Many “Hoarders” viewers have questioned why individuals who suffer from compulsive hoarding are not treated in the same manner as those who have problems with substance abuse and addiction. The notion of compulsion has been likened to addiction, yet they are very different constructs.  Let’s take a look at the what we know about the similarities and differences in order to answer the burning question of why can’t someone clean a hoarder’s home for him/her. For brevity’s sake, let’s look at the two behaviors in simplistic terms (although they are both quite complex):

First and foremost, the constructs of compulsion and addiction are different, but not mutually exclusive.  A compulsion is defined as an intense urge to engage in a behavior (e.g, acquisition, avoidance of discarding). This behavior is typically enacted in order to reduce anxiety and distress or to avoid experiencing such anxiety or distress, although common use of the word simply refers to the urge.  An addiction is a multifaceted term that is historically described as a neurobiological disorder that involves a repeated behavior (e.g., drug use) despite negative consequences, tolerance to the drug (i.e., increasing amounts are needed to achieve the desired effects), and the experience of physical withdrawal symptoms (e.g., increased heart rate, tremors, sweating, possible seizures). Some more recent models of addiction suggest that psychological dependence alone may constitute addiction (e.g., gambling, shopping); however, many argue that these difficulties are better accounted for by other means such as impulsivity, mood dysregulation, or other factors; thus, addiction continues to require withdrawal and physiological dependence as diagnostic criteria.

In terms of how the two behaviors look neurologically, there is still much to learn about brain function and dysfunction in these problems, particularly in hoarding. Prominenthoarding behavior in those who have been diagnosed with obsessive-compulsive disorder have shown greater activity in the bilateral ventromedial prefrontal cortex (VMPFC) (emotion regulation), reduced glucose metabolism in the dorsal anterior cingulate cortex (cognitive, motor, and emotional processing; reward-based decision making), and increased metabolism in the right sensorimotor cortex. Hoarding symptoms appear to be associated with dysfunction in the frontolimbic network. Inaddiction, neuroimaging has shown abnormal activity in the prefrontal cortical regions and the amygdala (stimulus-reward associations) as well as the nucleus accumbens (i.e., striatum neurons) (reward). Addictive substances increase the level of synaptic dopamine (necessary for reward and reinforcement) in the nucleus accumbens and (in the case of opiates) act on the opioid receptors in this area. Synaptic plasticity in the nucleus accumbens and the dorsal striatum also contribute to drug craving and drug seeking behaviors.

Addiction behavior (e.g., drug use) initially produces a rewarding pleasurable feeling or “high” (positive reinforcement), which is sought (although this pleasure often habituates). When these substances are used repeatedly, molecular changes occur in the brain that promote continued use (continued reinforcement) and it becomes increasingly difficult for the individual to control the behavior as they seek to achieve a “high”. The behavior is then further maintained by the development of physical withdrawal symptoms when the drug use is stopped. Individuals then also continue the behavior to avoid experiencing withdrawal symptoms (negative reinforcement).  Hoarding behavior may also be maintained by positive reinforcement in that some individuals experience excitement as they find and acquire items; however, the behavior is more prominently maintained by negative reinforcement in that the individual experiences great distress and anxiety when faced with having to decide the disposition of a possession.  In other words, these individuals are able to relieve their distress by putting off making decisions about disposition or discarding items, which leads to increased clutter and continued avoidance of sorting and/or discarding items.   

Addiction is typically treated by detoxification (i.e., the initial stage of purging the drug from the body while reducing withdrawal symptoms) and rehabilitation (i.e., may involve medication and/or behavioral therapy). Behavioral therapy helps individuals maintain motivation, develop coping skills to resist cravings, develop more adaptive behaviors in response to antecedents (behavior triggers), develop problem-solving skills, avoid drugs, and prevent relapse in addition to improving communication skills and relationships. Cognitive-behavioral therapy has been demonstrated to be effective in the treatment of compulsive hoarding which involves helping individuals to change the way they think about and make decisions about their possessions in order to control their behavior and their emotional attachment to possessions.  This process involves a thorough behavior assessment (to learn each individual’s contributing factors), psychoeducation (to improve insight and knowledge of the disorder), exposure/response prevention (E/RP) (for those who actively acquire, this involves exposing them to situations in which they have the opportunity to acquire, while having them refrain from acquiring - - this may be difficult for them initially, but with repeated E/RP, they habituate, or get used to, the situation and their distress decreases), cognitive restructuring (helping them to identify the flaws/distortions in their thought processes and change them to more adaptive/accurate/positive thoughts), and excavation exposure (exposing them to having to engage in the process of de-cluttering by sorting through their items while utilizing and practicing improved decision-making skills).  

Is drug abuse as simple as taking drugs away from an individual and forcing them to detox? No, of course not. Why? The individuals would be very likely to do anything they had to do to find drugs and return to their drug use because not only must the individuals manage the strong neurobiological dependence that has developed, which will influence drug-craving and drug-seeking, but they have also not developed the skills necessary to cope with cravings, environmental “triggers”, and improve problem-solving, or address other psychopathology and stressors, which are common. This also would not address the persons’ motivation to change; without a desire to end addiction, treatment will inevitably fail.

Compulsive hoarding is no different. Why then can’t we simply remove individuals who hoard from their home and clean the home for them? First of all, doing so has the potential to cause significant distress and interpersonal conflict. Because of the great value placed upon many of these hoarded possessions, disposing them without the individuals’ consent typically causes them to feel violated and distraught.  Moreover, it is not at all likely to produce long-term change; the individuals will be likely to quickly re-acquire and clutter the home and will be more resistant to help or intervention.  Cleaning for them does not give them the opportunity to practice and learn important decision making skills, learn the function that hoarding has served in their lives, and learn strategies to cope with their intense emotions.  Exposure allows them to learn that the emotions that they have been avoiding (by failing to make decisions about items or discarding) are tolerable and that the intensity of distress and anxiety decreases (habituates) as they continue to expose themselves to proceeding through the process of decision-making and de-cluttering.  Therefore, they must do it themselves in order to be able to achieve long-term success and maintain the cleanliness of the home.