Friday, 23 March 2018

ABC's of the DSM-V: The Hoarder in my Home.

Hoarding disorder is something we’ve seen coming up a lot on TV lately with shows like “The Hoarder Next Door” and “Hoarders”. The shock value and uniqueness of the problems shown make for good reality TV; naturally it’s something that shocks us and makes us question how these things happen. Our natural reaction to hoarding is disgust and shock, but also a lot of the time hoarding behaviours are misunderstood as just stubborn behaviours and general bad habits, but it goes far deeper than that. Hoarding comes under as a form of OCD (Obsessive Compulsive Disorder) and the biology of it goes far deeper than just simple bad habits and collecting things. 

Hoarding has only recently become a recognised disorder, being added into the fifth edition of the DSM in 2013 so there are questions as to whether it falls under it’s own category or a symptom of OCD – Currently it is labelled as both, but that may change in future editions depending on what research will find. Currently, HD is defined by a persistent difficult discarding possessions (no matter what their value), perceived distress associated with discarding said items, difficulty discarding items resulting in accumulation of possessions that can affect daily living (blocked exits, no space, inability to move comfortably, and can be with either good insight (the individual recognises the problem) and delusional beliefs (the individual is unaware of the problem and refuses to acknowledge the issues, despite there being strong evidence to state otherwise).

Something I’ve found interesting in my experience of living with someone with HD with delusional beliefs is that it doesn’t matter how much they accumulate – they won’t go back to it and therefore wont notice if anything goes missing because of the sheer amount of clutter there is. Over time we’ve been getting rid of the mess – carrying out boxes and boxes of stuff and not once has the hoarder noticed because it’s gotten to a point where they don’t even know what they have or how much, but if you were to bring it up with them and say that you’re going to sell it or it needs to go in the bin because there’s no use for it, there is a lot of distress and emotions – even though the item is literally worth 10p.

There is the issue of no space, and it's gotten to a point where everything is uncomfortably cramped, a 3 bedroom house being reduced to 2, being unable to buy anything new or nice because there's no space, and having to think of where to put basic things like lamps or coat racks because there is literally almost no space to put anything so we're finding creative ways to stay out of the dark and be  organised. A skip costs £200 and even after spending over £1000, it's like nothing has left. It really brings a whole new meaning to spring cleaning!

Why does this happen though? Research is still limited on hoarding behaviours, but work by Frost et al. (2015) looked at the motives for the acquiring and saving behaviours in hoarding disorder and found that avoiding waste and saving for information were the most frequent motives for saving, whereas in OCD participants it was emotional attachment and in community controls it was saving for aesthetic reasons. Saving for aesthetic reasons is a standard reason for saving things, or emotional attachment, but avoiding waste and saving for information even when you will never need to access them for those reasons seems irrational – which is what HD is, it’s irrational. Anecdotal reports have found that avoiding waste links with feelings of guilt and irresponsibility, potentially due to them imagining potential uses for items despite them being far fetched or unrealistic.

Neurobiologically, genetic causes, problems with executive function and error monitoring have been linked to HD. Twin studies have found that compulsive hoarding is highly heritable (Iervolino et al.,. 2009), and environmental factors such as traumatic or stressful experiences (Mataix-Cols, 2014) can interact with genetics (particularly a section in chromosome 14 in those with families with OCD) and increase the risk of developing HD (Samuels et al., 2007). However, despite the links between HD and OCD, a study looking at the way the brain reacts to performance errors has found them to be distinctly different. For instance, fear of making an error may lead to an inability to decide what to discard and result in hoarding – this decision making ability is predominantly run by the orbito-frontal cortex and has been found to be highly active in participants with compulsive hoarding alongside the parahippocampal gyrus and anterior cingulate cortex when making decisions with emotional weight (eg. Personal possessions) (Tolin et al., 2008).

Treatment options are similar to OCD, certain medications combined with therapies such as cognitive behavioural therapy can help look at your behaviours differently and try and find different ways to approach clutter, alleviating distress and hopefully bringing more order to your mind and therefore your home (or wherever the hoarding problem resides). Having someone come in to professionally clean the place out and declutter/get rid of everything can make things a lot easier (like on the hoarding TV shows) - doing it yourself can be daunting, and so having someone there with a clear goal in mind can help make the process much easier.

So, what have we learnt? Hoarding disorder is a debilitating condition that can either occur alongside or separate to OCD, as a symptom or standalone disorder, and you’re at higher risk than most if you have someone in your family with OCD as genetics can predispose you to developing the disorder, particularly with unfortunate environmental factors (similarly to schizophrenia, but that’s a post for another day).

What are your experiences with hoarding? How has it affected you?

Frost, R. O., Steketee, G., Tolin, D. F., Sinopoli, N., & Ruby, D. (2015). Motives for acquiring and saving in hoarding disorder, OCD, and community controls. Journal of obsessive-compulsive and related disorders, 4, 54-59.  
Iervolino, A. C., Perroud, N., Fullana, M. A., Guipponi, M., Cherkas, L., Collier, D. A., & Mataix-Cols, D. (2009). Prevalence and heritability of compulsive hoarding: a twin study. American Journal of Psychiatry, 166(10), 1156-1161. 
Mataix-Cols, D. (2014). Hoarding disorder. New England Journal of Medicine, 370(21), 2023-2030.  
Samuels, J., Shugart, Y. Y., Grados, M. A., Willour, V. L., Bienvenu, O. J., Greenberg, B. D., ... & Wang, Y. (2007). Significant linkage to compulsive hoarding on chromosome 14 in families with obsessive-compulsive disorder: results from the OCD Collaborative Genetics Study. American Journal of Psychiatry, 164(3), 493-499.  
Tolin, D. F., Kiehl, K. A., Worhunsky, P., Book, G. A., & Maltby, N. (2009). An exploratory study of the neural mechanisms of decision making in compulsive hoarding. Psychological medicine, 39(2), 325-336. 

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