Hoarding disorder may negatively reinforce anxiety
Hoarding disorder (HD) is characterized by difficulty discarding objects, regardless of their actual value, due to the perceived need to save the items and the distress that stems from discarding them. Most individuals with hoarding also exhibit difficulties with excessive acquisition of objects, either passively (e.g., saving junk mail) or actively (e.g., buying goods). Hoarding results in the obstruction of living areas, impairment in functioning, and distress for both the individual and those around them. HD has a prevalence of about 1.5% to 5.8%, with higher prevalence among older adults compared to younger adults.
Anxiety in HD
Anxiety is a core feature in the cognitive-behavioral conceptualization of the development, maintenance, and treatment of HD. The anxiety in HD is usually associated with specific types of inaccurate beliefs about the meaning and usefulness of items or possessions (i.e., “saving beliefs”). These saving beliefs, which are outlined below, can cause individuals to experience anxiety and distress, especially when acquiring or attempting to discard possessions. When considering saving beliefs, it is important to recognize that unhelpful thinking patterns—hereafter called cognitive distortions—contribute to the maintenance of behaviors that drive saving, acquiring, and difficulty discarding.
Saving Beliefs and Cognitive Distortions in HD
Examples of common cognitive distortions related to saving beliefs in HD are presented below and are categorized by four main themes: emotional attachment, memory, control, and responsibility. The following is a non-exhaustive list of examples taken from the Saving Cognitions Inventory assessment measure (Steketee et al., 2003):
Emotional Attachment-Related Saving Beliefs
● “Losing this possession is like losing a friend.”
● “Throwing away this possession is like throwing away a part of me.”
● “This possession provides me with emotional comfort.”
Memory-Related Saving Beliefs
● “My memory is so bad I must leave this in sight, or I’ll forget about it.”
● “Saving this means I don’t have to rely on my memory.”
● “If I discard this without extracting all the important information from it, I will lose something.”
Control-Related Saving Beliefs
● “I like to maintain sole control over my things.”
● “It upsets me when someone throws something of mine away without my permission.”
● “No one has the right to touch my possessions.”
Responsibility-Related Saving Beliefs
● “If this possession may be of use to someone else, I am responsible for saving it for them.”
● “I am responsible for finding a use for this possession.”
● “I’m ashamed when I don’t have something like this when I need it.”
These saving beliefs may lead to certain compulsive behaviors. That is, in HD, saving beliefs are heavily linked to the negative reinforcement cycle of anxiety. When an individual with HD experiences a saving belief/cognitive distortion such as “Throwing away this possession is like throwing away a part of me,” the thought of having to discard this item brings on anxiety. When an individual saves an item rather than discards it in that circumstance, the anxiety experienced by the individual is immediately allayed in the moment. This experience of relief from anxiety, albeit temporary, is negatively reinforcing and therefore increases the behavior of saving items in the future. The person learns that by saving the possession instead of throwing it away, they are able to avoid and alleviate their anxiety. Thus, saving beliefs and related cognitive distortions can have an important impact on key aspects of HD. Here is an example of how this process may play out: “This item holds so much meaning, I couldn’t possibly part with it.” → heightened anxiety → “I will lose a part of myself if this item is gone.” → item is kept → temporary relief from anxiety → cycle of anxiety is exacerbated or maintained→ increased likelihood that items are saved in the future.
Anxiety in HD as a Co-Occurring Condition
While anxiety as an emotional response is a key part of the onset and maintenance of HD, anxiety disorders also commonly co-occur in individuals with HD. Studies have demonstrated comorbidity between HD and several anxiety disorders: Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, and Obsessive-Compulsive Disorder. There is also research to suggest that comorbid anxiety disorders (i.e., social anxiety) in HD may negatively impact treatment outcomes. Given that features of anxiety are core components of HD and comorbid anxiety disorders can also be present, anxiety phenomena should be directly addressed and targeted during treatment.
Treatment and Coping Skills for Hoarding
Primary treatment for HD is cognitive-behavioral therapy for HD (CBT for HD). Psychiatric medication, such as antidepressant medication, has shown some preliminary support for helping with hoarding, perhaps by addressing some of the underlying anxiety. Core elements of CBT for HD and related coping skills will be outlined next.
CBT for HD
● Exposure and Response Prevention (ERP) - Behavioral components of CBT for HD are centered around helping individuals become more used to the following:
○ Practicing tolerating any distress associated with decisions, instead of engaging in behaviors to alleviate anxiety (e.g., spontaneously throwing something away without going back to “undo” the decision).
○ Exposure to situations an individual may typically avoid, such as sorting through objects, in which one is encouraged to make a decision about discarding items (e.g., sorting through personal belongings with intent to de-clutter and discard hoarded items).
○ Exposure to situations in which an individual is encouraged to resist the urge to acquire (e.g., visiting thrift stores or flea markets or driving by/walking by free objects without bringing anything home).
● Cognitive Therapy - Cognitive components of CBT for HD are centered around identifying and challenging beliefs related to saving items.
○ Challenging saving cognitions involves examining the accuracy of saving beliefs/cognitive distortions and helping the individual come up with believable alternative thoughts.
■ “I can handle or problem-solve throwing out a meaningful possession.”
■ “Even if I need it in the future, if I don’t save it, I can just obtain that item again when I need it.”
■ “Even if discarding right now is giving me anxiety, making the decision to discard is most in line with my values and goals for the life I want to live.”
● Motivational Enhancement involves addressing the high level of treatment ambivalence expressed by individuals with hoarding by incorporating elements of cognitive interventions and behavioral techniques. These can be useful in maintaining motivation while addressing and treating HD.
○ Cognitive interventions challenge beliefs related to lack of motivation for changes (e.g., positive beliefs about behaviors or possessions):
■ “I don’t have a hoarding problem; I just don’t have the time to clean up the clutter.” → Alternative thought: “I have tried to set aside time to go through my things before, but I have struggled to make progress. I am curious about how my life could be different if I tried treatment, too.”
■ “I don’t want to change my house. My stuff makes me happy” → Alternative thought: “My family can’t come over if I keep all of this stuff. Seeing my family makes me happy, and I’ve really missed having people around.”
○ Behavioral interventions can likewise be useful in increasing motivation:
■ Opposite Action and Small Steps: “Even though starting this project feels overwhelming, I am going to commit to decluttering for 10 minutes. Doing something is better than doing nothing at all!”
■ Behavioral Activation: “I feel anxious about de-hoarding, but I know once I get started, I will feel better.”
■ Contingency Management: Putting in place a reward or incentive can help with decluttering or not acquiring more items.
● If 5 items are discarded, an individual could treat themselves to a non-material reward such as watching an episode of a favorite TV show.
● Research has also found success with monthly incentive payments contingent upon reduction in clutter (i.e., if in a given month an individual does not acquire any new items, they can be rewarded with a monetary gift).
■ Stimulus Control and Thoughtful Avoidance: Individuals can reduce/adjust triggers, set limits and create barriers to the behavior they are trying to reduce.
● Stimulus Control: An individual can make their debit/credit cards less accessible, delete stored card information on websites, or bring only limited cash to stores.
● Thoughtful Avoidance: Individuals can try refraining from aimlessly wandering around stores or markets and shopping with a list of needed items.
○ This may be considered in conjunction with exposure therapy (i.e., an individual may strive to avoid some stores to reduce acquisition cues, and they may also engage in efforts to visit notoriously triggering environments to practice not purchasing or acquiring any items in these locales).
■ Values Clarification and Pursuits: Individuals can also think further about what non-material things are important to them and their lives (i.e., values) and engage in related activities, which may enhance motivation for behavioral change/treatment seeking in individuals with HD. Values will be discussed further in the section below on acceptance and mindfulness-based interventions.
■ Family Training: Teaching family members about how to communicate more effectively, use a harm reduction approach, and reduce family accommodations may help increase motivation and desire for seeking treatment in their loved ones with hoarding.
● Executive Functioning Skill Building (i.e., skills designed to assist with cognitive functioning, such as those related to memory, attention, organizing, planning, sorting, time management, switching focus on tasks, inhibitory control, etc.)
○ Tips and tricks for decluttering if anxiety and executive functioning difficulties are getting in the way:
■ Make a plan ahead of time and follow it
■ Set limits (e.g., sort for a few hours rather than the whole day, limit areas of the home that one plans to sort through)
■ Sort items into three categories: keep, throw away, and donate
■ Cognitive rehabilitation (which can also be coupled with exposure therapy) draws on compensatory cognitive training principles and has been used to help with executive functioning difficulties exhibited by individuals with HD. Cognitive rehabilitation interventions teach individuals skills related to different aspects of executive functioning (e.g., planning, problem solving, memory, cognitive flexibility).
● Family Support
○ How Can Friends and Family of Individuals with HD Help?
■ It is unhelpful to force the individual to discard an item or tell them to “just throw it out,” or that “the item is useless; don't save it.” This equates to telling somebody who is feeling depressed or anxious to “just be happy” or “just don’t worry,” and these comments may feel invalidating and contribute to more anxiety and distress.
■ Validate distress and difficulties by saying “I can see that this item holds a lot of meaning for you and it can feel incredibly difficult to think about throwing it out,” or “I know that sorting through many items can feel overwhelming; how can I support you?”
■ If an individual is struggling with not obtaining more items or experiencing distress after discarding, engage with them and provide them with social support and connection.
● Therapist Support
○ Individuals with HD may also have a discussion with their therapist about CBT for HD, as research shows that specialized CBT may help improve treatment outcomes. Reasons people have for saving possessions are an important factor in treatment outcomes. Individuals with HD can ask their therapist to work with them directly on identifying and challenging beliefs they have related to saving possessions.
○ Even if a therapist may not have had formal or specialized training in HD protocols, providers with a CBT foundation can leverage additional HD resources to better help their clients with HD problems. For example, providers and individuals with HD can draw from resource texts such as Buried in Treasures, which is a guidebook that includes many of the aforementioned facts related to HD, as well as contains many research driven skills and interventions that can help with various HD related concerns.
○ Additionally, HD is associated with medical comorbidities, which can exacerbate hoarding and anxiety symptoms. A person with HD and their therapist can discuss this intersection between physical and mental health.
Acceptance and Mindfulness for HD
● Reminder of Values - Individuals with hoarding can remind themselves of other things they value (e.g., relationships/friendships) when feeling an urge to acquire more items or not discard possessions. Individuals with HD can remind themselves of the impact that HD may have on their relationships, which may help them resist the urge to engage in HD behaviors. For example, if a person values emotional connection with others, it might help for them to reflect on how time spent acquiring may be taking away from spending time with friends/family. Individuals can also make a four-part pros and cons list for buying/saving or discarding (i.e., pros of buying/saving items, cons of buying/saving items, pros of not buying/saving items, cons of not buying/saving items). This pros/cons list can help an individual determine which decision is most in line with their values and goals.
● Cognitive Defusion - Individuals with HD can practice observing and noticing their thoughts, emotions, or urges without engaging in them. When practicing cognitive defusion (i.e., distancing from one’s thoughts), it is important to resist urges to suppress, attach to, or assign meaning to thoughts. Instead, seeing thoughts as just words, letting them pass, and recognizing that having a thought or urge (e.g., to save or acquire) does not mean one must act on it, nor does it make the thought true.
● “Urge Surfing'' - Urges and emotions cannot last at a heightened state for prolonged periods of time and will naturally subside. Therefore, when individuals with HD are feeling intense urges to engage in HD behaviors, they could instead engage in another activity, particularly one that brings them a sense of mastery or accomplishment, or one that helps them regulate/manage their emotions instead.
Concluding Thoughts
In summary, anxiety symptoms and anxiety disorders are both important features of HD that can have a significant impact on symptom presentation and treatment outcomes for individuals with HD. It is hopeful to know however, that there are many available treatment options for individuals with HD, such as some of those named above (e.g., CBT, motivational interviewing, cognitive rehabilitation), that have demonstrated effectiveness for treating HD. Moreover, many researchers in the field of clinical psychology and social work are continuing to devote time and energy toward ongoing research on HD treatment. With such research endeavors, researchers hope to better understand mechanisms that contribute to beneficial outcomes and how best to use this information to continue to improve and bolster effectiveness of treatment. This article will hopefully point individuals with HD in the right direction and help guide individuals who are on the way to improving HD symptoms and enhancing quality of life. Additional information and resources can be found at https://hoarding.iocdf.org/
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Date of original publication: January 25, 2022
