Tuesday, June 1, 2010

Hoarding: Very Serious, Very Unrecognized

I've spent the last few weeks moving my stuff out of my old place and into my new one. Correction: A good deal of it wound up in the dumpster and a lot more will be donated to a yard sale event.

Coincidentally, in the middle of coordinating my move (which included acquiring a lot of new stuff), I attended a one-day seminar on Mental Health and Aging put on by NAMI San Diego and The Senior Mental Health Partnership. First talk of the day was on hoarding.

Much to my relief, I learned that I was an unmitigated slob, not a hoarder. As Catherine Ayers of UCSD explained, hoarding does not equate with messiness. Rather, I am merely too lazy to throw away my old things rather than being driven by an obsessive need to hold on to them. Someday there may be a DSM diagnosis for people like me, but not yet.

According to Dr Ayers, individuals who hoard have a distorted belief about the importance of a possession (such as a discarded water bottle) combined with an obsessional fear of losing that possession. The hoarding interferes with the individual's ability to use their home.

Accounts of individuals literally buried alive beneath domestic clutter may come across as comic, but the reality borders on tragedy. As Dr Ayers explained, 45 percent of older people who hoard could not gain access to the fridge and 10 percent could not use the toilet. Getting from one area of the house to the other typically involves negotiating labyrinthine (and often treacherous) "goat trails."

Hoarding is fairly common, accounting for 5.3 percent of the population. Hoarders are typically female, unmarried, and living alone. Never having been married is associated with greatest impairment. Hoarding tends to start in the 30s, with the severity increasing over time. Eighty-four percent of those who hoard have a first degree relative of similar disposition.

Behavior may include indecisiveness, perfectionism, procrastinating, difficulty organizing tasks, and avoidance. Dr Ayers also mentioned an abnormal desire to take control and exercise responsibility. She mentioned one individual who took it upon herself to tape NPR. Her home contained 500,000 tapes.

Three out of four hoarders shop too much, but a real danger, Dr Ayers pointed out, is from stuff that comes into the house, such as mail. Hoarded items tend not to be of high value, such as paper. Since it takes time to go through paper, that paper is not going anywhere.

The illness is attributed to a deficiency in informational processing, though not necessarily in older adults. Older adults may have good neuro-cognitive function, but may be deficient in other areas. Hoarding is listed as a symptom of OCD, but brain scans reveal a different pattern. The draft DSM-5 is proposing the new diagnosis of "hoarding disorder."

Unfortunately, Dr Ayers explained, hoarders don't go to doctors' offices seeking help. Having someone else clean out the place is only a temporary fix, as hoarders go right back to their old ways. SSRIs may help, and cognitive-behavioral therapy aimed at addressing hoarding behavior is in its infancy. Dr Ayers suggested that intensive outpatient therapy seems to be the most effective treatment, with a focus on getting the patient to decide on every item.

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Gina Pera said...

Very interesting, John. And I'm envious of your starting afresh in a new place, leaving the old clutter behind. That's got to be invigorating!

There are several new books on this topic, and I've heard the authors interviews on various radio programs.

Knowing about ADHD and its connection to hoarding and clutter, I'm always surprised that the experts never mention it. (Perhaps the books do; i haven't read them.)

Specialists can be very narrow, and can sometimes miss the forest for the trees. I'd listen as these experts touched on key ADHD challenges and yet talk about them with an air of mystery, as if we don't know why people might do these things.

For example, people with untreated ADHD often need all of their items on display -- not hidden away in drawers, closets, and cabinets -- lest they forget where they are.

They have trouble prioritizing, organizing, and choosing what stays and goes and where it goes when it stays. Decision making is a problem in many areas of life, and especially around clutter. Therefore, reading Dr. Ayers' last suggestion might make some people with ADHD break out in a cold sweat.

There can also be a greater-than-average tendency to "self-medicate" with shopping. Once the item is purchased, though, the dopamine stops flowing, and there the item sits. Pondering what to do with it only adds to mind-numbing stress, especially as yet another mounting credit-card bill arrives in the mail.

Some items are kept because they represent a memory they don't want to lose. And woe to those with a mild clutter problem who inherit the entire household of a parent, especially a parent who also had ADHD (76 percent genetic, you know) and a clutter problem. They might never dig their way out of that.

I realize there are often other issues at work with hoarding, but it's so important to know about those connected to ADHD because they are usually highly treatable. I've known many people who would just stare at a messy room, closet, or garage, not having a clue about where to begin to organize it. Yet, when they started taking a stimulant medication, the process became much clearer and less intimidating.

I should make clear that not all people with ADHD have a problem with clutter or hoarding. ADHD symptoms are variable. In fact, some people with untreated ADHD might go to the other extreme and ruthlessly purge the living space of clutter, some of which they might have to replace later. ADHD, at its core, is a disorder of dysregulation, so the behavior can swing from one extreme to the other.

I wrote a blog post about ADHD and clutter recently:

John McManamy said...

Hey, Gina. I've personally witnessed someone with ADHD freeze like a deer in the headlights around clutter or having to sort through a pile of bills and similar stuff.

Is it possible that hoarding can be both a symptom AND a diagnosis? Much like sleep dysregulation is both a symptom of depression and mania as well as a whole category of disorders.

Also, I am aware that clutter is part of depression. Again, like ADHD, many people who are depressed go shopping for the dopamine rush. Then the stuff sits in their houses, often unopened. Similarly, people can be too depressed or unmotivated or overwhelmed to organize and clean up.

Then there is anxiety to consider and the avoidant behavior this generates.

Hopefully, we will learn more as more brain scan studies are done, but obviously researchers need to be doing comparisons with those with ADHD.