How Does Hoarding Differ From Hoarding Disorder?

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From reality shows about obsessive compulsive disorder (OCD) and substance abuse, modern television programming has no shortage of content concerning mental health. One condition in particular has long been popular on our TV screens: compulsive hoarding. You’ll find “Hoarding: Buried Alive,” on TLC, “Hoarders” on A&E, “Britain’s Biggest Hoarders” on BBC One, and “Confessions: Animal Hoarding” on Animal Planet. Through their dramatic portrayals of this condition, these televisions show all beg the question: What is hoarding disorder — and how do we treat it?

Until recently, hoarding has been considered a subset of OCD. However, a growing body of evidence led the creators of the DSM-V to introduce hoarding disorder as a separate entity with its own distinct mechanisms. The differences between OCD and hoarding disorder are notable. They include a lack of awareness regarding the behavior’s real world impact, a decline in overall mental function, and an increased likelihood of having co-occurring mental health conditions such as personality disorders, anxiety, or depression — as well as certain genetic characteristics that clearly differentiate from OCD.

One study has been especially important in revealing these differences on a neurological level. The study was conducted by Dr. David Tolin and his colleagues at Yale University School of Medicine. They define the disorder as the “excessive acquisition of and inability to discard objects, resulting in debilitating clutter.” In the study, they tested a group of participants with hoarding disorder, a group with OCD, and a group judged to be mentally healthy. They asked each of the subjects to bring a collection of miscellaneous papers, including newspaper and junk mail.

While functional MRI brain scans were being conducted, they were presented with 50 pieces of their own items and 50 pieces of someone else’s, which were explicitly labeled as either their property or a stranger’s. For each item, they had to decide if they wanted to keep it or discard it, and it would immediately be shredded in front of them.

As expected, the hoarders chose to get rid of the least amount of their own items, and it took them longer to make a decision. Also interesting is the particular brain activity illustrated by the fMRIs — in those with hoarding disorder — was found in the anterior cingulate cortex (ACC), which is associated with detecting mistakes during uncertain conditions, and the mid- to anterior insula, which is linked to risk assessment and emotional decisions.

“The present findings of ACC and insula abnormality comport with emerging models of hoarding disorder that emphasize problems in decision-making processes that contribute to patients’ difficulty discarding items,” says the study’s authors.

In addition, the hoarders showed different brain activity from the other groups when presented with someone else’s papers — in that case their brain activity was much lower than normal. The study’s authors note that this is a pattern “reminiscent of that seen in patients with autism,” who often have rigid routines and obsessive behavior in a way that is similar to hoarders.

“The results of this study reflect an accelerating trend toward finding disturbed regulation of brain systems responsible for various dimensions of behavior that may cut across mental disorders as traditionally defined,” said Dr. Bruce Cuthbert, director of NIMH’s Division of Adult Translational Research.

The reality of addressing hoarding disorder is “complicated” — to say the least. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy have been shown to be mildly effective. Another possibility is transcranial magnetic stimulation (TMS), a therapy that uses non-invasive electrical stimulation of the brain. Ultimately, hoarding disorder is likely understudied — and much more research is needed before we can find a solution.

To inquire about treatment or help, please visit ocfoundation.org/hoarding.

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