SOWK 644 – Spring 2017
Explanatory Theories of Health and Mental Final
May 3, 2017
Doni Whitsett, Ph.D
Explanatory Theories of Health and Mental Final
Hoarding is a label that is not exclusive to the clinical sphere (Maier, 2005). In the colloquial jargon, it refers to a greedy person who does not share. For clinical purposes, it is the designation of a disease far more insidious and isolating than greed. Everyone in modern society owns things. We own clothes, hygiene items, knick-knacks and places to sleep and things to sit on. The average person owns more than they did 50 years ago (Steketee, 2013). A healthy person can relinquish items which are no longer useful to them, but a person who cannot separate from the object without emotional pain may be an individual who has hoarding disorder (Steketee, 2013). Per the National Alliance on Mental Health, 5% of the human race has symptoms of hoarding (2017). Hoarders are twice as common as people with OCD and far more common than schizophrenia and bipolar disorders (NAMI, 2017). Approximately 3,000 people a year are found to be hoarding animals. (Tolin, 2011).
The DSM-5, the most recent generation of the text identifying a mental disease, has listed Hoarding Disorder as a subgroup of Obsessive Compulsive Disorder (OCD), (Calamari, Wiegartz, Riemann et al., 2004). Compulsive hoarders tend to be older than conventional OCD sufferers. Four mandatory features and two issues of exclusion define HD. Per the DSM-5 published in 2013, the inclusionary items include: “Persistent difficulty discarding or parting with possessions, regardless of their actual value… due to a perceived need to save the items and distress associated with discarding them”. Other symptoms are keeping the collection components even though they clutter and make living spaces unusable. The only time a living area is in the intended formation is because someone other than the patient has intervened. This collecting is problematic because it limits social interactions, employment, and personal safety (American Psychiatric Association, 2013). Excessive items might be carried on the person or stored to be available to the collector (Frost, Gross, 1993). The Yale-Brown Obsessive–Compulsive Scale checklist measures behaviors, however, behavior sets are not the best way to describe the disorder because people with OCD may present with multiple types of symptom sets.
Hoarding is considered a disorder, as well as a symptom of other disorders because it harms the person doing the hoarding. Some collected items can become unsanitary and interfere with quality of life, and in some cases may become life threatening. While some researchers are content categorizing HD as a subset type of OCD, there are other potential explanations for what HD is, how it manifests and what the cause of it is. These ideas are important to suss out in each case for treatment purposes.
Theories to Explain Hoarding Disorder
Several theories have been applied to Hoarding. It is a disservice to the OCD relevant factors to ignore the implications of the Freudian theory, although it is not the singular or most applicable approach. Freudians categorize it as being part of the anal stage, others have labeled it as an impulse, a learned pattern, and as a means to have control over their environment (Kyrios, Worden, Steketee, DiLoreto, Tolin, Slyne, & Frost, 2014). According to the Freudian theory, a person stuck in the Anal Fixation stage would be prone to hoard belongings, become excessively frugal and clean compulsively (Berzoff, Flanagan, & Hertz, 2008, p. 37). Per Freud, learning to walk and gain autonomy coincides with the time when people are toilet trained. Having control over their excrement translated into having power over some part of their existence in a vast scary world. As we age we cannot easily celebrate our bowel movements as signs of independence, but we can transfer that need for indications that we have power to objects. Some people collect, clean and safeguard them in what is now called Hoarding Disorder. This approach is not my focus on the paper, however every OCD and HD article mentioned Freud.
A diagnosis of HD is often found in clients who report multiple and lifelong traumas compared against individuals who only fit the OCD criteria (Tolin, 2011). As discussed in class on February 28th, childhood anxiety is often a result of childhood trauma, bullying, or received as a hand-me-down trait from an anxious parent. Hoarding is tightly attached to depression and anxiety, and these issues are common in a person who has a problem with hoarding. General Anxiety Disorder, depression, alcohol dependence and social anxiety are all common characteristics of someone who hoards and these appear more with people who do not show symptomatology of OCD other than their hoarding behaviors (Tolin, 2011). People diagnosed with HD also frequently self-report multiple symptoms of ADHD.
Over half of HD patients studied reported that there was a traumatic event when the first signs of hoarding appeared (Tolin, 2011). Childhood trauma resulting in forms of PTSD have been tied to lack of impulse control (Chapman, 2014). Impulsivity Dysregulation and lack of control have been seen as a primary trait in people with hoarding disorder. One form of childhood trauma is the failure to bond with a caregiver (Schore, Schore, 2008) Other traumas include abuse, physical harm, extreme discipline, unpredictable environments and homes, and even home robberies (Tolin, 2011). These patients may fear more exclusion or shame (Cozolino, 2014). Fear or stress that lasts a long time damages the hippocampus and makes it more difficult for the brain to process stress in a healthy manner in the future. To avoid the stress of human interactions, people may turn their feelings of the memories with objects rather than people. The items that hoarders collect become transitional objects represent the people and memories important to the client. Every new item obtained on impulse is an attempt to make an emotional bond. Losing or separating from the item causes stress.
Bi-directional Health and Mental Health
The bi-directional nature of the relationship between physical and mental health is detrimental and sometimes catastrophic for people with HD. This population is service resistant and avoidant. When and if they do face bodily illness, they are not likely to reach out for medical attention. HD sufferers are likely to also be experiencing depression, excessive alcohol use and be isolated from others. As discussed in class, additional risks implications for physical health in people who are Hoarders include malnutrition, infection, insect and rodent infestations. People who are hoarders may have trouble maintaining their home residences. They risk eviction because of legal issues or an able to live within the shelter of their home because of the impact of the large amount of debris and other items which take up space where they would otherwise sit, sleep, eat and live. We discussed the life of the student who filmed “My Mother’s Garden” and noted that the neighborhood was pushing her to remove the evidence of her hoarding and harassing her in degrees that she found hurtful. The refrigerator may be blocked or used to store non-food items. This potential obstacle course potentially leads to Malnutrition. The subject of the film ate trash from public wastebaskets which conceivably had multiple bacteria harmful to humans. She had debris that blocked the pathway to the bathroom may make it so that defecation and urination and the appropriate receptacles is impossible. It may also block her the path to the shower and the client may be unable to bathe them. The physical ramifications of not cleaning the skin lead to boils and abscesses as well as flaky skin rashes and infections. People who hoard may be disorganized and not able to pay their bills. Money for utilities may have been spent on buying items
People with Hoarding Disorder (HC) are being studied to test the theory that hoarders are likely to also experience learning difficulties remembering and learning (Maier, 2005). This blends with the self-reports of hoarders who do not want to part with items because they represent bits of relevant information and if the item is displaced or removed, the patient feels that they are at risk of losing the corresponding information (Maier, 2005). Studies are also ongoing to test the correlation between impulsivity control and learning from consequences. As of now, the studies are reporting that people with HD are likely to have traits of impulsivity, remembering information and unpleasant results of bad choices and fear of both people and loss of information (Maier, 2005). All of these traits individually would present as barriers to treatment. With all of them combined, a client would understandably be service-resistant, and a clinician would have trouble working with and around these barriers,
In the 1980’s a study was done correlating the onset of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, also known as PANDAS with children who then went on to rapidly develop forms of OCD. The connection between health of the body and mind is evidenced by the physical body contracting an illness. The illness impacts the brain and results in a series of behaviour and symptoms that can be classified by the DSM as OCD type issues including hoarding (Doran,2015).
Neurobiology and the Brain Changes
During the human teen years, the brain changes at a fast pace and the Frontal hippocampal circuits develop (Cozolino, 2014, p. 34). This portion of the neural structure is used in the self-regulation, anticipation, and planning. These abilities are lacking in people who suffer from Hoarding Disorder. Hoarding Disorder patients have “Pure inhibitions and a greater need to answer impulses immediately.” They cannot postpone gratification (Kyrios et al., 2014). Abnormalities in this portion of the brain, be they developmental or damage from disease or injury are common in people who show signs of Hoarding. The Hippocampus is also where stress impacts the brain through the release of cortisol. The Adrenal system produces glucocorticoids during times of stress. Prolonged stress means a longer Exposure to this hormone. This hormone which is body interprets as cortisol can eventually lead to cell death and damage to the hippocampus. The hippocampus becomes smaller (Cozolino, 2014).
Most of the neurobiological studies on Hoarding Disorder (HD) have been focused on animals (Kyrios et al., 2014). Though the issue is old, the field of study is still unexplored. What has been documented includes ways that hoarding disorder varies from OCD. People with OCD have no problem making decisions, but people who have hoarding disorders have a large amount of trouble being decisive. They become engrossed in the minutiae and small issues and can’t see the overall concern (Kyrios et al., 2014). They cannot divide their belongings into large and general primary categories, (keep, donate, throw away). Compared to those people who have OCD, they took much longer and created multiple subcategories for their personal effects (Kyrios et al., 2014).. Damage to the ventromedial prefrontal and cingulate cortices often is apparent in the images of Hoarder’s brains (Kyrios et al., 2014).
Organic hoarding refers to people who have started this behavior after having a stroke or the onset of dementia (Maier, 2005). Scans of these brains show changes in the hippocampus where explicit memories are processed. These people are more likely to live in filthy conditions. The onset of their condition is easier to identify because they have had a major health issue which stands as a landmark to fighting they are free hoarding stays from their current status (Maier, 2005). Organic Hoarders do not have an emotional need to keep their items and can discard them easier than non-organic orders. They tend to collect items without fully understanding that they are building a collection nor do they have an emotional connection to the question of items (Maier, 2005). By the standards outlined in the DSM-5, organic hoarding is not a hoarding listed as a mental health issue. This is because the hoarding can be traced back and attributed to a physical Illness (American Psychiatric Association, 2013).
Having a goal to their collection is one of the primary identifiers of a non-organic hoarder. These hoarders may have started small and slowly over a long period the visible evidence of hoarding accumulated over many years. There was no major identifiable incident such as a stroke with the organic hoarders. Removing the hoarded items from the home of non-organic order extreme emotional pain because they are so connected to every item in their grouping (Maier, 2005). It is not an oriented collection where they just want to get one of every kind of something it is more that they cannot stop picking up everything they see and bringing it home with them and believing that every item that they had has a significant purpose. They might need an item, and so they can’t it just got it. Items which are clearly trash are not viewed or felt to be trash by the non-organic order.
Some hoarders do so in reaction to trauma (Chapman, 2007). Their connection to their objects and collections is an enhancement to their inner peace. As discussed in the class, people change and life is uncertain, but an object that can be held and looked upon remains the same. Connecting with humans requires trust that they will not be hurt. The inability to easily trust creates barriers and traction in the therapeutic relationship as well as is exemplified in the absence of social support and friendships for the patient.
Women are more likely to have HD than children or men (Saxena, 2007). The age difference between hoarders and patients with OCD who were not hoarders is greater than ten years, In fact, hoarding is a behavior which is seen more frequently in the elderly. There is a name for elderly hoarding, Diogenes Syndrome, so dubbed in homage to an ancient barrel dwelling philosopher. There are two levels of Diogenes Syndrome (Thomas, 2005). The first type Is a behavioral and lifestyle issue. It is not a mental disorder. These people may not have access to disposal for their feelings or may have so few belongings everything as a matter or neglect or comfort but not need. The secondary version of the syndrome is related to OCD.
The mental health repercussions of a hoarder might involve isolation from family and friends. The hoarder may be aware that they are receiving disapproval from those whom they loved so do not invite those people into their personal space anymore. People who care about the hoarder may be embarrassed by them and no longer wish to be seen with them in their home or their cluttered cars or even and an outside venue. Hoarding is hard to understand, and the science and research has not been thorough on the issue. Hoarding has only recently appeared in the DSM-5 (Kyrios et al., 2014). The general population assumes hoarding as a behavioral issue and not a psychological problem or a sign of emotional distress. The social support network of the hoarder erodes because the behavior is intolerable. People who are hoarders and ordered to establish some control over their life may not be able to see the mess they have made. If they can recognize that their behaviors are out of control and that they have so many items that it is impacting their life, this might make them feel worse about themselves. They might throw them into periods of depression and isolation and denial. Hoarding is a symptom and is a behavior related to a diagnosis as well as a stand alone diagnosis. Treating the behavior means finding out the root cause on the hoarding. This can be complicated and time-consuming, and there has been no established protocol which is routinely successful.
It has been found that most clients with hoarding disorder do not discover that they have this concern until it has been present in their life for at least a decade. Once HD is suspected, patients often become service resistant because they have difficulty recognizing the behavior is abnormal. Their attitude towards their disorder isolates them from family and friends who would otherwise encourage them and support them as they go through therapy. People who have this disorder are poorly motivated to resolve the issue and drop out of treatment frequently and with little instigation. People who have trauma issues understandably sensitive about how they are described. Word choice matters. It is important to separate the illness of hoarding from the individual who does the boarding. Stigmatizing words with better connotation is a good first step. Instead of saying hoarding, use phrases like collecting and saving. These words indicate the dignity the connection between the client and the objects which are impeding their ability enjoy life.
One study by Saxena, Maidment, Vapnik, Golden, Rishwain,, Rosen, & Bystritsky, in. 2002 treated people with HD and people with OCD in a multi-component treatment involving Cognitive Behavioral Therapy (CBT), partial outpatient enrollment for socializing skills and medication that had been used in this treatment previously with treatment-refractory OCD clients. The medication was a Serotonin reuptake inhibitor (Saxena, 2007). These customers were not cured, but their symptoms did decrease, and quality of life improved for them. CBT therapy addressed approaches Hoarding as an impulse problem, “designing a five-stage process for controlling impulses: identifying the impetus, inhibiting the automatic response, identifying alternatives, selecting a response, and implementing a response” (Berzoff, Flanagan, Melano, &d Hertz, 2011, p. 186). This approach attempts to empower the client with skills to reframe their choices and change thinking and behavior. When employed during a compulsive moment it may help the patient identify if they are selecting an item because they need it for practical us, want it for whimsy, or are drawn to it for the transitional object properties it may represent.
CBT for HD clients has the goal of strengthening the ability of the client to make decisions. These decision-making skills can be grown into the ability to make choices, organize and reduce clutter. At some point during the treatment process the location the hoarder is keeping their collection in will be cleaned out. This model of therapy is long term and may last over a year with some rooms of the living dwelling remaining in the overstuffed state while other areas are cleaned (Saxena, 2004).
Educating the patient about their illness and teaching them to identify the hoarding triggers such as feelings of anxiety or stress using the Subjective Units of Distress Scale. Teaching a hoarder to see and understand their avoidance attempts when they fail to pay a utility bill or expose their living situation to family and friends is the first step in helping them recognize their feelings and validate their emotions (Saxena, 2014). Once a client has full understanding of their symptoms and corresponding behaviour, they can be supported and guided into healthier choices such as not adding to their collection and not shopping. With enough support the crisis will pass and the client will be able to see that the hoarding behavior they have relied on for emotional safety is not necessary (Saxena, 2004). At some point the client will throw away items from their hoard and will hopefully see and feel that nothing bad happens to them as a result. They will be exposed to the truth that the collection does not offer them any actual protection. The behaviour of adding new items to the home should be halted as well.
Hoarding Disorder, or compulsive hoarding as some researchers insist it should be called, is a mental illness with a direct correlation to the structures of the brain. Some hoarding is a result of brain injuries including but not limited to strokes. Other forms of the illness reflect the small hippocampus and ventromedial prefrontal and cingulate cortices. Some patients show an altered brain chemistry that is a result of prolonged exposure to stress hormones. In both cases the altered brain is noticeable when compared with a healthy brain. HD impacts and reduced the quality of life for the patient as well as serves as an alienating force for those involved with them. Therapy approaches are evolving as is the definition and understanding of the illness. Currently there is no vaccine or proven treatment to end the hoarding and patients are likely to leave treatment and return their spaces again to a disruptive clutter. My hope is that more research is done and better interventions are created to sooth the destress of everyone involved.
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