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Hoarding: Making Disorder an Official Disorder

/ Published September 14, 2012

Here too, I saw a nation of lost souls,
far more than were above: they strained their
chests against enormous weights, and with mad howls
rolled them at one another. Then in haste
they rolled them back, one party shouting out:
“Why do you hoard?” and the other: “Why do you waste?”
“Hoarding and squandering wasted all their light
and brought them screaming to this brawl of wraiths.
You need no words of mine to grasp their plight.”

From The Inferno by Dante Alighieri*

How Smith played a crucial role in the effort to recognize hoarding as a legitimate mental disorder

The history of hoarding stretches from before Dante to a Smith College psychology laboratory, and now the condition may be officially recognized as a legitimate mental disorder.

In the United States, “officially recognized” mental disorders are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is published by the American Psychiatric Association. The DSM details all mental disorders and their diagnostic criteria; the fifth edition will be published in spring 2013. Third-party payers (including public and private insurers) use the DSM to determine what conditions they will cover. Every psychiatrist, psychologist, and social worker in the United States and much of the world must be well versed in the DSM. While it is important that the DSM keep pace with advancements in the science of psychopathology, there is considerable pressure to maintain a stable set of disorders—so the DSM is revised only infrequently and new entries must meet rigorous criteria and research standards. The last major revision (DSM-4) occurred in 1994.

One of the biggest proposed additions for DSM-5 is a disorder characterized by the acquisition of and failure to get rid of possessions that clutter the home, creating significant problems. Although final decisions about inclusion are yet to be made, “hoarding disorder” is likely to survive as one of the newest mental conditions.

Randy Frost

The earliest reference to hoarding occurred in Dante Aligheri’s The Inferno, part of an epic poem written in the 14th century. The Inferno is a vision of hell consisting of nine circles, each worse than the one before. “Hoarders” were condemned to the fourth circle of hell where they were doomed to battle with “wasters” by crashing heavy stones against each other. The stones symbolized their attachment to physical wealth. Other references date back several centuries. The Russian novelist Gogol depicts a wealthy landowner named Plyuskin (Dead Souls, 1842). Plyuskin filled his manor with all sorts of trash. The locals called him the fisherman for his habit of “fishing” around the neighborhood for “an old sole, a bit of a peasant woman’s rag, an iron nail, a piece of broken earthenware.” In Russian psychiatry, “Plyuskin Syndrome” is used to describe someone with hoarding problems. Dickens’ Krook, a character in Bleak House (1862), was described as “possessed with documents” in a store where “everything seems to be bought and nothing sold.” Krook brings to mind a man in one of my treatment studies who spent more than 20 years buying things with the intention of selling them to make money. But in those 20 years, he sold none of the things he purchased.

A few psychologists figure in the early history of hoarding. William James described acquisitiveness as an instinct that helped to create one’s sense of identity. Erich Fromm believed that acquisition formed a core aspect of personality. He distinguished normal acquisition from a “hoarding orientation,” a type of “nonproductive” character in which people gain a sense of security from collecting and saving things.

The modern era of research on hoarding began in a seminar at Smith in 1991. The topic was obsessive-compulsive disorder (OCD), and one of the readings suggested that hoarding was a subtype of OCD. An observant student (Rachel Gross ’92) asked if there was any scientific research on hoarding. There was none, so she set out to conduct the first such study for her honors thesis. We placed an ad in the local papers seeking people who considered themselves to be packrats or chronic savers. To our surprise, we got more than 100 phone calls. The study provided the earliest picture of hoarding and phenomena associated with it. It also challenged some long-standing beliefs. For instance, it had been believed that hoarding involved the saving of worthless and worn-out things. But many of our participants had rooms packed with new items never out of their packages and clothes with labels still attached. A second misconception was that people who hoard were not sentimental about their possessions. In contrast, our participants showed powerful emotional attachments to the most mundane things. This study was also the first to find that hoarding runs in families. Since then, a number of genetic and twin studies have confirmed the familial connection. Interestingly, we found no support for our initial hypothesis that hoarding would be associated with a period of material deprivation early in life. The definition of hoarding we created for this study formed the basis for the hoarding disorder criteria proposed for the DSM.

A few years later, another Smith student (Tamara Hartl ’95) and I published the first theoretical account of hoarding based on evidence we had accumulated to that point in time. The model outlined three major dimensions of hoarding: excessive acquisition, difficulty discarding, and clutter. In the model, we proposed that hoarding resulted from a combination of information processing deficits, dysfunctional beliefs about and excessive emotional attachments to possessions, and extensive difficulties with organization. Publication of this study in 1996 marked a change in the trajectory of research on hoarding. It formed the backdrop for dozens of studies on the phenomena of hoarding and its etiology. In the early ’90s, Smith College was the only institution conducting research on hoarding. By early 2012, there were more than a dozen research laboratories around the world doing so.

Ongoing research includes genetics, epidemiology, phenomenology, neuroimaging, and treatment, as well as studies of how hoarding is expressed in children and elders. Some of this work is going on now at Smith, and current students are among those performing the research. Since 1993, more than two-dozen Smith students have co-authored scientific papers on hoarding. If the DSM-5 does indeed include hoarding among its listed disorders, these Smith students will have made a significant and lasting contribution toward helping those with a previously undiagnosed and unrecognized disorder that has a long and documented history.

Randy Frost is the Harold Edward and Elsa Siipola Israel Professor of Psychology, With co-author Gail Steketee, dean of Boston University's School of Social Work, he wrote Stuff: Compulsive Hoarding and the Meaning of Things. He serves on the Scientific Advisory Board of the International OCD Foundation.

* J. Ciradi, translator, 1954. Rutgers University Press, p. 73–74.