Kaitlin Luna: Hello and welcome to Speaking of Psychology, a bi-weekly podcast from the American Psychological Association that explores the connections between Psychological Science and everyday life. I'm your host, Kaitlin Luna. You've probably seen it on TV shows about hoarding. People living in homes so full of clutter or mess that walkways are blocked, doors cannot be opened, and full rooms are unusable. In some cases, their homes may even be on the brink of becoming condemned. Despite the show's popularity, hoarding disorder itself is complex and hard to treat. It was only given its own official diagnostic criteria in the Diagnostic and Statistical Manual, commonly known as the DSM, in 2013.
There's still a lot about hoarding disorder that is not well understood, but we do know that it causes a lot of pain and suffering for the people who have hoarding disorder and their loved ones. Here to help explain more about hoarding, what treatment options are available, and how people can take the first steps to clearing the clutter is Dr. Julie Pike, a clinical psychologist and private practice who treats people with hoarding disorder. She has appeared on the Discovery TLC show “Hoarding: Buried Alive.” Welcome, Dr. Pike.
Dr. Julie Pike: Thanks for having me, Kaitlin. I appreciate it.
Luna: We're really happy to have you here on the show today. I think it's helpful to first start off by defining what hoarding is and what it is not. Can you give us a brief explanation of what constitutes hoarding disorder?
Pike: Hoarding disorder is a phenomenon where people collect so much stuff, so to speak, that they can't use their home or their space for its intended purpose. For example, we've all seen pictures and videos of homes that are so cluttered that can move to cars or garages or storage spaces. The important distinction is that we look for what we call impairment, meaning that it's causing some kind of problem in the person's life. For example, things can become a safety hazard. More frequently. it's that loved ones in the person with hoarding disorders lives are really upset about the clutter, and all of the things, and the difficulty in getting rid of things. Whenever we're making a distinction of what is a disorder and what is not, a disorder has to cause a clinical impairment. Meaning it has to be damaging in some aspect of life.
Luna: Okay. That's the tipping point between a home that's just messy or overly cluttered to being a hoarding home. Right?
Pike: Exactly right. Really, what we say in the APA DSM, the Diagnostic and Statistical Manual of Disorders, is that it has to cause distress, but it's more likely, in my experience, that hoarding causes impairment, so we say distress or impairment. People who hoard usually hoard things that don't have a lot of value to most people. They buy in bulk. They acquire so many things that people can't move through their homes. They can cause a fire hazard or safety hazard. In extreme cases, people will lose their homes, or they will lose their children. It can really become very dire for people.
Luna: Absolutely. Why do people with hoarding disorder have such a hard time letting things go? As you mentioned a lot of times it's things that to someone without hoarding disorder, to the general population, it's something that doesn't have value. Maybe it's paper. Maybe it's old that just sit in a room and not on display or something. What is it about someone's brain and how they appreciate and process information and when they're looking at something, they attach so much meaning to it, where others see it as trash basically?
Pike: I think it's a great question. One of the things that we know is that there is a chromosomal abnormality on chromosome 14 which is typically associated with information processing and decision-making. That abnormality is suggested to play a part here. I think it's always important for people, especially loved ones who have someone who hoards in their lives to hear that this is not volitional behavior, this is not someone being lazy, this is a genetic. There's a high genetic component. 80% of people who have hoarding disorder have a first-degree relative. It's a very, very high heritability index is what we call that.
You're very likely to have a first-degree relative if you have hoarding disorder, who also has it. Then the chromosomal component of chromosome 14 is really intriguing too. It's also very highly related to other disorders such as ADHD and occasionally, OCD, but more frequently other anxiety or depressive disorders. A lot of people that I've treated with Hoarding Disorder have a very difficult time staying focused and being linear.
Luna: When you talk about-- We just mentioned about being comorbid. Hoarding disorder in addition to something like depression or anxiety, I think it's important for our listeners to understand that someone with a hoarding disorder is probably suffering in some other way. As a psychologist, how do you treat that? Are you treating both at the same time? Are you focusing on what's leading to the hoarding disorder?
Pike: Good question. I treat both. For example, in my experience, it is very likely especially for people with later onset hoarding to have a trauma history, which is also important to think about. It's also, in my experience, this is just anecdotal, that people may have addictions to deal with. It's really important that we treat this holistically meaning that we look at all aspects that are getting in the way of someone's hoarding problem.
Luna: Also, I want to talk about, I know you and I spoke earlier about this, how do you define hoarding as opposed to being a collector? What are the differences? Some people might say, "I have a lot of stuff, but I collect antique China," for example. Where does it go from being a collector to a hoarder?
Pike: Collectors are usually very proud. They usually very carefully display, and curate and they usually want to show you their collections, whereas people who hoard, it's not that organized. It's not usually beautifully displayed, it's never beautifully displayed. There's usually a lot of secrecy and shame around hoarding. People hoard in private. Part of the reason for that is they are frequently given the feedback that their stuff is not valuable. What people need to understand is their stuff is precious to them.
Luna: Why do you think there's a lot of shame around hoarding? If you watch the programs about hoarding, you can see it, you can feel it. You can feel how so many people on this show, there's this sense of shame. Maybe it's because they're being confronted by family members and by people trying to intervene about the disorder that's causing chaos in their lives. What is it about hoarding disorder that might cause a person to feel a deep sense of shame?
Pike: I think most of the shame comes from being told frequently that their stuff is not worthwhile, and why can't you just get rid of this and it's not that hard and focus and just try a little harder. Whereas, the person who hoards it's not easy for them in any way. Their stuff is precious to them. It feels really good to acquire things. We get essentially a shot of dopamine and other feel-good chemicals every time we get something that we view as precious. We watch the brains of hoarders light up, when we're looking at scans when they acquire something, it feels great.
If you look at the opposite, it feels awful to get rid of things that you deem sacred. It feels awful to try to focus and become overwhelmed and have a really hard time getting rid of things.
My perception is that people in the outside world usually shame people who have hoarding disorder, sometimes they mean it and more frequently, they don't, they're well-intentioned. I've certainly had many cases where loved ones go in the house, when the person with hoarding disorder is not there and get rid of their stuff. It's constantly having to keep their stuff safe from the outside world.
Luna: What can I do to someone if someone came into their home and got rid of their possessions? I imagine that's not the best way to go about helping someone who has hoarding disorder.
Pike: Getting rid of someone's stuff against their will is one of the worst things you can do. We've actually had cases where people commit suicide. I'm not trying to suggest that that is a common response, but it has happened. It just causes a further breach of trust. It makes the person more dug in, because it now creates a fight dynamic. The reality is that if someone has hoarding disorder, even if you clean out every single thing in their house, they will fill that space again, it's only a matter of time. They tend to fill every space that they are allowed to. I've seen many people who filled their children's rooms because they're running out of space, they will buy new storage units. The analogy I always make is that getting rid of someone's stuff against their will is like trying to pour out alcohol if someone is an alcoholic, they're just going to go buy more.
Luna: You have to be ready to make a change if you want to see more change.
Pike: Yes.
Luna: You said that the person who's a hoarder doesn't usually see their behavior as a problem, so going along with what we just talked about, but everyone else in their life can easily walk in and say, "Well, we have a problem or situation on our hands." Why do you think that is? Is it because they assign such sentimental or deep value to the possessions they own?
Pike: Exactly, right. When we're looking at diagnosis, we're also as psychologists has to make a distinction in terms of the level of insight the person has around the problem. I would tell you, the majority of the people I've worked with, I've probably worked on around 400 cases in various ways and the majority of the people I see, I would say around 80% have poor insight into the problem, which it sounds very judgmental, it's not meant to be it.
What that means is that the person does not deem the hoarding a problem. They think the problem is that their loved ones have a problem with it, or government officials have a problem with it. Part of that is because their stuff is treasured and precious to them. I have had people who hoard who say, "I feel physical pain looking at an empty space, it seems so wrong to me.
Luna: Yes, that's why I do want to touch on too, it just seems like when you talk about if you forcibly remove things from a hoarder's home and did not address the underlying issues that the aftermath can be even worse than the original situation. It just seems like a lot of sense. People feel a sense of comfort when they have their spaces filled up and that an empty space might make them feel worried, scared and secure. Is that on point?
Pike: That's exactly on point. I think hoarding is so complex given that there's a genetic component, there's chromosomal, there's so much environmental pieces going on here, especially if you have a first-degree relative, chances are really good that you grew up in a home where there was hoarding, so that's probably also comfortable. We also know that people who have trauma often feel safer surrounded by their stuff. I've also talked to people where they say, "I just feel this emptiness and when I have my stuff around me, that void is filled temporarily at least."
Luna: Yes, that's really interesting to think about from that perspective, that it gives someone comfort. As I mentioned in the intro, that hoarding was only given its own diagnostic criteria in the DSM in 2013, but in the past, it was considered a subtype of obsessive-compulsive disorder. Has the fact that it's been given its own distinctive criteria benefited people with hoarding disorder? Why do you think it took so long for it to get its own place in the DSM?
Pike: Well, I think it's taken so long because it's been so poorly understood, and it's still not really well understood. Most of our research started around 1993, which is very late, but we have hundreds of years of documented instances of hoarding colloquially, and there's a reference in Dante to someone who hoards, very long time ago. The first task force in America to be set up was in Virginia in 1989, they formed a Hoarding Task Force. This is not something that has gone unnoticed.
I think what has really been beneficial with both the diagnosis and with the television shows is that people can give it a name, that to me, the point of making a diagnosis is not to label or stigmatize someone or pathologize them. The point of making a diagnosis is to inform treatment and increase understanding and empathy. I think really, the benefit of having a discrete diagnosis now is that we know what it is, we can explain it to people, we can perhaps even more importantly, explain it to loved ones and we can work on treatment methods.
Luna: I imagine showing hoarding on TV can be both detrimental and beneficial because, on one hand, you have people in the programs who are being helped, and you have people at home who see it and if they're a hoarder themselves or have someone in their life who's a hoarder, they may feel relieved that they're not alone and that there is help out there.
However, the people in the show, they could be subject to, like you said, being, I don't know, you know, stigmatized a little bit or ridiculed or disorder could be trivialized because I think it's so common for people to make a casual comment when they have a cluttered to home say, "I'm such a hoarder." Similar along lines of OCD, where people casually throw that statement around, but in fact they're likely probably don't have that disorder, and that there are people out there who do and it's very detrimental to their life. With all this shared, and given your experience on the TV programs or with clients in private practice, what are your thoughts? Do you think it stigmatizes hoarding? Do you think it's helped more people get help out there?
Pike: I think it's done both and I think it's a double-edged sword. The intended purpose of the show that I was on Hoarding: Buried Alive on Discovery, or TLC, was to look at the phenomenon of hoarding. and more importantly, to investigate effective psychological treatments. I think the shows have brought awareness which is incredibly important. I still daily get emails for help and email saying, "Thank you for showing us. I didn't know this had a name. My aunt has it. My mom has it. I didn't realize I grew up in a home and that's what it was."
I think it does help validate people that this is a known entity, we know what it is, 2.5%, or % to 3% of people suffer from it. You can imagine how many loved ones that reaches and affects. I think the flip side of that is, some people watch to relate and to learn, and other people watch to compare. I have so many people also come up to me and say, "I'm so glad I'm not a hoarder. I can never be like that. Let me tell you about how clean my house is."
I understand that as well. I think it's a difficult thing to understand. I get it. I think anything that we find difficult to understand or to relate to we have difficulty reaching empathy or compassion. I do hear a lot of jokes in popular media, in social media about hoarders and I don't love that word itself. I prefer to say people with hoarding disorder or people who hoard. It sounds like a slur to me. I think it has taken on that flavor.
Luna: It is really important, as you mentioned, to say people who have as opposed to hoarders. I think that's really important is how we describe people even in the same vein of addiction too because I've done a podcast about opioid addiction earlier in the summer this year, and I talked about people with addiction as opposed to addicts. How we talk about people with a disorder is really important.
Pike: Absolutely. I was funny, I was just thinking the same thing that labeling someone an addict or an alcoholic, suggests that that's all there is and then we can just put them in a box. People are so much more complex than that. I think if people are struggling with empathy and connection to hoarding or to addiction, because they look baffling from the outside, and I often make a comparison between addiction and hoarding. They don't have the same brain pathways or mechanisms, but I think they are equally baffling to the public and perhaps to the person who has the problem. I think we all know what it's like to feel ashamed. We all know what it's like to feel anxious or sad and that's really how we connect universally is by looking at shared emotions, which are universal.
Luna: What are some of those misconceptions about hoarding that you think are out there?
Pike: The biggest misconception about people who hoard is that they are lazy, which couldn't be less true. People who hoard are often perfectionistic and that actually becomes part of the problem in treating hoarding is that they want to do everything perfectly. They don't want to make a mistake and get rid of the wrong thing. They become so overwhelmed. They're not able to get rid of anything, which is true with most perfectionism. Most perfectionists become so overwhelmed that they start procrastinating, which is a huge component.
Another common misconception is that people who hoard are very reclusive or unfriendly and that is not my experience at all. The vast majority of people I've met with hoarding disorder are very gregarious. They are generous really to a fault. Very kind-hearted. Are very much family-oriented. Of course, there are exceptions, but by and large, the people I've met are extraordinarily friendly and loving and have big hearts.
Luna: I think it's really important for people to understand that. Again, it's not someone who's reclusive necessarily. People who have hoarding disorder are going out every day, going to work, raising families, being involved in their communities and yet they do suffer from a problem that's very serious. It is important to know that too that, maybe some of the things we see on TV programs can be misleading in that way or might portray people in a certain light that may not necessarily be the full scope of how they are.
Pike: Absolutely, agreed. I think people are just so much more complex than then disorder or mental health problem or physical problem.
Luna: What about hoarding across the lifespan? At what age do people tend to show hoarding tendencies? I know you've talked about the genetic component, but when do we see that part activated, and does it get worse as you get older?
Pike: It does, you are three times as likely to have hoarding disorder between ages 55 to 94 very specific. I have certainly seen hoarding as early as 11, but it's harder when you're a young person like that to know what you're seeing, "Is this kid who is just really fond of these things. "he confounding variable is that they have parents. Parents will make them get rid of things. In fact, I have had an increasing number of parents contact me and say, "I'm worried about my child. Could we come in and talk about their behaviors? Which I love. I love the idea that increased awareness of hoarding both through the creation of this separate diagnosis in 2013, and increased awareness through the television shows and talking about hoarding has allowed people to look out for some of the warning signs. "My kid can't get rid of things. They collect things, they have such a hard time sorting and settling. Is there anything that we could do so their life doesn't have to go down this trajectory?" I think that's incredibly hopeful.
Luna: Can you describe the process you use when working with a client who's hoarding disorder? I'm not sure if it varies depending on the age, but say someone in that range, that 55 to 94 range comes to you or their loved one comes to you and they have a hoarding disorder and they want to seek treatment. Can you describe how you approach working with a client like that?
Pike: How I approach working with a client like that is complex. It depends on who's contacting me. I would tell you that 95% of the time, the people who are contacting me are loved ones. It is very rare that people contact me because they personally want help with their hoarding disorder. The main reason that people who hoard contact me is they have some kind of really difficult circumstance like they're about to lose their home, they're about to lose their children. There is something that is so painful that it's pushing them to seek treatment. It's far more common that I am approached by families and friends.
In that case, I try to provide them with resources. I can give you those at the end of the show. I try to adjust their expectations and describe just how difficult it is for their loved one. I try to do what we call psycho education, which is teaching people about hoarding disorder, and correcting some of the stereotypes that we've been talking about and some of the misconceptions around hoarding that this is not the problem of a loved one being willful or just selfish or picking their stuff over loved ones, which is a common misperception. If the person who hoards who is usually brought by loved ones is willing to seek treatment, then there's a mix of cognitive behavioral therapies that I use.
The first part would be motivational interviewing, which is roughly speaking, a technique that is used to try to increase the person's desire to work on the problem and get them to commit on a values-driven basis. I also use ACT therapy, which stands for Acceptance and Commitment Therapy. It's a way of teaching people concrete tools so they can act in service of their own values, versus acting in service of fear or shame or despair and sadness, and that can be very helpful.
We also use something called exposure therapy, which is exposing the person systematically to the upsetting feelings and thoughts that they have about getting rid of things, and teaching them what we call distress tolerance, little by little. We also use some cognitive reframing and classic cognitive restructuring. If the common thought is, "I will die without my things," you can see that that is not really going to be conducive to someone letting go of items.
Luna: Are there particular treatments you think that are more beneficial than others? I've heard a lot about CBT being used in treatment of hoarding disorder. I know you use ACT, you use exposure therapy, you use CBT. Is there anyone you prefer of the other or is it just depend on the person?
Pike: I think it really depends on the individual case. I have had people with higher levels of insight if you want to call it that, that the very first shoot that I did, for “Hoarding: Buried Alive” , the lovely woman that I was working with had very high insight. She was very disturbed by the idea that her children would grow up with this problem and she was highly motivated to change. ACT therapy was a great choice for her. She was very values-driven.
It's not to say that other people with hoarding disorder don't have their own values. Of course they do. They love their families very much. They may just have a different level of insight. Motivational interviewing is, for me more geared towards helping people increase their insight, if that makes sense.
Luna: Absolutely, it does. Increase self-insight into oneself. That's what you mean.
Pike: Exactly. I would also say that there is no gold standard of treatment for hoarding disorder. It is very complex, and it is considered very difficult to treat. That's not to discourage people because there's certainly progress to be made. I have had people contact me years later to say, "Hey, I just moved cross country and it was fine." It's really exciting to hear that kind of thing.
I also think it's important to be realistic that this is a very complex problem that didn't develop overnight. It's genetically loaded. These are behaviors that have been entrenched for a long time. There are often. as we mentioned, other moving parts, meaning the person may suffer from other anxiety problems or ADHD.
In terms of medication, there is currently no medication that is considered particularly effective for hoarding disorder. That is not to say that medications can't be helpful though, because like we've talked about, there are often other problems going on. If a person suffers from extreme ADD or ADHD, using a stimulant or a medication for that might be helpful. If someone suffers from depression, which often causes low motivation and difficulty moving here and moving around and just attending to daily tasks, then they might benefit from what we call an SSRI medication used for depression and anxiety.
Luna: As you mentioned it, and I mentioned in the intro and what you talked about it is very difficult to treat, but we want to people to know that it can be treated, it can be managed that there is help out there.
Pike: Absolutely, 100%.
Luna: If someone's listening today, and they're ready to seek out help for their loved one, perhaps maybe they have high insight and they're ready to look into their own issue, what are the first steps they can take to get help?
Pike: That is my favorite question is providing resources because I think once we're educated about something, then we can take steps. If we don't know what it is, if we can't name it, then we don't know how to treat it. Luckily, we know what those steps are. There are a couple really extraordinary resources.
For people who are dealing with a loved one, my favorite website is called childrenofhoarders.com. It has a comprehensive index of therapists across the nation who specialized in treating hoarding disorder. It has professional organizers. It has support groups, so lots of really, really good resources on there.
In terms of learning more about hoarding disorder, my favorite website is called ocfoundation.org and that's the International OCD foundation. Since we know that hoarding used to be subsumed under OCD as a diagnostic category, I'm a member of that organization. They have just split out hoarding on its own. There's a lot of really good important information about treatment, and about what it is about epidemiology meaning how often it occurs and who. There's just really great resources out there.
Luna: That's really wonderful to share. I think that will be very helpful for people to know that there is help out there. As we wrap this up, I just want to know from your perspective, from taking away from this is that even though this is a difficult disorder to treat, there is hope out there. There is help. There are resources.
Pike: Absolutely, 100%. I don't think anybody has to live with the despair that hoarding disorder brings. I think, no matter how big the problem, it can always be lessened. Even if we can't erase it completely, it can certainly be bettered. I think most people would just take even a 10% decrease in the clutter or in the chaos, and the fighting that can occur. I think it's also really important to teach people how to treat their loved ones. I often work with families and I encourage family members to get help, whether it's from somebody like me or it's one of these websites because they are really informative.
Luna: For the family member, for the loved ones themselves to seek out additional help too.
Pike: Absolutely. It's very stressful to watch especially older parents who have increased fall risks. I get many, many relatives who are very concerned about their older parents who refuse to get rid of their things. It's unsafe or it could be a sanitary hazard. The older people get, their hording becomes more intense. That's often because their partner has been lost, whether that is being widowed or divorced. It's very typical once people lose a partner, that their hoarding is kind of unchecked and it gets worse and worse.
There are some medical conditions that can increase or exacerbate hoarding such as dementia. As people get older, they may not have had a hoarding problem in the past. Their hoarding might be due to dementia or a cognitive disorder. It's really important for families and loved ones to get all the support that they can and some really constructive, educated advice.
Luna: Thank you so much for joining us today, Dr. Pike. I really appreciate you sharing these really valuable resources and your really valuable insight into hoarding disorder. I think that people out there who are interested in this topic and want to learn more, you provided them with a lot of really great information to people that I think would be beneficial.
Pike: Thanks, Kaitlin. I really appreciate you having me on.
Luna: If you want to learn more about Dr. Pike and her work, you can visit juliepike.comopens in new window. Before we go, just a reminder that we want to hear from you. You can email your comments and ideas to Speaking of Psychology at apa.org. That's speakingofpsychology- all one word- .org. Please give us a rating on iTunes. We'd really appreciate it. You can find previous episodes of Speaking of Psychology on Apple, Stitcher, Spotify, or wherever you get your podcasts. You can also go to our website speakingofpsychology.org. I'm Kaitlin Luna with the American Psychological Association. Thank you for listening.
Julie Pike, PhD, is a licensed psychologist and expert in the treatment of anxiety disorders with extensive training from Southern Methodist University, Northwestern University, University of Kentucky, Duke University, and Dartmouth Medical School’s Department of Behavioral Medicine. She also specializes in the treatment of hoarding disorder, depression, hypochondriasis, trichotillomania, skin-picking and of trauma survivors of all types suffering from posttraumatic stress disorder (PTSD). Pike took part in the first randomized controlled trial of Cognitive Processing Therapy (CPT) for childhood sexual abuse survivors, an evidence-based treatment for PTSD that has proven highly effective. She later worked with the National Center for PTSD and participated in several randomized controlled trials of CPT for combat veterans. These studies later led to the nationwide initiative to train Veteran’s Administrations clinicians in CPT, allowing our vets to receive efficacious, quality care for PTSD. Pike’s research interests include the impact and treatment of childhood sexual abuse, the use of Acceptance and Commitment Therapy (ACT) across disorders and the implementation of efficacy-based CBT treatments in clinical settings. Pike makes frequent guest visits on Sirius Radio’s “Doctor Radio” as an expert source, and in other national media.
