How Can Primary Care Physicians Help Patients with Hoarding Disorder?

What you need to know

• Hoarding disorder is characterized by difficulty discarding possessions and excessive clutter that interferes with the use of living spaces.
• Many patients have poor insight into their hoarding behaviors, making diagnosis and treatment challenging.
• Primary care physicians can play a vital role in identifying hoarding disorder and coordinating long-term, compassionate care with other service providers.

Understanding Hoarding Disorder

Hoarding disorder (HD) is a mental health condition that affects approximately 2% of the population. It is characterized by three main features:

1. Difficulty discarding or parting with possessions
2. Excessive accumulation of items, regardless of their actual value
3. Clutter that prevents the normal use of living spaces

While many people may experience some of these tendencies to a mild degree, HD is diagnosed when these behaviors cause significant distress or impairment in daily functioning.

Hoarding can have serious consequences, including:

• Physical health risks from unsanitary conditions or fire hazards
• Psychological distress and reduced quality of life
• Strained relationships with family, friends, and neighbors
• Housing insecurity

It’s important to note that HD is distinct from collecting or simply having a messy home. The key difference is the level of distress and impairment caused by the hoarding behaviors.

Challenges in Diagnosis

Identifying hoarding disorder can be difficult for several reasons:

Late onset of help-seeking

Many people with HD don’t seek help until decades after symptoms begin. This delay is often due to:

• The gradual progression of hoarding behaviors
• Family members managing or hiding the severity of the problem
• Feelings of shame or embarrassment

Poor insight

A key feature of HD is that many patients have limited awareness that their hoarding behaviors are problematic. This poor insight means they may not:

• Recognize they need help
• Disclose hoarding-related issues to healthcare providers
• Acknowledge problems even when directly asked

Comorbid conditions

Hoarding often co-occurs with other mental health conditions, particularly:

• Depression (most common)
• Obsessive-compulsive disorder (OCD) in about 18% of cases
• Attention deficit hyperactivity disorder (ADHD) in up to 28% of cases

These comorbidities can sometimes mask the underlying hoarding behaviors.

The Role of Primary Care Physicians

Primary care physicians are uniquely positioned to help patients with hoarding disorder in several ways:

Early identification

While patients may not seek help specifically for hoarding, they often visit their primary care doctor for other health concerns. This provides an opportunity to:

• Observe potential signs of hoarding (e.g. poor hygiene, mentions of cluttered living spaces)
• Ask sensitively about home environment and ability to use living spaces
• Arrange home visits if hoarding is suspected

Building trust

Many people with HD are distrustful of others and reluctant to engage with services. Primary care physicians can:

• Develop long-term, compassionate relationships with patients
• Provide a non-judgmental space to discuss concerns
• Offer education about HD to reduce shame and stigma

Coordinating care

HD often requires a multi-agency approach. Primary care physicians can:

• Connect patients with local support services (e.g. mental health, housing, social services)
• Communicate with other healthcare providers and agencies involved in the patient’s care
• Advocate for patients’ needs within the healthcare system

Addressing safety concerns

When hoarding behaviors create safety risks, primary care physicians play a crucial role in:

• Assessing capacity and choice
• Balancing patient autonomy with safeguarding responsibilities
• Implementing harm reduction strategies when full treatment isn’t feasible

Treatment Approaches

While there is no single proven treatment for hoarding disorder, several approaches show promise:

Cognitive Behavioral Therapy (CBT)

CBT adapted for hoarding can help patients:

• Challenge beliefs about possessions
• Develop decision-making and organizational skills
• Practice discarding and resisting acquiring new items

Medication

Selective serotonin reuptake inhibitors (SSRIs) may be helpful, especially for patients with comorbid depression or anxiety. However, more research is needed to establish their effectiveness specifically for HD.

Multi-component interventions

Combining therapy, medication, and practical support (e.g. home organizing assistance) may be more effective than any single approach.

Harm reduction

For severe cases or when patients refuse treatment, focusing on minimizing health and safety risks may be the most realistic goal.

It’s important to note that forced cleanouts or removal of possessions without the patient’s consent are generally counterproductive and can worsen mental health.

Supporting Families and Caregivers

Hoarding disorder doesn’t just affect the individual – it can have a significant impact on family members and others living in the home. Primary care physicians can support families by:

• Providing education about HD and its treatment
• Offering resources for support groups or family therapy
• Addressing the mental health needs of family members/caregivers

Conclusions

• Hoarding disorder is a complex condition that requires long-term, patient-centered care.
• Primary care physicians play a crucial role in identifying HD, building trusting relationships with patients, and coordinating multi-agency support.
• While treatment can be challenging, a compassionate, non-judgmental approach focused on harm reduction and gradual progress can improve outcomes for patients with hoarding disorder.