Abarbanel Mental Health Center, 59100 Bat Yam, Israel.

Copyright © 1998 by W.B. Sounders Company 0010-440X/98/3906-0009503.00/0

ered a matter of degree, which may assessed according to a scale of severity of hoarding 6 behavior, as in other mental illnesses, such as depression or psychosis.

Hoarding is ordinarily hidden from others. The person is ashamed of his hoarding and rationalizes it. He may think "this may be needed some time." He may keep objects in his wallet "just in case he might need them." When the hoarding becomes more severe, the hoarder stops attempting to find excuses for his behavior. He becomes disorderly and lacks insight into the uselessness of the items he saves. He has no interest in help or treatment, and may react with hostility to any attempt to interfere with his activities.

Usually, those in the environment around the hoarder seek help--neighbors suffering from offen- sive odors emanating from the hoarder's apartment, worded relatives, or the family doctor who visits the home.

The pathological hoarder is disinterested in a visit from mental health personnel, as he does not consider himself a patient. The examiner might find himself feeling a needless intruder, with counter- transferendal reactions 7 and conflict as to the bound- aries between mental illness and social pursuits.

Pathological hoarding is a symptom common to several different disorders such as degeneration due to the aging processS; cognitive impairment and dementia9; character disorders1°; or at times it appears in an elderly person as the "end stage of a personality disorder. ''11 It may also be seen in obsessive-compulsive disorder, 12 schizophrenia, 13 anorexia nervosa, 14 and the rare Prader Willy syndrome.~5

More than indicating a diagnosis, hoarding seems to express social distress. It appears in lonely people, elderly persons who have undergone losses, and some who are Holocaust survivors.

DISCUSSION

The phenomenon of hoarding is interesting and involves many social agencies: welfare, health,

400 Comprehensive Psychiatry, Vol. 39, No. 6 (November/December), 1998: pp 400-402

HOARDING--WHAT DOES IT MEAN? 401

mental health, and the municipality. It is not a common phenomenon. In the catchment area of the psychiatric clinic, a moderately sized city of 200,000 residents, approximately five or six such cases come to the attention of the social services depart- ment during a year.

The biological explanatory model of hoarding includes its similarity to obsessive-compulsive be- havior. Hoarding is associated with higher scores on the Yale-Brown Obsessive-Compulsive Scale. 16 Hoarding was also associated with a higher level of general psychopathology, as measured by the Brief Symptom Inventory. 16

Repetitive behavior, such as hoarding, is some- times seen in schizophrenic patients. It is hypoth- esized that this reflects the failure of the hippocam- pus to modulate the impact of mesolimbic dopaminergic activity on the nucleus accumbens. 17

In a cognitive-behavioral model, hoarding is conceptualized as a multifaceted problem, includ- ing information-processing deficits, problems in forming emotional attachments, behavioral avoid- ance, and erroneous beliefs about the nature of possessions. 18

DEVELOPMENT AND POSSESSIONS

In the model of normal development, hoarding can be observed in children who collect things-- candy wrappers, rocks, etc. Adolescents may ex- press rebellion against their parents by forbidding them to arrange their belongings, as if they prefer to live with a mess in order to maintain a feeling of control over their possessions.

For many adults, it is difficult to part from old articles--an old piece of clothing that "maybe will be needed," or a piece of furniture that "it 's a shame to throw out." Each week, we face the weekly dilemma of whether or not to throw out the old newspapers. Throwing out means giving up something that will no longer exist; there are things we have not read and will never read. To save them brings immediate relief of conflict, at the price of denying reality; clearly, everything cannot be read.

Hoarding behavior was associated with decreased frequency of use of possessions and excessive concern about maintaining control over belongings.~9

The hoarder is expressing a symptom of problem- atic communication--It is an act performed alone, an intrapersonal matter, but the stench, dirt, blocked passages, etc, bring it to the attention of the neighbors.

It devolves that the person makes his/her exis- tence known to the environment. He/she informs the environment and him/herself that he/she has things, the house is full. The articles serve as a defense; warm objects that defend against a cold, alienated world that he/she experiences outside him/herself.

The Meaning of Time

The fact that hoarding is more common in old age evidences the meaningfulness of age and passing time. It may be that hoarding reflects preexisting personality characteristics carried to an extreme. However, it may be that the age of an object has a special meaning for the aged--- pictures, objects, and other mementoes represent his own past. They may symbolize relationships with others who are no longer living.

Collecting may express denial of aging--to collect things counters the process of depletion of internal assets, "being covered up" by objects against approaching death. He/she expresses the feeling that he/she still has a future in which he will need things.

The objects collected have meaning related to time. A newspaper is needed in the morning, the day after the news has occurred. The person who saves newspapers attempts to stop time; he stops the swiftness of life. Collecting junk "says" that things do not decay. Time does not decay objects nor people.

Regression and Chaos

Hoarding may signify regression, or may indi- cate an approaching disintegration. The person may be trying to organize and create order in his world to contend with inner chaos. The collecting outside of his body may express that inner order is deterio- rating.

In dementia, there is a general collapse of ego functioning, including the most basic, so that external aid must be provided. In pathological collecting, there is usually less self-neglect; not all ego functioning is impaired.

There are times when a patient in the psychogeri- attic ward collects things in his own bureau, creating a dilemma about whether or not to allow this.

The hoarding of the psychotic patient creates a vivid contrast with the empty, cold house that symbolizes the internal world of the schizophrenic patient. The hoarder's house is "full," but the

402 MELAMED ET AL

meaning remains the same, rather than being invisible, the internal chaos is externalized.

Intervention and Therapeutic Alliance

This disorder belongs to a similar category of social deviance as homelessness, which does not necessarily represent mental illness. In such devi- ance, there is an element of choice. Therapists do not actually know the diagnosis of the individuals involved, as they do not share their inner world with them.

The basic approach is individual, relating to the degree of illness and need for help of the person himself, not to the distress he causes the environ- ment. As a therapeutic contract usually fails to be established, both the therapist and the person are likely to feel uncomfortable about their meeting. The person may feel that an intrusion was forced

upon him, whereas the therapist is in conflict about refraining from action and allowing the person to remain living in filth, or forcibly intervening, which might not be needed. The missing piece of the puzzle is the inner world of the person. Without deep understanding of the behavior, it is difficult to help him; without a therapeutic contract, deep understanding cannot be achieved.

At times it is difficult to define the line differenti- ating between pathology and normal behavior.

Clearly, when the entire house is filled with stink- ing garbage, this is pathological; but what can be said of a collection of empty cans on the storage porch? In evaluating this, therapists should take into consideration the patient 's premorbid personal- ity, his/her basic mental disorder (if one exists), the subjective and objective suffering, the patient 's and family 's opinions, the level of danger to him/

herself, the interference or disturbance of other activities, and the development of the phenomenon over time.

We can assume that a Holocaust survivor, who is alive because he hoarded any available scrap of food, attaches special meaning to scraps of food, a meaning relating to his very existence, which is difficult for a healthy person to comprehend.

There is no simple solution to the therapeutic di lemma created by the hoarder. Therapists must use their clinical judgment to define the line between the "subthreshold symptoms" and "full disorder." Sometimes, hoarding may be a behavior that is unusual or embarrassing, but not one that requires intervention. Collaborative work with other therapists and community agencies might be use- ful. Deliberation and discussion of the subject are important for the therapist 's work when he con- fronts the possibil i ty of treatment for the person suffering from pathological hoarding.

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