Hoarding Disorder
Contributors:
Nicole A. Adamson, University of North Carolina-Pembroke, Chelsey A. Zoldan and Victoria E. Kress, Youngstown State University
Hoarding disorder (HD) was recently added as a distinct mental health diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental and Emotional Disorders (DSM-5; APA, 2013).
Those with HD typically begin to develop symptoms by the age of 20 years (Tolin, Meunier, Frost, & Steketee, 2010), and 2-6% of the United States population may be diagnosed with this disorder (APA, 2013). Although symptoms typically present earlier in the lifespan, the APA (2013) reported that HD is more commonly identified within the older adult population (i.e., 55-94 years); left untreated, symptoms typically escalate over time.
Individuals with HD experience unhelpful emotions and attachment to material belongings, which may or may not have actual monetary value (Timpano, Buckner, Richey, Murphy, & Schmidt, 2009). Some individuals with HD hoard animals; these cases are typically associated with higher degrees of psychological dysfunction and poor insight (Frost, Patronek, & Rosenfield, 2011). Whether hoarded items have monetary or sentimental value, those with HD experience very strong anxiety when they contemplate parting with their items.
In addition to the emotional distress associated with HD, those with this disorder typically live in unsafe environments (Timpano et al., 2009; Tolin, Meunier et al., 2010). Because it is difficult for individuals with HD to throw away anything of monetary or sentimental value, their homes become cluttered with items ranging from empty coffee cups to home decorations. Often, individuals with HD must navigate narrow walkways overcome with increasing masses of clutter (Ayers Bratiotis, Saxena, & Wetherell, 2010; Frost, 2010). This clutter can serve as a habitat for pests such as cockroaches or rats, create fire hazards, and result in public safety concerns. The clutter generated from hoarding can present significant challenges for fire and medical first responders during emergency situations (Bratiotis, 2013). Cluttered living spaces are also associated with increased risks of falling and medication misplacement, which could be particularly detrimental to the health of older adults (Ayers et al., 2010; Frost, 2010).
A final difficulty associated with HD is social isolation and impairment (APA, 2013). Individuals with HD are aware that others would not approve of their clutter and often prevent visitors from coming to their home. This can impede relationships with friends and family, or even inhibit caregivers from offering support to the individual. Additionally, threats of eviction, homelessness, and diminished financial resources related to hoarding may contribute to strain within relationships.
Identification/Assessment Strategies
When assessing for HD, counselors should first consider referring clients for a medical evaluation to rule out medical etiology of symptoms (e.g., a brain injury; Kress & Paylo, 2015). Counselors should assess for comorbid disorders; HD is often found in the presence of attention-deficit hyperactivity disorder (ADHD) and major depressive disorder (Frost, Steketee, & Tolin, 2011; Sheppard et al., 2010; Tolin, 2011). Additionally, HD is associated with higher levels of anxiety and lower levels of self-control compared to individuals without HD (Timpano et al., 2009; Timpano & Schmidt, 2013). The onset of hoarding symptoms has been associated with the occurrence of traumatic life events (Landau et al., 2011), and an exploration for a possible trauma history should be included as a part of any assessment.
Although HD symptoms are theorized to present in the same way across cultures (APA, 2013), cultural factors should still be assessed during treatment. Poverty and a lack of material resources was once assumed to be related to the development of HD, but researchers have refuted this as a significant contributing factor in the overall development of the disorder (Landau et al., 2011). Because those with HD typically have impaired insight, counselors should also be mindful of how a lack of insight may affect accuracy of client self-reports. The following inventories and assessment strategies may be useful in assessing HD:
Saving Inventory Revised (SI-R; Frost, Steketee, & Grisham, 2004)
The SI-R is a 23-item inventory with a 0-4 Likert scale that can be used with clinical and non-clinical samples. The inventory can be used to assess the full set of HD criteria outlined in the DSM-5 (Mataix-Cols et al., 2010). Counselors can use results of the SI-R to determine the extent to which a client experiences difficulty with acquiring, retaining, and discarding belongings (Frost et al., 2004).
Hoarding Rating Scale-Interview (HRS-I; Tolin, Frost, Steketee, 2010)
The HRS-I is a five-question interview that counselors can use to assess emotional distress in clients who might have HD. The instrument was developed specifically for HD and does not assess for symptoms of OCD (Tolin, Frost et al., 2010). The semi-structured interview requires some interpretations and should be used by professionals who are familiar with HD and related diagnoses.
Second-Hand Reports
Counselors should consult with loved ones and family members in order to gain the most comprehensive and holistic understanding of clients’ HD symptoms (Grisham & Williams, 2014). Family members and friends typically have a unique insight into the client’s struggles; multiple sources of data help counselors make the most accurate diagnosis (Grisham & Williams, 2014; Tolin, Frost et al., 2010). As previously mentioned, comorbid disorders and other physical difficulties might be related to HD symptoms (APA, 2013), and other mental health and medical professionals should be consulted when appropriate.
Behavioral Assessments
Individuals with HD experience strong emotions when faced with the possibility of parting with belongings (APA, 2013). Counselors can guide clients through a thought log in which thoughts, feelings, and behaviors related to discarding items are recorded (Grisham & Williams, 2014). Initially, counselors might help clients identify which possessions (or categories of possessions) are most valuable to them and which items are of less value. Then, counselors can lead clients into a conversation about hypothetically discarding items of less value. This conversation could be anxiety-provoking, and counselors should implement self-regulating strategies intentionally. Counselors can gain information about the level of severity associated with the disorder by observing the client’s reactions and thought logs throughout this process.
Next, counselors can move from hypothetical conversations into assignment of behavioral tasks related to discarding (Grisham & Williams, 2014). The counselor could ask the client to make successive approximations toward discarding one low-value item and maintain a thought log throughout the process. Counselors can use behavioral observations and the client’s thought log to understand the client’s level of distress and determine a starting place for the intervention process.
Resources
The SI-R, HRS, and additional HD assessment tools are available at http://www.hoarders.org/rpr.html
Intervention Strategies
Individuals with HD are five times more likely to be involved with mental health treatment than members of the general populations (Tolin, Frost et al., 2010). Yet they often initially present with symptoms of a co-occurring disorder such as ADHD or depression (Fullana et al., 2013; Hall, Tolin, Frost, & Steketee, 2013). As such, accurate diagnosis is a necessary precursor to effective intervention strategies. Once HD is identified, there are several treatment approaches that may be used to address the symptoms of the disorder.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is highly regarded as an effective strategy for working with HD symptoms (Steketee, Frost, Tolin, Ramussen, & Brown, 2010; Tolin, Frost, & Steketee, 2008). Researchers have found standard CBT protocols to be ineffective in treating HD (Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; Steketee & Frost, 2003, 2007). HD-specific protocols should address thoughts, feelings, and behaviors associated with hoarding behaviors and emotional distress (Steketee & Frost, 2007). Three main hoarding behaviors that should be addressed through CBT interventions are excessive acquisition of belongings, disorganization, and distress related to discarding. These components can be addressed through skills training, simulated or in-vivo exposure to distressing activities, and reframing unhelpful beliefs (Steketee & Frost, 2007; Tolin et al., 2008). These aforementioned treatment components (and CBT in general) have been applied and demonstrated treatment gains with this population in both individual and group settings (Muroff, Bratiotis, & Steketee, 2011).
Family-Based Therapy
It is especially important to involve family members when treating children or adolescents with HD. Ale, Arnold, Whiteside, and Storch (2014) found that CBT approaches that involved family members were helpful in reducing ways in which others reinforced the client’s hoarding behaviors. One aspect of family treatment involves family members using positive reinforcement when clients display reduced HD symptoms. Although family-based treatment is especially important for young clients, it can be helpful for clients of all ages.
Multidisciplinary Approaches
Treatment of HD requires the cooperation of the client, family members, and the community. Counselors should engage community resources and seek support from a variety of professionals when working with clients with HD (Bratiotis, 2013). Because HD presents a challenge to public health and safety, several community agencies may be involved, including fire departments, sanitation departments, departments of aging, child welfare agencies, and animal welfare services (Braitotis, 2013; Braitiotis et al., 2013). Clients with HD often require medical assistance for comorbid disorders or physical difficulties associated with the disorder and its symptoms. Hoarding disorder is associated with poor overall physical health; those with the disorder are likely to suffer from chronic medical conditions including cardiovascular problems, arthritis, sleep apnea, and diabetes (Tolin, Frost, Steketee, Gray, & Fitch, 2008). As such, mental health providers may need to work with an individual’s primary medical care provider. Because HD behaviors often occur over a long period of time, professionals are often needed to conduct home clean-outs and assist with organization of hoarded items (Bratiotis, 2013; Muroff, Steketee, Bratiotis, & Ross, 2012).
Resources
The International OCD Foundation has several resources available to clinicians, family members, and individuals with HD. Information about the disorder, its treatment and diagnosis, recent research, and other resources are available at https://hoarding.iocdf.org/
The Treatments That Work website offers several downloadable worksheets and assessment tools for use with individuals with HD. https://global.oup.com/academic/product/treatment-for-hoarding-disorder-9780199334940?cc=us&lang=en&
Frost and Steketee’s manual outlining CBT treatment for HD can be found at https://global.oup.com/academic/product/treatment-for-hoarding-disorder-9780199334964?cc=us&lang=en&
The accompanying workbook is available at
http://www.amazon.com/Compulsive-Hoarding-Acquiring-Workbook-Treatments/dp/0195310551
REFERENCES
Ale, C. M., Arnold, E. B., Whiteside, S. P., & Storch, E. A. (2014). Family-based behavioral treatment of pediatric compulsive hoarding: A case example. Clinical Case Studies, 13(1), 9-21. doi: 10.1177/1534650113504487
American Psychiatric Association. (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.; DSM-5). Washington, DC: Author.
Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. L. (2010). Age at onset and clinical features of late life compulsive hoarding. International Journal of Geriatric Psychiatry, 25(2), 142-149. doi: 10.1002/gps.2310
Bratiotis, C. (2013). Community hoarding task forces: A comparative case study of five task forces in the United States. Health & Social Care in the Community, 21, 245-253. doi: 10.1111/hsc.12010
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Published: February 2015
Updated: August 2016
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