COMPULSIVE HOARDING

Dr. Jennifer Patterson

Dr. Melissa Rowland

MidAmerican Psychological Institute, P.C.

Objectives

Define hoarding Identify different types of hoarding Causes of hoarding How hoarding evolves Treatment and prognosis How you can help

Definition of Hoarding

No consistent definition of hoarding

The term is used in different clinical and non-clinical contexts to describe a broad spectrum of behavioral abnormities

(Maier, 2004)

Commonly Accepted Definition

(1) The acquisition of and failure to discard a large number of possessions that seem to be useless or of limited value

(2) Living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed

(3) Significant distress or impairment in functioning caused by the hoarding

~Frost and Hartl

Misconceptions

It is not caused by:LazinessLack of standardsLack of responsibilityLack of intelligence

Individuals who hoard often have poor insight regarding their behavior; others are often more aware and bothered by the clutter.

Misconceptions (cont.)

The stereotypic term "crazy cat lady" is used in a pejorative sense to classify an older, female animal hoarder and there is no research to support such correlation.

Misconceptions (cont.)

Hoarding and cluttering are often used interchangeably. There are two differences:

1. People who have clutter can discard things more easily.

2. Their clutter does not debilitate their lives to the same degree.

Clutter is only a symptom of the hoarding problem

DSM-5 Hoarding DisorderA. Persistent difficulty discarding or parting with

possessions, regardless of their actual value.

B. This difficulty is due to strong urges to save items and/or distress associated with discarding.

C. The difficulties discarding possessions result in the accumulation of a large number of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).

DSM-5 Hoarding Disorder (cont.)D. The hoarding causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

E. The hoarding is not attributed to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder).

Hoarding Mentality

Scarcity Mentality“What if I need it?”

Frugality Mentality “Nothing should be wasted.”

Indecision Mentality“Should I get rid of this or not?”

(NSGCD, 2003)

Ordinary Hoarding Ordinary Hoarding

Primarily objectsPapersMagazinesReceiptsPlastic bagsOld news papers

OCD-based Hoarding

OCD-based hoardingA small number of

hoarding cases may be true or primary OCD.

Hoarding behavior is driven entirely by OCD symptoms such as contamination fears or symmetry obsessions.

OCD-based Hoarding (cont.)

Hoarding is a response to:

Obsessions/fears about contamination

Superstitious thoughts

Feelings of incompleteness

OCD-based Hoarding (cont.)

Hoarding behavior is unwanted and highly distressing and the person experiences no pleasure from it.

The individual shows little interest in saved items, especially not sentimental attachments or beliefs about the value of possessions.

Trash Hoarding

Trash HoardingFood wrappersFood containersUsed paper

towels/toilet paperOld plastic bags

Animal Hoarding Animal Hoarders

Can have in excess of 300 animals in a home

CatsDogsBirdsRats/mice

Animal Hoarding (cont.)

Accumulation of animals to the extent that:

Failure to provide minimal nutrition, sanitation and veterinary care.

Failure to act on the deteriorating condition of the animals or the environment. Failure to act on or recognize the negative impact of the collection on their own health and well–being.

Animal Hoarding (cont.)

Occurs in every community, and it is estimated that there are three to five thousand cases each year in the US, involving up to 250,000 animals.

The most difficult to treat usually claiming to be pet rescuers.

Where animal neglect and abuse are suspected, also assess for child & elder neglect and abuse if either co-reside.

(Arluke et al 2002, Patronek 2001)

Animal Hoarding (cont.)

For animal hoarders the relationship between clutter and function can be somewhat indirect.

It is not always the acquired animals that are the clutter as much as the accumulation of animal waste and product which renders an unhealthy living space.

Animal Hoarding (cont.)

People who hoard animals have a deep attachment to their pets.

Animals serve as a substitute for human-to-human relationships.

History of interpersonal difficulties.

Animal Hoarding (cont.)

It is extremely difficult to let the pets go despite hazardous living conditions and pleas from family members and city officials.

Animal hoarders struggle to comprehend that they are in fact neglecting their pets by their inability to provide proper care.

Most animal hoarders experience a tremendous amount of grief when they lose their animals.

Development

The age of onset for item/object hoarding is reported to be early adolescence.

Whereas for animal hoarding the age of onset is middle age or older.

In both situations the hoarding progresses and is chronic.

Development (Cont.)

Hoarding is a recognized MENTAL HEALTH DISORDER.

Hoarding behavior can occur in the context of several developmental, neurological, and psychiatric

disorders.

Co-morbidity Anorexia nervosa Bipolar disorder Dementia Depression Impulse control

disordersSuch as compulsive

buying or gambling Social phobia

Obsessive-compulsive disorder

Personality disorders

Schizophrenia Diogenes syndrome Prader-Willi

syndrome Head injury Autism

Prevelance 1.4 to 2 million people in the United States

have compulsive hoarding syndrome (Maidment, 2005; Collingwood, 2006).

Hoarding accompanies OCD in 25% to 40% of individuals diagnosed

(Seedat and Stein, 2002).

2-3% of the general population has OCD and up to one-third of those diagnosed with OCD exhibit hoarding behavior (Cohen, 2004; Haggerty, 2006).

Causes Social Isolation Dementia and Alzheimer’s Aging with mobility issues Traumatic life events Neurobiological/genetic factors

Causes (cont.)

Current research indicates compulsive hoarding is associated with abnormal brain function, particularly in a part of the brain called the anterior cingulate cortex (ACC). It also is inherited in families and appears to have a strong genetic component.

Causes (cont.)

The ACC plays a role in a number of functions frequently impaired in individuals who engage in compulsive hoarding behaviors:

focused attention problem solving motivation decision making

Signs of Hoarding (exterior)

Missing siding/roofing materials

Peeling paint/rotting wood

Overall poor exterior conditions

Odors Excessive exterior

storage Windows and shades

drawn Inoperable vehicles

Signs of Hoarding (interior)

Excessive storage Odors Excessive rodent and insect infestation Unsanitary conditions Poor appearance of person Numerous animals No utilities or improperly working

plumbing and electrical systems

How Hoarding Evolves

Three factors that contribute:

Amassing items at a frequent rate

Difficulty discarding items

Disorganization

Amassing Items

Frequent shopping is the most common way that people who hoard collect items—3 out of 4 shop too much.

Roughly 1 in 2 people who hoard report excessively collecting free things such as coupons, samples, advertisements, etc.

Food wrappers, containers, packaging materials also contribute to the collection.

Difficulty Discarding Items

Throwing away

Selling

Giving away

Recycling

Common Beliefs that Maintainthe Behavior

Belief of Future Necessity Fear of Identity Theft Waste Prevention Informational Content Emotional Attachment

Disorganization Most people with hoarding problems have

great difficulty with organizing their possessions.

Attempts at organizing usually result in: hours of moving possessions from one

place to another without any effective result.

Accumulation of boxes, filing folders, and categorization systems.

Frustration and loss of hope to change.

Impact of hoarding

Self-care becomes increasing difficulty Fire (death or serious injury) Rooms: inaccessible and unusable Social isolation Structural risks develop Infestation creating numerous health

risks Risk of becoming homeless

Hoarding and the Elderly Compulsive hoarding is known to co-exist with both

dementia and Diogenes syndrome; two conditions that are correlated with age .

Hoarding and hiding behaviors are commonly reported in nursing home patients with dementia.

It is not clear whether this behavior is a manifestation of dementia or these patients had a prior history of hoarding.  

Compulsive hoarders are more likely to be socially isolated and live alone.

Hoarding and the Elderly (cont.)

Hoarding prescription and OTC medications-not uncommon among the elderly

(MacIsaac & Bartus Adamson,1989)

Impact of Hoarding on the Elderly

Particularly dangerous for older persons, who may have physical and cognitive limitations.

Creates physical health threat due to fires, falling, unsanitary conditions, and inability to prepare food.

Substantial social isolation due to shame or embarrassment.

Treatment

No known ‘cure’ for compulsive hoarding Medication has little effect on Hoarding In home support works best “Collaborative Intervention” Combination of therapies/interventions

Treatment (cont.)

Treatment should focus on the following areas: 1) discarding2) organizing3) preventing incoming clutter4) introducing alternative behaviors

(Saxena & Maidment, 2004)

Prognosis

Compulsive hoarding is a chronic illness which requires unrelenting vigilance. Lots of resistance is expressed.

Combined treatment (medication and psychotherapy) is best.

Monitoring & Maintenance needed. Motivation and Compliance fluctuate greatly .

So often, well-intended therapists, concerned family members, and supportive clutter coaches will attempt to help by "getting right to business" with removing the animals. However, this approach often yields challenges in the long-term effectiveness of treatment and raises several treatment non-compliance issues. Removing animals and decreasing the compulsion to hoard are two important outcomes in treatment but in order to get to this goal, a framework for lasting change needs to be established first. Without ongoing therapy and support there is a higher risk for recidivism.

It is important to know…

Shame, guilt, and embarrassment are emotions often associated with hoarding behavior and because of this individuals do not readily seek out treatment.

It's important to seek out the assistance of a licensed therapist before going in and removing the animals.

Most hoarders experience anger, resentment, and may behave defiantly when loved ones try to help and having a professional will lessen the impact of these emotions.

Hoarding Interventions: What you can do to help.

STEP: 11. Assess the risk and respond

accordingly:Risk to the residentRisk to other residents Risk to “responders”

2. Who else needs to assess based on what you discover?

What you can do to help (cont.)

STEP: 21. Control your reactions to the sight and

smell of the unit2. Be aware of internal reactions and

judgements – don’t voice them, stay neutral and solution focused

3. Remember solutions are tied to underlying causes, refer accordingly

4. Bring tools to leave with tenant

Conclusion

Clinically significant hoarding is prevalent and generally considered difficult to treat.

Compulsive hoarding is an understudied mental health issue.

Prevention is often impossible, early intervention strategies reduce tragic outcomes.

Reference

Frost, R.O., & Gross, R.C. (1993). The hoarding of possessions. Behavioral Research and Therapy, 31, 367-381.

Frost, R.O., & Hartl, T. (1996). A cognitive-behavioral model of compulsive hoarding. Behavioral Research and Therapy, 34(4), 341-350. Interpersonal problems and emotional intelligence in compulsive hoarding. Images Authors: Grisham, Jessica R.1 jessicag@unsw.edu.au

Steketee, Gail2

Frost, Randy O.3 Source: Depression & Anxiety (1091-4269); 2008, Vol. 25 Issue 9, pE63-E71, 9p, 5 Charts

Grisham, J.R., Frost, R.O., Steketee, G., Kim, H. & Hood, S. (2006). Age of onset of compulsive hoarding. Journal of Anxiety Disorders, 20, 675-686.

Cohen, J. (2004). The danger of hoarding. USA Today; 2/19/04 [Electronic version]. Saxena, S. & Maidment, M. (2004). Treatment of compulsive hoarding. JCLP/In

Session, 60, 1143-1154. SK, A., Mataix-Cols, D., Lawrence, N.S., Wooderson, S., Giampietro, V., Speckens, A.,

Brammer, M.J., & Phillips, M.L. (2009). To discard or not to discard: The neural basis of hoarding symptoms in obsessive-compulsive disorder. Molecular Psychiatry, Vol. 14, pp. 318-331