The topic of compulsive hoarding has garnered much attention in recent years in the mainstream media.  Compulsive hoarding has been likened to addiction in some discussions of the problem, 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):

The (not-so) simple definitions

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.

The technical stuff

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. Hoarding 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. In addiction, 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.

Maintenance of the behavior itself

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.

What about treatment?  There are significant differences between evidence-based treatment of compulsive hoarding and addiction. Check Therapy That Works on Thursday to learn how the two difficulties differ.  Also, learn why loved ones, with the best of intentions, are not helping the individual when they offer to clean the home for them.

Why do YOU suppose this might be?  Find out Thursday on Therapy That Works.

This entry was originally written for the fascinating blog of organizer extraordinaire, Geralin Thomas, CPO-CD:

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