Some people are extremely neat, while others tend to accumulate a bit of clutter. Some people live in dirt and don’t seem to notice. Then there is the hoarder, whose possessions pile up until his home is a fire and a health hazard.

What goes on in the minds of very messy people? I think they can be separated into two types: those who are disorganized and those who have psychological disorders. The first group includes people who have trouble keeping things orderly.

They may have some spatial organization problems and just don’t know how to handle all the papers and objects that make up their home life. They are overwhelmed by everything, and as they give up in despair, the piles begin to pile up.

These people know they have a problem but cannot find the solution on their own. What they need is a lot of support and some simple systems to fall back on. Organizational consultants are people who have the ability to find the right place to put everything and can help those who suffer from disorder and disorganization to have a more orderly and less chaotic home life.

When even this does not help, it is because the person’s problems are more severe, perhaps they suffer from ADD (attention deficit disorder) and simply cannot cope with trying to keep all their things organized. These people need a lot more support, maybe even medicine, to be able to manage all their papers and possessions.

A more serious form of clutter concerns people who do not clean. We’ve all seen them on dirty house reality shows. These are the people who never change the sheets or the kitchen sponge; who rarely empty kitty litter, dust, sweep, mop, or even scrub a surface. Your kitchen and bathroom are Petri dishes that cultivate pestilence and pests, and yet they persist in their ways.

Chronic non-cleaners live in a nasty, smelly, and unsanitary environment, but they don’t seem too bothered by this, which is in itself a sign of a serious problem. Many of these people have a mental disorder that allows them to create a disorder and then live in it without worry. They may be able to function adequately in other areas of your life, but their psychological problems are demonstrated by the literal dirty secret of their dirty home.

A milder form of this problem are those people who let their dishes pile up in the sink for a week, don’t do laundry for a month, sweep the floor only occasionally, and rarely, if ever, dust. They wouldn’t qualify for TV shows, but the level of clutter and dirt in their homes is unacceptable for a normally clean and tidy person.

These people suffer from low self-esteem, passivity and inertia. They are overwhelmed by life and feel powerless to have any control over things. They have basically given up on themselves and their messiness is just one sign of trouble. They could benefit from supportive psychotherapy.

Finally, there are the hoarders. These people suffer from an extreme disorder. Your overwhelming anxiety and inner chaos is expressed through the need to accumulate as much stuff as possible and the inability to throw away anything, be it old clothes, wrapping papers, newspapers, or even your trash.

When I was in pre-med, I ended up sharing a house with a 27-year-old woman, let’s call her Jenny, who had a form of this problem. On the surface, she was an attractive, well-groomed young woman from a pleasant middle-class family. It was only by living with her that his problem was revealed. The first clue was that he locked his bedroom door and hid the key.

The only time I could see his room, I was surprised. There were so many things piled up on the floor that I had to go through them all to get to the other side of the room. He had invited me in only because he was in a panic: he had lost something in the two-foot-high piles and he needed my help to find it.

Every week Jenny went grocery shopping and came home with enough food to feed a family of six. He was a small person, yet he bought a dozen grapefruits, ten pounds of potatoes, two liters of milk, and three loaves of bread for his own consumption. Each night he cooked a big dinner and then dutifully put the leftovers in a plastic container that he would never look at again.

I checked the fridge and pantry every week, tossing out mushy grapefruits, stale leftovers (container and all), potatoes with long green sprouts, curdled milk, and moldy bread. I wondered at the time if he just missed his family, but later realized he just had to accumulate things. This was further demonstrated by his compulsive shopping; whose evidence lay piled up on her bedroom floor in the form of handbags, scarves, belts, sweaters, jewelry, and assorted shopping bags.

Jenny had filled the room across the hall with her bedroom overflow. One day I came home to find her sitting in the hallway, surrounded by bags, boxes, and stacks of things. He had emptied the room, hoping to sort years of possessions and throw out everything he could. She sat there, paralyzed, for several hours and finally gave up and put everything back in the guest room.

At the time, I thought she was just weird. It was a bit tight and had some strange habits, like stacking all the silverware in the utensil drawer without sorting the various forks, etc. in each slot of the tray. I didn’t realize that your problem had a name. It is actually a form of OCD, obsessive-compulsive disorder. There are many manifestations and compulsive hoarding is particularly challenging.

Jenny started dating Harold and decided to hide her problem from him. On the few occasions when he came to visit, they stayed in the living room. Throughout their entire relationship, Harold never saw his bedroom. I was wondering at the time what it would be like to be intimate with someone and keep such a big secret from them.

I moved in at the end of the year and never saw Jenny again. We got along well as roommates, but her problem made it impossible for us to be close. I thought of her from time to time, and once I was a psychiatry resident, I realized how instructive it had been to come face to face with someone who was described in my textbooks. There is nothing like seeing it first hand to recognize how concerned these people are. And it turns out that hers was a mild case. The most seriously ill cannot contain the disorder and the problem takes over their lives.

It is clear that, with the exception of those who have organizational problems, people living with extreme disorder or hoarding actually show signs of a significant mental disorder. Unless these problems are recognized for what they are and are treated by trained mental health professionals, people living in extremely disorganized, crowded or dirty environments will have no chance of making significant changes towards cleanliness and order.

(C) Marcia Sirota MD, 2010