Sunday, December 4, 2011


The DSM V study group for Anxiety Disorders is proposing  including hoarding with the Obsessive Compulsive disorders in  the new American Psychiatric Association diagnostic manual due to come out in the next year or decade, depending on hoarding controversies.  I actually have treated several hoarders but in retrospect am surprised that it has not come to my attention more.  When i did home visits i encountered it commonly but didn't register it as a disease as much as an adaptation of aging and poverty.
More recent cases have definitely fit a pattern as the patients were wealthy and their hoarding was causing them personal distress and social distress. In one case the person's residence was considered a fire hazard by the fire department and they were ordered to address the problem that had accumulated over decades. in another case the pateint insisted on wanting to unload the clutter but found it impossible to let go of anything.
There's no agreed definition as yet.  The terms for hoarding include, hoarding, compulsive hoarding, pathological hoarding, and disposophobia. The suggestion is that the collection of things of various values is outside the normal and somehow interferes with basic activities and mobility.
It should be noted that there's a potential implicit social discrimination in this definition because obviously the rich can aquire several homes beyond the normal and yet with all that space to store loot in it would clearly not interfere with their mobility or community safety.  Indeed if the very rich were truly concerned they could buy a fire department to put up beside their houses of hoarding.  This might well be what museums and galleries are, a window dressing for a more nefarious disorder, a whole area of discussion best left for the political sociologists..
The first cases of obvious hoarding i saw were 'downsized' elderly patients I did home visits on. Because their finances were such they'd had to move from large houses to small apartmentsl  One man was living in a few feet of his apartment with the rest of it serving as storage space.  The difference between most hoarders and 'collectors' is that 'collectors' have a better appreciation of 'value' and their collections have potential financial value.  One patient had an extraordinary number of comic books which caused his family to joke and make fun of him until the day he sold just one of them for thousands.  This does suggest that the term 'hoarding' needs to clearly separate itself from 'collecting'. Further, one man's treasure is another man's junk.
Somewhat tragically one of my patients thought his 'stash' was potentially valuable but due to his schizophrenia and head injury his assessment of value was grossly impaired. I asked him what he thought the 'stuff' he had was 'worth' and what it would have to be worth before he sold it.  His assessments were grossly off and grossly inflated. Yet I've a friend now who has kept furniture from an old house in a storage locker sufficiently long that she might well have put a downpayment on a new house with the accumulated rent that the storage locker has cost her to store her depreciating furniture.
There is a false sense in the general public that 'stuff' has intrinsic value without realization that the buyer and seller of second hand goods must be able to store them, have them viewed and connect buyer and seller in some way with alot of work establishing attractive prices. Ebay and Craig's List and Kikiji have all turned what might once have been called 'junk' into good transferable 'cash'.  This then is another consideration in the world of 'hoarding'.
I have personally the problem of replacing old stuff with new and taking an inordinate amount of time getting the old out.  I can think of several pairs of shoes due for disposal but i don't want to throw them in the dustbin and keep meaning to drop them off at the special bin for recycling clothes for the poor.  The constraints of time and the priorities of my life make acquisition more important than disposal.  When I trip over the old I'm more likely to raise the priority to a higher level which is a trait that most hoarders lack. They seem to develop a 'blind eye' to the increasing abnormality of their environment  in a way 'addicts' fail to see themselves as others do.
This has caused hoarding to overlap somewhat with shopaholism, one of the addictive diseases.  Compulsive buying though in research is showing up to be a distinctive disorder, possibly part of a spectrum, but definitely distinct from the inability to dispose of goods.  Hence the term 'disposophobia suggesting that true hoarders suffer less from acquring than a failure to let go.
There's been an attempt to differentiate hoarders in a way like the traditional a, b,c classification of personality disorders.  Cluster A hoarders then are more bizarre with schizophreniform hoarding and explanations.  These are those people who have food items in their refridgerators for years yet ignore this eat them and become sick because they can't accept that certain things have lost their value.  Alternatively cluster b extroverted personalities are more likely to hoard things with a future plan and wheeling dealing strategy. Cluster C being introverts and more overtly fearful with the ocd classification thrown in here would hoard because of fears of 'not having'.  B 's intend to get rich while c's would fear the future and believe they would need the 'loot' in the event of a catastrophe.
Certainly there's a lot of 'anxiety associated with hoarding.
One hoarder I saw that comes to mind began hoarding in grief though..  This may well be a way things such as this start. A major involuntary loss in life is dealt with by holding on to what one can.  I know  that one person simply could not let go of many things that had been associated with a previous loved one till they had worked through their grief.  Perhaps this will be considered a special subset or if clinicians do detailed enough histories they would find this more common as a starting point.  As yet no one knows simply because the studies haven't been done.
For hoarding to be a disorder it must be a concern to the individual or society.  It's important to note that my concern for my neighbour's collection of vintage cars has nothing to do with my concern for him. I have frank envy and this might well express itself as my wanting to help relieve him of his obvious burden and perhaps even assist "treating' his disease by taking that particularly nice porche off his hands.
In contrast my patient was simply ashamed and embarassed by her own inability to deal with collected clutter.  She had taken to closing rooms and not having people over. It was affecting her life dramatically.
My own treament in the few cases i've been priviledged to be of assistance has begun with an SSRI medication such as prozac or cipralex.  There are a variety of these and as yet there's not a clear picture of which is best.  With my OCD patients prozac certainly was the best but zoloft seemed to work best as a first line treatment for the ptsd patietns who were considered part of the overall 'anxiety' classification.  So I've used an SSRI to begin with and found that in the few cases I've treated the dosage necessary was higher rather than lower than the normal dosage.
Naturally I've provided some insight, cognitive behavioural and supportive psychotherapy. Motivation therapy approaches have helped. Planning and setting a date and keeping a journal have also been useful.
In addition I've encouraged the patient to go through the clutter with a friend or family member.  The fact is, I personally can't let go of old t shirts, each with a memory attached but a friend could well make the task very easy by noting that many of the ones I work on my boat or motorcycle with are long over due for turning to rags.
"It's a Wonderful Wife" is a company locally where a woman recognised that men and women often needed a person to do things like clean clutter which was the role of the 'traditional wife'.  I've given patients the card of this organization and  another whose name i have at the office. These people have for a reasonable fee done wonders to 'cure' the immediate problem.  The fire department was definitely satisfied with their assistance in one particular case.  Given the established use of 'anxiety buddies' well established for use in plane phobias and agaraphobia it's not surprising that this approach is so successful. However, the disorder is a relapsing, waning and recurring one and my patients had a tendency to get right back into the old patterns so medication and therapy had to be continued for at least a year .
To date MRI studies can distinquish hoarders with OCD from non hoarders with OCD. It appears that hoarders have the greatest activity in decision making areas of the brain suggesting impairment and difficulties in those areas.
At present the research is 'early' but it's a particularly interesting area considering the 1 and 99% placards at Occupy Wall Street  Perhaps in the near future the  Goldman Sachs and Humbug Scrooge will be treated for their disorders with brain surgery rather than dream therapy.

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