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The real hazards of hoarding with Dr. David Tolin
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In this episode of More Life, Hartford HealthCare’s Steve Coates digs into the topic of hoarding with Dr. David Tolin, medical director of the Anxiety Disorders Center at the Institute of Living, part of the Hartford HealthCare Behavioral Health Network.
Hoarding disorder is surprisingly common and can range from tolerable to hazardous and can make the person suffering, or the people around them, miserable.
Dr. Tolin helps us identify the difference between messy and hoarding and sheds some light on how a genetic predisposition, previous life event, or even impaired cognitive function may contribute to the disorder.
Who is Dr. Tolin?
Dr. David Tolin is the author of over 200 scientific journal articles, as well as the books Doing CBT: A Comprehensive Guide to Working with Behaviors, Thoughts, and Emotions, Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding and Face Your Fears: A Proven Plan to Beat Anxiety, Panic, Phobias, and Obsessions.
Dr. Tolin has been featured on the reality TV series “Hoarders,” “The OCD Project,” and “My Shopping Addiction,” and has been a recurrent guest on “The Oprah Winfrey Show” and “The Dr. Oz Show.”
Learn more about compulsive hoarding
Hoarding Disorder Research
The Anxiety Disorders Center at Hartford Hospital/Institute of Living is conducting a study investigating changes in brain functioning after treatment in people with Hoarding Disorder.
Learn more
I mean, a lot of people with hoarding disorder may actually find virtue in some of their behavior. They may say, I'm doing a good thing. I'm not wasting things. I'm preserving things. But of course, really what they're doing is they're hurting themselves and they're ultimately hurting the people around them.
SPEAKER_02Welcome to more life. In this episode, Hartford Healthcare's Steve Coates digs into the topic of hoarding with Dr. David Tolin, Medical Director of the Anxiety Disorders Center at the Institute of Living, part of the Hartford Healthcare Behavioral Health Network. Hoarding disorder is surprisingly common and can range from tolerable to hazardous and can really make the person suffering or the people around them miserable. Dr. Tolin helps us identify the difference between messy and hoarding and shed some light on how a genetic predisposition or previous life event or even impaired cognitive function may contribute to the disorder. Here's Steve and Dr. Tolin.
SPEAKER_01As somebody who is diagnosed as OCD, hoarding is confounding to me. But I understand, I understand how difficult it can be for some people. Doctor, tell me when it becomes a problem and how is it identified?
SPEAKER_00Yeah, that's a great question. Um, you know, there's a continuum here. I mean, obviously lots of people are messy, and that's not the same thing as hoarding disorder. I think it becomes an issue when one of two things is present. One is if the mess gets to the point where it's causing functioning to break down, you know, and the person is not able, for example, to cook in their kitchen or sleep in their bedroom or walk through their living room or use their stairs. I I think that's that's a clear sign that we've reached a problem. I think the other way in which this becomes a clinically relevant issue is when it's just making the person miserable or it's making the people around the person miserable, which which often happens in cases of hoarding disorder, that it's a really unpleasant problem to have. And, you know, even if it doesn't bother you, chances are it really bothers your loved ones.
SPEAKER_01And hoarding seems like a relatively new diagnosis. Is there a chemical reaction that is causing it? Is it trauma from your past? Is it something else from your past?
SPEAKER_00Well, there's likely no single cause of hoarding disorder, which is probably true of most psychiatric disorders, that there's no one thing that makes it happen. But we know from research that there is probably a genetic predisposition to developing hoarding. Um, we know that a lot of people with hoarding disorder describe a history of unpleasant or traumatic life events. Um, we know a lot of the time that people with hoarding disorder have impaired cognitive function. It's hard for them to pay attention or focus. Um we also see that there are some very real changes in how the brain functions when people with hoarding disorder have to make decisions, such that um the regions of the brain that are responsible for helping you to decide what's important and what's not important are not functioning very well. So there's probably a lot of things that are going into this, both psychological and environmental and biological, that that all probably combine to create this problem that we call hoarding disorder.
SPEAKER_01So if clinically somebody may be considered a hoarder, but maybe they live alone, maybe the people are living with it, it's not impacting them. How do you know that it's becoming a problem?
SPEAKER_00And it may not be. I mean, uh so in a lot of cases, it's you know, it's it's tolerable, in which case, you know, I don't think that necessarily everybody needs to get treated for it. But at least when the clutter gets more severe, one of the things that we start seeing is that there's a lot of hazard in the home. Um, you know, that there's um fall hazards, there's trip hazards, and importantly, there's fire hazard. You know, the city of Melbourne, Australia did the most comprehensive review of residential house fires. And one of the things that they found over a 10-year period was that hoarding cases accounted for a full quarter of all the people who died in house fires over that 10-year period. So there's a very real risk that's associated with hoarding as well.
SPEAKER_01Are you seeing a lot of patients coming to you, either being referred by themselves, by family members, or other clinicians?
SPEAKER_00It is relatively common. I mean, just in terms of its prevalence, I mean, the across studies, it looks like it's probably between two and three percent of the population, which may not seem like a very big number, but that's a lot. I mean, that's that's you know, much greater than the prevalence, for example, of obsessive-compulsive disorder. Um, it's greater than the prevalence of schizophrenia or panic disorder. So it's it's a fairly common mental disorder. And and in our practice, we do see that there are some people who refer themselves. There are some people who are kind of nagged into it by family members. Um, but at the same time, you know, there there's probably a lot of people out there that we don't see because they just flat out refuse to get treatment for their condition. And that's a real tragedy in a lot of cases.
SPEAKER_01Does hoarding as a disorder go hand in hand with other disorders, whether it's depression or or other behavioral health issues?
SPEAKER_00Yeah. So one of the things that we see, there's probably two things that we see a lot of in hoarding disorder. One is depression. Um, so we find that that at least half of people with hoarding disorder also seem to meet criteria for what's called major depressive disorder. So hoarding, you know, tends to be a depressing condition, and depression probably contributes further to hoarding. The other one that we see quite often is attention deficit hyperactivity disorder or ADHD. Um, looks like about 28% of people with hoarding disorder meet full diagnostic criteria for ADHD, but even beyond the diagnosis, about three-quarters of people with hoarding disorder have elevated symptoms of ADHD. So it's really common for people with hoarding disorder to describe uh some degree of cognitive impairment, which probably makes the decision-making process much harder.
SPEAKER_01If you're living with someone or you have a loved one that you think this could be a problem for, that you think hoarding could be causing them some danger, how do you broach this subject with them?
SPEAKER_00This is really tricky because you know you can't really force somebody to get treatment, and nor can you badger them into it. I mean, the problem that we run into is that that arguing with somebody about their hoarding problem not only doesn't help, it doesn't really make them wake up and and change their their behavior, but it actually has the opposite effect. You know, it when a when you argue with somebody about their hoarding, more often than not, what they seem to do is dig in their heels and they they kind of double down and and they they get defensive about it, which actually is uh a sliding back. So when I talk with with loved ones about the hoarding disorder, uh, you know, the first piece that I encourage them to think about is is um, you know, whose needs are you serving here? You know, is this actually affecting you? Are you in the are you in the the home? Are you being affected by the hoarding? Or is this more just, you know, you're living separately from your your parent and but you just can't stand to see them living this way? If it's the latter, you may actually need to kind of let go of that or lower your expectations for what's going to happen. But if it really is um affecting the person and it, and or it's a real safety hazard that that you know you feel obligated to address, then I suggest that people approach it gently, um, you know, in a non-argumentative way, because that's our you know, arguing is just going to trigger defensiveness. But I think that what you can do is you can say, mom or dad or whoever it is that's that is engaging in this behavior, I'm really concerned about you. You know, you don't even need to argue about whether it's hoarding or not, but just say, I'm really concerned about the the living situation here. It really makes me worry for your safety. Is there something that we could do about this? And then you kind of let that sit and you recognize as well that this is probably not just gonna happen in one conversation, you know, that, you know, if you think about any big behavioral change, whether it's losing weight or starting an exercise program or quitting smoking, I mean, it takes lots of starts and stops before this actually happens. You know, very few people just make the decision one time and say, okay, I'm gonna change, and then they radically change their behavior. So we need to kind of recognize that you're asking the person to make some really big changes, and it's gonna have to take place over several conversations.
SPEAKER_01To me, it almost seems these conversations might be even more difficult to have, not that they're not difficult to have, but than drugs or alcohol or other behavioral health uh issues, because sometimes you may not be able to identify, or that person may not be able to identify exactly what's going on.
SPEAKER_00It is, yeah. And and and you're right. I mean, a lot of people with hoarding disorder may actually find virtue in some of their behavior. They may say, I'm I'm I'm doing a good thing, I'm not wasting things, you know, I'm I'm I'm preserving things. But you know, of course, really what they're doing is they're hurting themselves and they're ultimately hurting the people around them. And I think to the extent that that you can make that clear when you talk to your loved one, I think that that's probably your best route to success. You know, so another way of saying this is um instead of just saying, I'm concerned about you, you could also say, I'm concerned for myself for the following reasons, or this is how this house is affecting me. And that may also be a way of bringing the information onto the table in a way that doesn't trigger defensiveness.
SPEAKER_01What are the treatment options for people suffering from hoarding? Is there medication they can take?
SPEAKER_00Yeah, at the moment, there are no medications that have been proven to be effective for hoarding disorders. So so um the one thing that we know through randomized controlled trials to be helpful is what's called cognitive behavioral therapy or CBT. And CBT is a form of psychotherapy that involves teaching the person to think differently and to practice new patterns of behavior. And so in our program uh for hoarding disorder, for example, we encourage people to bring stuff into the clinic and then to make decisions about it with our guidance. Not that we're gonna tell you to throw stuff away, but we're gonna help you with the decision-making process. Um, we have also constructed what we call the virtual store, which is a place where we've got a bunch of stuff that people with hoarding disorder might want to acquire. And we encourage them to practice tolerating their emotions and not picking things up. And so it's a very, you know, active form of treatment that's designed to help people learn and adopt new behavioral patterns.
SPEAKER_01We've seen reality shows about hoarding, very popular shows. Is this good to bring awareness to this condition?
SPEAKER_00Well, and and just, I mean, in the spirit of full disclosure, I'm on that show. Um, so I I I should just just so that you're aware. Um you know, I think that with any show, some people might watch it for the wrong reasons. And that's a shame if people are doing that. You know, if people are watching it for just kind of ghoulish reasons to watch somebody else's mess, uh, you know, I don't think that that's particularly helpful. But I've heard from enough people that they saw the show, that they recognized that they had a problem, that it inspired them to get some help. That it occurs to me, that it seems to me that that we are fundamentally doing a service. And if there are some people who are watching for the wrong reasons, I you know, I hope that they will change their their approach.
SPEAKER_01And you are seeing success stories for people who've come in to see you. What is success?
SPEAKER_00Yeah, we talk with family members a lot in our in our program. And and you know, one of the things that we're often challenged to do is to try to stop the arguing, you know, and just and and help the family to be become about something besides just arguing about hoarding, because A, that just swallows up um the functioning of the family, but but B, um it's a it's a losing proposition from the get-go. You know, you're just never going to win an argument about hoarding. So sometimes the best training we can give to a family member is to teach them not to start that fight.
SPEAKER_01Is there any research on the horizon that will be helpful for patients and families coming up?
SPEAKER_00We are just about to start some research now. I mean, we've been doing a lot of research on the efficacy of cognitive behavior therapy. We've been doing a lot of research on brain functioning in people with hoarding disorder, and we're now bringing those two points together. The the next big thing that we're gonna work on is uh a test of real-time fMRI neurofeedback. And what that means is that we're gonna put people in a brain scanner and we're going to have them making decisions about possessions while simultaneously seeing if they can train themselves to change their own brain function and to see if that helps make the decision-making process easier. Now, I don't think that that's gonna necessarily, I don't think that's necessarily gonna be a cure for hoarding, but I think that it may become a really important adjunct to cognitive behavioral therapy if it's successful.
SPEAKER_01Doctor, thanks so much for your time.
SPEAKER_00My pleasure. Anytime.
SPEAKER_02Thank you, Steve and Dr. Tolin. Be sure to check the links in this episode's notes to learn more about available resources and support. Follow more life to be notified each time a new episode drops. Just search Hartford Healthcare on your favorite podcast platform. For Hartford Healthcare, I'm Enron DePierre. Thanks for listening to More Life.
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