Psychiatric Issues in Hoarding

[I'd like to share this article which originally ran in Psychiatric Times, Volume 28, No. 8.  This is the full version of the original article with the website reference at the end. Randi Lyman]

Psychiatric Issues in Hoarding

Strategies for Diagnosing and Treating Symptoms of Hoarding

By Suzanne Otte, MBA, MSW and Gail Steketee, PhD | August 19, 2011

Ms Otte is Hoarding Research Project Affiliate at Boston University School of Social Work and Dr Steketee is Dean and Professor at Boston University School of Social Work. The authors report no conflicts of interest concerning the subject matter of this article.

In North America, an estimated 30% of the population maintains a collection of some sort.¹ The practice of collecting, in which individuals maintain collections of objects that are generally considered interesting and valuable is distinctly different from that of hoarding.² Compulsive hoarding is characterized by the following criteria^3,4:

• The acquisition of, and failure to discard, a large number of possessions

• Excessive clutter that precludes activities for which the living space was designed

• Significant distress or impairment in functioning caused by the hoarding

Hoarding has broad-reaching implications, including a substantial public health burden linked to occupational impairment, poor physical health, and demand for social services.⁵ For example, it is not uncommon for community public health departments to become overburdened with property complaints regarding unsanitary conditions and fire hazard risks, and the cost to address a problem (eg, repetitive clean-outs, repeated visits by health inspectors, multiple-agency involvement) is high.⁶ These costs have led to the establishment of community-wide task forces in a number of cities.⁷ However, efforts to reconcile the problem are often diminished by the relative unavailability or ineffectiveness of mental health services.⁸
In addition to the effects of hoarding on the community, family dynamics are often strained.⁹ Substantial distress, frustration, hostility, and rejection of hoarders are not uncommon.³ In a recent online study of hoarding, more than half of the participants were described as having poor or no insight into the severity of their hoarding behaviors, and family members’ attitudes of rejection were correlated with less awareness of illness among those who hoard.¹⁰
For the individual who hoards, outcomes may include substantial work impairment, eviction or threat of eviction, or having a child or elder removed from the home.¹⁰ In general, persons with hoarding problems seek treatment after age 40 years, although hoarding symptoms commonly begin in the early teenage years.¹¹ Those who hoard tend to live alone and may have a family member (parent, sibling, older relative) with the problem.^12-14
The prevalence of clinically significant hoarding in the general population ranges from 2% to 5%, and between 6 million and 15 million persons in the United States are affected, according to recent epidemiological studies.^15-17 Hoarding appears to affect more men than women, although women are more likely to participate in research and seek treatment.¹⁷
Hoarding is a significant psychiatric problem that occurs at twice the rate of obsessive-compulsive disorder (OCD) and at almost 4 times the rate of bipolar disorder and schizophrenia.¹³ It has been linked with impulse control disorders and appears to have high comorbid rates of major depressive disorder (MDD), social anxiety disorder, generalized anxiety disorder (GAD), attention-deficit/hyperactivity disorder (ADHD), and personality disorders.^18-26

What is already known about hoarding?

■ Clinically significant hoarding affects between 6 million and 15 million persons in the United States, according to recent epidemiological studies, occurring at twice the rate of obsessive-compulsive disorder (OCD) and at 4 times the rate of bipolar disorder and schizophrenia. It appears that hoarding is accompanied by high rates of comorbidity. A number of self-report and clinician-administered hoarding-specific measures aid in the assessment of symptoms and severity. Treatment for hoarding is guided by a cognitive-behavioral therapy (CBT) approach.

What new information does this article provide?

■ Historically, hoarding has been deemed a subtype of OCD, although forthcoming evidence suggests there are more differences than similarities. Hoarding is under consideration for inclusion in DSM-5 as a stand-alone disorder. A set of provisional criteria for hoarding disorder has been proposed and will require further study in the future. A recent study conducted by Frost and colleagues that examined the largest sample of participants to date confirmed that major depressive disorder was the most frequently occurring comorbid condition (more than 50%) and that kleptomania was a factor in 10% of the sample. This article highlights treatment options for hoarding that are available to practitioners, including alternative approaches focusing on self-help, support group, and Web-based delivery models.

What are the implications for psychiatric practice?

■ Individually administered CBT, following the protocol developed by Steketee and Frost, appears to be the most effective treatment, with a 70% to 80% rate of clinical improvement for patients who complete treatment. Given the expense and limited availability of individual treatment, alternatives, including group CBT, Web-based treatment, in-person self-help groups, and in-home coaching assistance, may provide sustainable and affordable approaches to this significant societal problem. Further research to better understand hoarding and to provide additional cost and resource-sensitive solutions is ongoing.

Historically, hoarding has been considered a subtype of OCD, although recent evidence suggests that there are more differences than similarities.13 Studies of patients with OCD have shown an 18% to 40% frequency of hoarding in adults and children and adolescents, although, hoarding is identified as a major or primary symptom in fewer than 5% of cases.19,26-29 Early studies that support this finding were derived from measures that do not adequately assess the presence or severity of hoarding (ie, Yale-Brown Obsessive Compulsive Scale30).8 Recent studies have incorporated reliable and valid measures (eg, Saving Inventory-Revised [SI-R], Hoarding Rating Scale-Interview [HRS-I], Clutter Image Rating [CIR]) that assess specific symptoms of hoarding as well as changes in symptoms following treatment.8

Comorbidity and implications for diagnosis
The identification of hoarding as a subtype of OCD has influenced scientific understanding of its comorbidity. Progressive research efforts have advanced the definition and measurement of hoarding, providing a more reliable diagnosis and assessment of comorbidity.^12,31,32 A recent study by Frost and colleagues (R. O. Frost, G. Steketee, D. F. Tolin, K. Glossner, unpublished data, 2011) examined 217 hoarding participants, the largest sample to date, who were recruited to meet diagnostic criteria for hoarding disorder (HD) currently under review for DSM-5.¹² The study confirmed that a minority of participants with HD (fewer than 20%) also had OCD diagnoses and that MDD was the most frequent comorbid condition (more than 50%). This was followed by GAD and social phobia in approximately 25% of HD participants.


The rates for posttraumatic stress disorder were relatively low (7%), but the HD sample was more likely than OCD patients to have experienced a traumatic event as an adult or as a child. This finding is consistent with earlier research about the frequency of traumatic events among those who hoard.^17,33,34 Inattentive ADHD was significantly more frequent in hoarding than in OCD (30% vs 3%), which supports the speculation that attention deficits are relatively common among those who hoard, but certainly this is not a universal characteristic.
It is not surprising that compulsive buying and excessive acquiring of free things were common among the hoarding sample (about 60%), and even the prevalence of kleptomania was surprisingly high at 10% of the sample. These findings confirm recent reports that more than 80% of people with self-reported hoarding acquire excessively.³⁵ Obsessive-compulsive personality disorder (OCPD) was the most frequent personality disorder found among hoarding participants, even when hoarding was omitted from the criteria for OCPD.

Status of DSM-5 diagnostic criteria
Today, hoarding is cited in DSM-IV-TR as one of the diagnostic criteria for OCPD and, when hoarding is deemed severe, a symptom of OCD.¹²Hoarding has been a core diagnostic criterion for OCPD only since DSM-III-R and as a possible OCD symptom within the differential diagnosis section OCPD since DSM-IV.^12,36 Given the presumption that hoarding was a symptom of OCD, many studies have evolved from this assumption and have influenced clinical understanding of the disorder.¹³ More recently, however, growing evidence supports the separation of hoarding from OCD.^13,36-38
In the interest of clarifying the clinical phenomenon, increasing public awareness, improving identification of cases, and stimulating further research and development of effective treatments for hoarding, a set of provisional criteria has been proposed (Table).¹² These will require further study in the coming years.

Theoretical model
The manifestations of hoarding (acquisition, difficulty with discarding, clutter), outlined in an emerging cognitive-behavioral model, are hypothesized to evolve from core vulnerabilities based on early life experiences, genetic predisposition, current mood state, and personality traits (Figure).^4,39,40 On the basis of this model, cognitive information processing deficits (focusing attention, decision making, organizing, and possibly perception) are thought to be persistent factors in generating hoarding. A combination of early experiences and cognitive challenges result in mistaken beliefs about and attachments to possessions, with resulting negative emotions that lead to avoidance behaviors (saving unneeded items) and clutter. In addition, objects that evoke feelings of positive attachment and experiences of pleasure may result in excessive acquiring and clutter.⁸

CBT methods and outcomes
The elements of mental health treatment for hoarding are based on the theoretical model for this multidimensional problem. The protocol uses a manualized cognitive-behavioral therapy (CBT) approach that incorporates assessment and goal setting, organizing and problem-solving skills training, exposure practice methods to reduce acquiring and remove clutter, and motivational interviewing to address patient resistance when it arises during treatment.^2,8,41
The tools to measure hoarding symptoms and severity include the SI-R, a 23-item self-report questionnaire that assesses difficulty with discarding, clutter, and excessive acquisition; a score of 41 or higher typically indicates a clinical hoarding problem.³¹ The HRS-I helps clinicians make a diagnostic assessment of the 5 main features of hoarding (clutter, acquisition, difficulty with discarding, distress, impairment), each rated on a 0 to 8 scale; the HRS-I can also be used as a self-report scale.³² The CIR is a pictorial measure of in-home clutter severity intended for use by patients, family members, clinicians, or independent assessors.⁴² The Saving Cognitions Inventory is a 24-item self-report measure of beliefs experienced by patients when they attempt to discard items; subscales of this measure include emotional attachment, concerns about memory, control over possessions, and responsibility toward possessions.⁴⁰

The most effective approach to date appears to be individually administered CBT, following the model and methods of Steketee and Frost.² A recent pilot study of 10 completers and a controlled trial with 37 completers yielded rates of 70% improved or much improved according to the therapists and 80% according to patients. Overall, 60% of patients showed clinically significant improvement following 26 sessions of individual CBT that included monthly in-home visits.¹⁰ Group interventions that included 20 sessions of CBT were only slightly less effective and appear to offer considerable potential for cost-saving solutions.²²

Further research is necessary to examine methods to enhance cognitive function (eg, attention, executive functioning) to improve the effectiveness of CBT.⁴³ Expanding study inclusion criteria to allow men and persons from other cultures, races, and socioeconomic status will help generate more information about outcomes and strategies appropriate for all persons who hoard.

Cost-saving, stepped-care strategies for delivering CBT
The delivery of in-person, individual or group therapy for hoarding depends on skilled clinicians trained to treat persons with this problem. Because individual and even group treatment can be expensive and unavailable to many individuals with this highly prevalent condition, alternative approaches have focused on the application of self-help bibliotherapy, online and in-person support groups, coaching, and Web-based CBT.
Muroff and colleagues⁸ describe a 2009 study undertaken by Pekareva-Kochergina and Frost. The researchers examined the benefits of a 13-week intervention during which 2 undergraduate students supervised by a senior clinician facilitated 2 self-help groups. Participants read Buried in Treasures: Help for Compulsive Hoarding,⁴⁴ a book describing hoarding, and were encouraged to practice the strategies proposed. At the close of the group sessions, 41% of participants rated themselves “much improved.” This student-led group yielded a surprisingly positive outcome for group members in a relatively short period.

In 2010, a Web-based self-help group for hoarding, established in 1998, was studied by Muroff and colleagues.⁴⁵ Members participated in online chats, accessed an archive of resources hosted on the Web site, and were required to post action steps and progress reports at least monthly. Both long-term and recent members showed reductions in clutter and hoarding symptoms over a 15-month period. More active participants on the Web site showed statistically lower levels of hoarding. This group represents an intervention model that holds the potential to economically extend treatment to a geographically dispersed group.

The benefit of in-home assistance by clinicians is time-consuming and costly. Muroff and colleagues8 introduced non-clinician, in-home assistants (trained undergraduate student coaches) into a hoarding treatment group to reinforce skills learned in group treatment and boost CBT-based outcomes for participants. Clinicians who led the group communicated with coaches through in-person and telephone group supervision and use of a system to track and docu-ment home visits throughout the 20-week treatment period. One group of participants received 4 home visits from one of the cotherapists, the second group received an additional 4 home visits from the undergraduate coaches. Although reductions in hoarding symptoms were not statistically significant, additional in-home assistance appeared to offer improved (albeit small) outcomes. Additional studies will help further define the effect of this enhancement to group treatment.
A pilot study is under way to test the feasibility, acceptability, and effectiveness of computer- and Webcam-delivered CBT for hoarding symptoms. Preliminary results show potential for a cost-effective, direct service solution to in-home locations where hoarding occurs.⁸ Initial outcomes of this 26-session, weekly home-based CBT treatment delivered via Webcam showed moderate improvement of participant’s hoarding symptoms and was administered over a 30- to 38-week period compared with an average 49 weeks of in-person treatment.
These stepped-care strategies demonstrate potential to assist a broader spectrum of patients using CBT hoarding interventions and offer a sustainable, economic approach to this societal problem. Given the large number of persons who hoard, the debilitating and potentially deadly consequences, and the sometimes limited insight into the severity of their symptoms, it seems essential to learn more about this complicated problem. Current CBT regimens are effective, but they are costly. Accordingly, more research is needed to better understand the disorder and to provide relief from this chronic problem.

References
1. Pearce S. On Collecting: An Investigation Into Collecting in the European Tradition. London: Routledge; 1995.
2. Steketee G, Frost RO. Compulsive Hoarding and Acquiring: A Therapist Guide. New York: Oxford University Press; 2007.
3. Frost RO, Gross RC. The hoarding of possessions. Behav Res Ther. 1993;31:367-381.
4. Frost, RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther. 1996;34:341-350.
5. Tolin DF, Frost RO, Steketee G, et al. The economic and social burden of compulsive hoarding. Psychiatry Res. 2008;160:200-211.
6. Frost RO, Steketee G, Williams L. Hoarding: a community health problem. Health Soc Care Community. 2000;8:229-234.
7. Steketee G, Frost R. Compulsive hoarding: current status of the research. Clin Psychol Rev. 2003;23:905-927.
8. Muroff J, Bratiotis C, Steketee G. Treatment for hoarding behaviors: a review of the evidence. Clin Soc Work J. 2010. doi:10.1007/s10615-010-0311-4. 2010.
9. Tolin DF, Frost RO, Steketee G, Fitch KE. Family burden of compulsive hoarding: results of an internet survey. Behav Res Ther. 2008;46:334-344.
10. Tolin DF, Frost RO, Steketee G. An open trial of cognitive-behavioral therapy for compulsive hoarding. Behav Res Ther. 2007;45:1461-1470.
11. Grisham JR, Frost RO, Steketee G, et al. Age of onset of compulsive hoarding. J Anxiety Disord. 2006;20:675-686.
12. Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010;27:556-572.
13. Pertusa A, Frost RO, Fullana MA, et al. Refining the diagnostic boundaries of compulsive hoarding: a critical review. Clin Psychol Rev.2010;30:371-386.
14. Saxena S. Recent advances in compulsive hoarding. Curr Psychiatry Rep. 2008;10:297-303.
15. Iervolino AC, Perroud N, Fullana MA, et al. Prevalence and heritability of compulsive hoarding: a twin study. Am J Psychiatry. 2009;166:1156-1161.
16. Mueller A, Mitchell JE, Crosby RD, et al. The prevalence of compulsive hoarding and its association with compulsive buying in a German population-based sample. Behav Res Ther. 2009;47:705-709.
17. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther.2008;46:836-844.
18. Frost RO, Steketee G, Williams L. Compulsive buying, compulsive hoarding, and obsessive-compulsive disorder. Behav Ther. 2002;33:201-214.
19. Samuels J, Bienvenu OJ 3rd, Riddle MA, et al. Hoarding in obsessive compulsive disorder: results from a case-control study. Behav Res Ther. 2002;40:517-528.
20. Frost RO, Steketee G, Tolin D, Brown T. Co-morbidity and diagnostic issues in compulsive hoarding. Paper presented at: Annual Meeting of the Anxiety Disorders Association of America 2006; Miami.
21. Frost RO, Steketee G, Williams LF, Warren R. Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls. Behav Res Ther. 2000;38:1071-1081.
22. Muroff J, Steketee G, Rasmussen J, et al. Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial. Depress Anxiety. 2009;26:634-640.
23. Steketee G, Frost RO, Wincze J, et al. Group and individual treatment for compulsive hoarding: a pilot study. Br Assoc Behav Cognit Psychother. 2000;23:259-268.
24. Hartl TL, Frost RO. Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study. Behav Res Ther.1999;37:451-461.
25. Meunier SA, Tolin DF, Frost RO, et al. Prevalence of hoarding symptoms across the anxiety disorders. Paper presented at: Annual Meeting of the Anxiety Disorders Association of America; 2006; Miami.
26. Mataix-Cols D, Rauch SL, Manzo PA, et al. Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 1999;156:1409-1416.
27. Frost RO, Krause MS, Steketee, G. Hoarding and obsessive-compulsive symptoms. Behav Modif. 1996;20:116-132.
28. Mataix-Cols D, Nakatani E, Micali N, Heyman I. Structure of obsessive-compulsive symptoms in pediatric OCD. J Am Acad Child Adolesc Psychiatry. 2008;47:773-778.
29. Rasmussen SA, Eisen J. Clinical features and phenomenology of obsessive-compulsive disorder. Psychiatr Ann. 1989;19:67-73.
30. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-1011.
31. Frost RO, Steketee G, Grisham J. Measurement of compulsive hoarding: saving inventory-revised. Behav Res Ther. 2004;42:1163-1182.
32. Tolin DF, Frost RO, Steketee G. A brief interview for assessing compulsive hoarding: the Hoarding Rating Scale-Interview. Psychiatry Res.2010;178:147-152.
33. Wheaton M, Timpano KR, Lasalle-Ricci VH, Murphy D. Characterizing the hoarding phenotype in individuals with OCD: associations with comorbidity, severity and gender. J Anxiety Disord. 2008;22:243-252.
34. Cromer KR, Schmidt NB, Murphy DL. Do traumatic events influence the clinical expression of compulsive hoarding? Behav Res Ther.2007;45:2581-2592.
35. Frost RO, Tolin DF, Steketee G, et al. Excessive acquisition in hoarding. J Anxiety Disord. 2009;23:632-639.
36. Wu KD, Watson D. Hoarding and its relation to obsessive-compulsive disorder. Behav Res Ther. 2005;43:897-921.
37. Abramowitz JD, Wheaton MG, Storch EA. The status of hoarding as a symptom of obsessive-compulsive disorder. Behav Res Ther.2008;46:1026-1033.
38. Pertusa A, Fullana MA, Singh S, et al. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both. Am J Psychiatry.2008;165:1289-1298.
39. Frost RO, Tolin DF. Compulsive hoarding. In: Taylor S, Abramowitz JS, McKay D, eds. Clinical Handbook of Obsessive-Compulsive Disorder and Related Problems. Baltimore: Johns Hopkins University Press; 2008:76-94.
40. Steketee G, Frost RO, Kyrios M. Cognitive aspects of compulsive hoarding. Cognit Ther Res. 2003;27:463-479.
41. Steketee G, Frost RO. Compulsive Hoarding and Acquiring: Workbook. New York: Oxford University Press; 2007.
42. Frost R, Steketee G, Tolin D, Renaud S. Development and validation of the clutter image rating. J Psychopathol Behav Assess. 2008;30:193-203.
43. Tolin DF, Villavicencio A. Inattention, but not OCD, predicts the core features of hoarding disorder. Behav Res Ther. 2011;49:120-125.
44. Tolin DF, Frost RO, Steketee G. Buried in Treasures: Help for Compulsive Hoarding. New York: Oxford University Press; 2007.
45. Muroff J, Steketee G, Himle J, Frost R. Delivery of internet treatment for compulsive hoarding (D.I.T.C.H.). Behav Res Ther. 2010;48:79-85.
46. American Psychiatric Association. DSM-5 development: F 02 hoarding disorder.http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=398. Accessed July 6, 2011.

This articles' original website: http://www.psychiatrictimes.com/display/article/10168/1932177] 

Treating People Who Hoard — What Works for Clients and Families

I want to share this very interesting and helpful article from Social Work Today. It was written by Jennifer Van Pelt, MA. I'm adding the entire article, but please don't hesitate to go to the site for additional information: http://www.socialworktoday.com/archive/051711p14.shtml

TV reality shows can help and hurt people who hoard. Find out why and know what really works best for clients and the families who care about them.

Popular “intervention” TV shows have begun dramatizing the clutter associated with hoarding: newspapers piled from floor to ceiling, clothes and linens stacked on furniture, stuff everywhere with only a narrow path to walk through a house. Extreme cases—where stray animals are packed into a small apartment or so many items have been accumulated that floors collapse—illustrate the severity of some instances of hoarding.

Approximately 3% to 5% of the U.S. population has a hoarding disorder (Tompkins, 2011), but the disorder affects many more, destroying marriages and home life and alienating family and friends.

“Media attention to hoarding has brought it out of the closet. People are more likely to talk about hoarding now,” says Terrence Daryl Shulman, JD, LMSW, ACSW, CAAC, CPC, founder/director of The Shulman Center for Compulsive Theft & Spending and an addictions counselor who works with hoarding cases as well as compulsive spending and theft.

“TV shows like A&E’s Hoarders have brought attention to a very secretive, shameful disorder and therefore have encouraged people and their families to get help,” says Gretchen H. Placzek, MBA, LCSW, MSW, a psychotherapist at East Bay Family Wellness in California who specializes in treating anxiety and works with individuals and families in cases involving hoarding. The show Hoarders depicts follow-up with solid therapeutic assistance and guidance, she says, adding that media attention has possibly even encouraged professionals to research the disorder and gain expertise to better assist people who hoard and their families.

However, the depiction of hoarding on TV has also contributed to misinformation about the disorder and its treatment.

“The negative aspect is that the shows may be seen as exploitive, and they do not always highlight the intense pain and suffering that goes along with a hoarding disorder,” explains Placzek.

Another downside, according to Shulman, is that hoarders may think “I’m not that bad” when viewing the extreme, shocking cases on TV, causing them to avoid or resist treatment.

The hard work needed to change hoarding behavior is downplayed by focusing on sensational cases, says Gail Steketee, LCSW, MSW, PhD, a professor and dean at Boston University who has been researching hoarding since the mid-1990s and has coauthored numerous publications with Randy O. Frost, PhD, a psychologist and professor at Smith College, including their most recent book, Stuff: Compulsive Hoarding and the Meaning of Things.

Her colleague, Christiana Bratiotis, PhD, LCSW, a postdoctoral fellow and Compulsive Hoarding Research Project director at Boston University, adds, “Sadly, these programs often portray an unrealistic intervention that minimizes the role of mental health treatment and sets up unrealistic expectations for hoarders and their families.”

Hoarding is a chronic disorder that gradually worsens, often over a period of decades, says Bratiotis. TV shows give the impression that appropriate intervention can occur in several days and without longer-term cognitive behavioral therapy (CBT).

“Professional organizers and clean-up companies are useful and necessary partners in the work, but they do not begin to be the totality of the intervention, and portraying that as the solution is to diminish the painful and difficult work needed to overcome a hoarding problem,” Bratiotis explains.

Acknowledging the Problem
Hoarding treatment begins with a person acknowledging the underlying problems that fuel hoarding behavior. The reasons for hoarding differ depending on the person, and treatment is challenging because people who hoard often do not realize their behavior is a problem or they are socially isolated and ashamed due to the condition of their home. Sometimes, they resist treatment because they think it will involve simply clearing out the clutter.

“Just cleaning out the stuff does not address the underlying psychological issues,” Shulman says. “It’s not a clutter problem; it’s a perception/thinking problem.” According to Steketee, no single condition causes hoarding. Contributing factors or stressors may include the following:

• being raised in a chaotic home or one with confusing family context, or moving frequently;
• cognitive processing issues that affect decision making and problem solving;
• attention-deficit disorder;
• anxiety and/or depression;
• excessive guilt about waste; and
• genetics and family history because hoarding behavior runs in families.

“Hoarding can also occur in people with dementia, schizophrenia, and obsessive-compulsive disorder [OCD],” says Steketee, “but it is not clear that the features and causes are the same.”

Currently, there is a common misperception that hoarding is caused primarily by OCD or anxiety. But although anxiety or compulsion may contribute to hoarding behavior, researchers now believe hoarding is not a type of OCD, and anxiety is not the primary driving force, Steketee explains.

For example, hoarders may experience anxiety or stress due to obsessive thoughts, such as grief over someone’s death or the loss of important things in their life, or perfectionist thinking. Hoarding helps prevent them from experiencing that anxiety or reduces the severity of it. Accumulating may be calming for the hoarder, Shulman says.

“Focusing on ‘things’ deflects the focus from the thought processes actually causing anxiety,” says Shulman.

“Hoarding may induce feelings of safety and security and/or reinforce identity,” adds Steketee.

The exact causes of hoarding are still uncertain, and research on the physiology and psychology of hoarding is ongoing. Geneticists are working to identify genetic loci related to hoarding behavior, says Steketee. An imaging study found that cerebral blood flow in a patient with OCD and severe hoarding exhibited a certain pattern during the most severe hoarding symptoms, and the pattern changed when the patient’s hoarding behaviors improved (Ohtsuchi, Matsuo, Akimoto, & Watanabe, 2010). A review of epidemiological, neurobiological, and treatment studies concluded that compulsive hoarding may be a discrete disorder with its own diagnostic criteria (Pertusa et al., 2010).

Currently, hoarding is not listed as a separate disorder in the DSM-IV but is mentioned as a symptom/criteria of OCD. However, a revision for the fifth edition, to be released in 2013, proposes that hoarding disorder be listed as a separate disorder under the heading of “OC spectrum disorders.” It is also likely to be removed from the criteria for OCD, says Steketee.

Treating the Behavior
Despite ongoing debate regarding the causes and diagnostic criteria of hoarding, there is no question that therapy is necessary. Hoarding typically leads to social isolation from family members, and involving family in the therapeutic process appears to contribute to improvement of hoarding behavior.

The first and most important component of family therapy is education. “Like any addiction, hoarding is a family disease; everyone is affected and each family member needs to be educated about it,” says Shulman. Families need to understand that hoarding is a disorder, and the treatment process is long.

“Psycho-education is almost always the first step in working with the families of people who hoard,” Placzek says. Family members must be educated about hoarding to have compassion and recognize it as a mental health issue. They need to understand that each accumulated item has meaning and value for the hoarder, she explains.

Addressing support and validation concerning the anger and hurt that many family members feel is another important step. The therapist needs to make sure the family understands that without their support and help, the hoarder is unlikely to get better, only progressively worse, Placzek says.

However, not all hoarders live alone and are socially isolated, and family therapy may be especially helpful when the hoarder lives with the family to deal with daily interactions during these situations. Impatience during the lengthy family therapy process is common, says Shulman. Often, “control drama” will erupt between the person who hoards and other family members, and this needs to be worked out to bridge the communication gap between them.

For married hoarders, additional couples therapy is often required because the hoarder’s partner is often codependent when it comes to the hoarding behavior, says Placzek. Or the partner may be impeding progress for the hoarder undergoing individual therapy, adds Shulman. When the hoarder lives with young children, elders, or people with disabilities, family therapy must address these special family issues, says Bratiotis. “Special protections must be taken to assure that these family members are safe and healthy and that the hoarding is not creating hazards that impact these vulnerable and protected people,” she notes.

Anecdotal reports from practitioners suggest that family therapy can be very successful when addressing hoarding behavior, but currently, no published research exists on the outcomes of family therapy for hoarding. Unpublished research has focused on the value of involving family members to get the loved one who hoards into treatment when that person is reluctant to seek therapy and/or does not recognize the problem, says Steketee.

However, research does support the benefits of cognitive and behavioral methods. Approximately 70% of people who hoard show improvement following 26 treatment sessions, Steketee reports. “Family therapy seems unlikely to be helpful unless the person who hoards also receives CBT to help them learn new skills, modify beliefs, and reduce discomfort that prevents them from discarding hoarded items,” she adds.

Common approaches to individual therapy for hoarders includes motivational interviewing, CBT, and decision-making skill building. “Motivational interviewing is essential since many people do not have good insight into the extent of the problem caused by their clutter and collecting behaviors. We also train skills to address cognitive problems like decision making and organizing as well as problem solving. We help people modify mistaken beliefs about possessions using CBT, and we use behavioral exposures to discarding and to not acquiring to reduce discomfort with these activities,” Steketee explains.

CBT using exposure therapy seems to be the best approach for hoarding treatment, says Placzek. Exposure therapy requires the hoarder to face his or her anxiety by organizing, sorting, and making decisions regarding what should be discarded and what will be kept while at the same time monitoring his or her anxiety level. The hoarder must go through this process to change maladaptive thoughts and, in turn, the hoarding behavior.

Family therapy is adjunctive and supportive for those undergoing CBT for hoarding. “I use CBT to guide the client’s treatment and when I’ve engaged families, it’s been through a family systems perspective. Often family are significantly impacted by the problem of hoarding, especially when living in the home, and are highly invested in the outcome,” says Bratiotis. Family members may be able to serve as behavioral coaches throughout the CBT process, though this may require significant therapeutic work with the family members and the hoarder, she adds.

Recently, researchers and psychologists have suggested using harm-reduction methods in family therapy to address hoarding behavior. Harm-reduction therapy focuses on helping family members develop a management plan for improving the safety and comfort of a hoarder’s home. For example, structural issues from the weight of accumulated items, the potential for fire, mold and dust, and vermin infestation may pose substantial risks to the person who hoards, especially an older adult who lives alone.

According to the researchers who propose this method, harm reduction assumes that it is not necessary to stop all compulsive acquiring or completely clear the hoarder’s home to stop harm. This therapy process involves setting small, achievable goals to reduce the risk of harm in the home (Tompkins). In some cases, enlisting the aid of the local health department may assist the family in communicating the danger of hoarding to their loved one. When a hoarder shares the home with other family members, harm-reduction methods can be used to communicate the potential harm of hoarding behaviors for others in the home.

People who hoard are most likely to improve when family therapy is combined with individual CBT and other interventions, such as medications to treat co-morbid conditions (e.g., depression) or working with a professional organizer in the home. The impact of family cannot be underestimated, though.

“Ultimately, success depends on how supportive, compassionate, and patient the family members are with the hoarder and on the level of motivation and commitment from the hoarder,” Placzek says.

— Jennifer Van Pelt, MA, is a Reading, PA-based freelance writer with 15 years of experience as a writer and research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.

References
Ohtsuchi, H., Matsuo, K., Akimoto, T., & Watanabe, Y. (2010). Fronto-limbic abnormalities in a patient with compulsive hoarding: A 99mmTc-ECD SPECT study. Psychiatry and Clinical Neurosciences, 64(5), 580-583.

Pertusa, A., Frost, R. O., Fullana, M. A., Samuels, J., Steketee, G., & Tolin, D. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30(4), 371-386.

Tompkins, M. A. (2011). Working with families of people who hoard: a harm reduction approach. Journal of Clinical Psychology, 67(5), 497-506.

Resources-
Web
• Children of Hoarders: www.childrenofhoarders.com

• East Bay Family Wellness: www.eastbayfamilywellness.com/hoarding-ocd-too-much-stuff

• International OCD Foundation Hoarding Center: www.ocfoundation.org/hoarding

Books
• Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding by David F. Tolin, Randy O. Frost, and Gail Steketee

• Compulsive Hoarding and Acquiring (therapist guide and client workbook) by Gail Steketee and Randy O. Frost

• Digging Out: Helping Your Loved One Manage Clutter, Hoarding, and Compulsive Acquiring by Michael A. Tompkins and Tamara L. Hartl

• Stuff: Compulsive Hoarding and the Meaning of Things by Randy O. Frost and Gail Steketee

5 Tips to Help Overcome Hoarding

Compulsive hoarding is a regular and potentially disabling problem, characterized by the gathering of excessive litter, to the extent that parts of a person’s home can no longer serve its intended purpose. It is also referred to as the act of saving many items that have been thrown away by general population. Examples of items that a hoarder might gather are broken appliances, newspapers, bags and magazines.

Hoarding can best be classified as a compulsive disorder in which a person has the potent habit of collecting and keeping useless items that have no value or benefit, but fails to discard them.

Approximately two million people in the United States are affected by compulsive hoarding, patients who display signs of hoarding normally suffer from other diseases, such as dementia, schizophrenia, anorexia and Alzheimer's. It's most present in patients with obsessive-compulsive disorder (OCD). Doctors aren't sure whether compulsive hoarding is a division of OCD or a different disorder.

This behavior is often hard to overcome because most hoarders do not acknowledge that they have this problem. However, the right treatment can in fact make a world of a difference in their life. Here we will look closely at five tips to help overcome hoarding.

1. Assess Your Needs
Ask yourself, "Do I truly need this item?" You may come up with one hundred different reasons why you need a particular item, but the question that you ought to ask yourself is whether you in fact will use it in the present or future. If you haven’t used it for many years, it is very probable that you will never use it again. The best thing for you to do is to discard these items in the trash can or sell them in a yard sale. You also don’t need to keep extras of anything; if you have one, you don’t need another.

2. Be Prepared to Face Your Fears
Overcoming hoarding is not always a simple task. You have to face your fears and stick to your plan of getting treatment to rid yourself of all useless belongings. During this process you may accidentally sell something that was of some worth or value. Just keep in mind that you can always buy a new and possibly better one. Stop worrying that you may discard something valuable, nothing bad will occur if you get rid of some of your belongings.

3. Stop Allowing Junk to Pile Up
Compulsive hoarding cannot be overcome in a few hours or few days, it is a continuous process. Once you have removed the existing mess in your abode, you also need to enforce measures to prevent the junk from piling up again. Be patient with this dilemma. and don’t allow hoarding to overwhelm you again. Clean and organize your belongings on a consistent basis.

4. Get Help and Get Treatment
It is possible to overcome compulsive hoarding. Remember to be yourself. However, receiving some amount of treatment from a mental health practitioner who specializes in this sort of behavior will help you to reach your goal. A psychotherapist specializing in cognitive behavioral therapy can help you to better understand why you accumulate useless things. After a proper diagnosis they will be able help you get rid of all the clutter in your home, and help you to develop your decision making and relaxation skills. Above all a therapist will be supportive if you encounter any setbacks along the way.

5. Reach Out to Other People
Loneliness is one of the main factors that causes hoarding to occur, that’s why it is never wise to confide yourself to your home. This will not aid you in overcoming hoarding.. If you are not comfortable inviting guests to your house because of the mess, make it a point to visit the homes of your relatives and friends.

These five tips for hoarders will greatly aid you to overcome hoarding, which segregates you from your loved ones. If you are knowledgeable that a loved one is a compulsive hoarder, don’t quarrel with them as this will make them more stubborn in their ways. Instead be equipped to listen to them and converse with them about how this behavior is preventing them from reaching their maximum quality of life.

For further info, check out this website: http://www.curiocabinetspot.com/tips-to-overcome-hoarding

Tomorrow We're Taking Your Leg: Hoarding & Suicide

I want to share this post by my friend & colleague Debbie Stanley, LLPC, NCC, CPO-CD:

My heart is breaking for Spencer Harris as I imagine what this was like for him.

I have often said that forced hoarding cleanouts are the psychological equivalent of involuntary surgery. Many people who hoard view their belongings as an extension of themselves, as Mr. Harris did. He killed himself on May 17, about a week after a 24-hour eviction notice was enforced on him. He was given a day--one day--to get out.

The eviction notice was issued by an official described as "experienced in handling hoarding situations."

News reports say Mr. Harris was given a temporary storage container in which to sort through his things and decide what to keep. In other words, an operatory in which to cut off his own leg, or arm, whichever he preferred.

They gave him a POD and a deadline. What he needed was a mental health professional and a psychologically realistic timeline. The introduction of a therapist truly "experienced in handling hoarding situations" and using the harm reduction approach would have greatly improved Mr. Harris's chances of developing better insight and integrating needed changes into his life, which by friends' accounts was vibrant and active.

24 hours to get gone. What must those 24 hours have been like for him? 24 hours of knowing that tomorrow, they'll be at the door to separate you from a part of yourself. Facing that sentence, perhaps you would flee and get a few states away before they could do it. But if you hoard, you can't carry all of yourself, all at one time. Paraphrasing Erma Bombeck, when you hoard you let your heart live outside your body, but people don't get that. Erma was talking about children. How can anyone care that much about stuff? It's just stuff.

And as long as the people in charge think it's just stuff, there will be more tragic endings.

HOARDING, COMPULSIVE SHOPPING AND OTHER "INVISIBLE ADDICTIONS"

They live in every community in the nation, and are a part of every extended family. In recent years, they’ve even begun making regular appearances on unscripted television shows such as Clean House, Obsessed, and Animal Rescue.

Sometimes they’re referred to as eccentric, strange or weird:

• Your mother’s uncle, whose “collection” of old newspapers and magazines looks more like a fire hazard than a tribute to days gone by.
• The friend who can’t seem to stay out of the stores or off the online retail sites, even though her shopping sprees have put her on the brink of financial ruin and her apartment looks more like a warehouse than a living space.
• The heartbreaking couple you saw on the news last night – the ones who, the health department discovered, had been keeping dozens of animals in their tiny, filthy house.

Hoarding animals and obsessively accumulating objects of no apparent value are two types of relatively common behavioral compulsions that appear to straddle the line between out-of-the-ordinary activities and mental illness.

In an effort to determine what types of extreme actions constitute a mental health concern, an international group of mental health experts met Oct. 1 and 2 in the Ontario (Canada) Science Center to talk about hoarding and other types of compulsive behaviors – commonly misunderstood obsessions that a Sept. 22 Canwest News Service article termed “invisible addictions.”

Misty Harris, who wrote the Sept. 22 article, reported that October’s “Many Faces of Addiction” conference was designed to bring about “the proposal of clinical criteria defining where normal indulgence ends and disordered behaviour begins.”

The challenge, according to Canadian addictions counsellor Anne McLaughlin, is that unlike chemical dependency, "process addiction" tends to have few detectable symptoms, with the behaviour either taking place in secret or being dismissed by family and friends as normal activity.

"It can be very isolating," says McLaughlin, who treats both sex addicts and their partners. "If someone drinks or takes drugs, at least it's visible."

Hoarding & Obsessive Collecting

The “invisible addiction” label may be valid as a means of identifying behaviors that don’t result in intoxication or other obvious forms of impaired motor functioning. But anyone who spends quality time in the presence of a person who cannot control behavioral urges will soon see that the disorder is far from invisible.

For people who are addicted to gambling, sex or the Internet, for example, their compulsions are made visible by financial problems or the inability to participate in normal healthy relationships.

But when it comes to hoarders or obsessive collectors, the evidence may be even more obvious – and, to many people, much more difficult to understand.

According to the website Understanding Hoarding, the following three primary attributes of compulsive hoarding were established in a 1996 article by R.O. Frost and T.L. Hartl, both of whom were then affiliated with the Smith College Department of Psychiatry:

1. The acquisition of, and failure to discard, a large number of possessions that appear to be of useless or of limited value
2. Living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed
3. Significant distress or impairment in functioning caused by the hoarding

In addition to these three diagnostic criteria, Understanding Hoarding also noted that most compulsive hoarders also possess four common personality traits:

1. Indecisiveness
2. Perfectionism
3. Procrastination
4. Avoidance

“Severe cases of hoarding may truly devastate a person's life if no help is sought,” the website reported. “[Hoarders] feel shame and this shame will gradually evolve into isolation.”

What Compulsive Hoarding Looks Like

In an article on the website of the Obsessive Compulsive Foundation (OCF), Karron Maidment, Program Coordinator/Behavior Therapist of the UCLA OCD Intensive Treatment Program, describes the experiences of the estimated 700,000 to 1.4 million Americans who are afflicted with compulsive hoarding disorder:

Hoarding is defined as the acquisition of, and inability to discard worthless items even though they appear (to others) to have no value. Hoarding behaviors can occur in a variety of psychiatric disorders and in the normal population, but are most commonly found in people with obsessive-compulsive disorder (OCD). …

Compulsive hoarding is not just an enthusiast's passion for collecting stamps, dolls, or baseball cards. … People with compulsive hoarding syndrome may have immense difficulty throwing anything away, from the oldest paper clip, to a used food container, to an out-of-date newspaper, for fear that they might need those items in the future.

Their homes are often full of stuff that the rest of us would call "junk." The most commonly saved items include newspapers, magazines, old clothing, bags, books, mail, notes, and lists.

Though most hoarders amass apparently useless objects, some people who have the disorder become obsessed with animals, bringing dozens – or in some cases more than 100 – dogs, cats or other creatures into their house. Overwhelmed by the logistical challenges of caring for so many animals in a space that was not designed for such a large-scale operation, animal hoarders put their own health and the health of the animals they have “rescued” at risk.

Defining the Problem, Addressing the Disorder

Though Frost and Hartl’s standards have achieved widespread acceptance, hoarding (like sex addiction, chronic shopping compulsions, Internet addiction and several other obsessive behaviors) has not yet been recognized by the “bible” of the mental health community, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

However, that may soon change.

One of the reasons for the October conference in Ontario was to discuss the possible inclusion of disorders such as these in the next DSM edition, which is scheduled to be released in 2012.

"Pathological gambling is in the DSM … and it really sets up a precedent for these other behavioral addictions," Toronto psychotherapist Edith Townsend told Canwest News.

Even without DSM recognition, compulsive hoarding has been treated via a variety of techniques, including medically assisted therapy (often involving selective serotonin reuptake inhibitors such as Prozac or Paxil) and cognitive behavioral therapy (CBT).

CBT appears to be the most effective approach, though treatment for compulsive hoarding is a notoriously slow process.

This featured article was written by Huge C. McBride, and published on Life Healing Center's site, a Recovery Center located in Sante Fe, New Mexico. For additional information and articles please view their website: http://www.life-healing.com

The Psychology of Hoarding

This morning I'm sharing information about an informative graphic that explains "The Psychology of Hoarding." This information includes the characteristics of hoarders, stats such as 75% of hoarders engage in excessive buying. As a professional organizer with many years of having the privilege of working with hoarders and their families, I've seen the challenges created by the financial and psychological ramifications of excessive shopping and acquiring. There is also the excessive acquiring of free items that this information notes as happening 50% of the time. We also explore the causes of hoarding and the anatomy of a hoarding house.

A very telling statistic states that by age 6, nearly 70% of children collect or store things. It's when the collecting turns to hoarding that the psychological issues of that persons life have changed, whether it's from a situational issue, genetic predisposition and/or a learned behavior. Collecting and hoarding are two very different reactions and behaviors in a persons' life. A collection can be collected over time, proudly cared for and can be on display. This is not the case when someone is hoarding items. There is a collection of seemingly useless items of limited or no value.

There is also statistical data on animal hoarding, where the person/s might not even be aware that they are harming the animals they hoard.

Some of the common personality traits of a hoarder are: neuroticism, anxiety, depression, self-consciousness, indecisiveness, perfectionism, vulnerability and impulsiveness. The treatments suggested are cognitive behavioral therapy with a 70% responsiveness, anti-depressants with mixed results and exposure and response prevention (ERP) with poor results.

At the end of this graphic, there are resources included. One of my favorite resource sites for hoarding and OCD information is the OCD Foundation.

Please check out this link for full information: http://images.psychologydegree.net.s3.amazonaws.com/hoarding.jpg

(This information was provided by http://www.pscyhologydegree.net/"> Psychology Degree)

When is a hoarder ready for prime-time? (Part 2)

Well, here's what happened. As I previously wrote, I have a hoarding client that can't afford to pay for my services. She was convinced that the only way she could have her hoard cleaned up was to get on one of the hoarding reality T.V. shows. She desperately wanted to take this route.

I was able to assess her living condition and advised her strongly against choosing the reality T.V. route. This lovely gal has many mental health conditions that would be exacerbated by making such a choice. She already suffers from an anxiety disorder, by being on T.V. she might end up in a psychotic state.

I spoke to my client's therapist today before having a conversation with my client. I shared my concerns for our client if she were chosen for a reality show. The therapist was able to speak at length to our client and then I connected with the client today too.

We had a really nice conversation about the realities of reality T.V. She didn't think of the fact that the show would broadcast all over the world. It would be searchable by millions and be out there forever. Her fear and shame for the condition of her home would be exposed to the universe. How would the T.V. show benefit her. I had her write a list of the benefits and drawbacks, and as she did this I asked her to say them to me over the phone. The benefits list was really small and the drawback list was really long. After this exercise, she said that she no longer thought that it was a good idea to take part in a reality show. Instead, she was going to ask her family if they could financially help her out, so she could pay for my services. She felt good about that decision.

Reality T.V. might work for some, but not for those that have complex mental health issues. Such mental health issues could dangerously escalate under such conditions. I'm about minimizing my clients' anxieties, stress and trauma. If you are interested in finding out more about hoarding, please check out the International Obsessive Compulsive Foundation: http://www.ocfoundation.org. Please send me any comments you might have about this issue. Thanks!

When is a hoarder ready for prime-time?

I recently received a call from a woman looking for a professional organizing to help her best friend who is a hoarder. The hoarder has lived in her home for 10 years. The caller wanted to hire me to work with her best friend, if the best friend would agree. The caller also wanted an idea of how much it would cost to de-clutter her friends home, once I conducted an assessment. She explained that her hasn't been in this home for many years, but a mutual friend had and was allowed to take pictures, which were then sent to her. Based on these pictures, she was able to give me a good idea of the condition of her best friend's home. She felt an urgency to reach out to me, once she saw the condition of the home, and also shared that the mental health of her best friend is deteriorating from her feelings of hopelessness and depression. The hoarder feels that she's mentally and physically drowning in her garbage and anxiety.

The hoarder has had two other people help her with the de-cluttering process, but both interventions have not produced successful results.

The hoarder has been extremely frustrated with her lack of progress, as well as her lack of financial resources. She is on disability and could never afford a professional organizer on her own. Her benefactor was also not fiscally able to afford my services after an initial visit, but our plan was for her to contact everyone that is close to the hoarder, and ask if they would chip in for a certain number of hours to help us get a good start at de-cluttering and clearing the hoard.

In the meantime, the hoarder is working with a therapist colleague of mine, which is really great news. I won't work with a hoarder that is not working with a psychiatrist and/or therapist for their hoarding behavior. Anyway, the sad news is that the hoarder is sinking deeper into depression and the best friend has not contacted me again. But maybe she's working on getting financial backers to help with the project (that's my dream scenario for this hoarding client).

While I was working with the hoarder during my initial visit, she mentioned that she would like to be on one of the television shows about hoarders, so that she could have a crew come and clear her house, since she can't afford the help herself. I'm always being contacted by television shows looking to cast hoarders, and I don't have hoarding clients that are mentally healthy enough to be on T.V., for all the world to see their life and have cast and crew touching their possessions, etc. They also don't like the idea that the world would see the condition of their home. Their shame is too great and their mental state of mind too fragile. There are plenty of people that do want the cameras into their lives and I respect them greatly for that.

I've heard all kinds of stories from my colleagues that have participated in these shows, and they have had many mixed experiences.

Often, we've come to know that hoarders return to their disorganized, acquiring without discarding ways if left to fend for themselves. Aftercare is necessary. They have to feel confident and comfortable with new clutter management techniques. And this is something that is a learned behavior over time, with the help of a collaborative team of many including but not limited to a therapist, psychiatrist, family and/or friends, professional organizer, social worker, local agency (if applicable), etc. Not just a hoarder trying to figure it out on their own after the cameras and crew are gone. The ironic thing is that after I spoke to the hoarders' therapist a few days ago, the producer of TLC's "Buried Alive" contacted me looking for a hoarder to cast. I don't think this hoarder's mental health issues are up to having a T.V. crew in her home, but you never know. I will let her therapist know about this opportunity, since she is very keen on having an intervention of this sort. Tune in for further details on this situation. Your comments are welcome.

Safety Risks of Hoarding

have worked with hoarders for over 10 years now and have come to understand some of the intricacies of hoarding behavior. I wanted to share some of the health & safety issues associated with the accumulation of extreme amounts of random items such as rotting food, trash, papers, household items, furniture, books, etc.

Hoarders are generally unaware of the fact that their lifestyle is a problem or causing a safety hazard to themselves, family and their animals (if applicable). Low self-awareness is one of the many psychological impairments a hoarder is challenged with. This lack of insight into their living conditions and lack of desire to change contributes to the health and safety concerns that arise from living in a filthy, possible insect & rodent infested environment.

The questions that have to be answered upon inspection of such an environment are:

Is there an immediate health & safety threat to the person/s that living in such an environment?

What kind of structural damage is there?

Are exits blocked creating fire & safety hazards for the occupants of the home & the accessibility by emergency services?

Is there adequate housekeeping?

Are the accumulated items posing a risk for slipping or falling injuries?

Are there rodents or is there insect infestation in the home?

Is there an odor problem due to urine or feces, live garbage & a lack of housekeeping?

Are these odors wafting over to the neighbors houses?

Are the adult/s in the home caring for themselves adequately?

If there are children and/or animals in the house, are they being cared for properly?

The hard road ahead is having the person living in these conditions realize the many health & safety risks this lifestyle poses for them and be willing to make a lifestyle change. Where does that motivation to make changes for their health & wellness come from? with limited insight, it can take a life threatening incident for the hoarder to reach out for help.

All to often the hoarder is living in isolation. Because of the many mental health issues the hoarder faces, without the proper intervention of mental health workers and related professionals, the hoarder faces a future of continued acquiring and larger health & safety risks.

Hoarding behavior is a mental health issue and a public health problem. Usually, the behavior has been occurring for a long time and requires patience and understanding. Frequently, it requires the help of other people and agencies. Neglect or abuse issues associated with elders, children, or animals may require emergency interventions. Code violations resulting from neglect or collection of materials may require emergency actions.

After meeting with a lot of caring families and friends that want to help, I always suggest to them that they do not touch the hoarders possessions without full consent of the hoarder. As a professional organizer, I'm one of the team players on the related professions collaborative team. I team up with mental health provides, local agencies, social workers and of course the family.

There are state & local agencies that can help hoarders in need. So states have hoarding task forces setup that are extremely useful resources. Here is a site that offers additional resources for hoarders & their families: http://www.ocfoundation.org

Digging Out: Helping Your Loved One Manage Clutter, Hoarding and Compulsive Acquiring

Your parents or your child or your sister or your brother or your best friend has a home that is stuffed to the gills with stuff. The dining room table is covered in piles, the kitchen is full of dirty dishes and garbage, even the sofa is piled so high with junk that nobody can sit. Perhaps some of the exits are blocked, and if there are stairs, chances are that there are even little piles of junk there. Maybe the paths through these rooms are narrowed down to "goat trails." Perhaps the furnace is broken or the plumbing is leaking or the appliances need servicing because nobody can come do the necessary work because of the clutter.

You worry about what will happen if someone gets sick or injured in the hoard, or BECAUSE OF THE HOARD. How will the paramedics get in? What if there is a fire, how would people escape when

the junk goes up like a tinderbox? Maybe there are kids who are forced to live in the mess and you need to figure out how to help them.

You want to do something to help, but what do you do?

The sad fact of hoarding is that so many people who hoard are extremely resistant to help and change. We, the family and friends, are either shut out from helping entirely or we jump into the EXHAUSTING process of dehoarding a house, only to watch the situation return to the way it was and even get worse, in

what seems like the blink of an eye.

We feel impossibly torn – we hold ourselves responsible for our loved one's wellbeing and safety and yet it seems like we are powerless to change the problem.

To make matters worse, until recently, there wasn't a lot of guidance on how to help someone with a serious hoarding problem.

But now, there's a book that speaks directly to us, the family and friends of people with SERIOUS hoarding problems:

Digging Out: Helping Your Loved One Manage Clutter, Hoarding and Compulsive Acquiring, Book Link: http://amzn.to/gFA9PI

In the words of the publisher "Many people who hoard understand the extent of their problem and are open to help. This book is not for them. Digging Out is for the concerned and frustrated friends and family members of people who do not fully accept the magnitude of their hoarding problem and refuse help from others. If you have a friend or loved one with a hoarding problem and are seeking a way to guide him or her to a healthier, safer way of life, this book is for you."

Digging Out gives specific harm reduction strategies to help anyone with a hoarding problem to live safely and comfortably in their home or apartment. This is not a book that promises to magically make the hoarding go away. Instead, it offers direct, specific strategies to:

• Manage health and safety hazards

• Avoid eviction

• Manage child protection issues

• Motivate your friend or relative to make longer-term lifestyle

changes

Learn how to:

• Handle a spouse or roommate with a hoarding problem

• Work through special problems faced by frail and elderly hoarders

• Heal strained relationships between people who hoard and their friends and family

If I could recommend just one resource for people who are living with the anxiety, shame and frustration of their loved one's hoarding issue, it would be Digging Out.

You can purchase Digging Out from Amazon: http://amzn.to/gFA9PI