ADHD & Hoarding | ADHD Awareness Month

ADHD and Hoarding disorder, it really is a very complex puzzle.

This month is ADHD awareness month, so at Clouds End we are taking some time to have a think about how ADHD and hoarding interact.

But first I’d like to give two apologies.

The interaction between ADHD and hoarding is not straightforward, with many researchers still trying to unpack the relationship between the two.

As such this post is: 1- more detailed than previous ones, as there are some key pieces of nuance that would be an injustice to leave out.

2- Nevertheless, there are many simplifications and aspects that I have had to skip over- or else this blog would turn into another thesis!

Please note: Throughout this blog I use a few phrases to distinguish between different kinds of people.

I use “hoarding behaviour” to discuss times when a person may show excessive clutter, but not have hoarding disorder, but perhaps as a result of another cause. “Those with hoarding difficulties” denotes when a person has issues that comes about as a result of their hoarding and “hoarding disorder” when a person has been given a diagnosis of hoarding disorder by a clinician.

ADHD in Hoarding Disorder

First things first, ADHD is characterised by psychologists as including persistent pattern of inattention and/or hyperactivity (trouble staying focused, and/or feeling restless of overactive) that impacts a person’s life (1).

For those with ADHD, sustaining attention on a task for a prolonged period, information processing and other brain processes are more difficult. We see a similar pattern in those with hoarding disorder, particularly difficulty in maintaining attention.

Those who struggle with hoarding difficulties are more likely to report that they have greater difficulty with attention and score higher on measures of ADHD than those who don’t struggle with hoarding (2, 3).

These findings were matched in the psychology lab. When asked to do attention tasks those with hoarding disorder struggle with sustained attention (being able to concentrated for a longer period of time) more than “typical” control participants- those without any psychological condition (4).

And in fact, we know that in those with hoarding disorder the level of attention difficulty can predict hoarding severity (5).

However, we know that this isn’t the only cognitive (thought-related) difficulties we find in those who hoard, we know that those who hoard also struggle with difficulties in memory confidence (how sure a person is that they will remember something later on) and decision-making, to name a few.

The differences in memory and decision-making difficulties highlights helpful nuances when understanding differences between ADHD and hoarding disorder.

For example, it has been shown that those with hoarding disorder report difficulties with memory, particularly confidence in their memory (6). This differs somewhat compared to those with ADHD, who seem to have greater difficulties with working memory (the ability to hold and use information to do a task) (7).

And although both those with ADHD and hoarding disorder show difficulties when making decisions, this presents differently. Those with ADHD show difficulties when making decisions due to higher levels of impulsivity (8). Compare this to those who hoard, who particularly struggle over-deliberating a form of perfectionism where a person finds it difficult to decide for fear of making the wrong decision (9).

If you like, those with ADHD make the first choice that comes to mind, whereas those who hoard struggle to decide because they spend a long time weighing them up.

In short, there are elements of hoarding behaviours that can look like difficulties seen in ADHD.

Hoarding behaviour in ADHD

While psychologists have shown inattention to be a key element of ADHD symptoms in hoarding disorder, there are elements of hoarding behaviour that are seen in ADHD.

Dr Sharon Morein and colleagues found that in one UK ADHD clinical, 20% of ADHD patients had significant levels of hoarding behaviours- the control group (those without ADHD) only had 2% of people with significant hoarding (10).

While psychologists are yet to completely unpack why this is the case, I suspect that there are several pathways that may contribute to this relationship, but two that I would like to focus on.

Firstly, a person having ADHD may make hoarding behaviour more likely from an executive-functioning perspective (skills the brain uses for planning, organising and self-control). For example, given that attention deficits are well documented in ADHD, it may be difficult for a person to focus on the task of organising/discarding for a meaningful amount of time.

Additionally, those with ADHD on average show poorer spatial memory (remembering where things are) (11), which makes organising one’s possessions more difficult. In fact, in conversations I’ve had with those who hoard, they will often report that they prefer having everything “out” in their home, rather than put away- because they feel it is easier to remember.

I think these cognitive impacts of having ADHD may make it more difficult for a person to discard, contributing to displaying more hoarding behaviours.

Secondly, those with ADHD are more likely to report traumatic life events compared to those without ADHD (12). We know that experience of traumatic life events is a known contributing factor to the development of hoarding disorder (13). There is perhaps a chance that because those with ADHD (on average) experience more traumatic life events, which may make the development of hoarding difficulties more likely.

Perhaps it is one of these mechanisms, or another even, that explains why we see more hoarding in those with ADHD.

So where does this leave us?

If you’re anything like me, the research on the link between ADHD and hoarding disorder probably leaves you with more questions than answers, but there’s some important practical takeaways we can learn.

First, it is important to note that a person can have ADHD and hoarding disorder, and these will interact- trying to just address one while ignoring the other is likely to only make supporting a person less effective.

Instead it is really important that we try to understand the specific difficulties that a person is facing:

• Do they have ADHD that may be making them more impulsive?
• Does a lack of confidence in their memory mean they hold onto things because they don’t want to forget?
• What is their ability to sustain attention to a task for a prolonged period of time?

Secondly, a person with hoarding disorder may show difficulties with attention should inspire us to be more patient for those that we support.

And lastly, those with ADHD who hoard are likely to struggle with slightly different issues than those without ADHD, particularly when trying focus on the task of discarding for long enough to make a significant amount of time.

My encouragement would be for all people to focus on small, achievable targets. Just spending 5/10 minutes each day on tackling hoarding difficulties is a great way of achieving good outcomes.

Neither difficulties related to ADHD nor hoarding can be addressed in one day, it requires months if not years of self-compassion and non-judgemental support.

 

 

 

References

1. International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https://icd.who.int/browse11. Licensed under Creative Commons Attribution-NoDerivatives 3.0 IGO licence (CC BY-ND 3.0 IGO).
2. Hartl, T. L., Duffany, S. R., Allen, G. J., Steketee, G., & Frost, R. O. (2005). Relationships among compulsive hoarding, trauma, and attention-deficit/hyperactivity disorder. Behaviour research and therapy, 43(2), 269-276.
3. Worden, B. L., & Tolin, D. F. (2023). A pilot exploration of ADHD symptoms in hoarding disorder: co-occurring disorders or part of the hoarding syndrome?. Journal of Affective Disorders Reports, 13, 100588.
4. Woody, S. R., Kellman-McFarlane, K., & Welsted, A. (2014). Review of cognitive performance in hoarding disorder. Clinical psychology review, 34(4), 324-336.
5. Tolin, D. F., & Villavicencio, A. (2011). Inattention, but not OCD, predicts the core features of hoarding disorder. Behaviour research and therapy, 49(2), 120-125.
6. Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour research and therapy, 34(4), 341-350.
7. Alderson, R. M., Kasper, L. J., Hudec, K. L., & Patros, C. H. G. (2013). Working memory deficits in adults with ADHD: A meta-analytic review. Clinical Psychology Review, 33(3), 293–315.
8. Barkley, R. A. (1997, updated 2015). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin.
9. Tolin, D. F., Frost, R. O., & Steketee, G. (2010). “A cognitive–behavioral model of compulsive hoarding.” Depression and Anxiety, 27(5), 463–475.
10. Morein-Zamir, S., Kasese, M., Chamberlain, S. R., & Trachtenberg, E. (2022). Elevated levels of hoarding in ADHD: A special link with inattention. Journal of Psychiatric Research, 145, 167-174.
11. Lynch, F. A., McGillivray, J. A., Moulding, R., & Byrne, L. K. (2015). Hoarding in attention deficit hyperactivity disorder: Understanding the comorbidity. Journal of Obsessive-Compulsive and Related Disorders, 4, 37-46.
12. Rucklidge, J. J., Brown, D. L., Crawford, S., & Kaplan, B. J. (2006). Retrospective reports of childhood trauma in adults with ADHD. Journal of attention disorders, 9(4), 631-641.
13. Landau, D., Iervolino, A. C., Pertusa, A., Santo, S., Singh, S., & Mataix-Cols, D. (2011). Stressful life events and material deprivation in hoarding disorder. Journal of anxiety disorders, 25(2), 192-202.