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Hoarding disorder

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Compulsive hoarding apartment

Compulsive hoarding (or pathological collecting) is a pattern of behavior that is characterized by the excessive acquisition and inability or unwillingness to discard large quantities of objects that would seemingly qualify as useless or without value.[1] Compulsive hoarding behavior has been associated with health risks, impaired functioning, economic burden, and adverse effects on friends and family members.[2] When clinically significant enough to impair functioning, hoarding can prevent typical uses of space so as to limit activities such as cooking, cleaning, moving through the house, and sleeping. It can also be dangerous if it puts the individual or others at risk for fire, falling, poor sanitation, and other health concerns.[3]

It is not clear whether compulsive hoarding is an isolated disorder, or rather a symptom of another condition, such as obsessive-compulsive disorder.[4] Prevalence rates have been estimated at 2-5% in adults,[5] and is greater in older adults than younger groups, in men versus women, and is inversely related to household income[citation needed]. Factors associated with the disorder include alcohol dependence as well as paranoid, schizotypal, avoidant, and obsessive-compulsive traits.[6]

In 2008 a study was conducted to determine if there is a significant link between hoarding and interference in occupational and social functioning. Hoarding behavior is often so severe because poor insight of hoarding patients, meaning the understanding of a hoarding patient that their behaviors are a problem. Without insight into what the problem is, it is much harder for behavioral therapy to be the key to the successful treatment of compulsive hoarders. The results found that hoarders were significantly less likely to see a problem in a hoarding situation than a friend or a relative might. [7] This is independent of OCD symptoms as patients with OCD are often very aware of their disorder.

Diagnosis

While the disorder is not listed in DSM-IV, the currently proposed DSM-V diagnostic criteria for hoarding disorder[8] are:

A. Persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions. (The Work Group is considering alternative wording: "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 symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible. If all living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
D. 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).
E. The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease).
F. The hoarding symptoms are not restricted to 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, food storing in Prader-Willi Syndrome).

Characteristics

According to Sanjaya Saxena, MD, director of the Obsessive-Compulsive Disorders Program at the University of California, San Diego, compulsive hoarding in its worst forms can cause fires, unclean conditions (e.g. rat and roach infestations),[9] injuries from tripping on clutter, and other health and safety hazards.[10]

The hoarder may believe that the hoarded items are very valuable, or know that the accumulated items are useless but keep them anyway, or attach a strong personal value to items which other people claim would have little or no value. A hoarder of the first kind may show off a cutlery set claiming it to be made of silver and mother-of-pearl, disregarding the fact that the packaging clearly states the cutlery is made of steel and plastic.

A hoarder of the second type may have a refrigerator filled with uneaten food items months past their expiration dates, but in some cases vehemently resists any attempts by relatives to dispose of the unusable food. In other cases, the hoarder will recognize the need to clean the refrigerator but due (in part) to feelings that doing so would be an exercise in futility, and overwhelmed by the similar condition of the rest of their living space, fails to do so.

Hoarders of the third type often keep "collections" as a hobby, such as linens and clothing, personal care items, small toys and trinkets, or old tools and machinery.

Living room in 2001

Obsessive–compulsive disorder

For many years hoarding has been listed as a symptom or a subtype of Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Personality Disorder (OCPD). The current DSM says that an OCD diagnosis should be considered when: 1. The hoarding is driven by fear of contamination or superstitious thoughts 2. The hoarding behavior is unwanted or highly distressing 3. The individual shows no interest in the hoarded items 4. Excessive acquisition is only present if there is a specific obsession with a certain item. [11]

Compulsive hoarding does not seem to involve the same neurological mechanisms as more familiar forms of obsessive–compulsive disorder and does not respond to the same drugs, which target serotonin.[4][10][11]. In compulsive hoarding the symptoms are presented in the normal stream of consciousness and as such, they are not perceived as repetitive or distressing like in OCD patients. More importantly, the statistics that indicate there is a prevalence of hoarding in 18-40 percent of patients with OCD, yet only five percent of compulsive hoarders experience symptoms of OCD. In another study, a sample of 217 patients diagnosed with significant hoarding, only 18% were diagnosed with OCD, as opposed to the 36% that were diagnosed with a major depressive disorder. There are significant differences and issues between the diagnostic features of compulsive hoarding and OCD which are being considered in a possible addition to the DMS-V of a new independent disorder such as compulsive hoarding. [12] It is also said that there may be an overlap with a condition known as impulse control disorder (ICD), particularly when compulsive hoarding is linked to compulsive buying or acquisition behavior. [13]

Book hoarding

Bibliomania is a disorder involving the collecting or hoarding of books to the point where social relations or health are damaged. One of several psychological disorders associated with books (such as bibliophagy or bibliokleptomania), bibliomania is characterized by the collecting of books which have no use to the collector nor any great intrinsic value to a more conventional book collector. The purchase of multiple copies of the same book and edition and the accumulation of books beyond possible capacity of use or enjoyment are frequent symptoms of bibliomania.

Animal hoarding

Main article: Animal hoarding

Animal hoarding involves keeping larger than usual numbers of animals as pets without having the ability to properly house or care for them, while at the same time denying this inability. Compulsive animal hoarding can be characterized as a symptom of a disorder rather than deliberate cruelty towards animals. Hoarders are deeply attached to their pets and find it extremely difficult to let them go. They typically cannot comprehend that they are harming their pets by failing to provide them with proper care. Hoarders tend to believe that they provide the right amount of care for their pets. The American Society for the Prevention of Cruelty to Animals provides a "Hoarding Prevention Team," which works with hoarders to help them attain a manageable and healthy number of pets.[14] Along with other compulsive hoarding behaviors, it is linked in the DSM-IV to obsessive–compulsive disorder and obsessive–compulsive personality disorder.[15] Alternatively, animal hoarding could be related to addiction, dementia, or even focal delusion.[16]

Animal hoarders display symptoms of delusional disorder in that they have a "belief system out of touch with reality".[17] Virtually all hoarders lack insight into the extent of deterioration in their habitation and the health of their animals, refusing to acknowledge that anything is wrong.[18] Delusional disorder is an effective model in that it offers an explanation of hoarders' apparent blindness to the realities of their situations. Another model that has been suggested to explain animal hoarding is attachment disorder, which is primarily caused by poor parent-child relationships during childhood.[19]

As a result, those suffering from attachment disorder may turn to possessions, such as animals, to fill their need for a loving relationship. Interviews with animal hoarders have revealed that often, hoarders experienced domestic trauma in childhood, providing evidence for this model.[19] Perhaps the strongest psychological model put forward to explain animal hoarding is obsessive–compulsive disorder (OCD).

Neuropsychology

Brain imaging studies using positron emission tomography (PET) scans that detect the effectiveness of long-term treatment have shown that the cerebral glucose metabolism patterns seen in OCD hoarders were distinct from the patterns in non-hoarding OCD. The most notable difference in these patterns was the decreased activity of the dorsal anterior cingulate gyrus, a part of the brain that is responsible for focus, attention and decision making.[20] A 2004 University of Iowa study found that damage to the frontal lobes of the brain can lead to poor judgment and emotional disturbances, while damage to the right medial prefrontal cortex of the brain tends to cause compulsive hoarding.[21]

Some evidence based on brain lesion case studies also suggests that the anterior ventromedial prefrontal and cingulate cortices may be involved in abnormal hoarding behaviors, but sufferers of such injuries display less purposeful behavior than other individuals that compulsively hoard, thus making the implication of these brain structures unclear.[22] Other neuropsychological factors that have been found to be associated with individuals exhibiting hoarding behaviors include slower and more variable reaction times, increased impulsivity, and decreased spatial attention.[23]

Treatment

Psychopharmacological Interventions

Obsessive-compulsive disorders are treated with various antidepressants: from the Tricyclic antidepressant family clomipramine (brand name Anafranil); and from the SSRI families paroxetine (Paxil), fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft) and citalopram (Celexa). With existing drug therapy, OCD symptoms can be controlled but not cured. Several of these compounds (including paroxetine, which has an FDA indication[24]) have been tested successfully in conjunction with OCD hoarding.

Therapeutic Interventions

Cognitive-behavioral therapy (CBT) is a commonly implemented therapeutic intervention for compulsive hoarding. This modality of treatment usually involves exposure and response prevention to situations that cause anxiety and cognitive restructuring of beliefs related to hoarding. Furthermore, research has also shown that certain CBT protocols have been more effective in treatment than others. CBT programs that specifically address the motivation of the sufferer, organization, acquiring new clutter, and removing current clutter from the home have shown promising results. This type of treatment typically involves in home work with a therapist combined with between-session homework, the completion of which is associated with better treatment outcomes.[25] Research on internet-based CBT treatments for the disorder (where participants have access to educational resources, cognitive strategies, and chat groups) has also shown promising results both in terms of short- and long-term recovery.[26]

Case studies

The following (edited) case study is taken from a published account of compulsive hoarding:[27]

The client, D, lived with her two children, ages 11 and 14, and described her current hoarding behavior as a 'small problem that mushroomed' many years ago, along with corresponding marital difficulties. D reported that her father was a hoarder, and that she started saving when she was a child ... The volume of cluttered possessions took up approximately 70 percent of the living space in her house. With the exception of the bathroom, none of the rooms in the house could easily be used for their intended purpose. Both of the doors to the outside were blocked, so entry to the house was through the garage and the kitchen, where the table and chairs were covered with papers, newspapers, bills, books, half-consumed bags of chips, and her children's school papers dating back ten years.

The following case study is taken from a published account of compulsive hoarding:[10]

A 79-year-old woman recently died in a fire at her Washington, D.C., row house when 'pack rat conditions' held back firefighters from reaching her in time. A couple of days later, 47 firefighters from four cities spent two hours fighting a fire in a Southern California home before they were able to bring it under control. There was floor-to-ceiling clutter that had made it almost impossible for them to come in the house.

Books

Film

Television

Hoarding has been frequently featured in reality television programming. Notable examples include Hoarders on A&E, Clean House on the Style Network, Life Laundry on the BBC, Extreme Clutter on OWN and Hoarding: Buried Alive on TLC, which had also previously aired one-time programs on the subject (Help! I'm a Hoarder and Truth be Told: I'm a Hoarder).

There have also been a number of observational documentaries on TV, notably Jasmine Harman's My Hoarder Mum and Me. Jasmine and her extraordinary mother Vasoulla tell their intimate story, as we get a glimpse of the heart-breaking struggle that is Compulsive Hoarding, a condition that affects 3 million families in the UK.

Hoarding has also occurred as a theme for characters in fictional television shows. These have included Oscar the Grouch from children's show Sesame Street, whose outrageous hoarding behavior is a common theme; Ambrose Monk from comedy-drama Monk, and Eli Goldsworthy from teen drama Degrassi: The Next Generation. Hoarding has additionally served as the story basis for episodes of CSI: Crime Scene Investigation, South Park, Necessary Roughness, Bones, The Simpsons, 2 Broke Girls and House.

See also

References

  1. ^ Frost, R., & Gross, R. (1993). The hoarding of possessions. Behaviour Research and Therapy, 31, 367–382.
  2. ^ Tolin, D.F., Frost, R.O., Steketee, G., & Fitch, K.E. (2008). Family burden of compulsive hoarding: Results of an internet survey. Behaviour Research and Therapy, 46, 334-344.
  3. ^ Tolin, D.F., Frost, R.O., & Steketee, G. (2007). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461-1470.
  4. ^ Cite error: The named reference steketee was invoked but never defined (see the help page).
  5. ^ Pertusa, A., Frost, R.O., Fullana, M. A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., Mataix-Cols, D. (2010). Refining the boundaries of compulsive hoarding: A review. Clinical Psychology Review, 30, 371-386.
  6. ^ Samuels, J.F., Bienvenu, O.J., Grados, M.A., Cullen, B., Riddle, M.A., Liang, K., Eaton, W.W., & Nestadt, G. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour Research and Therapy, 46, 836-844.
  7. ^ Tolin, David F., Fitch, Kristin E., Frost, Randy O., Steketee, Gail. (2010). Family Informants’ Perceptions of Insight in Compulsive Hoarding. Cognitive Therapy & Research, 34(1), 69-81.
  8. ^ http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=398
  9. ^ being taken invaded in large numbers[clarification needed]
  10. ^ a b Kaplan, A. (2007). "Hoarding: Studies Characterize Phenotype, Demonstrate Efficacy". Psychiatric Times.
  11. ^ Mataix-Cols, David, Frost, Randy O., Pertusa, Albert, Clark, Lee Ann, Saxena, Sanjaya, Leckman, James F., Stein, Dan J., Mastunaga, Hisato, Wilhelm, Sabina. (2010) Hoarding Disorder: A New Diagnosis for DSM-V? Depression and Anxiety, 27, 556-572.
  12. ^ Mataix-Cols, David, Frost, Randy O., Pertusa, Albert, Clark, Lee Ann, Saxena, Sanjaya, Leckman, James F., Stein, Dan J., Mastunaga, Hisato, Wilhelm, Sabina. (2010) Hoarding Disorder: A New Diagnosis for DSM-V? Depression and Anxiety, 27, 556-572.
  13. ^ Hartl TL, Duffany SR, Allen GJ, Steketee G, Frost RO (2005). "Relationships among compulsive hoarding, trauma and attention-deficit/hyperactivity disorder". Behaviour research and therapy. 43 (2): 269–76. doi:10.1016/j.brat.2004.02.002. PMID 15629755.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Hoarding of Animals Research Consortium (HARC) (2004). "Commonly asked questions about hoarding".
  15. ^ "Mental health issues and animal hoarding".
  16. ^ Berry, Colin, M.S., Gary Patronek, V.M.D., Ph.D. and Randall Lockwood, Ph.D. "Long-Term Outcomes in Animal Hoarding Cases" (PDF).{{cite web}}: CS1 maint: multiple names: authors list (link)
  17. ^ Patronek, Gary (May/June 2001). "The Problem of Animal Hoarding". Animal Law. 19: 6–9. {{cite journal}}: Check date values in: |date= (help)
  18. ^ Arluke, Arnie (2002-05). "Health Implications of Animal Hoarding". Health & Social Work. 27 (2): 125. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  19. ^ a b Frost, Randy (2000). "People Who Hoard Animals". Psychiatric Times. 17 (4).
  20. ^ Cite error: The named reference saxena was invoked but never defined (see the help page).
  21. ^ Univ. of Iowa on brain's cortex and compulsive hoarding.
  22. ^ Pertusa, A., Frost, R.O., Fullana, M. A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., Mataix-Cols, D. (2010). Refining the boundaries of compulsive hoarding: A review. Clinical Psychology Review, 30, 371-386.
  23. ^ Grisham, J.R., Brown, T.A., Savage, C.R., Steketee, G., & Barlow, D.H. (2007). Neuropsychological impairment associated with compulsive hoarding. Behaviour Research and Therapy, 45, 1471-1483.
  24. ^ Paxil treats Compulsive Hoarding
  25. ^ Tolin,D.F., Frost,R.O., & Steketee,G. (2007). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461-1470.
  26. ^ Muroff, J., Steketee, G., Himle, J., & Frost, R. (2010). Delivery of internet treatment for compulsive hoarding (D.I.T.C.H.). Behaviour Research and Therapy, 48, 79-85.
  27. ^ Hartl TL, Frost RO (1999). "Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study". Behav Res Ther. 37 (5): 451–61. doi:10.1016/S0005-7967(98)00130-2. PMID 10228316. {{cite journal}}: Unknown parameter |month= ignored (help)
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