Hoarding

1

• Hoarding
• and how to cope with it
• Dr Sarah Holroyd
• Consultant Clinical Psychologist, Epsom General
  Hospital
• and
• Howard Price
• Principal Policy Officer, CIEH

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(No Transcript)
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Definition

• Problematic hoarding consists of three components
• the acquisition of and failure to discard
  possessions that appear to be of little use or
  value.
• Living spaces sufficiently cluttered so as to
  preclude activities for which those spaces were
  designed.
• Significant distress or impairment in functioning
  caused by the hoarding. (Frost Steketee, 1999).

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The scope of the problem

• Hoarding as a clinical symptom is found in many
  different psychiatric disorders.
• It features in dementia, learning disability,
  schizophrenia, eating disorders, depression and
  personality disorders.
• It is most commonly associated with Diogenes
  Syndrome and Obsessive-Compulsive disorder (OCD).

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Diogenes Syndrome

• A term used to describe a condition of extreme
  self-neglect, domestic squalor, social
  withdrawal, apathy and tendency to hoard rubbish
  (Clark et al., 1975).
• A descriptive term, not a psychiatric diagnosis.
• Predominantly refers to the elderly population.

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Diogenes Syndrome

• Incidence is 0.5 per 1000 people aged 60 living
  at home.
• Equal numbers of males and females.
• Most sufferers live alone, suffer poor physical
  health and have a high mortality rate.
• 50 to 65 likely to have a formal psychiatric
  disorder (most commonly dementia, organic brain
  disorder, substance misuse, psychosis,
  depression, OCD, personality disorder).

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Diogenes Syndrome treatment issues

• Most sufferers will reject offers of help.
• Problem and risk often escalate to a point where
  compulsory action is required.
• The problem usually recurs even if help is
  initially accepted.
• Where a psychiatric disorder is present,
  psychiatric treatment may help but is often
  refused.

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Diogenes Syndrome treatment issues

• Best options for health agencies suggested from
  the literature
• Early assessment.
• Fast access to multi-agency services.
• Persistent encouragement and contact.
• Enlisting friends and families.
• Compulsory action (e.g. MHA assessment) as last
  resort.

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Hoarding in obsessive-compulsive disorder

• OCD is a form of anxiety disorder characterised
  by obsessional fears and compulsive acts or
  rituals.
• Hoarding can be a symptom of an
  obsessive-compulsive illness.
• Compulsive hoarding is a distinct sub-type of OCD
  which occurs in 20 to 30 of OCD cases.
• Compulsive hoarding is associated with greater
  impairment and co-morbidity than other forms of
  OCD.

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Hoarding in OCD

• OCD researchers have studied hoarding in clinical
  and community samples but not specifically in
  elderly populations.
• People with compulsive hoarding tend to be older
  than other OCD patients and their problems have
  often developed in childhood.
• Studies suggest that a cognitive-behavioural
  model can help explain the development of
  hoarding in OCD.

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Cognitive-behavioural accounts of hoarding

• In brief, distorted thoughts and beliefs
  (cognitions) give rise to anxiety and distress.
  Attempts to reduce distress through behaviours
  like avoidance or rituals make the problem worse
  over time. In hoarding the following cognitions
  are problematic
• Decision-making problems
• Emotional attachment problems
• Erroneous beliefs about possessions

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Treatments for compulsive hoarding in OCD

• Cognitive-behavioural therapy (CBT) is the most
  widely accepted treatment for OCD.
• This involves a programme of re-education about
  thoughts and beliefs, alternative coping
  strategies for anxiety, and resisting the urges
  to hoard.
• Medication for OCD can sometimes be effective but
  symptoms can recur once medication is stopped.
• Hoarding in OCD is particularly resistant to
  treatment even when the sufferer seeks help
  themselves.

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Hoarding some conclusions

• Hoarding can co-exist with a wide range of mental
  health problems or none at all.
• The development of OCD-type hoarding can be
  explained by cognitive-behavioural theory.
• Diogenes-type hoarding has not been adequately
  researched could it often be undiagnosed OCD?
• It is very difficult to treat regardless of
  aetiology.

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Statutory powers

• From the treatment of hoarders to the treatment
  of hoarding
• Complaints of smells, unsightliness or pests may
  lead to a duty to investigate
• Investigation may lead to a duty to intervene
• Health powers and amenity powers

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Statutory powers

• The health powers
• Public Health Act 1936
• filthy and verminous premises
• Environmental Protection Act 1990
• statutory nuisances
• Prevention of Damage by Pests Act 1949
• rats and mice

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Statutory powers

• The amenity powers
• Refuse Disposal (Amenity) Act 1978
• anything abandoned in the open air
• Town Country Planning Act 1990
• adversely affecting amenity of area

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Statutory powers

• The enforcement model
• Complaint / observation / information
• Criteria satisfied
• Statutory notice (reasonable time)
• Compliance non-compliance
• Enforcement - prosecution / Work in default

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Statutory powers

• Other considerations
• Human Rights Act / Convention
• Disability discrimination
• Political pressures
• Ombudsman
• S of S etc

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Case study

• Original complaint
• Oct 1993 complaint of smell from accumulation
  in rear garden
• Abatement notice under Public Health (Ireland)
  Act
• Notice not complied with summons issued
• Nuisance order made 10 days to clear up

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Case study

• Further complaints
• Nuisance order ignored further summons
• Oct 1994 fine. Attempt at clearing up
• Feb 1997 further complaints
• Statutory notice not complied with
• Court hearing adjourned good samaritan steps
  in

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Case study

• Inside
• Complaints of mice entry to house for first
  time
• Heavy infestation, rotting food etc
• Statutory notice not complied with
• Summons conditional discharge and costs
• Enforced by WID 11 skips

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Case study

• Conclusion?
• Problem recurred
• Further court hearing in 2002
• House unfit for human habitation
• 7 EHOs, 19 court appearances, 14,000 of work

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Survey

• The subjects
• 77 local authorities
• 209 cases active during 2003
• Men and women in roughly equal numbers
• 52 over 60y, 8 under 40y
• 82 living alone, 5 with partner
• 86 not working

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Survey

• The subjects
• 27 substance abusers
• 16 physical disabilities
• 21 family separations, mainly bereavements
• 37 receiving any care etc

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Survey

• The nature of the hoarding
• 50 were multiple collectors
• 11 undifferentiated household refuse
• 5 newspapers and magazines
• 4 clothing
• 4 animals
• Mechanical / electrical goods 9 men, 2 women
• Clothing 6 women, 2 men

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Survey

• The effects
• 33 spilt over outside the home
• 55 affected others
• 86 significantly affected habitability
• 70 presented significant fire hazard
• 59 presented serious risk of personal harm
• 65 contributed to infestations

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Survey

• The response
• Social services involved in 49 of cases
• Community health services involved in 31 of
  cases
• Landlords involved in 26 of cases
• Family / friends involved in 20
• In 11 of cases, only EHOs were involved

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Survey

• The response
• Public Health Act - 27 of cases
• Environmental Protection Act - 15 of cases
• Pests Act used - 11 of cases
• Enforcement action in 23 of cases
• Rehousing in 24 cases
• Possession proceedings in 9 cases
• Animals removed in 9 cases

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Survey

• The outcome
• Effectiveness short-term
• Statutory notices, rehousing, removal of animals
• Effectiveness long-term
• Social / mental health services, informal
  support, combination

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Survey

• The outcome
• 52 of cases reported resolved within the year
• 9 had recurred already
• 44 had arisen before
• In 60, EHOs expected to be called in again

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Survey

• Conclusion
• Small sample of authorities diverse range of
  cases
• Generally reflect the clinical picture
• EHOs powers provide temporary relief
• More hope from long-term, informal support
• Permanent resolution often remains elusive

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Guidelines

• Why?
• How best to approach cases in the future
• Reconcile conflict between duties and more
  sensitive approaches
• Lead to higher long-term resolution rate

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Guidelines

• Gather as much information as possible assess it
  carefully
• Do not make assumptions. Do not judge
• Rational arguments are not likely to succeed

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Guidelines

• Try to see the hoarding through the subjects
  eyes use neutral vocabulary
• Be clear about the goal and its justification
• Enlist help from family and friends if possible

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Guidelines

• Know in advance what other help is available
• Be aware of the likelihood of recurrence revisit
  sooner rather than later
• Be aware of the need to refer where serious risk
  of harm to subject or co-habitees or animals