+ Hoarding Disorder: Mental Health and Public Safety Janet Yeats, MA LMFT, Co-founder, The Hoarding Project MN Coalition for the Homeless – 9.15.14 www.thehoardingproject.org + Objectives n Recognize effective diagnosis and treatment strategies of hoarding disorder. n Describe alternative options to treatment other than a forced cleanout. n Apply evidence-based treatment strategies to address issues of safety in hoarding disorder. n Develop collaborative networks in your area to form a community response to hoarding disorder. + Who We Are n 501(c)(3) public charity n Mission: To promote an effective, ethical, and sustainable response to hoarding in communities, through research, education and prevention, and collaborative approaches to treatment. Background on +Hoarding Disorder: Inside the Mind of a Person Who Hoards + What is hoarding disorder? Quick answer: With the DSM5 hoarding disorder is a diagnosis, the common definition has 4 parts: 1. Excessive acquisition of stuff* 2. Difficulty discarding possessions 3. Living spaces that can’t be used for their intended purposes because of clutter 4. Causing significant distress or impairment (Frost & Hartl, 1996 ) *Not universal in all people who hoard + How many people hoard and are some people more likely to hoard than others? Research shows that n About 2-5% of the population hoard, which is about 15 million people in the U.S., on the high end (Iervolino et al., 2009; Samuels et al., 2008) n Likely this number is small – qualitative experience says 20-25%. n Older people hoard more than younger people n People with lower income hoard more than people with higher income (Samuels, et al. 2008) n No gender differences in prevalence rates (Timpano, et al., 2011) + Co-morbid Diagnoses n Hoarding Disorder is also associated with lots of other mental health issues: n 57% major depressive disorder n 29% social phobia n 28% generalized anxiety disorder (Frost et al., 2006) n 30-40%: OCD (e.g. Samuels et al., 2007) n 31%: Organic Brain Illness n 30%: Personality Disorders (Mataix-Cols, et al., 2000) n 20%: ADHD (e.g. Sheppard et al., 2010) n Dementia (Hwang et al., 1999) n Eating Disorders (Frankenburg, 1984) n Substance abuse (Samuels et al., 2008) + FAQ: What causes hoarding? The BIOPSYCHOSOCIAL Model of Hoarding Disorder states that: Family Communities Hoarding behavior arises from a variety of external and Social Biological internal variables that are biological, psychological, and Psychological social in nature. Cultures Environment We can’t talk about one of these pieces without talking about the others! + FAQ’s: What are the Biological Factors that contribute to hoarding? n Family history/genetic link (Pertusa, et al., 2008; Samuels, et al., 2007; Winsberg, Cassic, & Koran, 1999) n Course and progression: behaviors begin during childhood or adolescence (Frost & Gross, 1993; Grisham et al., 2006; Pinto, Eisen, Mancebo, et al., 2007; Samuels et al., 2002; Winsberg et al., 1999) n Brain functioning differences n Occipital and frontal lobes (Saxena et al., 2004). n These are the parts of the brain that are responsible for visual things and executive functioning (see below) n Information-processing (cognitive) deficits (Grisham, Brown, Savage, Steketee, & Barlow, 2007; Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Hartl, Duffany, Allen, Steketee, & Frost, 2005; Hartl et al., 2004; Lawrence et al., 2006) n Attention n Memory n Categorization n Complex thinking n Decision-making + FAQ’s: What are the Psychological Factors that contribute to hoarding? n Mental health/emotional distress (Frost & Hartl, 1996) n Poor coping/self-care n Co-morbid mental health conditions n Unresolved trauma and loss (Sampson & Harris) Triggering Event n People who hoard have specific beliefs about and attachment to their possessions (Frost & Hartl, 1996) Conditioned Emotional n Feelings toward object Response Response n Memory-related concerns n Desire for control n Responsibility and waste Behavioral n Aesthetics Reinforcer (+/-) n Hoarding behaviors can be reinforced over time (Frost & Hartl, 1996) n Acquiring things makes us feel good, so we want to do more of it n Getting rid of things makes us anxious, so we want to do less of it + FAQ’s: What are the Social Factors that contribute to hoarding? n Interpersonal relationships (Sampson, 2012; Sampson & Harris; Sampson, Yeats, & Harris, 2012) n Social support (Sampson & Harris) n Major life events/ transitions (Grisham, Frost, Steketee, Kim, & Hood, 2000; Kellett, Greenhalgh, Beail, & Ridgway, 2010) n Social stigma n Culture + FAQ: What’s up with animal hoarding? Is it the same thing as object hoarding? n Similarities: n Acquisition, difficulty discarding, clutter, n Quick answer: There are distress some similarities between n Many people who hoard animals also the two, but they differ in hoard objects several ways. n Co-morbidities n Differences: n Research on animal n Animal hoarding: squalor (100% of hoarding is about 20 years homes) behind object hoarding n Gender and age differences n AH: More women; later age n Know that people who n Types of objects: hoard animals began with n Objects: variety the best intentions, they did n Animals: one species not intend to harm animals. n Lack of treatment for A.H. n MAJOR mental health concerns (a mental health professional must be involved) + Is it safe to go into a hoarded home? Common safety risks: n Fire hazard There are definitely n Blocked exits concerns you must n Risk of falls/items falling n Lack of routine home maintenance be aware of before n Structural damage to building entering a hoarded n Risk of eviction and homelessness home. + What are the Safety & Health risks associated with hoarding? Safety Health n Fire hazard n Impaired functioning n Poor hygiene and grooming, nutrition n Blocked exits n Inattention to medical needs n Inadequate financial management n Risk of falls/items falling n Difficulty cleaning around clutter n Lack of routine home maintenance n Sleeping on floor instead of bed n Structural damage to building n Mental Health from increased weight and volume of clutter n Increased Health Problems n Molds, bacteria, dust, dirt n Risk of eviction and homelessness n Asthma, allergies, headaches n Rodent/insect infestation n Animal/human feces/remains (hanta virus, tapeworm, psittacosis, cat scratch disease) + Emotional/Psychological Impact of Hoarding Clean-outs on Clients Clean-outs can do more harm than good. n Can be traumatizing n Emotional Flooding n Even threats can be unhelpful n Can ruin relationships and trust “In all three instances of going in and cleaning these places up, within weeks of relocating the individual back into a clean environment, the individual passed away…it was such a dramatic change for them because we didn’t realize the impact of the sociological change.” (Brace, 2007) n It’s not sustainable n BUT sometimes it’s necessary + Mental Health + Public Safety: Implications of Diagnosis n Communities: Neighborhoods, Multi-family housing n Fair Housing And Equal Opportunity n Professionals: Code Enforcement, Fire, Law enforcement n Need for collaborative care + Diagnosis and Assessment of Hoarding Disorder + 300.03 Hoarding Disorder a. “persistent difficulty discarding or parting with possessions, regardless of their actual value” b. Difficulty due to a perceived need to save items and to distress associated with discarding them c. Difficulty discarding possessions results in 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, authorities) d. Hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others) e. Not due to medical condition (e.g. brain injury, cerebrovascular disease) f. Not due to another mental health condition (e.g. OCD, major depressive disorder, schizophrenia, neurocognitive disorders, autism) Specify if: a. With excessive acquisition b. Insight (good, poor, delusional) + What’s the difference between clutter, collecting, and hoarding? Clutter: possessions are disorganized and Hoarding: may be accumulated possessions become unorganized piles of around living areas Collecting: new clutter n No major difficulty with possessions = part of excessive acquisition larger set of items n Prevent rooms from AND no major being used for n Display does not difficulty discarding normal activities items impede active living areas in home n Motivation to n Can carry on normal display items: lost activities in home + Assessment: ASK! n First and foremost, ASK! n Examples: n Are any areas of your home difficult n Make sure to incorporate some to walk through because of clutter? form of question that can help n Are you unable to use any parts of indicate a problem at home your home for their intended with clutter, excessive purposes? For example, cooking, acquisition, or difficulty using furniture, washing dishes, sleeping in bed, etc? discarding. n Do you find the act of throwing away or donating things very upsetting? n Do you have strong urges to buy or collect free things for which you have no immediate use? n Have you ever been in an argument with a loved one because of the clutter in your home? + Assessment Tools n In office: n Home Visit: n Structured Interview for n ICD Clutter—Hoarding Hoarding Disorder Scale (Pertusa & Mataix-Cols,