A Psychiatric Disorder Causing a Potential National Crisis
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A Psychiatric Disorder Causing a Potential National Crisis
Jim Windell
It affects as many as 14 million people in the U.S., with one estimate stating it affects around two percent of the population. The prevalence and severity of this disorder increases with age, affecting roughly six percent of adults over the age of 70.4
What is the disorder?
The disorder is hoarding. And according to a report released earlier this year by the U.S. Senate Special Committee on Aging, as Americans grow older, the disproportionate prevalence of hoarding by older adults has national implications. The report, entitled “The Consequences of Clutter: How Hoarding Disorder Affects America’s Older Adults, First Responders, and Their Communities,” states that because hoarding disproportionately impacts older adults, experts worry that aging “could fuel a rise in hoarding in the coming decades.”
Hoarding disorder (HD) is a chronic and progressive condition that leads people to accumulate more objects than their homes can accommodate. While it may appear that it is a disorder that is confined to a smaller number of people, the report from the Senate Special Committee on Aging suggests that it is a much more troubling problem with indications that communities throughout the U.S. are already grappling with HD. An estimated one in six residents of Allegheny County, Pennsylvania, suffer from serious HD. In San Francisco, up to 25,000 adults may exhibit hoarding behavior. In Montana, public services in the Missoula area “see numerous cases of hoarding issues every month.”
In a recent article for Medscape Medical News, Kelli Whitlock Burton writes about hoarding and the implications for communities. She writes that HD is characterized by persistent difficulty discarding possessions, regardless of their monetary value. For individuals with HD, such items frequently hold meaningful reminders of past events and provide a sense of security. Difficulties with emotional regulation, executive functioning, and impulse control all contribute to the excessive buildup of clutter. Problems with attention, organization, and problem-solving are also common.
Burton indicates that as individuals with HD age, physical limitations or disabilities may hinder their ability to discard clutter. As the accumulation of possessions increase, it can pose serious risks not only to their safety but also to public health. Dozens of statements submitted to the Senate committee by those with HD, clinicians and social workers, first responders, social service organizations, state and federal agencies, and professional societies paint a concerning picture about the impact of hoarding on emergency and community services.
Data from the National Fire Incident Reporting System show the number of hoarding-related residential structural fires increased 26% between 2014 and 2022. Some 5242 residential fires connected to cluttered environments during that time resulted in 1367 fire service injuries, 1119 civilian injuries, and over $396 million in damages.
“For older adults, those consequences include health and safety risks, social isolation, eviction, and homelessness,” report authors noted. “For communities, those consequences include public health concerns, increased risk of fire, and dangers to emergency responders.”
What causes hoarding disorder?
It was once classified as a symptom of obsessive-compulsive personality disorder, with extreme causes meeting the diagnostic criteria for obsessive-compulsive disorder. That changed in 2010 when a working group recommended that HD be added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as a stand-alone disorder. That recommendation was approved in 2012. However, a decade later, much about HD’s etiology remains unknown.
Some research also suggests that dysregulation of serotonin transmission may contribute to compulsive behaviors and the difficulty in letting go of possessions.
“We do know that there are factors that contribute to worsening of hoarding symptoms, but that’s not the same thing as what really causes it. So unfortunately, it’s still very understudied, and we don’t have great knowledge of what causes it,” says Sanjaya Saxena, M.D., director of Clinical and Research Affairs at the International OCD Foundation.
There are currently no US Food and Drug Administration–approved medications to treat HD, although some research has shown antidepressants paroxetine and venlafaxine may have some benefit. Methylphenidate and atomoxetine are also under study for HD.
Nonpharmacological therapies have shown more promising results. Among the first was a specialized cognitive-behavioral therapy (CBT) program developed by Randy Frost, Ph.D., professor emeritus of psychology at Smith College in Northampton, Massachusetts, and Gail Steketee, Ph.D., dean emerita and professor emerita of social work at Boston University, Boston.
First published in 2007 and the subject of many clinical trials and studies since, the 26-session program developed by Frost and Steketee, has served as a model for psychosocial treatments for HD. The evidence-based therapy addresses various symptoms, including impulse control. One module encourages participants to develop a set of questions to consider before acquiring new items, gradually helping them build resistance to the urge to accumulate more possessions.
One novel program currently under study combines CBT with a cognitive rehabilitation protocol. Called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST), the program has been shown to help older adults with HD who don’t respond to traditional CBT for HD. The program, led by Catherine Ayers, Ph.D., professor of clinical psychiatry at University of California San Diego, involves memory training and problem-solving combined with exposure therapy to help participants learn how to tolerate distress associated with discarding their possessions.
The Senate committee report encourages policymakers to engage directly with individuals affected by HD and their families to better understand the impact of the disorder and inform policy development.
“I think the Senate report focuses on education, not just for therapists, but other stakeholders too,” Frost says. “There are lots of other professionals who have a stake in this process, housing specialists, elder service folks, health and human services. Awareness of this problem is something that’s important for them as well.”
To read to the original Senate committee report, find it at: /www.aging.senate.gov/imo/media/doc/the_consequences_of_clutter.pdf
To read the original Medscape Medical News report, find it with this reference:
Burton, K.W. (2024).Hoarding Disorder: A Looming National Crisis? Medscape Medical News.