Interpersonal attachment, early family environment, and trauma in hoarding: A systematic review

doi:10.1016/j.cpr.2021.102096

Clinical Psychology Review

Volume 90, December 2021, 102096

https://doi.org/10.1016/j.cpr.2021.102096 Get rights and content

Highlights

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Insecure attachment and trauma exposure are linked to more severe hoarding.
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Low family warmth and high control is linked to more severe hoarding.
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Specificity of these factors to hoarding over other disorders remain unclear.
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Methodological problems and small samples limit findings.
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Replicative and longitudinal research is needed.

Abstract

The formation of intense emotional attachments to objects, difficulty parting with possessions, and the extreme accumulation of clutter are key features of Hoarding Disorder (HD). Although substantial literature implicates processes such as dysfunctional beliefs and maladaptive emotional cycles in HD, little is known about the vulnerability factors that lead to their development and hoarding symptomatology. The current review sought to systematically collate and integrate findings from studies investigating the relationship between hoarding symptoms and three proposed vulnerability factors: i) interpersonal attachment, ii) early family environment, and iii) traumatic or adverse life events. A comprehensive search of the databases PsycInfo, PubMed, and Scopus identified a total of 39 studies for inclusion. The results presented a complex pattern that supported the presence of relationships between insecure attachment, cold and controlling family experiences, and exposure to adverse life events with increased hoarding severity. However, the specificity of these factors to HD over other clinical groups remains unclear and findings are limited by the heterogenous and small number of studies. We conclude by discussing the clinical implications and limitations of these findings and propose new directions for future research.

Section snippets

Research gap: Development of hoarding

Overall, the cognitive behavioural model provides a valuable and empirically supported framework for understanding the mechanisms by which hoarding symptoms are maintained and reinforced. However, major gaps remain in our understanding of the aetiology of HD and the factors and processes involved in its development. Despite evidence that individuals who hoard are excessively attached to their possessions and hold maladaptive beliefs about them, the ways in which developmental factors contribute

Interpersonal attachment insecurity

First proposed by Bowlby (1969/1997), attachment theory posits that humans have an innate tendency to seek proximity to significant others as a way of eliciting care and protection in situations of threat, distress, or uncertainty. Over time, individuals internalise the responses of their early attachment figures (e.g., parents) to this care-seeking, and develop internal working models which influence their expectations of themselves, others, and the environment (Sherman, Rice, & Cassidy, 2015

Early family environment

Broader aspects of the family environment, such as parenting style and family emotional climate, have also been shown to be important factors influencing a child's development and learning. Parental behaviours and family environments characterised by high emotional warmth, support, and appropriate boundaries have been found to predict positive psychological functioning in children (Milevsky, Schlechter, Netter, & Keehn, 2007; Smokowski, Bacallao, Cotter, & Evans, 2015). In contrast, parenting

Traumatic life events

Exposure to adverse life events has been well-established as a vulnerability factor for various psychological disorders (e.g., eating disorders, Borderline Personality Disorder; Porter et al., 2020; Trottier & MacDonald, 2017) and more general internalising and externalising difficulties (Curran, Adamson, Rosato, De Cock, & Leavey, 2018). Early hypotheses regarding hoarding suggested that it may be linked to experiences of material deprivation (Adams, 1973). While subsequent studies have

Review aims

In summary, HD is a debilitating condition associated with a high level of burden and impairment across multiple life domains. Although the cognitive behavioural model provides a good account of the processes by which hoarding symptoms are maintained, there remains a lack of cumulative evidence linking broader vulnerability factors to the development of hoarding symptomatology. A clearer understanding of the factors that contribute to the development of hoarding will improve our knowledge of

Method

The current systematic review was conducted following the guidelines listed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2009).

Results

Of the 39 identified papers, 12 reported on outcomes related to interpersonal attachment, seven on early family environment, and 25 on traumatic or stressful life events. Six papers examined more than one variable of interest (Barton, Salkovskis, & Walters, 2021; Frost, Kyrios, McCarthy, & Matthews, 2007; Kehoe & Egan, 2019; Kellett, Greenhalgh, Beail, & Ridgway, 2010; Kings, Knight, & Moulding, 2020; Kyrios et al., 2017). Table 1, Table 2, Table 3 summarise each study's details.

Discussion

The past two decades have seen a proliferation of research on and advancement in understanding of HD, centring around Frost and Hartl (1996)’s seminal cognitive behavioural model. However, much is still unknown regarding the pathways underlying hoarding development and vulnerability factors associated with the condition. To address this research gap, the current study conducted a comprehensive systematic review to collate and synthesise the evidence on hoarding and three potentially important

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

Kerryne Chia: Conceptualisation, Methodology, Investigation, Data Curation, Writing – Original Draft. Jessica Grisham: Conceptualisation, Methodology, Writing – Review & Editing. Dave Pasalich: Conceptualisation, Writing – Review & Editing. Daniel Fassnacht: Methodology, Writing – Review & Editing. Kathina Ali: Methodology, Investigation, Writing – Review & Editing. Michael Kyrios: Conceptualisation, Methodology, Writing– Review & Editing. Bronte Maclean: Investigation. All authors have read

Declaration of Competing Interest

All authors declare they have no conflicts of interest.

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Cluttered spaces, strained bonds: Examining the correlation between hoarding symptoms and social functioning among long-term care facilities older adult residents
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Symptoms of hoarding, such as the inability to part with possessions, leading to significant clutter, are commonly observed among residents in long-term care facilities in Egypt. This behavior significantly impacts their social interactions and functioning. Therefore, this study examined the relationship between hoarding symptoms and social functioning among older adult residents in long-term care facilities.
The study employed a cross-sectional survey on a purposive sample of 300 older adults.
Saving Inventory-Revised and Functional Idiographic Assessment Template-Questionnaire-Short Form were used.
The findings revealed a significant positive correlation between hoarding symptoms and social functioning (r = 0.682, p < 0.000). A linear regression analysis supported this correlation, establishing hoarding symptoms as a significant predictor of social functioning (adjusted R2 = 0.32).
The current study highlighted that a significant proportion of long-term care older adult residents displayed moderate hoarding symptoms and compromised social functioning. A noticeable positive association was observed between hoarding symptoms and social functioning. These results underscore the potential impact of hoarding symptoms on various aspects of social functioning. Given these findings, long-term care nurses should comprehend the various facets of compulsive hoarding behavior and devise effective strategies for assessment and intervention. Establishing support groups within these facilities could provide a platform for these residents to share their experiences and coping strategies. This could reduce interpersonal conflicts and argumentativeness and foster emotional expression and intimacy.
Childhood environmental unpredictability and hoarding: Mediating roles of attachment and security
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Life history theory provides a unified perspective for understanding human behaviors as adaptive strategies to specific environmental conditions. Within this theoretical framework, hoarding emerges as a behavior reflecting an evolved strategy in response to unpredictable environmental challenges, serving as a buffer against resource scarcity and enhancing survival prospects. This study aimed to explore the key roles of childhood environmental unpredictability, attachment, and sense of security in the development of hoarding. 662 participants completed scales on childhood environmental unpredictability, Revised Experiences in Close Relationships (ECR-R), sense of insecurity, and Savings Inventory-Revised (SI-R). The results showed that childhood environmental unpredictability was significantly positively correlated with hoarding. Attachment anxiety and sense of security individually mediate the effect of childhood environmental unpredictability on hoarding. Additionally, ‘attachment anxiety--sense of security’ and ‘attachment avoidance--sense of security’ serve as chain mediators in this relationship separately. This study offers insights into the cognitive-behavioral model of hoarding, highlighting the importance of life history theory in examining childhood environmental unpredictability's relationship with hoarding. It also integrates insights from the psychosocial acceleration theory into our comprehension of hoarding's development. Future research directions are also discussed.
Hoarding disorder: Questions and controversies
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Hoarding disorder (HD) is characterized by distress and difficulty letting go of possessions, leading to clutter that congests living spaces and interferes with daily activities. HD is common, with an estimated overall pooled prevalence of 2.5% of the general population. Because it is a relatively newly defined disorder, there are questions and controversies regarding its diagnosis and treatment that warrant exploration. In this manuscript, we clarify diagnostic boundaries between HD and related neuropsychiatric conditions, and consider how both shared and unique features of HD may inform strategies for treatment. We additionally discuss specific manifestations of hoarding behavior (e.g., animal hoarding); review motivations, beliefs, and characteristics that may contribute to hoarding behaviors; examine available evidence regarding the efficacy of different treatment modalities; highlight the challenges of engaging individuals who do not want care; and suggest a potential explanatory model for insight impairment in HD.
High levels of loneliness in people with hoarding disorder
2023, Journal of Obsessive-Compulsive and Related Disorders
Attachment theory suggests that hoarding is an attempt at compensating for unmet relatedness needs. We therefore expect high loneliness levels in hoarding disorder (HD). While previous studies have shown a positive association between hoarding and loneliness in non-clinical samples, few studies have examined loneliness levels in clinical HD samples. In Study 1, we examined loneliness in a treatment-seeking HD sample (n = 39). Results showed that 87.2% of HD sufferers reported high loneliness levels, which was significantly higher than loneliness rates in community samples. Loneliness was positively associated with hoarding severity even after controlling for depression. In Study 2, we examined loneliness in MTurk workers with clinical levels of hoarding (high hoarding [HH] group; n = 305) compared to MTurk workers with low hoarding symptoms (LH group; n = 775). Results showed high loneliness levels in 77.7% of participants in the HH group compared to 36.8% in the LH group. Differences remained significant for HH vs LH groups matched on depression. The positive association between loneliness and hoarding was also significant even after controlling for age, gender, marital status, and depression. Our results underscore the importance of assessing and addressing loneliness in the HD treatment.
Extending the cognitive-behavioral model of Body Dysmorphic Disorder: The role of attachment anxiety and self-ambivalence
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This study aimed to extend the cognitive-behavioral model of Body Dysmorphic Disorder (BDD) by exploring the role of insecure attachment and self-ambivalence on the relationship between two specific cognitive factors, namely appearance orientation (seeing the self as an aesthetic object) and appearance evaluation (negative appraisal of internal body image), on levels of BDD severity. A convenience sample of 304 Australian residents (72.4% females) completed online self-report measures; 53% reported clinical or subclinical levels of BDD. Attachment anxiety and self-ambivalence were both associated with BDD severity, as were both cognitive factors. The direct effect of attachment anxiety was no longer significant after controlling for self-ambivalence, appearance orientation and evaluation. However, significant specific indirect effects were found suggesting that individuals who report greater levels of insecure attachment and self-ambivalence exhibit greater appearance orientation and negative appearance evaluation which, in turn, results in higher levels of BDD. The indirect effect through self-ambivalence was strongest suggesting a central role of self in the relationship between attachment anxiety and BDD severity. The current research demonstrates the importance of attachment anxiety and self-ambivalence in the context of BDD and implicates their potential role in treatment; however, further clinical studies are needed.
Early life stress in adults with hoarding disorder: A mixed methods study
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Traumatic life events are common among individuals with hoarding disorder (HD), though rates of posttraumatic stress disorder are no higher than in other groups. HD symptoms typically begin to appear in mid-childhood, and early life stress (ELS) is a known associated feature of negative mental health outcomes. The specifics of this relationship are still unclear.
We obtained Early Life Stress Questionnaire (ELSQ) responses from 35 participants with HD, 22 participants with obsessive-compulsive disorder (OCD), and 23 non-clinical control participants. We combined these quantitative data with qualitative interviews exploring what role ELS experiences play in HD.
Per the ELSQ, individuals with HD reported significantly more ELS events than the non-clinical control participants. In qualitative interviews, HD participants described the ELS events that were most impactful in shaping their relationship to material possessions; these events tended to be long in duration and elicited feelings of scarcity of emotional support. Participants described relying on possessions in place of relationships and viewed possessions as potential sources of connection to peers.
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Review ArticleInterpersonal attachment, early family environment, and trauma in hoarding: A systematic review

Highlights

Abstract

Section snippets

Research gap: Development of hoarding

Interpersonal attachment insecurity

Early family environment

Traumatic life events

Review aims

Method

Results

Discussion

Funding

Author contributions

Declaration of Competing Interest

Psychiatry Research

Journal of Affective Disorders

Clinical Psychology Review

Comprehensive Psychiatry

Psychiatry Research

Journal of Obsessive-Compulsive and Related Disorders

Behaviour Research and Therapy

Psychiatry Research

Psychiatry Research

Journal of Psychiatric Research

Comprehensive Psychiatry

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Obsessive-Compulsive and Related Disorders

Psychiatry Research

Behaviour Research and Therapy

Journal of Experimental Social Psychology

Journal of Obsessive-Compulsive and Related Disorders

Journal of Anxiety Disorders

Journal of Affective Disorders

World Psychiatry

Public Health

Personality and Individual Differences

Journal of Obsessive-Compulsive and Related Disorders

Journal of Anxiety Disorders

Journal of Affective Disorders

Journal of Obsessive-Compulsive and Related Disorders

Journal of Psychosomatic Research

Behaviour Research and Therapy

Journal of Psychiatric Research

Journal of Psychiatric Research

Developmental Review

Clinical Psychology Review

Asian Journal of Psychiatry

Obesessive children: A sociopsychiatric study

Patterns of attachment: A psychological study of the strange situation

Diagnostic and statistical manual of mental disorders

Reasons to accumulate excess: Older adults who hoard possessions

Home Health Care Services Quarterly

Age at onset and clinical features of late life compulsive hoarding

International Journal of Geriatric Psychiatry

Investigating the diagnostic specificity of attachment and relational needs in hoarding disorder

Journal of Obsessive-Compulsive and Related Disorders

Attachment

An overview of problematic eating and food-related behavior among foster children: Definitions, etiology, and intervention

Child and Adolescent Social Work Journal

Parenting style and youth outcomes in the UK

European Sociological Review

A prospective test of cognitive vulnerability to obsessive-compulsive disorder

Cognitive Therapy and Research

Problematic eating and food-related behaviours and excessive weight gain: Why children in out-of-home care are at risk

Australian Social Work

Profiles of childhood trauma and psychopathology: US national epidemiologic survey

Social Psychiatry and Psychiatric Epidemiology

Resilience despite complex trauma: Family environment and family cohesion as protective factors

The Family Journal.

Early unpredictability predicts increased adolescent externalizing behaviors and substance use: A life history perspective

Development and Psychopathology

Review Article
Interpersonal attachment, early family environment, and trauma in hoarding: A systematic review