the etiology of compulsive hoarding
DESCRIPTION
This paper presents an overview of Hoarding Disorder as reported in the DSM-V with a focus on attachment theory as a possible etiology for hoarding disorder.TRANSCRIPT
Running head: COMPULSIVE HOARDING 1
The Etiology of Compulsive Hoarding
Chad J. Ressler
Liberty University
COMPULSIVE HOARDING 2
Abstract
Compulsive hoarding, as a disorder, was not included in the DSM-IV-TR. However, bodies of
research on the differences between OCD and hoarding, such as resistance to treatment and the
ego-syntonic and ego-dystonic natures of the disorders resulted in the inclusion of hoarding as a
separate diagnostic entity in the DSM-V. Popularized by the A&E show Hoarders, this disorder
was thrust into the spotlight. Research and treatment of hoarding disorder is still in its nascent
stages, but already researchers and clinicians have formed and tested several hypotheses that
have greatly advanced the knowledge of hoarding disorder. To understand the etiology of this
disorder eludes researchers despite many theories being advanced. Properly understanding the
etiology of hoarding disorder will lead to more effective treatment approaches. This paper will
examine hoarding disorder as listed in the DSM-V as well as to put forth the assertion that
attachment theory may provide clues to the etiology of hoarding disorder.
COMPULSIVE HOARDING 3
The Etiology of Compulsive Hoarding
Decades ago, compulsive hoarding was thrust into the national spotlight with the death of
two brothers, Homer and Langley Colleyer, in March 1947. Having a home filled with 120 tons
of debris, Langley died when debris collapsed onto him as he was delivering a meal to his
paralyzed brother; subsequently, Homer died of starvation (Grisham & Barlow, 2005). Recently,
the issue of compulsive hoarding has become popularized by the A&E television show
Hoarders. Clinicians such as Robin Zasio, David Tolin, and Mark Pfeffer combine with expert
clean up specialists such as Matt Paxton and Corey Chalmers to treat and de-clutter the homes of
compulsive hoarders around the nation. Though a television show, the experiences of the
individuals as well as the ramifications of the disorder are quite real and quite significant.
Compulsive hoarding follows a chronic course in an individual’s life and often results not
only in significant impairment and danger for the hoarder, but the effects ripple into
communities. Grisham and Barlow (2005) noted that in a survey of local health departments
“hoarding complaints were reported by 64% of the health officers and sometimes resulted in
significant cost to the community” (p. 45). As such, a fuller understanding of the nature and
causes of compulsive hoarding is necessary. Though research on and empirical studies of
compulsive hoarding are in their nascent stages, several conclusions have been made and future
directions for research garnered. Specific cognitive-behavioral treatment plans have been
established, and success has been met when treating those with hoarding disorder. What is
lacking, however, is a solid etiology of hoarding disorder. Though many theories have been
advance to explain the occurrence of hoarding disorder, it is perhaps attachment theory that will
provide some answers. This paper will seek to explain compulsive hoarding through the
COMPULSIVE HOARDING 4
epistemology of attachment theory and proposes that the cause of hoarding disorder is the result
of not developing secure attachments early in life.
Diagnostic Criteria of Hoarding Disorder
Hoarding disorder is defined as “the acquisition of, and inability to discard, possessions
of limited value, to a degree that precludes appropriate use of living spaces and creates
significant distress or impairment in functioning” (Grisham & Barlow, 2005, p. 46). The
prevalence of hoarding disorder is estimated to be roughly 2-6% in the U.S. and Europe affecting
males and females (APA, 2013). The recent inclusion of hoarding disorder in the DSM-V
closely follows the above definition with its diagnostic criteria. The diagnostic criteria for
Hoarding Disorder 300.3 (F42) are as follows:
A) Persistent difficulty discarding or parting with possessions, regardless of their actual
value.
B) This difficulty is due to a perceived need to save the items and to distress associated
with discarding them.
C) The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas and substantially compromises their intended
use. If living areas are uncluttered, it is only because of the interventions of third
parties (e.g., family members, cleaners, authorities).
D) The hoarding causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning (including maintaining a safe
environment for self and others).
E) The hoarding is not attributable to another medical condition (e.g. brain injury,
cerebrovascular disease, Prader-Willi syndrome).
COMPULSIVE HOARDING 5
F) The hoarding is not better explained by the symptoms of another mental disorder
(e.g., obsessions in obsessive compulsive disorder, decreased energy in major
depressive disorder, delusions in schizophrenia or another psychotic disorder,
cognitive deficits in major neurocognitive disorder, restricted interests in autism
spectrum disorder) (APA, 2013, p. 247).
One key feature of hoarding disorder, which is included as a specifier when diagnosing,
is that of excessive acquisition. Gilliam and Tolin (2010) note that self-reports of hoarding
indicate that 85% of hoarders report excessive acquisition, yet family reports push the percentage
to 95%. Levels of insight are additional specifiers when diagnosing hoarding disorder. Good or
fair insight, poor insight, and absent insight or delusional beliefs comprise this section of
specifiers (APA, 2013). Maladaptive behavioral processes are believed to contribute to the
hoarder’s difficulty perceiving the hoard as pathological. Tolin (2011) suggests that hoarders
suffer deficits in their ability to both recognize and become motivated to change. Hoarders are
often unaware that their behavior has reached a level of pathology, sometimes even rationalizing
their hoarding behavior.
While Grisham and Barlow (2005) note that it is in line with evolutionary adaptive
behavior to acquire and store goods to ensure survival, this normal collecting behavior does not
produce the effects seen in hoarding disorder. Normal collecting behavior does not result in
significant distress when having to discard (Criterion B), nor does it manifest the extreme clutter
that is characteristic of hoarding disorder (Criterion C) (APA, 2013). It also logically follows
that normal collecting behavior would seek after items that hold some value, however, those with
hoarding disorder will not discard, nor part with items regardless of value (Criterion A). As
such, following from criteria A, B, and C is the clinically significant distress caused by the hoard
COMPULSIVE HOARDING 6
which often results in unsafe and unsanitary environments (Criterion D) (APA, 2013). The
DSM-V notes that other common features of hoarding disorder include: “indecisiveness,
perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and
distractibility” (APA, 2013, p. 249). These ancillary features of hoarding disorder are in line
with research that suggests four main deficits that contribute to hoarding: “information
processing, beliefs about and emotional attachments to possessions, and emotional stress and
avoidance behaviors that develop as a result” (Grisham & Barlow, 2005, p. 47).
Diagnostic Process
Diagnosing hoarding can be notoriously difficult because one cannot observe in a clinical
interview that an individual is a compulsive hoarder. Unless self-reported, often a diagnosis is a
result of the individual being treated due to the involvement of a third party (e.g., police, family
member, or social service worker). However, once confronted with the prospect of a hoarding
diagnosis, David Tolin (2011) states that “hoarding symptoms should be assessed thoroughly,
using validated and specific measures” (p. 524). Though a recent diagnostic entity, assessment
measures have been developed to assist in diagnosing hoarding disorder. Two tools for
diagnosing the disorder include the Saving Inventory—Revised and the Saving Cognitions
Inventory (Grisham & Barlow, 2005). The SI—R contains 23 items with subscales examining
discarding, excessive clutter, and compulsive acquisition, while the SCI has 24 items that
measure hoarding beliefs and emotional reactions (Grisham & Barlow, 2005). Both scales have
good reliability and discriminate and convergent validity. Other tools for assessing hoarding
disorder would include the Yale-Brown Obsessive Compulsive Scale (YBOCS) and the
Obsessive Compulsive Inventory (OCI). While useful, these scales are not able to assess certain
COMPULSIVE HOARDING 7
specific aspects of hoarding as well as to discriminate between normal collecting and compulsive
hoarding (Grisham & Barlow, 2005).
Causes of Hoarding Disorder
The exact cause of hoarding disorder is unknown. Researchers have proposed various
etiologies of hoarding disorder; however, more research is needed on this disorder before any
firm conclusions can be made. Jumping to any one conclusion risks committing fallacies in
scientific thinking; specifically, the fallacy of confusing various kinds of causes (Geisler &
Brooks, 1990). The efficient cause of hoarding disorder is what needs discovered. The efficient
cause is that which produces the effect. With efficient causes there can be both a primary cause
and a secondary cause (Geisler & Brooks, 1990). A secondary cause is “a subsidiary efficient
cause used by the primary cause to produce the effect. There is a primary cause for every event,
but there may not be a secondary cause” (Geisler & Brooks, 1990, p. 174). It is necessary then
to examine those causes which may provide an answer as to the efficient cause of hoarding
disorder.
Biological
Hoarding can be the result of genetic and biological causes. Medial prefrontal and
orbitofrontal cortex damage is but one known cause of the onset of new hoarding symptoms in
those without a prior disposition to hoard (Ayers, Saxena, Golshan, & Wetherell, 2009).
Hoarding behavior can also be the result of the condition known as Prader-Willi syndrome. This
genetic disorder is present in 1 in 15,000 live births. Individuals with this disorder are small in
stature and possess small extremeties as well as hypopigmentation and hypogonadism (Storch,
Rahman, Park, Reid, Murphy, & Lewin, 2011). Those with Prader-Willi syndrome have a
constant need for food and it is estimated that they consume three to six times more food than
COMPULSIVE HOARDING 8
normal. It is this constant need for food that can often lead to food hoarding behavior (Storch et
al., 2011). Tolin (2011) adds that Chromosome 14 has been linked to hoarding as well as noting
that “the majority of hoarders described a first degree relative as a “packrat”, compared with a
minority of OCD patients without hoarding symptoms” (p. 520).
Psychosocial
Various psychosocial theories have been advanced to explain the cause, not the onset, of
hoarding symptoms. Two main causes that need exploration are stressful life events and
attachment related issues. The reason for this is that this paper asserts that attachment related
issues are the primary efficient cause of hoarding disorder while stressful life events are the
secondary cause. However, often stressful life events are assumed to be the cause due to the fact
that “inaccurate initial recall of hoarding onset may have led to the idea that hoarding onset
occurred only after extreme life events, when in fact it may have been present all along” (Ayers,
Saxena, Golshan, & Wetherell, 2010, p. 147).
Stressful Life Events. A study conducted by Tolin, Meunier, Frost, and Steketee (2010)
examined the relationship of stressful life events to compulsive hoarding. While the authors of
the study noted that there was a link between SLEs and compulsive hoarding, the link remained
unclear. The study they conducted sought to examine age of onset and course of compulsive
hoarding, the incidence of SLEs among those with compulsive hoarding, as well as to determine
temporal associations (Tolin, et al., 2010). Among other predictions was that SLEs would be
more common among those with compulsive hoarding. The researchers were able to sample 751
individuals who self-reported compulsive hoarding; the diagnosis and severity were assessed
using the Hoarding Rating Scale—Self-Report. Onset was found to be between the ages of 11-20
with 70% of the sample reporting an onset before age 21, and for 548 individuals, or 73%,
COMPULSIVE HOARDING 9
hoarding was chronic (Tolin, et al., 2010). The researchers used five categories of SLE’s in this
study: loss of job or functioning, change in relationships, loss or damage to possessions,
interpersonal violence, and other (Tolin et al., 2010, p. 834). For purposes of this paper, the
researches findings showed a high incidence of SLE’s among hoarders with 76% reporting
having experienced interpersonal violence. Disruption of relationships was also noted as a
contributor to symptom onset or increase suggesting a link between attachment and hoarding.
The researchers did note some limitations with this study with the major limitation being
the heavy reliance on self-report measures as well as retrospective reports of SLE’s. As was
indicated previously, self-reports can suffer from recall problems which could cause researchers
to commit a post hoc, ergo propter hoc fallacy. A biased sample is another limitation of this
study. The sample was drawn from individuals who were seeking treatment, thus indicating that
the sample used was from the more severe end of the hoarding spectrum rather than surveying a
more representative mix of hoarders who may have suffered from a milder form (Tolin, et al.,
2010).
A study of geriatric patients found that of 18 participants only 2 reported what could be
considered an SLE (relocation and divorce) during an abrupt increase in symptoms with one
participant going from none to moderate (Ayers, Saxena, Golshan, &Wetherell, 2010). The
problem with their sample, however, was that it was too small to make any generalizations.
Moreover, the sample was taken strictly from elderly patients, suffering from the same if not
more exacerbated self-report and recall problems as the aforementioned study. However,
similarities between the two studies should be noted. Age of onset for seven of the participants
was between 11-20 years of age with one reporting symptom onset at age 4. Participants also
COMPULSIVE HOARDING 10
reported that severity increased over the life span. In nearly every subject hoarding symptoms
originated in childhood and adolescence and increased with age (Ayer, et al., 2010).
Attachment Issues. Barlow and Grisham (2005) write, “correlations of attachment with
measures of hoarding suggest a positive association between anxious/ambivalent attachment and
hoarding, attachment to possessions, and saving cognitions” (p. 48). A unique study conducted
by Kellet, Greenhalgh, Beail, and Ridgway (2010) used an interpretative phenomenological
analysis to assess the experience of compulsive hoarders. Interpretative phenomenological
analysis is “particularly concerned with the exploration of unique individual experiences, rather
than seeking to make general or universal statements (Kellet, et al., 2010, p. 144). A sample of
11 individuals (3 male, 8 females) participated in this experiment which sought to examine the
lived experiences of hoarders (Kellet, et al., 2010). Interviews lasted between 1 and 1.5 hours
with tapes transcribed verbatim. Results of the study indicated that, again, hoarding behaviors
developed during childhood with individuals reporting complex relationships with the
possessions, including emotional attachment. Researchers noted an important subtheme that
emerged, that of individuals anthropomorphizing possessions and a “sense of fusion between the
hoarder and their possessions” (Kellet, et al., 2010, p. 146). One major drawback of this study
was that the authors noted that some of the individuals may not have met the definition of
compulsive hoarding and no clinical interviews or established tools for assessing hoarding were
used. However, the authors were able to visit 10 of 11 homes in the study (Kellet, et al., 2010).
As has been established, the onset of compulsive hoarding starts in childhood. It is
logical then to assume that stressful life events, while not a primary efficient cause, are a
subsidiary efficient cause. The reason for this is that children will first form their attachment
style and then filter all experiences through this cognitive schema. A stressful life event simply
COMPULSIVE HOARDING 11
reinforces their already insecure attachment style leading to exacerbation of their symptoms
whether it be onset of hoarding or an increase in the severity of hoarding.
Attachment is a trait as well as a relationship construct as has been pointed out by Hazan
and Shaver (1994). An insecure attachment style describes the quality of the relationship;
however, the experiences and features of that relationship are then represented in the mind and
behavior of the infant (Hazan & Shaver, 1994). If the infant cannot form a secure attachment
style to the primary caregiver then it is possible that a fantasy surrogate will be formed in order
to form a secure base. Hazan and Shaver (1994) write, “humans normally become attached to
multiple individuals and even to inanimate objects” (p. 71). It is thus logically possible that the
hoarder has formed a secure attachment with his or her possessions which may explain why
hoarding disorder is so resistant to both pharamacological treatment and psychotherapy.
Though his work was geared toward an epistemology of sexual addiction, the work of
Richard Leedes (1999) may be able to be extrapolated to explain the behavior of compulsive
hoarders. Leedes (1999) proposed that individuals will demonstrate differing responses to
separation and proximity seeking depending on their attachment style. When a person is unable
to form attachment relationships in reality, they will turn to fantasy in order to form a secure
base. Interestingly, in the aforementioned study by Ayers, Saxena, Golshan, and Wetherell
(2010), only 22% of their participants were married while 2005 Census data showed that 75.5%
of men and 54% of women were married. Infants form an Internal Working Model (IWM)
which allows them to predict the “responsiveness of a caregiver by past availability” (Leedes,
1999, p. 300). The primary caregiver then serves as the model from which all other interpersonal
relationships and evaluations of self-worth will be evaluated. Lest the author risk the charge of
committing the logical fallacy of hasty generalization, it should be noted that this is not to say
COMPULSIVE HOARDING 12
that attachment styles cannot or will not change, however, they are extremely resistant to change.
IWM’s that continue to be reinforced in infancy, childhood, and adolescence are extremely
difficult, though not impossible, to change (Hazan & Shaver, 1994). Leedes (1999) writes:
I propose that some insecure children become attached to a sexualized objectification
during a separate developmental phase, i.e., eroticization, at about 3-5 years old. It is
fundamental that the ethological purpose of the attachment system is to find a releasing
stimulus in the environment which creates warmth, bonding, and security (p. 300).
Though Leedes (1999) was examining attachment in relation to sexualized
objectification, it follows that since humans can form attachments with inanimate objects that
compulsive hoarders become attached to possessions at around 3-5 years old. This primary
efficient cause, while sufficient to produce hoarding in and of itself, can be combined with a
subsidiary cause, a stressful life event, to either induce or worsen symptoms.
Differential Diagnosis
When assessing for a differential diagnosis, it should be noted that the DSM-V reports
that as many as 75% of individuals with hoarding disorder also have a comorbid mood or anxiety
disorder (APA, 2013). Gilliam and Tolin (2010) noted that the percentage of those with hoarding
disorder and a comorbid Axis I and Axis II disorder to be 92%. More importantly, 20% of
individuals with hoarding disorder also meet the criteria for OCD (APA, 2013). Thus, several
factors need to be examined prior to diagnosing hoarding disorder.
Obsessive-Compulsive Disorder
Once a sub-type of OCD, hoarding disorder has now been listed as a separate diagnostic
entity, though individuals with OCD can present with hoarding symptoms. When examining an
individual for hoarding disorder, one should look for the presence of other OCD symptoms as
COMPULSIVE HOARDING 13
82% of those with hoarding disorder will not meet criteria for other forms of OCD (Tolin, 2011).
OCD patients who hoard possess an ego-dystonic quality of obsessions and compulsions in that
they recognize their illogicity. However, the behavior of the compulsive hoarder has an ego-
syntonic quality in that they rarely see that their thoughts and actions are illogical (Gilliam &
Tolin, 2010).
Medical Conditions
Hoarding disorder is not to be diagnosed if the presence of Prader-Willi syndrome is
suspected, nor should it be diagnosed if the hoarding is determined to be the result of traumatic
brain injury, surgical treatment damage, or cerebrovascular disease (APA, 2013). Organic brain
illness such as focal lesions of the telencepahalon and those suffering from dementia would also
be excluded from a diagnosis of hoarding disorder (Tolin, 2011). The presence of hoarding
behavior in these individuals must not be present prior to the onset of hoarding symptoms (APA,
2013).
Other Conditions
Hoarding disorder should also not be diagnosed if it results from the fatigue, lack of
motivation and energy, and psychomotor retardation of a major depressive disorder. Also, if
hoarding disorder is the direct result of an autism spectrum disorder or intellectual disability it
should not be diagnosed. Those with Alzheimer’s disease or other degenerative disorders should
not be given the diagnosis of hoarding disorder (APA, 2013).
Treatment of Hoarding Disorder
Steketee, Frost, and Kyrios (2003) write, “increasing empirical and anecdotal evidence
argues that hoarders report greater levels of emotional attachment to their possessions compared
to non-hoarders…these attachments are associated with beliefs about the meaning and
COMPULSIVE HOARDING 14
importance of possessions in the lives of hoarders” (p. 464). Tolin (2011) asserts that CBT
should be primary in the treatment of hoarding disorder. However, as has been noted, hoarding
disorder is notoriously resistant to treatment. Perhaps Rational Emotive Behavior Therapy
(REBT), developed by Albert Ellis, would serve best in the treatment of hoarding disorder. Ellis
maintained that if one could make a significant philosophical change and modify musturbatory
attitude, then that individual could change their self-defeating behavior and emotion (Murdock,
2009). If one assumes that attachment related issues are the cause of hoarding disorder, then
REBT style disputations may serve to effectively challenge the client’s thinking. Whether
inculcated in an individual through family or their own thinking process, many individuals
harbor irrational beliefs that result in unhealthy emotions and behaviors (Ellis & Ellis, 2011).
One main irrational belief is that an individual must have love and approval from significant
others. The hoarder, having formed an insecure attachment style, cannot unconditionally accept
him or herself because their IWM has reinforced that they are unworthy of love or approval.
One must then logically dispute this idea, and teach the client unconditional self-acceptance.
Another irrational belief that one would want to dispute with a hoarder is the belief that if
something once strongly affected one’s life that it should continue to affect it (Ellis & Ellis,
2011). This is opposed to rationality, whereby one should not be overly attached to past
circumstances, but rather accept the events.
For those suffering for hoarding disorder the goals and methods of treatment should be no
different. The goals of REBT are “ (a) identifying irrational beliefs and seeing how they cause
and maintain unhappiness and disturbance, (b) disputing them, and (c) rethinking and
reverbalizing beliefs into rational, self-helping, and life-enhancing forms” (Ellis & Ellis, 2011, p.
20). As Steketee, Frost, and Kyrios (2003) note, evidence does suggest that those suffering from
COMPULSIVE HOARDING 15
hoarding disorder do have difficulty in forming and maintaining relationships with others. In an
effort to achieve the goals of REBT with the hoarder, the “as-if” technique may prove beneficial.
The hoarder would be instructed to act as if they did not have trouble forming relationships with
others. They would be asked to try and initiate contact with someone they are acquainted with,
but perhaps do not know well. Homework assignments for this could increase in difficulty to
where they are to try and arrange to meet and spend time with this other person.
Biblical Worldview of Hoarding Disorder
Filtering hoarding disorder through a Christian epistemology can be an arduous task as
the exact cause of the disorder remains unknown. However, assuming the conclusion that
attachment related issues are the cause of hoarding disorder, one must then look to human beings
created in the image of God. REBT is designed to teach a person unconditional self and other
acceptance which is commensurate with how we are to view ourselves and others as made in the
image of God. Wayne Grudem (1999) writes, “the Hebrew word for “image” (tselem) and the
Hebrew word for “likeness” (demut) refer to something that is similar but not identical to the
thing it represents or is an “image” of” (p. 189). As such, we are to find our joy in knowing God
and recognizing that our chief end in life is to glorify Him (Grudem, 1999). Those with hoarding
disorder were not able to form a secure base with their primary caregiver resulting in an IWM
that tells them they are unworthy of love or responsiveness. This irrational belief can be
challenged by turning to the inerrant word of God which states in Lamentations 3:22-23, “The
Lord’s loving kindnesses indeed never cease, for His compassions never fail. They are new every
morning; Great is Your faithfulness” (NASB).
Jeremiah was a great prophet of God, but suffered greatly in his role as one of God’s
messengers. Drawing from the example of Jeremiah one can see many things that apply to
COMPULSIVE HOARDING 16
individuals’ lives today. Jeremiah was suffering emotional pain, and it is often said that
emotional pain is far worse than physical pain. Emotional pain can be dominating as one feels
things like anger, anxiety, depression, and self-hate. For those who have experienced this kind
of emotional pain, it is very difficult not to let it dominate.
Most of the time, people assume that what happens to them determines whether they live
a good life or not. As Backus and Chapian (2000) write, “It is not, however, events either past or
present which make us feel the way we feel, but our interpretation of those events…Our feelings
are caused by what we tell ourselves about our circumstances…” (p. 17). So, the problem is that
it is not what happens that causes the kind of emotionally dominating pain suffered by those with
hoarding disorder, but it is what they tell themselves about what happened. In Jeremiah’s case
he had many terrible things happen to him and he began to tell himself that what happened to
him deprived him of peace, that he had forgotten what prosperity is, and that all he had hoped
from the Lord was gone. He began to tell himself misbeliefs about his circumstances, and these
misbeliefs come directly from the evil one.
As we approach the treatment of hoarding disorder from a biblical perspective, one must
facilitate an atmosphere of empathy passing no judgment on the hoarder. Most likely, they have
experienced this in some form or another from family or peers and this will only serve to alienate
them. A level of trust needs to be cultivated within the context of the therapeutic relationship
whereby the client will see the therapist as a competent, loyal guide with respect to cognitive
restructuring. Logical disputation will be much more effective when the client trusts the
therapist, and homework assignment compliance would be assumed to high. Lastly, as all
human beings are made in the image of God, therapist must unconditionally accept the hoarder
thereby reinforcing the notion that the hoarder can unconditionally accept themself.
COMPULSIVE HOARDING 17
Conclusion
Hoarding disorder is a chronic and debilitating condition that not only affects the hoarder,
but results in substantial losses to friends, family, and, in some cases, the community. With its
inclusion in the DSM-V, hoarding disorder will continue to be robustly researched in order to
determine its causes. Biological and psychosocial factors have been advanced, and stressful life
events provide a good roadmap in understanding the disorder. However, SLE’s are only a
subsidiary efficient cause. The role that insecure attachment style plays in the development of
hoarding disorder perhaps provides answers as to its etiology. An individual who is unable to
form a secure bond with a primary caregiver must turn to something else, human or not, in order
to feel secure. Human beings are highly adaptable and can turn those attachment needs to
inanimate objects in order to provide themselves with such a basic need as security. Treatment
for hoarding disorder is still being refined, and this disorder has proven to be highly resistant to
even cognitive-behavioral therapy. While specific CBT techniques have been developed to deal
with hoarding disorder, initial results are mixed. By understanding its etiology, counselors will
have a better understanding of the tools they need to properly treat individuals who suffer from
this. REBT provides a very strong, well-established, and empirically verified therapeutic
technique to deal with compulsive hoarding. If attachment related issues are at the core of
hoarding disorder, then specific REBT techniques can more properly be utilized in disputing the
basis for the individual’s irrational beliefs. Fostering a sense of unconditional self-acceptance in
those who suffer from hoarding disorder as well as teaching them how to form and maintain
relationships with others may be the keys to helping individuals with hoarding disorder.
Researchers and counselors have a challenge on their hands in dealing with hoarding disorder,
but the body of research already produced shows promising results.
COMPULSIVE HOARDING 18
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. L. (2010). Age at onset and clinical
features of late life compulsive hoarding. International Journal of Geriatric
Psychiatry, 25, 142-149. doi:10.1002/gps.2310
Backus, W., & Chapian, M. (2000). Telling yourself the truth. Minneapolis, Minn: Bethany
Fellowship.
Ellis, A., & Joffe-Ellis, D. (2011). Rational emotive behavior therapy. Washington, DC:
American Psychological Association.
Geisler, N. L., & Brooks, R. M. (1990). Come, let us reason: An introduction to logical
thinking. Grand Rapids, Mich: Baker Book House.
Gilliam, C. M., & Tolin, D. F. (2010). Compulsive hoarding. Bulletin of The Menninger
Clinic, 74(2), 93-121. doi:10.1521/bumc.2010.74.2.93
Grisham, J. R., & Barlow, D. H. (2005). Compulsive Hoarding: Current Research and
Theory. Journal of Psychopathology and Behavioral Assessment, 27(1), 45-52.
doi:10.1007/s10862-005-3265-z
Grudem, W. A. (1999). Bible doctrine: Essential teachings of the Christian faith. J.
Purswell (Ed.). Grand Rapids, Mich: Zondervan.
Hazan, C., & Shaver, P. (1994). Deeper Into Attachment Theory. Psychological Inquiry,
5(1), 68-79. doi:10.1207/s15327965pli0501_15
Kellett, S., Greenhalgh, R., Beail, N., & Ridgway, N. (2010). Compulsive Hoarding: An
Interpretative Phenomenological Analysis. Behavioural and Cognitive
Psychotherapy, 38, 141-155. doi:10.1017/S1352465809990622
COMPULSIVE HOARDING 19
Leedes, R. (1999). Theory and praxis: A heuristic for describing, evaluating, and intervening
on sexual desire disorders when sexual expression interferes with humanistic
expression. Sexual Addiction & Compulsivity, 6, 289-310.
doi:10.1080/10720169908400199
Murdock, N. L. (2009). Theories of counseling and psychotherapy: A case approach
(2nd ed.). Upper Saddle River, N.J: Merrill/Prentice Hall.
Steketee, G., Frost, R. O., & Kyrios, M. (2003). Cognitive Aspects of Compulsive Hoarding.
Cognitive Therapy and Research, 27(4), 463-479. doi:10.1023/A:1025428631552
Storch, E., Rahman, O., Park, J., Reid, J., Murphy, T., & Lewin, A. (2011). Compulsive
hoarding in children. Journal of Clinical Psychology: In Session, 67(5), 507-516.
doi:10.1002/jclp.20794
Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2010). Course of compulsive
hoarding and its relationship to life events. Depression and Anxiety, 27, 829-838.
doi:10.1002/da.20684
Tolin, D. (2011). Understanding and treating hoarding: A biopsychosocial perspective.
Journal of Clinical Psychology: In Session, 67(5), 517-526. doi:10.1002/jclp.20795