Anxiety and Related Coping Skills in Hoarding Disorder

Hoarding disorder, a condition characterised by a persistent difficulty in getting rid of possessions, regardless of their actual value, has been observed to increase anxiety in sufferers. This disorder manifests itself in the compulsion to keep items and the associated distress experienced when attempting to discard them. In addition to the challenge of discarding possessions, people with hoarding disorder often struggle with excessive acquisition, either passively accumulating items such as junk mail, or actively making purchases.

The consequences of hoarding are many, including cluttered living spaces, impaired functionality and emotional distress for both the individual and those around them. Notably, the prevalence of hoarding disorder ranges from approximately 1.5% to 5.8%, with older adults having higher rates of the disorder than their younger counterparts.

Anxiety in HD

Anxiety plays a central role in the cognitive-behavioural framework for examining the development, persistence, and treatment of hoarding disorder (HD). Specifically, anxiety in HD is closely linked to certain distorted beliefs about the meaning and utility of possessions, commonly referred to as “rescue beliefs”.

These beliefs contribute to feelings of distress and anxiety, particularly when people with HD are faced with the need to acquire or discard items. It’s worth noting that cognitive distortions, characterised by unhelpful thought patterns, play a role in perpetuating behaviours associated with hoarding, acquisition and discarding difficulties.

Below are examples of common cognitive distortions associated with hoarding beliefs in HD, categorised into four main themes: emotional attachment, memory, control and responsibility. The list below presents a selection of examples from the Saving Cognitions Inventory assessment measure (Steketee et al., 2003):

Emotional attachment-related saving beliefs:

• “Giving up this possession is like losing a cherished friend.”
• “Giving up this item feels like giving up a part of my identity.”
• “This possession provides me with emotional comfort.

Memory related safeguarding beliefs:

• “My memory is so unreliable that I need to keep this item in sight to avoid forgetting it.”
• “By keeping this, I reduce the need to rely on my memory.”
• “If I throw this away without extracting important information from it, I risk losing something important.”

Control related storage beliefs:

• “I prefer to keep complete control over my belongings.”
• “It upsets me when someone disposes of my belongings without my consent.
• “No one has the authority to handle my possessions.

Responsibility-based storage beliefs:

• “If this possession could be useful to someone else, I have a responsibility to preserve it for them.”
• “It is my duty to find a purpose for this possession.
• “I will be ashamed if I do not have such an object when I need it.

These saving beliefs often contribute to compulsive behaviour. In HD, these beliefs form a negative reinforcement cycle with anxiety. When a person with HD experiences a savings belief or cognitive distortion, such as the idea that discarding an item is like losing a part of oneself, anxiety arises.

By choosing to save the item rather than discard it, the person temporarily reduces their anxiety. This relief of anxiety, although fleeting, negatively reinforces the behaviour of saving items, thereby increasing the likelihood of future saving. The individual learns that by saving possessions rather than discarding them, they can avoid and reduce their anxiety.

Thus, saving beliefs and associated cognitive distortions play an important role in the dynamics of HD. The following example illustrates this process: “This item has immense sentimental value; I cannot part with it.” → heightened anxiety → “Losing this item would mean losing a part of myself”. → Item is kept → Temporary relief from anxiety → Continuation or worsening of anxiety cycle → Greater likelihood of saving items in the future.

Anxiety as a comorbidity in HD

Anxiety not only plays a crucial role in the development and maintenance of hoarding disorder (HD), but is also frequently observed as a co-occurring condition. Studies have highlighted the co-occurrence of HD with various anxiety disorders, including generalised anxiety disorder (GAD), social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD).

In addition, research suggests that the presence of comorbid anxiety disorders, such as social anxiety, may have a negative impact on the effectiveness of treatment outcomes. Therefore, it is imperative to directly address and target anxiety phenomena in the treatment of HD, given their inherent importance in the disorder and their potential comorbidity.

Treatment and Coping Skills for Hoarding

Cognitive-behavioural therapy for HD (CBT for HD) is the primary treatment approach for this disorder. Although preliminary evidence suggests the potential benefit of psychiatric medications, particularly antidepressants, in addressing underlying anxiety, CBT for HD remains the cornerstone of therapeutic intervention. In the following sections, we outline the essential components of CBT for HD and the corresponding coping skills used in the treatment process.

CBT for HD

CBT for HD (Cognitive Behavioural Therapy for Hoarding Disorder) involves specific therapeutic techniques aimed at addressing the challenges associated with hoarding. It incorporates both behavioural and cognitive components to promote effective coping and behaviour change. Here are the key elements of CBT for HD

• Exposure and Response Prevention (ERP): This behavioural aspect of CBT for HD focuses on helping individuals build tolerance to distress without resorting to anxiety-reducing behaviours. Key goals include
  • Engaging in decision making without immediately undoing or reversing decisions, even when distress arises (e.g., refraining from retrieving discarded items).
  • Facilitating exposure to sorting possessions, actively making decisions about discarding hoarded items, and gradually reducing avoidance behaviours.
  • Facilitating exposure to situations that challenge the urge to acquire more items, such as visiting second-hand shops or flea markets without making a purchase, or passing by free items without taking them home.
• Cognitive therapy: The cognitive facet of CBT for HD involves identifying and challenging maladaptive beliefs associated with hoarding.
  • Key strategies include
    Challenging and evaluating the accuracy of storage beliefs and cognitive distortions.
    Developing alternative, more realistic thoughts that counter the rescuing beliefs. For example:
    • “I am capable of managing and resolving the fear of discarding meaningful possessions.”
    • “Even if I need an item in the future, I can get it again if I don’t keep it.
    • “Choosing to discard is consistent with my values and the life I want to live, despite the anxiety it may cause.”
• Motivational enhancement: Motivational enhancement is a valuable approach used in the treatment of hoarding disorder (HD) to address the ambivalence that individuals often express towards treatment. It combines cognitive interventions and behavioural techniques to maintain motivation while effectively addressing and treating HD. The following strategies may be used:
  • Cognitive interventions: Challenging beliefs related to lack of motivation to change by offering alternative perspectives. For example:
    • Shifting from “I don’t have time to clean up the mess” to “I’ve struggled to make progress before, but I’m curious about how treatment could improve my life”.
    • Moving from “My stuff makes me happy and I don’t want to change” to “Having my family over makes me happy and I’ve missed having people around”.
  • Behavioural interventions: Contrasting actions and small steps: Committing to a short decluttering session, even if it feels overwhelming, because doing something is better than doing nothing.
    • Behavioural activation: Acknowledging initial anxiety about decluttering, but recognising that progress will lead to improved well-being.
    • Contingency management: Introducing rewards or incentives to encourage decluttering or discourage the acquisition of new items. For example, treating yourself to a non-pecuniary reward after five items have been discarded, or receiving monthly incentives based on reduced clutter.
    • Stimulus control and deliberate avoidance: Reducing triggers and creating barriers to undesirable behaviours, such as limiting access to debit/credit cards or shopping with a list to avoid aimless shopping.
    • Value clarification and pursuit: Reflecting on non-material values and engaging in activities that align with these values to increase motivation for behaviour change and treatment seeking.
    • Family training: Training family members in effective communication, harm reduction approaches and reducing enabling behaviours to increase motivation and encourage treatment seeking.
• Building executive functioning skills: In addition, treatment for HD includes the development of executive functioning skills to address cognitive abilities such as memory, attention, organisation, planning, sorting, time management, task switching and inhibitory control. These skills aim to improve overall cognitive functioning and assist the individual in effectively managing hoarding related challenges.
  • Tips and tricks for decluttering when faced with anxiety and executive functioning difficulties:
    • Make a plan in advance and stick to it.
    • Set time limits for sorting sessions, focusing on a few hours at a time rather than tackling the whole day.
    • Categorise items into three groups: keep, discard and donate.
    • Consider cognitive rehabilitation, which can be combined with exposure therapy to address executive function difficulties. This approach teaches skills related to planning, problem solving, memory and cognitive flexibility.
• Family support:
  • Friends and family of people with hoarding disorder (HD) can provide valuable support:
    • Avoid pressuring the person to get rid of items or making dismissive comments about their value. Instead, validate their distress and difficulties by acknowledging the emotional significance of possessions.
    • Offer social support and connection if the person struggles to acquire more items or experiences distress after discarding.
• Therapist support:

In therapy sessions, people with HD can discuss the following

• • Explore specialised CBT for HD, as research suggests its potential to improve treatment outcomes. Focus on identifying and challenging beliefs related to keeping possessions.
  • Even if the therapist doesn’t have specific HD training, they can use available HD resources and draw on CBT principles to better help people with HD. Resource texts such as “Buried in Treasures” offer research-based skills and interventions for various HD-related concerns.
  • Recognise the relationship between HD and medical comorbidities that may exacerbate hoarding and anxiety symptoms. Discuss with the therapist the interaction between physical and mental health.

Acceptance and mindfulness for HD

Acceptance and mindfulness-based strategies can be useful for people with hoarding disorder (HD) in managing their symptoms and improving their wellbeing. The following approaches may be helpful:

• Value reminders: People with HD can reflect on their core values, such as relationships and emotional connection, to resist the urge to acquire more items or to refrain from discarding possessions. They can consider the impact of HD on their relationships and weigh the pros and cons of their behaviour. This reflection can lead to decisions that are consistent with their values and goals.
• Cognitive defusion: The practice of cognitive defusion involves observing and noticing thoughts, emotions, or urges without getting caught up in them. People with HD can recognise that thoughts are just words and let them pass, resisting the urge to attach meaning to them or act on them. This practice helps create distance from distressing thoughts and reduces their influence.
• “Urge surfing”: Instead of giving in to the intense urges associated with HD behaviours, individuals can engage in alternative activities that provide a sense of mastery or accomplishment or help regulate their emotions. By riding out the urges, individuals allow them to subside naturally over time.

Concluding thoughts

In conclusion, anxiety symptoms and anxiety disorders are important aspects of hoarding disorder (HD) that influence symptom manifestation and treatment outcomes. Fortunately, numerous treatment options, such as cognitive behavioural therapy (CBT), motivational interviewing and cognitive rehabilitation, have been shown to be effective in the treatment of HD.

Ongoing research in clinical psychology and social work aims to increase understanding of the mechanisms that contribute to positive outcomes and improve treatment effectiveness. This article serves as a guide to provide direction for people with HD to improve their symptoms and quality of life. Additional information and resources are available at https://hoarding.iocdf.org/.

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