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Brisbane, March 11, 2015
TOO MUCH MESS
Squalor and hoarding
by
John Snowdon
[email protected]
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Too much mess
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What do the terms ‘hoarding’ and
‘squalor’ mean? Do we like them?
Why do some people hoard excessively?
Why do some people live in squalor?
Should we intervene? If so, why?
Walking on the other side …
Media representations of squalor and
hoarding. Helpful and ethical, or not?
Who should take action?
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Man aged 60 years, sent on schedule which stated:
“Grossly disshevelled, unkempt. Living in profound squalor.
Deterioration in hoarding behaviour in recent months. Poor
hygiene. He stated that he only has one meal a day and has
not changed his clothes for several years. He … slept outside
to ‘protect his privacy’. Denied self-harm or harm to others
(yelling at night as well)”
Community team notes: “Referred by neighbour who was concerned
about X’s mental state. Has apparently been sleeping under an umbrella
outside his house (on front porch). Collects rubbish and fills back yard
with it. Has no running water or power. Stays out until 3 a.m., sleeps
until midday. According to neighbour, X shouts to himself in the early
mornings. Assessed outside front door as client refused to let us in. Poor
insight. Says he “chooses” to live like that. Does not see a problem”.
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In hospital 13 days. CT brain scan normal. Blood tests OK.
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Psychological report
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“Significant impairment on tasks of immediate
memory for verbally presented information. On
tests of executive functioning X fell within the
impaired classification overall… Difficulty
focussing his attention, in recalling novel
information and with tasks requiring more
abstract, higher level processing.
He demonstrated poor judgement and
impairment in self-direction and self-regulation.
This pattern of results may be indicative of a
frontal lobe condition.”
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Who should take action?
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9 years later, referral to community mental health team
from the client’s nephew. The family hadn’t seen X for 30
years, but his uncle wanted to see him before he (uncle)
dies. When they arrived at the property they found it to be
“in squalor” and X was unkempt.
“The neighbours state they have made numerous
complaints to council about the rats but nothing has been
done. X is sleeping on the front verandah amongst the
squalor and accumulated items”.
Hasn’t been in the house for 5 months. Unkempt. Aware
he needs to clean up. Orientated. Has money in the bank.
Showered. Given new clothes to take home …
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Meanings of words
Collecting
Accumulating (eventually amassment)
Hoarding
Pathological animal collecting (“hoarding”)
Environmental neglect (? self-neglect)
Severe domestic squalor
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Our common understanding is that
hoarding = storing for future
use, or to look at, perhaps
Squirrel away? Bower-bird mentality?
In recent years, excessive item or
material amassment has been widely
referred to as hoarding, even when
it’s not done purposely and the stuff
lacks use or value.
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Why do some people hoard?
Complex interplay of factors:
 Perceived value of items:
sentimental, practical (now or later), intrinsic
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Personality; need for security, comfort
Organisational: can’t decide whether/how to retain
Genetic
Beliefs, culture, attitudes
Neurobiological disturbance (e.g. brain disorder)
Erroneous beliefs
Attachment issues etc. We need psychologists!
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Hoarding
has been defined in the psychological literature as
the acquisition of, and failure to discard,
possessions of limited use or value.
The person actively acquires stuff ,
purposely keeps it, and (if it’s abnormal/pathological)
living spaces become too cluttered for activities
for which they were designed.
The person’s distressed and there’s significantly
impaired ability to function.
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DSM-5 Hoarding Disorder
A.
B.
C.
D.
E.
F.
Persistent difficulty discarding items, regardless of actual value
…due to perceived need to save the items, and distress
associated with discarding them,
…resulting in accumulation of possessions that clutter living areas,
thus substantially interfering with function and activities.
This causes clinically significant distress or impairment in
social, occupational or other important areas of functioning.
Not attributable to a medical condition (brain injury, stroke, etc)
Not better explained by the symptoms of another mental
disorder:
cognitive deficits (dementia), obsessions (OCD),
low energy (major depression), delusions (schizophrenia),
restricted interests (autism).
Specify if
(a) with excessive acquisition, (b) with good/poor/no insight
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Collecting
(as opposed to hoarding)
is selective object accumulation.
Pleasurable: Psychological benefit
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Normative collecting versus Hoarding Disorder
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Normative collecting
Selective. Cohesive theme.
Narrower range of categories
Planned, organised collecting
Not usually excessive.
Orderly display of collection
Distress rare (e.g. due to cost)
Minimal social impairment;
collecting adds to social life
No significant work
impairment
Nordsletten et al (2012). Comp.Psychiatry 54, 229-237
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Hoarding Disorder
Non-selective.
Lots of different categories
Lack of planning or focus
Commonly excessive.
Disorganised clutter
Distress is very common
Severe social impairment;
social withdrawal, single
Occupational impairment
common
Belk R (2014) in Frost & Steketee, Oxford Handbook
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of Hoarding and Acquiring.
A useful question regarding clutter?
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Tolin et al (2007), in a handbook for those who
compulsively acquire, save and/or hoard, asked
“To what extent does the clutter in your home
prevent you from using parts of your home for
their intended purpose? For example, cooking,
using furniture, washing dishes…....”
Tolin DF, Frost RO, Steketee G (2007). Buried in Treasures. Help for
Compulsive Acquiring, Saving and Hoarding. Oxford: Oxford
University Press.
Collecting, hoarding, accumulating,
disorganisation, mess, squalor: the OVERLAP
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Some people collect, hoard &/or accumulate clean
stuff in an organised fashion. Others may be minimalists.
You might hoard too much, so that even if it’s fairly well
organised, it’s too difficult to keep clean.
Disorganised hoarding may result in accumulating
messily and living in SQUALOR.
You might accumulate rubbishy stuff (‘cos you’re laid-back
and you haven’t got round to discarding it yet).
Or do people accumulate rubbish/waste/garbage/filth
because they’re too cognitively disabled to throw it out?
It’s not purposeful hoarding. Can lead to SQUALOR.
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Accumulation or hoarding?
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Accumulating papers ….
Accumulating emptied containers …
A. ACCESSIBILITY (clutter):
Score
0
1
2
3
Description
% of floor-space
inaccessible for use
or walking across
Easy to enter and move about
dwelling
SOMEWHAT IMPAIRED access but
can get into all rooms
MODERATELY IMPAIRED access.
Difficult or impossible to get into
one or two rooms or areas
SEVERELY IMPAIRED access –
e.g. obstructed front door. Unable
to reach most or all areas in the
dwelling
0-29%
30 to 59%
60 to 89%
90 to 100%
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DSM-5 Hoarding Disorder
A.
B.
C.
D.
E.
F.
Persistent difficulty discarding items, regardless of actual value
…due to perceived need to save the items, and distress
associated with discarding them,
…resulting in accumulation of possessions that clutter living areas,
thus substantially interfering with function and activities.
This causes clinically significant distress or impairment in
social, occupational or other important areas of functioning.
Not attributable to a medical condition (brain injury, stroke, etc)
Not better explained by the symptoms of another mental
disorder: cognitive deficits (dementia), low energy (major
depression), delusions (schizophrenia), restricted interests (autism),
obsessions (OCD).
Specify if (a) with excessive acquisition, (b) with good/poor/no
insight
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Prevalence of Hoarding Disorder
• 1.6% of 1698 a South East London population
aged between 16 and 90 years fulfilled criteria
for Hoarding Disorder.
• Studies (mainly in the US) say that 2% to 6%
of adults hoard excessively. But this would
include people whose hoarding would be
attributable to mental disorders such as
dementia, OCD and schizophrenia.
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Hoarding and squalor
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Maier (2004) drew together some of the
literature on hoarding, and posited that,
in many cases, so-called “compulsive
hoarding” is really an impulse-control
deficit, not a compulsion.
Acquisition and saving may result in
pleasure rather than being aimed at
avoidance of feared consequences.
And difficulty discarding may be related
to avoidance of decision-making rather
than a compulsion to retain.
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Conclusions from Maier’s review are that the
following can be called hoarding:
(1) some with OCD and others who hoard
have an urge to acquire, collect too much,
and have difficulty discarding.
(2) some with newly acquired brain disorders
have an urge to collect and may resist
discarding.
(3) some (e.g. with developing brain changes)
have difficulty with impulse control, and
acquire more than they discard.
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Maier pointed out that in various
neuropsychiatric disorders (dementia,
autism and let’s include schizophrenia)
acquisition isn’t compulsive and isn’t due
to poor impulse control. It’s “just motor
activity without clear intention or aim,
hence stereotypic, ritualistic.”
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People collecting in this way may be
indifferent to removal of the items.
He liked the term ‘collectionism ’ for this
behaviour.
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‘Organic’
accumulation
Hoarding disorder
ONSET
Sudden or insidious
Insidious (from
adolescence)
ABILITY TO
DISCARD
Variable.
Some don’t care
Cannot discard
ACQUIRING
Often indiscriminate
Perceived intrinsic, practical
or emotional value
SQUALOR
Frequent
Uncommon
PERSONALITY
CHANGE
Common
Not
COGNITIVE &
EMOTIONAL
PROCESSES
Disorganised
Indecision, abnormal
categorisation, behavioural
avoidance, attachment to
possessions, etc.
INSIGHT
Poor
Ranges from good to poor
PREVALENCE
< 1%
2–5%
FAMILIAL
Some reported cases
Yes
Do you hoard a lot?
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During your lifetime, have you ever
accumulated so many things that your
home was very cluttered
(to the extent that you could not use
some rooms for their intended purpose)
and you found it very difficult to discard
or give away these items?
Screening question in a 2008-10 London Community Health Study
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Why do some people with Hoarding
Disorder live in squalor?
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1. Unable to reach and clean all areas of
the home.
2. Strong attachment to, and difficulty
discarding, even dirty items.
3. Poor insight due to ‘blindness’ to filth.
4. Impaired neuropsychological function
in HD: inability to organise and clean.
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A mass of mess
Unclean
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ENVIRONMENTAL CLEANLINESS AND CLUTTER SCALE (all items 0,1,2,3)
A. ACCESSIBILITY (CLUTTER):
Not / somewhat / moderately / severely impaired
0-29%, 30-59%, 60-89%, 90-100% floor-space inaccessible
B.
ACCUMULATION OF ITEMS of little obvious value (what items?)
C. ACCUMULATION OF REFUSE OR GARBAGE:
None / little / moderate / lots
D. CLEANLINESS OF FLOORS & carpets (excluding toilet / bathroom)
E.
CLEANLINESS OF WALLS, visible furniture SURFACES & window-sills
F.
BATHROOM & TOILET: Not / mildly / moderately / very dirty
G. KITCHEN & FOOD: Clean / hygienic ……to very dirty / unhygienic
H. ODOUR: Nil / pleasant ………………………..to
unbearably malodorous
I
VERMIN: None / Few / Moderate / Infestation
[ Define ]
J.
SLEEPING AREA: Reasonably clean …….to very dirty
SCORE (max 30) …………
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ECCS scores
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A total ECCS score of >12 was found
to indicate, in most cases, that the
occupants were living in moderate or
severe squalor. The median ECCS
score in cases of SEVERE squalor
(as judged by JS and GH) was 22
(inter-quartile range 16 to 24).
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Where the Collyer brothers lived
Where the Collyer brothers lived in Manhattan
The Collyers’ cluttered staircase