What comes to mind when you read the word "addiction?"
Or do you think of shopping, sexual activity, video games, and gambling at an alarmingly high rate?
How about "compulsive hoarding?"
Is hoarding an addiction or purely a compulsive behavior? I asked myself this question after watching my colleague Dr. D.J. Moran on Animal Planet's Confessions: Animal Hoarding episode entitled "Chickens in My Home." This episode featured two individuals who hoard animals. My colleague Dr. D.J. worked with Kitten, a married woman who amassed a large population of cats.
During the intervention stage D.J. stated, "In this case, I see Kitten's form of hoarding as an addiction." This got me thinking... is it accurate to classify hoarding as an addiction? Are they the same thing? Can a client have one but not the other? I gave it some thought and decided that I think they're not the same thing and here's why...
Here's what we know...
• Compulsions are "Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. .. The disturbance is not due to the direct physiological effect of a substance" (DSM IV-TR).
• Addiction is a "compulsive, uncontrollable dependence on a chemical substance, habit, or practice to such a degree that obtaining or ceasing use may cause severe emotional, mental, or physiologic reactions" (Mosby's Medical Dictionary, 2009).
When considering how hoarding and addiction are different I first examined the psychological distinctions. The process of developing and maintaining an addiction is often dependent on pleasure as a reward. Most addicted individuals initially seek out the behavior or substance because it generates pleasure. The addiction is typically maintained by positive reinforcement. On the other hand, compulsive behaviors are often engaged in to alleviate pain and discomfort. Although a hoarder may initially experience excitement when acquiring items, the behavior is typically maintained in an attempt to decrease psychological pain.
Hoarding and addictions are also different in how they affect the brain and brain functions. Some experts now believe that continued addiction can cause persistent changes in brain structure and function (Hyman & Malenka, 2001; Leshner, 1997). Prolonged engagement in substance or behavioral addiction changes the structural and molecular makeup of the brain. However, there is no evidence at this time suggesting that hoarding also causes changes in the anatomy of the brain. Interestingly however, it has been found that specific brain anomalies are associated with higher incidence of abnormal hoarding behaviors (SK et al., 2009). MRI studies suggest that damage to the frontal lobe of the brain may lead to abnormal hoarding behaviors that were not present before the damage occurred (SK et al., 2009).
Addictive substances like amphetamines, cocaine, and morphine increase the amount of dopamine in the synapses triggering a reward and reinforcement response (Hyman & Malenks, 2001). Similarly, addictive behaviors such as gambling have a drug-like effect on the brain. Studies indicate the brain's blood flow in a pathological gambler anticipating a win changes much like that in the brain of a cocaine and morphine user (Goodman, 2008; Holden, 2005). Another distinction between addiction and compulsive behaviors, like hoarding, is the existence of tolerance, dependence, and withdrawal symptoms. These processes do not appear to occur in the brain of individuals who compulsively hoard.
Why is the distinction important?
Providing a clear distinction between addiction and compulsive behaviors is important for tailoring effective treatments. In the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) compulsive hoarding is considered a behavioral criterion for the diagnosis of Obsessive-Compulsive Disorder (OCD). Researchers are now suggesting that hoarding is not a compulsion related to OCD and is, in fact, being considered as an independent diagnosis for the fifth edition of the DSM (Mataix-Cols et al., 2010).
Effective treatment for compulsive hoarding usually involves a supportive clutter coach and a therapist to help the individual with decision making and behavior modification (Sanxena & Maidment, 2004). On the other hand, chemical addiction is typically treated by a period of detoxification which may or may not include in a hospital stay to monitor withdrawal symptoms. Treatment for behavioral addictions like gambling may include a period of hospitalization as well. Treatment for compulsive hoarding does not involve a detoxification period nor does it require hospitalization. Simply removing a hoarder from their home and placing them in an in-patient treatment facility will likely fail as an effective treatment. However, treatment for addiction and compulsive behaviors do share some commonalities. The use of behavioral therapies like CBT is common in the treatment of both addiction and hoarding. CBT focuses on replacing unhealthy, irrational thoughts and negative beliefs with healthier, positive ones and helps to increase healthy coping skills. Additionally, antidepressants and anxiolytics are effective in treating co-morbid disorders such as depression and anxiety often found with both addiction and compulsive hoarding (Saxena & Maidment, 2004).
It appears that...Compulsive hoarding is not considered an addiction in the clinical meaning of the word, although compulsive behaviors can exist in addiction. I have examined evidence of psychological and neurobiological differences between hoarding and addiction and have concluded that they are not the same disorder. The psychological motivation for starting and continuing hoarding is different from the motives for addictive behavior. Also,both hoarding and addiction affect and are affected by anomalies in the brain, but the mechanisms of this are different for each disorder.
Dr. DJ is a highly respected and well known expert in the field of treating Obsessive-Compulsive Disorder and compulsive hoarding. His use of the term "addiction" when describing Kitten's behavior was intended to communicate the idea that she has an insatiable need for cats. Much like an alcoholic does for beer or liquor. Colloquially speaking, addictions and compulsions are often referred to as being the same.
*The information contained in this post is for the sole purpose of generating a discussion and not to be considered a comprehensive review of information. This post is based on the opinion of the author. There remains a paucity of research on the subject and more research is needed to better understand the clinical differences between these disorders.
Deibler, M. (2010). Is hoarding a compulsion or an addiction? Retrieved January 25, 2011, from http://www.thecenterforemotionalhealth.com/compulsivehoarding.html
Goodman, A. (2008). Neurobiology of addiction: An integrative review, Biochemical Pharmacology, Vol. 75, Issue 1, pp.266-322.
Holden, C. (2005). Gambling as addiction. Science, Vol. 307, Issue 5708, pp.349.
Hyman, S.E., & Malenka, R.C. (2001). Addiction and the brain: The neurobiology of compulsion and its persistence. Neuroscience, Vol. 2.
Ledgerwood, D.M. & Petry, N.M. (2010). Subtyping pathological gamblers based on impulsivity, depression, and anxiety. Psychology of Addictive Behaviors, Vol. 24, No. 4, pp. 680-688.
Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, New Series, Vol. 278, No. 5335, pp. 45-47.
Mataix-Cols, D., Frost, R.O., Pertusa, A., Clark, L.A., Saxena, S., Leckman, J.F., Stein, D.J., Matsunaga, H., & Wilhelm, S. (2010). Hoarding disorder: A new diagnosis for DSM-V? Depression and Anxiety, Vol. 27, pp. 556-572.
Saxena, S., & Maidment, K. (2004). Treatment for compulsive hoarding. Journal of Clinical Psychology, Vol. 60, No. 11, pp.1143-1154.
SK, A., Mataix-Cols, D., Lawrence, N.S., Wooderson, S., Giampietro, V., Speckens, A., Brammer, M.J., & Phillips, M.L. (2009). To discard or not to discard: The neural basis of hoarding symptoms in obsessive-compulsive disorder. Molecular Psychiatry, Vol. 14, pp. 318-331