By Liz Seegert
We have all read stories of houses so cluttered that emergency personnel can’t enter to rescue a fire victim or help someone in need of urgent medical care. There are reality TV series revolving around the problem of hoarding. While it may make for sensational stories, hoarding, particularly among older adults, is a growing public health issue, often requiring intervention by social service agencies, police, fire departments and mental health professionals.
What is hoarding?
Hoarding is neurological disorder affects an estimated 5 percent of the U.S. population and has no true “cure.” Mental health experts define hoarding as “the acquisition of, and failure to discard, possessions which appear to be useless or of limited value.” The American Psychiatric Association introduced criteria for hoarding disorder in 2013 in their Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) noting that it is found in many patients who have obsessive-compulsive disorder (OCD). Scientists do not fully understand what causes hoarding behavior, but there is likely a genetic component as it tends to run in families. Onset may begin as early as adolescence; however, most researchers believe it worsens with age.
While both men and women hoard, studies have found that a majority of hoarders are female. This could be due to a longer life expectancy among women. Hoarders often are widowed, divorced or never married, and often live alone.
Other studies show that older hoarders have a more functional impairment and may be more socially isolated due to mobility issues, loss of a spouse, partner or friends. Approximately 15 percent of nursing home residents and 25 percent of community elder day-care participants hoard small items. The number of older people with hoarding issues is almost certain to increase as the population ages, according to this Washington Post story.
Older adults with hoarding problems:
- Have significant impairment in activities of daily living.
- Struggle to move within the home, find important items, eat at a table, use the kitchen sink, prepare food, and sleep in a bed.
- Tend toward indecisiveness, perfectionism, avoidance, procrastination, and problems with planning and organizing.
- Risk premature relocation to senior housing or eviction.
- Rarely seek help for these problems directly. Most come to the attention of service organizations through other agencies such as the emergency services, animal protection organizations, or public health authorities.
Often, people refuse to acknowledge they have a problem. They may blame it on lack of storage space. They may call it a “lifestyle choice” even while attempting to conceal the problem from others. The majority of older adults with HD report never having friends or family visit their home. This can make treating the disorder extremely challenging.
According to the Mayo Clinic, “Hoarding often creates such cramped living conditions that homes may be filled to capacity, with only narrow pathways winding through stacks of clutter. Countertops, sinks, stoves, desks, stairways and virtually all other surfaces are usually piled with stuff. And when there’s no more room inside, the clutter may spread to the garage, vehicles, yard and other storage facilities.”
Some people develop hoarding disorder after experiencing a stressful life event that they had difficulty coping with, such as the death of a loved one, divorce, eviction or losing possessions in a fire. Hoarding disorder can cause a variety of complications, including:
- Increased risk of falls;
- Injury or being trapped by shifting or falling items;
- Family conflicts;
- Loneliness and social isolation;
- Unsanitary conditions that aggravate existing health issues, such as dust, insect or rodent infestations;
- Medication mismanagement;
- Fire and mold hazards;
- Legal issues, such as eviction.
Why do people hoard?
As this Psychology Today article explains, “hoarding is always accompanied by varying levels of anxiety and sometimes develops alongside other mental illnesses, such as dementia and schizophrenia. Recent neuroimaging reveals peculiar commonalities among hoarders including severe emotional attachment to inanimate objects and extreme anxiety when making decisions.”
According to The Institute of Living, part of Hartford Hospital’s Anxiety Disorders Center, there are several types of common hoarding behaviors or triggers:
- Lack of executive skills. The person may struggle with the ability to plan and think about tasks, struggle with decision making (including what to do about their possessions), and avoidance behavior — they simply keep and store everything, from junk mail to old newspapers. They may have trouble deciding what is important because everything has some value, even items that are old, or broken. “Just in case” hoarders save boxes and boxes of their children’s old clothes, old nonperishable foods, decades of bills and credit card statements. They also may buy things because “they might need them” someday.
- Emotional upheaval. Many hoarders use the objects around them to feel more secure. They may feel anxious when pressured to throw out any object so avoid doing so. To them, each item has an emotional value. They may keep children’s clothing because it helps them remember their youth, even if their children are now middle-aged adults. Old receipts might trigger a memory of a special dinner or event. They attach emotional significance to seemingly unimportant objects, Even if they don’t remember the significance of each item, they feel it is important to keep it because at one time it had significance.
- Animal hoarding. Behavior includes not just accumulating many animals, but also failing to give them sufficient care, neglecting their needs even when they begin to deteriorate, and letting their living quarters slowly fall into disrepair due to old feces, rotten food, and other waste products. They mean well and love their pets, but can’t keep up.
Treatment options. The International OCD Foundation describes several treatment approaches used with people who have hoarding disorder:
- Motivational interviewing (MI). This technique seeks to increase the individual’s motivation to make positive changes in their behavior.
- Skills training. People with HD usually have problems with organizing, problem-solving and making decisions.; They learn specific skills that they can use in their recovery.
- Cognitive Behavioral Therapy (CBT). This technique helps individuals to examine the way they think and behave, and change thought processes or behaviors that may be problematic.
- Support groups. Groups connect the individuals to others who understand what they are going through in a shame-free environment. Some support groups are also treatment groups that offer a structured learning approach to making and achieving goals to recover from HD.
- Medication. Psychiatric medications work to change an individual’s brain chemistry and activity, such as reducing anxiety or improving mood. For many mental health conditions, including HD, the symptoms are thought to be caused by brain chemistry problems and certain areas of the brain not working as they should.
The University of California San Diego offers a Cognitive Rehabilitation and Exposure/Sorting Treatment (CREST) community program for older adults, which is free for those meeting eligibility criteria. It includes one-on-one cognitive behavior training with a mental health professional and exposure therapy: to help the individual learn to overcome feelings of fear and distress associated with discarding items, and improve decision-making skills about possessions.
Questions to ask
- What programs or mental health services are available in your community to help older adults who may have hoarding disorder?
- What is the difference between being an avid “collector” and a hoarder?
- Profile those who have overcome their hoarding problems and are now helping others, similar to this Boston Globe story.
Resources
- Institute on Compulsive Hoarding & Cluttering – from the Mental Health Association of San Francisco
- The OCD Foundation
- The Hoarding Disorder Resource and Training Group – NY Metro area
- The Philadelphia Hoarding Task Force
- University of Miami Hoarding research lab
- Pacific Standard article, “Why do you hoard?”
Experts
- Randy O. Frost, professor of psychology, Smith College, helped develop a model used around the country to help hoarders address their emotional reactions to reducing their possessions; 413-585-3911; rfrost@smith.edu
- Catherine Ayers Ph.D., a geriatric psychologist at the University of California at San Diego who has developed a cognitive behavior therapy for older people with the disorder. Division Director of the VA San Diego Healthcare System (VASDHS) La Jolla Mental Health Outpatient Clinics, Assistant Professor in the University of California San Diego (UCSD) Department of Psychiatry, and faculty member in the SDSU/UCSD Joint Doctoral Program in Clinical Psychology; cayers@ucsd.edu
- David F. Tolin, Ph.D., a clinical psychologist and expert on cognitive-behavioral therapy. Tolin founded and directs the Anxiety Disorders Center and the Center for Cognitive Behavioral Therapy at The Institute of Living, Hartford Hospital in Connecticut, and is a faculty member at the Yale University School of Medicine; 860-545-7709 or 860-545-7685.
