PI Brief Update

Hoarding as a disability - Dr Mark Burgin

12/07/23. Dr Mark Burgin explains why disability analysts are the ideal expert to assess and explain the nature of hoarding and what reasonable adjustments should be made.

Introduction

Hoarding is a mental health disorder characterized by the persistent difficulty in getting rid of possessions, regardless of their actual value. Hoarders often feel a strong emotional attachment to their possessions, and they may believe that they need to keep them in order to feel safe or secure. It can occur with mental health conditions, such as anxiety, depression, and obsessive-compulsive disorder.

Clutter can be a nuisance, but it is not a mental health disorder. People who are cluttered may experience some of the same problems as hoarders, such as difficulty finding things and feeling stressed or overwhelmed. However, they do not have the same strong emotional attachment to their possessions, and they are usually able to get rid of things when they no longer need them.

The prevalence of hoarding disorder is estimated to be between 2 and 6% of the population. It is more common in older adults and women. Hoarding can have a significant impact on individuals and families. It can lead to social isolation, financial problems, and health hazards. Hoarders may also experience anxiety, depression, and low self-esteem.

The causes of hoarding

Hoarding is a complex disorder that is not fully understood. There are a number of factors that may contribute to hoarding, including brain injuries and strokes, learning disabilities, traumatic experiences, genetics, brain chemistry, and personality traits. Sufferers often have low self esteem and acquire and hoard items in order to feel safe or secure.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard reference guide for mental disorders, defines hoarding disorder as a persistent difficulty discarding or parting with possessions, regardless of their actual value, excessive acquisition and distress and impairment.

Hoarders often have a strong emotional attachment to their possessions. This can occur due to neglect in childhood. Neglect caused difficulty forming healthy attachments with humans and transfer of attachment to things. Hoarding may be protective against personality disorders as the hoard becomes a comfort blanket.

The symptoms of hoarding can vary from person to person and can include:

· Difficulty getting rid of possessions, even if they are no longer needed or useful.

· A strong emotional attachment to possessions

· abnormal thoughts that their possessions are valuable or that they will need them in the future.

· Difficulty making decisions about what to keep and what to get rid of

· Accumulation of clutter in the home

· living in unsanitary conditions

· Difficulty using the home for its intended purpose.

· Social isolation

· Depression

· Anxiety

· Shame

· Embarrassment

· Procrastination

· Perfectionism

· Obsessive thoughts about possessions

· Compulsive behaviours related to possessions.

· Relationship problems

· Employment problems

Hoarders may also have difficulty making decisions about what to keep and what to discard. They may be overwhelmed by the amount of clutter in their home and may not know where to start.

Hoarding disorder can be a very isolating condition. Hoarders may feel ashamed of their clutter and may avoid social situations. They may also have difficulty maintaining relationships with family and friends.

Complexity of the hoard

A key concept in the assessment of hoarding is the complexity of the hoard.

· The amount of clutter: The more clutter there is, the more difficult it is to sort through and get rid of.

· The type of clutter: Some types of clutter, such as furniture and appliances, can be more difficult to remove than others, such as paper and clothing.

· The presence of health hazards, such as mould, pests, or fire hazards

· The location of the clutter: Clutter in high-traffic areas, such as doorways and hallways, can make it difficult to move around the home.

A mild hoard can generally be managed by most hoarders without outside professional involvement. However, a moderate hoard is generally too complex to sort for most hoarders unless they have professional assistance. Even mild hoards can cause a disability because it significantly interferes with a person's ability to function in their daily life.

Indications that the hoard is disabling is that the hoard is leading to health problems, such as fire hazards, injuries, and exposure to mould and pests. Other clues are difficulty in maintain the level of clutter, to get around their homes, mental health problems, such as depression, anxiety, and social isolation.

Severe hoards are generally too complex for even trained professionals as they would take too long to sort. When an expert classifies a hoard as severe then the only effective strategies are those that remove at least part of the hoard from the house.

Treatments

There are a number of treatments available for hoarding disorder. These include cognitive-behavioural therapy, exposure and response prevention therapy (ERP) and antidepressant medication. Treatment can be effective in helping hoarders to reduce the amount of clutter in their homes and to improve their quality of life.

Therapy can help hoarders to understand the causes of their hoarding and to develop coping mechanisms. Medication can help to reduce anxiety and depression, which are often associated with hoarding. Support groups can provide both social interaction and understanding. With treatment, many hoarders are able to make significant progress in reducing their clutter and improving their quality of life.

Where the hoard is mild then support should be offered to try to prevent it growing out of control. Simple advice such as keeping the hoard out of sight in a spare room, organised in boxes, regularly sorting through a box can empower the person. The aim is not to solve the hoard but allow the person to control the size and prevent it from expanding further.

Where the hoard is growing and has or will become moderate then a firm approach is required. Most hoarders are in denial will argue that the hoard is not bad enough to trigger the responses and that it is not increasing. The council needs to have a policy to deal promptly with these hoards and explain what will happen next.

The professional should explain that if the hoard increases then compulsory actions will be taken without sorting the hoard. They should instruct a disability analyst to determine the likely causes of the hoarding behaviour. Reasonable adjustments can then be used to structure the policy.

The hoarder may decide to move some of the hoard to a storage unit, stay in a hotel whilst professionals remove items or sort materials themselves for the professional to dispose of. The hoarder may decline this assistance and a further assessment is then made after a few months. If it clear that no progress (or worsening) has occurred then a court order needs to obtained.

Although making the hoarder homeless would lead to destruction of most of the hoard this is detrimental to their mental state. The court order should instead specify the amount of material to be removed from the property. This recognises the hoarder’s disability and rights under the Equality Act 2010 but also their needs for a smaller hoard that they can manage.

Conclusion

Hoarding is a serious mental disorder that can have a significant negative impact on a person's life. It is important to understand that hoarding is a disability and that people with hoarding disorder need reasonable adjustments. Evicting the hoarder should never be performed for hoarding alone as it is a disability and protected by The Equality Act 2010.

Management of the hoarder and their hoard requires professionals with experience and training in disability. They should use steps appropriate to the complexity of the hoard and not expect a hoarder to be able to manage a severe hoard even with support. Transparency about the next steps that will be taken is important to avoid prolonged discussions that have no benefit.

Although some hoarders will also breach their tenancy in other ways, most are otherwise excellent tenants. Removal of part of the hoard is part of the therapy as it increases the chance that the sufferer will engage with treatment in future. In an ideal world prevention would be used rather than legal processes to manage the social consequences of this condition.

This article was written with assistance from the Bard Large Language model from Google.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

Image ©iStockphoto.com/cerro_photography