Running Head: HOARDING 1

SOWK 644 – Spring 2017

Hoarding

Explanatory Theories of Health and Mental Final

Sonya Keith

May 3, 2017

Doni Whitsett, Ph.D

HOARDING 2

Hoarding

Explanatory Theories of Health and Mental Final

Hoarding is a label that is not exclusive to the clinical sphere (Maier, 2005). In the

colloquial jargon, it refers to a greedy person who does not share. For clinical purposes, it is the

designation of a disease far more insidious and isolating than greed. Everyone in modern society

owns things. We own clothes, hygiene items, knick-knacks and places to sleep and things to sit

on. The average person owns more than they did 50 years ago (Steketee, 2013). A healthy person

can relinquish items which are no longer useful to them, but a person who cannot separate from

the object without emotional pain may be an individual who has hoarding disorder (Steketee,

2013). Per the National Alliance on Mental Health, 5% of the human race has symptoms of

hoarding (2017). Hoarders are twice as common as people with OCD and far more common than

schizophrenia and bipolar disorders (NAMI, 2017). Approximately 3,000 people a year are

found to be hoarding animals. (Tolin, 2011).

The DSM-5, the most recent generation of the text identifying a mental disease, has listed

Hoarding Disorder as a subgroup of Obsessive Compulsive Disorder (OCD), (Calamari,

Wiegartz, Riemann et al., 2004). Compulsive hoarders tend to be older than conventional OCD

sufferers. Four mandatory features and two issues of exclusion define HD. Per the DSM-5

published in 2013, the inclusionary items include: “Persistent difficulty discarding or parting

with possessions, regardless of their actual value... due to a perceived need to save the items and

distress associated with discarding them”. Other symptoms are keeping the collection

components even though they clutter and make living spaces unusable. The only time a living

area is in the intended formation is because someone other than the patient has intervened. This

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collecting is problematic because it limits social interactions, employment, and personal safety

(American Psychiatric Association, 2013). Excessive items might be carried on the person or

stored to be available to the collector (Frost, Gross, 1993). The Yale-Brown Obsessive–

Compulsive Scale checklist measures behaviors, however, behavior sets are not the best way to

describe the disorder because people with OCD may present with multiple types of symptom

sets.

Hoarding is considered a disorder, as well as a symptom of other disorders because it

harms the person doing the hoarding. Some collected items can become unsanitary and interfere

with quality of life, and in some cases may become life threatening. While some researchers are

content categorizing HD as a subset type of OCD, there are other potential explanations for what

HD is, how it manifests and what the cause of it is. These ideas are important to suss out in each

case for treatment purposes.

Theories to Explain Hoarding Disorder

Several theories have been applied to Hoarding. It is a disservice to the OCD relevant

factors to ignore the implications of the Freudian theory, although it is not the singular or most

applicable approach. Freudians categorize it as being part of the anal stage, others have labeled it

as an impulse, a learned pattern, and as a means to have control over their environment (Kyrios,

Worden, Steketee, DiLoreto, Tolin, Slyne, & Frost, 2014). According to the Freudian theory, a

person stuck in the Anal Fixation stage would be prone to hoard belongings, become excessively

frugal and clean compulsively (Berzoff, Flanagan, & Hertz, 2008, p. 37). Per Freud, learning to

walk and gain autonomy coincides with the time when people are toilet trained. Having control

over their excrement translated into having power over some part of their existence in a vast

scary world. As we age we cannot easily celebrate our bowel movements as signs of

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independence, but we can transfer that need for indications that we have power to objects. Some

people collect, clean and safeguard them in what is now called Hoarding Disorder. This

approach is not my focus on the paper, however every OCD and HD article mentioned Freud.

A diagnosis of HD is often found in clients who report multiple and lifelong traumas

compared against individuals who only fit the OCD criteria (Tolin, 2011). As discussed in class

on February 28th, childhood anxiety is often a result of childhood trauma, bullying, or received as

a hand-me-down trait from an anxious parent. Hoarding is tightly attached to depression and

anxiety, and these issues are common in a person who has a problem with hoarding. General

Anxiety Disorder, depression, alcohol dependence and social anxiety are all common

characteristics of someone who hoards and these appear more with people who do not show

symptomatology of OCD other than their hoarding behaviors (Tolin, 2011). People diagnosed

with HD also frequently self-report multiple symptoms of ADHD.

Over half of HD patients studied reported that there was a traumatic event when the first

signs of hoarding appeared (Tolin, 2011). Childhood trauma resulting in forms of PTSD have

been tied to lack of impulse control (Chapman, 2014). Impulsivity Dysregulation and lack of

control have been seen as a primary trait in people with hoarding disorder. One form of

childhood trauma is the failure to bond with a caregiver (Schore, Schore, 2008) Other traumas

include abuse, physical harm, extreme discipline, unpredictable environments and homes, and

even home robberies (Tolin, 2011). These patients may fear more exclusion or shame (Cozolino,

2014). Fear or stress that lasts a long time damages the hippocampus and makes it more difficult

for the brain to process stress in a healthy manner in the future. To avoid the stress of human

interactions, people may turn their feelings of the memories with objects rather than people. The

items that hoarders collect become transitional objects represent the people and memories

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important to the client. Every new item obtained on impulse is an attempt to make an emotional

bond. Losing or separating from the item causes stress.

Bi-directional Health and Mental Health

The bi-directional nature of the relationship between physical and mental health is

detrimental and sometimes catastrophic for people with HD. This population is service resistant

and avoidant. When and if they do face bodily illness, they are not likely to reach out for medical

attention. HD sufferers are likely to also be experiencing depression, excessive alcohol use and

be isolated from others. As discussed in class, additional risks implications for physical health in

people who are Hoarders include malnutrition, infection, insect and rodent infestations. People

who are hoarders may have trouble maintaining their home residences. They risk eviction

because of legal issues or an able to live within the shelter of their home because of the impact of

the large amount of debris and other items which take up space where they would otherwise sit,

sleep, eat and live. We discussed the life of the student who filmed “My Mother’s Garden” and

noted that the neighborhood was pushing her to remove the evidence of her hoarding and

harassing her in degrees that she found hurtful. The refrigerator may be blocked or used to store

non-food items. This potential obstacle course potentially leads to Malnutrition. The subject of

the film ate trash from public wastebaskets which conceivably had multiple bacteria harmful to

humans. She had debris that blocked the pathway to the bathroom may make it so that defecation

and urination and the appropriate receptacles is impossible. It may also block her the path to the

shower and the client may be unable to bathe them. The physical ramifications of not cleaning

the skin lead to boils and abscesses as well as flaky skin rashes and infections. People who hoard

may be disorganized and not able to pay their bills. Money for utilities may have been spent on

buying items

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People with Hoarding Disorder (HC) are being studied to test the theory that hoarders are

likely to also experience learning difficulties remembering and learning (Maier, 2005). This

blends with the self-reports of hoarders who do not want to part with items because they

represent bits of relevant information and if the item is displaced or removed, the patient feels

that they are at risk of losing the corresponding information (Maier, 2005). Studies are also

ongoing to test the correlation between impulsivity control and learning from consequences. As

of now, the studies are reporting that people with HD are likely to have traits of impulsivity,

remembering information and unpleasant results of bad choices and fear of both people and loss

of information (Maier, 2005). All of these traits individually would present as barriers to

treatment. With all of them combined, a client would understandably be service-resistant, and a

clinician would have trouble working with and around these barriers,

In the 1980’s a study was done correlating the onset of pediatric autoimmune

neuropsychiatric disorders associated with streptococcal infections, also known as PANDAS

with children who then went on to rapidly develop forms of OCD. The connection between

health of the body and mind is evidenced by the physical body contracting an illness. The illness

impacts the brain and results in a series of behaviour and symptoms that can be classified by the

DSM as OCD type issues including hoarding (Doran,2015).

Neurobiology and the Brain Changes

During the human teen years, the brain changes at a fast pace and the Frontal

hippocampal circuits develop (Cozolino, 2014, p. 34). This portion of the neural structure is used

in the self-regulation, anticipation, and planning. These abilities are lacking in people who suffer

from Hoarding Disorder. Hoarding Disorder patients have “Pure inhibitions and a greater need to

answer impulses immediately.” They cannot postpone gratification (Kyrios et al., 2014).

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Abnormalities in this portion of the brain, be they developmental or damage from disease or

injury are common in people who show signs of Hoarding. The Hippocampus is also where

stress impacts the brain through the release of cortisol. The Adrenal system produces

glucocorticoids during times of stress. Prolonged stress means a longer Exposure to this

hormone. This hormone which is body interprets as cortisol can eventually lead to cell death and

damage to the hippocampus. The hippocampus becomes smaller (Cozolino, 2014).

Most of the neurobiological studies on Hoarding Disorder (HD) have been focused on

animals (Kyrios et al., 2014). Though the issue is old, the field of study is still unexplored. What

has been documented includes ways that hoarding disorder varies from OCD. People with OCD

have no problem making decisions, but people who have hoarding disorders have a large amount

of trouble being decisive. They become engrossed in the minutiae and small issues and can't see

the overall concern (Kyrios et al., 2014). They cannot divide their belongings into large and

general primary categories, (keep, donate, throw away). Compared to those people who have

OCD, they took much longer and created multiple subcategories for their personal effects

(Kyrios et al., 2014).. Damage to the ventromedial prefrontal and cingulate cortices often is

apparent in the images of Hoarder’s brains (Kyrios et al., 2014).

Organic hoarding refers to people who have started this behavior after having a stroke or

the onset of dementia (Maier, 2005). Scans of these brains show changes in the hippocampus

where explicit memories are processed. These people are more likely to live in filthy conditions.

The onset of their condition is easier to identify because they have had a major health issue

which stands as a landmark to fighting they are free hoarding stays from their current status

(Maier, 2005). Organic Hoarders do not have an emotional need to keep their items and can

discard them easier than non-organic orders. They tend to collect items without fully

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understanding that they are building a collection nor do they have an emotional connection to the

question of items (Maier, 2005). By the standards outlined in the DSM-5, organic hoarding is not

a hoarding listed as a mental health issue. This is because the hoarding can be traced back and

attributed to a physical Illness (American Psychiatric Association, 2013).

Having a goal to their collection is one of the primary identifiers of a non-organic

hoarder. These hoarders may have started small and slowly over a long period the visible

evidence of hoarding accumulated over many years. There was no major identifiable incident

such as a stroke with the organic hoarders. Removing the hoarded items from the home of non-

organic order extreme emotional pain because they are so connected to every item in their

grouping (Maier, 2005). It is not an oriented collection where they just want to get one of every

kind of something it is more that they cannot stop picking up everything they see and bringing it

home with them and believing that every item that they had has a significant purpose. They

might need an item, and so they can't it just got it. Items which are clearly trash are not viewed or

felt to be trash by the non-organic order.

Some hoarders do so in reaction to trauma (Chapman, 2007). Their connection to their

objects and collections is an enhancement to their inner peace. As discussed in the class, people

change and life is uncertain, but an object that can be held and looked upon remains the same.

Connecting with humans requires trust that they will not be hurt. The inability to easily trust

creates barriers and traction in the therapeutic relationship as well as is exemplified in the

absence of social support and friendships for the patient.

Diversity

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Women are more likely to have HD than children or men (Saxena, 2007). The age

difference between hoarders and patients with OCD who were not hoarders is greater than ten

years, In fact, hoarding is a behavior which is seen more frequently in the elderly. There is a

name for elderly hoarding, Diogenes Syndrome, so dubbed in homage to an ancient barrel

dwelling philosopher. There are two levels of Diogenes Syndrome (Thomas, 2005). The first

type Is a behavioral and lifestyle issue. It is not a mental disorder. These people may not have

access to disposal for their feelings or may have so few belongings everything as a matter or

neglect or comfort but not need. The secondary version of the syndrome is related to OCD.

The mental health repercussions of a hoarder might involve isolation from family and

friends. The hoarder may be aware that they are receiving disapproval from those whom they

loved so do not invite those people into their personal space anymore. People who care about the

hoarder may be embarrassed by them and no longer wish to be seen with them in their home or

their cluttered cars or even and an outside venue. Hoarding is hard to understand, and the science

and research has not been thorough on the issue. Hoarding has only recently appeared in the

DSM-5 (Kyrios et al., 2014). The general population assumes hoarding as a behavioral issue and

not a psychological problem or a sign of emotional distress. The social support network of the

hoarder erodes because the behavior is intolerable. People who are hoarders and ordered to

establish some control over their life may not be able to see the mess they have made. If they can

recognize that their behaviors are out of control and that they have so many items that it is

impacting their life, this might make them feel worse about themselves. They might throw them

into periods of depression and isolation and denial. Hoarding is a symptom and is a behavior

related to a diagnosis as well as a stand alone diagnosis. Treating the behavior means finding out

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the root cause on the hoarding. This can be complicated and time-consuming, and there has been

no established protocol which is routinely successful.

Treatment

It has been found that most clients with hoarding disorder do not discover that they have

this concern until it has been present in their life for at least a decade. Once HD is suspected,

patients often become service resistant because they have difficulty recognizing the behavior is

abnormal. Their attitude towards their disorder isolates them from family and friends who would

otherwise encourage them and support them as they go through therapy. People who have this

disorder are poorly motivated to resolve the issue and drop out of treatment frequently and with

little instigation. People who have trauma issues understandably sensitive about how they are

described. Word choice matters. It is important to separate the illness of hoarding from the

individual who does the boarding. Stigmatizing words with better connotation is a good first

step. Instead of saying hoarding, use phrases like collecting and saving. These words indicate the

dignity the connection between the client and the objects which are impeding their ability enjoy

life.

One study by Saxena, Maidment, Vapnik, Golden, Rishwain,, Rosen, & Bystritsky, in. 2002

treated people with HD and people with OCD in a multi-component treatment involving

Cognitive Behavioral Therapy (CBT), partial outpatient enrollment for socializing skills and

medication that had been used in this treatment previously with treatment-refractory OCD

clients. The medication was a Serotonin reuptake inhibitor (Saxena, 2007). These customers

were not cured, but their symptoms did decrease, and quality of life improved for them. CBT

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therapy addressed approaches Hoarding as an impulse problem, “designing a five-stage process

for controlling impulses: identifying the impetus, inhibiting the automatic response, identifying

alternatives, selecting a response, and implementing a response” (Berzoff, Flanagan, Melano, &d

Hertz, 2011, p. 186). This approach attempts to empower the client with skills to reframe their

choices and change thinking and behavior. When employed during a compulsive moment it may

help the patient identify if they are selecting an item because they need it for practical us, want it

for whimsy, or are drawn to it for the transitional object properties it may represent.

CBT for HD clients has the goal of strengthening the ability of the client to make

decisions. These decision-making skills can be grown into the ability to make choices, organize

and reduce clutter. At some point during the treatment process the location the hoarder is keeping

their collection in will be cleaned out. This model of therapy is long term and may last over a

year with some rooms of the living dwelling remaining in the overstuffed state while other areas

are cleaned (Saxena, 2004).

Educating the patient about their illness and teaching them to identify the hoarding

triggers such as feelings of anxiety or stress using the Subjective Units of Distress Scale.

Teaching a hoarder to see and understand their avoidance attempts when they fail to pay a utility

bill or expose their living situation to family and friends is the first step in helping them

recognize their feelings and validate their emotions (Saxena, 2014). Once a client has full

understanding of their symptoms and corresponding behaviour, they can be supported and

guided into healthier choices such as not adding to their collection and not shopping. With

enough support the crisis will pass and the client will be able to see that the hoarding behavior

they have relied on for emotional safety is not necessary (Saxena, 2004). At some point the client

will throw away items from their hoard and will hopefully see and feel that nothing bad happens

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to them as a result. They will be exposed to the truth that the collection does not offer them any

actual protection. The behaviour of adding new items to the home should be halted as well.

Hoarding Disorder, or compulsive hoarding as some researchers insist it should be called,

is a mental illness with a direct correlation to the structures of the brain. Some hoarding is a

result of brain injuries including but not limited to strokes. Other forms of the illness reflect the

small hippocampus and ventromedial prefrontal and cingulate cortices. Some patients show an

altered brain chemistry that is a result of prolonged exposure to stress hormones. In both cases

the altered brain is noticeable when compared with a healthy brain. HD impacts and reduced the

quality of life for the patient as well as serves as an alienating force for those involved with

them. Therapy approaches are evolving as is the definition and understanding of the illness.

Currently there is no vaccine or proven treatment to end the hoarding and patients are likely to

leave treatment and return their spaces again to a disruptive clutter. My hope is that more

research is done and better interventions are created to sooth the destress of everyone involved.

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