Hoarding 101

 

By Rebecca Beaton, PhD

Founder & Clinical Director of the Anxiety & Stress Management Institute
Dr. Beaton is also a frequent treating psychologist on the new TLC series “Hoarding: Buried Alive”

 

What is Hoarding Disorder (HD)?

Brief Definition: The excessive acquiring of and difficulty parting with possessions to the point of functional impairment. (For a complete diagnostic definition, please see proposed criteria for the fifth edition of Diagnostic & Statistical Manual of Mental Disorders below)


Facts:

• It’s currently thought to be a subtype of Obsessive-Compulsive Disorder (OCD) or one of the eight criteria for Obsessive Compulsive Personality Disorder (OCPD). It may affect up to 30% of people with OCD (Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine, 2010).
• The American Psychiatric Association has recently proposed that “Hoarding Disorder” be considered as its own discrete diagnosis in the fifth edition of the Diagnostic & Statistical Manual (DSM-5), which is slated to be released in 2012. Please see below for more information.
• Based on the neurological studies of HD, people with this disorder appear to have different neurobiology than individuals with OCD (Saxena, 2004). In addition, clients don’t respond to the treatment protocol used with OCD as well as individuals who present with typical manifestations of OCD (Ambdur, 2005).
• People with HD often present with additional mental health issues including Attention Deficit Hyperactive Disorder (ADHD), Generalized Anxiety Disorder, Social Anxiety, Major Depressive Disorder, Impulse Control Disorders, Schizophrenia, Dementia, and Bipolar Disorder.
• HD generally begins in childhood or early adolescence. It is a progressive illness that gets worse over time. Frequently, the person has had a history of acquiring clutter, but then a loss or a traumatic experience sets off a chain reaction, causing the disorder to worsen significantly.
• HD may run genetically in families and/or the individual may have learned hoarding behaviors from caretakers, which resulted in early neurological development that became increasingly reinforced over time. There is a phrase, “neurons that fire together, wire together.”
• HD affects 2-5% of the population.
• HD affects twice as many men as women.
• Three to six million Americans may suffer from symptoms of HD severe enough to impact their daily lives (Tolin, 2010)

 

Common Problems Associated with Hoarding:

I. People with HD tend to have problems processing information, which may include one or more of the following:

a. Problems with Attention
b. Problems with Categorizing (primarily with their own possessions - not other’s)
c. Problems with Decision Making
d. Elaborative Processing (e.g., finding multiple possible uses for an item other than the obvious intended use)
e. Problems with Memory

II. People with HD have strong beliefs about, as well as emotional attachments to, possessions that prove to be problematic to their long-term wellbeing. These beliefs are generally related to the following:

a. Value: The person feels that he or she needs to hang onto the item because of its personal or financial value. He or she may also have intentions to sell it or give it to someone, but the intentions rarely seem to come to fruition.
b. Waste and responsibility: Often the person is concerned about never having used an item and wants to be sure that it goes to good use somehow. Or, he or she may want to be sure items are recycled and not just discarded into a landfill.
c. Future Need or Concerns of Regret: The item may come in handy in the future.
d. Perfectionism: The person needs to make the perfect decision.
e. All or Nothing Thinking: “If I can’t possibly clean up everything, there is no point in starting.” The irony here is that cleaning up everything at once is generally too overwhelming for the person anyway.
f. Sentimental Attachment: Objects represent attachment to another person, time period, or experience.
g. Identity: The person may feel that his or her identity is supported by what he or she possesses (just as some people find their identity in what they do).
h. Feelings of Safety, Security, Protection, and Control: Having clutter around may make the person feel like he or she is safe in a cocoon. Another option is that having possessions that may come in handy in the future could make the person feel more in control.
i. Filling a Void: Shopping or collecting may fill up time or provide distraction from experiencing a sense of loss or any other form of emotional discomfort.

III. People with HD tend to get reinforcement for both acquiring and avoiding

a. Reinforcement to acquiring: Many people experience a “high” while looking for and finding a new possession or looking at one previously acquired.
b. Reinforcement for avoidance: Discarding a possession leads to anxiety, fear, grief or loss or maybe anger if pressured by another person. Therefore, it’s less stressful to avoid letting go of personal possessions.
c. Clutter becomes an external means of mood control: It maximizes the good feelings and minimizes the bad feelings for the individual. Not so ironically, it has the opposite effect on individuals with whom the person has an interpersonal relationship.

 

Common Misconceptions:

“It’s a behavioral problem and not a mental illness.” Hoarding Disorder (HD) is just beginning to get the attention that it needs for us to better understand this extremely debilitating phenomenon. Despite the fact that we don’t know as much about it as we would like, we still have enough information to know that it is, without a doubt, a mental illness. In fact, based on numerous studies, the evidence shows that people with HD have distinctly different neurobiology than individuals without HD.

“You can clean up their house for them, and then they can live a normal life.” This is a grave misconception. People with HD need to learn how to change the way they think about acquiring/purchasing/collecting as well as how they relate to their belongings. Otherwise, any efforts to clean-up for them will not only be a waste of time but could actually make their disorder worse. In most cases, the cleared home will be filled up again within months. Furthermore, the clean-up experience my cause the person to suffer from symptoms of posttraumatic stress disorder and or make him or her more resistant to accept future assistance.


Health and Safety Hazards:

Health and safety hazards have four main categories (based on the National Study Group on Chronic Disorganization’s Clutter Hoarding Scale):

 

I. Structure & Zoning Issues:

a Doors and stairways not accessible
b Fire hazards:

o Heating, ventilation, and air conditioning ducts blocked, completely or partially
o Narrowing or blockage of exits
o Flammable items on or near oven or stove
o Flammable items near small appliances
o Electrical cords or plugs compromised due to items placed upon or against them or inappropriate and/or excessive use of extension cords
o Storage of contaminants exceeds local ordinances

c Major appliances not working, including heating, air conditioning, or ventilation devices
d Mold or mildew on walls or floors
e Structural damage with may include faulty weather protection:

o Deteriorated or ineffective waterproofing of exterior walls, roof, foundation, or floors
o Broken windows or doors
o Missing or damaged gutters/downspouts

f Outdoor evidence of sewage backup
g Sewer or septic system nonoperational
h Standing water in basement or other rooms
i Plumbing non-functional
j No electrical power (rural homes not serviced by power companies are excluded)

II. Pets & Rodents:

a. Limited pet care
b. Number of pets exceeds local Human Society limits
c. Poorly maintained cages, aquariums, or pet living areas
d. Pets dangerous to occupants
e. Infestation of rodents or insects due to food left out or breaches in the external structure

III. Household Functions:

a. The accumulation of possessions may block the use of the refrigerator and/or freezer, preventing the proper storage of food items.
b. Difficulty getting to areas of the home may prevent general home maintenance (e.g., repairing leaks, changing air filters, etc.)
c. The accumulation of possessions may prevent access to stove, oven, or microwave preventing the individual or family from cooking or heating food appropriately prior to consumption
d. Clutter inhibits use of bedrooms, bathrooms, or living areas
e. Hazardous substances or chemical spills; hazardous substances or highly flammable material stored inside home (e.g., gasoline, leaking paint cans)
f. Broken glass

IV. Sanitization & Cleanliness:

a. Limited evidence of housekeeping, vacuuming, sweeping: The accumulation of dust, mold, and mildew may compromise air quality and cause respiratory issues.
b. Lack of clean dishes or utensils
c. Rotting food
d. Aged canned goods with buckled tops and sides
e. Towels and bed linens have evidence of long-time use and lack of cleaning or no bedding at all
f. Lice, roaches or other insect infestations
g. Human defecation present
h. Dirty or soiled laundry throughout house
i. Soiled food preparation surfaces
j. Overflowing garbage cans or garbage not contained in receptacles
k. Obvious and irritating odor
l. Mildew in bathrooms, kitchen or other areas with water leaks

 

How can I help someone with HD?

a. Be very patient.
b. Don’t take the person’s behavior personally.
c. Understand that if the person is an adult and no one else has power of attorney over his or her affairs, then the person has a right to live as they choose.
d. Build trust. Never throw any of the person’s belongings away without permission.
e. Don’t argue. People with HD tend to dig their heels in more when they feel pressured by someone.
f. Provide reflection. Ask the person about his/her long-term goals. Find the goals that aren’t consistent with hoarding behaviors, and gently point out that the current course of action is not congruent with these goals.
g. Encourage the person to seek help from a qualified professional – someone experienced in treating HD or at least experienced in treating OCD.
h. Do not enable the behavior (e.g., don’t loan the person money to go shopping, don’t offer to store any of his/her possessions in your garage, etc.).
i. Realize that ambivalence regarding help is normal.
j. Remember that, ultimately, it’s up to the individual to decide that he or she wants to change.
k. Be prepared for relapses. Overcoming HD often takes a course of three steps forward followed by two steps back. Remember that as long as the person is moving forward, progress is being made.

 

 


2010 American Psychiatric Association


Proposed Diagnostic Criteria
“HOARDING DISORDER”


1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209-3901
phone: 703-907-7300 email: apa@psych.org


Website Reference: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=398


The work group is recommending that this be included in DSM-5 but is still examining the evidence as to whether inclusion is merited in the main manual or in an Appendix for Further Research.


A. Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding.
B. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings (e.g., office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e.g., family members, authorities) to keep these areas free of possessions.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
D. The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease).
E. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder (OCD), lack of motivation in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autistic Disorder, food storing in Prader-Willi Syndrome).


Specify if:


With Excessive Acquisition: If symptoms are accompanied by excessive collecting or buying or stealing of items that are not needed or for which there is no available space.
Specify whether hoarding beliefs and behaviors are currently characterized by:
Good or fair insight: Recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
Poor insight: Mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
Delusional: Completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

 

 

RATIONALE

For Proposed Diagnosis of “Hoarding Disorder”

1. Epidemiological studies suggest that hoarding occurs in 2-5% of the population and can lead to substantial distress and disability, as well as serious public health consequences that warrant consideration as a mental disorder. Most cases do not meet criteria for OCD or OCPD. Accumulating data challenge the current view of a specific relationship between hoarding and OCD/OCPD, and whether these diagnoses cover all the severe hoarding cases.
2. The creation of a new diagnosis in DSM-5 would likely increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for Hoarding Disorder.
3. Criteria A-E: The proposed criteria are very similar to previously published criteria, which were based on research and clinical experience and that have been widely adopted by the field since 1996.
4. Specifiers:

a. The majority of people with hoarding disorder excessively acquire things either through buying or obtaining free things. However, not everyone with hoarding problems reports excessive acquisition, so including it as a diagnostic criterion would exclude people with true hoarding problems. Since recognition of and intervention for excessive acquisition is crucial for successful treatment of hoarding disorder, it is included as a specifier.
b. Available data suggest that a range of insight can characterize hoarding disorder. The proposed specifiers are similar to those proposed for other disorders, and they appear applicable to hoarding disorder.


Reference: Mataix-Cols D et al: Hoarding Disorder: A New Diagnosis for DSM-V?; Depression & Anxiety (2010; in press)


SEVERITY
Hoarding Scale Self-Report (HRS-SR) (Tolin et al., 2008)
Insight dimensions (proposed for OCD, BDD, ORS, and Hoarding Disorder): Brown Assessment of Beliefs Scale (BABS) (Eisen et al., 1998)


DSM-IV


This disorder is not listed in DSM-IV; therefore, DSM-IV criteria for this disorder do not exist.


In DSM-IV, ‘the inability to discard worn-out or worthless objects even when they have no sentimental value’ is one of the 8 criteria for Obsessive-Compulsive Personality Disorder (OCPD)


In the text accompanying the OCPD criteria, DSM-IV states:


“Despite the similarity in names, OCD is usually easily distinguished from OCPD by the presence of true obsessions and compulsions. A diagnosis of OCD should be considered especially when hoarding is extreme (e.g. accumulated stacks of worthless objects present a fire hazard and make it difficult for others to walk through the house). When criteria for both disorders are met, both diagnoses should be recorded” (p. 728)