The behavior consists of accumulating objects and materials around oneself or in spaces under one’s control, such as garages, attics, entire rooms or apartments, gardens, and so forth. The individual is unable to dispose of these items, or actively refuses to do so, and may leave them unused and piled up, paradoxically allowing them to deteriorate and eventually become unusable. This phenomenon is the subject of a dedicated television documentary series, Hoarders: Buried Alive (Accumulatori Seriali / Sepolti in casa), which describes the treatment of cases involving people who surround themselves either with objects or with animals, making the environments in which they live impractical, unhealthy, and dangerous, while sacrificing other aspects of their lives to the management of these “overloaded” environments.
The types of obsessive features associated with compulsive hoarding include obsessive indecisiveness and a tendency to postpone commitments, perfectionism, difficulty organizing activities, and avoidance (these features may reflect different aspects of the same behavioral pattern). Hoarding is the consequence of an inability to select, discard, set aside, file away, or exclude, or alternatively of an inability to choose, include, prioritize, or discriminate—the other side of the same coin.
The difficulty in classifying these disorders lies in the fact that hoarding, although associated with obsessive features, may nevertheless follow a mechanism that has little to do with obsessive-compulsive phenomena and is instead related to impulsivity. Some hoarders are in fact “compulsive” buyers, meaning that the problem is not so much an inability to throw things away as the active accumulation of new items through serial purchasing.
The individual’s relationship with the behavior therefore differs considerably depending on whether the underlying problem is an inability to discard objects or the accumulation of new ones.
The poor treatment response observed in at least some of these patients may precisely depend on the fact that reducing the obsessive “block” does not necessarily result in a reduction in purchasing behavior. Thus, for example, a person’s ability to dispose of useless objects may improve without eliminating the tendency to accumulate additional ones. The gratification derived from accumulation may also create a misunderstanding: the behavior may be regarded as disturbing by other people, such as family members, but not by the individual directly involved. In the absence of this awareness, it may be difficult to speak of medical treatment in the strict sense; rather, the intervention may take the form of negotiation with others, including family members, neighbors, and so forth.
More generally, various “repetitive” behaviors have been mistakenly regarded as equivalent to obsessive-compulsive disorder, whereas their underlying motivation is different, as is the individual’s relationship with the object of the behavior—which is desired rather than feared. Previous studies of impulse-control disorders have already shown that, when depressive or obsessive symptoms are treated as the central target, these symptoms may indeed improve without a corresponding improvement in the impulsive behavior itself.