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

What goes on in the minds of very messy people? I think that they can be separated into are two types: those who are disorganized and those who have psychological disorders. The former group includes individuals who have problems with keeping things tidy.

They might have some spacial organization issues and just don’t know how to deal with all the papers and objects that make up their home life. They become overwhelmed by it all, and as they give up in despair, the piles begin to accumulate.

These people know that they have a problem but can’t figure out 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 are skilled at finding the proper place to put everything and can help those who suffer from clutter and disorganization to have a tidier, less chaotic home life.

When even this doesn’t help, it’s because the person’s problems are more severe – perhaps they suffer from ADD – attention-deficit disorder – and simply can’t cope with trying to keep all their stuff organized. These individuals need a lot more support, perhaps even medication, in order to manage all their papers and possessions.

A more severe form of messiness pertains to those people who don’t clean. We’ve all seen them on the reality shows about dirty homes. These are the people who never change their bed sheets or the kitchen sponge; who rarely if ever empty the cat litter, dust, sweep, mop or even scrub a surface. Their kitchen and bathroom are petri dishes growing pestilence and plagues, and yet they persist in their ways.

Chronic non-cleaners are living in an unpleasant, smelly and unhealthy environment, but don’t seem overly upset by this, which is in itself, a sign of a serious problem. Many of these individuals have a mental disorder which allows them to create mess and then live in it without concern. They may be able to function adequately in other areas of their life, but their psychological problems are demonstrated by the literal dirty secret of their filthy home.

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

These folks suffer from low self-esteem, passivity and inertia. They are overwhelmed by life and feel helpless about having any control over things. Basically, they have given up on themselves and their messiness is just one sign of the problem. They could benefit from supportive psychotherapy.

Finally, there are the hoarders. These people have an extreme disorder. Their overwhelming anxiety and internal chaos is expressed through the need to accumulate as much stuff as possible and the inability to throw anything away, be it old clothes, wrapping papers, newspapers or even their garbage.

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. She was, on the surface, an attractive, well-groomed young woman from a nice, middle-class family. It was only in living with her that her problem was revealed. The first clue was that she locked her bedroom door and hid the key.

The one time I did get to see her room, I was shocked. There was so much stuff heaped up on the floor that I had to wade through it all to get to the other side of the room. She’d invited me in only because she was in a panic: she’d lost something in the two-foot-high piles and needed my help in finding it.

Every week Jenny would go grocery shopping, and would come home with enough food to feed a family of six. She was one small person, and yet she’d buy a dozen grapefruit, ten pounds of potatoes, two quarts of milk and three loaves of bread for her own consumption. Each night she’d cook herself a big dinner, and then dutifully put the left-overs into a plastic container which she never looked at again.

I’d go through the fridge and pantry each week, throwing out squishy grapefruit, rancid left-overs (container and all), potatoes with long green sprouts, curdled milk and moldy bread. I wondered at the time if she just missed her family, but I realized later on that she just had to accumulate things. This was further demonstrated by her compulsive shopping; the evidence of which lay piled on her bedroom floor in the form of bags, scarves, belts, sweaters, jewelery and assorted shopping bags.

Jenny had filled the room across the hall with the overflow from her bedroom. One day I came home to find her sitting in the hallway, surrounded by bags and boxes and piles of stuff. She’d emptied out the room, hoping to sort through years worth of possessions and throw out as much as she could. She sat there, paralyzed, for several hours and eventually gave up and put it all back into the spare room.

At the time, I thought that she was just odd. She was kind of uptight and had some strange habits, like piling all the cutlery into the utensils drawer without sorting the various forks, etc. into each slot of the tray. I didn’t realize that her problem had a name. It’s actually a form of OCD, Obsessive-Compulsive Disorder. There are many manifestations, and compulsive hoarding is a particularly challenging one.

Jenny began dating Harold, and chose to hide her problem from him. On the few occasions he came by to visit, they stayed in the living room. Over the course of their entire relationship, Harold never once got to see her bedroom. I wondered at the time what it must be like to be intimate with someone and keep such a big secret from them.

I moved out at the end of the year, and never saw Jenny again. We got along OK as room-mates but her problem made it impossible for us to be close. I thought about her from time to time, and once I was a psychiatry resident, realized how instructive it had be face-to-face with someone who was described in my textbooks. There’s nothing like seeing it first-hand to recognize how troubled these people are. And it turns out that hers was a mild case. More severe sufferers can’t contain the clutter, and their lives are taken over by the problem.

It’s clear that except for those who are organizationally impaired, individuals who live with extreme messiness or hoarding are actually exhibiting signs of a significant mental disorder. Unless these problems are recognized for what they are and are dealt with by skilled mental health professionals, the people who live in extremely disorganized, cluttered or dirty environments will stand no chance of making any meaningful changes toward cleanliness and order.

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