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Over the years on the front lines, I’ve worked closely with mental health professionals and read whatever I could find on the clinical research. (For a good overview of what’s been published, see the resources listed at the end of the book.)

However, even research psychologists aren’t sure exactly what’s going on. They do know that hoarding is not simply laziness. It is not confined to the poor and undereducated. It is most definitely a psychological disorder. But, like so many disorders, it may be described as a syndrome that is manifested in any number of behaviors.

Researchers also know that hoarders often have other identifiable medical issues, including dementia, obsessive-compulsive disorder, and depression. But they’re still figuring out if the other diseases lead to hoarding or if hoarding triggers them. And it’s not clear whether hoarding is its own mental disorder or a subset of some other category.

Dr. Suzanne Chabaud explains that researchers are discovering that although hoarding is being recognized as a symptom of certain disorders, like dementia and schizophrenia, there are other cases in which they are questioning the connection. For example, do hoarders with depression, anxiety, or attention deficit/hyperactivity disorder (ADHD) hoard because of those disorders, or do they develop those disorders separate from hoarding? Called “co-morbid disorders,” they often develop in tandem, but without clear proof showing that one causes the other.

In my work, I have almost always found there to be another definable mental disorder in evidence. When therapists or counselors like Dr. Chabaud work with hoarders, they try to find out what that other disorder (or disorders) might be, since simply getting a hoarder’s place cleaned up doesn’t address the underlying causes that led to the problem in the first place. The work doesn’t end when the dump truck pulls away from the house. The real work is just getting started.

I don’t play therapist with my clients. I am more of a coach, who also gets involved in the heavy lifting and logistics. But once my part of the job is complete, I want to know that I’ve done everything I can to set these folks on the path to recovery. Understanding the range of conditions that drive or accompany hoarding helps me to do that—and will be invaluable to anyone in this situation.

▶ Obsessive-Compulsive Disorder

Candace, whose story opened this chapter, had been in therapy and was diagnosed with obsessive-compulsive disorder (OCD). She’s not unusual—hoarding has traditionally been linked to OCD. One research study at Johns Hopkins found that up to 42 percent of patients with OCD were also hoarders.

At first glance this doesn’t make much sense. People with OCD are stereotyped as being off-the-charts clean and tidy, with all kinds of rules about items not touching each other and everything being in its special place. That doesn’t sound like hoarding.

Ironically, that obsession is actually the root of the problem. Candace frequently got bogged down while she was trying to get control of her stuff because she couldn’t make the perfect decision about what to do with her things. This dilemma created a constant internal struggle.

Candace would look at a stack of books and want to line them up neatly on a shelf. But of course there was no empty shelf in her house. Based on her behavior during the initial stages of the cleanup, I can only imagine her internal dialogue: “You’re doing this all wrong, you need an empty shelf. Don’t listen to those people trying to help you; they don’t know how to do it correctly. You can do the job way better by yourself. There’s just so much to do besides these books, and wait, you are doing it all wrong!”

So instead of cleaning off a shelf, or maybe deciding to donate the books, Candace became overwhelmed and exhausted and would then just toss the books onto a growing pile. She truly believed she would get to the mess later, but later never came.

Obsessive people can also become overwhelmed by fears: of losing an important