Compulsive Hoarding

1. Dr. Jennifer Patterson Dr. Melissa Rowland MidAmerican Psychological Institute, P.C. Compulsive Hoarding

2. Objectives • Define hoarding • Identify different types of hoarding • Causes of hoarding • How hoarding evolves • Treatment and prognosis • How you can help

3. 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)

4. 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

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

6. (3) Significant distress or impairment in functioning caused by the hoarding ~Frost and Hartl

7. Misconceptions • It is not caused by: • Laziness • Lack of standards • Lack of responsibility • Lack of intelligence Individuals who hoard often have poor insight regarding their behavior; others are often more aware and bothered by the clutter.

8. 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.

9. 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

10. DSM-5 Hoarding Disorder A. 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).

11. 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).

12. 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)

13. Ordinary Hoarding • Ordinary Hoarding • Primarily objects • Papers • Magazines • Receipts • Plastic bags • Old news papers

14. OCD-based Hoarding • OCD-based hoarding • A 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.

15. OCD-based Hoarding (cont.) Hoarding is a response to: • Obsessions/fears about contamination • Superstitious thoughts • Feelings of incompleteness

16. 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.

17. Trash Hoarding • Trash Hoarding • Food wrappers • Food containers • Used paper towels/toilet paper • Old plastic bags

18. Animal Hoarding • Animal Hoarders • Can have in excess of 300 animals in a home • Cats • Dogs • Birds • Rats/mice

19. 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.

20. 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)

21. 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.

22. 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.

23. 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.

24. 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.

25. Development (Cont.) • Hoarding is a recognized MENTAL HEALTH DISORDER. • Hoarding behavior can occur in the context of several developmental, neurological, and psychiatric disorders.

26. Co-morbidity • Anorexia nervosa • Bipolar disorder • Dementia • Depression • Impulse control disorders • Such as compulsive buying or gambling • Social phobia • Obsessive-compulsive disorder • Personality disorders • Schizophrenia • Diogenes syndrome • Prader-Willi syndrome • Head injury • Autism

27. 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).

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

29. 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.

31. 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

32. 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

33. 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

35. How Hoarding Evolves Three factors that contribute: • Amassing items at a frequent rate • Difficulty discarding items • Disorganization

36. 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.

37. Difficulty Discarding Items • Throwing away • Selling • Giving away • Recycling

38. Common Beliefs that Maintainthe Behavior • Belief of Future Necessity • Fear of Identity Theft • Waste Prevention • Informational Content • Emotional Attachment

39. 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.

40. 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

41. 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.

42. Hoarding and the Elderly (cont.) • Hoarding prescription and OTC medications-not uncommon among the elderly (MacIsaac & Bartus Adamson,1989)

43. 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.

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

45. Treatment(cont.) • Treatment should focus on the following areas: • 1) discarding • 2) organizing • 3) preventing incoming clutter • 4) introducing alternative behaviors (Saxena & Maidment, 2004)

46. 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 .

47. 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.

48. 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.

49. 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.

50. Hoarding Interventions: What you can do to help. STEP: 1 1. Assess the risk and respond accordingly: Risk to the resident Risk to other residents Risk to “responders” 2. Who else needs to assess based on what you discover?