EHJ February 2005, pages 12-14

Hoarding is linked to mental health problems. Tina Bexson explores the issues surrounding the condition

Hoarding. It's the new curse of the millennium, and involves not only old newspapers, general rubbish, items of food, and general household rubbish, but stray animals, and even faeces. It can cause influxes of pests, especially rats, and create quite horrendous smells.

Anyone who has been faced with the horrors of hoarding knows it poses a particularly unpleasant problem for environmental health teams, as well as being, of course, a serious environmental health risk, and a potentially disastrous safety hazard too.

"I remember having to go back with a patient to his home at night, and I have never been so terrified," reveals Satwant Singh, a nurse consultant who specialises in treating hoarders with cognitive behavioural therapy.

"It was dark when we entered the house, but he had a candle and the passageway in his house was piled high with dried newspapers and rotting fruit so we were constantly being hit with fruit flies. I thought 'oh my God, if he drops his candle the whole place will go up in flames immediately'."

Hoarding undoubtedly needs attention, but before we give a much needed insight into the intricacies of the condition, its causes, the motivations of hoarders, how to prevent it, whether it should be criminalised or treated, and if the latter, then how exactly and by whom, let's take a look at the immediate issues facing EHPs in their attempts to rectify the problems caused by hoarders.

As Barking and Dagenham LBC recently demonstrated by their court case involving the hoarder William Atkinson (EHN 48, 10 December, page 1), many councils are finding that notices served under Section 80 of the Environmental Protection Act 1990 can prove to be ineffective. Mr Atkinson continued to compulsively collect other people's rubbish, and was prosecuted twice for breaching the notices. He finally received a two-year antisocial behaviour order on conviction, dubbed a Crasbo, which the council hopes should act as a serious deterrent to his hoarding activities. Since breaches are a criminal offence, he could get sent to prison.

But the problem is that hoarders tend to have a compulsion to hoard, and as with alcoholics or drug addicts, unless they receive appropriate treatment which addresses the underlying reasons for their behaviour, they are likely to repeat it again and again. And if they do end up in prison, whether as a direct result of breaching a Crasbo or due to other offences, they will not only add to the 70, 000 plus inmates but also to the 70 per cent of these with mental health problems that rarely get treated inside.

Hoarding behaviour is on a continuum. According to Mr Singh, who is based at Grahman P & Partners GP practice, for Newham Primary Care Trust, the only PCT which appears to be providing specialised resources to treat hoarding, we are all hoarders to a certain extent. "Many of us keep too much information and papers on our desks because we think we will need them at some point, but others go so much further and compulsively hoard. I would say they account for between 1-5 per cent of the population."

Hoarding is also linked to obsessive compulsive disorder. OCD is an anxiety disorder where a person is compelled by irrational fears and thoughts to repeat what appears as pointless actions, again and again. This obsession is usually driven by the desire to reduce an underlying anxiety. A classic example is the repetitive washing of hands to prevent a perceived contamination.

"People with OCD often have a hoarding component, and people who hoard often have features of OCD," explains Mr Singh."But the difference is that hoarding is about people having something and not wanting to get rid of it because it has a specific meaning for them and they feel they might need it in both the near or far off future."

This means the difference is in terms of how the condition presents itself and the quality of the obsession. In fact, Mr Singh believes that hoarding is a specific condition all on its own. "But", he says, "it is not studied enough, we don't know enough about it, and there is not much of a general consensus about diagnosis and treatment."

However, new research from the University of Iowa has isolated a region in the frontal lobe of the brain that appears to control the behaviour of hoarding. The study, which appeared in the journal Brain in November, was undertaken to gain a better understanding of the causes of obsessive collecting behaviour. Dr Steven Anderson began by studying people who had developed a hoarding compulsion after sustaining a brain injury, and compared their brain scans with those taken from other brain injured patients who did not engage in any hoarding behaviour.

Dr Anderson found that the hoarders' scans revealed damage to a part of the frontal lobes of the cortex, and particularly on the right side. He said: "[Although] patients with OCD and some other disorders, such as schizophrenia, Tourette's syndrome and certain dementias, can have similar pathological collecting behaviour, we don't have a pointer located to where in the brain the problem is occurring. Our hope is that our findings with these brain lesion studies will lead to insights in these conditions as well," he says.

Dr Naomi Fineberg, an expert in OCD at Queen Elizabeth Hospital, Welwyn Garden City, says: "These studies are starting to confirm that hoarding may be different from the rest of OCD." She also believes that the more researchers can understand the neurobiology of hoarding, the more they can start to think about targeting treatments accordingly.

However, Professor Paul Salkovskis from the Institute of Psychiatry at King's College, London, says: "Knowing which area of the brain is affected does not help you in treatment one little bit. It is also potentially misleading because people feel if you can image a problem it means it is a biologically-based problem. But at this point there is no evidence that there is any biological difference between these patients." The answer to treatment, he says, "is cognitive behavioural therapy."

Mr Singh agrees, and says it's important to address what hoarders themselves say about why they hoard, and what purpose it serves them, which is usually as a coping mechanism. From an assessment he identifies what areas he and the patient need to work on together. It's a collaborative process. "We begin by looking at the easiest area to address, and work on it consistently and methodologically."

He says it's especially important to ask hoarders their thoughts about why they hoard. People hoard for specific reasons, not just because they like doing it, instead it's because they have some sort of personal attachment to whatever it is they hoard, whether it's a piece of paper that they think will come in handy at some point, or whether it's something that's part of them.

"I once worked with a patient who hoarded his own faeces because he didn't want to get rid of something that was or had been part of his body," said Mr Singh. "So the hoarding is connected to the meaning the person attaches to whatever it is they hoard. Another said she was hoarding bits of her hair because of the memories attached to it at the time it fell out. She believed that if she didn't keep the hair, she would forget the memories."

So therapy is about testing their assumptions or predictions about whatever they are hoarding at the time, and delving deeper into when the problem first manifested itself.

"We also deal with any relapse or underlying fears they have. They may think that if they throw something out then something terrible will happen. I try to work with the patients in their own home so I can see and assess the scale of the problem, and give them some support at the same time because it is very difficult and emotionally draining for them."

Mr Singh acknowledges that hoarders are very difficult to treat. He believes many often suffer from the condition without realising they have a problem. If they do realise it, it is often very difficult to get them to admit it, and say they want to do something about it.

This was undoubtedly the case with Mr Atkinson, who it should be noted, was previously offered help in various forms ranging from medication to behaviour therapy, but consistently refused to engage with any of the agencies who offered this.

"But when they want to do something about their hoarding, and fully engage in therapy to shift their beliefs about their need to hoard, then prognosis is good," Mr Singh explains. "I have had patients who've been very successful in recognising and then overcoming their problem."

The majority of Mr Singh's patients originally came forward because they had other conditions such as depression and anxiety, and through the assessment hoarding was found to be present too. In some cases though, it is by far the most serious problem they have.

He suggests that when councils inspect hoarders' premises for environmental health and health and safety concerns they should try and get another agency on board, as some councils already do, to assess whether the hoarding is connected to a psychological problem. It usually is. This could prevent it from reoccurring he says. "Otherwise councils will be returning to the person's home time and time again for the same issues."

Mr Singh believes that EHPs having to keep returning will create a great deal of distress for the hoarder. He warns that any enforcement officer involved in such a situation should be mindful of how to work around the problem. "Many EHPs have said that they would like to have more background of mental health problems so they can understand them better," he told EHJ.

He also believes it would be useful if they could be made more aware of the mental health issues surrounding hoarding. "I think that environmental health teams should have some understanding of how it manifests itself and what they should do when they encounter cases while visiting people's homes to deal with pests etc.

"It's about being sensitive and aware of the problem. I've dealt with environmental health in the past, and they say, 'this person is not always looked at as someone who is having a mental health problem'."

Howard Price, principal policy officer at the Chartered Institute of Environmental Health, is currently writing good practice guidelines on hoarding for environmental health departments in a bid to help them deal better with the problems they encounter.

For more information on hoarding go to: http://understanding_ocd.tripod.com/hoarding.html

Satwant Singh also treats patients referred to him by OCD Action (www.ocdaction.org.uk). Tel: 020 7226 4000.