Those who hoard bear the weight of their mess plus a mental disorder only now being understood. Treatment programs are just beginning.
An Arlington man in his apartment. Despite threats of eviction, he keeps piling up periodicals, saying he'd hate to miss good information. (Globe Staff Photo / Mark Wilson)
The stacks of newspapers and books rise waist-high in his apartment, and the living room couch is invisible under piles of boxes and bags. The stove is buried in kitchen paraphernalia. Piles of clothes and books on the double bed leave barely enough room for one sleeper.
"Would you like to sit down? I can move a few things," says the Arlington man, taking jars and papers off a chair. "I'm very good at shifting things around."
Why so much mess? "Sometimes it's just that I don't get to it," said the man, who asked to remain anonymous because he has been repeatedly threatened with eviction from his one-bedroom rental and promised to clean it up.
Long seen as an eccentricity or a facet of obsessive-compulsive disorder, severe hoarding is now increasingly viewed and studied as a mental health problem in its own right, a complex syndrome that is difficult to cure and tends to strike in middle age or later. It appears to affect 1 or 2 percent of the population, researchers estimate.
People who hoard are often misunderstood, said Jason Elias, a behavior therapist at McLean Hospital's Obsessive Compulsive Disorders Institute. "The general public thinks these people are just slobs or lazy, but actually most of the time it's because . . . of not wanting to waste things, and so wanting to make the right decision about a thing that it becomes overwhelming and they keep it."
Recently, researchers at Boston University and Smith College have assembled what they believe is the first systematic talk therapy for people with hoarding problems, a 26-session program that includes house calls.
Working with more than 100 Massachusetts clients with hoarding problems, they are also trying to piece apart the pathology of extreme hoarding and map its extensive overlap with other psychiatric problems such as depression and attention deficit disorder.
Pathological hoarding is far more than mere messiness or a pack-rat tendency , said hoarding specialist Gail Steketee, interim dean of the Boston University School of Social Work.
The people she and her colleagues treat and study tend to have reached the point where they lose whole rooms to piles of what to them are treasures and to anyone else looks like trash. Their homes are often tagged as potential threats to public health.
Yet otherwise, most tend to function fairly normally out in the world, said Steketee, who has coauthored a new book, "Buried in Treasures," that translates the therapy program for the lay public. "They may have some depression, some anxiety," she said, "but mostly they're attached to their things in ways that make it very difficult to get rid of them."
The Arlington man, for example, said he suffers from low-grade depression but is active civically and with several charitable organizations. He is a news watcher who says he accumulates periodicals because he would hate to miss good information. He is also handy at fixing things.
Most often, hoarding is considered a symptom of obsessive-compulsive disorder, an illness in which people cannot stop certain thoughts and behaviors, such as washing their hands or worrying about germs incessantly. About one-quarter of those people hoard.
But it may well be that hoarding is actually closer to an "impulse control disorder," like gambling, because those who hoard often experience active pleasure as they acquire or pile up their possessions, Steketee said.
Hoarding can involve emotions -- feeling safer among walls of clutter, for example. And thoughts -- like, "I'm sure I could use that broken tape deck someday!" And even unconscious values, like "More is better."
Researchers also have some initial clues that hoarders' brains may work differently. . One study published this year found that hoarders could sort common household items as quickly as nonhoarders. But when asked to sort cards representing items from their own homes, the hoarders tended to create more piles, work more slowly, and feel more anxiety than the nonhoarders.
It was as if their strong feelings toward their possessions got in the way of their thinking, the study in the journal Behavior Research and Therapy suggested.
Other influences on hoarding include several positive character traits: For example, a creative or ingenious person may more easily think o f possible uses for an object and thus find it harder to discard. A caring person might think of all the friends and relatives who might conceivably wring benefit from an item.
Hoarding may also hav e a genetic aspect, and family environment can influence it as well: In some households, for example, objects are invested with far more sentimental value than in others. Trauma can be a trigger, as can the kind of early deprivation suffered by many who grew up in the Great Depression.
Initial studies suggest that antidepressants offer little help for hoarding. More research has yet to be done trying other types of drugs, Steketee said.
The treatment she has developed with her colleague, Randy O. Frost of Smith College, attacks hoarding from several directions. It fosters skills at decision-making, sorting, and organizing and provides plenty of supervised practice at decluttering so hoarders can keep at it on their own after therapy ends. It also tries to address the deep-seated emotions that make it so hard to let go of things.
About half of the ir clients have gotten significantly better, Steketee said, rising from perhaps a 7 to a 3 on a photo test to determine their level of clutter, from pure neatness (1) to total chaos (9). That is not bad for a notoriously difficult problem, said Elias of McLean, who is not involved in Steketee's research. Hoarding is one of the most recalcitrant symptoms of obsessive-compulsive disorder.
The 26-session program definitely helped, the Arlington man said. But a visit to the man's apartment last week showed it is still filled with flotsam and jetsam.
He is more conscious now of his hoarding habits, he said, including procrastination and a tendency to say: "What can I do with this? How can I use it?" And he does believe that, thanks to the program, he accumulates detritus more slowly than he used to.
But the core of the problem remains somehow mysterious.
"If I could figure it out, I could cure it," he said.
Carey Goldberg can be reached at firstname.lastname@example.org.