Hoarding Disorder (HD) has been in the media spotlight. HD is a new psychiatric diagnosis added to DSM-5 in 2013. I have heard others ask in casual conversation “why would someone do that?” While this may sound like an answerable question to some, research has just begun to touch on the complexities of this disorder.
The DSM-5 describes HD as a “persistent difficulty discarding or parting with possessions, regardless of their actual value.” Patients suffering from HD often have co-morbid psychological conditions such as depression, substance abuse, Attention-Deficit/Hyperactivity Disorder (ADHD), obsessive-compulsive personality disorder, and schizophrenia. While middle aged and elderly people are more likely to be diagnosed with HD, many patients report their symptoms began in late childhood or adolescence. Trauma and other significant stress may not be a cause of HD but can significantly exacerbate it. Hoarding seems to follow a pattern of slow and insidious symptoms starting in late childhood, and then accelerating after age 40. Every patient with HD is unique but categories of some items seem to occur more frequently. Paper items such as newspapers, magazines, books and junk mail are frequently stacked in the home. Various types of containers such as food containers, boxes and bins may be present. “Freebie” items are sometimes sought after and stored in excess. Food, clothing and kitchen items are a prevalant category of items. Broken items that a patient with HD feels may be repaired “someday” may be difficult for the patient to part with. Some items pose a higher sanitation and health risk. Rotting food, urine, feces, or used toilet paper may be a primary issue for the patient. Subsets of patients with HD keep large numbers of animals as pets. The patient may feel they are providing adequate care to their pets despite the presence of feces, urine and a large number of animals in poor condition present in the home.
While a higher number of patients with HD are identified in urban areas, those in rural environments are more likely to die from problems in their environment. One theory about this disparity is that HD is identified more quickly in urban areas due to the complaints of neighbors regarding sanitation problems. Patients who are residing in a more isolated environment may not come to the attention of authorities until there is EMS contact for fire, injuries from falling items, the patient falling, or other medical crises. Patients with HD report a higher number of chronic medical conditions with less medical care contacts than those of the same age. There seems to be a cluster of medical illnesses occurring at higher rates and younger than average age. Obesity, hypertension (HTN), diabetes, lung disease, and obstructive sleep apnea (OSA) are a cluster of problems that seem to be more prevalant for these patients. Neurological problems such as stroke, dementia, seizure disorder and traumatic brain injury are reported more often by patients with HD. More systemic disease processes such as Systemic Lupus Erythematosus (SLE), and Fibromyalgia seem to be somewhat more prevalant. Researchers have begun to examine the genetics of HD. The presence of HD and Obsessive-Compulsive Disorder (OCD) seem to be more prominent in some families.
Treatment of HD has proven difficult for mental health professionals. Research in this area is urgently needed. HD accelerates with age so mental health professionals are likely to see more cases of this disorder as the number of older adults increases. Some patients have poor insight and can seem oblivious to their plight. Many describe themselves as “thrifty” or “saving things” for others should a need arise. Drastic interventions, like a forced clean-up of the home, have been shown to significantly increase the risk of suicide. Questions linger over what point hoarding behavior may constitute a danger to self, requiring involuntary hospitalization. HD seems to have a very high relapse rate with current treatments of SSRI medications and Cognitive Behavioral Therapy. Case management with routine home visits proved to be of benefit but legal and ethical dilemmas are present in this form of treatment. HD seems to be a condition of equifinality, meaning there are many paths involved in the earlier question of “why someone would do that.”
References
Ayers, C. R., Iqbal, Y., & Strickland, K. (2014). Medical conditions in geriatric hoarding disorder patients. Aging & Mental Health, 18(2), 148-151. doi:10.1080/13607863.2013.814105
Bratiotis, C., Steketee, G., & Schmalisch, C. S. (2011). The Hoarding Handbook: A Guide for Human Service Professionals. Oxford: Oxford University Press.
Drury, H., Ajmi, S., Fernandez de la Cruz, L., Nordsletten, A. E., & Mataix-Cols, D. (2014). Caregiver burden, family accommodation, health, and well-being in relatives of individuals with hoarding disorder. Journal of Affective Disorders, 159, 7-14. doi:http://dx.doi.org/10.1016/j.jad.2014.01.023
Saxena, S. (2007). Is compulsive hoarding a genetically and neurobiologically discrete syndrome? Implications for diagnostic classification. The American Journal of Psychiatry, 164(3), 380-384. doi:http://dx.doi.org/10.1176/appi.ajp.164.3.380
Rain Blohm, MS
WKPIC Doctoral Intern
