By Thomas Goldsmith

When household clutter makes it impossible for a person to reach rooms in his house, or for firefighters to do their jobs, hoarding has reached the level of a mental health disorder.

That’s the word from professionals in North Carolina, where therapists who specialize in the disorder and a state task force offer information and resources for family members, emergency workers and others concerned about hoarding. Hoarding isn’t just the odd collection of habits seen in cable television shows, but also a condition that can endanger people who practice it and others around them, therapists say.

“Denial of the problem can interfere with someone’s life,” Marty Lamb, a Raleigh licensed clinical social worker, said at a meeting this month of the North Carolina Partnership to Address Adult Abuse annual conference.

Increasing attention and more nuanced treatment for hoarding have taken place since its listing for the first time in 2013 as a separate disorder in the closely watched Diagnostic and Statistical Manual of Mental Disorders produced by the American Psychiatric Association.

Hoarding was long associated with older people, as seen in its old-fashioned name, “senile squalor.” The problem has had associations with such memorable characters as Charles Dickens’ obsessive Miss Havisham in Great Expectations, academics Kenneth J. Weiss and Aneela Khan noted in a 2015 article.

Task force promotes new approaches

In the nearer term, professionals have focused on learning to treat hoarding with different methods from those used with the related obsessive-compulsive disorder, including the testing of different medications. Emergency responders have expanded means of identifying hoarders and sharing knowledge about potentially hazardous houses. And both groups, along with family members, are learning more productive ways to communicate with those whose accumulations have reached the danger point.

“In my experience, if there is someone that has a lot of clutter, you really have to build a relationship with the person,” said Wendy Giannini, risk reduction coordinator for Wilmington Fire Department. “They don’t want people’s advice.

“Don’t say, as their kids have, ‘We’re going to pull a dumpster in the yard and load this stuff up.’”

The state Task Force on Hoarding offers means for identifying and dealing with hoarding.
This chart shows progressively more cluttered stages of hoarding in a kitchen, the kind of information that can be provided to firefighters before something happens.

North Carolina’s Hoarding Task Force brought together Giannini and representatives from the state fire marshal’s office, the Department of Health and Human Services, North Carolina Baptist Aging Ministry, the National Fire Protection Association, municipal fire departments across the state, even an NCSU expert on animal hoarding. The group no longer meets on a regular basis, but provides consultation and uses the state Department of Insurance’s website to make available the wealth of facts and guidelines it has assembled.

“We were encouraging other fire departments to either pick up the phone and call one of us, or look at some of the resources we have online,” Giannini said.

Fire hazards

Members of the Wilmington Fire Department actively seek out cluttered houses that seem likely to cause problems for emergency responders, sometimes to the point where firefighters have had to demolish walls to create ways out for themselves.

Medicare help line NC Dept of Insurance 855-408-1212“We are so active in knocking on folks doors and make sure they have smoke alarms,” Giannini said. “We deliver Meals on Wheels to an aging population, which gets us people’s homes a couple of times a month.

“They have to realize that if they get sick it’s going to be very difficult for first responders.”

After fire department personnel identify a house as potentially hazardous because of hoarding, information gets passed on to the entire team. Scarily, that sheer bulk of possessions can amp up the danger and damage caused by a fire.

“When it comes to fire, imagine your campfire; a heavy fire load would be lots and lots of logs,” Giannini said. “Hoarding puts you in a new risk, depending on what the clutter is: plastics, or fabrics, or even furniture. It’s more danger for the firefighters that are going to have search inside.”

New therapeutic approaches

Emergency personnel focus on preventing harm and facing risks from hoarding, leaving treatment to professionals such as Annette Perot, a Chapel Hill therapist who has had many patients with hoarding disorder. Often, Perot’s treatment involves meeting a client at the scene of the hoarding and introducing new methods of thinking about clutter in a non-threatening way.

“A good example might be one woman that I worked with had lots of lots of newspapers that she had saved,” Perot said. “She really valued learning and said, ‘One day I want to read these things.’

“What she wasn’t focused on and what we looked at was, how many of the newspapers does she have and how long would it take her to read all the newspapers that she has?”

The client realized that she would have to spend all day every day for more years than she has left to read all the papers.

“She said, ‘I actually want to spend time with my friends from church and with my grandchildren,’” Perot said.

“It wasn’t my telling her. The therapist is really helping the person to explore some other ways of thinking about possessions.”

As Raleigh therapist Lamb and others note, people who have crossed the line from collecting into hoarding often attempt to rationalize actions such as piling up hundreds of the same common item.

“Some people will say, ‘I know it’s not valuable now, but I’m keeping it until it is valuable,’” Lamb said.

Through cognitive behavioral therapy, hoarders can step out of the rationalizations that have propped up their obsessive collecting habits, Perot said. All the same, there’s a line that can get tricky between people who acquire collections of stuff and others whose heaps are large enough to collapse floors in their homes.
Functional MRI images of the anterior cingulate cortex (center) which became over-activated when hoarding disorder patients had to decide whether to keep or discard their own possessions; it was under-activated during decision-making about others’ possessions. Source: David Tolin, Ph.D., Hartford Hospital; Image courtesy: National Institute of Mental Health

“If someone in a nursing home has a drawer full of candy, is that hoarding?” Lamb said.

The appearance of hoarding disorder in the DSM-5 means that therapists can be reimbursed for treating it and that researchers are more likely to get funding for a focus on it. A 2014 study showed some value the use of Venlafaxine, or extended-release Effexor, in treating hoarding disorder.

Resisting the tug of stuff

Perot says there’s likely a nature-nurture basis for the frequently noted inherited occurrence of hoarding disorder. She’s also found that the condition can have its roots something as common as childhood collections.

“What we think is probably the case is that some people initially start having some of the symptoms or signs of hoarding early in their lives, like in pre-adolescence,” Perot said.

“It might mean having an overvalued sense of the value of possessions. In kids, for example, there’s oftentimes a sense of personifying possessions, in seeing a possession as like their friends.

“So they’d think it might hurt their possession’s feeling if they get rid of it.”

Therapists have also realized that different kinds of treatment work better even among specific groups of older people.

“The behavioral piece is helping people, to for example, to be able to be in stores and see things and feel this tug to buy something, but not to purchase it,” Perot said. “They initially feel distressed about parting with it. But if they let that feeling be there, they find that that feeling recedes.”

For people in their 70s and 80s, therapists can use a method in addition to behavioral therapy. .

“A much older population is more likely to have more problems with cognitive decline,” Perot said. “We have them do what is called cognitive rehabilitation. We do more stuff around ways of making lists, using a calendar, problem-solving and helping them not have as much clutter.

“When the mail comes in, they’re going to have a system of how to deal with it.”

What are the signs of hoarding?

A 2015 paper in the Journal of the American Academy of Psychiatry and the Law includes these symptoms for hoarding disorder:

“Persistent difficulty discarding or parting with possessions, regardless of their actual value;

“A perceived need to save the items and distress associated with discarding them;

“The accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, or the authorities); and

“Clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining an environment safe for oneself or others).”

The authors say that hoarding disorder also involves the person’s excessive gathering of things he doesn’t need, along with having a hard time getting rid of them.

Additional resources: International OCD Foundation site on hoarding disorder

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Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...