Although researchers have recognized the phenomenon of compulsive hoarding since at least the 1980s, hoarding was only defined and listed as a mental disorder in the 5th edition of the Diagnostic and Statistical Manual (DSM5) in 2013. While this clinical recognition comes relatively late, the idea that some people compulsively hoarded objects of living creatures has been recognized for centuries. A manifestation of hoarding, Diogenes syndrome, involves extreme self-neglect and was named after the ancient Greek philosopher who lived in a barrel in the 4th century BCE (Khan, Reference Khan2017). In recent years, documentaries and increased media attention have heightened awareness of the disorder within communities.
High levels of concern among family and friends about the hoarding, coupled with a lack of concern on the part of the individual who is hoarding, is typical (Steketee etal., Reference Steketee, Schmalisch, Dierberger, DeNobel and Frost2012), with lack of insight potentially more pronounced in older people (Kim etal., Reference Kim, Steketee and Frost2001). Risk factors for development of hoarding behavior includes core beliefs about personal adequacy and identity; information processing problems in decision-making and organizing, and strong emotional attachments to objects and fixed beliefs that reinforce acquiring and keeping items. Comparisons have been made between object and animal hoarding, which differ on a number of parameters but which again pose personal and community harm (Frost etal., Reference Frost, Patronek and Rosenfield2011). Social services (including animal welfare officers) are often called upon to attend to individuals whose hoarding is causing harm to themselves or others.
Hoarding is cited by many authors as a particularly difficult condition to treat (e.g. Steketee etal., Reference Steketee, Schmalisch, Dierberger, DeNobel and Frost2012). In older populations, it can have severe impacts of health, wellbeing, and family and community relationships; personal and public health and safety risks include falls, infestations of vermin, and fires (Ayers etal., Reference Ayers, Saxena, Golshan and Wetherell2010). Research suggests that hoarding increases in severity across the life span, with some data suggesting up to 25% of older people may experience hoarding symptoms (Marx and Cohen-Mansfield, Reference Marx and Cohen-Mansfield2003). Thus, the work by Pittman and colleagues (2021) on the implementation and evaluation of a community-based treatment for late-life hoarding is a much-needed addition to the extant literature. Cognitive Rehabilitation and Exposure/Sorting Training (CREST), specifically developed for older adults, not only has a solid empirical underpinning but also is perceived to be highly effective by participants (Davidson etal., Reference Davidson, Broadnax, Dozier, Pittman and Ayers2021). The research by Davidson and colleagues also found that participants within the CREST trial specifically were interested in relapse prevention; this is important as high rates of relapse after treatment are common with hoarding disorder, and recent research suggests that relapse rates have been negatively affected by the COVID-19 crisis (Mehra etal., Reference Mehra2020).
In the current study, Pittman and colleagues (2021) demonstrated significant improvements in participants who were of lower socioeconomic status with multiple medical and community (i.e. eviction) risk factors and give promising evidence of the sustainability of the intervention program. Concrete evidence of the programs’ success is the decision of San Diego County to expand the reach of the program to cover all of San Diego County, tripling the size of this intervention. The program has been translated into Spanish and successfully delivered to the Spanish-speaking community. This highlights the potential of the program to be successfully adapted and adopted in other regions of the USA and abroad to help address the significant physical and mental wellbeing challenges that hoarding disorder poses for communities. A recent meta-analysis (Postlethwaite etal., Reference Postlethwaite, Kellett and Mataix-Cols2019) of rates of hoarding disorder across 10 countries underscores that hoarding disorder is of global concern, and that proven, sustainable, and empirically validated interventions are urgently required. While there is no doubt that more research on interventions and stigma reduction, and greater investments in service development and delivery are required with respect to hoarding disorder (Mataix-Cols and de la Cruz, Reference Mataix-Cols and de la Cruz2018), the CREST intervention and its attendant data on treatment outcomes and patient and provider satisfaction is a welcome addition to this literature.
Conflict of interest
None.
Although researchers have recognized the phenomenon of compulsive hoarding since at least the 1980s, hoarding was only defined and listed as a mental disorder in the 5th edition of the Diagnostic and Statistical Manual (DSM5) in 2013. While this clinical recognition comes relatively late, the idea that some people compulsively hoarded objects of living creatures has been recognized for centuries. A manifestation of hoarding, Diogenes syndrome, involves extreme self-neglect and was named after the ancient Greek philosopher who lived in a barrel in the 4th century BCE (Khan, Reference Khan2017). In recent years, documentaries and increased media attention have heightened awareness of the disorder within communities.
High levels of concern among family and friends about the hoarding, coupled with a lack of concern on the part of the individual who is hoarding, is typical (Steketee etal., Reference Steketee, Schmalisch, Dierberger, DeNobel and Frost2012), with lack of insight potentially more pronounced in older people (Kim etal., Reference Kim, Steketee and Frost2001). Risk factors for development of hoarding behavior includes core beliefs about personal adequacy and identity; information processing problems in decision-making and organizing, and strong emotional attachments to objects and fixed beliefs that reinforce acquiring and keeping items. Comparisons have been made between object and animal hoarding, which differ on a number of parameters but which again pose personal and community harm (Frost etal., Reference Frost, Patronek and Rosenfield2011). Social services (including animal welfare officers) are often called upon to attend to individuals whose hoarding is causing harm to themselves or others.
Hoarding is cited by many authors as a particularly difficult condition to treat (e.g. Steketee etal., Reference Steketee, Schmalisch, Dierberger, DeNobel and Frost2012). In older populations, it can have severe impacts of health, wellbeing, and family and community relationships; personal and public health and safety risks include falls, infestations of vermin, and fires (Ayers etal., Reference Ayers, Saxena, Golshan and Wetherell2010). Research suggests that hoarding increases in severity across the life span, with some data suggesting up to 25% of older people may experience hoarding symptoms (Marx and Cohen-Mansfield, Reference Marx and Cohen-Mansfield2003). Thus, the work by Pittman and colleagues (2021) on the implementation and evaluation of a community-based treatment for late-life hoarding is a much-needed addition to the extant literature. Cognitive Rehabilitation and Exposure/Sorting Training (CREST), specifically developed for older adults, not only has a solid empirical underpinning but also is perceived to be highly effective by participants (Davidson etal., Reference Davidson, Broadnax, Dozier, Pittman and Ayers2021). The research by Davidson and colleagues also found that participants within the CREST trial specifically were interested in relapse prevention; this is important as high rates of relapse after treatment are common with hoarding disorder, and recent research suggests that relapse rates have been negatively affected by the COVID-19 crisis (Mehra etal., Reference Mehra2020).
In the current study, Pittman and colleagues (2021) demonstrated significant improvements in participants who were of lower socioeconomic status with multiple medical and community (i.e. eviction) risk factors and give promising evidence of the sustainability of the intervention program. Concrete evidence of the programs’ success is the decision of San Diego County to expand the reach of the program to cover all of San Diego County, tripling the size of this intervention. The program has been translated into Spanish and successfully delivered to the Spanish-speaking community. This highlights the potential of the program to be successfully adapted and adopted in other regions of the USA and abroad to help address the significant physical and mental wellbeing challenges that hoarding disorder poses for communities. A recent meta-analysis (Postlethwaite etal., Reference Postlethwaite, Kellett and Mataix-Cols2019) of rates of hoarding disorder across 10 countries underscores that hoarding disorder is of global concern, and that proven, sustainable, and empirically validated interventions are urgently required. While there is no doubt that more research on interventions and stigma reduction, and greater investments in service development and delivery are required with respect to hoarding disorder (Mataix-Cols and de la Cruz, Reference Mataix-Cols and de la Cruz2018), the CREST intervention and its attendant data on treatment outcomes and patient and provider satisfaction is a welcome addition to this literature.
Conflict of interest
None.