‘I’ve seen it be extremely debilitating’

‘When there is a significant hoarding disorder, it impacts on a person’s psychological wellbeing and physical wellbeing.
 
‘There are very high rates of comorbid physical health problems in hoarding clients, so intervening and catching it earlier on can really be beneficial for the person, their family and the community.
 
‘I’ve seen it be extremely debilitating.’
 
That is Professor Jessica Grisham, a clinical psychologist at the University of NSW School of Psychology who has specialised in hoarding disorder for 15 years.
 
She says the mental health effects of hoarding are more commonly recognised than its physical effects. While patients with hoarding disorder are more likely than the general population to experience anxiety and depression, she stresses the physical effects can be just as significant.
 
Firstly, Professor Grisham says, patients with hoarding disorder have a 4–11-fold increase in risk of life-threatening medical conditions such as respiratory distress, diabetes and heart attack.
 
Further health issues associated with hoarding disorder include chronic fatigue syndrome, arthritis, and higher rates of obesity.
 
Patients with hoarding disorder also report poorer quality of sleep and experience ‘significant’ functional impairment; they report an average of seven work-impairment days per month, which is more than that experienced by patients with depression, post-traumatic stress disorder, asthma and diabetes.
 
Professor Grisham says there is also a significant ‘community impact’ due to health and safety hazards associated with the condition.
 
‘There’s oftentimes a health hazard, particularly for elderly patients who hoard who might have a risk of falls that increase,’ Professor Grisham said.
 
There is also a ‘documented increased risk’ of fires and fire fatality. Professor Grisham says a large proportion of fire fatality occurs in houses where people hoard, as the physical presence of clutter increases the risk of fire occurring in the first place, ‘and then it’s very difficult for people to get out’.
 
Aside from the affected individual, Professor Grisham says the effects on the community cannot be overlooked, with clutter often attracting rodents and other kinds of vermin.
 
‘Neighbours [can] become really distressed, understandably, because of the clutter and health hazard,’ she said.
 
‘So it’s a real community issue and involves a whole-of-community response.’
 
Hoarding disorder was listed as a psychiatric disorder for the first time in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which came out in 2013.
 
Professor Grisham says there has since been growing awareness of the condition.
 
She says the key feature of hoarding disorder is an ‘excessive emotional attachment to possessions, leading to an intense difficulty discarding them’. While that is the core component, the issue must be severe enough to interfere with daily functioning for it to become a clinical diagnosis.
 
That may mean the house is so cluttered it cannot be used properly, or it may mean distress is being caused to the person who hoards or those around them, including neighbours.
 
While it might seem a rare diagnosis, Professor Grisham says the condition affects around 2.5% of the population.
 
She says there is a familial predisposition to hoarding disorder and an identified genetic contribution, and psychological factors such as trauma and stressful events can also contribute to its onset.
 
Furthermore, personality traits such as indecisiveness and attention difficulties, along with emotional interpersonal factors, may also play a role in its development.

Professor Jessica Grisham says cognitive behavioural therapy is a mainstay of treatment for hoarding disorder.
 
Professor Grisham says patients tend to present for treatment for the first time in their 50s and 60s, but the onset of the condition often stems back many decades, sometimes to late adolescence.
 
She believes GPs can play an important role in helping patients access treatment, but acknowledges that identifying a person with hoarding disorder in a consulting room is not straightforward.
 
‘We have some clients who are very well maintained … and you wouldn’t know [they have hoarding disorder] by talking to them or looking at them,’ Professor Grisham said.
 
While it is not practical to ask every patient about their home situation, there are often red flags that may alert a clinician to the fact a patient may be struggling with clutter.
 
Professor Grisham says patients often allude to issues during a consultation. They may also report family conflict, or say they are feeling stressed or overwhelmed at home. Family members can also present instead in order to talk to a clinician about a family member they believe has hoarding disorder.
 
When a patient hints at possible hoarding disorder, Professor Grisham recommends doing a screening tool known as the ‘clutter image rating’.
 
‘The clutter image scale shows different photo depictions of different rooms in a house and a person just literally points to which one their house looks like,’ she said.
 
‘It’s a really fast, easy tool for GPs to use for screening if they’re concerned [about hoarding disorder].’
 
Professor Grisham says it is vital to address this issue in a ‘supportive, non-judgmental’ way.
 
‘It’s a really difficult, challenging problem to treat in the context of the GP’s very high list of priorities,’ she said.
 
‘But if the first encounter [the patient with hoarding disorder has is] with someone who doesn’t react with horror or [the] immediate suggestion of a massive clear-out … that would be a great start.’
 
While it may feel uncomfortable to bring up the topic, patients are often willing to discuss their issues once asked.
 
‘If you ask [about hoarding issues] they would say yes they have a problem and they’re having difficulty managing their stuff,’ Professor Grisham said.
 
Clinicians should then direct patients towards resources and refer them for further help. Professor Grisham says there are resources throughout Australia for patients with hoarding disorder, including charity organisations, private practitioners, Lifeline and individual treatment programs.
 
Group therapy can also play a key role.
 
‘A lot of time clients in our hoarding group have such relief and validation in finding other people who have hoarding problems and that becomes a really important start and helps with their comorbid anxiety and depression,’ she said.
 
Professor Grisham wants GPs to let patients know that there are treatments.
 
Cognitive behavioural therapy (CBT) is the mainstay.
 
‘There are a couple of key treatment strategies,’ she said.
 
‘One of the most important ones is exposure to discarding, decision-making and to not acquiring [possessions].’
 
Professor Grisham says the aim is to gradually confront people with hoarding disorder with issues that they struggle with, such as discarding objects or not purchasing items in the first place.
 
With support, patients with hoarding disorder then learn to tolerate the distress of discarding possessions or not acquiring objects.
 
Professor Grisham is quick to note treatment is not always successful – there is a high dropout rate for participants, and some do not benefit from therapy.
 
‘But some people, a bit less than half [of participants in treatment], actually benefit significantly from treatment and make big changes in their lives,’ she said.
 
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