Hoarding Disorder: A Practical Guide to an Interdisciplinary Treatment 3030723410, 9783030723415

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Hoarding Disorder A Practical Guide to an Interdisciplinary Treatment Nassim Agdari-Moghadam

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Hoarding Disorder

Nassim Agdari-Moghadam

Hoarding Disorder A Practical Guide to an Interdisciplinary Treatment

Nassim Agdari-Moghadam Sigmund Freud University MMag. Dr. Nassim Agdari-Moghadam Vienna Austria

ISBN 978-3-030-72341-5    ISBN 978-3-030-72342-2 (eBook) https://doi.org/10.1007/978-3-030-72342-2 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword 1

With this publication, Dr. Agdari has placed a milestone in the field of hoarding disorder research. This book sheds light on the many facets of hoarding and their relation to each other: psychoanalytic aspects, social conditions, and pathological symptoms, all drawing from over 15 years’ experience in the field. This book is not only for interested researchers but also for those who are confronted in their daily lives with this phenomenon. As a practical guide, it should lead toward a better understanding of hoarding disorder sufferers. The case examples within this book describe each respective field and provide a detailed explanation of individual cases. I can therefore wholeheartedly recommend this work to the esteemed reader as a standard in the field of hoarding disorder. Sigmund Freud University Vienna, Austria  2018

Alfred Pritz

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Foreword 2

This practical guide looks at hoarding disorder from a psychoanalytical point of view. “Messie” is the term adopted by those affected. This term was subsequently coined by the media and is still in use both in clinical and social work, not to mention in discussion. The consideration of the phenomenon itself results on the one hand from the patient’s life and history of suffering and on the other from observing family, friends, colleagues, media, and those in the caring profession. An outside observer would infer that it is about people who are surrounded with so many things, that they can no longer use their apartment as a place of recreation. Regardless of whether this behavior is seen as a lifestyle deviating from the norm or as a mental disorder, for psychoanalysis it is in any case the result of an inner conflict. Hoarding behavior is an attempt to manage this conflict; an attempt which fails because the conflict is not uncovered but transformed, disfigured beyond recognition. It remains hidden from the affected and expresses itself in the exhausting, painful lives of those with hoarding disorder. Only patients can shed light on the conflict if they are willing to undergo psychoanalytic therapy and deal with their unconscious. They will embark on a journey with a psychoanalyst, following the path to understanding and thus change. This can be an unsettling experience: probably less troublesome in the end than to live a life with hoarding disorder but not every patient is willing. The life history of the suffering and the methods of psychoanalysis are unique representations and experiences; specifically different for each patient. The documentation of this psychoanalytic work is the essential basis for research. It is also one of the foundations of this practical guide. Dr. Agdari puts her practical experience into the context of psychoanalytic theory. She succeeds in showing the complexity of the disturbance and the various forms of dealing with it. The abundance of material and different aspects of the observations leave a door open for stimulating starting points for the reader to conduct their own work in this field. Dr. Agdari has been working extensively with patients at Sigmund Freud Private University. I am happy and grateful that she brings her experience to the public. Sigmund Freud University Vienna, Austria

Elisabeth Dokulil

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Preface

The term “Messie syndrome” or hoarding disorder describes those who have a particular way of dealing with objects and things. In recent decades, it has not been clear whether this is a new and independent disorder in the sense of the current diagnostic manuals, whether in the American Diagnostic and Statistical Guide mental disorders (DSM) or in the International Statistical Classification of Diseases (ICD). Since 2013, the phenomenon has been a new, independent mental disorder in the DSM-5 in the field of obsessive-compulsive disorder, namely under the description “hoarding disorder.” In the current draft of the ICD-11 which was released in June 2019, hoarding disorder is listed under obsessive-compulsive disorders. Therefore, it seems to be an historically important moment for both those affected and those involved in the treatment of the disorder. I have been working with patients and also scientifically engaged in this field for almost 15 years. I am always interested in people and their unique biographies. Each of them enabled me to deepen my knowledge of mental dynamics. Essentially, hoarding is a very complex disorder with a range of symptoms. Up to now, international scientific research has not been under any particular strain. Treatment guidelines for professionals and people working with those affected are mainly limited to behavioral therapy approaches. Therefore it was a challenge in both using psychoanalytic theories to create this practical guide and making aspects of this new disorder understandable. I am of the opinion that established psychoanalytic approaches still hold relevance for current issues, which can enlighten across a wide spectrum of professional groups. This publication, a culmination of my diploma thesis and my dissertation, can be seen as one step in that direction. Therefore, this book is targeted to those who predominantly work with the affected in a professional context; in the medical field this would involve all general practitioners and psychiatrists; in the social domain, social workers, caregivers, and carers; and finally in the field of mental health, psychologists and psychotherapists. At this point, I would like to thank Dr. Elisabeth Dokulil (formerly Vykoukal) and Prof. Dr. Alfred Pritz for preparing the groundwork, where scientific studies of hoarding disorder can be found at Sigmund Freud Private University. A drop-in and information center for those affected was also established. I would also like to thank them for their personal support, guidance, and the many stimulating discussions, especially at the beginning of my research process. ix

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Preface

My special thanks go to Prof. Dr. Reinhold Popp for the benevolent support and supervision of my dissertation and Prof. Mag. Dr. Gerhard Benetka for supervising my diploma thesis. I would also like to thank Dr. Katrin Lenhart for the friendly and competent support during the entire development process of this publication. I would also like to thank Dr. Freyberg for supporting this project. I would like to extend my gratitude to my patients who not only have opened up about their lives but have also graciously allowed me into their apartments. Last but not least, I want to thank my family and friends, who made this work possible through their support and who have followed the process with patience and sympathy. Vienna, Austria December 2020

Nassim Agdari-Moghadam

Preface to the English Edition

With this publication, the content is now available to English-speaking specialists and other interested parties. There were some translation challenges that I would like to briefly address. The German edition was published in 2018 and therefore the English edition you are now holding is not only a translation but also one that is slightly updated, in particular the changes to the ICD-11. Another important fact is that regarding the terms of Freud’s original texts; it should be noted that the drive was originally translated as instinct in the Standard Edition by Strachey. (Edition of the Complete Psychological Works of Sigmund Freud. 24 vols. Edited and translated by James Strachey. London: Hogarth Press, 1953–1974.) In this publication however, instinct and drive were used synonymously in order for a general understanding. A further challenge is the German-speaking terms and definitions, which cannot be fully clarified until the ICD-11 has been officially translated. I would like to thank Mrs. Svenja Grabner and Mr. Steven Hardaker who have helped me undertake the English version of this publication. Vienna, Austria January 2021

Nassim Agdari-Moghadam

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Contents

1 Introduction������������������������������������������������������������������������������������������������   1 1.1 History of Hoarding Research in Austria��������������������������������������������   3 1.2 Terminology and Definition����������������������������������������������������������������   4 1.3 International State of Research ����������������������������������������������������������   6 1.3.1 Relevance for Psychoanalysis������������������������������������������������   8 1.4 Social and Cultural Factors����������������������������������������������������������������  10 1.4.1 The Meaning of Objects in Our Society ��������������������������������  16 1.4.2 Having Instead of Being ��������������������������������������������������������  20 1.4.3 The Relevance of Security in Society ������������������������������������  24 References����������������������������������������������������������������������������������������������������  26 2 A Review of the Fundamentals ����������������������������������������������������������������  29 2.1 Theoretical Considerations ����������������������������������������������������������������  29 2.2 Causes and Development of Hoarding Disorder��������������������������������  32 2.2.1 The Importance of Orality������������������������������������������������������  37 2.2.2 The Importance of Anality������������������������������������������������������  39 2.2.3 Shame and Guilt����������������������������������������������������������������������  46 2.2.4 Summary of Drive Theoretical Concepts��������������������������������  51 2.2.5 Object Relations Theory ��������������������������������������������������������  54 2.2.6 French Psychoanalytic Concepts��������������������������������������������  61 2.3 Symptoms ������������������������������������������������������������������������������������������  66 2.4 Epidemiology��������������������������������������������������������������������������������������  69 2.5 Diagnostic Considerations������������������������������������������������������������������  70 2.5.1 Diagnostic Manuals����������������������������������������������������������������  71 2.5.2 Diagnosis��������������������������������������������������������������������������������  75 2.6 Comorbidity����������������������������������������������������������������������������������������  80 2.7 Spectrum Disorder������������������������������������������������������������������������������  84 2.7.1 Animal Hoarding��������������������������������������������������������������������  85 References����������������������������������������������������������������������������������������������������  88

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Contents

3 Treatment Recommendations ������������������������������������������������������������������  93 3.1 General������������������������������������������������������������������������������������������������  93 3.1.1 Individual Therapy������������������������������������������������������������������  94 3.1.2 Group Therapy������������������������������������������������������������������������  96 3.1.3 Support Groups ����������������������������������������������������������������������  96 3.1.4 Patient Home Visits����������������������������������������������������������������  97 3.1.5 Pharmacotherapy��������������������������������������������������������������������  98 3.1.6 Treatment Matrix��������������������������������������������������������������������  99 3.2 Features and Challenges �������������������������������������������������������������������� 102 3.2.1 General Guidelines����������������������������������������������������������������� 102 3.2.2 Relationship Work������������������������������������������������������������������ 104 3.2.3 Ego Psychology and Functions of the Ego ���������������������������� 110 3.2.4 Inhibitions and Limitations���������������������������������������������������� 114 3.2.5 Challenges������������������������������������������������������������������������������ 115 3.2.6 Transference and Countertransference������������������������������������ 115 3.2.7 Trivialization and Denial�������������������������������������������������������� 117 3.2.8 Disgust, Shame, and Guilt������������������������������������������������������ 118 3.2.9 Disease Progression and Prognosis���������������������������������������� 119 3.3 The TH-I-N-G-S Intervention Concept���������������������������������������������� 120 3.4 The Perspective of Family Members�������������������������������������������������� 123 3.5 The Perspective of Children���������������������������������������������������������������� 125 3.6 Interdisciplinary Exchange ���������������������������������������������������������������� 127 References���������������������������������������������������������������������������������������������������� 130 4 Psychodynamic Aspects: Self-Image�������������������������������������������������������� 133 4.1 Overview of the Core Categories�������������������������������������������������������� 133 4.2 Case Vignettes������������������������������������������������������������������������������������ 136 4.2.1 Ms. O., the Reasonable ���������������������������������������������������������� 136 4.2.2 Ms. P., the Communicative ���������������������������������������������������� 141 4.2.3 Mr. U., the Cautious���������������������������������������������������������������� 146 4.2.4 Ms. V., the Fighter������������������������������������������������������������������ 149 4.2.5 Ms. X., the Dedicated ������������������������������������������������������������ 154 4.2.6 Mr. Y., the Seeker�������������������������������������������������������������������� 159 4.2.7 Mr. Z., the Lonely ������������������������������������������������������������������ 163 4.3 Summary �������������������������������������������������������������������������������������������� 167 References���������������������������������������������������������������������������������������������������� 170 5 Concluding Remarks and Future Prospects�������������������������������������������� 171 References���������������������������������������������������������������������������������������������������� 176 6 Diagnostic Tests������������������������������������������������������������������������������������������ 177 References���������������������������������������������������������������������������������������������������� 181 Index�������������������������������������������������������������������������������������������������������������������� 183

About the Author

Nassim Agdari-Moghadam  was born in Teheran and raised in Vienna. She has many years of experience in private industry. She completed extra-occupational studies in European economy and business leadership and extra-occupational studies of psychotherapy science. She was trained as a psychoanalyst. She received the Marianne Ringler research prize and City of Vienna Health award. She works in private practice as a psychoanalyst and child analyst. She is a training analyst and supervisor of the Sigmund Freud Private University Vienna. For more details on her current occupations and publications, see www.agdari.at.

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Introduction

Introduction This chapter reviews the history of hoarding research in Austria, which began with the initiative of those affected to reach out and found a support group. As I move on to the current state of international research, I address terminology and definition issues. This is followed by an overview of different perspectives on social and cultural implications. Specifically, I explain the significance of material possessions in modern-day society as well as their role in creating a sense of security, providing a rationale behind the relatively new phenomenon of hoarding disorder. Particular emphasis is placed on the connection between consumer culture and hoarding symptomatology. Today, it is largely considered the norm to buy, consume, discard, and buy again. Alongside this throwaway cycle, other interconnections of society and hoarding are also revealed. In 2005, when a support group for people affected by hoarding was started as part of a new university for psychotherapy sciences in Austria, nobody was aware of the historical relevance of this event. The support group had arisen simply from the need of those affected to share their suffering with others. Up until then, participants had believed they were alone in their experience. Seeing there were others with the same kind of behavior initially provided them with great relief. At the time, people involved were unaware that they were dealing with a new mental disorder on the rise. No one knew just yet how many people were affected by hoarding behavior, or how great the psychological strain hoarding problems could cause. More and more individuals were actively seeking help. However, the resources to answer the demand for assistance was still lacking. As the professional community was only beginning to explore hoarding as a pathological phenomenon, there were no mental health experts available who fully understood this form of expression or could have offered their support. At the beginning of hoarding research, it was unclear whether the phenomenon described a way of life, a trend, or a mental disorder. Standard diagnostic tools used © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 N. Agdari-Moghadam, Hoarding Disorder, https://doi.org/10.1007/978-3-030-72342-2_1

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1 Introduction

to identify disease, particularly the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorder (DSM), did not yet include any such phenomenon as hoarding. Those affected, however, have always suffered considerable impairment and psychological strain in their day-to-day lives. Their tireless commitment and active participation gradually changed the picture and contributed to a broader awareness. Section 1.1 gives a more detailed overview of the history of hoarding research in Austria, specifically the role of Sigmund Freud University of Vienna. It is above all the phenomenon’s complexity and many different forms that continue to feed my curiosity. From the very beginning, my work with patients and later scientific discussions have been characterized by a certain kind of excitement, as if being involved in the discovery of something new. In 2013, the DSM-5 for the first time included a separate entry for hoarding disorder, confirming that a new mental illness was born. The official recognition of hoarding disorder shows just how relevant the issue is at present. The latest revision of the ICD-11 followed suit to list hoarding as an independent disorder in the obsessive-compulsive or related disorders category. This can be seen as a breakthrough for both the professional world and patients. Over the next few years it remains to be seen the extent to which the topic will become even more relevant. The inclusion of hoarding disorder in the DSM-5 and ICD-11 marked an essential step in the right direction toward providing relief for individuals with HD. While establishing a new mental disorder may be viewed critically, I would like to draw attention to the benefits this entails, including standardized approaches and methods applied in science and improved access to treatment in practice. The chapter on diagnostic considerations (Sect. 2.5) gives a more detailed account of the advantages and disadvantages of current research developments. Current research goals and objectives –  Studying hoarding in a clinical setting –  Combining and analyzing international research results –  Examining and classifying hoarding behavior from a psychoanalytical viewpoint –  Fostering exchange with colleagues, social workers, doctors, and caregivers –  Providing a survey of scientific discussions of hoarding disorder or compulsive hoarding

Over the last 80 years, several articles and reports have appeared about individuals who hoard. However, it was not until the 1970s that the scientific community began to publish relevant articles on PubMed. These publications have only been sporadic, and up to the release of the German edition of this book, a comprehensive guide to hoarding was still lacking. This book is the first practical guide for professionals that details the state-of-the-art in German-speaking hoarding research. It provides professionals from different disciplines concerned with hoarding with a complete guide to the definition, cause, development, and treatment of the disorder, directly addressing the need for diagnostic measures and therapy options for this very new disorder. The first part focuses on the beginnings of German-speaking hoarding research at Sigmund Freud University, Vienna. The scientific discussion of the phenomenon

1.1 History of Hoarding Research in Austria

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has intensified only recently, which is why the history of hoarding research in the German-speaking world is a rather brief one. At Sigmund Freud University and its outpatient clinic, pioneering work was carried out by an HD research group and professionals in the field. In addition to detailing this work, this introductory part also examines issues of terminology and definition, as well as the social and cultural factors of influence applying to hoarding. The second chapter is devoted to compulsive hoarding or hoarding disorder and provides several different perspectives. To help better understand hoarding phenomena, I begin by explaining preliminary theoretical considerations such as related to the underlying causes as well as symptoms and features of the disorder. The chapter concludes with problems of diagnosis, emphasizing the broad spectrum of hoarding disorder and a need to differentiate comorbidities. In the third chapter of this book, I provide an overview of current treatment recommendations and the unique challenges of HD treatment. The special issue of how to protect the interests of children and adolescents growing up in homes with hoarding parents shall be touched on. The chapter also demonstrates the benefits of and opportunities for interdisciplinary exchange. It presents a set of assumptions providing the foundation for a medical and psychotherapeutic treatment that helps us better understand and reduce the suffering of individuals affected by HD, and to finally induce behavioral changes. The fourth chapter supplements the theoretical and practical considerations presented in previous sections by discussing the psychodynamic aspects based on a set of case vignettes. The book is complete with a summary and recommendations for future research and some of the most common test procedures relevant to diagnosing HD.

1.1

History of Hoarding Research in Austria

In Vienna, the study of HD began with an interview on a radio show. Shortly after this interview in 2001, the group analyst Elisabeth Dokulil, née Vykoukal, began to offer group therapies for those affected. From the very beginning, the demand was high. Due to Dokulil’s initiative and continuing efforts, Sigmund Freud University established the first Austrian self-help group for individuals with HD as part of its outpatient clinic in 2005. It was a happy coincidence that I was allowed to participate in this group as a student. The group was exceptional in that it proved difficult for participants to appear in scheduled meetings. They were unable to meet regularly and continuously at the same time and place. Gradually, we came to understand the reasons and motives for this inability and created a framework to accommodate it. I was part of a student group at Sigmund Freud University to offer assistance and support to the participants of this self-help group, using participant observation. This method is still practiced at Sigmund Freud University today. The intensive involvement with HD patients provided me with a unique opportunity to delve into their lives and better understand their day-to-day problems. It was an excellent opportunity to gain first-hand experience with hoarding behavior

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and learn about it from a practical perspective. This intensive involvement also enabled me to learn about group dynamics in a self-help setting. Soon after the self-help group for patients started, the need for self-help groups for relatives became evident. Intervision and supervision groups formed, allowing psychotherapists at the university outpatient clinic to offer individual and group therapy. In the next years, the study in the field intensified, and publications on HD followed. Over the years, we have hosted four HD conferences at Sigmund Freud University. We saw another milestone when our HD research group won second place in the 2008 competition for the City of Vienna Health Award. Over the years, I have been able to work with many HD patients, developing a close familiarity with their problems and practices. After completing my training as a psychoanalyst, I started offering therapy to individuals with HD. I also work with professionals, inviting them to participate in my seminars and supervision sessions. This exchange also inspired the idea of this book, aiming to provide psychotherapists, doctors, psychologists, social workers, family assistants, and others professionally involved in HD with a practical guide in treating affected individuals.1

1.2

Terminology and Definition

There was neither an exact term nor a precise definition of hoarding disorder in the German-speaking world until standard diagnostic manuals included the illness. However, the latest German revision of the ICD has not yet come into effect, which is why there is still a certain degree of variation in terminology and definition. Researchers refer to compulsive hoarding behavior as “Messie-Syndrom” [1], “Vermüllungssyndrom” [2], “Diogenes-Syndrom” [3], “Organisations-Defizit-­ Störung” [4], or “Desorganisationsproblematik” [5]. In the early 1980s, American and German self-help movements mainly used the word Messie to describe hoarders. Sandra Felton, herself a hoarder, was the first to use the term, describing the mess associated with compulsive hoarding. However, the problem with this term is that the ending in ie appears belittling. It is hence inappropriate, rendering it unfitting for use in professional discourse. In the German-­ speaking world, hoarding disorder was one of the first mental health problems patients themselves had brought to the professionals’ attention. It is, therefore, hardly surprising that confusion as to its terminology would arise. Professionals are still working to create a standard language and criteria to differentiate diagnoses. The global English-speaking community has adopted the term hoarding from American research early on. Initially, the name was strongly associated with OCD (compulsive hoarding). In 2013, however, hoarding was included in the DSM-5 as a separate, isolated disorder (hoarding disorder). The ICD-11 now lists hoarding in the obsessive-compulsive disorders category.

1  For the sake of readability, I henceforth refer to this group of people as professionals or mental health professionals.

1.2 Terminology and Definition

5

Hoarding derives from hoard (German Hort), which etymologically describes a hidden treasure, hiding place, or cave. The word was extinct in Middle High German and revived later through the discovery of The Song of the Nibelungs ([6], p. 423). From a psychological perspective, these etymological roots, meaning treasure and hiding place, is particularly impressive. The historical use of the word is almost equally fascinating. At the beginning of the twentieth century, before the term became more common, it primarily described money and gold values ([7], p. 558). Although this usage has become almost obsolete and people today no longer associate hoarding with accumulating money or gold, it is essential to know that compulsive hoarding indeed reflects the idea of keeping a treasure. Especially from a psychoanalytical point of view, the root of the term, therefore, points to the unconscious deeper meaning of hoarding. Another term often used in the context of compulsive hoarding is collecting. The practice of collecting, however, does not capture the suffering associated with hoarding and the complexity of these behavior patterns. Therefore, it is recommended to clearly distinguish the rather everyday practice of collecting from hoarding disorder. Individuals affected by HD do not have collections; objects accumulate unintentionally. The objects they hoard do not belong to a specific set of items, even though individual preferences may play a role. While some individuals tend to accumulate paper items, including books, magazines, or newspapers, others are more inclined to acquire technical devices. Such preferences, however, do not make hoarders collectors. Collectors follow a systematic approach, where they organize items according to specific criteria such as date or design. Hoarding, however, arises from the subjective urge and inability to give anything away. The verb to collect stems from the suffix col-, which originally meant together. The same applies to sammeln in German, which, based on the suffix sam-, refers to gathering objects together that are similar ([6], p. 783). Individuals with HD do not collect items in that they do not select and organize them deliberately, at least not in the traditional sense of collecting. Consequently, professionals recommend using the term hoarding in English and Horten as its German translation. In the German-speaking literature, the phenomenon has primarily been translated as pathologisches Horten (pathological hoarding, hoarding disorder). In line with scientific discourse, I also preferably used the term throughout the German edition of this book. One should also note, however, that Messie-Phänomen (messy phenomenon), Messie-Syndrom (messy syndrome), and pathologisches Horten have evolved alongside each other and are to be understood synonymously. A standard translation of hoarding disorder is currently pending. At the time of writing this book, the German edition of the ICD-11 was still a work in progress. Some evidence suggests that the term will most likely be translated as pathologisches Horten. A translation as zwanghaftes Horten (compulsive hoarding) or Sammel- und Hortstörung (collecting and hoarding disorder) does not seem to sufficiently incorporate the psychodynamics of the phenomenon. These terms also do not account for the patients’ inability to discard objects. The term pathologisches Horten may not

6

1 Introduction

be ideal as it describes hoarding as pathological. However, it does help us take hoarding patterns more seriously and reduces the chance of belittling those who are affected or even fall into ignorance of their suffering. Individuals with HD do not collect items in that they do not select and organize them deliberately, at least not in the traditional sense of collecting. Consequently, professionals recommend using the term hoarding in English and Horten as its German translation.

1.3

International State of Research

HD or compulsive hoarding has received tremendous media attention in recent years. Patients have written self-help books for other patients, and many guidebooks have circulated. Self-proclaimed hoarding experts have entered the picture and continue to shape widespread conceptions. This book is meant as a practical guide for professionals in the field. Relevant literature has been reviewed carefully in the preparation of this book, aiming to provide readers with a compilation of the most insightful findings made so far. This chapter gives an overview of the current state of research, as this is important for any serious discussion of the matter. To give a holistic view of hoarding and its scientific discussion, I also look at how the disorder has developed in the Anglo-American world. What were the most significant developments and achievements of Anglo-American research in the field? What are the research interests of reputable international scientists? These and related questions shall be answered in the present section. I would particularly like to draw attention to the Scientific Community, a group of interacting scientists active in the English-speaking world, particularly the USA. The work of this group clearly distinguishes itself from self-help counseling. It is how the disorder is displayed, which sets the scientific approach apart from the sensational and often repellent form of presentation adopted by popular science. Whenever we speak of a new mental disorder, it is important to share new insights and knowledge worldwide, particularly diagnostic tools. It is vital that diagnoses follow uniform criteria, regardless of whether they are made in Austria, Texas, or India. The requirement for standard diagnostic systems and globally applicable treatment options was also one of the central reasons to create the ICD. A critical reflection on the underlying difficulties with such diagnostic manuals is presented in Sect. 2.5. In 1975, PubMed yielded the first-ever result for the search term hoarding. The article was titled “Diogenes Syndrome: A Clinical Study of Gross Neglect in Old Age.” With this first study dating back less than 50 years, hoarding research in its infancy. In German-speaking countries, the Diogenes Syndrome was first mentioned by Joachim Klosterkötter and Uwe Henrik Peters. However, they only discussed the phenomenon in the context of geriatrics [3]. In 1987, the American Journal of Psychotherapy published the article “Compulsive Hoarding” [8]. In 1990, the article “Hoarding as a Psychiatric

1.3 International State of Research

7

Symptom” [9] appeared in the Journal of Clinical Psychiatry. It was with this publication that the subject finally began to attract greater scientific interest. In the early 1990s, a few isolated discussions followed. By the mid-1990s, scientific interest had drastically increased to the extent that numerous psychological and psychiatric publications have been produced every year since. However, German-speaking literature on hoarding has remained scarce. The most seminal German-language works are the following: The work of Gisela Steins first focused on hoarding from a socio-psychological perspective. She introduced the concept of disorganization [5]. Renate Dettmering coined the term Vermüllungssyndrom, literally clutter syndrome. The psychiatric phenomenon she described was characterized by social isolation, cluttering as a form of relief and panic reactions to removing the clutter [2]. The Swiss Annina Wettstein first applied a cultural science approach to hoarding in 2005 [10]. In Messies—Sucht und Zwang, the psychoanalyst Rainer Rehberger presented several case studies demonstrating parallels between hoarding and obsessive-­ compulsive disorder as well as severe attachment problems in the histories of those affected [11]. In the meantime, Sigmund Freud University had applied an interdisciplinary approach to the subject. Their research combined psychotherapy and psychiatric results and later published them in the anthology Das Messie-Syndrom [1]. More recently, significant German-language contributions were made by the naturopath Veronika Schröter, who published her book Messie-Welten in 2017 [12] and by Katrin Külz and Ulrich Voderholzer with the 2018 [13] manual Pathologisches Horten. The first known case of excessive hoarding became public in the late 1940s with the death of the Collyer brothers. Homer and Langley Collyer came from a wealthy and educated American family. The two became known for their eccentric lifestyle. They lived in seclusion and social isolation in their house in Harlem, New  York City. The windows and doors were blocked and traps installed throughout the house. After their parents had died, the brothers continued to live in the house alone, completely shut off from the rest of the world. When someone reported the smell of decomposition emanating from the Collyer house, the police broke into the building and found the two brothers were dead. At first, they only found Homer Collyer, who had died of thirst. Days later, Langley, who had been nursing his sick and blind brother, was also found dead. The police reported that he had released one of his traps and been buried underneath debris. Following this discovery, the police removed over 100 tons of material from the house [14]. This first public case of hoarding was moving and shocking at the same time. It is this strangeness within others, the abnormal, that both attracts and repels us. As I mentioned previously, the academic and scientific interest was sparked by the self-help movement. Clinical psychologists and psychiatrists have increasingly become interested in hoarding from the early 1990s onward. Remarkable work in the field is done by Randy Frost, Professor of Psychology at Smith College, Massachusetts; David Mataix-Cols, Professor and Psychologist at the Karolinska Institutet in Stockholm; David Tolin, Clinical Psychologist at Yale School of Medicine, Connecticut; and Jack Samuels, Associate Professor at Johns Hopkins

8

1 Introduction

University, Baltimore. Their research teams each must be acknowledged for their pioneering work in the field. With his publication of “The Hoarding of Possessions” in [15], Randy Frost has laid the foundation for his research. His team has published several studies on the topic every year since. David Mataix-Cols has contributed several studies, particularly regarding the relevance of establishing hoarding as an independent disorder.

1.3.1 Relevance for Psychoanalysis Reviewing the current literature on hoarding, one could get the impression that psychoanalysis does not provide answers or treatment options. Psychoanalysis almost seems to have fallen into oblivion in the face of global psychology or psychiatric research. The behavioral approach overshadows all other theories, apparently offering answers to any questions pertaining to the human psyche and mental illness. However, there are several studies that suggest otherwise, one being “Diagnosis and Assessment of Hoarding Disorder” [16]. It is one of the very few works that touch on the work of Sigmund Freud and Erich Fromm, even if just in their introduction. The research cites the “anal triad” formulated in Freud’s drive theory, pointing to its decisive role in theoretically conceptualizing obsessivecompulsive disorders. The authors of “Hoarding Versus Collecting” also refer to Freud and Fromm: In contrast to the theoretical conceptualizations of hoarding offered in previous work (Freud, Fromm), these operational criteria were intended to define the features that characterize hoarding at a pathological, rather than merely idiosyncratic, level. ([17], p. 167)

The theory of psychoanalysis is much more than the mere enumeration of idiosyncratic personality traits. Psychoanalytic models offer methods to gain an etiological understanding of psychological phenomena. The normal originates in the pathological, yet at a stage of development when the pathological still forms a part of normal development. Freud claims to have studied neuroses to develop a deeper understanding of psychoses. He regards psychoanalysis as providing the foundation for an understanding: People are beginning to understand – best of all, perhaps, in America – that the psycho-­ analytic study of the neuroses is the only preparation for an understanding of the psychoses, and that psycho-analysis is destined to make possible a scientific psychiatry of the future which will not need to content itself with describing curious pictures and unintelligible sequences of events {…} ([18], p. 205 ff.)

Studying psychoanalytical work in relation to the pathogenesis of disorders and symptom formation yields numerous opportunities to explain and treat mental illness. It is striking that many of today’s assumptions and research results are rooted in psychoanalytical theories and concepts, which have postulated them early on. This is why, in this work, I generally cite the primary sources from which these psychoanalytical ideas and schools stem.

1.3 International State of Research

9

Initially, Anglo-American research groups regarded hoarding as a symptom of obsessive-compulsive disorder; only after several years of research did a more critical approach emerge. It can be assumed that this classification of hoarding under the broad umbrella of obsessive-compulsive disorders originated in the clinical setting. In the US, the first studies on hoarding were conducted at clinics with hundreds of patients already diagnosed with OCD previously. Sigmund Freud University has taken a more exploratory approach from the very onset of research. This approach attempted to experience, describe, and document the phenomenon as such. In other words, Austrian research into hoarding has developed from a psychoanalytical approach known from ethnopsychoanalysis. Students accompanied the university’s self-help group and enabled researchers to experience and observe patients unaffected by any previous hypotheses. Sigmund Freud and later Béla Grunberger already postulated the unique role of doubt in obsessional neuroses. An extensive study with more than 1100 subjects confirmed this characteristic trait of obsessive-compulsive disorder (cf. [19]). Thomas Maier has published the most recent scientific discussion of pathological hoarding in Switzerland. Citing the DSM-5 and the problem of defining hoarding patterns, the author explores the question of whether hoarding is a symptom or a syndrome. Maier examines the differences between the symptoms of pathological hoarding and obsessive-compulsive hoarding and concludes that hoarding is distinct in that it lacks the intrusive and ego-dystonic character [20]. According to psychoanalysis, the intrusive character of OCD arises from obsessive thoughts and actions. However, pathological hoarding reflects another aspect of OCD, namely that of being unable to discard or part with possessions. Therefore, the symptoms are neither intrusive nor ego-dystonic. International studies soon came to recognize the connection to obsessive-compulsive behavior. Tests demonstrated an overlap of patients with obsessive-compulsive disorder and those who exhibited symptoms of hoarding. Psychoanalytic models have associated hoarding symptoms with the spectrum of obsessive-compulsive disorder from the very beginning. This mutual agreement of scientific and clinical theories is remarkable. There are very few studies on hoarding in child and adolescent psychiatry, yet there is evidence to suggest some compelling connections. Hoarding tendencies often become apparent as early as in childhood, meaning that they could be treated early on. The Canadian study “Three Reasons Why Studying Hoarding in Children and Adolescents Is Important” defends the need for early treatment. The authors argue that the symptoms of hoarding first appear in childhood and consequently develop chronically and persist into adulthood. Hoarding is also associated with a variety of negative experiences and consequences (see [21]). When diagnosing children and adolescents, we have to remember that they repeat and intensify developmental phases. They are also just learning how to deal with their aggressive and sexual impulses, which often finds expression in untidy rooms and a resurgent pleasure in the anal, or the “dirty.” It is decisive for a child’s psychosexual development if this is just a phase, eventually completed successfully, or if parts of this behavior become chronic as an integral part of their personality.

10

1 Introduction

Problems related to this stage of development usually only become apparent when affected individuals move out of their parental home into a place that they have to take care of on their own. This is when pathological hoarding tendencies also become visible for the first time. A study of 109 children diagnosed with anxiety disorder found that in 22% of the cases, the parents exhibited hoarding behavior. The participating children with an inclination to hoard also demonstrated higher scores regarding aggression, attention problems, fearfulness, obsessive-compulsive behavior, or symptoms of depression. The results suggested a clear connection between these behavior patterns and emotional dysfunction. In principle, it can be said that affected children exhibit not just one, but multiple patterns of abnormal behavior. Further research will be required to develop a more substantial picture of how anxiety disorder, attention deficit disorder, and pathological hoarding intersect (see [22]). Psychoanalytic developmental science suggests that much of the behavior that may manifest itself as a mental disorder in adulthood can be observed in children as part of ordinary developmental phases. Relevant studies emphasize the profound and indisputable importance of child and adolescent psychiatry, as well as child and adolescent psychotherapy, in studying and treating later mental disorders. Notwithstanding, we also have to address the question of the extent to which pathological hoarding may be genetically determined or passed on through identification. Pathological hoarding behaviors are reported more frequently in families, especially among first-degree relatives [23]. Exploring the nature-nurture problem in greater detail, however, would go beyond the scope of the present discussion. Professionals should still bear this possibility in mind when working with hoarding patients. Hoarding behavior is reported more frequently in families. Professionals need to be aware that family members—especially first-degree relatives—are very likely to develop similar hoarding patterns.

1.4

Social and Cultural Factors

Which social factors influence hoarding behavior? Which future developments can we predict today? Social and cultural criticism represents an essential component of psychoanalytic tradition. Consequently, the social and cultural implications of hoarding disorder shall also be reviewed in the present work. Particular attention is drawn on the role of consumption and possession in hoarding. The characteristic manifestation of hoarding symptoms requires us to look at models and concepts of the closely related humanities. It should be noted, however, that I have written this practical guide primarily based on psychological, psychotherapeutic, and psychoanalytic research. The inclusion of findings from related disciplines grounds in the motivation to provide a well-founded practical guide, aided by an interdisciplinary view on hoarding patterns. The social implications of hoarding disorder prompt me also to incorporate a sociocultural perspective into the discussion. However, a complete representation of relevant sociological and ethnological concepts is not

1.4 Social and Cultural Factors

11

possible in the present context. This chapter thus reflects the tension arising from the necessity to include a multidisciplinary approach and the difficulty of discussing ideas and theories of other sciences in more depth. It is to be hoped that, once the ICD-11 has fully established hoarding as an independent illness, interdisciplinary research groups will contribute to a deeper and more complete understanding. Against this backdrop, the present chapter addresses the following questions: –– What social factors should we consider when including a mental disorder in the diagnostic system? –– What does this striking phenomenon reveal about the society in which it originated? One of the aims of this chapter is to provide an overview of the dominant social factors of influence on the hoarding phenomenon. How can society contribute to the way we handle objects and their possession? What on-going developments can we observe, and what is our responsibility? Is it a coincidence that hoarding patterns are increasingly becoming manifest in this specific shape and form, or can this development be attributed to social developments of our time and place? In this context, I also aim to discuss how far establishing a mental disorder through diagnostic manuals is relevant for health insurance companies and in the broader economic context. Consumption Possession is an essential component of hoarding behavior. The urge to want to possess different objects represents a core aspect of the phenomenon. However, the inability to let go is far more critical in the development of this disorder than the act of acquiring objects. Merely consuming objects without displaying a marked difficulty to discard the used objects would not constitute a disordered behavior. On the contrary, this circle of consuming, disposing of, and re-consuming commodities reflects everyday practice in modern American and European societies. It is, therefore, considered the norm rather than deviant behavior. Consumption describes our way of dealing with things. It is more than just about buying items, denoting a process by which a commodity becomes a personal good. The concept of consumer culture defines our handling of things no longer as a mere consequence of production, but as an independent behavior. This view has been criticized particularly concerning its separation of production from consumption (see [24], p. 52 ff.). Fetishism Any attempt to explain our peculiar relationship to inanimate objects from a psychoanalytic perspective will be incomplete without considering Freud’s article on fetishism [25]. The Freudian fetish concept and social factors of influence also relate to the theories of Karl Marx, most importantly, the commodity fetish. If we want to better understand the social causes of hoarding disorder, we must become familiar with the Freudian and Marxian perceptions. As the focus of this

12

1 Introduction

book is on the theories’ relevance for hoarding research, it only marginally discusses their relationship. Other works provide an in-depth analysis of how the theories of Freud and Marx interconnect. Marx sought to explain the historical genesis of capital, whereas Freud was primarily concerned with the connections between individual attitudes toward money and their origin in childhood attitudes toward feces. Wolfgang Harsch addresses the relationship between Marx and Freud as follows: According to Marx and Freud, intellectual products are unconsciously determined by material products; those made by hand by Marx and those made by the body by Freud. While Freud diagnoses and treats the individual, neurotic attitude towards money, Marx diagnoses the pathology of an economic epoch, the capitalism. ([26], p. 450)

Despite these contradictory aspects, Harsch also argues that there are several parallels between Marxian and Freudian thought. He observes that there is a shared interest in the de-fetishization described by Helmut Dahmer [27]. Even if this may be true, psychoanalysis, by its very nature, is not tied to any ideology or political interest. It represents its own independent discipline that cannot be considered subordinate to any such beliefs. On the contrary, analyzing, interpreting, and developing an understanding of unconscious structures can be rooted only in an independent, emancipatory system. Freud considers the fetish as a construct to deny female castration and believes that the removal of gender differences plays a crucial role in this context. The fetish can be seen as a token of triumph over the castration threat, also protecting against it ([25], p. 154). In this sense, fetishism represents a form of compromise. Another aspect worth considering in this context is Freud’s argumentation for the apparent autonomy of desire. The fetish constitutes a substitute for the male genitalia and is easily accessible. Where others have to make an effort and exert themselves, the fetishist can easily obtain sexual satisfaction. Freud’s interpretation of the fetish is also distinguished by its ambivalence, for the fetishist simultaneously experiences feelings of affection and hostility (cf. [25], p. 149 ff.). This psychoanalytical view of the fetish is of particular interest to the hoarding phenomenon. This is because the core of hoarding problems seems to lie in the inability to separate from things: to dispose of them and throw them away. It is loss, separation, or fear of impending castration that makes the accumulation of things a necessity. Hoarding can even be understood as a re-enactment of this underlying fright of castration. At first, material goods such as objects, papers, or clothing are assigned a distinct, almost physical meaning. The fear of castration resonates with accompanying fantasies on a subliminal level. When the homes of those affected are vacated, as is sometimes necessary, this underlying fear becomes a reality. In this context, we also have to be aware of the complicated relationship between castration fear and separation anxiety. According to Freud, separation anxiety represents our prime fear: the fear of losing objects. This is interesting in so far as mainstream psychoanalysis quotes Freud’s ideas as one-person psychology. From these depictions, one could assume that Freudian concepts exclusively focus on

1.4 Social and Cultural Factors

13

intrapsychic events. Research often neglects and denies that Freud’s work has always allowed for the existence of the other. Consequently, intersubjectivity theories cannot claim to be original in this sense; they only draw attention to specific aspects. Broadly speaking, the fear of loss and separation is our first fear, whereas the fear of castration is characterized by a heightened intensity, mainly due to its highly narcissistic markedness. (The case vignettes presented in Chap. 4 document and emphasize the distinct nature of fear of loss and separation). However, this does not imply that the fear in birth is simultaneously the first instance where a child experiences castration fear. In other words, the anxiety in this context does not arise from the equation of the child with a penis. For although birth signifies an objective and physical separation from the mother, the narcissistic infant is not able to perceive and interpret the event of separation as such (cf. [28], p. 161). Most relevant to hoarding are the antecedents of the castration complex: weaning and sphincter training. According to Sandor Ferenczi, castration would result in the definite separation from the mother, where a reunion would be impossible (see [29], p. 90 f.). This needs to be taken into account, especially when hoarders are forced to vacate their homes and part with the accumulated objects. The forceful evictions often initiated in excessive hoarding revive early subliminal fears. Extreme psychological reactions usually accompany such reactivation of original anxieties. To facilitate the understanding of hoarding in this context, I would like to refer back to Grunberger’s considerations. Grunberger argues that the fetish represents an anal part-object that unites the full spectrum of anal dimensions. The anal part-­ object is given not only sexual but narcissist significance. An individual with a fetish oscillates between the fear of castration and the fear of their own aggression. The fetishist projects their anal conflict and narcissistic impulses onto the inanimate object, thereby attempting to resolve the inner dispute. The fetish, a reversed phobic object, dominates (see [30], p. 123 ff.). Yet, the perceived relief from the conflict represents only the other side of the coin. The underlying conflict between the fear of castration and the fear of one’s own aggression persists. Through the possession of the objects, feelings of powerlessness can be diminished, and anxiety can be subjectively controlled. Following the above considerations, it shall be noted that the disorder also serves a specific purpose, namely reducing the patients’ fear. In this sense, we may even regard HD as having a beneficial component. As with other mental disorders, the symptoms have an underlying dynamic that professionals should consider in treating HD patients. The processes occur unconsciously, unintentionally, and above all, they are inaccessible at first, both to the affected individual and the psychotherapist. Only through psychoanalytic psychotherapy can the unconscious be made conscious, step by step. According to Freud, fetishes represent a magical quality attributed to objects. Individuals with a fetish for a specific commodity or the commodity in general regard these things as inherently valuable. It is vital to recognize that their conflict

14

1 Introduction

constitutes a compromise. Often, the individual objects are no longer recognizable; everything combines to a mixed whole. Commodity Fetishism The belief that commodities have fundamental value, also known as commodity fetishism, is deeply rooted in Marxism. Marx explained the underlying concept of commodity fetishism based on people’s tendency to ascribe subjective qualities to commodities. A commodity is therefore a mysterious thing, simply because in it the social character of men’s labour appears to them as an objective character stamped upon the product of that labour; because the relation of the producers to the sum total of their own labour is presented to them as a social relation, existing not between themselves, but between the products of their labour. (Marx [31])

In commodity fetishism, products of human labor become independent entities: commodities with a life of their own. Social relations between humans are translated to the relations between goods or cost prices (see [31], p. 49 ff.). Commodity fetishism starts by interpreting the relations between people. This is why capitalist societies often exhibit a distorted view of human interaction. It originated in the initial aim to determine the price and value of labor. In the 1950s, when consumerism faced sharp criticism, the concept of commodity fetishism changed. Since then, it has denoted people’s attitude toward things rather than the relation between the objects themselves. A decisive factor in this development was the emergence of advertising and the promises regularly made in marketing. Commodity fetishism is now no longer about exploiting labor in the Marxian sense, but about integrating consumers into capitalist production and the resulting loss of individual independence (see [32], p. 234 ff.). On that note, hoarding becomes apparent as a disorder that is specific to our time and culture. Hoarding patterns the way we experience them today could have only emerged and developed in a consumer society. The origin of hoarding not only lies in capitalist societies in the narrower sense and in the consumption of goods in the sense of acquiring and consuming; above all, it resides in our overarching approach to objects. The way we handle objects has fundamentally changed. Material culture has molded our society, both in industrialized and developing countries. Marx’s underlying assumption that goods are essentially made by humans and can be charged with narcissistic value is becoming obsolete in modern-day society. The division of labor, technical progress, and on-going conflation of cultures and societies as a result of globalization do not allow for simple connections between the development, production, purchase, and consumption of goods. These socially and culturally relevant developments are also essential in dealing with a new disorder, especially in times when it is difficult to escape the omnipresence of goods. It is obvious that if we experience fundamental difficulties with getting rid

1.4 Social and Cultural Factors

15

of things and disposing of them, we can easily lose control over the number of things we own. An ethnological and philosophical examination of these issues would undoubtedly yield interesting insights; however, it would go beyond the scope of this chapter. Consequently, I shall get back to the questions that have prompted this chapter. In how far is it relevant for health insurance companies, businesses, and the economy in general that a new mental disorder is included in standard diagnostic manuals? It is mainly economic interests that are at stake here. In many countries, health insurance companies cover treatment costs for officially recognized illnesses. Funds are made available for research. For example, both Germany and Switzerland ensure the costs of psychotherapy are covered for all people. Austria as of yet has no comprehensive plan to provide free access to psychotherapy nationwide. The costs are generally high and systems are not fully developed. Up to this day, there have only been a handful of research groups worldwide working on pathological hoarding. A significant change is expected in the coming years. Alain Ehrenberg’s work [33] will be particularly relevant to any future investigation into mental illness and its social implications. The central questions in future research will be: Does society influence subjective suffering, and, if so, in what ways? Is a dialogue between external conditions and internal instances and conflicts conceivable? In his paper “Das Unbehagen in der Gesellschaft” Ehrenberg undertakes a comparison between French and American societies and reveals some remarkable results. He traces the development of diseases in the last century and describes relevant changes within psychoanalysis in both countries. A vivid language and strong emphasis on terminology, including terms such as narcissism, ego-ideal, splitting, and identification, have transformed the neuroses into a social pathology. These mechanisms are also at work in the emergence of hoarding as a mental disorder of our time. Individual psychological suffering is associated with social and sometimes political structures. This shift in focus, Ehrenberg explains, can be seen as a part of a more general phenomenon, eventually inducing a shift in psychiatry toward mental health: In contrast to traditional psychiatry, mental health affects not only the health, but also the ability of sociality among today’s people. ([33], p 499)

This focus on people’s mental health enables us to recognize personal suffering as a problem we all share, thus giving more considerable significance to individual misfortune. This is also where the relevance of the diagnostic manuals becomes apparent for us all. The social awareness of the disease increases with the inclusion of an emerging mental disorder in the existing classification systems. Of course, this entails both advantages and disadvantages. It can be assumed that hoarding will be of great interest for television, probably even more so than is already the case. For example, in the USA, David Tolin, Professor at Yale School of Medicine, has been involved in the production of several shows on hoarding disorder. The social factors of influence are strongly dependent on cultural aspects

16

1 Introduction

and will be different in the Anglo-American world than in Europe or, for example, Asia.

1.4.1 The Meaning of Objects in Our Society If we take a closer look at living spaces cluttered with inanimate objects, the Freudian image of Pompeii’s burial surfaces. Freud understood this image as a metaphor for repression, preserving something emotional yet isolating it where it can no longer be accessed. Freud’s early work is strongly influenced by the idea of catharsis. Ideas and scenarios shed light on hidden emotions, removing layer after layer. Cluttered homes evoke this sense of something lying hidden, buried, and conserved. Historically, layer after layer also becomes preserved. With things being added, collected, carried from one place to another, the younger is closer than what is further away in time. Because of the accumulation of things, it is very often difficult or even impossible to clean the rooms. Most of the time, dust collects everywhere, providing another protective layer. This layer separates hoarding individuals from the outside world, almost as if it could protect them from the possibility of being injured or insulted. Randy Frost has been particularly interested in information processing and forms of memory in his work as a clinical psychologist. Frost points out that hoarding individuals store experiences and information in “layers,” whereas most other people store them in clusters. He [34] argues that memories are usually structured according to context or phase of life, such as school years, professional life, leisure activities, etc. HD patients, on the other hand, create stacks and layers of memories. The current things and objects are close at hand, and that which lies in the past is physically located beneath these more recent layers. This also means that there is a basic form of organization and order in hoarding behavior. Collecting is a cultural achievement. In his 1930 essay, “Civilization and Its Discontents,” Freud provides a clear yet forceful definition of culture: culture is “the whole sum of the achievements and the regulations which distinguish our lives from those of our animal ancestors and which serve two purposes—namely to protect men against nature and to adjust their mutual relations.” ([35], p. 89). Freud draws attention to three components of the resulting requirements of civilization. They reflect both the achievements of a culture and the level of civilization a country has achieved: beauty, cleanliness and order. (ibid.). Most individuals with HD do not collect at all, i.e., not in the traditional sense of collecting. According to Manfred Sommer, collecting is the gathering together of what belongs together yet has been scattered so far. “The same things are always collected.” ([36], p. 26). It requires a plan and a goal, which clearly distinguishes collecting from hoarding. A hoarder’s experience is characterized by the feeling that things accumulate in their homes, rather than being actively gathered. If we do not constantly sort, tidy up, and dispose of things, such accumulation is a logical consequence of life. We buy things or receive them as a gift and bring them home.

1.4 Social and Cultural Factors

17

Occasionally, we can find collections among all this clutter, such as a stamp or a mineral collection. However, these collections are rather rare. What is both striking and interesting is the amount of paper that typically piles up in homes: scripts, magazines, books. Ernest Jones already mentions a close connection of printed matter, especially books, and feces. He believes that this symbolic relationship arises from the underlying idea of pressing, smearing, or imprinting (see [37], p. 128 ff.). This symbolism also correlates with the interpretation of hoarding behavior as reflecting an unconscious taboo pleasure. Another aspect of the printed matter is that it provides orientation in society and in the world. In this sense, it can also be seen as representing a form of motherly care. These aspects of hoarding, however, need to be evaluated in individual therapy. The material accumulated in homes of individuals with HD, especially paper, can perform various functions. Since magazines, books, and all other printed articles very often make up the majority of the clutter, we have to pay special attention to this aspect. It is also interesting to note that the German term Materie, the English matter, and the French matière derive from the Latin materia, which can be translated as wood, timber, or lumber, as well as task, disposition, and talent. In his interpretation of dreams, Freud points out the importance of wood as an unconscious symbol of the female. This is because it represents a material out of which things are made (cf. [38]). The first object relationships and, consequently, the early relationships with the mother, the father, or other prime caretakers are of essential importance. Another striking feature of some individuals with HD is their veneration of the dead. In almost every home, one can discover multiple possessions of relatives who have already died, often packed in boxes and not yet processed or sorted. This resonates with Werner Münsterberger’s theory on the collection of ancestral remains. Münsterberger describes the collecting of ancestral bones and skulls as a special form of denial, a mixture of conscious fear and unconscious aggression. On the one hand, the collected bones provide proof that a person no longer exists. On the other hand, death is denied through the assignment of some magical power to the deceased (cf. [39], p. 96 ff.). One could even say that, today, it is no longer just the skull or individual bones that are collected and arranged on an altar, but—citing Johann Wolfgang von Goethe—all possessions: “What you inherit from your father must first be earned before it’s yours” ([40], p. 28). Hoarding may reflect a form of denial and undoing. It serves as a strategy to disavow loss and separation, as well as aging and even death, hence satisfying the desire for everything to remain as it is. The boundaries between the living and the inanimate become partially removed and distinctions are no longer valid. Things are perceived as having a soul, and as such they can be loved in a way that we usually only love humans and other living beings [41]. In the following, I present some sociological and philosophical aspects of goods, value, and money. These considerations are relevant to the study of hoarding

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because, as part of the collective unconscious, they can also be considered as a vital part of our living environment. Sociological and Philosophical Aspects Georg Simmel was one of the great pioneers of sociology, who described the way money influences not only our relationship with things, but also the relationship between things themselves. His work theorized the objectification of values: The value of things seems to us to be a feature of things, which of course can’t be, since an object does not have a value in the sense that it e.g. has a color. (cf. [42], p. 113)

This aspect is particularly interesting because persons with HD often argue for value of things they accumulate. Logical arguments can hardly convince them to part with objects, as their subjective value is substantial. This also means that hoarding may not be about things per se, but that it is about the value ascribed to them— what they mean to the individual, what they remind them of, what they represent. Only once the underlying principle is understood can the symptomatic behavior be changed. The personal attribution of values, however, renders change or the reduction of things difficult in most cases. Sometimes, a minimal standard of required order is the only way to ward off an eviction. According to Simmel, traditional values are continuously being replaced by new monetary values. Connection seems to be replaced by freedom, whereas this freedom does not yet know any specific goal. If, for example, a farmer sells his house and farm, it initially gives him freedom but he also loses a “a reliable object for his personal activities” ([43], p.  144). This illustrates that the changed meaning of things is inevitably accompanied by an experience of loss. On the other hand, the fact that the increasing exchange of property and services for money is depersonalizing life, becomes an occasion for a search for new and more deeply perceptible styles and symbols that want to compensate for this loss. (ibid., p. 146)

From this point of view, it becomes clear in how far the hoarded objects have a balancing effect. The meaning of objects surrounding us has changed. “We live by object time,” Jean Baudrillard notes, meaning that we let the rhythm of objects dictate our daily lives. We observe things as they are made, develop and finally become useless. In earlier cultures however, Baudrillard continues, objects were permanent and survived entire generations ([44], p. 43 ff.). In the process of evolution, other materials were discovered and we started making objects mechanically. Very few things are continued to be made by hand. In order to understand the meaning of objects, we are required to touch on the field of ethnology, particularly so-called material culture. An in-depth discussion of this field would go beyond the scope of this book. Therefore, I focus on the aspects that are relevant to the study of hoarding and intend to give a condensed overview.

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Material culture defines materials, objects and their significance in a specific culture or community. Material culture is the sum of all objects used in a society, whereby it is not so much about the meaning of the objects as such, but about the way they are included in the daily lives of people. Material culture studies also deal with the question of whether humans actually produce objects or only use them (cf. [24], p.  18 ff.). Collaboration between researchers in psychoanalysis, ethnology, and cultural philosophy could yield interesting findings. Often it is more expensive or complicated to repair things than to buy them new. This is one of the principles of consumer culture. What does it mean to be an individual that does not throw anything away or only very little in a society that is fundamentally built on such principles? Consumption depends on us throwing things away and on things not lasting forever. Individuals who hoard seem to have turned away from these very social values. Baudrillard even speaks of a “garbage-can sociology: tell me what you throw away and I’ll tell you, who you are!” ([44], p. 60) Hoarders have difficulties with exactly this act of getting rid of objects. If we look at the diagnostic criteria laid out by the DSM-5, we will see that the core problem is not to be found in possession, but in loss or separation—in getting rid of something. Consequently, hoarding is a form of rejecting the throwaway and consumer society of our time. A notable exception is individuals with hoarding disorder and symptoms of shopping addiction. On a conscious level, hoarding is very much about the availability of things. Objects should be there when we need them. Many HD patients hoard things of the same kind, especially objects of everyday use. This seems to be an expression of the patients’ speechlessness. Something needs to be articulated. Yet, they do not have the means, or any means other than hoarding, to express it. Things can be acquired independently and at any time. This freedom creates a feeling of independence and allows people to enact apparent autonomy and the emancipation from human relationships. Housing Housing has a central role in hoarding. The home is where the problem comes forth. With reference to Dieter Funke’s Psychoanalyse des Wohnens, Psychoanalysis of Living [45], I discuss some of the aspects related to housing below. The house is seen as a third skin, providing another layer of protection on top of our clothing and the actual skin. In this analogy, the way we choose to live has a lot to say about our personality. Freud’s Interpretation of Dreams [38] discusses the meaning and symbolism attached to houses at length. However, it is not just the houses, but also the individual rooms which carry meaning. Funke draws inspiration from Freud’s structural model of the psyche. In this model, the interacting parts of the human psyche can be equated with parts of a house. The super-ego and ego-ideal inhabit the attic, representing a person’s values and norms. The ego lives in the bedroom and the living room and is reflected in the staircases and corridors, while the id can be found in the basement. The basement is where the drives and the repressed reside ([45], p. 101).

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1 Introduction

In this context of interpretation the functions of each room and their symbolism is highly interesting. The kitchen stands for orality and, consequently, performs functions of motherly care. The bathroom is a place of intimacy and can be seen as related to anality. The bathroom is one of the few places where we are mostly alone. The bedroom is of special significance as the place where we sleep. The time of sleep is the time of retreat from this world, the time of dreams, and the time of ghosts and spirits. If dreams are the inner keeper of sleep, the bedroom is the outer keeper. (ibid., p. 105)

The living room is where those living under the same roof meet and exchange. In addition, there are also the children’s rooms and study rooms. This division of a home into rooms of different functions emerged at the beginning of the early modern era (ibid., p. 42). Before that, people had spent most of their lives in one room. This division of space seems to be of substantial importance in diagnosing HD. Listing the symptoms of HD, the DSM-5 also raises the question if and to what extent the living areas are cluttered and becoming more and more inaccessible. The division of a house into levels, however, is just as important as its division into rooms. Architectural research has shown that the first and second floors of a house were the best furnished levels before the end of the nineteenth century, in the so-­ called Gründerzeit. Over the last century, this has significantly changed. With the installation of elevators and lifts, the upper floors, especially the attic floor, and their furnishing have received increasing attention. From these considerations, it follows that in order to successfully treat hoarding, we need to assess and evaluate the respective individual significance of living spaces. Hoarding is closely tied to the subjective attribution of values, whether this concerns things or spaces. In some cases where people hoard, their bedrooms are cluttered to an extent where they can no longer be used for their original purpose. Therefore, we need to ask ourselves: what significance do the individual rooms and their functions have for the individual? The home is where the problem surfaces. The squalor serves to express what it looks like inside a person who hoards. Cluttered living areas and hoarding behavior reveal a sense of feeling overpowered. The role of fear in hoarding cannot be disputed.

1.4.2 Having Instead of Being Erich Fromm’s standard work necessarily raises the question if hoarding is more about the idea of having taking precedence over being. Fromm outlines that the nature of ownership is based on the relationship between subject and object. He goes on to say that the subject ultimately identifies with the object: “I am what I have.” The subject and object are things, and their relationship is not a living-­ productive one. In his mode of existence theory, Fromm relates things to the concept of having. The being mode of existence refers to active experiences of life, some of which are internal (cf. [46], p. 73 ff.).

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21

On the one hand, our current economic systems require us to produce and, as a logical consequence, consume continuously. On the other hand, we are forced to pause and ask ourselves about the limits of these developments, or what their psychological consequences are. People used to go to small shops, to the butcher and the greengrocer, nowadays everything we need is available in supermarkets. Buying things also once had a communicative component. Today, we can wander gigantic shopping malls on our own without interacting. On some floors, window after window promises limitless abundance. This has been the case ever since the first department store, “Le Bon Marché,” opened. Consumption is no longer limited to the purchase or usage of things. It is rather about transforming things into personal goods. This is consumption in its modern sense (cf. [24], p. 51 ff.). The traditional relationship aspect is lost in the purchase. It is only in recent years that a new trend is beginning to emerge. People have started to produce things on a small scale again, personally selling their handmade creations in niche markets or online shops. However, the changed relationship aspect not only concerns our habits of buying and acquiring; it has affected all forms of human relationships. Alex Honneth’s reflections on the reification of society [47] provide interesting insights on the subject of changing human relationships. Honneth observes a general a shift of perspective in today’s society. He bases this theory on four central considerations: firstly, he notes that contemporary literature tends to portray social worlds in which the inhabitants treat themselves and others essentially as if they were inanimate objects. As examples of this reification ensuing from emotional emptiness he cites Raymond Carver, Harold Brodkey, Michel Houellebecq, Elfriede Jelinek, and Silke Scheuermann. Honneth sees another proof of reification in the fact that feelings and desires are enacted until those confronted with these enactments begin to perceive them as parts of their own personality. In a way, a certain commercialization of feelings can be observed. As a third aspect, Honneth cites the ethical dimension of reification, where other subjects are treated not as individuals with human characteristics, but as insentient and lifeless objects, as things or commodities. This can be found, for example, in the marketing of love relationships or the use of surrogate mothers. The fourth observation Honneth provides relates to current brain research, which claims to be able to explain human feelings and behavior based on the neural circuits in the brain. The attempt to explain complex internal phenomena in this way declares the human being a machine, a thing ([48], p. 14 ff.). It is hoped that the major sociological and philosophical theories relating to hoarding will be studied and correlations described in future research. This is especially important considering the presumed impact of social circumstances on the unconscious experience of hoarding individuals in the world. I, therefore, propose that the relationship between hoarding and social phenomena shall be investigated in greater detail. The Japanese celebrity Marie Kondo has sold millions of books on the subject of organizing. Her books are considered bestseller in Japan, Europe, and in the United States. This shows just how much the influence of objects on our lives has already

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1 Introduction

begun to attract society’s attention. We have many more things at our disposal than ever before, more than we would ever need and therefore, inevitably have to deal with them. The sorting, tidying, folding, and arranging of objects and our possessions alone consumes a considerable amount of time. In a way, things are assimilated by acquisition. Once we possess them, they become a piece of ourselves. The ego experiences an expansion through the things we acquire. We are what we have. A complete discussion of the philosophical aspects of having or possessing shall be provided elsewhere. For the present purpose, I can limit my observation to the two modes of existence, having and being. The mode of existence of having is easier to describe, because it refers to things and allows for a rather clear-cut definition. However, being is more complicated, including the experiences of humans and their mere existence in this world. We will never completely succeed in grasping and describing the experience of individual existence (cf. [46], p. 88 ff.). Nevertheless, it can be pointed out that, psychoanalytical self-awareness can aid personal development, which in turn gives new significance to our existence, our identity and our thus strengthened ego. To put it simply, psychoanalysis provides the means to reduce the importance of things and objects (having), thereby repositioning our actual being at the center of life. Similar considerations can be found in Hans Peter Hahn’s research [24]. Hahn believes that a change in consumption can be viewed based on two theories, each represented by a separate group of researchers. Representatives of the one group are convinced that greater importance is attached to things in societies with fewer possessions. They argue that a change in consumption behavior is reflected in an increasing arbitrariness of objects. Others emphasize that the functionality of things lies in the foreground in the same societies. Consequently, they assume that in consumer societies the importance of things is increasing. Change in consumption is seen as people’s tendency to increasingly define themselves through possessions as they are searching for orientation within the society (see [24], p. 83 ff.). It is thus the objects in the form of material possessions that must provide security and orientation. Baudrillard borrows essential components from psychoanalysis as he describes the world of objects as one of generalized hysteria. The difficulty of determining the suffering based on a symptom can be compared to the difficulty of satisfying the subjective need of a particular object. Baudrillard postulates an insatiable hunger that can never be satisfied, but will always show in one way or another ([44], p. 95). Having instead of being might be the central belief in hoarding. The things we possess define our very being. The underlying goals of acquiring new things may be found in expanding one’s identity and increasing one’s self-esteem. The luxury industry feeds off of this guiding principle. However, these considerations, complete with the study of envy, suggest that, above all, internal representations are characterized by uncertainty and instability. From attachment theory, we know that persons with insecure internal representations feel deficient in socializing with others. They often avoid or cling to relationships and are unable to develop successful attachment strategies. Attachment

1.4 Social and Cultural Factors

23

theory claims that these models, once established, may only be replaced when new safe and reflected experiences are made. The psychotherapist, for example, might provide a secure basis for such positive developments. The question of whether and by which experiences life can be enriched after a period of insecurity will have to be discussed in future attachment research (see [49], p. 331 ff.). As described earlier in this book, the home is the place where hoarding problems show. This is the place where the symptoms unfold. Mathias Hirsch [50] writes about the house as a cultural occurrence. He is particularly interested in the question of what lies hidden in the obvious or what is unknown in the known. Some of his considerations are certainly relevant to hoarding research. With reference to Bruno Bettelheim’s remarks on “Hansel and Gretel,” Hirsch describes the house as the place of “oral greed.” The unconscious conception of the house as a body reminds us of the nurturing body of a mother—a mother who gives her body to nourish her child (cf. [50], p. 36). As long as technology is unable to replicate uterine functions in the laboratory, we are all born from another body. Our first home is the body of another human being: the mother. Each of our lives begin in the unknown. It should be noted that this common human intrauterine experience and the emergence of the unconscious may also provide valuable insights in migration research. What unconscious symbols can be unveiled in the study of hoarding? It is certainly no coincidence that the home, the house or apartment, is the site of where hoarding patterns become manifest. While Hirsch focuses on the house, his theory can also be applied to apartments. Modern living culture delineates the ambivalence of the human desire to settle down and be safe, on the one hand and a craving for freedom and autonomy, on the other. It only seems fitting that we would call a place of home an im-movable property. The home, whether it is a house or an apartment, symbolizes both birth and death. These first and last places are the same for all people. We are all born from the womb and the last place we go to is a grave. The symbolism of housing cannot be stressed enough in this context. Bear in mind the child’s dependence in the parental home and the later independence obtained in one’s own home. In addition, living spaces are often understood as an equivalent for the self, for the psyche and its functions and also as an extension of the ego. The house can mean family happiness, security and being cared for; but it can also stand for existential fears, threats and paranoia. Hirsch also points to the role of houses in horror movies and analyzes the symbolic meaning of ghost houses (see [50], p. 47 ff., 209 f.). This extensive symbolism attached to housing is a central aspect of hoarding. Professionals are encouraged to explore the dimensions of symbolic meaning in each individual case and work with their patients to understand the underlying symbols of their hoarding behavior. Dominik Schrage argues that the need to make a decision between throwing away and keeping things [32] only arises from a change in the way we perceive things. Schrage impressively demonstrates that the ever-increasing possibilities to consume and growing markets allow us to use objects to indicate social prestige.

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1 Introduction

The change in how we deal with objects on a daily basis and the perceived shift in expectations cause us to question what is necessary and what is desirable (ibid., p. 251 ff.).

1.4.3 The Relevance of Security in Society Security is intrinsically linked with fears and worries. As of yet, psychoanalysis has not been able to develop a consistent theory of fear. Different ideas and approaches continue to coexist. From previous findings on hoarding, we know about the special role of fear in this disorder. Attachment theory, which is rooted in psychoanalysis, but has partially distanced itself from basic psychoanalytical assumptions, offers some interesting input. As Klaus E. Grossmann [49] writes, psychoanalytic theories can complement each other. If we just make a connection between the psychoanalytical understanding of the inner world and the influence of the outer world on this inner world as postulated by attachment theory, we can deepen our overall understanding of human existence. Grossmann describes that the helplessness and powerlessness of insecure children may increase emotional consequences of intrapsychic conflicts, which is because they do not help to diminish the underlying fear (cf. [49], p. 320 ff.). One of the most central questions is: how safe can individuals feel in a capitalist society? The present paper is limited to the psychological aspects of this question. In his seminal book, To Have or to Be [46], Fromm explains the duality of consumption in today’s affluent society. On the one hand, consumption reduces anxiety because what we have consumed cannot be taken away from us; but, on the other hand, the satisfaction thus generated only lasts for a short time. Consequently, we are forced to consume more. “I am what I have and what I consume” ([46], p. 37). This ambiguity also applies to many people with hoarding issues. There is an irresolvable ambiguity in hoarding: On the one hand, things and objects reduce anxiety and promise security; on the other hand, every new possession compounds the fear of loss. For individuals who hoard, objects symbolize security and consequently, reduce fears and radiate a generally calming effect. Individuals are highly alarmed by impending changes and experience distress as soon as they are required to dispose of or reduce the amount of their possessions. At the same time hoarders feel safe as they hold on to things and are captivated by the fear of having to lose or give up on their possessions. Naturally, that which is familiar gives security. As babies we hold on to our mothers’ breast; later we cling to toys; “acquire” knowledge, a job, a partner, children and in the end, we even want to control what happens our last will. Despite all this, we admire the heroes of mythology and religion who leave everything behind and venture out into the world (cf. [46], p. 107 ff.). These conflicting needs and wishes exist side by side, giving rise to several questions: –– What significance do these conflicting theories have for individuals? –– Do affected individuals truly feel safe? –– What are the underlying conscious and unconscious fears?

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–– To what extent do objects reduce fears? It can prove beneficial to ask these subjective questions in the context of psychotherapy. They touch on critical psychological aspects and we need to develop a deeper understanding of the motives behind hoarding. However, we must not forget about the patients’ suffering. Many describe feeling impaired in their daily lives and unable to induce change, therefore experiencing considerable psychological strain. Dieter Funke describes the home as an outer room providing access to an inner room. Referring to the concept of “Wohn-Ich” (living ego), Funke describes a threefold movement (cf. [45], p. 123). Threefold movement of the living ego (according to Funke) –  Returning to a safe room and finding a retreat –  Staying in a room and feeling safe and protected within the boundaries of this room –  Opening the room and moving its boundaries

Throughout this publication, I repeatedly emphasize the strong influence of caregivers and their required competencies and skills (Chaps. 2 and 3). Understanding how basic trust and a feeling of security grow is absolutely vital. In his essay, Peter Fonagy [51] demonstrates the possible benefits of synthesizing psychoanalysis and attachment theory and how we could achieve it. The ideas formulated by attachment theorists give valuable incentives to intensify research in security. Following John Bowlby and Wilfred Bion, Fonagy emphasizes the central ability of a mother to hold her baby emotionally, recognize its mental state and signal that she will manage the situation. If secure attachment results from being taken care of emotionally, an insecure attachment may reflect the caregiver’s rejection. Fonagy explains that the rigidity of inner world representation is above all discernable in work with borderline patients. Specific experiences, including the enactment of a particular role or provocation, can only be evoked in other individuals in this way (ibid., p. 304 ff.). Conclusion The history of hoarding research essentially began with the formation of self-help groups, first for individuals with hoarding behavior and shortly after for their relatives. The continuing efforts of those affected have eventually prompted professionals to recognize the phenomenon and start exploring it in greater detail—a circumstance that is both interesting and remarkable. For a long time, it was unclear whether hoarding was a lifestyle or a disorder. The DSM-5 was the first diagnostic tool to define hoarding as an independent disorder. Soon after, the ICD-11 followed suit. While in America, professionals commonly use the term hoarding disorder, German-speaking countries are still lacking a standard terminology, awaiting the official translation of hoarding disorder into German. As of now, the term pathologisches Horten (hoarding disorder) is recommended. A precise definition appears to be further complicated by the manifold social and cultural factors influencing hoarding behavior. The apparent connection between consumption and possession,

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1 Introduction

on the one hand and a failure to discard objects, on the other, shows that it may be beneficial to discuss hoarding in the light of a throw-away society and consumerism. Questions to be asked include: how do social factors relate to individual suffering? What role does housing play? What is the symbolic meaning of living spaces? Note that we are all born from a space that is foreign to us—our mother’s womb—and are bound to leave this world in a grave.

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2 5. Freud S. Fetishism, vol. 21. Standard ed; 1927. p. 149 ff. 26. Harsch W. Das Geld bei Marx und Freud. Psyche. 1985;5:429–55. 27. Dahmer H. Libido und Gesellschaft. Studien über Freud und die Freudsche Linke. Frankfurt a. M.: Suhrkamp; 1982. (First publ. 1973). 28. Freud S. Inhibitions, symptoms and anxiety. Standard ed; 1926. p. 20. 29. Green A.  Der Kastrationskomplex. Bibliothek der Psychoanalyse. Gießen: Psychosozial-­ Verlag; 2007. 30. Grunberger B. Narziss und Anubis. Die Psychoanalyse jenseits der Triebtheorie, Bd 1. Wien: Verlag Internationale Psychoanalyse; 1988. 31. Marx K. The capital. Band 1, (2018). Cologne: Anacoda Verlag; 1867, E-book. 32. Schrage D. The availability of things: a short genealogy of consumption in: Krisis. J Contemp Philos. 2012;1:5–19. 33. Ehrenberg A. Das Unbehagen in der Gesellschaft. Frankfurt a. M: Suhrkamp; 2011. 34. Hartl TL, Frost RO, Allen GJ, Deckersbach T, Steketee G, Duffany SR, Savage CR. Actual and perceived memory deficits in individuals with compulsive hoarding. Depress Anxiety. 2004;20:59–69. 35. Freud S. Civilization and its discontents. Standard ed; 1930. p. 21. 36. Sommer M. Sammeln. Ein philosophischer Versuch. Frankfurt a. M.: Suhrkamp; 1999. 37. Jones E. The theory of symbolism. Br J Psychol. 1918;9(2). 38. Freud S. The interpretation of dreams. Trans. James Strachey, in Standard Edition; 1900. p. 4–5. 39. Münsterberger W. Collecting: an unruly passion: psychological perspectives. Princeton, NJ: Princeton University Press; 2014. 40. Goethe JW. Faust I, First part, E-Book; 1908. 41. Burgess AM, Graves LM, Frost RO.  My possessions need me: anthropomorphism and hoarding. Scand J Psychol. 2018;59(3):340–8. 42. Boudon R. Die Erkenntnistheorie in Georg Simmels Philosophie des Geldes. In: Kintzelé J, Schneider P, editors. Georg Simmels Philosophie des Geldes. Meisenheim: Verlag Anton Hain; 1993. p. 113–42. 43. Köhnke KC.  Die Verdrängung der Werte durch das Geld. Zu Georg Simmels Philosophie des Geldes. In: Kintzelé J, Schneider P, editors. Georg Simmels Philosophie des Geldes. Meisenheim: Verlag Anton Hain; 2001. p. 143–53. 44. Baudrillard J. The consumer society: myths and structures. Revised ed. London: SAGE; 2017. p. 55–104. 45. Funke D. Die dritte Haut. Psychoanalyse des Wohnens. Gießen: Psychosozial-Verlag; 2006. 46. Fromm E. To have or to be? vol. 2013. London: Bloomsbury Academic; 1976. 47. Honneth A. Reification: a new look at an old idea. New York: Oxford University Press; 2012. 48. Honneth A.  Verdinglichung. Eine anerkennungstheoretische Studie. Frankfurt a. M.: Suhrkamp; 2015. 49. Grossmann KE. Vom Umgang mit der Wirklichkeit. Die Entwicklung internaler Arbeitsmodelle von sich und anderen in Bindungsbeziehungen. In: Bohleber W, Drews S, editors. Die Gegenwart der Psychoanalyse—die Psychoanalyse der Gegenwart. Stuttgart: Klett-Cotta; 2001. p. 320–35. 50. Hirsch M.  Das Haus. Symbol für Leben und Tod, Freiheit und Abhängigkeit. Gießen: Psychosozial-Verlag; 2006. 51. Fonagy P, Luyten P, Allison E, Campbell C. Reconciling psychoanalytic ideas with attachment theory. In: Shaver P, Cassidy J, editors. Handbook of attachment. New  York: Guilford Press; 2018.

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A Review of the Fundamentals

Introduction In this section, I aim to explore and describe the phenomenology of hoarding disorder in detail. Psychoanalytic theories and assumptions, such as those related to psychosexual development or aspects of orality and anality, provide the foundation for this in-depth discussion. I will draw on theoretical concepts from object relations theory and French psychoanalysis, aiming to facilitate an understanding of narcissism and super-ego development relevant to the present context. In doing so, I will reveal the extent to which psychoanalytic concepts aid the analysis of an emerging disorder. Furthermore, I will demonstrate the resulting practical implications and their benefits for psychotherapists, regardless of their discipline, as well as doctors and social workers. To round off this chapter, will provide an overview of specific hoarding symptoms, diagnostic criteria and insight into relevant epidemiological studies undermining relevant psychoanalytic aspects.

2.1

Theoretical Considerations

Aiming to create a comprehensive practical guide for professionals, I have intensely studied various psychoanalytic theories and concepts and distilled the essence relevant to hoarding disorder. Based on this hermeneutical approach and constant oscillation between the fundamental theories of psychoanalysis and actual manifestations of hoarding, this chapter attempts to develop a new basic understanding of the phenomenon and present a complete picture of the disorder. Close interconnection of theory and practice provides one of the cornerstones of psychoanalysis. From the very beginning, psychoanalytic research has been considered primarily as field research. The history of psychoanalytic research is a history of case studies. Even if far from the only unifying thread, these case studies present one of the essential common threads in psychoanalysis. It is therefore evident that © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 N. Agdari-Moghadam, Hoarding Disorder, https://doi.org/10.1007/978-3-030-72342-2_2

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psychoanalytic research would have difficulties fitting in with today’s philosophy of science. By modern scientific standards, the classical empirical methods might be considered inappropriate in the context of an emerging science of the human psyche such as psychoanalysis. Despite this criticism, or precisely to address this issue, the present practical guide has remained in the tradition of psychoanalysis and represents a further attempt to explain and understand phenomena from the practical experience with those affected. Psychoanalytic methodology and theory have developed from this approach, i.e., through analyzing individual cases. By pointing out the value and benefits of this approach to practice, I hope to be able to contribute to the advancement of psychoanalytic research and to create a deeper understanding of hoarding disorder, which will ultimately benefit all those concerned by the problems related to the disorder. In particular, I aim to address the questions and needs of professionals working in this field. Fundamental questions in HD treatment –– How can psychoanalytic theory aid doctors, psychotherapists, caretakers and social workers in understanding hoarding disorder? –– What insights can we gain from the symbolism and symptoms of cluttered houses and living spaces? –– Which personality structures are affected? –– Is it possible to develop theories on the etiology of the disorder? –– How do dispositions develop and how can we approach them? –– Which treatment models can we develop to support professionals and experts? Symptoms Are Masterpieces of the Inner Theater ([1], p. 40) Joyce McDougall describes how symptoms originate within the ego of the soul early on, representing an ego structure designed as an attempt at self-healing. The creation of this structure requires tremendous effort on behalf of the self and is closely linked to sacrifice, fear and suffering. Fateful words understood by a child as rebuke and punishment are banished from consciousness. The aim of the compromise is twofold: on the one hand, it is to comply with the prohibitions of the adult world and on the other hand, to hold fast onto the incestuous longings reflected in childlike love. Psychological phenomena arising from this compromise represent the momentarily ideal solution available to the human psyche. This conception provides one of the central underlying assumptions of psychoanalysis. We need to be aware of this mechanism, especially if we want to achieve a change in behavior. In general, all psychological phenomena, including hoarding disorder, represent the best possible way out available to the person concerned at a given moment. Hoarding behavior is inextricably linked with the patients’ living spaces, cluttered with things. Consequently, knowledge of the psychological function of hoarded objects, as well as the deeper meaning of living spaces to the patients and humans in general, is essential. It is interesting to note in this context that both the spaces we live in and the bodies we inhabit can be regarded as rooms. Therefore, we

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cannot but ask what hoarding reveals about the patients’ “rooms.” In what way may the body be cluttered and what may the things be that clutter the body—or the mind? What is the symbolic relationship between cluttered physical rooms and possibly cluttered mental representations? How do the inner and outer spaces relate? If we want to understand our use of space and how this relates to hoarding, we should certainly consider the first room or space a human inhabits. The physical is where our lives begin. The ego is a physical one, Freud wrote [2], whereas our lives begin even before we have our own body. Before we are born, we live inside a foreign body. It is within this body that we develop our own body: the mother’s physical presence and influence of her unconscious shape the infant’s earliest reality. The relationship we have with our parents affects our development, similar to the bond between the parents as a couple. There are various ways and means in which the mother relates to the infant’s body. Both the bodily functions and factors such as vitality and affectivity come into play here (cf. [3], p. 140 ff.). These considerations suggest that the idea of space, be it mental or physical, provides a fundamental element in early psychological development. Psychoanalysis has often been, and still is, accused of blaming the parents for not having acted appropriately. Those who criticize psychoanalysis in this way, however, seem to have misunderstood its underlying principles and aims, for psychoanalysis is about gaining knowledge about the human psyche, knowing that most parents take care of their children to the best of their ability. Despite the fact that parents are assumed to only want the best for their children, developmental and psychological disturbances occur. In order to determine what disturbances may lead to the development of hoarding patterns, we must ask: –– What is the underlying cause of hoarding and what is its purpose? –– Where does the behavior originate? –– What do the great theoreticians and practitioners of psychoanalytic history reveal about hoarding? Joyce McDougall developed a theory of alexithymia, which can also be appropriated for our purpose, namely to describe hoarding disorder: As close bodily contact and gestural forms of communication with the mother diminish, these are gradually replaced, through the use of language, by symbolic communication. The infant becomes a verbal child. From this point on, the contradictory wish to be an individual while remaining an indissoluble entity, compensated by the acquisition of an unwavering sense of individual identity. (ibid, p. 35)

The transition from the preverbal stage of development to language acquisition seems to be decisive in the development of hoarding disorder. Which rooms are available to the child and in which ways are the rooms used? To what extent are the parents or other guardians capable of translating between physical, symbolic and verbal spaces? Which forms of expression does a child acquire? Which certainties and uncertainties are passed on unconsciously?

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These first or very early “in-between” spaces are vital. Many hoarding patients speak of a sense of security obtained from possessions, yet not found in other people. It is a feeling of insecurity then, that lies at the core of hoarding and this insecurity must have its roots in the patients’ earliest development. Interestingly enough, many patients describe their experience of everyday family life as uncommunicative. Their parents have shown tendencies to avoid conflict, discussion and any kind of argument. The patients themselves have never learned how to name and verbally express emotions. A lack of words is characteristic of their family background and their consequent adult lives. In this context, I would like to emphasize the preverbal nature of the hoarding phenomenon. Hoarding can be seen as the enactment of emotions and feelings that the affected individuals cannot put into words. The objects, pieces of paper and clothes littered across the living spaces represent scraps of an untold story. The apartments of hoarding patients speak volumes. The clutter expresses an inner mess, a possible conflict and the feeling of being overwhelmed. The cluttered homes express what the patients do not have words to express, as they are themselves suffering and speechless. They hoard highly symbolic objects and things and the rooms they inhabit become overburdened. The rooms are often cluttered to the degree that they no longer serve their actual purpose. While the outer rooms are filled to capacity, the patients’ inner rooms are perceived to be empty and lacking. This again elicits the question as to what disturbances may have occurred within the early psychological space between mother or another caregiver and the infant. This question is essential in particular because things come before words. When treating hoarding patients, we have to be aware of two aspects: hoarding behavior provides the human psyche with presently the best possible solution and the preverbal stage in early development has a major influence on the development of the disorder.

2.2

Causes and Development of Hoarding Disorder

This relatively new hoarding disorder or Messie-Syndrom, as the German-speaking literature may refer to this mental health problem, has challenged professionals worldwide by defying a clear definition. The complexity of the phenomenon and its manifold manifestations make it difficult to grasp and challenge us to achieve a systematic description. Definition Despite the complexity of hoarding behavior, it is one of the aims of this work to formulate a basic definition and facilitate the overall understanding of the disorder. As explained previously, in the German-speaking world, the phenomenon is widely known under the term Messie-Syndrom. Messie derives from the English

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word mess, which also translates into chaos or clutter and is used to refer to people who clutter their homes with things, thus limiting their living space to an extent to which it is almost no longer inhabitable by today’s standards. Sandra Felton first introduced the term, talking about her own experience as an American affected by hoarding behavior. Felton had already offered self-help groups for hoarding individuals at the beginning of the 1980s. Almost 20 years later, the phenomenon first attracted attention in Germany and the first self-help groups were founded. It was not until the late 1990s that the phenomenon of pathological hoarding or hoarding disorder met the interest of the global scientific community. From the onset, international—specifically Anglo-American research has described the phenomenon as hoarding disorder, which in German translates to pathologisches Horten (pathological hoarding). Some of the earliest research also referred to compulsive hoarding due to the close association of hoarding with OCD. In the present handbook, the preferred term is hoarding disorder, the name established by standard diagnostic manuals and respective literature. In the German edition, the more general Messie-Syndrom and pathologisches Horten appear as equivalents alongside each other. While the first term is common usage and the latter rather confined to professional context, the terms denote the same behavior and are generally considered synonymous. Causal Factors and Development It is generally not easy to shed light on how a mental disorder develops. We must assume that the relatively new occurrence of hoarding disorder is multifactorial in its development. From a psychoanalytic point of view, this is not surprising. The development of the human psyche and its strong dependence on caregivers pose several challenges in our overall personal development. Its intra-uterine existence seems to be short in comparison with that of most animals, and it is sent into the world in a less finished state. As a result, the influence of the real external world upon it is intensified and an early differentiation between the ego and the id is promoted. Moreover, the dangers of the external world have a greater importance for it, so that the value of the object which can alone protect it against them and take the place of its former intra-uterine life is enormously enhanced. ([4], p. 154f)

If parents fail to meet their child’s earliest needs sufficiently, disturbances may occur early on. These disturbances lay the foundation for problematic behavior to develop and become manifest later on. It has been observed that experiences of separation and loss and other traumatic events in early development have a significant role in the emergence of pathological hoarding patterns. Patients often report the feeling of not having received enough: enough to eat, enough care or enough emotional nourishment. One of the first questions we need to address to understand a hoarding individual’s situation is as follows: were the first caregivers able to sufficiently engage with the infant and interpret and translate their needs correctly?

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Table 2.1  The stages of psychosexual development Stage Oral (birth–1 year)

Anal (1–3 years)

Phallic or oedipal (3–6 years)

Latency (from 6 onward)

Genital (from 12 onward)

External events Nourishment through sucking at the breast Perception of the world through the mouth Sucking, swallowing, biting Discovery of defecation Retention and expulsion Toilet training, smelling, inspecting, touching Pleasure in voyeuristic and exhibitionistic behaviors Discovery and manipulation of the genitals Erotic feelings toward one parent Consolidation of previous developments Intellectual inquisitiveness Acquisition of skills, knowledge and social strategies Biological and physical changes Identity development Detachment from the parents

What contribution can psychoanalytic Freudian theory make in our attempt to answer and understand such questions and consequently treat hoarding? The five stages of psychosexual development are a core element of psychoanalytic theory (Table 2.1), giving insight into character development and how pathological behavior, including excessive hoarding, develops. The stages of psychosexual development are determined by the dominant erogenous areas of the body. The oral phase, beginning at birth and continuing into the first year of life is followed by the anal phase between the second and third years of life. Children undergo the phallic stage or oedipal phase from age 4 to age 5. At the age of 6, a calmer phase, the so-called latency period begins. The next stage, which approximately sets in at the age of 11–12 years, marks puberty and transition into adolescence and later adulthood. These developmental stages, crucial for the development of our personality, are pivotal to understand hoarding. An in-depth look at the stages is provided below, starting with some of the most central aspects of “pregenital sexual organization” described by Freud in his article “The Disposition to Obsessional Neurosis” [5]:  he Importance of Hatred and Anal Eroticism in the Symptomatology T of Obsessional Neurosis Feelings of hatred develop in particular from a sense of displeasure resulting from the rejection of the external world. Regression to the corresponding developmental stage—the anal phase—reinforces hate and aggression. We have to be aware of the anger, shame, defiance and aggressive tendencies in hoarding individuals. These feelings have a major part in effectuating patients’ impairments in daily functionality. Feelings of hatred and having been rejected or unwanted by the parents are essential in this context.

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The Psychosexual Development Stages as a Psychoanalytic Basis Examining the disposition to obsessive-compulsive behavior, one must also recognize the significance of sexual partial drives, particularly the passive impulses of anal eroticism, which must be included in any such discussion. In hoarding disorder, the sexual partial drives and anal eroticism coincide with difficulties letting go or giving and throwing things away. Two forces are at work here: hoarding behavior reflects the oral drive, while difficulty letting go points to the anal drive. A closer look at these central drives and the respective development stages as well as their relevance to hoarding is presented in the following sections. The Importance of Regression to Previous Development Stages Regressing to an early development stage is a common defense mechanism in psychology and relevant to hoarding disorder. Most obsessional neurosis symptoms are shaped by reaction formations and defense mechanisms, employed to develop opposing behavior patterns. An unwanted impulse or thought is to be reversed with the help of, for example, obsessional washing and cleaning, rumination or counting. In those affected by hoarding symptoms, the defense mechanisms are exhausted and can no longer maintain socially desirable behavior. The home becomes the stage where the unconscious erupts. It is where the unconscious surfaces and, at least in part, enters the conscious as it can no longer be hidden. Inevitably, this leads to another aspect of hoarding disorder. Taboo pleasures and anal drives are displayed in a distorted form. What essentially distinguishes hoarding disorder from obsessive-compulsive disorder is that its development hardly shows any reaction formations or sublimations. The case of one particular patient who was educated and always elegantly dressed, provides an account of how one can take pleasure in rummaging and sorting garbage. The patient described how he liked to put on gloves and occupy himself for hours with what he found in his neighbors’ containers. He did not need to eat the bread his neighbors had thrown away but he did so because he felt bad about wasting food that was not spoiled. Possible Connections Between Ego Development and Libido Development Libido development designates the development of sexuality, characterized by a fixed sequence of psychosexual development stages. A patient’s psychosexual development and its role in the development of pathological behavior can, of course, only be determined in a psychotherapeutic setting, supported by deep psychological analysis. Hoarding disorder is shaped by a complex relationship between ego development, defense mechanisms, and libido development. More individual case studies and reports from psychotherapeutic practice are required to enable us to make general statements about what experiences in the course of ego and libido development effectuate hoarding behavior.

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 he Complexity of Determining a Disposition to Obsessional Neurosis T in Comparison to Hysteria In the process of growing up, we are subject to complex developments of ego and sexual functions. Based on this assumption, Freudian theory asserts that dispositions to obsessional neurosis or other pathological behavior originate from developmental inhibitions. Neither educational nor therapeutic ambitions aid the treatment process. Professionals are recommended to waive both personal and institutional demands and instead focus on the patients themselves, giving priority to the possibilities and abilities of the individuals concerned. What is the significance or possible benefit of hoarding to the human psyche? The patients’ homes reveal hoarding patterns that do not seem to follow a specific system or organization in any specific way. The only rule that can be established in hoarding is that the new or more recent superimposes the old. By equating spatial representations with dreams, the concepts of compression and displacement may help illustrate the mechanisms at work here. Hoarding individuals perceive objects as being attached to experiences or memories of such experiences, and they are afraid they might forget something that must not be forgotten. The hoarded objects can be understood as traces of memory. A patient of mine once told me that she could not part with the things in her possession. This was because the memory associated with these things would be gone. Her case demonstrates the fear in hoarding that internal representation might not suffice to keep memories or experiences alive; they need to be maintained, protecting the corresponding representations in the outside world. The personal outside world, in particular the homes of the patients, can be seen as extensions of their inner spaces. A feature unique to hoarding disorder is the constant doubt, intolerance of uncertainty [6, 7] and frequent indecision experienced by patients. Freud’s early work postulated the connection between compulsion and doubt. In his “Notes upon a Case of Obsessional Neurosis” [8], he explains the conflict between feelings of love and hatred toward the other. Love does not erase hatred but only pushes it into the unconscious, from where it can continue to affect the human psyche and, consequently, our behavior. Freud elaborates that the feelings of hatred have a paralyzing and inhibiting effect. This explains the indecision and the doubt taking over the patients’ lives. At the same time, Freud declares compulsion to be a form of compensation for doubt. The substitute action allows the patients to rechannel and discharge pent-up energy (ibid., p. 453 ff.). A general indecisiveness, difficulty making decisions, and general ambivalence can be perceived in many hoarding individuals. Freud’s in-depth description of how human sexuality develops from the very beginning can be regarded as one of his most significant achievements. In “Character and Anal Erotism” [9], referencing the “Three Essays on the Theory of Sexuality” [10], Freud emphasizes the importance of sexual arousal experienced in specific areas of the body, for instance, the genitals, mouth, anus, and bladder, which have consequently become known as erogenous zones. A person’s later erotic

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life, however, is only shaped by a part of these erogenous zones. The instincts that cannot be appropriated for genital sexuality are diverted by sublimation or other mechanisms [9]. A significant contribution to the pathology of hoarding disorder can be made by drawing on the first two stages of psychosexual development. Therefore, the following sections are devoted to giving a detailed account of orality and anality and emphasizing their relation to hoarding disorder.

2.2.1 The Importance of Orality Many terms of psychoanalysis have been adopted and appropriated for everyday usage. In order to avoid confusion, precise definition and delineation of psychoanalytic terminology are imperative. Joseph Sandler and Christopher Dare, authors of “The Psychoanalytic Concept of Orality” [11], cite three main uses of the term oral, which may refer to: –– Behavior or sensations relating to the mouth –– Early phenomena of infancy in which the mouth is the primary organ of pleasure –– Psychological processes derived from the infant’s early relationship to the first caregiver (mother) Psychosexual development begins with the oral. The oral stage is the first phase of development wherein the infant absorbs the world through the mouth. Oral needs are satisfied by inserting objects into the mouth. The oral is the infant’s first organ through which it sees and feels the external. Otto Fenichel observed that there is a close connection between thumb-sucking and nourishing through the breast or bottle, whereas prenatal ultrasound technology today enables us to identify that thumb-­ sucking occurs as early as in the mother’s womb. This provides evidence that the mouth represents the first organ of pleasure even before children learn to breathe. This first phase of psychosexual development is primarily characterized by demanding and receiving. Through the mouth, the infant seeks to absorb the outside world. This is expressed in an insatiable appetite and greed for more. Hoarding is a direct reflection of this desire in its characteristic possessiveness and inability to let go of possessions. Otto Fenichel portrays the role of orality as follows: The aim of oral eroticism is first the pleasurable autoerotic stimulation of the erogenous zone and later the incorporation of objects. […] The appearance of an especially intense greed, either manifest or, after its repression, in the form of derivatives, is always traceable to oral eroticism. ([12], p. 63)

Orality resurfaces in the urge to integrate the outside into the inside world through absorption. This desire for integration biologically originates from the erogenous zones. Drive theory illustrates that some of the main features of the phenomenon derive from the phase of oral eroticism and are directly linked to disorders and disturbances experienced in this first phase of psychosexual development. These early

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developmental disruptions serve as a feasible explanation for the resistance to therapy, often displayed by individuals concerned. The problems of treating disorders in infantile development are well known from practice. This means that HD patients are not resistant to therapy per se, but a crucial understanding of the disorder’s etiology can be provided for successful treatment [13]. Greed is one of the central characteristics of orality. A new dimension of expression is added to oral greediness once the teeth begin to erupt, and the ability to bite is discovered. In Melanie Klein’s theory, greed is a form of introjection, in a state of anger. Biting leads to the destruction of an object, preventing the desired oral satisfaction. The introjected object becomes worthless or, even worse, turns into a “persecutor seeking retaliation” ([14], p.  415). Following this line of thought, greed comes to represent the aggressive nature of orality. Ultimately, there can be no satiation or satisfaction. These aspects of greed are known from psychoanalytic analyses of orality in other mental disorders, including depression, addictions, or eating disorders. The vignettes discussed later in this book reveal the occurrence of different oral comorbidities (Sect. 4.1). The overview of orality presented by Sandler and Dare also cites Erik Erikson’s concept of basic trust. By admitting to a range of competencies inherently present in the infant, Erikson’s approach criticizes Freudian theory, claiming that the oral stage is primarily characterized by the infant’s dependence [11]. However, Erikson’s concept and Freudian theory coincide regarding the inclusion of hoarding disorder in psychoanalytic theory. They agree that, in the phase where basic trust forms and orality prevails, disruption must have occurred, triggering the development of pathological behavior patterns in the person’s later life. This also explains why it is difficult for therapists or other professionals to establish and maintain a stable relationship of trust with the patients. Section 2.3.9, which illustrates the significance of anality, refers to Karl Abraham’s concept of libido organization [15]. Abraham’s theory also provides a more detailed examination of individual stages in orality and anality. A range of dissociative symptoms, up to psychotic breakdowns, has been observed in hoarding individuals required to give objects away and let go of things. The idea of parting with possessions aggravates the patients’ inner conflict and reinforces a feeling of being torn inside. The patients verbally mark objects of the outside world as their property, such as by using possessive pronouns. They signal that what is outside the body still belongs to the body or is a part thereof. This is the significance of inanimate objects in hoarding individuals. They feel like all their possessions are a part of the physical self or the ego, rendering a distinction between components of the ego and the outside world impossible. The home signifies an extension of the body, becoming inseparable from the self. The theoretical approaches to partial drives provide an explanation for the phenomenon. The boundary between the inner and the outer world and between the body and the environment provides a bridge to the next phase in development. Needless to say, the individual phases do not occur in isolation or independent of each other. Evident interaction and overlapping mean that each phase is inextricably linked to the other phases and separation is impossible. The hermeneutic approach is applied

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all the same, as it has proven helpful in describing and understanding the stages individually before combining them as a whole. Organizing the early developmental process into stages merely represents a thought structure designed to aid our understanding of early psychological developments. Basically, the aspects of orality and the characteristics of the anal stage coexist, as do the disturbances and impairments in the development of the Messie-Syndrom or hoarding disorder. Fenichel notes that, besides the things infants can insert in their mouths, there are also things they naturally avoid putting in their mouths. Language assists children in satisfying their need to orally integrate what they cannot actually swallow. They use possessive pronouns to indicate what is theirs. The child becoming aware of feces being separated from their body calls the excrement their own and, in doing so, expresses their desire to integrate the outside with the inside world. The bodily discharge is symbolically reintegrated through the mouth. Thus possession means things that do not actually belong to the ego, but that ought to; things that are actually outside but symbolically inside. ([12], p. 281)

Following this reasoning, the hoarding individuals’ possessions can be understood as indicating an inner emptiness that has not yet penetrated the conscious. The ego symbolically depends on things in the outside world, aiming to extract meaning from them and feel whole again. This may signify that introjects are partially damaged or defective. The importance of the ego and its functions are elaborated on in Sect. 3.2.3, focusing on the theoretical assumptions of ego psychology.

2.2.2 The Importance of Anality The second stage in psychosexual development is the so-called anal phase; wherein pleasure is derived from the skin and particularly the sensitive mucous membranes of the rectum. This is also when defecation becomes associated with a sense of gratification. Abraham’s pivotal papers [15–17] built on and extended the Freudian theory of the anal character and consequently provide valuable input for this discussion. Abraham [16] undertook a detailed examination of Freud’s anal triad of personality, including the character traits of pedantry, parsimony, and persistence, and added to this an in-depth account of the anal aspects of psychosexual development, which he extended with his own concepts. The central anal aspects of psychosexual development are not limited to stimulation of the anal erogenous zone but also related to the feces. These serve as an instrument, eventually transforming into a libidinous object. With the awakening of differentiation between inside and outside world, the feces come to represent a part of one’s own body. They are considered by the child as a product of its very self. The feces are expelled into the outside world as an object that is potentially lost. In other words, the excrement may be regarded as a child’s possession: “The incorporated object has become a part of the subject’s ego, and when this object

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is projected again it retains a certain ‘ego quality’, even in the external world.” ([12], p. 428.). This sheds light on the perceived and psychological value attached to things and objects in the outside world. They are perceived as an integral part of the inner world placed outside the body. If a person is coerced into separating from their belongings, a part of the ego may be lost, and the ego is threatened with disintegration. This conception may serve as an explanation of why forced evictions can lead to a complete collapse of the ego functioning and cause psychoses. The things and objects that are forcefully taken away from an individual are unconsciously perceived as portions of the ego, and a psychotic breakdown can be regarded as a response to the loss of an object. It is specifically the meaning and symbolism subjectively attributed to things and objects that indicate a direct relation to the anal stage. Toilet training represents a complex intrapsychic process, that can yield different behavior manifestations and developments. Certain anal pleasures are first perceived in the sensations accompanying the mother’s care when diapers are changed. This care and, later on, conflicts aroused by the child’s training toward cleanliness gradually turn the autoerotic anal strivings into object strivings. Then objects may be treated exactly like feces. ([12], p. 67)

Consequently, objects can be understood as narcissistic extensions. In other words, the surrounding objects are perceived as extensions of the ego, enabling autoerotic libido to expand. Toilet training represents a critical period in human psychosexual development and constitutes a special challenge in child education. The phase is shaped by the conflict between complying with cultural demands on the one hand and sacrificing one’s own libido on the other. This intrapsychic experience is in itself conflictual, even if considered independent of how the caregivers approach toilet training. (This is the main reason why this work deliberately refrains from including assumptions of relational and intersubjective psychoanalysis.) Modern theories often neglect the very foundation of psychoanalytic drive theory, namely the postulation that opposing forces are at work in the human psyche, bearing a fundamental potential of conflict. The significant influence of mother-child interaction on personality development was extensively hypothesized in Freud’s oeuvre and elaborated on in the works of Melanie Klein, Wilfred Bion, and Donald Winnicott. As long as relationships are used as the main source of explanation for psychodynamic patterns and the concept of object relations is misused, mainstream psychoanalysis denies its very origin and fails to fulfill its original purpose. Yet the writings at the core of psychoanalysis offer an array of concepts and tools that aid the dynamic comprehension of disorders such as hoarding. Freud described three personality traits that make up the anal character. These include orderliness, parsimony, and obstinacy. The development of a certain kind of stubbornness and willfulness are typical of disturbances experienced in the anal stage. It is in this phase that the infant, for the first time, acquires a sense of self-determination and realizes that they have control over something that the other wants from them.

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Abraham provides further elucidation: They furthermore show the same self-will in regard to any demand or request made to them by some other person. We are reminded of the conduct of those children who become constipated when defaecation is demanded of them, […] Such children rebel equally against the ‘shall’ (being told to empty their bowels) as against the ‘must’ (a child’s expression for the need to defaecate); their desire to postpone evacuation is a protection against both imperatives. ([18], p. 377)

A patient talked about how she and her five siblings were living with her parents in a space extending to no more than 40 sqm. Her father, an alcoholic and dictatorial in his education style, used to take control of her entire life and forced her to keep the home in meticulous order. He regularly initiated inspections, as she would call them, of cabinets and cupboards. She herself grew up to become a pedantic young adult, always very tidy and emphasizing the importance of cleanliness. Her involvement in a life-threatening accident and the subsequent death of a family member triggered her hoarding behavior. Her extremely well-groomed appearance would have never revealed her suffering from excessive hoarding. Her father had always told her that one must keep everything clean from the inside out. Later in her life, this principle was reversed: on the outside she was neat and tidy, while the inside was unkempt and scruffy. It is precisely these behaviors of resistance and defiance that often persist throughout treatment and continue to recur. If we want to understand what the symptoms of orderliness or disorderliness mean, we have to look at the goal of early psychosexual development, in particular the anal stage. In this phase, children acquire basic cleanliness and a sense of order. We need to be aware, however, that the demand for the child to let go of their excrement bears yet another conflict. The child perceives their excrement as a part of the body. How can something so intimately connected to themselves be bad or even disgusting? How can it be something one would want to discard? The child is only just beginning to learn and accept that there is not only good in the Id but that it also contains that which is bad. The experience of hoarding individuals is often characterized by a certain kind of pressure. They feel like they should clean up and that they must throw things away. We, therefore, need to emphasize how the individual can gain space and gradually transform the shoulds and musts into cans and mays. Defiance is always to be understood as a reaction. Once it becomes possible to leave the set path, there will also be an opportunity to pursue one’s own will and take action. Toilet training marks a significant phase in our lives. While children in the anal stage regard defecation as a gift to the parents or other caregivers, they also notice the ambivalence associated with the process. The object, a part of the child’s own body and perceived self, is rejected and simply flushed down the toilet. This is when the evil is no longer just located in the outside world, but also discovered inside. Günter H. Seidler connects the children’s release of feces with the idea of the “Danaergeschenk” (Greek gift), whose ambiguity arises from the intention to give a gift that is not a gift (cf. [19], p. 132 ff.). These considerations

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coincide with practical observations made in our society and in hoarding. Objects and things, possessions in general, are considered as valuable and praised by our consumer society. The fact that, despite their alleged value, we give or throw things away, even destroy them, is largely denied. A few reports about milk lakes, plastic polluting the sea, or the dumping of western rubbish in Africa occasionally remind us of our habit of getting rid of things before we move on to consuming new ones. Abraham describes the persistent tendency to postpone and defer actions. The action avoided by hoarding individuals is to tidy up, clean their homes, and bring order into their lives. The evacuation of the bowels calls forth a pleasurable excitation of the anal zone. To this primitive form of pleasurable experience there is presently added another, based on a reverse process – the retention of the faeces. ([16], p. 425)

The anal stage also denotes the child’s transition from taking pleasure in retention to experiencing enjoyment in expulsion. Procrastination, i.e. the act of delaying tasks, is a phenomenon especially to be observed in relation to schoolwork or later professional contexts. The behavior reflects a similar form of pleasure gaining in holding on to objects, as known from the anal phase of development. This pleasure can also be observed in individuals who hoard, subsuming the characteristic dynamic of apparent indecision. The patients constantly grapple with the question of whether they should part with something or not and derive pleasure from this in-­between state. From this, we can infer that the cause or causal factors for the patients’ indecision and can be found in their early libido development. Individuals suffering from hoarding behavior typically also have difficulties with time management. Some of the habits consistently to be observed in hoarders is that they tend to be late, miss deadlines, and multi-task in order to save time. Abraham already identified a shift from greed for money to greed for time ([16], p. 116). In the same vein, Ernest Jones emphasized: “the concept of time is, because of the sense of value attaching to it, an unconscious equivalent of excretory product, and the reaction just mentioned is also shown in regard to it; that is to say, people of this type are particularly sensitive to their time being taken up against their will, and they insist in every way on being master of their own tune.” ([20], p. 268). The concept of time, however, does not exist in the unconscious. Ownership recurs as one of the central themes in hoarding. The phenomenon is not a new occurrence, but its relevance has persisted over time. It is astonishing just how up-to-date Abraham’s reflection reads: This fact of a libidinal over-emphasis of possession explains the difficulty our patients have in separating themselves from objects of all kinds, when these have neither practical use nor monetary value. Such people often all sorts of broken objects in the attics under the pretext that they might need them later. Then on some occasion or other they will get rid of the whole lot of rubbish at once. Their pleasure of having a mass of material stored up entirely corresponds to pleasure in the retention of faeces. We find in this case that the removal (evacuation) of the material is delayed as long as possible. The same persons collect bits of

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paper, old envelopes, worn-out pens and similar things, and cannot get rid of these possessions for long periods of time, and then at rare intervals they make a general clearance, which is likewise associated with pleasure. ([16], p. 385)

The last sentence in this depiction reflects the drama of hoarding, where the presumed pleasurable act of cleaning up and removing debris never takes place. Abraham’s description of personality traits can be considered as a theory of general psychology, yet does not apply to individuals concerned with hoarding disorder. In fact, hoarding individuals do not amass objects in the attic alone, but they clutter their entire home. They are also typically unable to clear out the living spaces from time to time. This is exactly where the core of the problem lies, as hoarders perceive meaning in the chaos they create and seek to justify and protect it. Hoarding affects active living areas and drastically limits the areas’ functionality. The relentless and uncontrollable urge to save objects is accompanied by a lack of pleasure in acting out aggression in cleaning or discarding things. What do the objects mean to the individual if it is impossible for them to part with them, discard them? The hoarding individual must identify with their possessions in such a way that throwing them away would reduce their very own worth. If the possession were to diminish, if they owned less, they themselves would become less, gradually turning into a nobody. Inanimate objects are treated as if they were animate and a living extension of the self. They must be used, protected, and never be given up. Abraham asserts that “throwing away objects is the equivalent in the unconscious to evacuating faeces.” He goes on to say that “the disinclination to throw away worn-out or worthless objects frequently leads to a compulsive tendency to make use of even the most trifling thing.” ([16], p. 386). Freud’s assumption was that the words excrement, money, or gift, as well as child and penis, are easily confused in the unconscious. Toilet training coincides with the first time the child has to make a decision. The child can actively control whether to release the feces, and “sacrifices them to love” ([21], p. 130), as Freud writes, or retain them for the autoerotic satisfaction of their own needs. Freud thus explains the emergence of willfulness or defiant behavior, originating from narcissistic insistence on anal eroticism. Defiance is a natural response of the ego to the demands posed by others. Another correlation observed and described by Freud is that, in this analogy, the feces are regarded as a part that is, at the same time, connected to the body and can be removed from it. An equation is made with the penis, which also represents a part of the body that could potentially be lost. The anal defiance is superseded by the ensuing castration complex, which, in the anal phase, can only be understood as a disturbance of original narcissism (see [22], p. 159 ff., [21], p. 127 ff.). The above considerations are particularly interesting if viewed in the context of hoarding. Hoarding individuals perceive things and objects as something physical, as parts of the self that are not at one with the ego. When their homes are forcefully evicted, they display symptoms of psychotic breakdowns and the ego is threatened to collapse. Even if in-depth research and more case studies and clinical analyses are imperative to corroborate these connections, they are remarkable.

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The potential relationships between the emergence of hoarding and early psychosexual disturbances also serve to explain the persistence of symptoms and the related resistance to treatment often observed in hoarding individuals. Even if their homes are cleared of all clutter, hoarders will often revert to previous behavior patterns and clutter the living spaces again. The pivotal role of this first decision, confronting children in the anal phase, should be emphasized. The first conscious decision to hold on or let go is the first decision to be made between the other and the self, between object-love or narcissistic love. The hoarder’s peculiar relationship to objects can be traced to early disturbances and interferences in the patients’ first object relations. This basic assumption can prove vital in establishing trust and a stable therapist–patient relationship and may help derive treatment recommendations. Responses of defiance mark a crucial step in ego development in the anal phase. In order to successfully treat hoarding patients, professionals are advised to consider that each renunciation of an instinct requires a form of recognition or reward. The extreme distress concomitant with the urge to hoard, which can even trigger psychotic episodes and endanger the self of a collapse in functioning, is well known from practical work with hoarding individuals. Evictions pose a special threat to the people concerned. These individuals affected by hoarding may start enormous fears by thinking they can lose something, a type of fear of castration. Jones argues that the castration anxiety, “i.e. of some valued part of the body being taken away, though, of course, this has other sources as well,” is deeply intertwined with this complex, while there are also other causal factors that come into play ([20], p. 268). Since the cluttered rooms symbolically represent an extension of the ego, any attempt to remove or reduce the clutter becomes an imminent threat, unconsciously triggering the resurgence of the infantile fear of castration. In principle, any fear of separation or loss can be interpreted as castration anxiety. In hoarding disorder, this anxiety has its source in narcissism. Example A patient once reported that he would deliberately scatter paper slips and other objects across the apartment after separating from his partner. It was an attempt to make the home appear less lonely. Especially in his former girlfriend’s room, he would throw items on the floor to make the room look as if it was actively used. This way, he no longer felt alone and was convinced it would be easy to put everything back in place once he would not need to compensate the emptiness anymore (see Sect. 4.2.7, Mr. Z.). In a different case, a hoarding individual had kept an ashtray with two cigarette stubs on the cluttered coffee table, although he was not a smoker himself. He explained that the stubs were the last two cigarettes his deceased partner had smoked. She had died suddenly in an accident and never returned home. The ashtray and cigarette pack she had opened just before she left had been sitting on the coffee table for over 15 years, preserving the atmosphere of her presence.

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Having looked at the relevance of objects in hoarding, we also need to consider the special role of the places where hoarding symptoms emerge. From what has been said above, we can infer that the hoarders’ homes represent both the Id and the ego. They reveal everything, good or bad, about the person. Abraham presumes that a disordered room or disarranged drawer unconsciously mirrors the bowel filled with excrement (cf. [16]). The evident analogies to anal eroticism are manifold: the bowels represent a place of ingesting, digesting, and distinguishing between that which is nourishing and that which can be expelled. Children and money represent the most striking fecal symbols. Freud postulates a close connection between money and dirt. Several examples are presented in his works, including the term “Dukatenscheißer” (shitter of ducats) (cf. [9], p. 174). Freud’s cloacal theory explains this conceptual connection between feces and children. During the anal stage of development, the infant is presumed to perceive the anus as an organ capable of releasing something. The infant develops the theory that they were themselves mysteriously created from their mother’s excrement. Jones undermines the theory by providing examples from nature, including flowers growing from fertile soil [23]. Following the above theoretical considerations, the cluttered homes of hoarding individuals may be regarded as bearing treasures, reversing the process. Who determines what is garbage, what is meaningful and meaningless? The cycle of life can only be understood through death. Even if these considerations are almost completely repressed in everyday life, their existence cannot be denied and may affect us unconsciously. Ambivalent feelings of fear of loss while taking pleasure an erogenous excitation can be displaced and transformed. Cupidity and Collecting mania, as well as prodigality, have their correlating determinants in the infantile attitude toward feces. ([12], p. 283)

Through toilet training, the child acquires the ability to take control of certain bodily functions and functions of the self. As a consequence, they encounter their first experience of narcissistic satisfaction. Further aspects to be considered in this context are self-control and the desire to dominate others (ibid., p. 130 ff.). Hoarding exhibits several of the anal characteristics of obsessional neurosis, particularly including the difficulties throwing things away or giving something away. These difficulties usually show alongside distinct, predominantly unconscious fears, especially the fear of loss and castration. The preceding oral stage was the phase of receiving and ingesting. Hoarding is characterized by pathological behavior associated with a problematic attitude toward both giving and receiving. Abraham divides the anal-sadistic phase into a twofold approach to gaining erotic pleasure. He describes the primitive excitement of expulsion, closely related to destruction, on the one hand, and identifies the subsequent pleasure of retention or taking control on the other. We have come to the conclusion that the melancholic patient regresses to the lower level of that phase but does not make a halt there. His Libido tends towards a still earlier phase – the cannibalistic phase – in which his instinctual aim is to incorporate the object in himself. In

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2  A Review of the Fundamentals his unconscious he identifies the love-object he has lost and abandoned with the most important product of bodily evacuation – with his faeces – and re-incorporates it in his ego by means of the process we have called introjection. ([15], p. 481)

Hoarding is presumed to represent a regression to a cannibalistic phase in early development, wherein the urge to save objects may signify an unconscious attempt to reintegrate objects that have previously been lost. The central concept of incorporation enables a connection with the body, i.e., the site of all psychic events. Abraham elaborates on the development of object-love and illustrates areas of psychoanalytic sexual theory that require further research. His considerations are based primarily on the so-called narcissistic neuroses, as well as those neuroses that are closely related to the narcissistic ones. These considerations also prompted Abraham to discuss aspects of cannibalism: On the level of partial cannibalism we can still detect the signs of its descent from total cannibalism, yet nevertheless the distinction between the two is sharply marked. On that later level the individual shows the first signs of having some care for his object. We may also regard such a care, incomplete as it is, as the first beginnings of object-love in a stricter sense, since it implies that the individual has begun a conquer his narcissism. But we must add that on this level of development the individual is far from recognizing the existence of another individual as such and from ‘loving’ him in his entirety, whether in a physical or a mental way. His desire is still directed towards removing a part of the body of his object and incorporating it. This, on the other hand, implies that he has resigned the purely narcissistic aim of practicing complete cannibalism. ([15], p. 488)

The object-love can optimally only develop if narcissism is successfully integrated.

2.2.3 Shame and Guilt Another characteristic feature of hoarding is that those affected struggle with feelings of shame. The shame affects the persons’ everyday life, refusing to show their homes or invite others in. However, it is not only feelings of shame but also guilt that plagues hoarding individuals. According to Léon Wurmser, whose research extensively focused on problems of shame, guilt, and resentment, the dimensions of shame are manifold. On the one hand, shame represents fear: the fear of being shamed, the fear of being unmasked, and the fear of humiliation. On the other hand, shame is a complex depressive affect, instigating a necessity to hide or disappear. Moreover, shame is a character trait, representing a reaction formation due to the need to hide behind a mask and inhibit one’s curiosity (cf. [24, 25], p. 38 ff.). From a drive theory point of view, shame can only be understood by acquiring familiarity with psychosexual development, ego development, and object relations development. Margaret Mahler describes the intricate process as follows: We feel that our contribution has a special place in the psychoanalytic study of the history of object relationship. Early psychoanalytic writings showed that the development of object relation-

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ship was dependent upon the drives [10, 12, 15, 18]. Concepts such as narcissism (primary and secondary), ambivalence, sadomasochism, oral or anal character, and the oedipal triangle relate simultaneously to problems of drive and of object relationship. Our contribution should be seen as supplemental to this in showing the growth of object relationship from narcissism in parallel with the early life history of the ego […] ([26], p. 6)

The phase of separation and individuation, roughly corresponding to the second year of life, is decisive in hoarding behavior. Separation and individuation coincide with and complement the equally important anal phase. Consequently, Mahler’s concepts provide an interesting expansion and supplementation to Freud’s psychosexual development model. Early childhood development comprises several difficult, complex steps and phases children have to complete. We learn how to deal with experiences of loss early on, including internal losses, loss of the mother’s breast, or the end of their symbiotic relationship with the mother. For Mahler, the phase of separation and individuation primarily relates to the imminent danger of object-loss. Mahler is reluctant to equate this fear of losing an object with the fear of separation, where her theory diverges from John Bowlby. The British psychoanalyst refers to the physical separation from the love-object, whereas Mahler denotes a growing intrapsychic sensation, based on the presence of imminent danger (cf. [26]). Associations between object-loss, fear of separation, and separation from the love-object provide a key factor in hoarding disorder. A 2010 study, researching the question of how material deprivation and hoarding interconnect, confirms these assumptions. No clear link was found between levels of material deprivation and hoarding, although the themes of “loss and lack” in the context of emotional deprivation may offer a more fruitful line for further research. ([27], p. 201)

No connection between material deprivation and hoarding became apparent; however, emotional deprivation through loss and separation is evident. Anglo-American academic research currently does not provide sufficient explanation for such findings. It is interesting only on a superficial level that material deficiencies cannot explain hoarding symptomatology. The basic assumptions of psychoanalysis enable a more profound interpretation. The most relevant psychoanalytic concepts are the unconscious, theories of fear, ego, and libido development, as well as psychosexual development. The psychoanalytic approach elucidates that the hoarded objects bear little relation to material deficiency. The objects must be considered given their psychological meaning and value, looking at the characteristics individually attributed to them. Many patients with hoarding behavior have suffered early emotional deprivation or received insufficient care as infants or children. Some patients can even remember instances of severe humiliation and debasement. Therefore, respect and appreciation provide the cornerstones of establishing a fruitful therapist–patient relationship and lay the foundation for successful treatment.

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Micha Hilgers [28] describes different manifestations of shame. The central categories of shame in hoarding disorder are existential shame, ideality shame, and oedipal shame: Existential Shame Hilgers defines existential shame as the subjective impression of a person being considered undesirable or invisible to the other. For example, he mentions unwanted children or children who do not have the right gender in their parents’ eyes. Similar feelings of shame arise when parents consistently fail to respond to their children’s verbal or nonverbal self-expression. Existential shame occurs in everyone, even if the degrees to which it becomes manifest vary. Every person at one point in their life has had an experience in which they feel misunderstood or neglected. The narcissistic wounds thus created vary from person to person; however, any of these wounds have a significant effect on further psychological and personal development. Ideality Shame Hilgers defines ideality shame based on the discrepancies between self and ideal self. Such discrepancies are typical of hoarding personalities. Many hoarding patients report projects and plans they had never realized. The category of ideality shame also coincides with the shame-guilt dilemma. Those affected experience self-­condemnation and blame themselves for having failed toward their own standards. They consider themselves as flawed and feel ashamed for their suffering and inability to change. Personal inadequacies play a crucial role in this context. Many patients exhibit pronounced creativity and develop innovative ideas of order. However, their implementation would require a detailed plan and effort, which prevents them from realizing their ideas. Experiences of repeated frustration, mixed with a staged inability to realize self-defined goals and plans, become manifest in ideality shame. A patient once explained that, in her perception, the apartment only superficially appeared to be chaotic and messy. For her, the clutter signified a painful reminder of hobbies she had yet to engage in, plans she had not yet implemented, joys she had not yet experienced, and ideas she would eventually want to realize (see Sect. 4.2.1, Ms. O.). Oedipal Shame The third category of shame defined by Hilgers is the oedipal shame, denoting a feeling of rejection and exclusion. Those experiencing oedipal shame feel superfluous. They consider themselves unnecessary members of a group, perceiving themselves as the youngest, most inferior, or smallest group member ([28], p. 26 ff.). Narcissistic components, however, are present in all three manifestations of shame affect.

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Hoarding and the typical messiness purport the idea that something must be hidden or buried underneath the things and objects. Forced evictions often cause hoarding individuals to suffer a mental breakdown. Both the fear of castration and shame of castration become obvious in this behavior. Wurmser’s genesis of shame provides the foundation for the present conception of castration shame. Castration shame reflects a personal defect or flaw. It coincides with a fear of shame, originally shaped by a threat of exposure and embarrassment (see [25], p. 278 ff.). The shame theorist illustrates that feelings of shame develop from traumatization. In particular, the experiences of unrequited love or inappropriate responses to personal desires effectuate shame. Wurmser thus constructs a theory of shame at the core of which a feeling of unworthiness lies. Shame surfaces in statements such as: “I’m weak, dirty and damaged” (ibid., p. 297). In hoarding, the value individually attributed to things and objects is of central importance. Hoarding individuals always ascribe specific meaning to the things they accumulate, identifying themselves with the hoarded objects and things. This aspect, and the process of partial identification, give the impression that hoarders treat their hoarded objects as if they were animate. Infantile libidinous desires and narcissistic degradations occur as wounds to one’s self-esteem and leave lasting scars. It is crucial to note that these psychological aspects are transferred to the physical world through projection onto things and objects. The question arises whether hoarding individuals unconsciously stage the collapse. In some cases, the behavior becomes so obvious that it attracts public attention. The contradictory nature of hoarding surfaces: on the one hand, hoarders seek to keep to themselves, hiding and living a reclusive lifestyle, and on the other hand, hoarders put the objects up for display. A basic understanding of how guilt and shame develop is vital to the further discussion of hoarding. Therefore, I intend to give a brief outline of how psychosexual development and guilt connect. Feelings of guilt are inherently unconscious, revealing interesting aspects of the oral and anal phases of development. Freud [29] looks at the phenomenon of guilt from two different angles. While we cannot dispute the close relationship between fear and guilt, Freud asserts that the term guilt feelings can only apply to conscience phenomena, which are the result of super-ego development. It can be assumed that fear differs from the guilt experienced before the age of 4. According to Abraham, guilt feelings originate in the process of overcoming cannibalistic, i.e., aggressive impulses in the early anal-­ sadistic phase. Trauma theorist Sándor Ferenczi states that guilt emerges during anal development, establishing the concept of sphincter morality. The obedience and assimilated behavior displayed by children who experience rigorous toilet training are particularly noteworthy in this context (cf. [30]). Hoarding individuals experience intense feelings of shame and guilt. It can be assumed that the super-ego presents itself as overly strict and sadistic. The conservative ego-ideal cannot be satisfied. This sphincter morality is central to considerations of early super-ego development and the emergence of the super-ego.

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Most individuals affected by hoarding display perfectionist ideas and fantasies of establishing a system of order. Reality and ideals differ so greatly that any approximation or reconciliation seems impossible. The characteristic trait of obsessional neurosis, Fenichel emphasizes, is the ego’s dependence on the super-ego. This conception suggests further intrapsychic conflict mechanisms whose intrinsic complexity requires additional effort on behalf of the ego. The ego must not only defend itself against the impulses of the id but also against the super-ego (cf. [12], p.  169 ff.). Auto-aggressive impulses can be conceived in terms of masochistic tendencies. These interdependencies of psychological entities support the assumption that auto-aggressive impulses in hoarding, including impairments of personal living areas, could represent instances of masochistic drive satisfaction. Consequently, we also have to consider aspects of drive satisfaction and a possible adhesiveness, or inertia, of the libido. It is to be hoped that individual case studies from psychoanalysis and psychotherapy will reveal further connections in the future. Hoarders have a peculiar relationship with the objects they seek to save. There seem to be no boundaries between the ego and the objects. This situation recalls images of the first weeks after birth, where mother and child are already physically separated but remain connected on a mental level. Mahler describes this phase of development as characterized by the inexistence of clear boundaries and the lack of a conception of the inner and outer world. Margaret Mahler’s description of this phase provides insight into psychoses and other psychotic phenomena: The essential feature of symbiosis is hallucinatory or delusional somatopsychic omnipotent fusion with the representation of the mother and, in particular, the delusion of a common boundary between two physically separate individuals. This is the mechanism to which the ego regresses in cases of the most severe disturbance of individuation and psychotic disorganization […]. ([26], p. 45)

The borders to the outside world are first the skin, then the clothes and, by extension, the rooms we live in. Based on this assumption, we need to ask what pathological hoarding reveals about a person’s relationship to the outside and inside world? What purpose does the hoarding fulfill? What does this way of living mean for the self and reveal how we feel in our bodies? Bodily sensations transport the onset of identity development and object separation. The body-ego emerges from physical contact in care situations. These kinesthetic experiences significantly contribute to learning how to integrate physical sensations and how we feel about our bodies ([26], p. 49 ff.). Symptoms spread to the ego’s outer extensions: the space surrounding us, i.e., the home. Following Freud, Mahler points out the importance of the complete psychotic break with reality: the withdrawal from the libidinous human object world. The infant does not possess autonomous bodily defense functions and is confused about the inner and outer organismic self (cf. [26], p.  63 ff.). The question emerges of whether hoarding could represent an attempt at withdrawing from the world, i.e. the mother.

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Based on Wurmser’s (1981) phenomenological study of shame, the significance and relevance of conflicts of shame in hoarding can be detailed as follows: Shame is above all representative of the fear of being humiliated and exposed. Hoarding individuals are often ashamed of their homes. Strangers are usually not allowed to enter, and if they are, it is because they are trusted or needed to enter. Shame can also be seen as a reaction formation to counteract exhibitionist desires. Those affected experience conflict with unconscious and forbidden desires. The ambivalence surfaces as hoarding individuals feel ashamed and need to hide, while also experiencing the urge to display. This contradiction also explains, besides other factors, the success of popular television shows portraying individuals who hoard. Feelings of shame are rooted in tensions between the ego-ideal and the ego. The extremely high standards of the ego-ideal hardly give the ego a chance to fulfill its expectations. HD patients report exaggerated standards of order and the pressure of unfinished projects and plans that have never been implemented. Demanding extremely high standards of order and expecting each object to be used in specific ways, hoarding individuals constantly overburden themselves. The unconsciously staged situation triggers renewed feelings of powerlessness and frustration. The inevitable failure in the light of these self-imposed demands is familiar and repeated in a cycle. Shame often serves as a cover affect for deeper-seated forms of fear, such as fear of separation or castration (see [25]). Hoarding may represent the attempt to reintegrate lost objects. Some patients identify with inanimate objects. Sensitivity for this component of hoarding, as well as empathy for the patient and awareness for different conflicts of shame, can prove beneficial in providing support. Detailed analysis and interpretation of intrapsychic phenomena such as shame and guilt feelings may contribute to understanding the disorder. This aspect is especially interesting given a modern society where public figures’ self-portrayal gives the impression that a certain shamelessness is not only becoming socially acceptable but even considered desirable. It has to be noted that feelings of shame contain several positive aspects in terms of identity development. According to Hilgers, we can only learn about ourselves and gain self-awareness by progressing through and eventually resolving shame conflicts. The question remains whether a person can consciously address the shame experienced in the revelation of personal deficiencies, dependencies, or attacks. Shame is a sting or thorn that encourages coping with reality as long as the person concerned has sufficient opportunities to cope with and acquire new skills ([28], p. 301)

2.2.4 Summary of Drive Theoretical Concepts Orality and anality can only be understood in a psychoanalytic context. They are theoretically designed as stages but are to be understood as parallel processes that may at times overlap (see Sect. 4.2.6, Mr. Y.). This implies that […] “the partial

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introjection need not be effected in an oral way but can be thought of as an anal process.” ([15], p. 490). Hoarding individuals do not generally focus on a specific type of object. The hoarded things can be regarded as objects in themselves, as fetishes, so to say. Relevant literature describes the development of object-love as partial love. This theory allows us to understand the perversions as a specialization of interest to a certain object, which is a specific part of the body. Freud describes different functions of anal eroticism. It can serve as a vehicle of enjoying taboo pleasures or a medium of the desire to be loved by the father, and it can express anger toward the father. This theory is less bound to organs or organ functions than the later explications presented by Karl Abraham (see [31]). Abraham’s work has essentially contributed to advancing and extending the psychosexual stages originally defined by Freud. Consequently, Abraham’s concepts are indispensable for comprehending the symptoms of hoarding disorder. The following sections shall outline the libidinal organization stages and the sources of object-love, formulated by Abraham [15]: Early Oral (Sucking) Stage: Autoeroticism Abraham states that “we regard the earliest, autoerotic stage of the individual as being still exempt from instinctual inhibitions, in accordance with the absence of any real object relations” ([15], p. 496). The newborn is presumably still psychologically one with the mother. This strong connection means that no other object relation can be developed at this stage. As previously mentioned, the homes of individuals affected by hoarding may be interpreted in terms of enacting the regression to an early stage in psychosexual development. In the homes, cluttered with objects, everything is within reach. The objects are readily available to be ingested, reminding of the oral stage, wherein the child is primarily driven by an urge to put things into the mouth. The illusion that everything is available at any time has become the patient’s reality. This staged omnipresence of objects represents the denial of dependence. Everything is present and yet not retrievable or ready to be used. We know many clinical cases where patients could only use their beds or one single chair. Daily necessities are practically placed at arm’s length, evoking the image of the infant held close to the mother’s breast. The patients’ narcissistic vision is that they are sufficient and do not depend on the other to feel complete. They create a reality in which they are independent of other people and live the illusion of complete autonomy. Late Oral (Biting) Stage: Narcissism and Object Incorporation Fear emerges to repress the infant’s instinctual cannibalism. The process of overcoming the infantile wish to incorporate the object and its functions bears feelings of guilt. The oral object relationship urges the infant to want to devour the other and incorporate its characteristics. Individuals who hoard likewise devour the object. Everything inside the home becomes conflated with the ego. Everything becomes one. This serves to explain why hoarding individuals are unable to separate from

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objects. Every attempt to remove an object signifies an attempt to amputate a part of the body. Any separation represents an experience as traumatic as castration. A void is created in space and in the body. This void is the source of oral greed and oral envy also originates from this empty space. This conception also explains the hoarders’ tendency to over-consumption, be it with regard to eating, watching television, or accumulating possessions. For a more detailed discussion of this aspect, however, more research is required. Early Anal-Sadistic Stage: Partial Love and Incorporation In this stage, the object of love is represented by only a part. The individual’s attitude toward this part (e.g., penis, breast, feces, etc.) is ambivalent. The part-objects enable the incorporation of the object. From an outside perspective, one might think the accumulated things are useless bits and pieces, with no specific meaning. However, each thing may represent a part of a whole that the hoarder seeks to restore. A patient once used the metaphor that his life was in ruins, eliciting the assumption that the hoarded objects represent the ruins of his life. In fact, many homes of hoarding individuals evoke the drama of a war scene or bombing. The scene is one of destruction, with everything scattered throughout the apartment and nothing left in place. Late Anal-Sadistic Stage: Partial Love The part-object is overemphasized, while the significance of the object as a whole diminishes. The importance of personal relationships diminishes. Things are given priority as they cannot harm, leave, or disappoint their owner. They simply are. Early Genital (Phallic) Stage: Object-Love and Genital Exclusion In the early genital stage, also known as the phallic stage, feelings of shame are suppressed. Shame is one of the key factors to be considered in treating those showing medium insight into the problematic nature of their behavior. These patients are aware that their behavior is a rebellion against existing ideas of order. Final Genital Stage: Object-Love The emerging social awareness of the child serves to regulate libidinous instincts. Appropriate psychoanalytic treatment can help patients achieve this level in adult life. In addition to describing the libidinous organization levels, Abraham also assigned disorders and respective symptoms to the different stages of development. He asserted that melancholia arises from the second stage, whereas paranoia has its origin in the third stage. Professionals aiming to understand the complexity of the human psyche have to be familiar with all the stages. We can begin to understand the factors influencing and causing hoarding behavior only if we consider the different factors at play in psychosexual development. Abraham’s organizational

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stages also touch on some of the fundamental theoretical models of psychoanalysis, including greed, envy, shame, and guilt. Appropriating both Freud’s and Abraham’s theory in hoarding disorder analysis, professionals also need to be aware of their differences. In her 2012 paper, “On the early history of anal eroticism,” Ulrike May outlines the essential differences. She points out that Abraham, in contrast to Freud, does not consider intestinal contents as carrying narcissistic meaning. The feces are not experienced as an intrinsic part of the ego. May admits that the autoerotic-narcissistic character of psychological development, which was central to Freud, has almost been lost in developing his theories further (see [31]). May concludes that theoretical thinking seems to be more strongly influenced by Freud’s students, such as Abraham, than we are aware of, at the same time emphasizing how much the more recent theories differ from Freudian thinking. Different concepts and theories do not have to be mutually exclusive but should be allowed to coexist. This is also why this guide aims to include different theories and considerations, allowing them to exist alongside each other, often complementing each other and sometimes contradicting each other. After all, these interfaces provide valuable insights for an advanced understanding of hoarding disorder and, ultimately, its treatment.

2.2.5 Object Relations Theory Hoarding disorder symptoms, particularly the cluttered homes, evoke associations with object relations theory. The other seems to occupy a central role. In Melanie Klein’s theories, the other is acknowledged as being present at all times. The other represents a prerequisite for experiencing the self. Kleinian thought postulates that the infant’s developing ego is subject to diffuse fears. One fear dominates in particular: the fear of being destroyed. In order to defend itself against such destructive inner fears, the ego employs the mechanism of splitting. The external object is split into good and evil, laying the foundation for the later development of the defense mechanisms of introjection, idealization, or denial. The Kleinian model of the human psyche assumes two positions: the paranoid-­ schizoid and the subsequent depressive position. The first position in Kleinian development psychology is based on the assumption of so-called part-objects. The ego and its relations split into idealized and persecutory parts. The second position represents a development stage wherein the ego becomes integrated. The object is perceived as possessing both good and bad components. The respective developments associated with these positions were initially understood as sequential development phases. Klein’s concept of position, however, significantly differs from the conception of development stages or phases. For Klein, the term position denotes an “oscillation process” ([14], p. 563). It refers to a dynamic state of mind where it is possible to move back and forth. In the further development of Klein’s theory, the two positions came to be understood as forms of organization, not confined to infancy but persisting a lifetime. The perception of part-objects differs from the

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perception of whole objects. The development of the ability to perceive objects as a whole is not only the consequence of differentiated perception; in Klein’s view, it is mainly based on the ability to tolerate anxiety in the depressive position without having to revert to the paranoid-schizoid position (ibid., p. 517 ff.). The ability to tolerate anxiety and other states of ambivalence is a required ability to be acquired by the infant, whereby the process can only be successfully completed in an adequate environment. Psychoanalysis postulates that our inner world consists of objects. These inner representations denote introjects of external experiences and object relations. The infant constructs their inner world from both real and hallucinatory perceptions of the environment. According to this conception, the objects in the hoarder’s cluttered homes are symbolic representations and re-enactments of the inner objects. The antagonist of introjection is projection, transferring psychological contents to the outside world. Hoarded objects are not to be understood as projections but in terms of extrojection of internal qualities and affective states. It is assumed that disturbances occur in the mental translation of repetitive projections and introjections. According to Klein’s model, the object is real. It is evaluated based on its presumed intentions toward the ego. These intentions may relate to love and gratitude or to hate and envy. The infant is presumed to have a relationship with environmental objects from the very beginning. These relationships are referred to as object relations (cf. [14], p. 517 ff.). Theories of intersubjectivity and relational psychoanalysis are to be understood as advancements of Kleinian models of thinking. An understanding of how inner object relations develop enables a profound analysis of the processes of transference. We all are limited in our reactions by personal capabilities. Moving beyond these capabilities presupposes a heightened level of self-awareness and intense self-reflection. Internal object relationships—that is, the internal world of the patient—consist predominantly in relations to archaic objects which, for different reasons, have not developed. These archaic objects are objects into which, in infancy and childhood, the child has projected great parts of itself, and has introjected them. Therefore they do not necessarily correspond to or much resemble the original external objects. Because of these projections the internal objects are distorted. The patient goes on relating to them in ways similar to those in infancy—that is, they are often perceived as dangerous and hostile. The patient experiences anxiety, against which he uses defensive patterns, and the analyst will be perceived by the patient in the very way he perceived his objects, and will react to the analyst accordingly. [32]

How does the human psyche develop? What micro-experiences with their mother or other caregivers do children need to make to develop the ability to distinguish between reality and fantasy? Projective Identification The concept of projective identification is owed to Melanie Klein’s research. Projective identification does not only present a defense mechanism, but it also

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describes the first mode of communication between infant and mother. The infant communicates with their mother through introjections. The mother absorbs these, mentally digests them, and consequently returns them to the infant. Her thinking transforms the infant’s sensations and feelings into something familiar. In this way, the infant’s entire psychological condition develops. Based on this mechanism, the ego can take form, and this ego can distinguish between conscious and unconscious; between seeing and imagining; fantasizing and dreaming; sleeping and waking. If this exchange between mother and child is disturbed, this may result—in extreme cases—in aggression toward the infant’s own mental abilities, culminating in the formation of psychosis (see [33], p. 238 ff.). Hoarding disorder suggests that disturbances have occurred in the transformation phase. The required translation of the child’s communication of conscious and unconscious experiences could not be sufficiently fulfilled and the child had to cope with these events on their own. The symptoms of staging inner representations and extrojecting clearly indicate unwanted interferences at this prelinguistic stage of development. Digestion denotes a process of transformation; in other words, the translation of emotional experiences into good, so-called alpha elements. These are considered suitable for being mentally digested. Bad or evil aspects are referred to as beta elements. Unsuitable for digestion, these can only be expelled as raw and undigested elements of emotion. They remain mere sense impressions and emotions that the person experiences remain unchanged (see [34], p. 52 ff.). One possible interpretation of hoarded objects is, then, that the objects represent undigested elements of emotion that can no longer be kept inside. They have to be expelled from the body into the outside world. With his concept of “learning from experience” (1992), Bion refers to the transformational work required from the mother. Through her ability to dream (rêverie), the mother can enter into communication with the infant and digest inner and outer experiences. Based on Bion’s theory, disorderliness can be interpreted as a form of spitting out undigested elements of emotion [35]. They are the beta elements that could not be transformed into digestible alpha elements. Chaos in a patient’s outer world can thus point to intrapsychic chaos, necessitating the expulsion of bad and indigestible elements and making them visible to the outside world. Severe hoarding, i.e. the accumulation of environmental objects, may metaphorically be understood as a form of vomiting. The behavior turns the chaos of the psyche outward, maybe because the patient is no longer able to tolerate the inner state of disorder. When working with HD patients, we need to be aware of such unconscious mechanisms, as they will help us avoid a sudden outbreak of severe reactions and violent behavior. Carefully raising awareness is central to both psychotherapeutic and medical work. Particularly when working with patients on-site, entering their homes, unconscious mechanisms can recur and continue to affect the patients. They may even trigger violent reactions and behavior, not only in the patient but also in the therapist or other professionals.

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Michael Balint’s theory of the ocnophil and philobat further elucidates pathological hoarding, specifically the role of object relations [36]. Balint’s model defines two approaches to handling the object confronting the infant after the birth trauma, one being characterized by seeking closeness with the objects and the other avoiding them. For Balint, the primary relationship, primary love, is to be found in the undifferentiated environment in which objects first emerge. The child, first confronted with the emergence of objects, has two ways of dealing with them. They either create –– an ocnophil world, aiming to be close to objects, displaying the tendency to cling to them, or, –– a philobatic world, characterized by an urge to develop skills in handling as well as mastering objects. The ocnophil path leads to a dependence on objects, a clinging tendency (cf. [37]). Psychological development depends on the eventual shift from the ocnophil to the philobatic world. In the context of hoarding disorder, it seems crucial that objects assume or at least help maintain functions of the ego. Balint thus helps us understand the underlying process, while Bion explains the crucial dimension. The objects provide security, and they seem to offer suitable protection from unconscious inner fears. Especially in the first weeks and months of life, infants depend on their caregivers. This dependence, continuing for years to come, is significant for our psychological development. The infant’s relation with life and death occurs in the setting of his survival being dependent on his external objects, and on the balance of power of the life and death instincts which qualify his perception of those objects and his capacity to depend upon them and use them. […] Ideas of immortality arise as a response to these anxieties, and as a defence against them. ([38] p. 295)

In the context of pathological hoarding, these considerations are revealing. The hoarding of objects represents an attempt to deny separation, loss, and, ultimately, death. Many patients experienced separation from or the loss of a caregiver during their childhood. The sudden changes ensuing from such a traumatic experience, compounded by the lack of a substitute caregiver and insufficient intrapsychic digestion of the event, can be named as essential influencing factors in the development of hoarding disorder (see Sect. 4.1). Hoarding individuals are often concerned with the issue of security. Security can be obtained by possessing everything one could possibly need and keeping these things within reach. This could be seen as a precautionary measure, preparing for any eventuality. One no longer needs to rely on trust alone for things to be available when needed. Balint describes the development of the ocnophil character as follows: One is to create an ocnophilic world based on the phantasy that firm objects are reliable and kind, that they will always be there when one needs them, and that they will never resist being used for support. ([37], p. 52)

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Surrounded by objects, hoarders create a safe haven that provides comfort at all times. The objects release unconscious fears or at least help keep them at bay. They protect the ego from destructive anxiety. Psychoanalysis here also allows for parallels to be drawn to concepts of narcissism. Bion provided interesting conceptions on the meaning of rooms. Bion describes rooms (living rooms, cellars, and storerooms) as places where the object once was contained. The rooms function as mirrors and representations of early intrapsychic rooms. In his contribution “Transformations,” he explains the importance of the translation of phenomena and sensations. He explains this by giving the example of a patient seeking the help of an analyst to help him cope with diffuse anxiety and discomfort. The analyst transforms the patient’s statements. While the patient describes his situation as feeling trapped and anxious, the analyst has his own vocabulary and begins to speak of an inner object and depersonalization. Bion admits that there is a range of terms that can be used to describe the same situations. He also uses the mathematical term invariant and suggests talking about “a place, where the thing was” or the designation “space” ([35]). Most hoarders do not focus on specific types of objects; they hoard a seemingly random selection of things. A few cases are known, however, where patients hoarded the most bizarre items. Some hoard bodily wastes, such as urine or clipped nails, others tend to hold on to garbage, refusing to dispose of used or broken things. This type of behavior is very likely based on severe personality disorder or disorder related to schizophrenia. Klein’s theory has proven to provide valuable insights into the psychotic aspects of these phenomena. Many analyses of both children and adults confirm Melanie Klein’s assumption that their persecutory anxiety stems from early sadistic fantasies of using one’s own poisonous urine and excrements to attack, for example, the mother’s body (cf. [39], p. 375 ff.). In the narrower sense of hoarding, these fantasies have little to no relevance. In most cases, hoarding is due to more serious mental illnesses, which must be given priority in the process of diagnosis and treatment. Again, splitting off unwanted parts and transferring them to the other, or digesting unbearable elements through the other in order to be able to accept these parts is the underlying principle of projective identification. The activity we know as ‘thinking’ was in origin a procedure for unburdening the psyche of accretions of stimuli and the mechanism is that which has been described by Melanie Klein as projective identification. The broad outline of this theory is that there exists an omnipotent phantasy that it is possible to split off temporarily undesired, though sometimes valued, parts of the personality and put them into an object. ([34], p. 31)

Klein describes the role of unconscious destructive forces and satisfaction of security needs as a defense against them as follows: I think that the child’s compulsive, almost greedy, collection and accumulation of material (including knowledge as a substance) is based, among other things which need not be mentioned here, upon its ever-renewed attempt (a) to get hold of ‘good’ substances and objects (ultimately, ‘good’ milk, ‘good’ faeces, a ‘good’ penis and ‘good’ children) and with their help to paralyse the action of the ‘bad’ objects and substances inside its body; and (b) to

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amass sufficient reserves inside itself to be able to resist attacks made upon it by its external objects, and if necessary to restore to its mother’s body, or rather, to its objects, what it has stolen from them. [39]

In the context of hoarding disorder, Melanie Klein’s above deliberations are more relevant than ever. The two unconscious mechanisms at work in hoarding are, on the one hand, suppressing the inner evil parts through the accumulation of good objects in the external world, and, on the other hand, defending oneself against attacks by external objects. Hoarding provides a means to cope with severe inner conflicts and deal with traumatic experiences and psychological distress. Hoarding also reflects the underlying desire for independent, autonomous satisfaction. Patients seek to be independent of the other. Specific functions of hoarding may thus be understood in terms of masturbation. The subject becomes entirely independent, carrying the source of both sexual desire and satisfaction of this desire. There is no need for the other. Satisfaction depends on the subject. This psychological construct, however, is illusory. Patients with hoarding disorder often experience serious distress. Still, this tendency to seek satisfaction in the self rather than the other serves, to explain libido adhesiveness and narcissistic tendencies in hoarding. The satisfaction derived from a preoccupation with objects, sorting, organizing, rearranging, and transporting them, can be viewed as anal masturbation. Donald Meltzer, a psychoanalyst in the Kleinian tradition, describes the indicators of anal masturbation as follows [40]: The most common form (see Freud, and Abraham) utilises the faecal mass itself as the masturbatory stimulant. Either its retention, slow expulsion, rhythmic partial expulsion and retraction, or the rapid, forced, and painful expulsion are accompanied by the unconscious fantasies which alter the ego state. This change in mental state can be noted in child patients when they return from defaecating during sessions. The habit of reading on the toilet, special methods of cleansing the anus, special concern about leaving a bad smell, anxiety about faecal stain on underclothing, habitually dirty finger nails, surreptitious smelling of fingers, etc. are all tentative indicators of cryptic anal masturbation. ([40], p. 38)

This compares to hoarders’ habit of spending hours with objects in what directions the patients’ libidinous energy flows can provide valuable incentives for treatment. Greed and Envy Klein’s conception of greed and envy provides additional insight into hoarding. Melanie Klein attributes greed to an imbalance of libidinous and aggressive drives. If inner and outer failures intensify aggressive drives, greed also intensifies. Aggressive drives and greed are closely intertwined, constantly spurring each other on. This cycle of greed also plays a major role in forming persecutory anxiety, as greed is projected, and a fear of the object’s greed ensues. With other words, when in the fusion of both instincts the life instinct is stronger than the death instinct— the libido is stronger than the aggression—the good breast can be saved in child. (cf. [39]).

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Fears, in particular the fear of object-loss, are central to hoarding. The fear of losing a beloved object increases greed. Related aspects of orality and anality are detailed in Chap. 1. Klein refers to these aspects as being closely linked to greed. “A oral-sadistic form combined with greed is trying to deprive the maternal body of all that is good and desirable. The other possibility is to attack the body by filling evil substances and split-off parts of yourself, a mostly anal nature.” [39]. The oral and anal aspects of aggressive drives and desires projected onto the object are best grasped when assuming a symbolic relationship between the homes and the mother’s body. Envy is often associated with penis envy, the counterpart of the castration complex. Klein can be referred to as extending Freud’s notion of penis envy, who postulated that envy originates from the oral. Envy of the mother’s breast, on the other hand, is rooted in the infant’s first relationship with their mother. At a time at which the first beginnings of sexual satisfaction are still linked with the taking of nourishment, the sexual instinct has a sexual object outside the infant’s own body in the shape of his mother’s breast. ([10], p. 222)

This further extends and affirms the relevance of this early developmental phase. It is important to note such observations about the emergence and development of theories. Psychoanalytic research has been accused of idealizing its founding father; however, the roots of psychoanalytic theories must not be forgotten or denied. Another interesting correlation can be discovered between fascination and envy. Fascination, derived from fascinare, means to describe, bewitch, or enchant. It can be traced to the noun fascinum, a phallus symbol. The connection between the eye and the penis and between voyeurism and exhibitionism is undeniable. Wurmser points out the relation to the Greek baskainein; it means to enchant but also to envy and slander. The exhibitionist wants to fascinate above all with his penis, as a defense against his deep shame and castration fears. (cf. [24, 25], 2011). Patients are ashamed to invite people into their cluttered homes, while at the same time displaying exhibitionist tendencies. The homes are transformed into a stage where patients reveal themselves, providing a source of both pleasure and disgust. The sensationalist nature of hoarding disorder has (unfortunately) also been discovered to perfectly lend itself to popular television. The viewers’ interest is in psychological phenomena becoming visible. Television shows on hoarding disorder are gaining popularity throughout American and the German-speaking world. The extent to which these public presentations of hoarding disorders create stigma and increase the suffering of those affected is rarely considered. In times of selfies and professional self-presentation, it has become difficult and unpopular to question these trends. In America, it has recently also become common practice for doctors and psychotherapists to offer advice and help online or on television. Only in the decades to come will we be able to determine which of these trends prove to be effective and should be continued as valid psychotherapeutic methods.

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2.2.6 French Psychoanalytic Concepts Psychiatric discourse does not suffice to grasp psychoanalytic concepts. Neither do the diagnostic manuals suffice to capture the psyche’s complex nature and deviations from a presumed norm. The French psychoanalyst André Green analyzed the connection between madness and passion [41]. Until recently, when the avant-garde movement began thinking madness was in vogue, madness had been considered a taboo topic. People who displayed deviant behavior were considered nervous disease (nervös) rather than crazy (verrückt). Psychiatry dominated the scientific landscape. Green’s achievement was to create a synthesis, closing the gap between philosophies of the ego and the id by integrating madness into his research (cf. [42]). The psychosexual and libido development theories explain the close connection between passion and madness and they corroborate the perception of hoarding as a disorder in its own right. What explanations does Green’s approach offer to understand the excessiveness of hoarding? The borderline cases, which give us so much difficulty in our analyses today, suffer both from too much deficiency and from too much of too much. “What is too much is too much,” goes the popular saying. There is no better way to describe excess than this tautology. There is also no standard, no folding rule, no weight with which one can measure how far parents or psychoanalysts can go too far. Melanie Klein, Bion and Winnicott have often been accused of this. Because there is the paradox: when uttering the unheard one has to go too far so that those who hear it can keep at least a minimum of it. ([42], p 260)

According to Green, the excess portrayed by hoarding serves to reveal an actual deficit. This conception corresponds to the above deliberations on hoarding. The question is: what lack are patients seeking to compensate in hoarding? They fill rooms with things that they are unable to part with, perceiving them as valuable. This behavior indicates an emotional overload. People who hoard, create walls and mountains of items, most of us would consider as junk. In doing so, they make things visible while trying to hide them from the outside world. What do rooms signify in the unconscious? What role does sexuality play in hoarding disorder? Janine Chasseguet-Smirgel’s work on perversion suggests that dream-like representations point to a close connection between hoarding and sexuality or even perversion. In dreams, genitals or sexuality are often depicted as building complexes, rooms, and staircases (cf. [43], p. 138 ff.). More in-depth research on perversion and sexuality is required to shed light on this topic and its relevance to hoarding and it is hoped that contributions of this kind will soon contribute to a more comprehensive understanding of the disorder. Compared to the significance of object relations, the capacity to love seems underdeveloped in persons who hoard. Not only the rooms themselves but also the objects accumulated inside the rooms have to be understood as representative of the ego functions. Emotions of fear, aggression, and defense are essential influencing factors in hoarding disorder. Therefore, we need to ask to what extent hoarding reduces fear. Are patients

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unconsciously willing to pay the heavy price of neurosis to defend themselves against anxiety? Hoarding is essentially about anal-erotic drives resurfacing. In the unconscious, mental images, concepts, ideas, fantasies, and symptoms seem to coexist. Their equivalence and equality in the unconscious mean that they can easily be confused and may, at times, be used interchangeably. Extending the presumed equation of penis = child = feces ([21], p. 132) in the context of hoarding, we can postulate the equation of penis = child = feces = objects. This reasoning helps us recognize the patients’ inner conflict and attempt to ward off the threat posed by castration anxiety. At the same time, hoarding behavior provokes castration. The patients clutter their homes to the point where the amassed objects have to be removed forcefully. The Freudian equation of penis = child = feces can be extended to include the objects in hoarding. This points to the significance of objects in the human unconscious. Extension of the equation illustrates the mental function of the objects. The psychotic episodes and collapse of the self in hoarders confronted with eviction correlate with the above equation and its extension. In line with what has been established previously, the equation suggests that hoarding represents the enactment of infantile part-objects of the unconscious. The part-objects could be associated with either an excess or deficit experienced in the early childhood environment. Individual meanings are to be determined in a psychotherapeutic setting. Hoarding disorder symptoms reveal an unresolvable inner conflict. The patients are constantly alternating between the pressing need to tidy up and the marked inability to do. The contradictory nature of the disorder points to the influence of ego-ideal and super-ego development. Chasseguet-Smirgel postulates a significant difference between the ego-ideal, the heir to primordial narcissism, and the super-­ego, the heir to the Oedipus complex. The ego-ideal aims to restore its lost omnipotence, while the super-ego, as defined by Freud, is the result of the castration complex. In terms of symptomatology, hoarding re-establishes omnipotence of the ego-ideal by amassing possessions. The patients’ homes represent a state of primordial narcissism, where everything required is within reach. In this analogy, super-­ego development coincides with conscience formation and poses an imminent threat to the ego-ideal. Most people who hoard are aware that their behavior deviates from what is considered socially and culturally acceptable. Sometimes they know that it is only a matter of time before their behavior is discovered and intervention becomes inevitable. Psychoanalysis describes the different phases of super-ego development. In his seminal work “The Ego and the Id” [2], Freud uses the term super-ego synonymously with the ego-ideal. He further describes that conflicts between the ego and ego-ideal reflect the tension between the physical and the mental, between the outer world and the inner world. In hoarding, the super-ego assumes an uncompromising position, with those affected constantly feeling guilty, deficient, and unable to live up to the ego-ideal standards. With his theory of narcissism, Béla Grunberger is essential for the present discussion [44]. His discussion of the [45] demonstrates the importance of narcissism

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in obsessive-compulsive disorders. OCD patients appear to be highly dependent on the outside world to obtain narcissistic satisfaction. Narcissism is central both in the development and treatment of obsessive-compulsive disorder. Abraham [15] first pointed out the role of narcissism in obsessional neuroses, discussing connections between obsessive-compulsive disorder and depression. His approach is particularly interesting, considering that research has established depression as a common OCD comorbidity. Research shows that up to 75% of people with hoarding disorder are also affected by affective disorder and/or anxiety disorder [46]. The interaction of the disorders can only be clarified in individual analysis and therapy. The fact that diagnostic criteria for hoarding disorder have only recently been defined means that, for a long time, people used to play symptoms down. It is only logical that a phenomenon would not be treated as a serious disorder as long as it was not recognized as such. Many patients experienced hurtful misconceptions, including the idea that the problem could be solved if they just pulled themselves together and cleaned their homes. Yet even today, patients have to battle stigma and judgment. We only have to imagine, drawing an analogy, the trauma professionals could cause by advising a person with depression to simply pull themselves together. The second aspect addressed by Grunberger is the importance of defining the patient’s object relation as therapy progresses. The narcissistic object relation is susceptible to narcissistic injury and, consequently, narcissistic rage ([45], p.  51 ff.). It is one of the main characteristics of hoarding that the objects have personal meaning and value. It is to be expected that the experience of object-loss always entails narcissistic injury. In his theory of narcissism, which initially coincides with drive development, Grunberger argues that orality originates before the emergence of drives. He considers the oral to be rooted in narcissism, which can be traced to the prenatal period. It is widely assumed that, in this early period, orality and narcissism overlap. However, an often neglected factor is that the effect of orality extends from the prenatal into postnatal life. Typical traits of oral personalities are marked by greediness and insatiable hunger. Objectlessness shapes the oral phase of development. Oral personalities compare to overindulged children whose caregivers did not enforce appropriate limits. Experiences of frustration are crucial in psychological development. It appears that oral personalities received too much love in childhood, yet not the love they needed. The ambivalence between a certain kind of helplessness and the denial of the need for help becomes obvious in the process of analysis ([44], p. 138 ff.). Comparing the oral character and overindulged children is of particular interest in discussing the patients’ resistance to therapy. The persistence of oral character traits may be a reason why hoarding individuals find it hard to accept help, let alone ask for it. Therapy may be met with great resistance and, in any case, requires sensitivity and patience on the part of the therapist. Grunberger [44] also contributes to explaining the wide variety of accompanying symptoms in hoarding, including doubt, indecision, unpunctuality, and

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recurring failure to set priorities. The psychoanalyst defines doubt as a predominant characteristic of obsessive-compulsive disorder. This doubt indicates an inner conflict between the urge to conquer and, at the same time, defend against the penis. Grunberger, referencing Freud, further explicates that knowledge represents the opposite of doubt. At the same time, knowledge can be interpreted in terms of mastery. It is, then, about mastery of the penis. Since this thirst for knowledge constitutes a taboo topic, doubt moves into the place of knowledge. This pattern can be observed in almost any manifestation of obsessive-compulsive disorder. In the beginning, there is a desire to master the penis, followed by respective defense mechanisms. Feelings of insecurity, indecision, and hesitation are also worthy of being noted in this regard. They all point to the ego’s deeper anxiety, rooted in this conflict (see [45], p. 58 ff.). Hoarding disorder is essentially a reflection of these inner conflicts and processes. From a behaviorist point of view, a perceptual disorder could be diagnosed and neurobiological approaches would be likely to discern a dysfunction of the brain in the area responsible for decision-making. Clinical, behavioral psychology, and neuropsychology are primarily interested in aspects of perception, attention, and memory performance, including the structure of memory. These disciplines’ main subject focuses on the patients’ abilities to make decisions and act [47]. It is to be hoped that more interdisciplinary work will be carried out in the future. The exchange between individual disciplines is likely to provide new insights and valuable incentives for further research and clinical treatment. From a psychoanalytic point of view, doubt and indecision represent inhibitions in terms of an inner prohibition. Grunberger states: In my opinion, this fearfulness stems from the fact that the impulse to act is deprived of all its drive components. This must lead to the energetic collapse of thinking, since this is not supported by the substantiality which the drive energy would give to it, so that it necessarily leads to doubt. (see [45], p. 65 ff.)

Grunberger’s notion of the early super-ego is essential. It is undeniable that the functions of the super-ego have an impact on hoarding. Freud points out that we are more familiar with super-ego functions from crowd behavior than from individual experience: Here, indeed, we come across the remarkable circumstance that the mental processes concerned are actually more familiar to us and more accessible to consciousness as they are seen in the group than they can be in the individual man. In him, when tension arises, it is only the aggressiveness of the super-ego which, in the form of reproaches, makes itself noisily heard; its actual demands often remain unconscious in the background. ([29], p. 142)

We ever so often wonder: what will people say? This question reflects the pressure of public opinion. Grunberger argues that it is essential to consider both the individual and the collective because collective phenomena are rooted in the individual psyche (see [45], p. 70 ff.). It can be assumed that hoarding disorder is based on complex super-ego conflicts. This is especially true for those who suffer and

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show insight. Many symptoms indicate conflicts between the super-ego and ego, or between the super-ego and ego-ideal. Grunberger, invoking Freud and Chasseguet-Smirgel, explicates that the ego-­ ideal is rooted in narcissism, and the super-ego displays an oedipal character. In an attempt to highlight the opposition at work within psychic life, he introduces the following sequences: the narcissistic sequence, progressing from narcissism to ego-­ideal, narcissistic injury, and shame as well as the instinctual counterpart, comprising super-ego, castration anxiety, and guilt (ibid., p.  73). In the development of the early super-ego, Grunberger distinguishes between the passive-anal and the active-­anal super-ego. The former is assumed to require the infant to abandon the prenatal state of happiness and complete autonomy to replace them by absolute dependence. The process is said to inflict the primal narcissistic wound. The oralnarcissistic phase extends for a short period after birth. Based on this assumption, Grunberger also established his distinction between passive-anal and active-anal super-ego development. In the passive phase, the infant no longer locates the source of discomfort inside, but they shift it to their mother. This could provide a possible framework for super-ego development. The active-anal phase brings more autonomy and independence. The child learns to develop its own will and how to control defecation (ibid., p. 71 ff.). The conception of an early super-ego, which is formed in several stages in the anal phase, proves useful in understanding hoarding. Grunberger’s narcissistic and instinctual sequences are elucidated in more detail below: Narcissism, Ego-Ideal, Narcissistic Injury, Shame The narcissism hypothesis is based on the fundamental human desire to retreat to prenatal existence. Primary narcissism differs from secondary narcissism based on its objectlessness. In the early oral phase, it can be assumed that there is no difference between cathexes and identifications. Grunberger conceives narcissism as parallel to drive development and postulates that a conflation takes place only later when the development is successfully completed [45]. The infant is psychologically one with the mother. This state wherein everything is related to the self eventually conflates with parental identifications, ideals, and role models to form an ego-ideal [22]. The ego-ideal develops from the parents’ criticism of the earlier narcissistic stage. The criticism offered in the phase of infantile narcissism for the first time also confronts the child with the experience of insult, rejection, and deficiency. The ego-­ideal develops by repressing the Oedipus complex. Historically, the ego-ideal was conceptualized from the super-ego. Only later was the super-ego conceived as an entity separate from the ego-ideal. The development is similar to that of the ego, rooted in the id and thus carrying essential unconscious functions [2]. For the ego-­ideal, this means that aspects of the super-ego remain in the deeper structures. This development is essential in hoarding disorder; the ego-ideal dominates. Most patients have detailed ideas about order and report of plans and intentions they have long been waiting to put into action. Divergence from the ego-ideal causes feelings of shame. People with hoarding disorder can be assumed to have an especially rigid

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super-ego and rigid ego-ideal conceptions. Through constantly oscillating between reality and their own ideals, they develop shame and feelings of inferiority. Drive, Super-Ego, Castration Anxiety, Guilt The idea of drives as the root of all psychic processes is central to Freudian psychoanalysis. Drives are psychological representations of somatic sources of stimulation. In Freud’s structural model of the human psyche, the super-ego is an inner judge. It comprises all internalized prohibitions and represents conscience and morality. The super-ego organizes drives and decides about their fate. Both ego-­ ideal and super-ego represent parental relationships, where the castration complex originates. Castration anxiety, as interpreted as a fear of loss and separation, is decisive in hoarding disorder. As mentioned previously in this work, castration anxiety arises from equating the penis with something detachable from the body, hence also related to defecation. The tension between the conscience and the ego gives rise to feelings of guilt. In psychoanalysis, feelings of guilt denote an unconscious structure of motivation and behavioral patterns that lead to failure or suffering. It is paramount in primary care and treatment of hoarders to be aware and understand the mechanisms at work here.

2.3

Symptoms

As outlined previously, hoarding disorder is a relatively new phenomenon, which did not receive much scientific attention until the 1990s. However, hoarding disorder symptoms have been observed and documented for over 100 years. [48]. In his 1899 Lehrbuch für Studirende und Aerzte, precisely in the chapter on psychopathic conditions, Emil Kraepelin describes what he calls “impulsive insanity.” His deliberations also include descriptions of compulsive acts, which is remarkable for his time. Kraepelin cites compulsions as indifferent in content and provides two main manifestations of such irresistible impulses: the fire-setting tendency and senseless thievery. Kraepelin does not offer any explanation where this kind of impulsive behavior stems from and highlights that the stolen goods are usually worthless for the perpetrator and are often returned. It seems that these tendencies are closely related to morbid shopping addiction or collecting mania, which often extends to completely worthless things ([49], p. 558).

The scattering of objects throughout living areas is characteristic. The hoarded objects do not seem to be organized in a specific way and chaos dominates the scene. In Manfred Sommer’s philosophical reflections on collecting, we can identify a connection between the object and the ego. He writes about the “absent-­minded diffuse ego”: Occasionally I collect myself. But am I a thing? Well, what is not can still be. What I know of others can also happen to me. Even I am not immune to being torn apart by wild animals, torn to pieces by an explosion, being quartered by my own kind. [...] My body is a thing.

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And, like everything else, it consists of parts: it can be broken down into them, and then scattered with them. It is unlikely that I would be able to collect myself afterwards. ([50], p. 124)

Sommer refers to the idea of recollecting oneself, meaning to regain an inner sense of calm, become aware of one’s purpose. The hoarding could be understood as a transferral of this intrapsychic process from the inside to the outside world. The early self-help groups demonstrated that hoarding disorder develops independently of social or economic characteristics. Differences arise from the individuals’ interests and from the objects hoarded based on these interests. The extent to which hoarding affects other areas of life may also vary. Some may only have a small apartment in which they find an opportunity to hoard things; others, however, own larger properties or even clutter warehouse space. Hoarding disorder occurs independently of gender, age, education, profession, origin, or economic status. Characteristics such as income and assets may affect the severity of the disorder in terms of how many properties are affected. The fact that hoarding behavior is independent of biological, cultural, or social conditions reinforces the phenomenon’s universality. Therefore, the diagnostic criteria laid out in the diagnostic manuals are meant to be universally valid. Observations made in self-help groups largely support current research findings, even though more women tend to participate in the groups. The reasons for this can be manifold. For one thing, women are more likely to seek professional help from specialists. For another, men have been observed to show the tendency to be less insightful when it comes to hoarding problems. The group of HD patients with fair to good insight are mostly women, on evidence. I would like to point out here that the responsibilities of tidying up and cleaning are socially still mainly attributed to women. The age of participants in the self-help group ranges from 20 to 75. Education does not seem to be an influencing factor. Highly educated individuals and school dropouts are found among those affected, and every possible level in between (see Sect. 4.2.2, Ms. P.). The symptomatology of hoarding disorder revolves around accumulating objects of any kind. Therefore, this work uses the term object synonymously for things, i.e., inanimate things. The term object goes back to objectum, which denotes an accusation or charge. This meaning is also reflected in the term objective, meaning “to be a given uninfluenced by the subject.” ([51], p. 661). All people, things or also ideas, which are directed to drives for the purpose of satisfaction, are called objects in psychoanalytic theory. ([52], p. 73).

The “Language of psychoanalysis” ([53], p. 335 ff.) lists three main aspects in an attempt to define the relevance of the object: –– The drive seeks satisfaction through the drive object, the correlative of the drive. Freud describes the object to be the variable in drive theory. The drive and the

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object are not linked, which is why the object can be chosen based on its perceived suitability to satisfy the drive ([54], p. 215). Hoarding disorder represents a delusional satisfaction, a fantasy. The hoarded objects do not actually provide satisfaction; they provide comfort, at the most. –– As a correlative of love (or hate), the object appears appealing, desirable, a love-­ object, or part-object. The object relations, designating a person’s relationship to the other, are important in this context. –– In traditional philosophy, the object is conceived as a correlative of the perceiving and knowing subject. The possible meanings of the word object are particularly interesting concerning the unconscious. In psychoanalysis, objects denote people. The homes of hoarding individuals are objectified representations of the individuals’ biography. The accumulated objects constitute a peculiar form of objectifying the environment and indicate a lack of language or voice. Objectification, or reification, provides a means to conserve and protect memories, relationships, and experiences. The reification concept gained prominence chiefly due to the Hungarian philosopher Georg Lukács, who defined it as “a relationship between people, with a material characteristic.” (as cited in [55], p. 20). Hoarding disorder is a reversal of this principle by creating a relationship with things shaped by a special emotional character, usually only to be found in human interaction. Axel Honneth considers aspects of attachment research and cites the works of Donald Winnicott. Honneth elaborates that reification may also coincide with observation, raising the question of how far active participation and interaction may be possible. The philosophical aspects of reification provide valuable inputs, rendering this concept worth considering in more detail. Honneth describes his attempt to reformulate Lukács’ reification concept. Lukács described his concept 80 years ago with an outlook on future society developments. However, his means were lacking and his generalizations sweeping. (cf. [55], p. 103f). One of the key questions regarding hoarding disorder is: why is the phenomenon so closely related to obsessive-compulsive disorder? The question can be approached from two perspectives: Firstly, international and Anglo-American research has primarily become aware of the existence of hoarding disorder recognizing it in patients who had already been diagnosed with OCD. Secondly, Freud provides an answer from a drive theory perspective: We can at any rate lay down a formula for the way in which character in its final shape is formed out of the constituent instincts: the permanent character-traits are either unchanged prolongations of the original instincts, or sublimations of those instincts, or reaction-­ formations against them. ([9], p. 175)

From the clinical setting, it is known that OCD patients often display the defense mechanism of reaction formation. Reaction formation and sublimation often appear in the form of compulsive behavior and obsessive thoughts. Hoarding disorder is often accompanied by the re-activation of infantile drives, which appear altered and sometimes distorted.

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For individuals with hoarding disorder, the objects take on many meanings. It can be assumed that their resurgent drives have shifted from the object relations to the objects. From this, we can infer that the objects coincide with the unconscious objects. The hoarded things are objects of both love and hate. The marked ambivalence is typical, pointing to the complexity of the object relations in hoarding disorder. To understand a HD patient’s relationships with the environment and environmental objects, we need to look at the object relations in their early childhood. Hoarders unconsciously re-enact or reproduce previous relationships. An analysis of these central relationships requires time, which is also why psychoanalysis is a lengthy process. Patients can only learn to understand the re-enactment of past experiences step by step and, in the next step, need to process the realization of transferred relations emotionally. As of yet, there is no possibility of accelerating this process.

2.4

Epidemiology

For many years, it seemed impossible to determine the prevalence of hoarding disorder until respective studies were conducted. A twin study in the UK investigated over 5000 participants and revealed that 2.3% of the British population suffered from the illness [56]. In Germany, 4.6% of the population are affected [57], while US research estimates that up to 5.3% of the population [58] have hoarding disorder. The most recent epidemiological study on hoarding disorder was completed in 2013 and estimated a prevalence of 1.5%. The initiators of this latter research attribute the divergence of the findings to problems of terminology and definition [59]. However, it can be assumed that the number of persons suffering from hoarding is higher than research can presently determine. Regardless of what the actual prevalence of hoarding disorder may be, scientific interest is growing fast, and the need for treatment options is higher than ever. A 2012 clinical study systematically investigated the spread of the phenomenon in India. The study largely agreed with western research findings, confirming that hoarding disorder occurs in both sexes and independent of education and economic status. Differences were found concerning the role of marital status. Some international studies indicate that most hoarding individuals are single, widowed, or divorced and live alone. In India, however, no link between hoarding and marital status could be identified. The family’s sociocultural importance in Indian culture provides a possible explanation, where family needs are given priority to individual needs. Even today, it is still customary in India for parents to choose their children’s future spouses. The expectations of the family outweigh individual preferences. Another interesting result yielded by the same study is that there may be a geographical influence. The Indian study found that hoarding was more prevalent in urban areas. The lack of space in urban areas may be one of the causes for this circumstance [60]. However, economic aspects could also play a role, assuming that

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poverty is a common issue of the rural population and not so much in urban settings. The economically weaker sections of the population are assumed to be preoccupied with different issues, struggling to survive every day. A Chinese study provides evidence that the DSM-5 diagnosis of hoarding disorder is also valid in China. The authors, however, also argue for specific culturally sanctioned aspects to be considered. These include the thriftiness of the Chinese population [61]. In Chinese culture, hard work and frugality constitute the core values; lavish behavior and wastefulness are condemned. These cultural aspects provide interesting insights and are certainly worth mentioning; however, they must not be overemphasized in diagnosing HD. Even within Europe, different conceptions of order and thriftiness exist alongside each other. The value attached to orderliness may differ from country to country, yet its influence on diagnosing hoarding disorder is minor. The diagnostic guidelines for hoarding disorder largely remain unaffected by such cultural differences and are likely to be globally applicable. A detailed analysis of a person’s situation seems far more important in the process of diagnosis. Many patients grew up with thrifty parents. Modesty may present a possible common denominator. Often such modesty is inherited from the parents, who teach their children to be careful with money and possessions because there is little of both (see Sect. 4.2.1, Ms. O.). An international study involving 14 female researchers from 11 countries reviewed the ICD-11 recommendations regarding their applicability in classifying obsessive-compulsive and related disorders. The authors concluded that a revised classification in the ICD-11 would prove beneficial for those affected by advancing the development of new treatment options and instigating further research. It was expected that the creation of an OCRD grouping would promote understanding, particularly in the areas of phenomenology, diagnosis, and management [62].

2.5

Diagnostic Considerations

Recent years have seen a surge in media interest in pathological hoarding. Reality TV has exploited the peculiar nature of the phenomenon, primarily the overcluttered homes of sufferers, creating sensationalist formats about hoarding. Admittedly, hoarding symptomatology is rather sensational in itself, drawing public attention and even eliciting a certain fascination. Hoarding is a cry for attention. At the same time, patients attempt to hide their habit of accumulating things to the point where they interfere with their daily life. The fascination for hoarding probably results from this central ambivalence. On the one hand, we experience excitement at the sight of severe hoarding. We have all progressed through the anal phase of partial drives and can relate to the pleasure retrieved from this behavior. On the other hand, we may also feel disgusted, employing the defense mechanism of reaction formation to counteract desires deemed socially and culturally unacceptable. Professionals are recommended to intensely reflect on their own feelings and reactions in connection with severe hoarding before engaging in work with HD

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patients. Detailed considerations on feelings of disgust, as well as guilt and shame, can be found in Sect. 3.2.8 on the characteristics and challenges associated with hoarding. The question to be asked is: how can hoarding disorder be approached from different points of view, and how can these can be integrated to better comprehend hoarding? How can the history of disorders aid our understanding of hoarding? Between antiquity and the early modern period, it was common practice to summarize disease patterns and define them based on the principle of causality. It was not until the end of the nineteenth century that representatives of the unitary psychosis and a dualistic model emerged (cf. [63], p. 327 ff.). Disease research and particularly the study of psychiatric and psychological phenomena have time and again been accompanied by great controversy. Different approaches to generating an understanding of diseases and disorders have partly contradicted each other or coexisted. The more recent history of psychiatry has also seen the emergence of the so-called antipsychiatry. We should be aware that each period has brought new findings and new schools of thought, also in psychological disciplines. The history of psychiatry has always been concerned with illness and trying to understand pathological phenomena. The antipsychiatry of the 1960s set out to question and challenge standard psychiatric theory and practice (ibid., p. 337). The emergence or discovery of disorders or diseases always raises the same fundamental questions, including how to name and define a presumably pathological phenomenon. Even if the definition of a new disorder entails criticism and controversy, any effort to establish a unified terminology and methodology to describe phenomena and help better understand those affected must always be welcome. In recent decades psychiatry has been compelled to look for new ways of naming and classifying illnesses for two reasons. First, because of the failure of attempts to create universally convincing illness systematics and second, because of the necessity of binding conventions of psychiatric terms of illness. (ibid., p. 338)

Phenomena, developments, and findings of psychotherapy pose a special challenge in this context. This is mainly due to inadequate methods of description and definitions in modern science.

2.5.1 Diagnostic Manuals What requirements must future diagnostic manuals meet? What are the difficulties of publication and application of these manuals? The criticism diagnostic manuals are met with often also provides constructive input for constant revision. After all, the aim is not to promote the development of new disorders and diseases, but rather to be able to communicate effectively and internationally. The WHO recommends professionals use diagnostic manuals as the worldwide standard, hoping to establish a universal system for diagnosing and treating disorders.

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Shortly after the World Health Organization (WHO) was founded in 1948, the International Classification of Diseases (ICD) was released for the first time. At first, psychiatrists were skeptical about the use of these classifications and largely rejected the first ICD editions, ICD-6 and ICD-7. It was only with the ICD-8 that one gradually began moving away from national classifications toward an internationally valid system. In 1952, almost simultaneously and entirely independent of this development, the American Psychiatric Association (APA) published the Diagnostic and Statistical Manual (DSM). From the 1980s onward, the role of these diagnostic systems completely changed. The developments of the last decades indicate that, while the ICD seems to be the preferred standard in clinical settings, the DSM remains dominant to this day. Innovations and adaptations presented by the DSM regularly influence the revision process of the ICD [64]. However, today’s dominance of these systems does not mean they are not in need of scrutiny. The questions remain as to the manuals’ purpose. We might also have to consider a general revision of what is so widespread that it almost qualifies as common sense. What developments have the last decades brought about and where are the diagnostics headed? Professionals largely agree that the manuals facilitate the exchange of information. They also value the manuals for providing aid in generating funding from local health insurance companies. These are particularly interested in the effects and impacts of illnesses, as well as their progression. In the face of all these different interest groups, diagnostic manuals are, then, also a political issue. Patients, relatives, doctors, psychotherapists, clinical psychologists, social workers, medical institutions, universities, pharmaceutical companies, health insurance companies, courts, lawyers, as well as teachers and corporate institutions, all have different perspectives and interests when it comes to making diagnoses. The diagnostic systems are rooted in the medical sphere, precisely in psychiatry. But what about the young science of psychotherapy? Do we need an independent psychotherapeutic diagnostic model? These are just some of the questions to be asked in discussing today’s standing of the diagnostic manuals; however, going deeper into this discussion is far beyond the scope of this work. Suffice it to say that the field of psychiatry covers a plethora of health care issues, more than the discipline of psychotherapy could presently set out to address. The WHO, above all, represents a political entity. By implication, the manuals they publish, and whose use they promote, must be considered from a political standpoint. It is essential to understand the consequences of these diagnostic manuals, the losses they inflict, and the benefits they entail. The coming decades will inevitably bring new revisions of the diagnostic manuals, opening discussion, and possibly having us mourn over the loss of what we believed to have already achieved. Perhaps something new can emerge when the users of these manuals, including professionals from different disciplines, step forward to admit to the currently inconsistent conceptualization of disorders and diseases, especially in the psychiatric-­psychodynamic field, and provide their input for improvement (cf. [65], p. 20 ff.).

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Having to let go of previous achievements will be paramount to progress further in the field. The DSM-I and DSM-II were largely shaped by psychoanalytic terminology. The DSM-I described anxiety disorder as a correlative of psychoneurotic disorders. Psychoanalytic concepts such as those of the unconscious, defense mechanisms, and conversion were used. In the DSM-II, anxiety was introduced and described as the main symptom of neuroses. Anxiety neurosis was established, and hysterical, phobic, compulsive, and depressive neuroses were described. The DSM-­ III revised the categorization of anxiety disorders and divided them into social phobias, phobic disorders, obsessive-compulsive disorders, and post-traumatic stress disorders. The DSM-VI has been expanded to include further diagnoses such as acute stress disorder as well as mixed anxiety-depressive disorder. In the current DSM-5, anxiety disorders have been divided into several sections, including anxiety disorders, stress-related disorders, and obsessive-compulsive disorders. The now separate chapter on obsessive-compulsive disorders includes several new disorders. Among them are hoarding disorder, trichotillomania, and others. Selective mutism and separation anxiety in childhood and adolescence are also included in the chapter on anxiety disorders [66]. What are the consequences of these revisions, especially in relation to hoarding disorder? The DSM-5 no longer lists obsessive-compulsive disorders as part of the anxiety disorders category; a separate chapter has been dedicated to these disorders. This sounds interesting at first; one might think that OCD has gained in importance and independence. The problem, however, is that previous knowledge about the etiology of these disorders is getting lost in the process of positioning OCD in this way. From a psychodynamic and depth-psychology point of view, psychoanalysis is credited with having presented and explained the underlying connections. Obsessive-­compulsive disorders can, psychologically speaking, be grasped only when considered in relation to anxiety disorders. Hoarding disorder is classed in the obsessive-compulsive and related disorders spectrum. Professionals are advised to consider the broader context in diagnosing hoarding disorder. It is essential to be aware that this disorder is etiologically related to obsessive-compulsive and anxiety disorders. The problem we are currently facing is fundamental. A feasible solution to address the shortcomings of the diagnostic manuals has not yet been proposed. As of yet, the manuals appear to be the best possible compromise. They undoubtedly provide a useful tool, aiding global communication between doctors and psychoanalysts and other groups of professionals. They do not, however, present ultimate truths. Myriad theories have been established to approach the complexity inherent in psychological phenomena and behavioral patterns. The diagnostic manuals are a mere construct, an attempt at describing these phenomena in a simplified form. As such, they should represent a comprehensive tool applicable regardless of the theoretical approach taken by their user. Psychotherapeutic, psychiatric, cognitive, psychodynamic, and neurobiological proponents should all find their theories compatible with the manuals’ contents. The diagnostic manuals are at the same time solution and problem.

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Michel Foucault identified the central problem of psychology. From a holistic point of view, which assumes each disease has a psychosomatic component, Foucault’s conception can hardly be integrated. Now, psychology has never been able to offer psychiatry what physiology gave to medicine: a tool of analysis that, in delimiting the disorder, makes it possible to envisage the functional relationship of this damage to the personality as a whole. ([67], p. 12)

Standards of medicine cannot simply be transferred to psychotherapy. This not only applies to everyday clinical practice, but also to scientific theory. Still, professionals in the psychotherapeutic context do not have any recognized alternatives to the diagnostic manuals available. Both psychoanalysis and other medical disciplines require careful reflection of their diagnostic and therapeutic work. Such reflection does not seem to pose a challenge to somatic medicine. There are sufficient tools to address and compare issues of diagnosis, illness, and therapy. But what about psychoanalysis? Conflicting ideas often accompany diagnosis, illness, and therapy. The complexity of this situation challenges us to consciously observe, analyze, and eventually learn to understand it, knowing that there are also and above all unconscious mechanisms at work here (see [65], p. 49). As matters stand, hoarding disorder represents a separate disorder in the compulsive-­obsessive and related disorders spectrum as defined by the latest revision of the DSM-5 American diagnostic manual. The DSM-5 has been revised to reduce the overall number of disorders as compared to the DSM-IV. Another significant change relevant to hoarding was the separation of obsessive-compulsive disorder from anxiety disorder (see [68], pp. 1110 ff.). This is especially important considering that, in only a few decades, the psychoanalytic connection evidenced between obsessive-compulsive behavior and anxiety could be lost and possibly correlations ignored in future diagnosis and therapy. To undermine the connection’s significance and relevance, I would, at this point, like to emphasize one of the psychoanalytic core principles. Psychoanalysis postulates that unconscious fears are the underlying causal factor in psychological disorder: fears of confrontation and conflict, which could not be appropriately processed early on and thus continue to exert their influence through the unconscious. Michael Ermann identifies the main categories of fears of conflict: fear for basal security and safety, fear of persecution and abandonment, fear of loss and separation, as well as fear of love deprivation in developing autonomy, narcissistic fears in self-­development, and fear of punishment and inner conflict in oedipal development ([69], p. 25 ff.). The separation of obsessive-compulsive disorder and anxiety disorder in the current diagnostic manuals ignores these evident connections and interactions. The DSM-5, clearly influenced by a biologist stance, defines a mental disorder as reflecting a significant disturbance in cognitive, emotional, or behavioral processes and mental dysfunction. This definition is far removed from psychoanalytic conceptions, failing to sufficiently address the core concepts of neuroses and ps

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Table 2.2  Hoarding disorder F 42. Diagnostic criteria for hoarding disorder according to DSM-5 (Based on [68], p.  154; reprinted with permission from Hogrefe Verlag Göttingen from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, © 2013 American Psychiatric Association, German version © 2015 Hogrefe Verlag) Hoarding Disorder 300.3 (F42) A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome). F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder). Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Specify if: With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

ychoses. The DSM-5 emphasizes that conflicts between the individual and society do not constitute mental disorders (70], p. 29 ff.). Unfortunately, this fundamental assumption is often ignored in practice.

2.5.2 Diagnosis Previously classified as a criterion for and symptom of obsessive-compulsive and related personality disorders, hoarding disorder is now defined in the DSM-5 as a mental disorder in its own right [71]. Hoarding still appears under the category “Obsessive-Compulsive and Related Disorders,” but is now finally recognized as an illness that can occur independently. The official diagnostic criteria for hoarding

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disorder, as listed in the 2013 update of the Diagnostic and Statistical Manual of Mental Disorders, are presented below (Table 2.2). Supplementary information is provided for each criterion, facilitating the diagnosis of hoarding disorder as an independent mental disorder [72]: Ad A The first criterion emphasizes the patients’ difficulty letting go. They experience severe distress at the mere thought of either giving things away, recycling, discarding, or selling them. “People with hoarding problems save more of everything, regardless of its value” [72]. In addition, the symptom of hoarding disorder is described in the latest revision of the DSM-5 as “persistent.” This implies that people with hoarding disorder do not display such behavior as part of going through a phase but over an extended period. They find it almost impossible to separate from possessions because they find them useful, aesthetic, or emotionally valuable. Ad B The difficulty parting with things and the unrelenting need to preserve them is explained based on a range of reasons. For one thing, people with hoarding disorder are emotionally attached to their possessions, associating them with a specific person, incident, place, or time in their life. Hoarders save things because they could be useful one day or find them aesthetically pleasing. Sometimes they serve as an aid to memory as if the memory were otherwise lost. The hoarded objects also seem to convey a sense of security in the face of a perilous world. What is remarkable is the almost infinite number of reasons why things must be kept. The pronounced need to keep these objects is particularly valuable in diagnosing the disorder because it clearly distinguishes hoarding from other disorders where the accumulation of objects can appear as a side effect. Ad C The third criterion defined by the DSM-5 describes a consequence of hoarding, namely the substantial chaos and clutter caused by the tendency to accumulate objects. This category describes the accumulation of things to the point where living spaces are no longer suited to their original purpose. The living spaces even become the source of potential risks, including the risk of a house fire. Often the functionality of living space, such as proper use of the bedroom, toilet, bathroom, and kitchen, are no longer given. The DSM-5 specifies that “active living areas” are affected and not just the attic, basement, or garage. Clutter is primarily also amassed in the bedroom, living room, kitchen, and in the hallway. Ad D The previous criteria also means that people with hoarding disorder suffer from an impaired social life. If social interaction cannot take place outside the home,

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the patients usually do not engage in social life at all. Visitors to the home are not welcome. Consequently, many people with hoarding disorder suffer from loneliness and isolation (see e.g. Sect. 4.2.3, Mr. U.). Ad E To distinguish hoarding disorder from other phenomena, we must exclude other medical conditions to have caused the behavior. Ad F Similar to the previous criterion, the last indicator to be checked is whether the hoarding behavior can be determined to be excluded as a symptom of another mental disorder. Excessive Acquisition of Objects Serious diagnosis of hoarding disorder also requires investigating if a person’s hoarding behavior is associated with an excessive acquisition. In other words, it must be determined if the difficulty discarding objects is also linked with an urge to constantly buy and acquire new things even if they are not needed, or there is not enough room. Hoarding disorder is frequently accompanied by symptoms of compulsive buying disorder or oniomania. If observations confirm a concomitant obsession with buying new things, this is a strong indicator of the excessive acquisition associated with hoarding disorder. Until a few years ago, the connection between hoarding and the obsession with buying was unclear. An extensive study with more than 1500 participants illustrated that only a small percentage (5–19%) was affected by excessive hoarding, not, however, with a similarly unusual urge to buy things. The study also revealed that buying behavior has an impact on the severity of hoarding. It can be assumed that a marked urge to buy things directly correlates with a more severe case of hoarding disorder [73]. Insight The second factor to be considered is that of insight. A distinction is made between patients who display fair to good insight and those with poor or no insight. Persons with good or fair insight realize that the beliefs and behaviors associated with their own hoarding behavior (regarding their difficulty separating from things and their excessive acquisition and accumulation of objects) are problematic. This group of patients is open to medical and psychotherapeutic support and sometimes actively seeks help. Hoarding individuals with little insight are confident that their beliefs and behaviors (regarding their difficulty separating from things and their excessive acquisition and accumulation of objects) are not problematic. Even obvious contrary evidence cannot convince them that their behavior is an issue that must be dealt with.

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Lastly, we also encounter patients who hoard who do not show any insight at all and exhibit delusional beliefs regarding their situation. They are genuinely convinced that the beliefs and behaviors (regarding their difficulty separating from things and their excessive acquisition and accumulation of objects) are not problematic. Even obvious contrary evidence cannot convince them that their behavior is an issue that must be dealt with ([68], p. 154). Patients with poor or no insight very rarely seek professional help themselves. It is either the relatives who turn to specialists or neighbors and other acquaintances who report to the authorities because they are concerned about a person’s wellbeing. Patients in this group are usually very self-contained and are generally not willing to change. The number of people with hoarding disorder and little to no insight is not known. Their secluded lifestyle makes it particularly difficult to estimate how many people are affected. The patients’ different levels of insight mean that treatment must be adapted accordingly. People in the first group, i.e. those with good or fair insight, are assumed to be aware of their problematic behavior and living situation. This usually facilitates primary care and treatment. The patients often seek help on their own, confide in their doctor or contact a psychiatrist and show a general willingness to address their situation. They also attend self-help groups and actively engage in the psychotherapeutic process. Poor insight or delusional beliefs, on the other hand, often impede the patients’ treatment progress. At present, it can be assumed that the level of insight gives some indication of how the ego is structured. If there is little to no insight, the ego structure must be restored. Patients in this group usually have difficulty looking after themselves or taking sufficient care of their own needs. It is crucial for professionals to understand that this group of patients first and foremost needs primary care. In the psychological and psychosocial context, this means that a relationship of trust must be established before any further steps can be taken. Sensitivity on the part of the therapist and an accepting and generally favorable atmosphere are paramount. Only once these basic conditions are established, can the patient begin to gradually take responsibility and regain the ability to develop insight. The patients’ obsession with buying new items often correlates with their level of insight. It has been shown that people who hoard and have good insight can manage, in phases, not to acquire new objects and keep the level of their possessions constant. Patients with good insight are more likely to cooperate in setting up plans and agreements to improve their living situation. In cases where little to no insight is displayed, priority must be given to establishing a relationship of trust and restoring the patients’ ability to develop insight. The coexistence of different (often conflicting) approaches to mental disorder complicates the discussion. The importance of brain research has strongly influenced developments in psychiatry. In Geschichte der Psychiatrie, Heinz Schott and Rainer Tölle describe that, only a few decades ago, it was common practice to discuss psychiatry in relation to its connection to the humanities, especially philosophy and anthropology. Over the years, this exchange has diminished and there is hardly

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any dialog between these disciplines taking place today. At present, psychiatry is primarily interested in findings of neuroscience and brain research. Traditional medical anthropology questions are being excluded and ignored ([63], p. 508). The question is whether neurosciences can contribute, and how, to the dialog between psychiatry and psychology. What are the aspects that might get lost in the process? One of the main differences between the ICD and the DSM is that the ICD represents a comprehensive medical classification system, whereas the DSM focuses on mental disorders. The ICD is the globally binding standard for classifying both physical and mental disorders. The DSM sees itself as a practical and functional guideline or manual, providing extensive criteria for practical diagnosis. Innovations in the ICD-11, as approved by the World Health Assembly in May 2019, include listing hoarding disorder under the category of obsessive-compulsive or related disorders. Qualifiers have been established to include levels of insight, ranging from poor to absent insight to fair to good insight. Patients at Sigmund Freud University or those engaging in psychotherapeutic processes have been observed to have fair to good insight. However, exchange with other professional fields has shown that many individuals who hoard have little to no insight. Their denial of the problematic nature of hoarding also explains why they make up the smaller part of patients encountered in practical work. Primary care is often provided by relatives, friends, or social workers instead of therapists or other professionals. The publication of the DSM-5 has also attracted a great deal of criticism. Allen Francis, who had been involved in drafting the DSM-III, accused recent developments of creating diagnostic inflation. The pharmaceutical industry, which strives to maximize profits, was the main beneficiary of these developments (see [74]). Even though this criticism certainly has its validity, we must also critically note that Francis had been an active part of this controversial system for years and only began to question it after having retired from his work. The history of psychiatric diagnostics and diagnostic systems constitutes an independent discipline, which is why further deliberations on the topic should be left to researchers in the field. The present discussion shall be concluded by pointing out the theoretical and practical limitations of diagnostic systems. Markus Jäger asserts that these systems presently cannot go beyond a “minimum linguistic consensus.” The inclusion of a new disorder in a diagnostic system alone does not provide any final truths about a mental disorder (cf. [70], p. 95 ff.). This is also evidenced by research findings following the inclusion of hoarding disorder in the DSM-5. The classification of a new disorder facilitates interdisciplinary and international discussion and enables dialog between professionals worldwide, but it is not to signify the last word on a subject. Diagnostic manuals constantly need to be adapted as symptoms change and new disorders emerge. Psychological developments are always prone to interference and will continue to find new ways of expression. Scientifically young phenomena, as represented by hoarding disorder, require particularly intense scrutiny. Many open questions need to be addressed by future research and by engaging in an open discussion with those who are affected. The inclusion of hoarding disorder in the ICD-11 has certainly generated a great deal of

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attention and provided an incentive to increase research endeavors. It is to be hoped that professionals of different disciplines will engage in the discussion to address the complexity of hoarding disorder and provide solutions to improve current treatment options.

2.6

Comorbidity

Comorbidity describes the simultaneous occurrence of mental disorders in one person. Patients with hoarding disorder have been found to show high comorbidity rates with other disorders. These include depressive episodes, anxiety disorders, self-harming behavior, addictions, and eating disorders. Many HD patients also report difficulty in concentrating or focusing on one thing. Some also display impulsive behavior patterns, prompting the diagnosis of attention deficit hyperactivity disorder (ADHD). Evidence has been produced for the interdependence of depressive symptoms and hoarding disorder. If depression affects a patient’s ability to go to work or fulfill everyday tasks, it is only logical that they will also have difficulty organizing their homes. A precise diagnostic assessment is required to determine the underlying disorder. Despite high rates of comorbidity with depression, hoarding disorder can also occur entirely independent of depressive symptoms. One of the international studies on the subject is presented in the Australian paper “Characteristics, Circumstances, and Pathology of Sudden or Unnatural Deaths of Cases with Evidence of Pathological Hoarding” (2017). The paper explores the living conditions of people who died suddenly and who were reported to have lived in homes that indicated hoarding tendencies. A total of 61 cases were examined. The results yielded obvious correlations between the factors of social isolation and severe physical and psychological impairment of people who had died in their own homes [75]. These alarming findings must be taken seriously and demonstrate the importance of interdisciplinary work and urgent need for new strategies. The comorbidity of pathological hoarding with several other mental disorders made it difficult for years to distinguish the phenomenon from depressive episodes and obsessive-compulsive disorders. Only in recent years have we seen the emergence of criteria to address the problem of definition. Most importantly, Brian J. Hall and his research group [76] could show that hoarding disorder is not necessarily a consequence or symptom of another psychiatric diagnosis. In 2011, an American study investigated the connection between anxiety disorder and hoarding disorder. It was shown that hoarding often coincides with symptoms associated with anxiety disorder. The authors attribute this correlation to deficient problem-solving abilities observed in both disorders. Patients with anxiety disorder have been evidenced to lack confidence in their ability to solve problems or the ability to manage the problem-solving process. These findings raise a doubt about the DSM-5 classification of hoarding disorder under the OCD group. The symptoms of anxiety disorder correlate more strongly with hoarding disorder symptoms than those of OCD [77].

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One of the seminal works in international research was published in 2010, a contribution to Depression and Anxiety [78]. The title was: “Hoarding Disorder: A New Diagnosis for DSM-5?” The research group responsible conducted an extensive literature search in the databases PubMed, ScienceDirect, Scopus, and PsychLit. The keywords included: hoarding, collecting, packrat, OCD, OCPD, anankastic personality disorder, impulse control disorder, and compulsive buying. The respective literature was analyzed based on a set of predefined questions. The meta-­analysis of a total of 21 studies found evidence for hoarding to represent an independent factor, i.e. a distinct entity. The authors criticized the classification of hoarding as an OCD symptom as possibly short-sighted. This is because only a small percentage of patients with hoarding disorder show other forms of obsessive-­compulsive behavior. The authors believe that the number of differences outweighs similarities between hoarding disorder and OCD. They argued for the creation of a new diagnosis, which would take these factors into account. Evidence was produced that compulsive hoarding denotes a persistent psychological behavior pattern in individuals; the theories of Freud, Fromm, and Jones on the anal personality support respective findings. Several studies suggest that the number of clinical cases represents 2–5% of the overall population. These factors indicate that the splitting of diagnoses is valuable and they support the DSM-5 decision to include hoarding disorder as a separate disorder. A direct correlation between hoarding and material deprivation could as yet not be established. However, an extraordinarily high number of patients are reported to have suffered trauma or similar stressful events in their past. Hoarding does not seem to represent a response to material deprivation. Individuals with hoarding disorder and those who do not hoard did not essentially differ in their responses to the question: “When you were young, was there a period of time when you had very little money?ˮ The findings of this study are obviously not immune to criticism. The answers to these questions are assumed to have been carefully thought-through, where hoarding is intrinsically linked to a person’s unconscious. Most studies of these kinds do not give sufficient credit to the unconscious, neglecting a crucial component of the disease and making it difficult to integrate the psychoanalytic view. Yet, most of the research findings confirm the assumption that objects are used symbolically and may be regarded as representing inner psychic events or functions. Studies focusing on children [79, 80] evidenced that the habit of collecting often starts at the age of 25–27  months and culminates at around 6 years of age. The children’s love for collecting, however, does not seem to be related to adult psychopathology. Many psychopathologies in adults represent a regression to what is generally considered a normal phase of development in children—this is also the observation made in the context of hoarding. It was also found that hoarding is highly prevalent and seems to run in families. A twin study [81] corroborated the assumption that hoarding can be genetically determined and develop from environmental factors. The authors of the study, too, enunciated the importance of establishing hoarding disorder as an independent diagnosis. They argued that individuals who hoard were to receive more attention and improved treatment. They anticipated that defining hoarding disorder as an

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entity would generate public interest, raise awareness, and help provide appropriate diagnostic tools and treatment options. The classification of a new disorder always requires weighing the advantages and possible disadvantages. Before hoarding disorder was included in the DSM-5, many patients were misdiagnosed or were not diagnosed at all. With the recent establishment of hoarding disorder as a diagnosis, it is hoped that international research in the field will advance, and new findings in terms of etiology and treatment can soon be integrated into primary care. Many researchers agree that the precise definition of psychopathologies is a sensitive issue. Many of the central questions cannot be answered, including: at what point does a behavior change from being normal to pathological? Answering this question is difficult, not least because it bears the risk that normal behavior becomes pathologized. Many people who hoard are not aware that their behavior is problematic. For them, it seems the norm. The spouses or other members of the family or neighbors may think differently. The consequences of deeming an individual’s behavior as pathological have to be considered. Treating people against their will raises many ethical issues. Despite this controversy, the advantages seem to have outweighed the disadvantages of establishing hoarding disorder as a distinct entity. Recent years have produced many scientific studies that have been able to provide evidence and justify the decision to declare hoarding as a mental disorder and include it in respective diagnostic manuals. Many international research groups have implored and supported the DSM-5 to include hoarding disorder. The ICD-11 followed suit shortly after. New questions arise from establishing hoarding disorder as a disorder in its own right. Studies have been carried out to address gender or age differences. The disorder has been evidenced to occur equally frequently in both women and men. There are no significant differences in terms of gender. The average age of participants in relevant studies is 50 [82]. Some studies claim to have found evidence for hoarding symptoms to emerge as early as in childhood, at the age of 12–13 years; the problematic excessiveness takes hold in the thirties [83]. In order to avoid unwanted associations with obsessive-compulsive disorder, hoarding disorder was preferred over compulsive hoarding. Studies of hoarding comorbidity have observed high rates of depression and anxiety disorder. More than 61% of those who hoard also display an obsession with shopping. Correlations with kleptomania require further investigation [78]. In 2011, Randy Frost and his research group initiated a study on comorbidity, in which they found further evidence to suggest that hoarding is not a symptom of obsessive-compulsive disorder. The hoarding participants with diagnosed OCD comprised less than 20%. However, it is interesting to note that people with OCD make up only 1–2% of the average population. The authors emphasize essential differences between hoarding and OCD, while at the same time admitting that there are certain correlations [46]. The psychoanalytic theories discussed in the present work (see Sect. 2.2) shed light on where OCD and HD intersect. The presented theories primarily address the etiological roots of the two psychological phenomena.

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Another study investigated the relationship between “stressful life events” and the onset of hoarding disorder. It was found that a significant proportion of those affected (more than 50%) stated a connection between traumatic life events and the onset of the disorder. However, in obsessive-compulsive disorder only one in ten indicated that the onset of symptoms coincided with a traumatic life event. It is striking that, in cases where symptoms emerged before the age of 10, they were not perceived as being linked to traumatic experiences. The authors suggest that this may be related to memory performance in early childhood and propose a longterm study to clarify these hypotheses [27]. However, one could also assume multiple traumatizations. Other hypotheses could be conceivable as well. Could it be possible, for example, that psychoanalytic findings influence people in such a way that they automatically link their traumatic experiences with later developments and decisions in their lives? The answer to these questions and possible relations are only to be found in the unconscious. It can be assumed that individuals with hoarding disorder have experienced stressful and traumatic events in their past. High comorbidity rates are reported for affective disorders and anxiety disorders, as well as sleeping and eating disorders. An interesting study [84] was devoted to clarifying the difference between hoarding disorder and collecting. This addresses the central question: at what point does something become pathological? The answer to this question is inextricably linked to cultural aspects and will differ depending on the period of time in which it is asked. The difficulty determining pathological mental patterns, the authors emphasize, lies in difficulties defining their boundary to the normative. When we assume the average to represent the norm, pathological behavior is such that deviates from the average. The further removed it is from the normal, the more we are confident in naming it pathological. This conception, however, defines pathological behavior in relation to the norm, making it all the more difficult for hoarding to be defined in a society driven by consumerism. More criteria will be needed to address this issue. What is normal, and at what point does something become pathological, really is the central question in dealing with any mental illness. We are constantly challenged to revise our definition of normal and pathological and to re-think established and work out new methods to delineate one from the other. Another interesting question to be asked in hoarding research, especially in view of how digitalization has affected modern society worldwide, is whether there is a phenomenon we could term digital hoarding. A Dutch study describes a case of an individual presumably affected by digital hoarding. The authors call for digital hoarding to be recognized as a subtype of hoarding disorder [85]. One of the major diagnostic criteria of hoarding consists in the difficulty separating from objects and the urge to constantly acquire new things. A consequence of this behavior is that rooms in apartments and houses, and sometimes also cars are overcluttered with objects. Hoarding is typically accompanied by great psychological distress and pressure and their behavior cannot be attributed to any other mental or physical disorder.

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The phenomenon of digital hoarding does not meet such essential criteria of hoarding disorder. A tendency to hoard digital data does not result in impairments in social or occupational life or in other essential areas of functioning to the extent that hoarding disorder does. One could diagnose the behavior as obsessive-­compulsive disorder, based on the obsession to accumulate digital content. However, I propose that each case must be explored and diagnosed individually. As of yet, current research findings do not speak for the necessity to create a subcategory for digital hoarding behavior. A German study examined the criterion of uninhabitable housing. A total of 186 subjects took part in the research. The authors concluded that uninhabitable housing does not constitute a criterion sufficient enough to describe a disorder. Any psychiatric spectrum disorder may, over time, cause the affected persons to neglect their homes, not being able to sufficiently care for it or maintain a certain standard of housing. The authors advocate a diagnostic approach solely based on the underlying problematic behavior rather than its consequences and argue that treatment must be adapted to individual requirements [86]. A limitation of this study, however, is the selection of investigated houses. The study only looked into cases that the social-­psychiatric service had categorized as exhibiting catastrophic conditions at one point in the last 5 years. The criteria on the basis of which houses were deemed catastrophic were that they were extremely limited in their original functionality or could no longer be entered or posed a danger to those entering or living nearby. People with hoarding disorder do not always live in such desolate conditions. At the core of hoarding disorder is the patients’ inability to part with objects. This inability is closely linked to the fear of losing objects. The mere thought of their loss conjures up great distress in those affected. The role of the patients’ homes and the associated impairments in their daily lives are recognized only in the third criterion defined by the DSM-5. Cluttered living areas are considered as a consequence of hoarding behavior. Further criteria are provided by the observation that patients experience extreme psychological distress not caused by any other mental illness or physical disorder.

2.7

Spectrum Disorder

Despite the inclusion of hoarding disorder into the DSM-5 and the precise definition of respective diagnostic criteria, many open questions remain. The analysis of comorbidity is an essential step in the diagnostic process. The extent to which hoarding represents a spectrum disorder will have to be clarified in future research. The DSM-5 includes detailed deliberations regarding patients’ obsession with buying and individual level of insight. The homes of patients are cluttered to various degrees, depending on the severity of the disorder and for how long a person has already been struggling with respective psychological issues. Patients with hoarding disorder frequently report having experienced traumatic experiences of separation or relocation. Many of them, at one point in their life, lost their homes, or went through phases of homelessness. The patients possibly

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clutter their homes in an attempt to deprive themselves of everything before anyone else can. One patient reported extreme separation anxiety. He had already lost a lot in his life, including several jobs, different apartments, and many relationships. He reflected on his habit of reveling in memories when a specific object, for example, a book he liked or a pocket knife from an earlier phase in his life, crossed his mind, and he immediately was overcome by panic. He could not help but get up and start looking for the specific item he was thinking of. He would search for hours and be only satisfied once he found what he was looking for. He coined the term search attack to refer to this form of panic attack. The question is what the actual object of these search attacks was. Could his behavior be seen as a form of displacement with a positive outcome? He always seemed to have found what he was looking for. But did he also find what he was longing for? To what extent might these search attacks constitute a mechanism to distract from what really mattered, probably something much more unpleasant? (Sect. 4.2.6, Mr. Y.). Experience has shown that hoarding disorder does not fully develop until patients move into the first homes of their own. While living in the parents’ home, the chaos usually remains confined to one bedroom and an untidy children’s room has never provided cause for serious concern. Interestingly enough, many patients report that their now cluttered homes awakened negative associations from the moment they moved in. I once had a case where the parents had bought and furnished an apartment and the patient who later moved into it did not like the style. Another patient inherited his grandmother’s apartment and was not allowed to change anything. He had to keep the furniture and hesitantly started to add his things. From the very beginning, he felt like there was no room for him and he simply could not find a way to take possession of the apartment or to make it his own. Many patients feel like a specific event in their life triggered or marked the beginning of their pathological hoarding behavior. The most common traumatic experiences are deaths, separations, unemployment, accidents, or illness.

2.7.1 Animal Hoarding Animal hoarding is a phenomenon closely related to hoarding disorder. This chapter should provide practical and theoretical insights on the topic, aiming to determine the similarities between the phenomena as well as the aspects in which they diverge. Similar to hoarders, animal hoarders have been reported to have difficulty letting go. While the DSM-5 specifically defines “possessions” as the object of hoarding disorder, animal hoarding displays several parallels. A detailed comparison of the two phenomena seems justified. Research into animal hoarding describes the behavior based on the following criteria [87]: –– Possession of more than ten animals.

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–– Failure to provide even minimal standards of nutrition, sanitation, and veterinary care. –– Inability to act on the deteriorating condition of the animals (disease or even death) or the environment (overcrowding or unsanitary conditions), or the impact on their own health and wellbeing. We have to be aware that animal hoarding describes the keeping of an unusual number of pets in the home. The above criteria for animal hoarding invoke psychodynamic factors that are essentially different from those in hoarding disorder. The decisive pathological aspect in animal hoarding lies in the inability to provide sufficient care for the animals rather than the urge to keep more. A 2015 study refers to hoarding as Noah syndrome, describing it as a variant of Diogenes syndrome [88]. The current stage of research suggests that animal hoarding is based on serious dysfunctional behavior. The results of one of the recent studies indicate that cases of animal hoarding require substantial work and monetary resources [89]. The DSM-5 does not include animals into the diagnostic criteria for hoarding disorder. There are still some similarities: both types of pathological behavior develop chronically, exhibit an unrelenting urge to be near the animals or the objects, and, ultimately, involve an intense emotional attachment to the hoarded animals and objects. But there are also significant differences, especially with regard to the patients’ living areas. Animal hoarding comes with sanitary conditions of severe neglect, often posing health risks [46]. Further differences and similarities, as well as psychological specifications, are to be investigated in further research. Concern has been expressed [90] with regard to defining animal hoarding as a type of hoarding disorder according to the DSM-5 criteria. This criticism is primarily based on the rejection of comparing animals to objects. Furthermore, animal hoarding poses serious health threats, especially due to the sanitary issues and poor animal care, usually associated with the phenomenon. Animal hoarding increases the risk of animal and zoonotic diseases. This also elicits the recommendation to take extensive psycho- and socio-therapeutic measures along with somatic and psychiatric steps when working with animal hoarders (ibid.). The problem of animal hoarding cannot be solved by taking the animals away, providing them with proper care, and offering somatic and psychiatric care for the owner of the animals. Once the opportunity arises, animal hoarders will continue the pattern of hoarding a larger number of animals. The phenomenon entails a complex range of issues, especially due to the fact that hoarding behavior directly affects other living beings. It is advisable for veterinarians, animal welfare organizations, and different health care services to work closely together and ensure the long-term welfare of the involved persons and animals [91]. It has also been suggested [92] that animal hoarding could be a form of delusional disorder. This is evidenced by the fact that animal hoarders believe to be taking the best possible care of their pets, despite failing to meet even minimal standards of care and sanitation for both themselves and the animals.

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In international research, pathological hoarding is clearly distinguished from Diogenes syndrome. Several studies have defined Diogenes syndrome based on the following characteristics [93]: –– –– –– –– ––

Self-neglect Domestic squalor Refusal of help Social isolation Shamelessness

These characteristics indicate that Diogenes syndrome represents a more serious disorder. In order to determine the exact differences between this phenomenon and hoarding disorder, further research is required. The very denotation Diogenes syndrome is to be questioned. Diogenes rejected material comfort and advocated a philosophy of modesty. His name has been inappropriately applied to serious conditions of neglect. A French study proposes the use of distinct categories and places hoarding and squalor at the extremes of a two-­ dimensional scale. The authors raise the question of whether, in terms of etiology, hoarding disorder and Diogenes syndrome could represent different manifestations of the same underlying disorder [94]. Animal hoarding only bears little relation to the pathological behavior of hoarding objects. Evidence suggests that the underlying psychodynamics in animal hoarders essentially differ from patients with pathological hoarding issues. Studies on hoarding individuals who own animals could not determine any significant correlations between pathological hoarding behavior and the number of animals kept in the patients’ homes [95]. The classification of animal hoarding remains open. Another study was carried out in Brazil, investigating possible links between animal hoarding and OCD. The results are remarkable: two people, i.e., approximately 0.5% in 420 participants, displayed animal hoarding symptoms [96]. Further research, specifically epidemiological surveys, are required to comprehend animal hoarding and establish differential diagnostic criteria. As current research does not reveal any significant correlation between animal hoarding and hoarding disorder, the subject shall not be discussed further in this book. The underlying psychodynamics of hoarding animals and failing to give proper care has been evidenced to greatly differ from hoarding inanimate objects. Further differential criteria are required to prevent misconceptions and possible mistreatment in either of the cases. I would like to point out here that this work focuses on hoarding disorder or the Messie-Syndrom. Conclusion Knowledge of basic psychoanalytic concepts, including the stages of psychosexual development, is imperative for understanding the phenomenology of pathological hoarding. Particularly aspects of orality and anality and the period coinciding with

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toilet training are vital in the development of hoarding and must be considered in working with HD patients. One also needs to be aware of the fact that hoarding individuals experience a range of accompanying symptoms. Indecision, doubt, unpunctuality, and feelings of shame and guilt are typical traits recognized in those suffering from hoarding tendencies. However, the complexity of the human psyche renders any general statements about the origin or causes of a disorder such as HD extremely difficult, if not entirely impossible. Respective considerations are by no means meant to be presented as facts but should assist the practical work with patients. Applying psychoanalytic concepts to the study and treatment of mental disorders has proven extremely rewarding. Psychotherapists of all disciplines, as well as doctors and social workers, can greatly benefit from a familiarity with psychoanalytic foundations. Theoretical concepts from object relations theory and the French psychoanalytic school are useful in understanding both narcissism and super-ego development. For a profound comprehension of hoarding disorder, further in-depth descriptions of symptoms, diagnostic criteria, concomitant phenomena, epidemiological aspects, and comorbidities are required.

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2 0. Jones E. Anal erotic character traits. J Abnormal Psychol. 1918;13(5):261–84. 21. Freud S.  On transformations of instinct as exemplified in anal erotism. Standard ed. 17; 1916–17e. 22. Freud S. On narcissism: an introduction. Standard ed. 14; 1914. 23. Jones E. The theory of symbolism. Br J Psychol. 1916;9:181–229. 24. Wurmser L.  Scham und der böse Blick. Verstehen der negativen therapeutischen Reaktion. Stuttgart: Kohlhammer; 2011. 25. Wurmser L. The mask of Shame, The master work series. London: Johns Hopkins University Press; 1981. 26. Mahler MS, et al. The psychological birth of the human infant, symbiosis and individuation. New York: Basic books; 1975. 27. Landau D, Iervolino AC, Pertusa A, Santo S, Singh S, Mataix-Cols D. Stressful life events and material deprivation in hoarding disorder. J Anxiety Disord. 2011;25:192–202. 28. Hilgers M. Scham. Gesichter eines Affekts, 4. Aufl. Göttingen: Vandenhoeck & Ruprecht; 2012. 29. Freud S. Civilization and its discontents. Standard ed. 21; 1930. 30. Klein M. The psycho-analysis of children. London: Vintage; 1997. 31. May U. Zur Frühgeschichte der Analerotik. Psyche. 2012;66(3):213–46. 32. Riesenberg Malcolm R.  Interpretation: the past in the present. Int Rev Psychoanal. 1986;13:433–43. 33. O’Shaughnessy E. W.R. Bions Theorie des Denkens und neue Techniken der Kinderanalyse. In: Bott SE, editor. Melanie Klein Heute, Bd 2. Anwendungen. Stuttgart: Klett-Cotta; 2002. p. 237–55. 34. Bion W. Learning from experience. Washington, DC: Rowman and Littlefield; 1994. 35. Bion W. Transformations (first ed. 1965). New York: Routledge; 2018. 36. Balint M.  Primary love and psychoanalytic technique. New Ed Edition. New  York: Routledge; 1985. 37. Balint M. Thrills and regression. Abingdon/New York: Taylor & Francis/Routledge; 1987. 38. Jaques E. Death and the mid-life crisis (first ed. 1965). In: Melanie Klein today, volume 2: mainly practice: developments in theory and practice. Abingdon/New York: Taylor & Francis/ Routledge; 2003. 39. Klein M. A contribution to the theory of intellectual inhibition. In: The collected works of Melanie Klein, vol. 1. New York: Routledge; 2017. (First published in 1931). 40. Meltzer D. The Claustrum: an investigation of claustrophobic phenomena, The Harris Meltzer Trust. Strath Tay: Clunie Press; 2018. (First published in 1992). 41. Green A. The work of the negative. London: Free Association Books; 1999. 42. Green A. Geheime Verrücktheit. Grenzfälle der psychoanalytischen Praxis, 2. Aufl. Gießen: Psychosozial-Verlag; 2003. 43. Chasseguet-Smirgel J.  Die Anatomie der menschlichen Perversion. Gießen: PsychosozialVerlag; 2002. 44. Grunberger B. Narcissism: psychoanalytic essays. London: Free Association Books; 1989. 45. Grunberger B. Narziss und Anubis. Die Psychoanalyse jenseits der Triebtheorie, Bd 1. Wien: Verlag Internationale Psychoanalyse; 1988. 46. Frost RO, Steketee G, Tolin DF.  Comorbidity in hoarding disorder. Depress Anxiety. 2011;28:867–78. 47. Grisham J, Baldwin P. Neuropsychological and neurophysiological insights into hoarding disorder. Neuropsychiatr Dis Treat. 2015;4:951–62. 48. Steinberg H, Carius D, Fontenelle LF. Kraepelin’s views on obsessive neurosis: a comparison with DSM-5 criteria for obsessive-compulsive disorder. Braz J Psychiatry. 2017;39(4):355–64. 49. Kraepelin E. Psychiatry, a textbook for students and physicians, vol. 2. 6th ed. Canton, MA: Science History Publications; 1990. (First published in 1988). 50. Sommer M. Sammeln. Ein philosophischer Versuch. Suhrkamp: Frankfurt a. M; 1999. 51. Kluge F. Etymologisches Wörterbuch der deutschen Sprache, 24. Aufl. Berlin: DeGruyter; 2002. 52. List E. Psychoanalyse: Geschichte, Theorien, Anwendungen, 2. Aufl. Stuttgart: UTB; 2014.

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53. Laplanche J, Pontalis J-B. Language of psycho-analysis. New York: Routledge; 1988. (First published in 1973). 54. Freud S. Instincts and their vicissitudes. Standard ed. 14; 1915. 55. Honneth A. Reification: a new look at an old idea. New York: Oxford University Press; 2008. 56. Ivanov VZ, Nordsletten A, Mataix-Cols D, et  al. Heritability of hoarding symptoms across adolescence and young adulthood: a longitudinal twin study. PLoS One. 2017;12(6):e0179541. 57. Mueller A, Mitchell JE, Crosby RD, Glaesmer H, de Zwaan M. The prevalence of compulsive hoarding and its association with compulsive buying in a German population-based sample. Behav Res Ther. 2009;47:705–9. 58. Samuels JF, Bienvenu OJ, Grados MA, Cullen B, Riddle MA, Liang KY, Eaton WW, Nestadt G. Prevalence and correlates of hoarding behaviour in a community-based sample. Behav Res Ther. 2008;7:836–44. 59. Nordsletten A, Reichenberg A, Hatch SL, de la Cruz LF, Pertusa A, Hotopf M, Mataix-Cols D. Epidemiology of hoarding disorder. Br J Psychol. 2013;203:445–52. 60. Chakraborty V, Cherian AV, Math SB, Venkatasubramanian G, Thennarasu K, Mataix-Cols D, Reddy YCJ. Clinically significant hoarding in obsessive-compulsive disorder: results from an Indian study. Compr Psychiatry. 2012;53:1153–60. 61. Wang Z, Wang Y, Zhao Q, Jiang K. Is the DSM-5 hoarding disorder diagnosis valid in China? Shanghai Arch Psychiatry. 2016;4:103–5. 62. Stein DJ, Kogan CS, Atmaca M, Fineberg NA, Fontenelle LF, Grant JE, et al. The classification of obsessive-compulsive and related disorders in the ICD-11. J Affect Disord. 2016;1:663–74. 63. Schott H, Tölle R. Geschichte der Psychiatrie. München: Beck; 2006. 64. WHO, Dilling H, Freyberger HJ, editors. Taschenführer zur ICD-10-Klassifikation psychischer Störungen, 3. Aufl. Unter Berücksichtigung der German Modification (GM) der ICD-10. Bern: Huber, 2006. 65. Landis EA. Logik der Krankheitsbilder. Gießen: Psychosozial-Verlag; 2001. 66. Crocq MA.  A history of anxiety: from hippocrates to DSM.  Dialogues Clin Neurosci. 2015;9:319–25. 67. Foucault M. Mental illness and psychology. Berkeley: University of California Press; 1987. Written in 1954 and revised in 1962. 68. Falkai P, Wittchen H-U.  Diagnostisches und Statistisches Manual Psychischer Störungen DSM-5. Göttingen: Hogrefe; 2015. 69. Ermann M.  Angst und Angststörungen. Psychoanalytische Konzepte. Stuttgart: Kohlhammer; 2012. 70. Jäger M. Aktuelle psychiatrische Diagnostik. Ein Leitfaden für das tägliche Arbeiten mit ICD und DSM. Stuttgart: Thieme; 2015. 71. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, DSM-5. Washington, DC: American Psychiatric Association Publishing; 2013. 72. Frost RO, Steketee G, Tolin DF. Diagnosis and assessment of hoarding disorder. Annu Rev Clin Psychol. 2012;8:219–42. 73. Frost RO, Tolin DF, Steketee G, Fitch K, Selbo-Bruns A. Excessive acquisition in hoarding. Anxiety Disord. 2009;6:632–9. 74. Francis A.  Saving normal: an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: Harper Collins; 2013. 75. Darke S, Duflou J. Characteristics, circumstances, and pathology of sudden or unnatural deaths of cases with evidence of pathological hoarding. J Forensic Legal Med. 2017;1:36–40. 76. Hall BJ, Tolin DF, Frost RO, Steketee G. An exploration of comorbid symptoms and clinical correlates of clinically significant hoarding symptoms. Depress Anxiety. 2013;30:67–76. 77. Tolin DF, Meunier SA, Frost RO, Steketee G. Hoarding among patients seeking treatment for anxiety disorders. J Anxiety Disord. 2011;25:43–8. 78. Mataix-Cols D, Frost RO, Pertusa A, Clark LA, Saxena S, Leckman JF, et al. Hoarding disorder: a new diagnosis for DSM-5? Depress Anxiety. 2010;27:556–72.

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79. Evans DW, Leckman JF, Carter A, Reznick JS, Henshaw D, King RA, Pauls D. Ritual, habit and perfectionism: the prevalence and development of compulsive-like behavior in normal young children. Child Dev. 1997;68:58–68. 80. Zohar AH, Felz L.  Ritualistic behavior in young children. J Abnorm Child Psychol. 2001;29:121–8. 81. Iervolino AC, Perroud N, Fullana MA, Guipponi M, Cherkas L, Collier DA, Mataix-Cols D.  Prevalence and heritability of compulsive hoarding: a twin study. Am J Psychiatry. 2009;166(10):1156–61. 82. Pertusa A, Fullana MA, Singh S, Alonso P, Menchón JM, Mataix-Cols D. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? Am J Psychiatry. 2008;165:1289–98. 83. Frost R, Gross RC. The hoarding of possessions. Behav Res Ther. 1993;31:367–81. 84. Nordsletten A, Mataix-Cols D.  Hoarding versus collecting: where does pathology diverge from play? Clin Psychol Rev. 2012;32:165–76. 85. Van Bennekom MJ, Blom RM, Vulink N, Denys D. A case of digital hoarding. BMJ Case Rep. 2015;10:bcr2015210814. https://doi.org/10.1136/bcr-2015-210814. 86. Lenders T, Kuster J, Bispinck R. Der Dortmunder Vorschlag zum praktischen Vorgehen bei unbewohnbar gewordenen Wohnungen  – Untersuchung von 186 Fällen von Vermüllung, Wohnungsverwahrlosung und pathologischem Horten  – Messie-Syndrom. Fortschr Neurol Psychiatr. 2015;12:695–701. 87. Worth D, Beck AM.  Multiple ownership of animals in New  York City. Trans Stud Coll Physicians Phila. 1981;3(4):280–300. 88. Saldarriaga-Cantillo A, Rivas Nieto JC.  Noah syndrome: a variant of Diogenes syndrome accompanied by animal hoarding practices. J Elder Abuse Negl. 2015;27:270–5. 89. Dozier ME, Bratiotis C, Broadnax D, Le J, Ayers CR. A description of 17 animal hoarding case files from animal control and a humane society. Psychiatry Res. 2019;272:365–8. 90. Gahr M, Connemann BJ, Freudenmann RW, Kölle MA, Schönfeldt-Lecuona CJ.  Animal Hoarding: eine psychische Störung mit Implikationen für die öffentliche Gesundheit. Fortschr Neurol Psychiatrie. 2014;82:330–6. 91. Reinisch AI. Understanding the human aspects of animal hoarding. Can Vet J. 2008;49:1211–4. 92. Frost R, Steketee G, Williams L. Personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls. Behav Res Ther. 2000;38:1071–81. 93. Amanullah S, Oomman SK, Datta SS.  Diogenes syndrome revisited. Ger J Psychiatry. 2009;12:38–44. 94. Lavigne B, Hamdan M, Faure B, Merveille H, Pareaud M, Tallon E, et al. Diogenes syndrome and hoarding disorder: same or different? L’Encephale. 2016;10:421–5. 95. Ung JE, Dozier ME, Bratiotis C, Ayers CR.  An exploratory investigation of animal hoarding symptoms in a sample of adults diagnosed with hoarding disorder. J Clin Psychol. 2016;12:1114–25. 96. Campos-Lima AL, Torres AR, Yücel M, Harrison BJ, Moll J, Ferreira GM, Fontenelle LF.  Hoarding pet animals in obsessive-compulsive disorder. Acta Neuropsychiatry. 2015;2:8–13.

3

Treatment Recommendations

Introduction This chapter gives an overview of the most promising treatment recommendations, including psychotherapy, medical supervision, and pharmacological treatment. Also, I present several psychosocial concepts that have proven remarkably successful in treating patients with hoarding disorder. Specifically, these include the offer of self-help groups and home visits. A particular focus is placed on relationship work, as it is particularly relevant to primary care and treatment of individuals affected by hoarding. Inspired by the treatment matrix, I discuss the success achieved when combining different treatment options. I also introduce the TH-I-N-G-S intervention model, while at the same time highlighting the specific needs of children to hoarding parents. The chapter concludes with reflections on how professionals of different disciplines could promote interdisciplinary exchange for advancing current treatment options.

3.1

General

With the introduction of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, hoarding disorder was first officially recognized as a mental disorder in its own right. The International Classification of Diseases followed suit and decided to define hoarding disorder as a separate illness in its 11th revision. The definition of this new psychiatric diagnosis is likely to have far-reaching consequences in health care. Due to its classification as a mental disorder and the establishment of respective diagnostic criteria, hoarding disorder now has distinguishing features, which set it apart from what may have been considered a mere preference or normal behavior. Increased media attention is likely to encourage individuals with hoarding

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symptoms to seek professional help, where it has been avoided in the years before. Psychotherapists, general practitioners, psychiatrists, and social workers must expect a surge in hoarding patients. However, the inclusion of a new disorder in an international diagnostic manual also generates controversy and criticism. Many open questions remain, and the demand for professional training and supervision is higher than ever. Recent years have shown that different institutions and organizations working with hoarding patients have a great interest in training their staff on pathological hoarding or, in German, Messie-Syndrom. Many professionals lack experience working with hoarding patients or do not know how to address their needs appropriately. There is still a great deal of uncertainty in practice, and many aspects are awaiting their scientific discussion or investigation. Ongoing questions include the very definition of hoarding disorder, its delineation from or interaction with other mental disorders, and successful treatment options. Work with hoarding patients has proven to be characterized by many challenges, mainly arising from the fact that many of those affected show little to no insight. The frustrations typically associated with hoarding disorder complicate the patient–therapist relationship and usually make it difficult for professionals to continue providing support and achieving progress in treatment. Consequently, psychotherapists, doctors, and caregivers often find themselves helpless, developing a strong need for interdisciplinary exchange and findings supported by science. This manual addresses this gap and provides professionals of different disciplines with a comprehensive instrument to aid their work with hoarding patients. Different treatment options and their relevance to hoarding disorder are discussed in more detail in the following section. I point out several approaches that have proven particularly promising in the present context. These include the treatment matrix and the TH-I-N-G-S intervention model. While I discuss these approaches and their uses, I shall also refer to the unique challenges in dealing with patients who pathologically hoard, including their aggression potential. Finally, the importance of relationship work is highlighted and aspects of child welfare and other relatives’ situation are discussed.

3.1.1 Individual Therapy Psychotherapy encourages patients to practice self-reflection and process events in their biography, that may have influenced the course of their lives. Depending on the context and needs of the patient, individual or group therapy may be an option. The therapeutic context provides a safe environment where patients can approach the core of their suffering step by step and learn to understand what lies beneath it. What are the experiences patients have made that continue to affect them so that they feel like they must restrict themselves? What major life events can they report? What motives do the patients disclose and have (unconsciously) prompted them to lead their lives this way? The psychotherapeutic process builds on a mutual

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relationship of trust and respect. The therapeutic alliance provides the foundation for successful treatment. It enables the patient to open up about their suffering and—if we want to draw on the metaphor of hoarding—box by box, room by room, reveal and process information. Psychotherapy aims not only to provide psychological support but also to reduce distress and suffering and enhance overall well-being. Providing the patient with the tools required to reflect on personal relationships and behavior patterns enables them to reduce insecurities and improve self-confidence. Observations at Sigmund Freud University and a Florida State University study confirmed that intolerance of distress and uncertainty is interactively associated with hoarding symptoms. Higher levels of distress and uncertainty could be determined in patients with hoarding symptoms compared to the control group [1]. A behavioral approach currently dominates the American landscape of psychotherapeutic research, possibly explaining why recent studies cite behavioral therapy as the most successful psychotherapy method. We should note, however, that the tools available significantly influence our perception. For example, studies repeatedly provide evidence that deep psychological approaches to mental suffering may require more time but have a more significant and longer-lasting effect. Regardless of the method employed, the psychotherapeutic setting should be one of trust and respect, where the patient feels safe to share private information and begin to understand the way unconscious processes affect their lives. I cannot stress enough, then, that psychosocial work is relationship work. The unique relationship between patients and therapists, doctors, or social workers requires an extraordinary effort. The therapeutic alliance directly influences the therapy outcome, forming the foundation for mutual agreements. Despite knowledge of factors influencing the therapeutic alliance positively, there is no guarantee for a successful treatment outcome. Working with patients who suffer from hoarding disorder is characterized by many unique challenges. Failure and relapses are not rare. A lasting change in the patients’ behavior requires patience and empathy from therapists and other professionals. Progress is typically slow, and in many cases, still only possible if the therapeutic process continues for several years and combines different methods and forms of support. In some cases, lifelong treatment and care may be necessary. Like chronic physical disease may require continuous medication, hoarding disorder may be controllable only if treated continuously as well. Psychotherapy may be an option for organizing a patient’s inner world before enabling them to start organizing their environment. Tackling the outer world, specifically the patients’ homes, may help achieve short-term success. However, we should be aware that such an approach is likely to prompt extreme patient reactions and frustration on behalf of helpers and others involved. Such approaches are fruitful only on the surface but do not typically show sustainable results. If we want to achieve a lasting effect and continuous relief for those suffering, considering a combined approach of different treatment methods is vital.

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3.1.2 Group Therapy Group therapy may be a viable alternative to individual therapy and has been a standard treatment method in hoarding disorder. The community created through group sessions can generate a sense of stability and provide support. Many patients with hoarding disorder live in seclusion, isolated from society, and lack personal relationships. For many hoarders, group therapy is the only form of social interaction. Associating with other hoarders usually makes it easier for patients to express their distress and address feelings of shame. The phenomenon of cohesion is one of the central influencing factors in group therapy and represents the equivalent to the therapeutic alliance in individual therapy. Cohesion describes a strong sense of solidarity and unity. It creates an environment where individuals feel safe to share inner thoughts and feelings with the group and receive acceptance. The relationships of individual members with the group therapist, other group members, and the group shape the overall cohesion (see [2]). Different relational structures and opportunities for transference provide the individual’s psyche with several options to develop. In the group setting, individual members may choose to make themselves the center of attention or hold back. The conflict culture develops differently in a group than it does in a relationship between two individuals. Group therapy also allows individual participants to form alliances with members or form opposing opinions. One of the most significant benefits of group therapy is that it allows members to re-anact familial or primary relations. Participants tend to unconsciously repeat previous relational experiences, primarily those made with their parents or sibling rivalry. Group therapy has many benefits, yet does not come without also including some limitations. For instance, in contrast to individual psychotherapy, group therapy offers more scope for avoidance. This could also be why group therapy generally meets a high acceptance rate among patients with hoarding disorder. An essential difference between social groups and therapy groups is that the latter provides a unique opportunity to develop and test the personal ability to deal with conflict. One of the necessary experiences to be made in the therapy group setting is to bear a certain level of discomfort and remain committed to not harming others at the same time. Coherent groups exhibit similar features as some families, particularly managing conflict while staying loyal to each other. The environment is such that members are encouraged to express their feelings and receive constructive feedback. Reflecting on and processing the conflicts experienced by individual members fosters cohesion and allows the group to grow.

3.1.3 Support Groups The support group at Sigmund Freud University was founded by Elisabeth Dokulil (formerly Vykoukal) in 2005. Students have accompanied the self-help group from the very beginning and it has remained open to external patients to this day. The Sigmund Freud University self-help group is unique in that it is:

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–– A low-threshold program, where meetings take place weekly and include patients, family members, and professionals –– Free of charge and does not require registration –– Moderated, accompanied, or observed by advanced students Many participants in the support group have reported that the offer has provided relief for the first time in their therapeutic experience. The self-help group was the first institution to offer an active exchange with other patients. At the same time, moderation through students ensures a professional and safe environment. The self-help movement is not a new occurrence and looks back on a long history. Support groups gained prominence in the 1960s’ and 1970s’ when they were adopted in the context of emancipation and to take a stand for individual autonomy. Support groups have become a significant model to ease psychological distress in hoarding disorder, especially regarding the patients’ difficulties organizing themselves. In recent years, a shift from personal interaction to online interaction has also been observed in the self-help movement. Many groups have become virtual. Self-help in hoarding disorder remains mostly dependent on traditional forms of interaction and personal meetings. Patients with difficulty organizing meetings may find it even harder to meet online, where they must navigate different platforms and learn about new tools.

3.1.4 Patient Home Visits Home visits are a useful tool, perfectly complementing other forms of care in hoarding disorder. At Sigmund Freud University, home visits have become a successful concept to intensify care and support for hoarding individuals. Over an extended period, students pay patients weekly visits of 2 h at the maximum. These meetings include setting weekly goals and together working on their achievement. This way, the students foster the patients’ autonomy and increase their self-confidence while providing overall relief. Home visits adhere to strict guidelines and are temporarily limited. Their purpose is not to tidy up the patients’ homes or help them clean, but to formulate personal goals and eventually develop a system of order that the patients can implement and maintain. Home visits provide step-by-step guidance in regaining self-responsibility and the ability to act. A central aspect of this process is setting priorities. Many people with hoarding issues are unable to prioritize, which is why external support in this regard has proven very beneficial. However, home visits and other forms of on-site support can only achieve the desired effects if the patients are open to and agree with the concepts. Students working in this program as part of their mandatory internship are required to attend regular supervision and reflect on their experience and actively exchange with professionals in the field. The students’ self-experience is an integral part of their training and lies at both the very foundation and core of their education to become psychoanalysts. This is because self-awareness is the key to developing

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genuine empathy and understanding of patients, as well as their behavior and the psychological mechanisms that may underlie specific patterns. The offer of student home visits essentially differs from the work of social workers or supervisors often externally assigned to hoarding individuals. These are often put in charge of the patients’ homes, helping them keep order and regularly clean. The social workers must actively work out a solution with the patients, encouraging and supporting them in clearing their homes from any clutter and organizing their belongings. Problems may occur when patients break agreements, for example, by failing to adhere to provisions regarding necessary order and cleanliness. Social workers often receive instructions to ensure that clients observe house rules and that neighbors are not disturbed by the patients’ hoarding behavior (such as bad odor coming from their homes or insects infesting the house). The challenges in caring for and supporting hoarding individuals mainly arise from having to set and observe clear boundaries. What actions are necessary to protect the well-being of those involved? Where can we allow scope for negotiation? General statements and advice is very rarely helpful in this context, as every situation is different. Detailed analysis of a patient’s situation is paramount to determining the measures to improve a person’s living situation and deciding which concepts best suit the person’s progress. The Japanese organizational expert and bestselling author Marie Kondo developed her method to counteract chaos and clutter in the home. The central question to the KonMari method is: does it spark joy to own this object? Professionals in hoarding disorder need to know that such questions do not facilitate working with patients who obsessively hoard. Most of those affected by hoarding disorder cannot answer the question at all or only answer it in the affirmative—and end up not being able to part with anything, which is the core of the problem.

3.1.5 Pharmacotherapy Diagnosing hoarding disorder requires a detailed examination. This includes recognizing or eliminating other diseases and conditions that may be associated with signs and symptoms. An essential step in the diagnostic process is determining whether it is necessary to use prescription medication as a complementary form of treatment. Several international studies have shown the medication to provide little to no relief in hoarding disorder. Patients with OCD, on the other hand, have been found to benefit from medical treatment. Psychotherapy and the use of SSRIs (selective serotonin reuptake inhibitors) have proven to be more efficacious for HD patients with depressive symptoms than patients suffering from HD alone. However, it should be noted that hoarding disorder has mostly been proven resistant to pharmacotherapy and to require a more complex form of combined treatment. An Australian meta-study investigated the effect of pharmacotherapy in patients with hoarding disorder, analyzing 7 studies with 92 subjects in total. Most of the participants were diagnosed with obsessive-compulsive disorder. More than half of them (58 participants) responded favorably to the prescribed medication, which

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mainly included SSRIs. These results call for intensified pharmacological research on hoarding disorder [3]. A 2014 study demonstrated that treatment with venlafaxine, an SNRI (serotonin-­ norepinephrine reuptake inhibitor), is particularly promising. In this study, almost all participants (23 of 24 patients) showed significant improvements in their hoarding behavior [4].

3.1.6 Treatment Matrix Hoarding symptoms are inflexible and changes in behavior can be achieved only in steps. The patient’s insight, motivation, and psychological resources directly influence treatment success, regardless of the approach. The treatment options are grouped in internal and external treatments. While psychotherapy, pharmacotherapy, and social work can be regarded as providing internal support, self-help groups and patient home visits provide external help. The treatments described above can be combined to create a treatment matrix. This matrix (Table 3.1) gives an overview of the options available and depicts frequent combinations. While not providing an exhaustive representation of treatments, the matrix serves to visualize some of the most meaningful combinations. It is meant to provide a practical tool in evaluating the patient’s unique situation and modifying the care concept as required. The combination of psychotherapy, support group visits, and, in some cases, even additional support through home visits has proven extraordinarily successful in treating hoarding disorder. The high intensity and different modes of care and Table 3.1 Treatment matrix Internal treatments

Psychotherapy (individual or group therapy)

Pharmacotherapy

Social work and counseling

Support groups

Facilitate selfexperience and reflection, conflict management, relationship work, and exchange with other patients in the group

Provide support and relief without tackling the root of the problem, bearing the risk of ignoring essential causal factors

Provide external support and symptom relief without tackling the rootof the problem, bearingthe risk of overburden for patient and professional

Patient home visits

Can be combined with other forms of treatment

Provide short-term relief without addressing underlying conflicts, bearing the risk of overburden

Offer care and counseling in everyday tasks without treating the actual problem

External treatments

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treatment facilitate the patient’s acceptance and positively influence treatment success. Combining psychotherapy with participation in support groups has yielded similarly positive outcomes. Psychotherapy gives the patient a safe space to focus on themselves, and the group setting offers an opportunity to exchange with other patients. Consequently, this model has been well received and has been the preferred option in many cases. Psychotherapy and home visits have proven similarly effective and popular in hoarding treatment. Combining these individual treatment options not only offers ideal conditions for the patient to experience relief in different ways but also helps divide responsibilities and allocate specific steps in the treatment to respective professionals. Similar to the treatment of other mental disorders, hoarding treatment is a multidimensional process. It requires the patient to address inner conflicts and to process traumatic experiences. Another vital aspect of hoarding treatment is restoring and maintaining the functionality of living areas and a minimum of hygiene and order. Pharmacological treatment combined with a support group temporarily relieves symptoms but fails to tackle the actual problem. This approach can bear the risk of worsening the patient’s situation, as it neglects to address their disorder’s actual causes. Attempting to treat hoarding disorder through counseling and social work alone, or through family support, is challenging and burdensome. The patient’s need for intensive support in everyday life can severely affect the patient–caregiver relationship. Once the relationship is impaired, the patient may perceive the offered help as a threat and attempt to ward it off. This especially applies to home visits and other forms of intervention in the patient’s personal life, which may be necessary to prevent health and safety hazards. For example, the caregiver insists that the patient throws away food because it expired a long time ago or is no longer edible for other reasons. The caregiver’s responsibility to take care of the inedible food to be discarded can negatively affect the interpersonal relationship. Therefore, reflection and other options to experience relief are indispensable to complement the social worker’s or other caregivers’ daily work. The treatment matrix serves as a tool for professionals to consider the possible combinations of therapies and individually adapt the treatment. This tool allows professionals to address external and, above all, neglected internal conditions in hoarding disorder. From the above and practical experience, we know that providing those affected with the necessary care and achieving long-lasting improvement is an intricate task. Professionals treating hoarding patients must always be aware of the big picture. In the case of imminent danger, we must act. The hazards in advanced hoarding can be manifold. Cases have been reported where stacks of paper surrounded the heating system, bearing fire hazards, or where piles of cardboard or books had reached a height at which their collapse could have buried any person walking beneath. In other cases, the hygiene level had deteriorated to a state where the patient’s home had already become infested with cockroaches or other insects. These cases serve to name some of the most common hazards associated with extreme hoarding. Professionals continuously need to evaluate the patient’s situation and exchange with other parties involved before taking action. Above all, the patient’s and other people’s health and well-being are our primary concern.

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Regardless of the psychotherapeutic method we apply, treatment should be concerned with determining and confronting the causes rather than tackling the symptoms by cleaning up or decluttering the homes. Psychotherapy may benefit from addressing the following questions: –– How can life become worth living again? –– Why does the patient feel they do not deserve room, or why do they feel the need to limit their space? –– What are their development potentials and sphere of influence? –– How is their social life structured? Do they receive support from the partner, family, friends, or acquaintances? –– Does the patient have any hobbies, or are they involved in any leisure activities? These questions are particularly suitable for the first interview. As psychotherapy progresses, we can move on to discussing the underlying factors causing hoarding behavior and encourage the patient to reflect on their biography and life experience. Years of practical work with HD patients have shown that symptoms are usually very persistent, and that change can take place only in small steps. The first aspects we need to evaluate are the patient’s level of insight and psychological distress. If the patient is insightful and willing to change, the treatment process will look very different from when intervention becomes necessary due to external requirements. We have to be aware that a discrepancy between personal values and social values does not constitute mental illness per se. The formulation of such conflicts may seem trivial but we must not ignore them. It is all too human to allow personal experiences, lessons, values, and ideas to influence our work. Our personality can even provide a treasure trove, enhancing our scope of action and fostering our understanding of hoarding disorder. However, this is only the case if we continuously practice self-reflection and careful evaluation. Doing so can only benefit our work with HD patients and, for that matter, any patient. Certain aspects of mental illness may stir our own emotions because they are not at all alien to our unconscious. Another essential aspect that needs to be addressed is the treatment duration. Psychoanalytic research has provided evidence that the earlier a developmental disorder occurs, the longer the required treatment. Based on the theories presented in this book, we can assume that hoarding disorder classifies as an early disorder. Early disorders are such that develop from stress and traumatic experiences in early childhood, adversely affecting the very early psychological development. The psychotherapeutic and psychiatric treatment of HD patients primarily requires psychotherapists, psychologists, and doctors to work together. Hoarding, however, also confronts other professional groups, including social workers and counselors. Practical experience and research and the above-introduced treatment matrix suggest that cooperation between various professionals will take center stage in future intervention and treatment concepts. I would like to emphasize once more that hoarding disorder is a multidimensional phenomenon and, therefore, it is only logical that the different professional groups involved need to work together to improve the treatment efficacy. We need to utilize all resources available and adapt

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treatment to the patient’s situation, meaning their level of insight and experience of psychological distress. Since hoarding disorder finds different manifestations and patients are not always aware of the problems their behavior entails, there is no one-­ size-­fits-all treatment. With patients with little to no insight, the focus will be on supporting, training, and supervising social workers, family members, and other caregivers. Constant evaluation of whether the patient presents a danger to themselves or others is at the core of this work.

3.2

Features and Challenges

3.2.1 General Guidelines The working alliance is seen as providing the foundation for most forms of care and counseling, psychotherapy, and medical treatment. One of the prerequisites for creating a fruitful relationship with the patient is to develop an accepting and supportive attitude toward the patient. Constant reflection and participation in supervision and intervision are paramount to maintaining a professional attitude in the long term and even in difficult situations. In psychotherapy and, especially, in psychoanalysis, self-reflection is one of the fundamental therapeutic principles. The professional’s attitude and stance set the right tone for a good rapport. Approaching the patient with a generally positive and empathetic attitude is crucial. In the beginning phase of working together, this can help align the therapeutic goals with the patient’s actual needs. Furthermore, mutual respect and attentiveness and a nurturing perspective have been shown to facilitate the treatment process. Professionals are strongly advised to regularly attend supervision and engage in psychoanalytic reflection on their thoughts and feelings. This way, they can evaluate and counteract arising inhibitions and personal difficulties hindering their work. Psychotherapeutic training has long utilized these tools, and while they are not familiar in other contexts, there is evidence supporting their implementation in any areas of care. The more we know about ourselves, the more comfortably we can respond to others and interact without bias. Our scope of action can grow, and we will develop new opportunities and perspectives to approach our patients. Heinrich Racker describes the necessity of a good self-awareness as follows. More precisely, another person’s unconscious can be grasped only in the measure in which one’s own consciousness is open to one’s own instincts, feelings, and fantasies. It is true, that the understanding of another’s unconscious also exists when one’s own consciousness is closed against the perception of this same psychic content in oneself; and what is more, it is true that at times one perceives in the other exactly that which is very much rejected within oneself. ([5], p. 25)

In many social and psychosocial institutions, continuous supervision is standard practice, either established as a mandatory requirement or an optional offer. Self-­ awareness still needs to be integrated as an element of medical, educational, social, and psychosocial training, as this would very likely not only increase the professionals’ confidence but also ensure the long-term quality of their work. Further

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research and scientific examination are required to detail a model for integrating supervision and self-reflection in practice. Attitude and Communication Professionals in hoarding disorder are likely to have acquired the basics of developing a professional attitude and communicating effectively in training. The following deliberations may seem obvious and self-evident; however, it is precisely such routine practices that require the most reflection and awareness. Whether part of medical or social work, the first interview should always serve to: –– Assess the patient’s current situation –– Evaluate their living conditions and possible previous diagnoses –– Refer them to a psychotherapist or other professionals who can eliminate or determine other conditions related to hoarding signs and symptoms Every conversation must be characterized by a particular sensitivity for the current state of the relationship between professional and patient and should signal respect and acceptance to the person concerned. The structure of conversation may vary from the first to the successive interviews. It is crucial for the professional to remain impartial at all times and to listen attentively. Actively engaging with the patient’s conscious utterances and remaining alert to any unconscious content that may be conveyed can make it challenging to maintain one’s own inner order and composure. Consequently, it is advisable to record the contents after each conversation and the resulting feelings and thoughts. This method facilitates reflection and opens the opportunity to revisit specific issues. We have to be aware that many conversations with social workers or counselors take place in emergencies. In particular, the work with patients with little to no insight is frequently characterized by pressure, even though the pressure is known to hinder the cooperation. The conflict arising from the necessity to intervene and the patient’s resistance represents a unique challenge for all parties involved. Ideally, the first step is establishing a trusting relationship and a favorable atmosphere. This step is central to working with the patient in identifying the skills they can mobilize and what they are momentarily capable of doing to improve their situation. In the early treatment phase, patients primarily need someone who is present and whom they can trust. Patients are more likely to accept help if they have someone in their life whom they can trust to step in for their needs until they are stable enough to do so themselves. As elaborated on in the previous chapter, any kind of force and pressure applied in treating HD patients can have a detrimental effect on the treatment success. This is because such pressure reactivates factors that have caused the disorder in the first place, reinforcing symptoms. The fewer musts patients experience, the more wills they can develop. Truthfulness, honesty, and trust are the pillars of a fruitful patient– therapist relationship, creating room for ego functions to develop and regenerate. Self-efficacy and motivation need time and attention to develop. As a further consequence, the patient’s insight and a willingness to change can ensue.

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3.2.2 Relationship Work Relationship work is central to hoarding disorder treatment not only due to the significance of the therapeutic alliance but also because the subject of attachment is intricately associated with the disorder. Therefore, we need to pay closer attention to this aspect. It classifies as common knowledge, especially among professionals in the psychological and psychiatric context, that separation and loss can cause severe inner conflict in children. However, the problem is usually associated with how separation and loss, or other traumatic life events, are processed internally. Whether they can be successfully processed or not often depends on the support children receive from outside. John Bowlby describes the problem as follows: We believe that for some people it is so difficult to express their distress because the family they grew up in and still associate with sees a child’s attachment behavior as something that can be overcome as quickly as possible. Such families tend to refer to crying and other forms of protest about separation as childish and anger or jealousy as objectionable. ([6], p. 123)

Recognizing and accepting these forms of protest and anger seems crucial in dealing with hoarding symptoms. Hoarding disorder has a conspicuously auto-­aggressive component. Those affected are willing to accept severe impairments in the functionality of their living spaces. We then have to ask how these aggressive impulses developed and became integrated into the patient’s daily life. The difficulty of giving or throwing objects away indicates a form of inhibited, yet physically expressed aggression. This aggression is necessary for integrating the personality, as Donald Winnicott describes: Prior to integration of the personality there is aggression. A baby kicks in the womb; it cannot be assumed that he is trying to kick his way out. A baby of a few weeks thrashes away with his arms; it cannot be assumed that he means to hit. A baby chews the nipple with his gums; it cannot be assumed that he is meaning to destroy or to hurt. At origin aggressiveness is almost synonymous with activity; it is a matter of part-function. ([7], p. 204)

Winnicott considers impulses as originating in the body [7]. In hoarding, we can observe that affective relationships with inanimate objects often replace relationships with living beings. We necessarily have to question the patient’s ability to love. Here immediately comes the main source of aggression, instinctual experience. Aggression is part of the primitive expression of love. A description of this in oral terms is appropriate since I am studying the first love impulses. (ibid, p. 205)

Many patients report failed relationships, in particular romantic relationships. In some cases, hoarding was even the reason why the relationship ended. Many HD patients collect objects of daily use around the bed or turn their bedroom into a workspace. They place their desk and computer next to the bed, diverting its functionality and sabotaging the possibility for a relationship to develop. We have to

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wonder: could hoarding serve to avoid entering into an intimate, long-term relationship? At least, this would explain why hoarding often concentrates on the patient’s sleeping area and drastically inhibits the bedroom’s functionality. International large-scale studies have provided evidence to support this association between the difficulty of living in a relationship and hoarding. The majority of HD patients live alone. They are either single, divorced, or widowed. It is an art to live alone, but it is also an art to live in a relationship. Inanimate objects gain relevance in a person’s life when they are disappointed by other people, especially their loved ones. One patient quite aptly described that she could not have consciously chosen to either live a social life or in seclusion; her unconscious took over this choice. The other, which was first represented by the mother and later embodied by the intimate partner, seems to be a correlative. These considerations require us to take a closer look and develop a thorough understanding of how significant relationships are in hoarding disorder. To this end, I shall first and foremost refer to John Bowlby, notable for his attachment theory, which extends Klein’s concept of “object relations” and Mahler’s “symbiosis and individuation.” Bowlby’s Attachment Theory Attachment behavior describes behavior patterns by which we generate proximity to other persons. Results of recent studies suppose a link between insecure attachment and hoarding disorder [8]. The infant displays a range of instinctive behaviors, seeking the caregiver’s attention. Much of its behavior is characterized by watching and listening and occasionally vocalizing or crying. Provided that the attachment figure can take proper care of the infant, these behaviors support the formation of a bond between the two. Hoarding disorder points to disturbances in this phase of micro-experiencing and insufficient development of the attachment bond between infant and caregiver. It is important to note that attachment behavior essentially differs from behavior related to feeding and sexuality. Attachment constitutes an emotional bond in its own right and, as such, occupies an independent key role in human development. Attachment represents a form of emotional nourishment. Ultimately, healthy attachment behavior between adults and children sets the foundation for the ability to develop healthy emotional relationships in adulthood. HD patients generally experience relationships with other people, and other social aspects, as inhibiting. At first sight, this contrasts with the patients’ high level of acceptance of support groups and group therapy. However, group settings provide individuals more room for avoiding intimacy and addressing uncomfortable topics. This is because the attention is distributed instead of focused on just one person. The situation is different when it comes to forming a more intimate bond with just one other person. Patients often perceive such relationships as more confrontational. We have to bear this in mind if we aim to establish a therapeutic alliance. It may be beneficial, especially in the beginning, to work in a team to assess whether the patient can bond with a person.

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When intervening in the patient’s home, professionals are advised to coordinate in a team. Alternating between visits allows the care professionals to divide responsibilities and reduce the stress associated with home visits for all parties involved. Attachment behavior serves not only to create emotional bonds but also to maintain proximity and communication with the attachment figure. The ability to maintain closeness or distance, where appropriate, and sustain a sound basis of communication is crucial for integrating social aspects. The objects allow them to protect themselves from any kind of social intervention. The objects build a wall of protection. Once a reduction in the patients’ possessions is achieved, their accessibility is assumed to increase, making them more responsive and open to emotional relationships. Certain attachment-seeking behaviors are activated only under certain circumstances. Bowlby cites insecurity, exhaustion, fear, or lack of response from the primary attachment figure as situations in which the child may resort to specific action patterns. He elaborates that if the child’s attachment system is activated, the caregiver must respond sensitively and affectionately, such as by touching, holding, or reassuring it. Following this, the child’s interaction with their primary attachment figure can develop in many different ways. Bowlby notes that intense feelings begin to arise during the stage when bonds are formed, maintained, and broken [9, 10]. The developing emotions reflect the state of attachment, rendering the psychology of emotions a psychology of attachments. Psychoanalysis aids the therapeutic process by which these developmental micro-­ experiences can be made accessible, experienceable, and understandable. In other words, understanding early childhood relations are crucial in illuminating hoarding and its deeper causes. Attachment behaviors reflect an individual’s unique survival mechanisms. We can assume that the relatively long physical dependence on the attachment figure in early life creates a psychological dependence later on. The infant’s helplessness and the resulting dependencies play a decisive role in their further development. Nevertheless, it is not a child’s attachment behavior alone that molds its development and ability to enter into meaningful relationships in later life. The parental nursing behavior, i.e., how the parents, particularly the primary attachment figure, respond to attachment behaviors, is crucial. The caregiver’s responsiveness is vital to strengthening the child’s bond and reinforcing its attachment behavior system. This observation is particularly impressive, if we consider that the system remains active throughout life and fulfills a central biological function. Bowlby emphasizes that the adults’ activation of attachment behavior is neither a pathology nor a regression or immature behavior. Attachment behavior does not denote a specific phase or stage of development, but functions as an internal working model. This model accompanies a person throughout their entire life, shaping their ability to create, maintain, or end relationships. It is a crucial function enabling us to manage relationships with other adults. While the attachment system lays the foundation for adult social behavior in the

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early years of life, it is also assumed that human attachment behavior can change and thus be corrected later on. Bowlby argues that many psychopathologies reflect disruptions in early attachment development rather than regression or fixation. Psychological disorders are manifold and can occur at any age. Bowlby recognizes missing affection and a person’s habit of quickly breaking off relationships or failing to maintain a strong bond to others as a central manifestation of psychopathology. Relational difficulties also stand out as a notable feature of hoarding disorder. Patients often report early separations and experiences of loss in their early life. Impairments in their social life and inhibitions experienced in encounters with others may be consequences thereof. The experiences that an individual makes with primary attachment figures during the early years of immaturity (between infancy and adolescence) have a tremendous impact on later behavior patterns. This is why the psychoanalytic concepts of transference and countertransference are central in working with HD patients and decisive in achieving an advanced understanding of their situation. The personality’s integration of attachment behaviors reflects the patterns of emotional bonds (Bowlby). In children, we can observe the development of the inner psychic world: It must be remembered that in childhood we are watching the human being only gradually becoming able to distinguish between the subjective and objective. A state of what looks like delusional madness easily appears through the child’s projection of inner world experience. ([7], p. 208)

There has not been a single scientific discipline to this day that can deliver a satisfying explanation for how these intrapsychic microprocesses in the infant develop. However, multiple theories and concepts address essential psychological functions, most of which begin to unfold after birth. As cited before, patients with hoarding behavior often exhibit a marked aggression potential. While this aggression is generally subdued in interpersonal relationships, it emerges in the form of auto-aggression in the patient’s handling of inanimate objects. In his essay “Aggression in Relation to Emotional Development,” Winnicott succinctly describes the mechanism lying at the core of aggressive behavior: The main idea behind this study of aggression is that if society is in danger, it is not because of man’s aggressiveness but because of the repression of personal aggressiveness in individuals (ibid., p. 204)

This means that a vital step for hoarding patients is learning how to utilize and transform aggressive impulses and driving forces for the benefit of their own well-being. However, the concept of aggression is far more complex, one of its central qualities being the social value it can come to have: In health, the individual can store badness within for use in an attack on external forces that seem to threaten what is felt to be worth preserving. Aggression then has social value. (ibid., p. 209)

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Winnicott’s essay on “Psychoses and Child Care” postulates a so-called transitional or intermediate space. In this in-between area, separating the inner and outer worlds, illusion exists. The mother’s love and illusory identification allow her to recognize the infant’s needs and respond to them. The mother’s love and her close identification with her infant make her aware of the infant’s needs to the extent that she provides something more or less in the right place and at the right time. (ibid, p. 223).

Later on, the infant learns to imagine or create the illusion of unity with the mother, acquiring the ability to comfort themselves, even if just for a short period. When the child replaces the mother’s verbal comfort with the thumb, a blanket, or a teddy bear, these are all signs of a so-called transitional object being created. Winnicott argues for an approach in which we acknowledge the infant’s madness and very carefully dose the disillusion necessary to achieve a distinction between subjective and objective reality. We can still observe remnants of this transitional area in adults who draw on art and religion or get involved in clubs and communities to make this experienced absence more bearable. However, Winnicott continues, if individuals are not capable of making a clear distinction, holding on to the intermediate area of experience in a way that goes beyond mere enjoyment; this may be a sign of psychosis (ibid., p. 113 ff.). Furthermore, Winnicott introduces the concept of primary maternal preoccupation to describe the good enough mother. According to Winnicott, the mother shifts into a preoccupation with her infant’s needs directly after giving birth, permitting her to enter a heightened sensitivity. Winnicott considers this state in terms of a psychological condition and postulates that the mother must be sufficiently healthy in order for this condition to develop. If the mother is able to respond to the infant’s needs appropriately, the child’s life is less likely to be disturbed by reactions to other circumstances (ibid., p. 157 ff.). In dealing with HD patients, it is vital to develop a similar kind of sensitivity for their illusory state of mind in order to be able to collaborate and together translate their deeper needs. Transitional Objects and Phenomena Based on Winnicott’s theory of the intermediate space, we can understand hoarded objects as transitional objects. Transitional objects and phenomena are a theoretical construct developed by Winnicott [11]. These objects represent the infant’s first possession and allow them to test reality. Their relevance becomes most obvious such as when the child prepares for sleep or attempts to self-comfort when afraid. Remember that, in hoarding behavior, the accumulated objects perform a fearreducing effect, providing those affected with a sense of stability and security. In infancy, transitional objects are primarily objects that facilitate the transition from maternal attachment to entering into curiosity for the outside world. In hoarding disorder, disruption is likely to have occurred in this transitional phase. In “Transitional Objects and Transitional Phenomena,” Winnicott impressively demonstrates the infant’s first possession. While the influence of oral arousal and

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satisfaction is apparent, other factors at play here remain to be investigated in more detail. In this context, Winnicott emphasizes the following aspects: ([7], p. 230):

1. The nature of the object. 2. The infant’s capacity to recognize the object as “Not-Me.” 3. The place of the object—outside, inside, at the border. 4. The infant’s capacity to create, think up, devise, originate, produce an object. 5. The initiation of an affectionate type of object–relationship.

Winnicott explores the area between oral eroticism and object relation. This intermediate or in-between space, or the space between thumb and teddy bear, describes a transitional object and transitional phenomena ([7], Transitional Objects and Transitional Phenomena, p. 229 ff.). For Winnicott, these spaces are decisive. They are where the inner psychic reality develops—and later enables the adult to exchange ideas in a group or identify with others. As a further consequence, the transitional space is also where culture originates and develops. I hope it will be understood that I am not referring exactly to the little child’s teddy bear or to the infant’s first use of the first (thumb, fingers). I am not specifically studying the first object or object-relationships. I am concerned with the first possession, and with the intermediate area between the subjective and that which is objectively perceived. (ibid., p. 231)

From this, we can extrapolate that hoarding is not about the individual object, but about the sum of things. Winnicott’s notions of the transitional object and the child’s relationship to this object are extremely revealing for hoarding research. The qualities in the relationship defined by Winnicott can also be applied to the relationships hoarding patients establish with their possessions. It is surprising just how fitting the application of Winnicott’s special qualities in the relationship (ibid, p. 233) seems in hoarding: 1. The infant assumes rights over the object. […]. 2. The object is affectionately cuddled as well as excitedly loved and mutilated. 3. It must never change, unless changed by the infant. 4. It must survive instinctual loving, and also hating and, if it be a feature, pure aggression. 5. Yet it must seem to the infant to give warmth, or to move, or to have texture, or to do something that seems to show it has vitality or reality of its own. 6. […] it is not an hallucination. 7. […] It loses meaning, and this is because the transitional phenomena have become diffused, have become spread out over the whole intermediate territory between ‘inner psychic reality’ and ‘the external world as perceived by two persons in common’, that is to say, over the whole cultural field.

Patients with hoarding disorder also assume rights over objects. As professionals working with HD patients, we can observe their ambivalent feelings toward the objects. On the one hand, they love and revere their possessions, but on the other hand, they stack and pile them on top of each other, and sometimes the objects are even broken. But even then, when objects are broken and no longer fit for use, they are still considered valuable to the hoarder. It is rare for their

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possessions to lose meaning, rendering them just as significant as the infant’s transitional object. Transitional phenomena and transitional objects facilitate the transition from a state of feeling connected to, almost united with the mother to the child’s first efforts to become more autonomous. This transition coincides with an emerging sense of self-determination and self-awareness. In other words, the onset of ego development initiates processes of detachment from the mother toward autonomy. The following section surveys the major ego development steps and specific ego functions relevant to hoarding disorder.

3.2.3 Ego Psychology and Functions of the Ego How are the ego functions structured in hoarding disorder? The cluttered living areas, one of the prime features in pathological hoarding, are considered an expression of the id. As Freud put it, those affected have the impression: ([12], p. 140). This phrase carries a double meaning in hoarding disorder, as those affected often lack control of both their inner and outer worlds. One of the first steps in working with HD patients is often to establish a connection with the ego, i.e. that part of the personality that suffers and wants to change. In The Ego and the Mechanisms of Defence (2012), Anna Freud emphasizes the ego’s role in psychoanalytic theory. She asserts that the object of psychoanalytic therapy have always been the ego and its disorders. Examinations of the id have pursued this one goal: the elimination of these disorders and the restoration of a healthy ego (cf. Freud 2012, p. 14). Since the id and its mechanisms are not merely accessible to observation and the super-ego components often coincide with the ego components, she argues that focusing on the function of the ego will yield the most advantages. Now this means that the proper field for our observation is always the ego. It is, so to speak, the medium through which we try to get a picture of the other two institutions. ([13], p. 6).

Although the analyst must remain impartial toward all the three instances and give equal attention to all elements, we also know that the patient’s defense complicates this task. Anna Freud’s work accentuates the importance of appropriately addressing defense phenomena. Hoarding treatment professionals need to raise questions concerning the patient’s obstacles and possible blocks. What prevents them from changing when they want to live differently? What are the assumptions and patterns of thought underlying their perceived inhibitions and prohibitions? Which defense mechanisms and inner conflicts play a part in weakening the ego functions? Ego psychology assumes that a comprehension of health based on the exploration of and engagement with ego functions helps determine the causes of neuroses. If we aim to understand the inter-systemic conflicts and connections between the ego and id or ego and super-ego, we require more research into intrapsychic relations (cf. [14], p. 48 ff.). To substantiate the need for research into this aspect, however, we first have to know how this psychoanalytical approach can contribute to hoarding research and hoarding treatment.

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A closer look at the ego functions reveals that HD patients face significant difficulties in precisely these areas. The most relevant functions of the ego (as described by ego psychologist Hartmann [14]) are: Motility and Perception Patients with hoarding disorder are often unable to differentiate between the outer and inner worlds sufficiently. This issue becomes apparent in their perception and treatment of external objects as parts of their identity or something internal. Patients who have little to no insight perceive their symptoms as ego-syntonic and, therefore, not disturbing. Reality Testing Some stages of hoarding disorder indicate problems with boundaries. Internal boundaries seem not to have sufficiently developed. Consequently, they are projected to the outside world, where they are otherwise made visible. Action and Thought Some patients’ actions are not consistent with their thoughts. The feeling of not being master in one’s own house is an issue. Especially patients with good or fair insight grapple with this problem. Human Nature A disposition to develop a specific mental disorder may be present in an individual’s personality structure. However, it is difficult to determine which came first. Questions that remain unanswered to this day include: At what point does a personality disorder begin to form? To what extent does the formation depend on genetic factors, and how far do environmental factors influence it? Apart from Hartmann’s discussion of the nature-nurture problem and the difficulties of differentiation, his thinking is strongly influenced by drive theory. Hartmann adopted the psychosexual phases and their conflicts as central concepts in personality development. Coordination and Integration Hoarding disorder is linked with an inhibited self-regulation and an impaired ability to synthesize impulses or emotions. These limitations surface in respective symptoms. The disorder develops as the patients’ only form of self-regulation. This observation is in line with what was previously said in this book about mental disorder representing the momentarily best possible solution. Intentionality Intentionality describes a child’s ability to focus their attention and align their perception and action in such a way as to be able to work toward a specific goal. Patients affected by HD typically have many different interests and are known for getting involved in many different areas and goals at once. Their lack of

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decision-making ability makes it difficult for them to devote themselves to one goal or focus their energy in one activity ([14], p. 102 ff.). These ego functions are crucial in hoarding disorder. The patients’ perception of the outside world is particularly interesting in this context. For example, from eating disorder research, we know that the perception of those affected often departs from reality. Patients with eating disorder often have a distorted body image. Therefore, we also have to ask how far an HD patient’s perception is impaired. Do HD patients feel comfortable in their homes? Can the ego of the affected person provide a protective barrier, or are the objects hoarded to take over this essential function of the ego? To what extent can those affected think and act freely? The tendency to develop specific symptomatology is always also attributable to individual personality traits. Can hoarding, then, be understood as self-regulatory behavior that, at a given moment, seems the most sustainable solution? To what extent is the capacity for intentionality developed in those affected by hoarding disorder? To what extent are they able to live according to their personal goals and wishes, and to what extent are they enslaved by their symptoms and experience them as disturbing and restricting? If we consider the significance of the ego functions, behavioral approaches to perception, memory, recognition, and information processing in hoarding become understandable. The ego functions are regulated differently from patient to patient. Further studies are required to develop a more profound comprehension of the ego functions and their relevance to hoarding. Freud was the first to postulate: “The ego is first and foremost a bodily ego” ([15], p. 26). The most prominent post-Freudian theory stems from Heinz Hartmann, dividing the ego functions into three autonomous apparatuses, namely the physiological aspects, somatic apparatuses, and finally, the structures that underlie the body-ego (cf. [14], p. 104). Although the exact relationship between the apparatuses remains an issue of dispute, it is unquestionable that ego development and libido development are paramount in hoarding disorder. In this synopsis of psychoanalytic approaches, it is therefore essential to distinguish between the individual theories, even if their boundaries have to be understood as fluid. Hartmann emphasizes the close interactions and interconnections between object relations and ego development as follows: It is obvious that these apparatuses, somatic and mental, influence the development and the functions of the ego which uses them; we maintain that these apparatuses constitute one of the roots of the ego. ([14], p. 101)

The interactions between ego development and object relations are a prime concern in hoarding disorder. The disturbances in the development of object relations are indicative of early disturbances in ego development. The body has a central role in ego psychology, representing the mediator between the inner and outer worlds. Objects are the most important representatives of the outside world. Hartmann admits that the ego depends on stable relationships not only to the instinctual drives but also to the objects in order to develop appropriately.

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However, this is not to say that generalizations about causal relationships are valid without precise distinction. Hartmann stresses that there can be no simple, causal connection between ego development and a deficient relationship with the mother. Above all, it is the constancy of objects which shapes ego development (ibid., p. 33 ff.). Stable ego development is decisive for the later ability to process experiences. By implication, it is a critical factor in hoarding disorder. The hoarded objects act as an auxiliary ego, an extension of the ego in the outside world. The objects reduce fears and provide security. Essential parts of the ego functions are transferred to the patients’ possessions. These considerations help us understand why it is challenging to build a trusting relationship with those affected and why the relationship can be fragile even after many years of working together. What complicates the situation further is the value and meaning hoarders ascribe to their possessions. How could one part with something that occupies such a vital position in one’s life? The relationship of the ego to psychoanalytic treatment is not easy to describe. Anna Freud defines the complex and contradictory tasks and functions of the ego in psychoanalysis as follows (cf. Freud 2012, p. 37 ff.): Tasks and functions of the ego in psychoanalysis (according to Anna Freud) • The ego is an effective ally of the analyst and, as such, supports the process through constant self-observation and informs about other institutions. • The ego is an enemy of the analysis because it is biased and falsifies facts or withholds them. • The ego is itself the object of analysis, so the ego’s defensive operations must be made conscious. This knowledge is indispensable in treating and caring for patients affected by hoarding. Psychoanalytic treatment is a sensitive balancing act requiring the analyst to remain objective and direct equal attention to the unconscious elements in all psychic institutions. This task is even more difficult to fulfill in medical and social settings. To maintain a high quality of professional work with HD patients, we have to be aware of the dynamic forces and defense mechanisms influencing this work. The most common defense mechanisms in hoarding are those of obsessive-compulsive disorder. They include reaction formation, seclusion, and denial. Reaction formation especially shows in aggressive impulses. Upon initial contact, the patients often appear reserved and quiet. They do not show adequate handling of aggressive impulses. They either turn inward in the form of auto-aggression or outward in the form of outbursts of anger. Reinforcing the ability to deal with conflict and communicate effectively and appropriately in disagreements is one of the prime goals. Frequently, reaction formation also occurs in combination with regression. By employing the strategy of seclusion, patients separate what belongs together. This explains why some have difficulty perceiving an object on its own or in its entirety. An empty, old box, for example, is kept for its flower print on the cover,

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which is perceived as lending it an exceptional aesthetic; the item’s actual state is disregarded. The American hoarding expert Randy Frost recognizes an “intense perceptual sensitivity” in people affected by hoarding [16]. However, there may be several explanations, all denoting the same issue. The defense mechanism of seclusion is a well-known strategy, often used by children when they experience extreme stress and trauma. Finally, denial is a defense mechanism that involves refusing to accept the existence of unwanted aggressive and sadistic impulses ([17], p. 135 ff.). An awareness of these different strategies not only helps the analyst to understand a person’s behavior, but also benefits the patient. Defense mechanisms are unconscious processes, allowing a person to avoid dealing with unwanted emotions. The HD patients’ preoccupation with objects in hoarding can be viewed in this light. However, this form of denial and ignoring reality is also dangerous. The avoidance or denial of painful feelings has a price, even if it may momentarily appear like the best possible solution.

3.2.4 Inhibitions and Limitations The disorder’s prime symptom of clutter bears the risk of trivialization. One might be inclined to downplay the problem of keeping order in one’s home. But imagine telling a patient with severe depression that they just needed to pull themselves together, or an anorexic patient that they simply had to eat. The psychological problems are much more profound and complex than they appear on the surface. This does not mean that we can ignore the surface expression of mental illness. While psychoanalysis can help unearth the causes and improve in the long run, immediate action may be necessary to protect the patient’s well-being. Patients with eating disorders sometimes have to be hospitalized to ensure their survival. Often this happens before we could even begin to explore the deeper issues. There are no general tips and tricks to be applied in working with hoarding individuals, except for practicing self-reflection, which is always beneficial. Whether counselor, family member, doctor, or therapist, we all have to attend to the Messie in ourselves. Where do we show hoarding tendencies? Do we enjoy accumulating things or find it easy to let go? Can we find traces of the phenomenon in our own life? Which areas in our life would we describe as chaotic? Do we delight in order or disorder in our home, in individual rooms, or in our car? Working with patients affected by hoarding can be very stressful and lead us to push our psychological limits. We are challenged to reflect on and become aware of our ideas of cleanliness and order. What are our cleaning habits? What do we associate with cleaning? What relevance and meaning do things have in life? How many objects and which objects do we need to feel good? Dealing with our own ideas of cleanliness and order enables us to develop empathy and approach patients with the required sensitivity for their situation. If we carry inner inhibitions and personal prohibitions into practice, this can make the daily work with those affected by hoarding even more difficult.

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We once had a patient who described that when a female counselor helped him clean up the home, he was reminded of a situation where his mother had overstepped his boundaries. They had together practiced multiplications when she would urge him to repeat the multiplication table again and again. He remembered that he had hardly been able to bear the situation, feeling like he would have to scream any minute. He had felt actual physical pain and eventually broken down crying. When his counselor now asked him to put his used glass into the dishwasher, he could not do it because he felt like he was urged to do so by someone else (see Sect. 4.2.7, Mr. Z.). We have to be aware that, when working with HD patients, the demons of their past may reawaken. We have to be prepared to deal with them at all times, knowing that our patients’ demons may also confront personal inhibitions, limitations, and possible conflicts. Therefore, we must be in touch with our inner world and know how to utilize emerging feelings and thoughts.

3.2.5 Challenges Hoarding symptoms are most evident in the patients’ homes. It is essential to be aware that the squalor often associated with hoarding is the expression of a mental disorder. If one focuses exclusively on this surface symptomatology, such as by taking measures to discard objects and clean the living areas, this can quickly lead to frustration and failure. We continuously need to evaluate whether the symptomatology bears immediate health risks or safety hazards. Removing the clutter from the patients’ home is always a highly sensitive issue and should not be done without it being necessary or obtaining prior consent. Intervention through evacuation is rarely necessary, and even when it is, we have to know that this will affect the patient’s health. It is always of paramount importance to work out the best possible solution, where a forced eviction should always be the last way out and measures to stabilize the patient should be sought. Remember that previous psychiatric diagnoses should not guide our work. The focus should be to provide quick and practical assistance in restoring daily functionality and improving the patients’ state of health and living. An American study pointed out the importance of recognizing and treating the disorder appropriately. The situation of people living in squalor should be taken seriously, and eviction prevented. If we learn to raise awareness and find adequate measures to address the issue, we may even reduce homelessness ensuing from forced evictions [18].

3.2.6 Transference and Countertransference The above general guidelines in treatment can be just as helpful as knowing about relevant psychological concepts, most prominently transference and countertransference. If we want to understand those affected by HD, we must make that which

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is strange to us our own, or rather find strangeness within ourselves. Reflecting on and discussing the phenomena of so-called transference and countertransference provides us with a good opportunity. In general, countertransference phenomena are the totality of the analyst’s unconscious reactions to the analyzed person and their own transference [19]. What transference and countertransference phenomena do professionals in psychotherapeutic, medical, or social work face? In psychoanalytic theory, transference describes the resurfacing of feelings experienced in previous relationships. Countertransference describes events where the therapist transfers emotions to the patient. “Language of Psychoanalysis” defines transference as a process by which we can revise unconscious desires. Countertransference, on the other hand, refers to the analyst’s unconscious reactions (ibid.). It is undoubtedly worth exploring these two psychoanalytic terms in greater detail. In this present guide, however, I focus on the manifestations most relevant to hoarding. Aggressive Countertransference Phenomena In order to be able to perceive countertransference phenomena, we first have to deal with ourselves. Instigating processes of self-experience and psychotherapeutic or psychoanalytic methods enable us to detect blind spots in ourselves. Heightened self-awareness allows professionals to utilize personal feelings, thoughts, and fantasies in their daily work, rather than having them interfere with their work. The psyche can be used as a tool and instrument to understand the patients better. Professionals need to ask themselves two central questions: –– How do we deal with our aggressive tendencies and feelings? –– How do we deal with our patients’ aggressive impulses? Aggressive Tendencies in Ourselves In addition to supervision sessions and the deliberate reflection with colleagues, self-experience is a recommended method to address subjective emotions and feelings. Not only professionals but also other members of a patient’s care network are advised to consciously address personal actions and feelings, asking themselves the following questions: –– –– –– ––

In which situations do aggressive feelings arise? Which narratives and reports stir feelings of helplessness and frustration? What impulses can we perceive in ourselves? How can we learn to deal with our aggression?

These questions confront the essential issues that both professionals and non-­ professionals working with HD patients face. Once we learn to understand these aspects of ourselves, we can offer support in breaking specific behavior patterns that continue to impact another person’s life negatively.

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Aggressive Impulses in Patients HD patients are likely to demonstrate aggressive behavior if they do not know another way to defend themselves. Their expressions of stubbornness and defiance or anger and rage constitute emotional reversals of inner fears. We have to acknowledge that those who hoard value their individuality and attempt to preserve their identity when threatened. It is only natural that hoarding patients expect others to take their ideas and opinions seriously. A patient once aptly stated that they do not want to subject themselves to the general public’s dictates. In the course of analysis, he found that his hoarding began as an act of refusing his mother’s strict approach to raising him. The case of this patient and others reveal that those affected by hoarding symptoms generally lack an adequate strategy to deal with personal aggressions. Inhibited aggression is a prevalent feature of hoarding disorder. The patients’ need for harmony and effort to avoid conflicts is striking. In most cases, HD patients exhibit a limited capacity to manage conflicts. Otto Fenichel points out that to be obstinate quite literally means to maintain one’s position and defend it against another person’s position [17]. He describes obstinacy as a passive kind of aggressiveness. The anal stage in psychosexual development coincides with a child’s discovery of its ability to control the sphincter and practice the first acts of defiance. Fenichel develops this theory by making a correspondence between aggression development and activity ([17], p. 124). To generate a deeper understanding of aggressive impulses in ourselves or in our patients, we are advised to ponder and examine etiological factors of influence and our behavior in dealing with those often-uncomfortable parts of our personality.

3.2.7 Trivialization and Denial The practice of supervision has demonstrated that pathological hoarding is usually discussed only later on in therapy. Feelings of shame, guilt, and fear contribute to this development. We have to remain attentive throughout the therapeutic process and be particularly alert to any moments when the patient might casually mention their home’s orderliness or disorderliness. If the patient repeatedly touches on a topic without deliberately seeking to discuss it in-depth, this topic may be relevant to therapy. Therapists, doctors, and other professionals who work with HD patients while not knowing about the state of their homes should ask for photographs. Pictures could help them adequately evaluate the extent of the patients’ hoarding behavior. Since keeping order in the home is an everyday topic concerning us all, issues in this regard can easily be overlooked and trivialized. Who does not own a set of drawers or a cabinet that could be labeled chaotic? We all have a specific idea of the order in our home. We may occasionally plan to rearrange something, sort papers, clothes, or other belongings. Some have work piling up on their desk, while others

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do not mind driving an untidy car. We need to be mindful of distinguishing between such everyday phenomena and the phenomenon of pathological hoarding. Trivializing hoarding tendencies will not help those affected, yet we have to remain impartial and open toward their perception of possessing things.

3.2.8 Disgust, Shame, and Guilt In hoarding treatment, disgust is a central topic. From a psychoanalytic point of view, disgust represents a reaction formation. Therefore, professionals working with HD patients are strongly advised to contemplate personal taboo pleasures or parts of the personality that derive pleasure from the dirty. In “Three Essays on the Theory of Sexuality,” Freud explores psychological resistance to sexual impulses. The most prominent mental forces cited by Freud are disgust, shame, and pain [20]. The ways in which the unconscious calls attention are manifold. Professionals working with hoarding occasionally develop obsessional washing behaviors or severe nausea and vomiting. It can be challenging to overcome these signs of resistance, and it certainly requires us to address their causes. The topics that we regularly need to assess include guilt, shame, and inferiority. We need to remind ourselves that shame reflects the pain of feeling unloved or unlovable. This feeling often stems from early trauma and later reappears in the form of shame, whether it be of perceived weakness, deficiency, filthiness, or untidiness [21]. One patient talked about her childhood and reported that, as the youngest child, she was her father’s favorite. She remembered how her father would regularly return home drunk and mistreat her siblings and spare her. He sent her brothers away to apprentice for board and lodge. He rejected the older sister and physically abused toward her. Some nights, he would wake her up and force her to sing him a song. The patient felt guilty, even though she knew this unjust treatment was not her fault. The sister later became an alcoholic herself, and the patient tried to support her by accompanying her to AA meetings and therapy. This glimpse into a person’s guilt raises several questions: how can one mentally process guilt? Is not every feeling of guilt looking for an adequate punishment? How can sibling rivalry and envy exist and develop alongside guilt? Psychological trauma usually occurs as a result of experiencing a distressing event. While most traumatized persons have themselves been the victim of such a distressing event, traumas can also develop in those who witness others being tormented or victimized. Consciously evaluating and understanding personal shame and guilt is paramount for professionals in order to be able to adequately deal with the shame and guilt their patients often experience in hoarding. Training and Support Professionals in hoarding disorder require training and support in their daily work. They should participate in respective seminars and study the relevant literature. Above all, intervision and supervision, and the exchange with colleagues have

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proven to provide the most fruitful support. These methods are particularly suitable for working with hoarding symptoms. They provide an impartial and objective setting for professionals to reflect on their feelings and behaviors and discuss these with competent colleagues. In psychotherapy, these forms of exchange are prerequisites, both in training and daily practice. Other groups of professionals involved in hoarding treatment should follow suit to adopt these measures and implement them into their support system. The work with HD patients and especially aspects such as the confrontation with severe squalor do not always leave professionals unaffected. They are strongly advised to evaluate and differentiate their inner world continually. The better we know ourselves, the better we can recognize the other and accept them for who they are. Freud knew that, for psychoanalytic professionals, personal analysis should always be the starting point for encounters with others. In “Future prospects of psychoanalysis,” he notes: That no psychoanalyst goes further than his own complexes and internal resistances permit; and we consequently require that he shall begin his activity with a self-analysis and continually carry it deeper while he is making his observations on his patients. Anyone who fails to produce results in a self-analysis of this kind may at once give up any idea of being able to treat patients by analysis. ([22], p. 145).

3.2.9 Disease Progression and Prognosis Experience has shown that it is unlikely for professionals to be able to heal hoarding disorder. Already the first interventions put personal expectations of relatives and other helpers into perspective. Improvement is a lengthy process as therapeutic success can be achieved only in small steps. An awareness of the tedious process therapeutic care entails and the difficulty of achieving relief again stress the importance of knowing one’s limits. We can sustain treatment over an extended period only if we remain alert to our limits and counteract overburden. We have to be careful with our resources and not let resistances and the persistence of symptoms discourage the process. The prognosis of hoarding disorder is determined by individual factors and cannot be generalized. The factors are characterized by an intricate interaction, as has already been explored at length in the above chapters. Consequently, treatment success can look very different from patient to patient. The following questions help us understand what making progress could mean to the individual patient and how they could achieve it: –– What is success in the treatment of hoarding disorder? –– How is the patient’s personality structured, and what psychodynamics are present? –– How old is the patient, and what is the history of their living situation? –– Does the patient live alone, or are relatives directly affected? –– What is the patient’s current living situation? What level has the clutter or squalor reached in their living areas?

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–– How stable is the patient’s ego structure? How do resistances and defense mechanisms manifest themselves? –– How have the object relations developed? Based on the answers to these questions, success can significantly vary. It was a great success for a patient with good insight not to add objects to the cluttered home. His progress meant that he could reduce the shopping so that he only brought daily essentials into the house and regularly took out a small bag of trash. After years of psychotherapy, another patient managed to clear out her entire apartment and deliver it to the landlord. She even succeeded in clearing out a storage room and move into her own little space where she regularly tidied up and kept herself organized. Studies have repeatedly confirmed that reducing and improving hoarding symptoms requires great effort and patience. There is no easy or fast way to alleviating severe squalor and getting rid of hoarding habits, once pathological. Hoarding disorder has been evidenced to describe a chronic disease associated with a high level of distress for those affected. These findings have been confirmed by a recently published meta-study, which examined 20 studies with approximately 500 participants. This study demonstrates the need for high-quality research designs, specifically evidence-based interventions [23]. However, the question remains to what extent these evidence-based research designs can make inner psychic worlds describable and accessible. Many patients affected by hoarding disorder have experienced childhood trauma and severe attachment disturbances early on. These, in particular, render the treatment of hoarding disorder difficult and are a possible explanation of why the patients’ willingness to change is usually low. Despite these difficulties, a combination of professional treatment options, as mentioned before, can increase the probability of recovery. When visiting patients in their homes, it is also important to define goals based on their ideas of order. This helps counteract overburden and coercion. Such would only inhibit the possibility of progress. Below, I introduce an intervention concept growing out of years of intense work with HD patients. This concept is implifies the core aspects of treating and assisting individuals who hoard pathologically.

3.3

The TH-I-N-G-S Intervention Concept

The TH-I-N-G-S intervention concept summarizes the major steps in hoarding treatment, beginning with the situation analysis (Therapeutic overview). Further steps include the active exchange (Intercommunication) between therapist and client to define the parameters of working together and work out prospects and chances

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(Negotiation) for fruitful cooperation and change. In the next step, the actual change occurs, and the patient can evolve (Generation of strategies), paving the path for developing a new orientation in life (Skills reorientation). This model responds to the necessity of a simple tool to give an overview of the essential steps in treating HD patients. The concept has proved useful, especially for professionals assisting in the patients’ homes. It provides social workers and family counselors with easy-to-­ apply guidelines for dealing with and supporting persons with hoarding disorder. Therapeutic Overview The first step in setting up adequate treatment is to gain a therapeutic overview. It denotes the method by which we assess the patient’s current condition. The situation analysis should cover several sessions of dialog and generate a good overview of the patient’s health and living situation. During this beginning stage, the exchange with doctors and psychotherapists can aid the professional evaluation of the patient’s physical and mental state. The therapeutic overview can also help detect resources that the patient may draw on in later cooperation. Especially in this early phase of treatment, it is advisable to formulate the questions in close relation to the diagnostic criteria as this will aid the diagnosis: Introductory questions for therapy – Does the patient have a history of difficulty parting with objects, regardless of their actual value? – Is this difficulty due to an inhibition to pick the items up and discomfort experienced when throwing things away? – Are the active living areas cluttered and congested by possessions in a way that compromises their use? Are the living room, bedroom, kitchen, and wet rooms fit for use in the intended way? – Are there active living areas that are uncluttered? If so, what is the reason for these areas not being affected by the hoarding? –  Does the hoarding impair social, professional, or other areas of functionality? –  Does excessive procurement and acquisition of objects accompany the hoarding? –  What is the patient’s level of insight?

The patient’s living situation can be assessed based on the patient’s description or photographs. Depending on the situation, home visits may also serve to clear the overall situation. Intercommunication Communication is one of the cornerstones of effective treatment. Throughout the treatment process, opportunities for equal dialog should be created. Choosing the appropriate environment and creating an atmosphere of trust is central to establishing a therapeutic alliance that allows for honest and fruitful exchange. I cannot

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stress enough the importance of relationship work in this context, and the aspect of intercommunication in the TH-I-N-G-S model reflects this. It denotes all the essential steps from approaching the patient to establishing contact and deepening the therapist–client relationship. It can be very helpful to know that psychoanalysis postulates a link between hoarding disorder and the etiology of obstinacy and defiance (see Sect. 2.2). We should not be surprised by the persistence of symptoms and possibly fierce resistance reactions. Every form of compulsion and impatience could aggravate such reactions and impede the way to improvement. Forceful actions and pressure should be avoided at all costs. Establishing a sense of collaboration is the basis for psychotherapeutic work and will also facilitate medical and social work. Any ambivalences and conflicts that may occur should be addressed right away. The following questions can help us be mindful of central aspects that could influence the exchange between professional and patient: how can the patient strengthen their self-­perception and regain autonomy? Which ambivalences and resistances emerge? How can ambivalences be understood based on an attitude of curiosity? How does the patient deal with conflicts? Are they avoiding conflicts? How can we encourage the patient to develop more wants in their life and let go of the musts? Negotiation The previous phase of intercommunication should contribute to creating a trustful relationship and a safe environment for the patient to develop new prospects. The process of getting to know the patient and establishing a relationship serves to lay the foundation for further cooperation. Ideally, the patient feels accepted in such a way that allows them to open up and articulate personal feelings and thoughts. The therapist and other professionals need to remain impartial. If we begin to recognize feelings of resentment, resistance, or prejudice, we need to seek opportunities for supervision or self-reflection and work on regaining our composure. Only if we remain unbiased can we convey a sense of fairness and loyalty and maintain good cooperation with the client. We should also maintain an interest in collaborating at all times. We should monitor the development and prepare to handle setbacks and relapses. We can only take the patient so far in treatment as we are willing and able to go ourselves. Sensitivity and compassion enable hoarding disorder professionals to assume certain functions of the ego that the patients cannot perform themselves. In this sense, professionals may temporarily take the position of a twin- or mirror-ego. They may take over essential inner functions and care for the patients where they cannot. Throughout therapy, the patients gradually reclaim these functions and relearn how to take proper care of themselves. People with hoarding disorder do not typically lack knowledge about cleanliness and order. There are even patients who professionally clean for others. The mechanisms in pathological hoarding are far more complex.

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Generation of Strategies The next phase requires close cooperation. It is usually the measures that the patient implements themselves that are most effective in the long run. The professionals are required to assist, such as cleaning up the home. In this phase, most of the work occurs on-site, which is why it usually coincides with home visiting. This phase aims not to clear out the entire home, but rather to take small steps toward stabilizing the situation and improving the patient’s living conditions. The professional may want to discuss future steps and other forms of assistance with the patient. Note that the home visits almost always entail the renunciation of instincts on behalf of the patient. Depending on the mutual agreement and current goals, the patient may be working on not buying any more items or letting go of certain items. The professionals involved in this stage of intervention should bear in mind that any instinct renunciation requires compensation. Therefore, we need to point out possible rewards awaiting the patient upon renouncing an instinct. The patient needs to see the benefit they can derive from renunciation. The reward can look very different in each case. Once, a patient agreed to clean her bathroom to welcome her grandson into her home. Another patient fell in love and recognized the importance of a clean home if he ever wanted to invite his girlfriend over to see him. Generating strategies is the main goal of this phase. Skill Reorientation The final stage of intervention is that of finding a new orientation in life. The main focus is on assessing the achievement of interim goals and discussing the resulting consequences. Has the condition of the patient’s home changed? Has the functionality of active living areas been restored? Is the patient able to perform small tasks independently, such as throwing away a small bag of garbage every day? Are there any options for the patient to receive support in their home? To what extent can or does the patient want to induce further change? How has the patient’s state of health changed? Does the patient engage in psychotherapy, or do they receive psychiatric care? Is there a need or possibility for inpatient treatment? Is the patient currently threatened by the necessity to move out of their home, or do they face eviction? Which short-term and long-term care options are available, and which are they willing to accept? Has their level of insight changed? Are other family members, relatives, or children involved?

3.4

The Perspective of Family Members

Since the hoarding symptomatology becomes apparent primarily in a patient’s home, hoarding treatment must also involve other people living in the same household. It is known that HD patients have different levels of insight into the problematic nature of their behavior. The need for help is most notable in family members

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and relatives living with patients with little to no insight. It is essential to our work not to neglect the relatives’ needs in this context. Partners, parents, or children may be deeply affected by pathological hoarding and lack support from outside. Assessing the children’s situation in a hoarding individual’s household provides a unique challenge for the professionals. Prioritizing the children’s interests in this context is paramount, and a highly intricate matter (Sect. 3.5). For partners and spouses living with someone who hoards, the situation is burdensome on many levels. On the one hand, they suffer restrictions in their active living areas due to their partner’s hoarding behavior, and, on the other hand, they want to support and help the other. It is a balancing act for them to remain empathetic toward the partner and provide adequate support while realizing when it is time to seek professional help. Relatives of HD patients may display behavior patterns similar to codependency in alcoholism. The following questions may help identify symptoms of codependency: –– Do the relatives protect the hoarding individual and show unconditional compassion? –– Do they take over responsibilities and tasks to support the hoarding individual? –– What do the relatives feel toward the hoarding individual, and what is their perception of them? –– Do they encourage hoarding by acquiring items themselves? Whether working in a medical or psychological setting, professionals always need to consider and include the patients’ relatives. In psychotherapeutic treatment, it is often a question of methodology whether relatives are invited to participate in sessions. However, experience has shown that including all the family and other persons from a patient’s support system is beneficial regardless of the method applied. We have to be aware that codependency can be a vital aspect sustaining an individual’s hoarding behavior over a long period. In many cases where hoarders live with other people, they unconsciously arrange an internal working system, allowing the hoarding to go unheeded over several decades. Professionals are advised to involve relatives in working with HD patients, especially those who share a household with the hoarding individual. The relatives’ resources, level of codependency, and attitude toward the patient are to be carefully assessed. Example A patient once reported that she did not have much space as a child. Her room was small, and she owned very few things. Among them was a puppet that she dearly loved throughout her childhood. Her wardrobe was tiny and only included two pairs of shoes. As an adult, she made sure that she would always have enough room for her belongings. When she married her first husband, they agreed that she would have her own salon in the house while he was granted a study of his own. For decades, the two lived in a large house, sharing a living and bedroom while at the

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same time each enjoying their private rooms. When the patient remarried, she was only allowed to have a closet of her own. Her second husband was very orderly and did not like to see things lying around in the house. She had to keep all her things in a separate closet and suffered under this strict order. Over the years, the situation also affected the relationship. In 2013, a study evaluated symptom severity ratings by hoarding patients compared to family member ratings. The results of this study substantiate the assumption that those affected tend to under-report their symptoms. The authors advocate a three-pronged assessment approach to generate a more realistic impression of individual hoarding disorder severity. They propose that ratings of hoarding severity should be made by the HD patient themselves, their relatives, and an independent evaluator such as a clinician or therapist [24]. This approach could benefit both future research and clinical treatment, not least because it considers that defense mechanisms and codependency affect the family members. The threefold assessment could also aid the process of setting up individual treatment plans. Another patient told of the good life he had with his wife and 2 children until they divorced after 20 years of marriage. All these years, he rented a small apartment outside the family home. His wife knew about the apartment and was glad that she did not have to deal with her husband’s hoarding this way. In a way, she kept the hoarding out of their family life and denied its existence. From working with the patient, it became evident that the issue of denial accompanied his entire life. For a very long time, he did not know who his father was and when the father finally agreed to meet him, he turned out to be available only when it was convenient for him. He visited him a couple of times a year, and also brought some precious gifts. However, he did not show any interest in finding out how the boy was doing in school or what worries he had. The small apartment the patient later rented allowed him to relive this form of defense. It allowed things to pile up while remaining invisible in everyday family life. Thus, the patient created a double life, reminiscent of the life he had as a child with his father, who could only meet on special occasions. Consequently, the patient’s hoarding can be understood as a materialized representation of unconscious denial.

3.5

The Perspective of Children

Professionals must not forget that parental hoarding may represent a threat to child welfare. The perspective of children and adolescents growing up to and living with parents who hoard requires special attention. Taking decisions in the child’s best interest provides professionals with a particular challenge. On the one hand, every child has the right to proper care, especially regarding nutrition, sanitation, medical care, and shelter. On the other hand, a child also has the right to be with their parents or primary caregivers (according to current law in most countries of the world, following the UN Convention on the Rights of the Child). The parents’ relationship with their children is unique and crucial for the children’s personal development,

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and yet it may sometimes be necessary to separate children from their parents to protect them. Such a decision should, of course, never be taken lightly, and the children should only be separated from their parents if they are not being properly cared for. If a parent’s hoarding represents a threat to the child’s health and well-being, it is necessary to act and enforce measures to protect them immediately. Professionals have to be prepared for the conflicts and unique challenges arising from such a situation. Whether or not the family will accept support from outside and be willing to participate in therapy and other treatment options depends on their resources and attitudes. The following two questions are vital in determining the current situation and possible steps to be taken: –– Does the hoarding pose an immediate threat to the child’s welfare? –– Are the parents or other primary caregivers able to seek adequate help, or does the situation require immediate external intervention? In some cases, an official notice of child endangerment may draw attention to parental hoarding. A family may also be known to respective authorities for other reasons and already receive different forms of support, in which case the situation must be monitored and changes in the child’s perspective assessed continuously. It can be assumed that there are also many cases where hoarding individuals lack insight and are, therefore, unable to seek and accept help. Child welfare in hoarding requires psychotherapeutic, educational, and legal intervention. Professionals from different fields need to carefully analyze and evaluate a variety of circumstances and living conditions. The severity of hoarding disorder and the associated difficulties ensuing for children can be just as manifold as the possible intervention methods. It is then paramount to exchange with all parties involved and find individual solutions in the child’s best interests. Questions to assess the child’s welfare – What are the mental and physical health and general condition of the child? What personal or social resources does the child have? What is the child’s attitude toward hoarding? How does the child describe their situation? – How severe is the hoarding? To what extent are the child’s living areas affected? Is the functionality of their home impaired? What is the current state of the kitchen, bathroom, and toilet? Are the rooms adequately heated? – How many children are there in the household? How old are they? How is their dependency on the parents or other caregivers structured? – How many caregivers are there? Are both parents hoarders? Does the family receive support from other relatives or external institutions? – To what extent is the family willing to accept help such as psychotherapy, psychiatric treatment, or other support forms?

The sanitary and other requirements ensuring a child’s welfare depend on their age and current development needs. When an infant is involved, the case has to be treated very differently from when an active toddler or largely independent teenager

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is concerned. It is of prime importance to assess whether the child can take responsibility for their health and hygiene or depends on their parents. Further assessment of the situation requires professionals to discuss the parents’ level of insight, the severity of the disorder, and possible comorbidity. There is no reason to assume that hoarding parents do not properly love and care for their children. The diagnosis of hoarding disorder does not necessarily entail the neglect of children. Investigating a child endangerment report in hoarding disorder is a delicate task and requires a detailed assessment of the individual situation. Risk factors and the family’s resources need to be evaluated before further steps are taken. The quality of attachment and relationship between parents and children is vital for the children’s development. Anna Freud, who pioneered child psychoanalysis, pointed out that there are no generally applicable guidelines [25]. Every decision that may affect the child must take its personality and unique resources and circumstances into account. The child’s emotional development and social abilities are just as important as their physical and mental resources [26]. The above considerations demonstrate the complexity of working with parental hoarding. Many different factors influence the necessity for intervention if children are involved. The parents’ mental and physical resources and those of the children are decisive in determining what steps need to be taken. Professionals have to analyze each situation individually and pay close attention to the relationship between parent and child and their attachment behavior. The analysis of the patients’ internal resources complements the assessment of external circumstances and the family’s living situation and the extent to which it is impaired by parental hoarding. The parents’ willingness to seek and accept support is also a key factor. The necessity to evaluate the overall situation and the individual influencing factors when children are involved has been well known from practice for decades. Despite the apparent nature of this matter, or maybe because of it, we should emphasize it over and over again.

3.6

Interdisciplinary Exchange

Both research and practical experience have shown that hoarding disorder is highly complex and very difficult to treat. Treatment of hoarding disorder requires close cooperation between different professional groups. This is especially true when children are involved, but also when they are not, hoarding treatment can only benefit from the interdisciplinary exchange. Over the years, more and more findings have substantiated the benefit of interdisciplinary work. It is expected and hoped that future research will provide “interdisciplinary-bridge-builder” [27]. Interdisciplinary cooperation in health care aims to reduce the burden and increase the quality of life for those affected by hoarding disorder. Combining the perspectives and methods of different professional groups has been evidenced to increase the probability of alleviating symptoms and improving a patient’s overall health and well-being.

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One of the first steps in treatment, regardless of the treatment method, is to set up an initial interview and attempt to grasp the patient’s overall situation in just a few follow-up meetings. Each discipline may approach this initial analysis based on different requirements. While doctors may focus on medical aspects, social workers are more interested in exploring the patient’s social behavior. Uniting these different views can be decisive in identifying which treatment options will be most efficacious in each case. Each discipline has its methods, whereas we cannot determine a method generally applicable to all hoarding cases. Explorative approaches, assessing a patient’s medical and psychiatric history, and behavioral observation, each have their validity and should inform rather than exclude each other, and benefit future hoarding research and the development of adequate treatment options. Patients suffering from hoarding symptoms should be encouraged to develop a sensitivity for and interest in different perspectives. People who work professionally with HD patients should practice an awareness of the unconscious and remain alert to what patients communicate, either openly or between the lines. Freud knew of the importance of words ([28], p.  301 ff.). We can deliberately use words to stir emotions in our patients and should be aware of their effects in every professional conversation. A conversation is always more than the sum of the exchanged words; above all, it is about what is conveyed on a deeper level, beneath the surface meaning of the words. Ideally, the therapist and the patient speak the same language, and speaking the same language means grasping the hidden content and meaning of the other person’s words. The different professional approaches can be condensed in another psychoanalytic tool. Freud proposed “free-floating attention” ([29], p.  377) to describe the analyst’s necessary state of mind when communicating with the patient. It includes listening to the patient attentively and openly. The analyst is required, above all, to remain free of judgment and eliminate any internal resistance. Whatever the patient utters or otherwise reveals about themselves should be treated impartially. Maintaining this prescribed attitude is difficult, particularly in the light of Freud’s claim that no one can be free of prejudice and that subjective reality influences even the professional analyst’s perception. This apparent controversy is crucial. In the end, we are required to actively engage with our patients, knowing about our internal and external circumstances, difficulties, conflicts, potentials and abilities. The exchange of unconscious contents influences every human encounter and relationship. The decisive difference in professional relationships is that the responsible doctor, social worker, analyst, therapist, and any other professional are expected to willingly address and deal with their inner worlds and continuously reflect on personal psychological mechanisms. It can also be assumed that most HD patients require continuous long-term support and care. One of the prime objectives in treatment should thus be to find a way to strengthen a patient’s ability to care for themselves and remain in treatment.

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The closeness of psychiatric history and the history of psychology and psychotherapy means that the terminology is centered around illness and disorder. Describing psychological phenomena in this light is not undisputed. Despite this controversy, it is necessary to investigate the etiology and pathogenesis of mental disorders, providing a common ground for psychotherapists and medical professionals to cooperate in developing treatment concepts and prevention methods. It must be assumed that ethics commissions will be required to make statements and assess hoarding treatment problems in the coming decades. Early on in this book, I also mentioned the problematic tendency of international research to neglect psychoanalytic findings. I cannot help but wonder why hoarding research groups hardly include any psychoanalysts. Where does modern psychoanalysis stand and why are there hardly any synergies with psychological and psychiatric research? The research subject and methodologies appear to differ significantly. However, it is precisely the exchange with other schools and disciplines that could advance psychoanalysis and vice-versa. Some would deny the existence and validity of psychoanalysis altogether and argue that representatives of the different psychological disciplines had enough difficulties communicating within their school of thought. Psychoanalysis grew out of the analysis of individual cases; however, the ways in which its findings and resulting theories could benefit, add to, or confirm the results of large-scale studies must not be neglected. A further focus of future research in pathological hoarding will be on diagnostic and therapeutic work in child and adolescent psychotherapy and psychiatry. A few isolated studies advocate independent diagnosis in childhood and adolescence (e.g., [30]). However, the authors of these studies also admit that the results are currently insufficiently evidenced, and further investigation is required. From the above, we can infer a great need to intensify hoarding research. Specifically, we can infer the following objectives and demands for future research and the consequent development of practical methods and treatment options. Objectives for future hoarding research – Promoting the international integration of psychoanalytic findings with clinical psychology and psychiatric research – Fostering the cooperation and exchange between professionals across multiple disciplines concerned with hoarding disorder – Addressing the issue of potential over-pathologization and reinforcing the requirement of comprehension, treatment, and research –  Administering further epidemiological studies and explicit research on treatment options

Conclusion There are several forms of therapy and intervention that have proven efficacious in treating hoarding disorder. The most common and promising methods include psychotherapy, medical supervision, and pharmacotherapy. A set of psychosocial concepts such as participation in support groups and structured home visits have emerged as successful treatment options. The success of working with HD patients

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is substantially influenced by the underlying relationship work and the establishment of a fruitful therapeutic alliance, regardless of which methods are individually applied. Each case may require a different approach, whereas the proposed treatment matrix provides an overview of possible and meaningful combinations. Particular attention should be paid to the role of transitional phenomena and transitional objects in hoarding disorder. Knowledge of these phenomena and objects can provide worthwhile insights into the patient’s fundamental relationships and foster a deeper understanding of psychological events, further assisting the formation of a trustful relationship. Professionals are also advised to take account of the patient’s ego functions, which may also aid the therapeutic alliance. The TH-I-N-G-S intervention concept provides a step-by-step guide for professionals to structure their work and gradually achieve progress with individual patients. Particular attention in treating hoarding individuals must be paid to the perspective of any involved relatives, specifically children living with hoarding parents. To appropriately address parental hoarding and protect the child’s welfare, close cooperation and exchange between professionals from different fields is paramount.

References 1. Mathes BM, Oglesby ME, Short NA, Portero AK, Raines AM, Schmidt NB. An examination of the role of intolerance of distress and uncertainty in hoarding symptoms. Compr Psychiatry. 2017;10(72):121–9. 2. Yalom Irvin D.  Theory and practice of group psychotherapy. 5th ed. New York: Basic Books; 2005. 3. Brakoulias V, Eslick GD, Starcevic V. A meta-analysis of the response of pathological hoarding to pharmacotherapy. Psychiatry Res. 2015;229:272–6. 4. Saxena S, Sumner J.  Venlafaxine extended-release treatment of hoarding disorder. Int Clin Psychopharmacol. 2014;29:266–73. 5. Racker H. Transference and countertransference. New York: Routledge; 1982. 6. Bowlby J.  Das Glück und die Trauer. Herstellung u Lösung affektiver Bindungen, 4. Aufl. Stuttgart: Klett-Cotta; 2011. 7. Winnicott D. Aggression in relation to emotional development. In: Caldwell L, Robinson HT, editors. The collected works of D.  W. Winnicott: Volume 3, (1946-1951). Oxford: Oxford University Press; 1946-1951. 8. Danet M, Secouet D. Insecure attachment as a factor in hoarding behaviors in a non-clinical sample of women. Psychiatry Res. 2018;270:286–92. 9. Bowlby J. Attachment and loss: Vol. 1. Attachment. 2nd ed. New York: Basic Books; 1982. (Original ed. 1969). 10. Bowlby J. A secure base: clinical applications of attachment theory. London: Routledge; 1988. 11. Winnicott D. Playing and reality. London: Tavistock Publication; 1971, www.archive.org 12. Freud S.  A difficulty in the path of psycho-analysis. In: An infantile neurosis and other works; 1917. 13. Freud A. The ego and the mechanisms of defense. The writings of Anna Freud, Vol II. Rev. ed. New York: International Universities Press; 1967 (First publ. 1936). 14. Hartmann H.  Ego-psychology and the problem of adaptation. New York: International University Press; 1958. 15. Freud S. The ego and the Id. Standard ed. 19; 1923. 16. Frost R, Steketee G, Greene K.  Interventions for compulsive hoarding. J Brief Treat Crisis Interv. 2003;25:323–37.

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17. Fenichel O. The psychoanalytic theory of neurosis. New York: Routledge; 1996. (First published 1946). 18. Rodriguez CI, Herman D, Alcon J, Chen S, Tannen A, Essock S, Simpson HB. Prevalence of hoarding disorder in individuals at potential risk of eviction in New York City. J Nerv Ment Dis. 2012;200:91–4. 19. Laplanche J, Pontalis J-B. Language of psycho-analysis. New York: Routledge; 1988. (First published 1973). 20. Freud S. Three essays on the theory of sexuality. Standard ed. 7. London: Basic Books; 1905. 21. Wurmser L.  Die Maske der Scham. Die Psychoanalyse von Schamaffekten und Schamkonflikten, 3. Aufl. Magdeburg: Verlag Dietmar Klotz; 2007. 22. Freud S. The future prospects of psycho-analytic therapy. Standard ed. 11; 1910. 23. Thompson C, de la CLF, Mataix-Cols D, Onwumere J. A systematic review and quality assessment of psychological, pharmacological, and family-based interventions for hoarding disorder. Asian J Psychiatry. 2017;2:53–66. 24. Dimauro J, Tolin DF, Frost RO, Steketee G. Do people with hoarding disorder under-report their symptoms? J Obsessive Compuls Relat Disord. 2013;4:130–6. 25. Freud A.  Normality and pathology in childhood: assessments of development. New York: Routledge; 2018. (First published 1965). 26. Freud A. Normality and pathology in childhood. Assessments of development. New York: Int. Univ. Press; 1965. 27. Leuzinger-Bohleber M, Canestri J, Target M. Frühe Entwicklung und ihre Störungen. Klinische, konzeptuelle und empirische psychoanalytische Forschung. Kontroversen zu Frühprävention, Resilienz und ADHS. Frankfurt a. M.: Brandes & Apsel; 2009. p. 301–11. 28. Freud S. Psychical (or mental) treatment. Standard ed. 7; 1890. 29. Freud S. Recommendations to physicians practising psycho-analysis. Standard ed. 12; 1912. 30. Morris SH, Jaffee SR, Goodwin GP, Franklin ME. Hoarding in children and adolescents: a review. Child Psychiatry Hum Dev. 2016;47:740–50.

4

Psychodynamic Aspects: Self-Image

Introduction This chapter presents several case vignettes that each provide valuable insights into the everyday life of hoarding individuals. To treat and care for HD patients professionally, we must comprehend the interaction between the patients’ biographies, intrapsychic processes, and personal resources. For a comprehensive, realistic representation of self-images, I have carefully selected different vignettes from clinical practice. For a better overview, the subjective contents drawn from the vignettes are classified and analyzed in six categories. These core categories enable professionals to focus their treatment approach and set priorities when dealing with hoarding disorder patients. The categorization presented in this chapter derives from a qualitative study (my own unpublished master’s thesis) conducted at Sigmund Freud University. The study included 12 interviews with patients who described themselves as “Messies.” Evaluation of these interviews revealed that the patients’ hoarding behaviors could essentially be grouped into six categories. Most of the interviewees were, at the time, attending the Sigmund Freud University support group. They perceived hoarding as the cause of their mental distress and, consequently, had good insight.

4.1

Overview of the Core Categories

Category 1: Subjective Causal Theories This category subsumes all reasons given from the patients’ subjective perspective for being or having become a hoarder. It is interesting to note that all interviewees, without exception, began telling their stories with a view from childhood. From psychoanalysis, we know that the human psyche connects psychological phenomena with biographical events and, in particular, childhood experiences. Depth

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psychotherapy is a suitable method to bring to light memories of the unconscious, allowing the patient to reflect on and process them. Therapists and other professionals working with patients need to be aware of the importance of relationships and show interest in the relationships that may have had the most significant influence on their patients’ lives. It may also be fruitful to explore which memories are associated with hoarding symptoms, paying close attention to the explanations given and experiences shared by those affected. Category 2: Comorbidity At the time of this qualitative study (2010), the ICD-10 or DSM-IV diagnostic manuals had not yet defined hoarding disorder as an independent mental disorder. The theoretical debate of the time revolved much around the complicated issue of comorbidity. The comorbidity category identifies any expressions related to other mental disorders and treatment concepts. International research on the topic confirms the assumption that hoarding disorder has high comorbidity. Pathological hoarding has been observed to be accompanied by great psychological distress and a wide range of symptoms also of other conditions. The high comorbidity rate in hoarding individuals is also one of the reasons we can diagnose hoarding disorder only by exclusion. If the hoarding symptoms are clearly not attributed to another disorder, we can diagnose HD. Since research into the field is still very young, we must await more extensive studies into comorbidity in hoarding disorder before making more precise statements. Category 3: Experiences and Fear of Loss, Separation Anxiety Without exception, the interviewed patients mentioned experiences of loss in early childhood and believed to have suffered anxieties due to these experiences. Half of the interviewees experienced loss due to a prime caregiver’s death before the age of 10; the second half stated that they had experienced several losses combined with psycho-emotional deficiencies in early childhood. Their losses were manifold: early long-term separation from a caregiver, symbolic loss of a caregiver because they were emotionally unavailable or not available enough, and sometimes material deprivation. Loss and separation anxiety is a prevalent theme in the biographies of HD patients. Separation and fear of loss are significant factors in the etiology and formation and the development of this disorder. There is a clear connection between loss and the difficulty of separating from items, even if this connection can individually vary. Category 4: Relationships and Attachment Who were the patient’s prime caregivers and what were their relationships? What were the relationships in the family? As was pointed out previously in this book, relationships play a significant role in hoarding disorder. Even if the interviewees were not explicitly asked about their previous and current relationships, they revealed that their early relationships, especially with the prime caregivers, had significantly influenced their hoarding disorder. This is a frequent observation in

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hoarding patients. However, patients’ relationships with themselves and other people are also important, which is why professionals need to pay close attention to the qualities of their relationships, including family, friends, and acquaintances. Pathological hoarding makes it very difficult for those affected to manage social contacts, especially in their homes. Neither friends nor family usually get invited into the patients’ homes. Social interaction mostly takes place outside the house, if at all. Hoarding inevitably also affects the family as well as partners and children living in the same house. A separate section in this book is therefore devoted to the sensitive issue of children’s welfare (Sect. 3.5). The development of a feeling of security and basic trust is closely intertwined with a child’s early relationships with their prime caregivers. In other words, an infant’s first relationship experiences are decisive in forming a sense of security and trust. If children sufficiently develop these internal representations, they do not usually need to resort to external resources to reduce anxiety in later life but can find these in themselves. There are clear connections between the development of early object relationships and anxiety development (Sect. 3.2.2). Category 5: Fear, Aggression, and Defensive Behavior Due to their interaction and interconnection, fear, aggression, and defensive behavior are listed as one category. The three components of this category are linked both on a temporal and spatial level. The results of the study illustrate that the interviewed patients had to battle numerous fears in their childhood. When they were initially confronted with these fears, they did not have any means to defend themselves. The helplessness becomes emotionally preserved and carried into adulthood and surfaces in the form of aggressive behavior. This aggression finds symbolic expression in the patients’ living areas. The primary anxiety, or the first experiences out of which later anxiety develops, is a manifestation of unmastered tension. It is an automatic occurrence that takes place whenever the organism is flooded with excitement; the symptoms of the traumatic neurosis show that it is not limited to infancy. ([1], p. 132)

Following this line of thought, the cluttered homes may be understood as a defense against early fears and anxiety. Category 6: Psychological Stress Each of the participants of the study expressed considerable psychological distress. However, it must be pointed out that they were all members of our support group and, therefore, individuals with good insight. Of course, there are also many hoarding patients with little to no insight. These patients do not typically express any psychological distress as they do not perceive their behavior to be burdensome, neither for themselves nor for others. In some cases, patients even describe phenomena of morbid gain. Some patients report external requirements that appear much more burdensome than their disorder, including requirements arising from difficult work or love relationships. Primary morbid gain describes a means to avoid these

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stressors. Secondary morbid gain refers to any form of support and care from outside. These gains motivate the patients to maintain symptoms and continue being ill. Literature also sometimes acknowledges a tertiary morbid gain. This phenomenon is far less well studied and refers to the gains from an illness received by third parties. Therefore, we need to ask: what role do hoarding patients have in society? What is the cultural and historical significance of the lifestyle they choose? What are the connections between hoarding and the consumer society of our time? Section 1.4 discusses these questions and other social and cultural implications of the disorder in more detail. Even if not all HD patients perceive their condition as distress, its psychological burden is still considerable. It also explains the exceptional commitment of those affected to raising awareness of the disorder. Usually, psychological and psychiatric phenomena are discovered, researched, and named by professionals. In pathological hoarding, it was, for the first time, the patients’ own commitment that brought attention to the disorder and raised the need for systematic research in this field. This fact, however, may also be representative of modern-day society.

4.2

Case Vignettes

The following presents seven narrative interviews with patients from the Sigmund Freud University support group. The transcribed interviews were subjected to a global analysis. In the next step, the evaluation was based on the grounded theory methodology developed by Anselm Strauss. I personally knew most of the interviewees from conferences or from the support group. It can be assumed that since I had been in contact with some of the patients for a long time, they were generally very willing to share intimate details about themselves.

4.2.1 Ms. O., the Reasonable Ms. O. was a slim, casually dressed woman in her early 30s. She was very introverted and sat far away from me for the interview. Ms. O. was the youngest interview partner. She saw herself as a typical migrant child; her parents came to Austria as immigrant workers in the 1970s. Together with her younger brother, she grew up with her parents in Austria. At the age of 7, however, she was sent away to her grandparents and returned to Austria after she had finished elementary school. Subjective Causal Theories Ms. O. focused a lot on her mother’s nervousness: “As far as I can remember, I have emulated my mother’s restlessness and, I think, that’s what caused my messiness and other behaviors. […] Even when she was pregnant with me, she was very afraid and stressed because she did not have any relatives in Austria.”

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The patient described at length the situation she was born into. The parents were very young and had only recently arrived in Austria, leading a very modest lifestyle. From an early age onward, the patient contemplated issues of lack and waste, a habit she presumably had adopted from her parents: “My parents were very poor, and we lived in very modest circumstances, they worked hard and saved their money. […] My aunt was the first one to recognize my messy tendencies. I could have a part of a wardrobe for myself and my clothes, and it was always a mess. […] I always perceived things to be valuable, probably because I knew that they cost something. So, I started collecting: tapes, books, magazines.” A combination of hard work and austerity enabled the family to eventually buy a home. The proud parents bought Ms. O. her first apartment and furnished it. However, she never felt at home: “In puberty, I shared a room with my brother, then I got my first apartment. But it was just another compromise. The furniture was already in there, and in 10 years of living there, I couldn’t bring myself to make myself at home.” This observation in her own behavior relates to a very common conception of hoarding as an inhibiting force preventing patients from doing things they would want to do. It is typical for hoarders to start a task and never finish it. The condition of Ms. O.’s home acted as a mirror, reflecting a life not lived: “I guess, from a purely objective point of view, my apartment is simply a mess. For me, it is all these unlived hobbies, plans, joys, and ideas, which continue to hurt me. I know what I want to do, yet I can’t get around to it. In a way, I’m not the director of my life. I feel like I have no control over my life.” Comorbidity Ms. O. was reserved and shy. She used to suffer from insomnia and social anxiety, which she had been trying to get under control through psychotherapy. Her case presented obvious connections between hoarding and social inadequacies. The condition of her apartment did not help to improve her social life. Ms. O. explained: “Early on, I had difficulty engaging with other people. This social anxiety is another problem of mine. There were times when I also had terrible problems sleeping: I couldn’t sleep through the night. I always woke up and remembered something. I constantly had this feeling that something must be done, be it work-related or something that I thought I had to do for myself.” Experiences and Fear of Loss, Separation Anxiety Ms. O. had to take responsibility for herself and her younger brother at a very early age. She described herself as a well-behaved and well-adjusted girl who was always ready to help others: “My parents were the typical guest workers. They were always working and never had time for anything else. […] My brother and I were always home alone for hours. So, I just took over the responsibility. Back then, I was only 4 or 5 years old. […] I was very cooperative; I helped wherever I could and did what I was told. I probably saw it as my duty, so to speak, and thought that I’d just have to do these things, and so I did.”

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After Ms. O. had completed the first grade of elementary school, she was sent to live with her grandparents in another country. “When I was 7 years old, my parents sent me to a different country, where I lived with my grandparents for a year. After that, I spent several years with my mom’s aunt.” Being sent away from home marked a huge turning point in Ms. O.’s young life. Her everyday life changed suddenly, and she quickly had to adapt to life in a new country, living with relatives she did not know well. We must wonder: how did the young girl process this unexpected separation from her parents? Likely, the young child could not understand the parents’ decision at that point. How did Ms. O. make sense of the decision back then? Relationships and Attachment Ms. O. remembered her mother as a constantly stressed woman who appeared helpless most of the time. While she was left with a rather negative image of her mother, Ms. O. had very positive memories of her other relatives: “I felt very comfortable with this aunt. She was very good with children and people in general. She was witty and creative. […] I know that she also had problems and that there were things that weighed on her mind. But she had never burdened me or others with her problems the way my mother did. With my mother, I very early got the impression that she was constantly nervous and easily overburdened.” Ms. O.’s parents remained her closest caregivers throughout her childhood and adolescence. Ms. O. visited them daily even as an adult. Up until shortly before the interview, she would sometimes even visit them twice a day. This could have been due to her sense of duty or her need to look after her parents. Ms. O. also suffered from the fact that she could not share her home and her possessions with anyone else. She did not feel like she could invite anybody into her home, which was far too messy. Therefore, most of her days looked the same: “I went to my parents’ place and spent time with them. I would get up early in the morning and call in on them. I had coffee at their place and went to work. After work, I would come back. I consider myself a social person, and I do have a social life outside of the home. What I lack is social interaction within these four walls, where I express myself, in a way, through the things that I have or own. These things, they also reveal something about me, and I can’t really share that.” Ms. O. found it difficult to build and maintain social relationships with people outside of her family, partly because of her social phobia and partly because of her hoarding. The hoarding made it almost impossible for her to invite guests into her home. She would not even have been able to allow people into her bathroom. In the interview, Ms. O. recalled a specific childhood event in which her parents did not stand up for her. Ms. O. wished that her parents had helped her and taken her side. How did this situation affect her even in later life? How does it relate to her hoarding? The neighborhood boys were playing with the go-kart and wouldn’t let me have my turn. My parents would see me get really frustrated, but none of them would stand up for me to get my turn. […] This was when I lost the motivation to make any wishes.

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Fear, Aggression, and Defensive Behavior Ms. O. stopped making wishes because this is what she had learned early on. At a young age, she had to show responsibility and make reasonable and supportive decisions. The family led a very modest life, and a lot of sacrifices had to be made. The parents largely rejected their children’s material wishes and expected them to understand the need to be careful with money and not spend it on unnecessary things. This might have contributed to the young Ms. O. eventually giving up dreaming and wishing for things: “I experienced frustration very early on. I remember that my longing for certain things or activities was mostly met with disappointment. […] I soon noticed that things were too expensive for us, that I couldn’t spend much money on anything, and that I simply had to save my money. I was taught to watch out for bargains. […] Even as a child, I learned how to accept compromises. The things I could buy were always functional and cheap.” Later in life, Ms. O. began to question these values, including her family’s cleanliness and sense of order. The parents’ strict attitude required her to be disciplined and to take good care of everything. However, one day, she began to wonder if there are not more important things than keeping the carpet clean. She would also begin to tell herself that it was okay to spill something because things like this just happened. “My mother considered it one of the worst things to spill something. If something got spilled on the carpet or elsewhere, she was devastated. My mother’s reactions and statements made me think a lot about the value of things. I think there are just so many worse things that could happen than spilling something on the floor.” The family life was characterized by virtues such as order, self-discipline, and control. It is interesting to note how parents set examples and how they influence our perception of life. Do they consider life as difficult, arduous, and primarily consisting of hard work or a joyful gift? In Ms. O.’s case, it is obvious how her parents’ view on life influenced her own: “My parents taught me that life is mostly a burden. Everyday life was always hard for them. There were many duties. It was mostly about work. They didn’t get a chance to take a breather or simply rest. […] I never learned, what I can imagine might be normal for some people, that life can also be fun and that you can enjoy yourself.” Later, Ms. O. moved to a larger city, hoping that she could create a life of her own in an apartment where she would finally feel at home. Moving to a different city was also an attempt at creating an emotional distance from her parents. The geographical distance should help her escape her parents’ influence and live more independently: “A few years ago, I spontaneously moved to the city. There were a lot of things in the apartment that needed to be fixed, but I still slept on a mattress in the living room. The bedroom is full of clothes and tools and boxes. […] Until now, the apartment has remained unfinished. I haven’t allowed myself to make myself comfortable in my own home.” The state of her home also prevented her from leading an active social life: “I can’t expect others to put up with the mess in my apartment. It’s a scene I can’t identify with. The chaos is not me said. And that’s how my anxiety developed. I was

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afraid of being rejected, also because of my immigrant background. I considered myself as embarrassing, inadequate, and socially incompetent.” Despite these different challenges, Ms. O. tried to break away from her parents and live her life independently: “My parents were not happy about me moving away. My father said that this was not what he had imagined. […] They wondered why I wouldn’t just find myself a nice man. They thought I should have long been married by then.” Her initial plan was to renovate the entire apartment and, once it was finished, proudly present it to her parents. This never happened: “I had planned to invite my parents as soon as I had arranged everything in the apartment as I had imagined it, but I just never got around said to it. My brother visited me once. My parents know where I live and have the address, but I’ve never invited them inside.” Ms. O.’s hoarding made it impossible for her to invite her parents. It was a strategy to prevent the parents from visiting because, in the unconscious, she did not want them in her home anymore. Ms. O. explained: “I just want to have fun and overcome this kind of inability. […] Yes, I feel like I’m unable to be happy said. I’m always imagining what it will be like to be happy someday, to simply be enjoying myself. I’m constantly trying to get there, but my plans just never work out. Something always interferes.” There were significant discrepancies between Ms. O.’s and her parents’ concept of a happy life. Ms. O. was said eager to create a different life for herself. Even though she did not agree with her parents’ way of life, she found it difficult to distance herself from their ideas and live according to her own standards. An inner conflict ensued when her strong sense of duty and bond with her family forbade her to break away. This dilemma very likely took root in her early sense of responsibility and simultaneous inability to live up to her mother’s strict ideals: “When I was 11 or 12 years old, I started helping with the household tasks. While my parents worked on Saturdays, I was at home cleaning the apartment said. My mother did this annoying thing where she would ask me if I had done this or cleaned that. Every time she got back from work, she would ask me about what I had gotten done. […] Sometimes, I had forgotten something and the criticism that followed just stuck with me. There was always something that I’d done wrong because I hadn’t done it the way my mother would’ve liked me to. I could never be sure whether anything I did was right at all.” Psychological Stress In many cases, pathological hoarding provides a form of self-punishment. The patients’ standards of order and cleanliness are often far too high to be achieved. Ms. O. confirmed this assumption: “I have always put myself under pressure. At school, I would only start studying the night before an exam. I somehow never managed to focus and get started on time. […] My clean-up activities have been similarly tormenting and stressful. Even if I knew I would get visitors, I left myself little time to clean up. I ended up having to do it all at once in the shortest period, leaving myself completely exhausted with no energy whatsoever left for my guests.”

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Ms. O. also experienced great distress at the mere thought of her plans, projects, and intentions, all of which had remained unfulfilled and unrealized up to the day of the interview and probably far beyond: “I’ve bought and collected many newspapers and books with the intention to read them all, but I just can’t do it. I haven’t gotten around to reading any of them. In the back of my mind, I’m constantly thinking of my plans and all the things that I still want to do.” All these plans put her under pressure and reminded her of what needed to be done daily. Ms. O. saw the cluttered apartment as the reified representation of her failure to live life: “For me, the stress I feel is representative. I see my life as a series of failures, and I do feel lonely. I see my home as making up a part of my self-worth, a part of my personality, which I also must get in order. There are just too many unfinished things and unfulfilled wishes.” Overview Ms. O. had to learn to assume responsibility for her brother and herself at an early age. She was obliged to act like an adult early on in her childhood. It can be assumed that, given the strict and specific parental expectations and requirements, there was not enough time and room for Ms. O. to complete essential development phases. Virtues like thriftiness, discipline, as well as cleanliness, and order were the priorities in her upbringing. Ms. O. had always tried to meet parental expectations and react maturely and reasonably. She developed ideal ideas about how a home had to be furnished and how a meaningful and happy life had to look like. However, these ideals were not attainable and had to be revised. In psychotherapy, Ms. O. also learned to address her satisfaction of auto-aggressive and masochistic drives. By moving to a different city, she attempted to distance herself from her parents. The separation seemed promising at first, yet Ms. O. had difficulty fighting the compulsion to repeat certain behavior patterns.

4.2.2 Ms. P., the Communicative Ms. P. was a short, chubby woman, always smiling. The curious and bright look on her face gave the impression she was always in a buoyant mood. The patient grew up as an only child. When she was born, her parents were 40 years old, which was rather unusual for the time. Ms. P. became pregnant at the age of 16. She got married and lived with her husband and the baby at her parents’ place until she was 20 years old. Soon after she got divorced, she met her second husband and moved in with him. Subjective Causal Theories Ms. P. remembered the strict and authoritarian style of her upbringing. From her point of view, it was the cause of her hoarding disorder: “I believe that what I’ve really been going through these past years is guilt. In my mind, I’ve always felt guilty. Surely, it can’t be the main reason, but guilt is ever so present for me. I had a very strict upbringing, my father especially was very strict.”

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As discussed at length in Sect. 2.2 of this book, the anal phase of early development is decisive in hoarding. Even though the interview with Ms. P. was not part of extensive research or detailed exploration, it allowed remarkable glimpses into the psychodynamic aspects at work in this context. This was especially the case when she shared the following: “I owned one pair of shoes. Every day, I had to wear the same pair of shoes. Only once my shoes were completely worn out, I would get a new pair. My parents were poor, so I was poor. I didn’t have many things.” Many biographies of hoarding patients include phases marked by scarcity and a pronounced focus on saving money. The patients limit the functionality of their living areas and their own scope of activity through hoarding behavior. They unconsciously repeat situations they experienced earlier in their lives. This also seems to hold true for Ms. P.: “My messiness has slowly crept in, I think. I always slept in the same room as my parents, and it wasn’t until I was 12 or so that I moved into the cabinet. […] It was a small living room and bedroom. There was my bed, a couch, some cupboards, and a table. It was a tiny space.” Ms. P.’s later hoarding came to represent a re-enactment of the spatial confinement she experienced in her childhood and teenage years. Ms. P. had recognized a problematic attitude toward cleanliness and order in her parents early on: “My mother was not an organized person. She just had her stuff lying around on the armchair but couldn’t stand seeing my things spread out across the room. Maybe it’s not even related to my hoarding, but I feel this inner aversion to becoming like my mother. And yet, I’m exactly like her today.” Order and chaos awaken different memories in the patient. Many hoarding patients experience chaos as something familiar. On the other hand, many patients have had more intense experiences with quite the opposite. Most patients share a set of virtues revolving around self-control, discipline, and high standards of organization and order. The inner pressure of what should and must be done often needs to be counteracted. Ms. P. described her struggles: “When my children entered kindergarten, we both [Ms. P. and her husband] went to work. In the evening, I had to do the dishes, wash the laundry, do the ironing, and my husband was watching TV. I thought he just had to see how I was feeling all this time. […] I was speechless in this relationship, so I just sat down next to him and didn’t talk to him. This was when things started to go wrong. And when my son moved out, it got even worse.” Ms. P. wanted to be seen in her relationship with her husband. She longed for him to recognize her needs. However, she felt speechless and was unable to express her needs and wishes. Infants depend on their mother or another prime caregiver and their ability to translate their very needs and desires and appropriately address them. Memories of early childhood years are largely lost due to childhood amnesia. Often, all we can retrieve is a feeling or one-dimensional association: “I’ve heard that the first 3 years are the most formative in childhood. The deficiencies you experience in the first 3 years of your life; the feelings associated with them are what you carry into adulthood. Unless you have the means to check it, you don’t know what happened, whether it was that your parents didn’t comfort you when you were crying

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or that you were hungry. As a baby, you don’t know how to express yourself except by crying. Who knows what my crying meant? So many things happen during childhood, which you probably can’t remember as a grown-up.” Comorbidity Ms. P. was very familiar with feelings of melancholy and sometimes consciously used them for her protection: “I wasn’t very happy in the apartment. I don’t know; maybe I used it as an excuse for saying I was depressed because the apartment had very little daylight.” Frequently, individuals who hoard have seen themselves forced to name a longer recognized or better known mental disorder such as depression so that others take them more seriously in their suffering. Ms. P. had a similar experience: “I once had a water pipe burst in my home, and the firemen who came into my apartment reported me to the health department. They said that my home was in such a state it would be full of insects as soon as summer came around. They didn’t understand my situation. I told them I was depressed and simply couldn’t do it.” Experiences and Fear of Loss, Separation Anxiety My aunt once bought me a pair of high heels. I said to my father that these belonged to me and that I would wear them. He said: ‘You don’t own anything, you don’t possess anything, you don’t own a single thing, and life was given to you by us!’ This sentence still hurts me today and makes me angry. Today I could say to my father: ‘See, now I have things, I have a flat, and it’s full of junk, but it’s my junk.

With the many things Ms. P. possessed, she could have proven her father wrong. The price she paid to obtain this sense of satisfaction was high. The moment she received her high heels and tried to assert her ownership to her father is crucial. We must ask ourselves about the relevance of the high heels in this scene. Questions as to the patient’s drive development might also provide valuable insight into the background of her hoarding disorder. Ms. P. not only contended with her parents to achieve freedom but later also in her relationship with her husband. Married life became more and more difficult, especially because of the untidiness in the apartment, as Ms. P. believed. Her husband even threatened to throw her out of the shared home. “‘If you can’t manage to keep order, I can throw you out; this is my apartment,’ he said. I probably unconsciously thought: if he can throw me out, why should I bother?” She repeatedly found herself in situations where she felt like nothing belonged to her and that she had no bearing on her life. For Ms. P., pathological hoarding was an undesirable part of her personality, yet a part of herself nevertheless. She had the feeling that she could part with it if need be; hang it on the coat rack or shove it into the closet and leave the apartment without it: “I only live when I go out the door. It’s like I have two personalities. I could say I change my personality in the hallway: When I leave the apartment, I hang one personality on the coat rack, and when I get back, I take it down again.”

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Relationships and Attachment Ms. P. described the relationship with her parents as very ambivalent: “My relationship with my mother was good. But I felt my mother was weak, and my father was strong. He was choleric. He always knew how things ought to be. I also turned out to be hot-tempered, and I still am today, even if my temper has become a little calmer.” As a 16-year-old girl, she became pregnant, and her parents abandoned her at first: “They made me marry the man who got me pregnant, and my father still kicked me out of the house. He said: ‘You’re pregnant and I can’t have you live with me like this. You can sleep under a bridge.’ He kicked me out. So, I lived with my first husband, who shared a one-room apartment with his mother. I lived in one room with my mother-in-law; you can imagine how well that went. It didn’t work out at all. Two months before birth, they brought me back. It was my whining mother who would say: ‘The poor child is having a baby.’” Ms. P.’s parents had her later in life, and so she often struggled with loneliness as a child. She spent a lot of time alone. Even when they visited friends, there were no children around to play with: “Whenever we visited another family, there were all these old people. They didn’t even have toys, and their children were already out of the house.” Even in her marriage, Ms. P. felt lonely. Her husband was a field worker and spent a lot of time abroad because of his job. The loneliness accompanied her up to the time of the interview. She was ashamed of the state of her apartment and did not allow herself to let visitors inside. The hoarding made it impossible for her to invite anybody in, contributing to her lonely life: “I can only meet my friends or acquaintances in a coffee house or somewhere else. Sometimes I go to their places, and they know. I tell them I’m sorry, but I’m too embarrassed to show my apartment. I couldn’t expect anyone to put up with the mess.” Fear, Aggression, and Defensive Behavior Ms. P.’s childhood was shaped by fear, primarily the fear of her choleric and violent father: “I once played with a couple of girls, and they suggested we go three alleys over. I said I wasn’t allowed to. I was only allowed to play in front of the house. Of course, they persuaded me, and, I don’t remember exactly how it happened, but suddenly, my father came and had a wooden spoon, and he was running after me. He was very angry because he was worried. I was terrified!” Ms. P. was subjected to her father’s unbearable anger and violence for years and could only defend herself when she became a mother herself: “I had my child very young. Then I told him that if he hit me again, I would hit back. It hurt me deeply that he would treat me like that in front of my own child, and I just could not imagine raising my child like that.” As a young mother, Ms. P. found housework tiresome and pointless. She only did what was necessary, and she did it reluctantly: “I hate housework, there’s not a single chore I enjoy doing, except maybe cooking. If somebody could clean up after me in the kitchen, I would be happy.” Despite this reluctance to do household chores, Ms. P. always told herself that once she had her own apartment, she would do better at keeping her home clean. When her aunt died, she moved into her first own apartment. However, she did not manage to keep it in order.

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It was the first time that Ms. P. had her own place to live. Before her aunt died, she had lived with her parents and later with her husband. However, she was unable to make this place her own and fully spread out the way she had imagined. Her severe difficulty discarding or parting with items took hold. “Only when things are broken can I throw them away,” she explained. Her desperation occasionally even led her to deliberately step on things to break them so that she could finally let go of them. By destroying items, she could also act out unconscious aggressive impulses. These would even cause her to put herself in danger of slipping or hurting herself: “I can only chuck things out when they’re broken, not before. I throw them on the floor and step on them, so I can put them in the trash. It’s stupid. I’ve slipped and hurt myself several times, and my bones aren’t young anymore.” Psychological Stress In the interview, Ms. P.’s distress seemed secondary. She suffered massive restrictions concerning her social life. On several occasions, she expressed her wish to be able to invite friends into her home: “It stresses me out that I can’t invite anyone over. It’s such a burden on my quality of life, always having to fear someone could ask to come inside.” The difficulties and consequences of her hoarding caused great distress. She could barely manage everyday life, failed to keep appointments or meet deadlines, and was always late: “I’m very often stressed because I can’t find my stuff. I miss dates and deadlines, and I’m always fiddling around till it’s too late again. Everyday tasks have become a burden. I have 20 pens lying around, only 2 of which still work. The heels of my shoes are totally worn out; I should have long thrown them in the trash, but I can’t, so I just leave them.” It is typical for hoarding individuals that items accumulate in their homes because they do not want to waste anything. Individuals who hoard often think economically and try to save things. On the other hand, their handling of objects consumes a lot of energy. Ms. P. was very aware of this and clearly stated her desire to change and use her energy differently in the future: “It’s also a waste of energy, of time, and I remind myself that I’m almost 65 years old and wasting so much of my life. I’m always thinking of what I could with all that time, how well I could be living. I have many creative ideas, and I have a lot of interests.” Overview Ms. P.’s case illustrates just how unheeded pathological hoarding can go. Hoarding disorder does not have to be visible to others at first sight. As soon as Ms. P. left her apartment, she also left behind her hoarding. It was confined to the home and almost completely nonexistent outside. The question to be raised is: to what extent did the patient feel she could exert influence and control over her possessions and life? Ms. P. seemed to have control over her belongings and was even able to determine their fate, such as by deliberately destroying them. Once objects were defective and no longer fit for use, she could separate from them.

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Ms. P. was an eloquent person with a large circle of friends and many acquaintances. It was striking in the interview that she repeatedly referred to her speechlessness and her inability to express her needs and wishes. The strict upbringing and the authoritarian, even violent father are very likely to have facilitated hoarding disorder. Her childhood was strongly shaped by scarcity and the need to save and live modestly.

4.2.3 Mr. U., the Cautious Mr. U. was a short, stout man who attracted attention with his reserved and introverted personality. He grew up in a small town and had a sister 10 years younger than him. In his childhood, he spent a lot of time with his grandparents because his parents were mostly at work. After completing his training, he worked for years for the same company until it had to file for bankruptcy. Ever since he had been looking for a new job and used his time to attend further training courses. He considered himself a hoarder mainly because part of his apartment was too cluttered to be accessible. He described his behavior as follows: “I’ve even kept old socks or other clothes that had holes in them because I thought I’d eventually stitch them. […] Things have piled up this way, and I haven’t thrown anything away. I’ve left everything lying around, and I’m generally not very keen on cleaning. I guess this is how this mess came about.” Subjective Causal Theories Hoarding has been observed to occur more frequently in people who have a family member with hoarding disorder. Habits and attitudes are unconsciously passed on from generation to generation. The way parents, grandparents, or even aunts and uncles handle objects and assign meaning seems to play a significant role. This observation also holds true for Mr. U. “My grandmother was also a hoarder. She hoarded piles of stuff. […] There were rooms in her house that nobody could enter. […] My aunt is a hoarder too. She has her own house and an apartment and lives with my parents because everything is full.” When hoarding is accompanied by excessive acquisition and procurement, extreme squalor and drastic impairment of living areas are often the results. Mr. U. explained: “There was a time when I didn’t have a washing machine. I didn’t always want to go to the shared laundry room, so I kept buying new things, shirts, socks, and stuff, and that was when things quickly piled up.” However, for Mr. U., pathological hoarding was more than just a convenient way to avoid undesirable situations; it was also his way of expressing a political stance and resisting modern consumer society. In the interview, he said: “In a way, I see hoarding as a form of protest. It’s a protest, especially against this throw-away society, which is consuming and consuming and throwing stuff away. […] It’s to honor and cherish the old.” Mr. U. recognized his parents’ emphasis on the value of things at an early age. Both parents had to work a lot, so Mr. U. grew up mostly with his grandmother. She

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gave him many toys, hoping to provide comfort and compensate for the parents’ absence: “I used to collect toys. Maybe I was given too many toys. I think it was because they couldn’t give me their love because they both spent so much time at work. Of course, they’d give me heaps of toys.” Comorbidity Mr. U. suffered from depression for years. At the time of the interview, he had learned to manage his depression with psychotherapy and medication. In the course of the illness, he went through different phases of intensity. He reported of times when he was hardly able to leave his bed. The mere thought of having to go shopping triggered panic attacks. Conflicts and difficulties with work colleagues and finally the loss of his job could have been factors that aggravated his situation: “In the company I worked for, I was bullied. It was unbearable. I was glad that the company eventually closed. It meant that I was finally free, and all that pressure was gone. But I later realized that I lacked social contacts, I was becoming increasingly lonely, and I was moving in a direction I didn’t want to. It was a long process, and I spent a considerable amount of time at home in bed. I couldn’t move, and I couldn’t go shopping because of the panic attacks.” It is often the patients’ own standards and ego-ideal that increase pressure and psychological distress. Mr. U. described his struggles with depression: “Eventually, I reached a point where I couldn’t continue. I became more and more depressed, and I lost all hope. I no longer cared about anything. I was just in bed and withdrew from it all.” Experiences and Fear of Loss, Separation Anxiety Mr. U. remembered that he also experienced severe separation anxiety whenever his mother had to drive to work. During the interview, he could not reflect on his anxiety and his fear of loss in more detail. However, he remembered the goodbyes from the mother as something very traumatic. The grandparents were there, but they could not comfort him: “Separating from my mother was often incredibly difficult. […] She worked shifts and always had to leave very early. Every time she had to leave at night to go to the office, it was, well, I was sad. I was with my grandparents, but I cried every time she drove away.” Another situation that Mr. U. remembered as burdensome was when the grandparents’ house had to be torn down. For Mr. U., the demolition of his former home was extremely distressing: “To this day I can’t bear to put a foot on the piece of land where the houses once were. I can’t even look at the place. I just can’t. All these memories, they make it extremely difficult for me. I couldn’t watch the teardown because it just hurt me to see the excavator destroy the old house where I spent such a big portion of my childhood.” Relationships and Attachment After losing his job, Mr. U. became aware of how much he suffered a lack of social contact. At the time of the interview, his relationships were limited to the support

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groups he attended and various consultation sessions offered to him by the psychosocial service: “I’ve practically built a castle, created my own space. […] I’ve isolated myself, and I haven’t been willing to welcome anyone in my home.” Mr. U. primarily interacted with other hoarders as well as with doctors and his psychotherapist. It can be assumed that relationships with professionals and interaction in a confined space, such as in guided groups, have a fear-reducing effect and are therefore more likely to be accepted by HD patients: “Now, I go to two support groups. I also see a therapist and social services offer consultations, which I go to once a month.” Fear, Aggression, and Defensive Behavior For Mr. U., pathological hoarding provided a means to protect himself. It allowed him to set a clear boundary between the outside world and the inside world, building a wall by accumulating things. When Mr. U. moved into a friend’s apartment, he did not bother to invest a lot of time into redecorating it. It was not the apartment he had envisioned for himself, and so he did not feel at home. Over the course of time, items amassed and gave the apartment its own character; hoarding was his way to take possession of it. In his words: “It was an apartment that I didn’t want. I got it from my mother along with all the furniture. It’s also a very dark apartment. It doesn’t have any color. The things that are now lying around at least give it some color. […] If you tidied the place up, it would look sterile, cold, and not at all cozy.” Hoarding disorder confronts patients with their difficulty in making decisions. Mr. U. reported that he found himself unable to be more selective. He had pronounced difficulty choosing between things. This is interesting in the light of the great value HD patients attach to their possessions: they treat things as if they had a soul. Mr. U. believed that he could not simply play God, and other patients, similarly, do not consider themselves as having the power to decide over their possessions’ fate. Mr. U. remembered his childhood years as very difficult. His parents were mostly absent, and he was always trying to get his grandparents’ attention. When he was 10 years old, his sister was born, and the situation became even worse. Mr. U. was convinced that his sister was a planned child. The interview could not shed light on the extent to which feelings of envy and sibling rivalry had already been processed and reflected in psychotherapy. Mr. U. stated: “My sister was wanted by all of us, but of course there was certain jealousy. I guess that’s obvious. Before she was born, everything was about me, and, suddenly, I was left out and no longer received enough attention.” Psychological Stress Mr. U. surrounded himself with items the way he would have liked to surround himself with other people. At the same time, Mr. U. felt trapped between the things and trapped in ambivalence. On the one hand, he longed for social interaction, and, on the other hand, his social anxiety dominated: “I suffer most of all from isolation, from loneliness, from having created some sort of substitution. It’s occurred to me that I give things so much meaning, sometimes I think I somehow humanize them.”

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In addition, his ideals of order made it difficult for him to even begin cleaning up, which is typical for hoarding individuals. They cultivate the idea of a perfect home, but continue to submit to their unconscious drives. Only the drive objects have shifted from feces to items. Mr. U. explained: “I have a very large collection of videotapes. But I haven’t gotten around to labeling them. I’ve been trying for a while now. I’ve planned to do five tapes a day, but I can’t manage. I don’t have the time, and yet I keep trying, again and again.” Mr. U. had a proud collection of over 5000 videotapes. Even with strict discipline, labeling five a day would have meant 3 years of work. Mr. U.’s inability to meet his daily goal meant that he was confronted with his failure daily. Overview Mr. U., a humble and quiet man, lived a secluded life. He especially suffered from loneliness and a lack of relationships, which, from his point of view, were inflicted upon him by his hoarding. He had unusually high ideas of order, resulting in overburdening himself. He must have been struggling with continuous conflicts between his ego and ego-ideal. Early separation from his mother and the ensuing identification with his grandmother could also be determined as important factors in developing a disposition for hoarding disorder. Mr. U.’s case was further aggravated by a marked difficulty with making decisions. Mr. U. attached great value to the things he owned, a factor which is important to note. He repeatedly compared the role things had in his life with the importance human relationships usually have for people. We need to ask: when did this shift take place, and how did it connect with the development of his libido?

4.2.4 Ms. V., the Fighter Ms. V. was an extremely well-groomed woman, elegantly dressed and always smiling. In the support group, she often attracted attention with her reflected statements. In the interview, she stated that she considered herself healed because she found the “key”: hoarding was a misaligned coping strategy. Ms. V. grew up in the country with four brothers and her parents. The grandmother, who was one of her prime caregivers, died when Ms. V. was 10 years old. Ms. V. explained that she came from a dysfunctional family. She said that her mother was depressed, and her father had a drinking problem. At 14 years of age, she moved out of her home to a girls’ boarding school. After graduating from high school, she studied for a few years, then dropped out and started working. Subjective Causal Theories As a child, Ms. V. did not have her own room. When her grandmother died, she tried to live alone in her grandmother’s apartment. She was only 11 years old and did not know how to heat the room. Therefore, she moved back in with her parents, where

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she eventually got a room of her own. She had always been sloppy and chaotic, and she never got to know anything else: “Well, I must say, I grew up in a ‘Messie’ household. My parents’ house was always a mess. They only cleaned up at Christmas or when they knew someone was coming to visit.” The mess Ms. V. was confronted with at an early age could have been the result of her mother’s overburden. She was a mother of 4 and depressed and might not have had the energy to clean the house. Having grown up in an untidy home, Ms. V. later felt comfortable in the mess of her own apartment. Although Ms. V. was aware that her way of life and the way she cluttered her living areas were very different from what most people are used to, she defended herself against false assumptions: “You are stigmatized for it. People say you’re a lazy bum or sick. I mean, even if I am sick, I want to be in control. I don’t subjectively experience myself as sick, but I know that I’m different. That’s the difference. A thalidomide baby with too-short arms just knows it’s different. It doesn’t see itself as sick, but different. Yes, it [hoarding disorder] adds a limitation to life, just like alcoholism, which used to be seen as a weakness of character and is now considered a disease. It’s no different with hoarding.” Her parents’ laissez-faire attitude characterized her upbringing. Ms. V. did not know many boundaries. Wolfgang Johann von Goethe once famously wrote that children should be given two things: roots and wings. In other words, they need a balance between attachment and autonomy. Ms. V.’s upbringing might have been an influencing factor in her hoarding: “My mother said she didn’t raise us, we just grew up on a farm in the country.” The interview could not determine how far Ms. V. experienced her mother’s behavior as neglect of providing her with attention and care. However, she explained that her cluttered apartment might express what she otherwise does not know how to put into words, a common theme in hoarding. “People see it [the hoarding] as a problem, but in reality, it’s a coping strategy, maybe to deal with feelings one doesn’t know how to handle. It’s like smoking to calm the nerves or, perhaps, like drinking to get control over one’s emotions.” Ms. V. accepted the mess in her apartment, the accumulated things, the narrow corridors, the impaired life quality because it gave her some sense of peace. She was convinced that her hoarding, the mess, and the many things, satisfied some inner needs she was not aware of. Comorbidity During puberty, Ms. V. developed an eating disorder. She suffered from bulimia for almost a decade. A support group helped her recover. “I was extremely emotionally unstable. The slightest problem made me want to kill myself. It was just trivial things that caused emotional outbursts. It was also a problem of low self-esteem. I was overweight as a child. At 15, I went on my first diet and lost 10 lb, and after a few months, I gained the weight back. I was 17 when I went on my second diet. That was when I discovered vomiting and still couldn’t maintain my weight loss. From then on, I had bulimia.”

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Ms. V. spent many years searching for an explanation for her behavior. She read self-help books and attended seminars that were supposed to teach her how to keep order. Eventually, she met a psychiatrist who diagnosed her with ADHD. The diagnosis provided Ms. V. with great relief. Finally, she felt like she knew what was wrong with her: “I bought a book, […] and while reading it, I realized that all it said actually applied to myself. Then I […] found myself a psychiatrist online because I wanted a diagnosis. I went to community college and took up a course on how to declutter. This is how I found this support group. […] I can relate to more because ADHD is not so much of a problem for me. It just helps me to know where I fit in. It taught me a lot about myself.” For Ms. V., it was important to engage with herself, her actions, and her life. She had always been looking for explanations and was relieved to find out that there are other people like her and that she was not alone. Experiences and Fear of Loss, Separation Anxiety Well, the first difficulties I can remember arose when I was ten years old. That was a difficult time for me. My grandmother died, and even though I was not emotionally close to her, she was still an important figure in my childhood. Soon after, my younger brother was born, and, on top of that, I had to change schools.

The grandmother’s death, coinciding with her brother’s birth, marked a turning point in the young girl’s life. The events might have caused the family to lose sight of the other children’s needs. The question is also whether Ms. V. had the resources to properly process her grandmother’s death. How did the family handle goodbyes and separation? “My father died when I was 17. Our relationship could have been described as co-existence. I had problems with intimacy, allowing intimacy. […] My parents, yes, I think they did not give me enough, but I wouldn’t call them bad either.” Ms. V. often felt lonely, and only in adulthood did she understand that her mother was herself ill. She knew that things had gone wrong in her family and blamed these dysfunctions as the cause for her brother’s suicide: “My mother was manic-­ depressive, but for a long time I didn’t know. And my brother had that too. He committed suicide 20 years ago when he was 35. He was worse than I am.” Relationships and Attachment With the help of the support group and psychiatric and psychotherapeutic treatment, Ms. V. managed to recover from her eating disorder. The dialog in the support group and what it taught her about herself enabled her to finally enter into a love relationship: “I don’t remember exactly how long it took, but in this self-help group, I eventually overcame my food addiction. Before that, I wasn’t capable of or willing to have a relationship. But that’s changed now. I found a boyfriend, and our relationship lasted a pretty long time, almost 9 years.” Ms. V. suffered from the problems arising from pathological hoarding, mainly from impairments in her social life. “There are so many restrictions in my life, some

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of which are self-imposed. I don’t invite people over. I can’t have a normal social life, and I’m not even sure that’s what I want. But, right now, I don’t have a choice.” Ms. V. grappled with an inability to choose between a social and secluded life. She felt her unconscious took the decision. In this context, Ms. V. also mentioned her difficult relationships with her family: “My relationship with my mother was very ambivalent. My mother and I were just too different. […] I certainly didn’t have a close relationship with my mother; I probably wouldn’t have had a relationship with her at all if she hadn’t been my mother. She wasn’t the kind of person I would have chosen. Most of my relationships were problematic, even with my brothers.” In the light of Ms. V.’s failed relationships, her lifestyle as a single and the state of her apartment are particularly interesting: “My bedroom consists of islands. It’s been 2 years, I think, since I last vacuumed my bedroom.” As we know from the interview, Ms. V. had experienced her early relationships, especially the family relationships, as difficult and stressful. Her later love relationship also failed. The interview gave the impression that Ms. V. was unable to allow someone to get close to her. The thick layer of dust that covered her apartment was a protective layer. Ms. V. was familiar with feelings of loneliness: “I remember feeling lonely, for example, when I was 8 years old, my parents didn’t understand me. […] So, I did feel lonely, and I think I was alone in this family. I had a big family, but I was all alone. I was emotionally completely left alone. Nobody was ever interested in my feelings.” Fear, Aggression, and Defensive Behavior Ms. V. had to cope with several changes of school within a short time. During this time, she felt very alone. There was no one she could have turned to. She remembered these childhood events but could not recall the feelings they evoked back then: “These feelings from childhood, I can’t feel them no more. I can’t remember them. […] If someone asked me how they felt, I probably wouldn’t know. I’d say I don’t remember.” Psychoanalysis postulates that previous experiences that can no longer be remembered are expressed in different ways. They are often re-enacted and unexpectedly surface. The spatial restriction and amassment of items associated with hoarding often reflect the patients’ previous experiences. Hoarding has been evidenced on multiple occasions to represent a means to re-enact decisive life events. In Ms. V.’s case, boundaries were a recurring theme. Knowing and respecting another person’s individuality are prerequisites for building a successful relationship. Children must learn how to respect boundaries, also their own. Only if they are given privacy and the right to keep a secret can they develop their personality. Ms. V. shared her view on boundaries: “Somebody else violating my boundaries, even if not intentionally because they might not have been aware of my boundaries, I have to say, that’s a very delicate matter. It makes me slightly aggressive. […] I can’t stand people who don’t know how to behave, these violators, so to say. My mother was like that. […] If the garden fence is not enough to keep people from prying, I have to get a barbed-wire fence.”

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In school, the young Ms. V. had felt great pressure due to her family’s expectations, which she had internalized. Later, Ms. V. grappled with the decision to study. In the end, however, she realized that going to university had never been what she wanted: “When my final exams rolled around, I had 3 weeks’ time to prepare between my written and oral exams. In the first week, I didn’t study at all; in the second week, I studied a little bit; and in the third week, I didn’t know where to start. Now that I think back, I’d say school was difficult for me, mainly because I didn’t have anyone to confide in. I was lonely. I did have a couple of girlfriends, but none of my friendships were very open. We didn’t talk about our feelings or so. My mother’s family is a family of academics, and […] they have these specific values. They consider a person valuable, so to speak, only when they are an academic themselves. Of course, I picked up on this attitude, and of course, I wanted to study, which was when this whole procrastination problem showed. At school, I had all these deadlines, which I could handle. But at university, it didn’t work out anymore. It wasn’t my thing, to be honest. It had never been my wish to study; it had been my family’s expectations that had made me want to study.” Psychological Stress Ms. V. did not directly suffer distress from her hoarding symptoms. It was neither the mess nor the clutter that bothered her much. She suffered above all from her difficulties interacting with people. She perceived her ability to build and maintain relationships as limited and would have wanted to extend her scope to shape her relationships. Ms. V. suffered massive restrictions in her quality of life and, therefore, had been anxious to understand inner inhibitions: “I suffer from the fact that I’m not […] normal, and that I don’t have a normal apartment. I don’t suffer so much from the mess, but I suffer from the pressure to restore order. I suffer from the fact that I can’t live without all these restrictions. I live in a kind of corset. I have so many limitations, which I partly impose on myself.” The society’s perception of hoarding individuals is not very nuanced, and media depictions rarely correspond to the reality of hoarding disorder. Hoarders are often portrayed as lazy and weak in character, and very few people are interested in the background of the squalor. Ms. V. suffered from this misinterpretation and lack of understanding: “The stigmatization connected with it really is a source of suffering for me. It’s also why I hide the hoarding. […] Even as a child, I suffered because we had such a messy house.” The symptoms seem to provide those affected with an opportunity to hide unwanted feelings and memories of the past. Ms. V. understood her hoarding as a form of self-therapy: “We basically therapize ourselves, but nobody understands that. It really is a form of self-therapy; only the therapy itself brings a new problem. At least, that’s how I see it.” And in a way, Ms. V. is correct in her assumption that hoarding presents a form of therapy. As was stated previously in this book, any mental disorder, and deviation from the norm, is an attempt to correct an imbalance. Therefore, hoarding can also be described as fulfilling an economically stabilizing function. The content of what patients would have to confront if they did not hide

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them beneath the squalor must only be unearthed in the context of trusting counseling sessions or psychotherapy. Overview Ms. V.’s case illustrated that hoarding does not necessarily impede the ability to work. Ms. V. was perfectly able to regularly go to work and attend to her day-to-day duties. Her job required precision and diligence, qualities which she was well able to deliver. The above extracts from her interview demonstrate that the spectrum of the disorder can be diverse. Hoarding disorder can develop very differently, depending on a person’s abilities and resources and their willingness to accept support such as through psychiatric or psychotherapeutic treatment. Despite her difficult emotional relationships and stressful childhood circumstances, Ms. V. had always found the strength to seek help and accept support.

4.2.5 Ms. X., the Dedicated Ms. X. is a woman in her 40s, with blonde hair and an athletic build. She was very concerned with her appearance. For the interview, she chose to appear in elegant casual clothes. Her winning personality combined vivaciousness with curiosity and eloquence. Ms. X. spent the first years of her childhood with her parents in the countryside. Her mother was a housewife, and her father was a workman. When she was 7 years old, her mother died after a long battle against cancer. A period of instability followed, where different people cared for Ms. X. The situation stabilized when her father remarried, and she moved in with her stepmother and stepbrother. The time between her 10th and 16th birthday was challenging for the young girl. She struggled with the new situation, adapting to life with her new family in a tiny apartment. When she was 16  years old, the apartment next door became vacant, and she could move in on her own. This first own home of hers, for the first time, gave her space to spread out and pursue her interests and tend to her needs. At that time, she also first noticed that she had difficulty keeping order and separating from things. Ms. X. married in her early 20s and had three children. At the time of the interview, she was divorced and had been living on her own for several years. She was very committed and ambitious with a promising career; she even went back to university to get a second degree. Subjective Causal Theories Ms. X. remembered her mother’s illness and that she spent considerable time in the hospital. After her mother’s death, Ms. X. was passed from one presumed aunt to another, all her mother’s friends. For a long time, she did not have a stable caregiver relationship. She experienced her father as overburdened and helpless during that

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time: “There were all these different people who tried to care for me, but many of them were helpless themselves. So, I had to take responsibility for myself very early on, […] for what I did. […] I guess this is how I found comfort in holding on to things. They gave me a sense of stability and brought some sort of structure to my life. This is how I explain it.” The objects Ms. X. began to accumulate gave her security and protection; qualities her caregiver system failed to provide her with as a child. The items assumed the role of people, which they had not been able to fulfill. In retrospect, Ms. X. understood her hoarding as having resulted from an interplay of various factors: “In my first home of my own, I noticed that I have trouble organizing myself and things. I’m always rearranging my furniture, always looking to change things. […] I also find it difficult to throw things away, and the most basic things have become incredibly important to me. Yes, it’s this need to keep things. […] My personality also has something to do with it. I’m interested in a lot of things. I like to gather knowledge.” The fact that HD patients attach disproportionate value to mundane items marks them out as different in our modern consumer and a throw-away society. Individuals who hoard do not adhere to prevailing social norms of acquiring, consuming, and discarding and starting the cycle all over again. Ms. X. shared a scene from her childhood, which is particularly interesting in this context. She clearly remembered a situation in which she expressed discontent as a child but was not taken seriously by her parents: “I’ve never understood what this defiant age in children is about. […] I was always defiant. But I felt I had a point. A lot of times, I felt like my mother, my father, and others mistreated me. Back then, they treated children differently. […] I suffered because I wasn’t taken seriously as a person.” Against this background, it seemed even more critical for Ms. X. to be taken seriously with her condition. Ms. X. knew how to clean and keep order, and it was not idleness that prevented her from doing so. Instead, the patient suspected a possible genetic component or disposition. She often had to think of her father’s hoarding: “The moment my father told me about his work, I realized he had the same problem; […] that he found it difficult to finish something. He had a colleague at work; […] this colleague always helped him, which I found so revealing.” Ms. X. longed for a person she could trust and who would stand by her side with understanding and patience. “I have this ideal, this idea that there must be somebody out there knowing what I need and helping, supporting me, but I think that’s just an illusion. […] Of course, this person could be a therapist.” Comorbidity Before hoarding disorder became a mental health problem in its own right, patients with hoarding symptoms had received diverse diagnoses. Ms. X. was diagnosed with both ADHD and depression. Her vibrant, curious nature and inability to focus, along with her sometimes-impulsive behavior, could be interpreted as an expression of hyperactivity and, consequently, connected to ADHD.

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Experiences and Fear of Loss, Separation Anxiety Ms. X. not only lost her mother at a young age but also, symbolically speaking, her father. Following her mother’s death, he appeared helpless and weak, unable to handle the situation and his responsibilities. Consequently, Ms. X. had to learn how to take care of herself and live independently and responsibly at a very early age. Further factors that could provide insights into the cause and progression of her disorder are her libido development. The question of how the young girl could organize and integrate her aggressive impulses and fears is also vital. How can we interpret the intense fear of losing a piece of information or a specific object? Listening to HD patients speak of their possessions; one would suspect that they are not at all what this is about. One gets the impression that the patients try to hide a secret, a traumatic experience, which at the same time, must not be forgotten. The feelings possibly stirred by these experiences, whether associated with love and affection or despise and rejection, seem to have shifted from actual events to objects and things. Ms. X. explained: “I have so much information, but don’t know where to put it. I wonder if I can get this information out of my head, maybe place it elsewhere, even if just for a moment. But where do I put it? […] And will I find it again?” Ms. X.’s urge to gather information to finally gain understanding and receive explanations is highly interesting. It could be interpreted in terms of the child’s relentless pursuit of an answer for her mother’s death, desperately trying to make sense of why her mother fell ill and had to die. Ms. X.’s failure to sort and file all this information she had collected was accompanied by a feeling of fear: the fear that something might be lost if she would lose sight of it for just a moment. This conflict fostered her necessity to keep all this information, and the things close. Her hoarding expressed precisely this inner chaos. The patient could not bear it any longer and had to project it to the outside world somehow. Relationships and Attachment Ms. X.’s stepbrother was 2 years older than her. The apartment in which the blended family lived consisted of a bedroom, kitchen and cabinet, and the toilet was in the hallway. The family of 4 lived in this apartment during the week. The weekends were often spent in a house on the outskirts of the city. “I had no friends during this time. […] So, I developed a love for this boy, which was very weird, because we were brother and sister, and then again, not really. […] But it was also nice because it gave us hope, both of us. We both suffered so much and then somehow fell in love with each other and led a strange double life for a couple of years. At some point, we realized that we had nothing in common apart from our story. […] So, we parted ways, and we never met again.” On several occasions, Ms. X. refers to the small apartment they used to live in. We need to ask what this confined space meant to Ms. X. It is also interesting to note that she managed to keep a secret, even in this small space: the almost incestuous relationship with her stepbrother.

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Hoarding disorder connects to inner struggles and conflict, often causing great distress for the patients. On the one hand, some patients, especially those with good insight, are committed to renouncing their drives, and, on the other hand, they experience great satisfaction if they do not deny them. During her marriage, which lasted almost two decades, Ms. X. lived in three apartments. Every time the apartment became too cluttered, her husband insisted on moving. In the end, the relationship failed because of the hoarding and the resulting lack of order and organization. “We couldn’t manage to organize our lives. […] Many things remained unfinished. […] My partner could never meet my expectations regarding the household, regarding cleaning. […] I felt like this was just a symptom, the tidying up, and our inability to keep things in order. It was something neither of us was good at, obviously, and I would have liked to work it out with him.” Frequently, hoarding individuals find relatives and friends to offer help cleaning up. It has often been observed that, when hoarders reject those offers, their relationships with those wanting to support them diminish. The situation often leads to serious relationship conflicts, which Ms. X., too, experienced. She had reached a point in her life where she decided that she was better off living on her own. She had lost all hope that there would be someone who could help her out of her situation: “I don’t want to live with anyone else right now. […] I don’t trust anyone either, and I certainly don’t believe anyone could really help me.” Ms. X. felt torn. On the one hand, as mentioned above, she wished for professional guidance and support, and, at the same time, she doubted that there was anyone who could provide it. Anxiety, Aggression, and Defensive Behavior Even as an adult, Ms. X. had a problematic relationship with her father. His second marriage felt like a betrayal. Ms. X. felt like her father had misunderstood and abandoned her: “What he did was just stupid. He simply did not react appropriately; he did not understand my situation. […] He didn’t even want a child; my mother wanted one. […] Anyway, I thought his remarriage was a breach of trust, so I quickly gave up the hope that he could be someone to support or help me.” As an adolescent, Ms. X. did not feel wanted. We can discern hints of the Oedipus conflict in the young girl, who considered herself rejected by her father. However, the interview did not reveal any more details in this context. If we turn our attention to Ms. X.’s home, we have to remind ourselves that the clutter and even squalor often have a deeper meaning. We can frequently observe a certain kind of speechlessness in hoarders. Ms. X., too, mentioned that in her family, one did not openly address problems or solve conflicts. “Now, this is just a guess, but it makes sense to me that my mother might have suffered from speechlessness in her relationship with my father. I also find it difficult to talk to him. […] My father claims we never argued, and I simply can’t believe that. Saying that we never argued sounds as if we never had a problem.”

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Strict order, discipline, and a lack of communication characterized family life. The parental expectations and morals were asserted: “Yes, my parents were strict. There was an unspoken morality, but we treated each other nicely, and there never was any violence. Nobody ever broke things; it was clear that this was a nasty thing to do.” Psychotherapy could have provided a useful method to explore Ms. X.’s perceived speechlessness and its connection to the family’s value system. It would have been particularly interesting to explore how the family used to handle disagreement and conflict in more detail. How did Ms. X. control her own aggressive impulses and destructive emotions? Ms. X. remembered her mother’s perfection in making the beds: “My mother, for example, she had already undergone surgery and just had one of her breasts removed […], and she still made the beds every morning. In the morning, we got up, aired the room, and then nicely arranged them as if one had wanted to take a picture for a magazine. And she did it with all her might, […] she could hardly move […], but smoothed out these blankets, and she neatly arranged the pillows, and so on […]. Today, I think, this could have been because she did not want to give up on the last things she was still able to do while already being sick, or maybe it was just a stubborn way of holding on to these stupid rules; rules of order. There was this mad perfectionism in her, but it also made her unique.” This description reveals that Ms. X. had ambivalent feelings toward her mother. Back then, she was worried about her sick mother. Her mother had not been able to address her feelings and those of her daughter. She hung on to life and tried to maintain a specific image of everything still being perfect. Ms. X. might have adopted the compulsion to keep order from her mother: “I get so caught up in an idea, and I’m afraid that, once it’s done, I won’t like it and won’t be able to change it. […] I guess that relates to my problem getting stuff done, and then there’s this problem of order. I really don’t know, for example, how to file documents in a meaningful way.” Psychological Stress Ms. X.’s distress primarily arose from never being able to find anything. She was always searching for things and missing deadlines. Hoarding had already taken over her entire life: “I feel bad about it, really bad. But even days before [a deadline], I’m feeling unwell, almost paralyzed. I just can’t get myself to sit down and tackle a task. I guess there comes this point at which it’s no longer healthy. It’s not healthy one way or the other, but I feel like I can’t go on like this. I want to set a limit. […] This pressure, it’s intense […]. It’s not how I want to live at all.” Ms. X. was a very dedicated person, both professionally and socially, but whenever she was alone in the apartment, she was overcome by this claustrophobic feeling. “It’s not that I don’t see all this. […] I feel like I’m trapped. I just sit there, thinking that I must do something about it, but I can’t. Then I get depressed and completely encompassed by this feeling.” Ms. X. had been struggling with hoarding and finding an explanation for many decades. For the most part, her hoarding revolved around gathering information in the form of printed media. When she received the diagnosis, she finally understood

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what her behavior was about, but still found herself unable to fully justify her hoarding: “I finally have a name for it [the hoarding] and dare to talk to other people about it, that’s one thing. […] But I find it hard to get across that, although I generally have my life under control and don’t have serious issues, I still have a massive problem. That’s what makes it so difficult for me to open up about it and make others understand what it’s like for me.” Overview Ms. X.’s case exemplifies that hoarding disorder is not linked to a person’s level of education or social background. Ms. X. was a well-read, educated woman. She had a successful career, yet she had a mental health problem, and this illness had accompanied and burdened her all her life. Despite having lost her mother early and experienced her father as a weak man, Ms. X. was well able to fulfill daily duties and live a generally good life. She completed a higher education, built a career, and started a family. Just like other hoarders, Ms. X. did not gather any items specifically. She had great difficulty separating herself from things and information. Therefore, her hoarding could be understood as an attempt to regain influence and power over her life and handle fears of loss.

4.2.6 Mr. Y., the Seeker Mr. Y. had full hair tinged with gray. His facial features were soft; his elegant wool vest and his glasses underlined his intellectual and calm appearance. Mr. Y. grew up in the country with his brother and stepbrother. His mother died when he was 2 years old; his father then remarried, and he died when Mr. Y. was 6. The relationship with his stepmother was full of conflict, so he applied for a job at sea at 14. At the age of 19, he married an Indian woman, and they had a daughter. He later got divorced and remarried. Mr. Y. is very well-read, and he is an eloquent speaker. Listening to his stories was always a great pleasure. His life resembled a story in an adventure novel. Despite his fascinating way of telling stories, his other side occasionally surfaced, revealing lifelong struggles with hoarding, alcoholism, and drug abuse. Subjective Causal Theories Mr. Y. began his story with a look at his childhood. As early as 6, he realized that he was messier than his brothers. His relationship with his stepmother was problematic, and he considered his hoarding disorder a reaction, as his way of protest against being raised by his stepmother: “It developed out of my rejection of my stepmother, of everything she said. I didn’t do any of what she told me to, and I certainly didn’t do any housework. […] I guess that’s how it started, my habit of not getting stuff

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done. Even now, at the age of 55, I sometimes question the point in, let’s say, taking out the trash or ironing. I’ve never ironed in my life.” Mr. Y.’s reluctance to do housework remained unbroken when he married at 19. His ex-wife was a hoarder too. She had come from a wealthy family and used to being taken care of by her servants. The young couple, despite their aversions, attempted to maintain order, yet failed. Mr. Y. was convinced that his ex-wife had never learned how to take care of a home properly: “So, my approach to cleaning was entirely different from my wife’s approach, and it failed. I believe this was because I had never been taught how to do it. I tried so hard and failed over and over. I prioritized things, remembered where I had stored the most important items. It was bad. I lost several apartments because of it.” Mr. Y. explained his hoarding in terms of his urge to resist submitting to social norms and morality: “I suppose it’s some unconscious protest against common conceptions of order or decency.” Mr. Y.’s hoarding was an act of defiance, escaping his stepmother’s control and influence, as well as her unloving nature. Comorbidity When Mr. Y. went to sea as an adolescent, he began drinking. Later, when he married his wife, he started taking benzodiazepines and tranquilizers, soon developing a severe addiction. He considered himself a child of his time: the hippie movement and sexual revolution. He said that everyone who had had the chance had gone to India and tried mind-expanding drugs back then, and so had done too: “I could drink a lot without going crazy. I never binged, I rather kept a level, and I was constantly drinking to do so. It was what I learned early on. At sea, the sailors hardly drink water or anything else. They drink Coke or sparkling water only mixed with liquor. During my time at sea, I learned how to handle alcohol, or how to drink. It wasn’t forbidden, and it certainly wasn’t a crime to drink on the ship. Of course, we all had to function and make sure that the ship was safe, but we didn’t have any restrictions as long as we fulfilled our duties. […] Well, and later my wife and I nursed our hangovers by taking benzodiazepines and tranquilizers.” Mr. Y. began consuming alcohol as a teenager and, thus, a journey of lifelong addiction, which had had long-term consequences and left its mark on his psyche: “I sometimes get suspicious. I’m afraid people are accusing me of something or threatening me or fighting me, or think they are spies. So, I take my meds, but they diminish any emotion, whether joy or sorrow.” At the time of the interview, Mr. Y. had overcome his addiction. He was in psychotherapeutic and psychiatric treatment. He had a natural suspicion toward other people, and his thought was often determined by paranoia. He also tended to fall into episodic depression, which often caused him to devalue his life and consider himself a failure. Experiences and Fear of Loss, Separation Anxiety Mr. Y.’s life was ridden with losses. He lost both parents when he was only a child. The death of his mother was denied, almost hidden from him; he had never received

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an explanation: “Concerning the death of my mother, well, it was something they tried to keep away from us children. Nobody talked to us about it, they said she wasn’t gonna come back, or sometimes we were even told she would come back, but she had to stay in the hospital for a little longer. It was all a bunch of lies. I was so upset, […] that’s why I have this anger.” The connections between his anger and aggressive impulses and his addictions are particularly interesting in the light of his hoarding. It is also essential to note that his stepmother’s value system was very different from Mr. Y.’s. Mr. Y. loved books, and his stepmother would burn the father’s library just to save money. “We had a skating rink, which she then dug up to plant potatoes. She bought chickens and a pig, which was completely unnecessary. […] A phone call would have been enough, and my grandparents would have come to fill our basement with supplies. They had a huge farm, but she wanted to prove to them that she could feed us herself.” Mr. Y.’s stories were very vivid. They made his listeners recognize the little boy in him, who had lost both his parents and, soon after, had the two things taken away from him that had given him the most joy in his life: the library and the skating rink. Later in his life, Mr. Y. lost many different apartments. He was once homeless. His hoarding appeared like a re-enactment of loss. It seemed as if he deprived himself of anything he owned and loved, which caused great distress: “It’s the fear of loss alone. I’ve already lost a lot: apartments, relationships, and more. This fear of loss makes me panic. It makes me search, and I can only be satisfied once I find what I am looking for—until I feel urged to look for something else again.” It was unclear what Mr. Y. wanted to find when he experienced one of his panic attacks. His nervousness is a form of transference with a good outcome. He always ended up finding what he was looking for. The question remains whether it was really what he needed, what he longed for. Relationships and Attachment Mr. Y. strongly identified with his father, which is mainly derived from his hoarding. His image of manhood stemmed from the 1950s: the father was supposed to work and provide for the family; when he came home, his slippers and a warm meal should be waiting for him. In the home, the man should not have to lift a finger: “My father wasn’t a homemaker. He always left things as they were. Well, maybe it was me who took over some of the chores that the time. He left everything lying around, but you can’t do that in a relationship today.” Mr. Y. hardly mentioned any friends or acquaintances during the interview. He only referred to his social environment and expressed an absolute contempt: “We couldn’t invite people over. […] And, every day, the neighbors were scribbling things onto my wife’s dirty windows or wherever there was a lot of dust.” The neighbors’ scribbles were insults written on the windows with their fingers. Mr. Y. also mentioned what it must have felt like for his child to grow up in such a household. He felt guilty because he could not be the father he had wanted to be: “Of course, the daughter suffered from this mess. Her daddy played chess with her and was a clever man, but at the same time, she must have been humiliated.”

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Mr. Y. was unable to make family life work. He repeatedly left the family and stayed away for long periods of time: “My wife sent me back to Europe to work and send money to India, just like it was the custom there. But it didn’t work out that way. It was such a wild time; it was the 70s; it was the time of the sexual revolution. Everyone was experimenting with all kinds of things, and there were no families but shared flats and hippie friends, and hell knows what.” Fear, Aggression, and Defensive Behavior Mr. Y. despised his stepmother and openly expressed his hatred for her: “I’ve developed quite a hatred for my stepmother. I almost pushed her down the cellar steps once. She was always drunk. She kept her double-liter bottles in the cellar and always went down and took a sip. […] At some point, I had just written her off as a hillbilly.” Mr. Y. described their relationship as a “permanent battle,” from which he could only free himself in puberty. He applied for admission to a nautical school in Germany and, consequently, spent his time at sea until he turned 19. One could understand this choice as a counterphobic enactment of his central issue. This is because, especially on a ship, where there is little space, cleaning and keeping order is essential. It is also interesting to note that his stepmother enjoyed drinking alcohol, which, in addition to the early oral aspects of the patient’s addiction, suggests unconscious identification processes. Mr. Y. was looking for things daily. The thought that something could be lost regularly triggered a panic attack and an ensuing searching frenzy, which in his opinion was due to his general fear of loss: “Well, about this fear of loss: I have lost a lot—many apartments, many, many relationships, and many more. And this fear of loss, it triggers my panic. And then I have to search, and I am only satisfied when I have found it until I get another attack. I recognize that this is ‘the sick’ in me, and these search attacks, well, if I could only sit down, drink a sip of water, and calm down and think about it […] But when I can’t find something right away and become anxious I could have lost it, then my searching becomes even more frantic, and I make a huge mess. When I’m searching stuff, I’m always so nervous and restless.” Mr. Y. was often overwhelmed by the thought of loss and consequent search attacks. They indicate how threatening it felt to him to lose or forget something. In German, Suche (search) and Sucht (addiction) are not etymologically related, and yet the similarity of the words almost suggests that they could be used interchangeably in Mr. Y.’s case; his frantic searching pointed to generally addictive behavior. Psychological Stress Everyday tasks took Mr. Y. a lot of energy. His struggles began early in the morning when he had to force himself not to cause any chaos: “I really suffer. I suffer from my inability to keep order even at breakfast.” His hoarding makes Mr. Y. feel like a failure. His pride was wounded, and it also caused him a narcissistic wound. “When I think about it, I don’t feel good about it.

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It’s the story of a loser, of failure, knowing you’re about to lose your apartment or having to pay for stuff, or going bankrupt. None of this is pleasant.” However, in his wife’s cultural environment, Mr. Y. also had positive experiences with little property: “In India, people have almost nothing. What do you need? A coat. And the less a room contains, the cooler it is. The climate is very different there, and it’s an entirely different system.” Overview Mr. Y. described his stepmother as foreign to him. In his depictions, it almost seemed as if she were from a different country. She was a practical countrywoman, and his father was a well-read academic. The fact that he then married a woman from another country at a very early age is remarkable. Due to his drug abuse, Mr. Y. also had psychotic experiences. However, hoarding was never just the consequence of his drug-taking phases; rather, it was a phenomenon that accompanied him throughout his life. In Mr. Y.’s case, we can recognize the strong influence of oral and anal aspects, as well as instances of regressive behavior in the development of his hoarding. Mr. Y. lost his mother and later his father, both when he was still very young. These very early losses, the family’s handling of death, and the intrapsychic resources were decisive in his development. No one can replace the parents; however, in Mr. Y.’s case, his stepmother could not even remotely live up to her parental role.

4.2.7 Mr. Z., the Lonely Mr. Z. is a slender, tall man with a youthful appearance. There was something very peculiar about the way he walked: his steps were small and quick. He always seemed rushed, not just because of his walk. His gestures were fast-paced, as was his language. He grew up in a large Austrian town and had a younger brother; at 5, he lost his father in an accident and grew up with his mother and grandmother. His relationship with his mother was ridden with conflict and very difficult. Mr. Z. dropped out of his physics course after a few semesters. Since then, he had earned a living with various part-time jobs. The patient, in his mid-30s, longed for meaningful relationships, both friendships and love relationships. Subjective Causal Theories His parents had not sufficiently encouraged Mr. Z. to develop age-appropriate autonomy. In his everyday life, he was regularly exposed to negative prophecies. Mr. Z. well remembered the so-called double-bind statements of his mother: “Yes, she took over certain tasks for me, in an unhealthy way; she organized my book bag, so yes, as stupid as it sounds, she took care of it herself, so to speak, that I remain as dependent as possible. At the same time, she complained that I was so dependent.”

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An adolescent child does not know how to classify and handle ambiguity. A child cannot fulfill expectations that are not communicated to them, leaving them confused. How could they live up to an unspoken, unconscious expectation; to an ideal image they do not know. When confronted with such ideals, children are deprived of their opportunity to learn and develop through trial and error; everything they do is wrong and is criticized. Mr. Z. shared his experience in detail: “Well, yes, there was a time in elementary school when I fought a lot with my mom. It was terrible, almost unbearable. I was lucky to have had a close friend. I don’t think I could have dealt with that pressure if I hadn’t had him. I was put under so much pressure.” Subjective feelings and inner experiences are not easily accessible; only through the stories can we trace critical incidents in a person’s life. The matrix that emerges when patients link present behavior with past experiences and report them based on associations is highly interesting: “It might sound funny, but it’s so hurtful when you’re always being urged to put away your glass. It’s just like back then, when my mother didn’t respect my limits, and I just couldn’t stand it anymore when she asked me how much eight times eight was. I felt like I was dying from the pain it caused me, and it’s very similar now, and I just can’t handle it when I’m told to put a glass in the dishwasher.” Mr. Z. remembered learning situations with his mother as painful and mental torture. It is remarkable that a boy who experienced such violations and psychological pressure would later find schoolwork easy and even study physics at university. Comorbidity At the age of 5, Mr. Z. was, as he put it, “sent to therapy” by his mother. The therapist would accompany him throughout elementary school. Mr. Z.’s depictions suggest that it was mainly his mother who had felt his behavior to be different from that of his peers. However, in puberty, Mr. Z. began to self-harm. In different phases of his life, he also suffered from depression and received psychotherapeutic and psychiatric treatment. Experiences and Fear of Loss, Separation Anxiety It was also at the age of 5 that Mr. Z. lost his father in an accident. His fear of loss was particularly evident in his relationships with later girlfriends. He had difficulty separating from them, even when he had decided to break up the relationship: “I had such a great life for a while, yes, it all worked out great for me, and, yes, I was a very happy person for a while. I had a great girlfriend, and everything was going well. At that moment, when I was doing so great, when I was head over heels in love, that was when I found out that my mother had cancer. She died within half a year. She died, and then my girlfriend left me. Then I had troubles at work, and I was devastated, and my life was in ruins again. So, I did what I always did in those situations: I started the next therapy.” Mr. Z.’s metaphoric expression of his life “in ruins” evokes the image of his home: the debris, the items cluttering the rooms, could be representative of the ruins of his life. Many homes of people who hoard recall images of war and destruction; of a place destroyed by a bomb or some other destructive power unleashed on site.

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Mr. Z. succeeded again and again, but always only for a short time, to restore order in his life. He managed to clear his apartment so that it then looked like an averagely sloppy student room. He could easily put the things in boxes, but the quality of the things lying around seemed to fulfill a unique function. Mr. Z. had to be surrounded by the objects to have them at hand when he needed them. Relationships and Attachment At the beginning of the interview, Mr. Z. pointed out that his parents lived apart when he was still a child. His father had his apartment nearby while Mr. Z. lived with his brother and mother at his grandmother’s house. “My father stayed in an apartment that was only 5 min away. Still, we were so far apart. […] Our family was always divided between these places.” His father lived alone, and Mr. Z. moved back and forth between his father’s and mother’s places. He did not have a home. The relationship with the mother was very problematic, marked by countless arguments. His mother humiliated Mr. Z., shouted at him, and she called him names, and regularly insulted him. “The most painful childhood memories, the worst experiences were—it must sound stupid—the situations when I had to practice multiplication tables or do some dictation exercise in German, things that were about learning something by heart and reproducing it mechanically. My mother thought I was not very good at these things, so she scolded me. I don’t think she ever really became physically violent, but she always belittled me, called me names, and yelled at me very loudly. Yes, today, I would say she tormented me. I also saw it that way back then, that she tortured me and, yes, that’s what she was doing.” For long stretches of his life, Mr. Z. felt lonely. It seems particularly remarkable to me that this feeling emerged even before he went to kindergarten and continued to accompany him like a common thread into adulthood: “I felt very alone in kindergarten, and long before. […] It bothered me even more as a senior that I was a bit lonely and had no girlfriend. […] And during my studies, I grew even lonelier.” The theory of transitional phenomena and objects seems to be of particular interest in this case. Based on this theory, Winnicott describes the function of thumb-­ sucking and a child’s cuddle blanket. The objects are a necessity for the child until object relations can be developed. Suppose the child is raised by a “good enough mother” and grows up in an empathic environment. In that case, the importance of transitional objects or phenomena gradually diminishes, and the child can increasingly relate to the environment (see [2]). Mr. Z. explained what caused him great distress: “That I am so lonely and somehow feel that I cannot establish meaningful relationships with other people; that I can’t share something meaningful with someone else.” Sometimes hoarded items also represent an attempt to deny emotional injuries and broken relationships: “I have two rooms I more or less don’t use. One of them has a bit of trash in it. It was the room where my ex-girlfriend lived, where she cleaned out her shit. I threw some trash on the floor, not much, just enough so it wasn’t clean. You could quickly remove it, and it still looks empty even though there’s some trash on the floor. And I’ve got a big living room, which is a bit dirty, but I’m not using it.”

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Fear, Aggression, and Defensive Behavior As a child, Mr. Z. did not have the opportunity to influence the situation. His own needs were largely ignored. Limits were neither set nor respected. “Limits of what was acceptable to me and what wasn’t, well, somehow that didn’t matter; if I wanted something or not, if I still wanted something or if I only tolerated it—there was no stopping.” Mr. Z. believed that several of his relationships with women went to pieces, not least because of his difficulty cleaning up. He gathered many items around his bed to have them exactly where he needed them when he needed them. He referred to his bedroom as his bedroom/study because it included his desk and computer. He did not just sleep in the room but also worked there. Considering the state of his apartment and relationships, we must ask whether his hoarding served the patient to avoid serious long-term relationships. What else could it mean that the bedroom was exceptionally cluttered and impaired in its functionality? For Mr. Z., this symptomatology represented the prime “dealbreaker” in a relationship. He was never able to keep things tidy and in order, and that was, from his point of view, the reason why his girlfriends had all left him. From when his father had died, Mr. Z. grew up mostly with female caregivers: his mother, aunts, grandmother, and his mother’s girlfriends. It would undoubtedly be worthwhile exploring how far Mr. Z.’s lack of a male caregiver had influenced his development and identification process; however, the interview did not yield more detailed insights. Mr. Z. solely explained: “I grew up in three apartments: my father’s, my grandmother’s and aunt’, and my mother’s. Then there was another aunt and a friend of my mother. My father died when I was 5 years old, and after that, I was surrounded only by women. My mother never remarried. It wasn’t until much later that she had a boyfriend, and I didn’t get to know him.” When Mr. Z. faced community service, he developed a “terrible fear.” His major concern was the requirements of order and punctuality. He was terrified he would have to go to a “military institution,” which he believed community service was about. However, in reality, it was very different: “During my time in community service, I was very happy because I had this neat structure.” This statement is particularly interesting, as it implies that the patient could not have been happy living in a cluttered home at all; he must have experienced enormous psychological stress. Psychological Stress Mr. Z.’s distress was immense. It arose from the impaired functionality of his living areas combined with his time-consuming search frenzies for documents and daily items and the perceived inability to invite friends into his home: “I think that’s kind of the main problem: that, on the one hand, you’re messing with yourself this way and that, on the other hand, you’re messing up all your relationships.” But Mr. Z. had been familiar with the feeling of loneliness for a very long time. He first had to deal with loneliness in his very early childhood, and the feeling intensified in his student days. “This terrible loneliness, that’s what I’ve most suffered

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from. It wasn’t that I was only sitting at home, depressed, and not doing anything. It was the loneliness and the feeling that I could not build a meaningful relationship with any other person; that I couldn’t share anything important with anyone; and, of course, that I didn’t have a girlfriend. […] Well, back then, I sometimes asked myself, what if I died and never had had a relationship? It didn’t seem so far off. So, I started therapy.” However, the effort of having to clean and tidy up, for example, to invite friends, weighed more heavily on Mr. Z. than the loneliness. He described his dilemma as follows: “All this tidying up; it’s like having to walk on tiptoes all the time; it’s exhausting.” This renunciation of drives took up a lot of energy and required adequate compensation. Overview Mr. Z.’s childhood was shaped by a conflict-ridden relationship with his mother, who he experienced as dominant and disrespectful of his boundaries. She regularly overstepped his bounds and was also very controlling. Mr. Z. experienced great distress based on the loneliness that had accompanied him all his life and caused a deep longing for a love relationship with a woman. He blamed his hoarding for the failure of his relationships. The various therapists that Mr. Z. had visited in his life could not recognize and correctly assess his hoarding disorder. Adequately diagnosing hoarding disorder is vital for successful treatment, and this is where psychotherapy and psychiatry had fallen short for decades. Until the definition of hoarding disorder as a mental illness, hoarding problems were often misunderstood. It is to be hoped that, in the future, the issues of order and difficulty separating from things will be taken more seriously in both research and practice.

4.3

Summary

The seven cases presented in this chapter provide insight into individuals’ subjective life experiences affected by hoarding disorder. For a better understanding, I have classified the patients’ statements into different categories: –– –– –– –– –– ––

Subjective causal theories Comorbidity Experiences and fear of loss, separation anxiety Relationships and attachment Fear, aggression, and defensive behavior Psychological stress

The qualitative study that provided the basis for this chapter focused on the patients’ statements on fear, aggression, and defensive behavior. The condensation of narratives in this category is striking.

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Insights gained in this category are also important due to their diagnostic significance. Obsessive-compulsive disorders were long classified in the context of anxiety disorders. This classification was rooted in the psychoanalytic conceptions of the unconscious. However, with the publication of the DSM-5, this classification has changed. I consider this development highly questionable because neuroses mostly develop from repressed fears, which persist in the unconscious. Psychoanalysis provides valuable contributions for professionals to understand the underlying dynamics. However, if we lose this connection, we also risk losing groundbreaking psychoanalytic findings, which offer such promising insights into hoarding disorder. The case vignettes presented above also demonstrated the spectrum of the phenomenon and its relation to aspects of fear, aggression, and defense. For the first time, these vignettes allow us to trace the psychodynamics of the disorder and get a glimpse into its causes and development: HD as a Survival Strategy: Continuation of Instinctual Drives The behavior is neither a reaction formation nor a sublimation. It is almost as if original drives continue to persist. The vital difference is that the drive object has shifted from the feces to everyday items. Hoarding is a way of protecting, cherishing objects. They are considered valuable and useful. Hoarders feel most strongly about libidinous objects and objects reminiscent of what they have lost earlier in their life. In many cases, we can observe a shift of libidinous feelings from relationships to items. HD as Auto-aggression: Masochistic Drives When children experience aggression and find themselves unable to protect and defend themselves, they develop aggression as well. Their helplessness causes anger, and, eventually, they can only overcome this anger by turning the aggression against themselves. The cluttered living areas, the impaired functionality of their homes and lives signify major restrictions and, consequently, express the patient’s auto-aggressive, masochistic drives. HD as Re-enactment: Compulsion to Repeat In other cases, hoarding may also serve to re-enact previous situations and life events. The clutter and squalor represent overburden and powerlessness, which the patient may have experienced in their childhood or in traumatic life events. The chaos symbolized the chaos patients might encounter in their own lives, which they are unable to address. HD as Protection: Between Pleasure and Reality Principle Hoarded objects also function as a physical boundary between the inside and outside worlds. When patients find themselves unable to erect and maintain a mental boundary, they sometimes have to build a physical wall between themselves and

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others. The homes of hoarding individuals are often cluttered to the point at which they become inaccessible to outsiders. Their social life, if they have one at all, takes place outside the home. HD as a Symptom of Unconscious Fear of Conflict If children cannot process early fears and consequently suppress them, they continue to exist in the unconscious. Hoarding provides a means to ward off these fears and continue to confine them to the unconscious. HD patients often suffer the compulsion to excessively organize, arrange, search, and manipulate their possessions, keeping themselves busy for hours. The importance attributed to the things often compares with the extent people have in our lives. This ascription of value recalls Jean Piaget’s theory of infantile animism. Animism describes situations in which children attribute human qualities to inanimate objects and experience things as living. Freud understands animism in terms of projection ([3], p. 374). Professionals must know about these functions of objects and to understand the meaning things have for their patients. The qualitative study underlying this chapter also illustrated various advantages of considering HD as a separate mental disorder. The definition of hoarding as a disorder in its own right has naturally attracted criticism. However, the benefits of its inclusion in the world’s major diagnostic manuals are apparent: (a) It enables a clear distinction from other disorders despite the high comorbidity. (b) The different manifestations suggest different structural levels of a so-called core or root disorder. Research is expected to intensify in this area and in the development of the condition. (c) Patients often suffer substantial distress before they seek help. Their behavior has been stigmatized and not been taken seriously, which has prevented them from seeking assistance. By recognizing HD as an illness, we can contribute to a broader understanding and ease the patients’ distress and loneliness. (d) The centrality of anxiety, aggression, and defensive behavior, which became evident in the case vignettes, supports the hypothesis that HD is to be located among the anxiety disorders. The association of HD with OCD is questionable and must be researched in the future. (e) The inclusion of HD in current diagnostic systems and the associated recognition of the disorder as being worthy of treatment finally also enables patients to receive funding from health insurance companies. Consequently, more resources will be invested in developing treatment concepts. Group therapy has been proven to be one of the most promising therapy forms. Conclusion The case vignettes offer first-hand accounts of what it is like to live with hoarding disorder. The reports provide exciting insights for professionals in the field, yet also have their limitations. The vignettes are fragmentary and only allow glimpses into the patients’ everyday lives. They do not provide a complete picture of hoarding

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disorder and how it affects a person’s life. Specific topics are only touched upon briefly. The case vignettes were extracts from qualitative patient interviews rather than based on clinical observation and long-term engagement with them. Despite these limitations, the case vignettes give a good overview of how the patients’ life experiences, intrapsychic processes, and personal resources interact with hoarding symptoms. Professionals will significantly benefit from expanding their expertise by understanding these complex interconnections in hoarding disorder. It will ultimately enable them to adapt treatment according to each patient’s needs and background. The case vignettes selected for this practical guide are meant to provide a realistic and comprehensive representation of environments and personality types found in hoarding disorder. They have been chosen to allow different personalities to speak for themselves, adding a first-hand experience component to theoretical hoarding research. Furthermore, the case vignettes serve to draw attention to an aspect that has been widely neglected in international research, namely the role of sociocultural conditions. They are essential, especially given the observation that hoarding disorder occurs independently of gender, age, education, or profession.

References 1. Fenichel O. The psychoanalytic theory of neurosis. New York: Routledge; 1996. (First published in 1946). www.archive.org. 2. Winnicott D. Playing and reality. London: Tavistock Publication; 1971. 3. Freud S. Totem and Taboo: some points of agreement between the mental lives of savages and neurotics. Standard ed. 13. New York: Norton; 1912–13a.

5

Concluding Remarks and Future Prospects

This book consolidates the knowledge I have personally gained in practice and intended for use in practice. I wrote this book with the experiences and needs of both professionals and patients in mind. Years of experience working with hoarding individuals and exchanging with other professionals in the field have revealed many shortcomings in diagnosis and treatment, which this manual seeks to address. This manual does more than address these shortcomings; it aims to remedy them, and it does so by drawing on the riches of psychoanalytic theory. The first chapter provides as a light introduction to the topic, beginning with fascinating facts about Austrian hoarding research history. Interestingly enough, hoarding research in Austria was inspired by a small support group at Sigmund Freud University, Vienna. This group assisted hoarding individuals in raising their voices and creating awareness for the phenomenon. Furthermore, this first chapter unveiled basic terminology and definition problems. When I wrote the book’s German edition, official diagnostic systems did not include hoarding disorder. The discussion of basic terminology was particularly relevant in giving incentives for including and naming the relatively recent mental phenomenon. Now that both the DSM-5 and ICD-11 list hoarding disorder as an independent mental health problem, questions of terminology and definition reveal interesting considerations in retrospect. The terms zwanghaftes Horten (compulsive hoarding) and Sammel- und Hortstörung (collecting and hoarding disorder) have been circulating yet do not sufficiently describe the pathological behavior. The DSM-5 classifies hoarding disorder as a subcategory of OCD and OCPD. While this definition seems reasonable, it falls short of recognizing that hoarding is not inherently compulsive; the obsessive-compulsive character derives from separation issues. In other words, what is compulsive about pathological hoarding is the patients’ persistent difficulty discarding possessions or parting with them in another way. The term Sammel-und Hortstörung (collecting and hoarding disorder), on the other hand, bears the risk of mistakenly associating hoarding disorder with

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 N. Agdari-Moghadam, Hoarding Disorder, https://doi.org/10.1007/978-3-030-72342-2_5

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collecting. However, HD patients do not collect; instead, the items collect themselves. Consequently, hoarding disorder is, in fact, the preferred term, or in German pathologisches Horten. Presently, we are still at the beginning of hoarding research. The inclusion of hoarding in universally applied diagnostic manuals marked a vital step in the right direction, emphasizing the relevance of the phenomenon and the great level of distress it causes both patients and their relatives. The scientific community will soon intensify research endeavors and create cooperation with clinics and other relevant institutions. The lack of research data and large-scale studies also means that professionals have had very little resources available. The definition of hoarding disorder in the ICD will close this gap and inspire the foundation of new training courses and other education and qualification options. The medial attention given to the sensational side of hoarding disorder, despite it being highly questionable, is also likely to help raise awareness and inspire patients to finally seek and accept psychotherapeutic, medical, or social support. HD patients experience severe distress, and their need for assistance is often great. It is to be hoped that the current developments and an increase in research (funding) will also give rise to more support groups and other services. Some of the fundamentals professionals need to understand are the social and cultural implications. The definition of hoarding disorder as a mental health problem has far-reaching consequences for those who suffer from pathological hoarding; however, several other social factors contribute to the development of hoarding. After all, we must understand that hoarding causes significant social impairment. Forming a therapeutic alliance that is stable enough to achieve treatment success requires a unique attitude. This attitude provides the basis for fruitful cooperation. I want to refer to Stavros Mentzos, who describes the therapeutic stance that should underlie all social and health professions: The patient is not viewed as a defective, handicapped, disturbed individual but as a person caught in insoluble contradictions. This attitude, together with the conviction of analogies and similarities between the so-called pathological and the so-called normal, derived from comparative psychodynamics, enables the therapist to develop an intensely empathetic but at the same time respectful, mindful human relationship, which is one of the best prerequisites for a promising treatment. ([1], p. 282)

Also, we must address the significance of items in modern-day society. What is the meaning of having and being? What does it mean to us to feel safe, and how do we achieve safety and security in this ever-changing world we live in? There is no easy way of answering these highly philosophical questions. Several approaches to answering them can be found in current ethnological, philosophical, and sociological findings. The complex nature of hoarding, thus evidenced, implies that the phenomenon must be looked at from different angles. If we want to adequately comprehend, diagnose, and treat hoarding disorder, we must closely work with other disciplines and foster our interdisciplinary thinking. I have provided glimpses of how this interdisciplinary approach could look like, borrowing from different

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theories and linking them with psychoanalysis. This kaleidoscopic approach brings us closer to answering many of the open questions of hoarding than ever before, even if more research is needed to create a complete picture. The second chapter of this practical guide explores the facets of hoarding disorder in detail and presents the book’s essence. It discusses possible causes and developmental factors, shedding light on the development of hoarding from a mental disposition to a severely distressing disorder. The chapter also includes a detailed description of the most common symptoms of hoarding disorder. Hoarding behavior revolves around material possessions. Hoarders do not usually gather any specific items but accumulate everyday objects and attach personal meaning to them. The psychoanalytic concept of objects is central in the context of hoarding disorder. The theory of the unconscious, human drives, and psychological conflict offer a coherent explanation for the patients’ exceptional attachment to objects. Drive theoretical concepts indicate a strong link between hoarding disorder and pre-genital sexual order and compulsive-obsessive behavior. In particular, aspects of aggression, defense, and inhibition are decisive. The theories of orality and anality also aid our comprehension of this disorder’s roots. Other concepts that are relevant to understanding and treating hoarding disorder are castration anxiety and castration complex. Shame and guilt are also central to hoarding. These various psychoanalytic aspects demonstrate that hoarding is more than possessing too many things; it is a complex interplay of psychological aspects, many of which take root in early childhood trauma and basic human fears. Knowing about these aspects aids not only our general understanding of the disorder but also the diagnostic process. Therefore, I have devoted a whole section on the diagnostic considerations, including symptoms and comorbidities, and the spectrum nature of hoarding. The diagnostic manuals are essential in determining when to draw the line and answering at what point hoarding becomes pathological. We need to be aware that politics and finances influence many of the decisions taken in this context. We need to be aware of the entities that may be interested in supporting and funding the ICD or DSM. We need to ask what implications these entities’ decisions have for professionals and patients. For example, the World Health Organization regularly publishes data on the rapid rise of mental health issues and interest in treatment options. The question is how this interest relates to the work of psychotherapists and other professionals in the field. We also need to know how these developments affect our standing and overall professional field. The third chapter presents specific treatment recommendations. They derive from practical experience and focus on the options that are evidenced to be most fruitful and suitable. They range from individual and group therapy to support groups and home visits. I also touch upon pharmacotherapy and emphasize the importance of adapting treatment to individual needs by combining different methods. The treatment matrix illustrates different treatment options and how they can benefit each other for maximum success. Specific recommendations for how to interact with HD patients aid the overall process. Transference and countertransference, denial, shame, and guilt are essential factors that professionals must consider.

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Moreover, professionals must not neglect the situation of relatives and, particularly, children affected by parental hoarding. The issue of child welfare is particularly delicate and should be considered with the greatest of care. A step by step intervention concept can aid the process of appropriately addressing these issues in practice. Current research findings and international studies substantiate my discussion of the special features and challenges of HD treatment. Consequently, I provide an extensive and in-depth analysis of hoarding disorder and demonstrate, once more, the importance of psychoanalytic theory. The ego functions from ego psychology are linked to hoarding and demonstrate the relevance of defense mechanisms. The Kleinian school provides further insights by expanding Freudian concepts related to objects in terms of the human other. Klein’s theory deepens our understanding of psychological processes and intra-psychic conflict. This also helps us explain how hoarding satisfies the need for safety. This need directly relates to the patients’ defense against inner destructive forces. Attachment theory and Winnicott’s work provides further valuable findings. The concept of the transitional object elucidates vital aspects of hoarding disorder by postulating the existence of a psychological interspace. Besides Klein and Freud, Winnicott’s theory also offers a plethora of ideas and concepts that are highly interesting in discussing any psychological phenomena, including hoarding disorder. The French psychoanalytic school, especially the works of Grunberger, also offers explanations for inner psychological conflict as being one of the prime causes of hoarding. The development of the super-ego and ego-ideal is worth considering, and narcissistic concepts also influence hoarding behavior. Considering the complex nature of hoarding disorder and its treatment, I would like to emphasize the importance of interdisciplinary work and exchange between professionals. Clinicians are required to interact and exchange, and the whole academic world is challenged to look beyond individual disciplines and achieve cooperation and convergence. This will ultimately benefit both professionals and patients. In summary, I would like to give a brief overview of some of the most notably conclusions to be taken away on the relevance of psychoanalysis for hoarding disorder research and treatment: Psychoanalytic aspects of hoarding disorder – The main symptom of hoarding disorder, i.e., the excessive hoarding of seemingly worthless items, evokes basic human drives, albeit in a shifted and distorted way (cf. [2]) – The unconscious surfaces and makes inner processes visible in the active living areas of patients – Aspects of orality and anality contribute to an understanding of hoarding disorder and its pathology – Psychoanalytical considerations of shame and guilt enable a broader understanding of hoarding – Psychoanalysis of one’s own limits, inhibitions, and difficulties in dealing with those affected enables and opens new treatment and care scope

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The present work was largely developed from qualitative research and is based on a critical-hermeneutic approach. However, as stated at the beginning of this section, this approach is strongly influenced by my own attitude and my belief in psychoanalytic theory and practice. I would like to quote one of my most important teachers: Why it [psychoanalysis] still maintains its justification today, and perhaps more than ever, is not only due to the wealth of enabling insights, hypotheses and reflections, but simply to its beauty in itself because it  - the psychoanalytic method  makes the direct and amazing connection of aesthetics and ethics present and alive to us, as only a truly aesthetic object can. ([3], p. 196) My concern is also to awaken other professionals’ curiosity and interest in psychoanalytic theories and thinking. Psychoanalysis has yielded profound insights into the human psyche, many of which are threatened to be overshadowed and forgotten. This work should counteract this questionable development and clarify just how relevant psychoanalysis is today. As a side note, psychoanalysis still exists far from the global psychological and psychiatric research, and there are apparent intersections. However, despite certain parallels, psychoanalytic theory has not found its way into the current mainstream academic landscape. A shift in attention would necessitate extensive political debate between the various disciplines. As long as each discipline publishes its research results exclusively in journals specifically designed for its purpose, hardly any exchange can occur. There is hardly any room within individual disciplines to discuss other findings, which means that there is no chance of engaging in fruitful mutual exchange or identifying mutually exclusive positions. Therefore, this publication also attempts to contribute, even if just a small one, to create a new perspective on the sciences that would allow each discipline to go beyond its own horizons. In 2013, the DSM-5 was released with some revisions and new classifications. This new edition reduced the number of diagnoses by 15 compared to the DSM-IV. Some previously quite persistent disorders, such as burnout syndrome, were no longer included. However, hoarding disorder was included as a new mental health problem. The ICD-11 followed suit and defined hoarding disorder as a separate diagnosis. In light of these changes, it is important to note that neither individuals nor institutions must accept and adapt to seemingly unavoidable trends. The definition of a new mental disorder has far-reaching consequences for many different entities involved, most importantly for the patients and the professionals offering care and support. Then, the prime question is how to deal with such developments in the future and how to address inevitable conflict and find a feasible solution (cf. [4]). How can we influence future developments and changes and manage them? Which factors do we need to consider to aid the necessary interdisciplinary work? Again, the point is not to submit ourselves and adapt to new trends without questioning them. The challenge is for us to probe current developments and create a common ground; psychoanalysis provides the means and concepts for this. This is also why it is so vital to consider the social aspects of hoarding and other disorders.

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5  Concluding Remarks and Future Prospects

After all, the future is what we make of it and how we design it with today’s resources. In the context of hoarding disorder, this means that there is still a lot to uncover. Much theorizing and exploring, analyzing and probing are necessary. This psychoanalytic manual for HD professionals provides the foundation for this work, presenting the many facets of the disorder and the missing link between them. This book by no means claims to be a full account of hoarding disorder. Since it is a new psychological phenomenon, it is not possible to capture it in its entirety yet. Based on its broad perspective and inclusion of individual cases and its theoretical basis, this book lends itself perfectly as a first tool to achieving a more holistic view of hoarding disorder. The above is to say: the development and treatment of hoarding disorder have yet to be researched at length. At the moment, we still know very little about this mental disorder. Consequently, we are also in need of establishing and expanding treatment and care options. We also need to find new ways of fostering the exchange between patients, their relatives, and professional groups involved. Together, we can create a space where clinical experience and theoretical study can converge and achieve a complete picture of the disease. Most of all, I hope that we will continue to be able to work with patients in an appreciative and caring manner—regardless of how the situation will develop. To focus on the patients and provide them with relief should be the prime goal of any future endeavor. It is their accounts, their willingness to share, which will ultimately help us comprehend hoarding and develop a system in which their distress can be alleviated, if not prevented.

References 1. Mentzos S. Lehrbuch der Psychodynamik. Die Funktion der Dysfunktionalität psychischer Störungen. Göttingen: 3. Aufl. Vandehoeck & Ruprecht; 2009. 2. Freud S. Character and anal erotism. Standard ed. 9; 1908b. 3. De Mendelssohn F. Das psychoanalytische Subjekt. Schriften zur psychoanalytischen Theorie und Technik. Wien: SFU-Verlag; 2010. 4. Popp R. Einblicke, Ausblicke, Weitblicke. Aktuelle Perspektiven in der Zukunftsforschung. Münster: Lit; 2016.

6

Diagnostic Tests

Introduction I want to wrap up this book by providing a brief overview of test methods to diagnose hoarding disorder. In total, I present six different tests that are commonly used in assessing a patient’s mental health and hoarding behavior. The first test represents a brief self-assessment questionnaire created as part of a diploma thesis by Gina Kaissidis (former Borsos) at Sigmund Freud University. The other five methods are well-established measures to diagnose and assess the severity of hoarding disorder. They are listed in the Oxford Handbook of Hoarding and Acquiring [1], edited by Randy O. Frost and Gail Steketee. The handbook provides an outstanding resource for professionals and detailed further information. Messie Quick Test Gina Kaissidis’ Messie Quick Test is a ten-item questionnaire. It is a quick method to assess the patient’s hoarding severity. Items 1–4 are the core of this test. Question 1 is particularly relevant because, if a patient answers this question negatively, a life-threatening condition can be assumed. Question 4 help determine whether a patient is messy or a Messie (Table 6.1). Scoring the Messie Quick Test: For items 1, 2, 3, 7, 8, and 10, reverse the score as follows: –– –– –– ––

Strongly agree means 1 point = 4 points. Agree means 2 points = 3 points. Disagree means 3 points = 2 points. Strongly disagree means 4 points = 1 point.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 N. Agdari-Moghadam, Hoarding Disorder, https://doi.org/10.1007/978-3-030-72342-2_6

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6  Diagnostic Tests

Table 6.1  Messie Quick Test (cf. [2]) Strongly agree 1 2

3 4

5 6 7

8 9

10

Agree

Disagree

Strongly disagree

Do you have difficulty receiving a doctor’s home visit even when you are sick? Are there bags and boxes full of things in your home because you do not know where else to store them? Do you sometimes find the state of your home distressing? Could you manage to clean your home within a day to receive guests for a festive dinner? Do you enjoy inviting friends and family into your home? Do you regularly (at least once a month) welcome visitors into your home? Is your home cluttered with things so that you sometimes must be careful not to step on anything? Do you have difficulty throwing things away even when they are broken? Do you know exactly where you currently store your documents (e.g., registration certificate)? Do you have difficulty focusing on one subject, especially when cleaning?

If a question is not answered then the test is foregone. Add the scores of items 1–10. The total score can range from 10 to 40 points. Results below 23 indicate no problems. A total score of 26.5 or above warrants attention; a total score between 23 and 26 suggests a gray area and a possible transition toward hoarding disorder. The average score for people with hoarding disorder is 31.74. The average score for the control group in Kaissidis’ research is 14.20. Hoarding Rating Scale Interview (HRS-I) The Hoarding Rating Scale Interview [3] is a brief semi-structured interview that serves both as a diagnostic tool and a method to assess hoarding severity. Current research findings substantiate the assumption that HRS-I delivers both high reliability and validity. The questionnaire consists of five questions, each addressing one of the main symptoms: clutter, difficulty discarding, acquisition, distress, and impairment. A suspected sufferer can answer the questions by rating their difficulty with the five aspects on a scale from 0 for “Not at all difficult” to 8 “Extremely Difficult.” The five questions are:

6  Diagnostic Tests

179

Hoarding Rating Scale Interview (HRS-I) 1. Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home? 1

0 Not at all

2 Mild

3

4 Moderate

5

6 Severe

7

8 Extreme

2. To what extent do you have difficulty discarding (or recycling, selling, giving away) ordinary things that other people would get rid of? 1 Mild

0 None

2

3 4 Moderate

5 Severe

7

6

8 Extreme

3. To what extent do you have a problem with collecting free things or buying more things than you need or can use or afford? 0

1

2

3

4

5

6

7

8

0 = No problem 2  =  Mild, occasionally (less than weekly) acquiring items not needed, or acquiring a few unneeded items. 4 = Moderate, regularly (once or twice weekly) acquiring items not needed, or acquiring some unneeded items. 6 = Severe, frequently (several times per week) acquiring items not needed, or acquiring many unneeded items. 8 = Extreme, very often (daily) acquiring items not needed, or acquiring large numbers of unneeded items 4. To what extent do you experience emotional distress because of clutter, difficulty discarding, or problems with buying or acquiring things? 0 Not at all

1

2 Mild

3

4 Moderate

5

6 Severe

7

8 Extreme

5. To what extent do you experience impairment in your life (daily routine, job/ school, social activities, family activities, financial difficulties) because of clutter, difficulty discarding, or problems with buying or acquiring things? 0 Not at all

1

2 Mild

3

4 Moderate

5

6 Severe

7

8 Extreme

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Saving Inventory-Revised (SI-R) The Saving Inventory-Revised [4] is a 23-item questionnaire. It represents a self-­ report measure to assess the severity of hoarding disorder. The SI-R consists of three parts, each of which reflects one of the main symptoms of pathological hoarding. It includes nine questions on the clutter in the patient’s home, seven questions on their difficulty discarding possessions, and seven questions on their acquisition behavior. UCLA Hoarding Severity Scale (UHSS) The UCLA Hoarding Severity Scale [5] is a semi-structured interview consisting of ten questions. The scale is designed for use in conjunction with a clinical interview. Professionals can include additional questions to clarify answers and increase accuracy. Therefore, the UHSS enables professionals to counteract typical problems of self-report measures. The UHSS is a suitable method for both diagnosing hoarding disorder and assessing the symptom severity. Home Environment Index (HEI) As is well known, hoarding and severe clutter can cause sanitation problems in a sufferer’s home. The Home Environment Index [6] is a tool to assess these sanitation risks. The method represents a self-assessment questionnaire. It consists of 15 questions designed to assess the level of squalor and clutter. The questionnaire considers both the patient’s housing conditions and personal hygiene. Clutter Image Rating (CIR) The Clutter Image Rating [7] provides a useful measure of clutter. The method is designed to generate an accurate estimate of a patient’s problem with clutter, based on the assumption that people have different ideas about what a cluttered home looks like. The Clutter Image Rating consists of a series of pictures of rooms that are cluttered to different extents. Nine images are provided for each room (kitchen, bedroom, and living room), ranging from entirely clutter-free to severely cluttered. Professionals can show these images to a suspected HD patient and ask them to select the image best representing their homes. Studies have evidenced high test-­ retest reliability rates and high inter-rater reliability.

References

181

References 1. Frost RO, Steketee G, The Oxford Handbook of Hoarding and Acquiring, Oxford University Press, 2014, https://doi.org/10.1093/oxfordhb/9780199937783.013.01. 2. Kaissidis G.  Der Messie Quick Test. Eine Quantitative Studie anhand einer empirischen Fragebogenuntersuchung. Wien: Diplomarbeit an Sigmund Freud Privatuniversität; 2012. 3. Tolin DF, Frost RO, Steketee G.  A brief interview for assessing compulsive hoarding: the hoarding rating scale-interview. Psychiatry Res. 2010;178(1):147–152. 4. Frost RO, Steketee G, Grisham J.  Measurement of compulsive hoarding: saving inventory-­ revised. Behav Res Ther. 2004;42:1163–1182. 5. Saxena S, Ayers CR, Dozier ME, Maidment KM. The UCLA hoarding severity scale: development and validation. J Affect Disord. 2015;175(1):488–493. 6. Rasmussen JL, Steketee G, Frost RO, Tolin D, Brown TA. Assessing squalor in hoarding: the home environment index. Community Ment Health J. 2014;50(5):591–596. 7. Frost RO, Steketee G, Tolin DF, Renaud S. Development and validation of the clutter image rating. J Psychopathol Behav Assess. 2008;30:180–192.

Index

A Anality, 39–41 Animal hoarding, 85–87 Assumptions, 29 Austria hoarding research, history, 1–4 International state, research, 6–10 philosophical aspects, 18, 19 social and cultural factors, 10–25 terminology, 4, 5 Autoeroticism, 52 C Cautious, 146–149 Clutter Image Rating (CIR), 180 Commodity fetishism, 14 Communicative, 141–145 Comorbidity, 134, 137 Consumption, 11 Countertransference phenomena, 116 D Dedicated, 154–159 Diagnostic and Statistical Manual of Mental Disorder (DSM), 2 E Envy, 60 Existential shame, 48 F Fetishism, 11–13 Fighter, 149–153 Fundamentals, hoarding disorder anality, 41–46

causal factors, 33, 34 causes, 33 comorbidity, 80–84 development, 35 diagnosis, 75–79 diagnostic considerations, 70, 71 diagnostic manuals, 71–75 ego development, 35–37 epidemiology, 69, 70 French psychoanalytic concepts, 61–65 Greed, 60 object relations theory, 54, 55 orality, 37–39 projective identification, 55–59 Shame, 46–51 spectrum disorder, 84–87 symptoms, 66–69 theoretical considerations, 29–32, 52 G Greed, 59, 60 H Hoarding disorder, 29–44, 46, 47, 52–54, 56–66, 68, 69, 72–74, 167, 171–176 Hoarding Rating Scale Interview (HRS-I), 178, 179 Home Environment Index (HEI), 180 Housing, 19, 20 I Ideality shame, 48 Intentionality, 111–114 Intercommunication, 121, 122 Interdisciplinary exchange, 127, 128 International Classification of Diseases (ICD), 2

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 N. Agdari-Moghadam, Hoarding Disorder, https://doi.org/10.1007/978-3-030-72342-2

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Index

184 L lonely, 163–167 M Messie Quick Test, 177, 178 N Narcissism, 52, 65 Negotiation, 122 O Object love, 53, 54 Oedipal shame, 48–51 P Partial love, 53 Perception, 111 Pharmacotherapy, 98 Psychoanalysis, 8 Psychoanalytic theory, 29, 171 Psychodynamic aspects, 134, 135, 168, 169 aggression, 140 Mr. U comorbidity, 147 experiences, 147 fear, 148 psychological stress, 148, 149 relationships, 148 subjective causal theories, 146, 147 Mr. Y comorbidity, 160 experiences, 161 fear, 162 psychological stress, 162, 163 relationships, 161, 162 subjective causal theories, 159, 160 Mr. Z comorbidity, 164 defensive behavior, 166 experiences, 164, 165 psychological stress, 166, 167 relationships, 165 subjective causal theories, 163, 164 Ms. O aggression, 139 comorbidity, 137 experiences, 137 fear of loss, 138 relationships, 138 subjective causal theories, 136, 137

Ms. P aggression, 144, 145 comorbidity, 143 experiences, 143 relationships, 144 subjective causal theories, 141, 142 Ms. V comorbidity, 150, 151 fear, 151–153 psychological stress, 153, 154 relationships, 151, 152 subjective causal theories, 150 Ms. X, 154 anxiety, 157, 158 comorbidity, 155 experiences and fear of loss, 156 psychological stress, 158, 159 relationships, 156, 157 subjective causal theories, 154, 155 psychological stress, 135, 136 relationships, 134, 135 subjective causal theories, 133, 134, 137, 142 Psychological stress, 135, 136, 140, 141, 145, 146 R Reasonable, 136, 137, 140, 141 Relationships, 135 S Saving Inventory-Revised (SI-R), 180 Seeker, 159–163 Skill reorientation, 123 Spectrum disorder, 85, 86 Support group, 96, 97 T TH-I-N-G-S intervention concept, 93, 121 Threefold movement, 25 Transference, 116 Transitional Objects and Transitional Phenomena, 108 Transitional phenomena, 110 Treatment recommendations, 93, 94 attitude, 103 Bowlby’s attachment theory, 105–108 challenges, 115 countertransference, 116, 117 disease progression, 119, 120 disgust, 118, 119

Index ego psychology, 110–112 family members, 124, 125 general guidelines, 102 group therapy, 96 guilt, 118 individual therapy, 94, 95 inhibitions, 114 interdisciplinary exchange, 127–129 limitations, 115 patient home visits, 97, 98 perspective of children, 125–127 pharmacotherapy, 98

185 relationship work, 104, 105 support group, 97 TH-I-N-G-S, 121, 123 transference, 116 transitional objects, 108–110 treatment matrix, 99–101 trivialization, 117, 118 Trivialization, 117 U UCLA Hoarding Severity Scale (UHSS), 180