Interpersonal attachment, early family environment, and trauma in hoarding: A systematic review

"Falling between the cracks": Investigating the competing challenges experienced by professionals working with people who hoard

Hoarding disorder is characterised by both the distress associated with discarding and the resulting accumulation of possessions that clutter the home environment, and represents a substantial public health and social problem, requiring an effective multi-agency response. Although a recognised psychiatric condition since 2013, hoarding disorder is under-recognised within mental health treatment provision, and evidence-based treatment pathways are lacking. This study aimed to explore multi-agency working in practice and similarities and differences in how hoarding support is perceived across a broad range of front-line professionals. 35 semi-structured interviews representing a wide range of services from health, social care, housing, and the voluntary sector were conducted and analysed thematically. Three overarching themes are reported: Unique challenges of supporting people who hoard, Conflicting needs of client vs. needs of the organisation, Managing role boundaries and psychological tensions. Findings consistently highlight the challenges specific to these cases. However, they also point to a lack of consensus between professional groups in terms of perceived problems and risks to be addressed. Collaborating effectively with others to meet the psychological needs of clients while ensuring risk mitigation and addressing broader organisational, environmental, and community concerns was found to be a key challenge and associated with often going beyond designated role boundaries to support the person. Our findings point to a need for greater support and training of a diverse set of professionals in psychological models of people who hoard to enhance knowledge, awareness, and confidence of the psychological dimensions of hoarding disorder, and to support them in feeling more emotionally and practically prepared. The results indicate a need for greater integration of mental health measures in the assessment of hoarding cases, and to ensure adequate care pathways with dedicated psychological support along with assignment of case workers/coordination.

Through the mind's eye: mapping associations between hoarding tendencies and voluntary and involuntary mental imagery

BACKGROUND

Preliminary evidence suggests that mental imagery may be an important clinical feature in hoarding. Individuals who hoard use objects as receptacles for memories, and experience more frequent, intrusive and distressing images compared with the general community. However, the specific nature of these associations remains poorly understood.

AIMS

We aimed to investigate whether hoarding traits were related to the ability to voluntarily generate imagery in different sensory modalities, and uniquely with the tendency to experience negative intrusive imagery. We also aimed to understand the mechanism by which mental imagery experiences may confer vulnerability to hoarding problems.

METHOD

Undergraduates (n=328) completed questionnaires assessing hoarding, beliefs about objects, imagining ability across the senses, and negative intrusive imagery, as well as symptom measures of depression, obsessive-compulsive disorder and post-traumatic stress. We conducted Pearson's correlations, hierarchical regressions, and mediational analyses.

RESULTS

Hoarding tendencies were associated with reduced visualising ability, but not with the capacity to deliberately generate imagery in other senses. Hoarding was also uniquely associated with the tendency to experience negative involuntary imagery when controlling for symptoms of depression, obsessive-compulsive disorder, and post-traumatic stress. Object-memory beliefs partially mediated the relationship between hoarding and reduced visualising ability. Object attachment partially mediated the relationship between hoarding and negative intrusive imagery.

CONCLUSIONS

Results suggest that visualisation difficulties may promote a reliance on objects to facilitate recall, and experiencing negative intrusive imagery may strengthen object attachment. Findings may inform imagery-based conceptualisations and treatments of hoarding problems, such as imagery training or modification interventions.

Conquering the 'Collected Treasures' of Older Adults With Dementia: A Qualitative Study on Caregiver Strategies and Challenges

AIM

To explore hoarding scenarios in older adults with dementia, document management strategies and assess caregiver challenges in these scenarios.

DESIGN

This study employed interpretative phenomenological analysis to guide data collection and analysis.

METHODS

Purposive sampling recruited 20 caregivers of older adults with dementia from long-term care facilities and community elderly centres in Taiwan. Semi-structured interviews, lasting for about 1 h, were conducted with caregivers of older adults with dementia. The study's quality was assessed using five techniques: peer debriefing, member checking, inter-coder agreement, audit trail, and thick description.

RESULTS

Key themes included hoarding scenarios, checkpoints of pre-decluttering, attitudes towards hoarding, language used for communication, management approaches for decluttering and caregivers' challenges. Caregivers highlighted the importance of assessing the emotions, cognitive function and backgrounds of older adults with dementia before decluttering for effective management. The onion skin peeling method for gradual decluttering was recommended. Success was more likely when caregivers maintained a positive attitude and adapted communication to the speech patterns of older adults with dementia. Challenges arose from ineffective communication, extreme resistance to decluttering and the need to work in highly unpleasant environments.

CONCLUSION

Caregivers face a range of complex challenges when managing hoarding behaviours in older adults with dementia. Pre-decluttering assessments, a positive caregiving attitude, effective communication and stepwise decluttering strategies can enhance the care experience and support caregivers and individuals with hoarding tendencies.

IMPACT

Managing hoarding behaviours in older adults with dementia requires comprehensive cognitive and emotional assessments, collaborative decluttering and tailored communication. The CALM guideline from this study provides an evidence-based framework for advanced nursing practice in this area. Through interdisciplinary leadership, refining guideline use and developing training programmes, nurses can standardise and enhance care quality, fostering adaptive, supportive environments for individuals with dementia and hoarding behaviours.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Environmental enrichment attenuates maternal separation-induced excessive hoarding behavior in adult female mice

BACKGROUND

Previous studies have demonstrated that early life stress (ELS) impacts hoarding behavior in adult humans. This study aimed to assess the potential mitigation by environmental enrichment on hoarding behavior in rodents caused by maternal separation, thereby providing insights into therapeutic strategies for hoarding disorder.

METHODS

Newborn mice were randomly divided into four groups. The control group was allowed to grow naturally. The maternal separation group underwent two weeks of maternal separation. The short-term environmental enrichment group received two weeks of environmental enrichment intervention after the two weeks of maternal separation. The long-term environmental enrichment group received five weeks of environmental enrichment intervention after the two weeks of maternal separation. Hoarding behavior was assessed during adolescence and adulthood. Hippocampal tissue from adult female mice was analyzed using LC-MS/MS-based metabolomics. Spearman correlation analysis was then performed to assess the relationship between differentially expressed metabolites and hoarding behavior.

RESULTS

Environmental enrichment attenuates maternal separation-induced excessive hoarding behavior in adult female mice. The untargeted metabolomics of the hippocampal region in female mice showed that long-term environmental enrichment reversed multiple differential metabolites, including Substance P, which were mainly concentrated in metabolic pathways such as cancer choline metabolism, glycolipid metabolism, and linoleic acid metabolism.

CONCLUSIONS

Our findings indicate that ELS and long-term environmental enrichment have sex-dependent effects on adult hoarding behavior, potentially related to altered hippocampal metabolism. This study highlights the importance of environmental enrichment in mitigating the long-term effects of early maternal separation on hoarding behavior.

Cluttered spaces, strained bonds: Examining the correlation between hoarding symptoms and social functioning among long-term care facilities older adult residents

BACKGROUND

Symptoms of hoarding, such as the inability to part with possessions, leading to significant clutter, are commonly observed among residents in long-term care facilities in Egypt. This behavior significantly impacts their social interactions and functioning. Therefore, this study examined the relationship between hoarding symptoms and social functioning among older adult residents in long-term care facilities.

METHODS

The study employed a cross-sectional survey on a purposive sample of 300 older adults.

TOOLS

Saving Inventory-Revised and Functional Idiographic Assessment Template-Questionnaire-Short Form were used.

RESULTS

The findings revealed a significant positive correlation between hoarding symptoms and social functioning (r = 0.682, p < 0.000). A linear regression analysis supported this correlation, establishing hoarding symptoms as a significant predictor of social functioning (adjusted R2 = 0.32).

CONCLUSION

The current study highlighted that a significant proportion of long-term care older adult residents displayed moderate hoarding symptoms and compromised social functioning. A noticeable positive association was observed between hoarding symptoms and social functioning. These results underscore the potential impact of hoarding symptoms on various aspects of social functioning. Given these findings, long-term care nurses should comprehend the various facets of compulsive hoarding behavior and devise effective strategies for assessment and intervention. Establishing support groups within these facilities could provide a platform for these residents to share their experiences and coping strategies. This could reduce interpersonal conflicts and argumentativeness and foster emotional expression and intimacy.

'A more human approach … I haven't found that really': experiences of hoarding difficulties and seeking help

BACKGROUND AND AIMS

People with hoarding behaviours often struggle to engage in treatment. This study aimed to explore the experiences of a sample of people who identify as engaging in hoarding behaviours and who are seeking support. Exploring motivation to seek help, the barriers those who hoard face in accessing support and what facilitates accepting help, can aid understanding of how best to intervene.

METHOD

Eight individuals who self-identified as seeking help in relation to hoarding behaviours were recruited via social media and support groups. Interviews were conducted by telephone or video call, before being transcribed and analysed using interpretative phenomenological analysis.

RESULTS

Participants described complex help-seeking narratives and reported continued ambivalence about addressing their hoarding behaviours. The four group experiential themes identified were Wrestling with identity; Who can I trust?; Services don't fit; and Being overlooked: 'they're too busy looking at the thing, not the person'. Difficulties trusting others and services were identified; services were experienced as rejecting and many participants sought help for problems other than their hoarding. Problems accessing appropriate help for hoarding were predominant in the narratives, although participants who had accessed peer support described this as valuable.

CONCLUSIONS

There are both internal (e.g. fear of judgement; feeling overwhelmed) and external (e.g. service gaps) barriers that make finding useful help for hoarding behaviours very difficult. Services may facilitate those seeking help by taking a compassionate and person-centred approach to hoarding problems.

How household chaos affects social withdrawal of rural children: the indirect role of executive function and receptive language ability

Executive function (EF) and receptive language ability play an important role in the relationship between household chaos and social withdrawal. Young children are neglected in household chaos research and suffer from the negative outcomes of households in China. However, few studies have focused on the relationship between household chaos and social withdrawal in young Chinese children and the chain mediating effect of EF and receptive language ability. This study included 922 preschool-age children (62.58 ± 8.03 months) and their primary caregivers and their teachers were recruited from 21 rural preschools in Guangdong Province in China. Our results show a positive direct effect of household chaos and social withdrawal. Furthermore, an indirect sequential effect of household chaos and social withdrawal on EF and receptive language ability was found. Our findings (a) highlight the significance of paying more attention to household chaos and revealing a better understanding of the effect of EF and receptive language ability on households at an early age and (b) indicate that interventions should be provided to improve the home environment when children are young.

Do they really care? Specificity of social support issues in hoarding disorder and obsessive-compulsive disorder

OBJECTIVES

Unmet interpersonal needs may play a role in excessive emotional attachments to objects for people with hoarding disorder (HD). Previous research indicates that social support (but not attachment difficulties) may be specific to HD. The study aimed to evaluate social networks and support in HD relative to clinical controls with obsessive-compulsive disorder (OCD) and healthy controls (HC). The secondary aim was to explore the extent of loneliness and thwarted belongingness. Potential mechanisms for deficits in social support were also considered.

DESIGN

A cross-sectional between-groups design was used to compare scores on measures in those with HD (n = 37); OCD (n = 31); and HCs (n = 45).

METHODS

Participants completed a structured clinical interview by telephone (to assign diagnostic categories) followed by online questionnaires.

RESULTS

Whilst individuals with HD and OCD both report smaller social networks than HC, lower levels of perceived social support appear to be specific to HD. The HD group also showed higher levels of loneliness and thwarted belonging compared to OCD and HC. No differences were found between groups for perceived criticism or trauma.

CONCLUSIONS

The results support previous findings of lower levels of self-reported social support within HD. Loneliness and thwarted belongingness also appear significantly elevated within HD compared with OCD and HC. Further research is required to explore the nature of felt support and belonging, direction of effect and to identify potential mechanisms. Clinical implications include advocating and promoting support systems (both personal supporters and professionals) for individuals with HD.

Hoarding Disorder: The Current Evidence in Conceptualization, Intervention, and Evaluation

Hoarding disorder is characterized by difficulty parting with possessions due to strong urges to save the items, leading to the excessive accumulation of items. High clutter levels result in varied personal, social, and legal consequences. Specialized treatments, including individual, virtual, and group cognitive and behavioral therapies, community-based interventions, and peer support approaches have shown preliminary effectiveness. Animal, attachment, and neurobiological models are expanding our understanding of the etiological bases of the disorder. Specialized populations such as children, older adults, and involuntary patients are highlighted as requiring special consideration for intervention and risk mitigation. Directions for future research are identified.

Hoarding mysteries Jack would appreciate

Hoarding disorder (HD) is a multifaceted problem that presents challenges both for understanding its dimensions and for developing effective treatments. We are grateful to have known Dr. Stanley J. Rachman and his incredibly thoughtful approach to clinical psychology and research on anxiety, obsessive-compulsive disorders (OCD) and their treatment. His work has helped set the stage for our own efforts to study this challenging condition. The discussion below reviews a range of mysteries we and others have encountered in working with people who exhibit HD symptoms. Of particular interest to us are questions about biological vulnerabilities like heritability and the high rate of concurrent health problems and whether hoarded objects might serve as safety signals that protect people from traumatic life events. We are curious about the attachment process in HD and whether attachment to objects is related to early parental experiences that affect self-concept. We raise questions about the several information processing problems often seen in people with HD - attention focusing, memory, and associative responses to objects and information. Raising many questions are observations about strong emotional attachments to objects and multiple reasons given for saving them, as well as what sometimes appears to be remarkable aesthetic appreciation and creative interest in objects. Emotions in HD seem to range more widely than in some psychological disorders as both positive and negative reactions appear to reinforce excessive acquisition and difficulty discarding. Clutter blindness may be an effort to avoid confrontation with overwhelming clutter in the home. Finally, we comment on difficulty achieving more positive outcomes following a carefully designed cognitive and behavioral treatment for HD and encourage the next generation of researchers to follow in Jack Rachman's footsteps as they try to unravel these mysteries.

Redefining object attachment: Development and validation of a new scale

BACKGROUND AND AIMS

Object attachment is the emotional bond or connection that we have with possessions. Although thought to be ubiquitous, when excessive, object attachment is presumed to contribute to compulsive buying and hoarding problems. Unfortunately, our understanding of this relationship has been limited by the constraints of existing object attachment measures. In this paper, we developed and validated a new self-report questionnaire, called the Object Attachment Security Measure (OASM).

METHODS

We developed an item pool based on previous measures and consultation with 24 experts in the field. After piloting, we administered this measure to a large sample (Final N = 365), along with self-report measures of hoarding, compulsive buying, and previous object attachment measures.

RESULTS

We found that the OASM distinguished between secure and insecure object attachment. Both subscales showed excellent internal consistency and test-retest reliability over a two-week period. Additionally, they demonstrated excellent convergent and divergent validity, and criterion validity with measures of hoarding and compulsive buying symptoms. We also found that insecure, but not secure object attachment, was uniquely related to hoarding and compulsive buying symptomology.

DISCUSSION AND CONCLUSION

Our findings extend theoretical models, highlighting the role of insecure object attachment. Future research in both clinical and consumer behaviour fields should utilise the OASM, as reducing insecure object attachment and potentially encouraging secure object attachment could decrease maladaptive possession use and increase sustainable consumption.