How Does Lack of Awareness Impact Hoarding Disorder?

What you need to know

• People with hoarding disorder often underestimate how much clutter is in their homes
• This lack of awareness, called anosognosia, gets worse as clutter increases
• Poor awareness is linked to difficulties with certain cognitive skills like inhibiting responses
• Understanding these connections may help improve treatments for hoarding disorder

Understanding hoarding disorder and awareness

Hoarding disorder is a mental health condition where people have extreme difficulty discarding possessions, leading to excessive clutter that disrupts their lives. A key challenge in treating hoarding disorder is that many people with the condition don’t seem to recognize how severe their clutter problem is. This lack of awareness, called “poor insight” or “anosognosia,” can make it hard for people to seek help or stick with treatment.

Researchers are trying to better understand this awareness issue in hoarding disorder. They want to know how common it is, what might cause it, and how it relates to other aspects of thinking and behavior. This study explored these questions by looking at how people with hoarding disorder rated their own clutter compared to how independent evaluators rated it. The researchers also had participants complete cognitive tests to see if certain thinking skills were connected to awareness of clutter.

How the study worked

The study included 71 adults diagnosed with hoarding disorder who were interested in treatment. Here’s how the researchers assessed their awareness of clutter:

1. Participants rated the clutter in their homes using a standardized picture scale called the Clutter Image Rating (CIR). This involves choosing images that best match the level of clutter in different rooms.

2. Later, an independent evaluator visited each participant’s home and used the same CIR scale to rate the actual clutter levels.

3. The researchers compared the participants’ ratings to the evaluators’ ratings to see how accurately people judged their own clutter.

A subset of 53 participants also completed computerized tests of various cognitive abilities like attention, memory, and response inhibition.

Key findings on clutter awareness

The study found that people with hoarding disorder tend to underestimate their clutter levels:

• 58% of participants rated their clutter as less severe than the independent evaluators did
• 30% underestimated their clutter by a significant amount (at least 20% lower than the evaluator’s rating)
• 4% rated their clutter as half as severe as the evaluator did

Importantly, the worse a person’s actual clutter was (based on the evaluator’s rating), the more likely they were to underestimate it. This suggests that as hoarding gets more severe, people’s awareness of the problem tends to decrease.

The researchers didn’t find any connection between how people rated their own clutter and standard questionnaires used to assess hoarding symptoms. This implies that asking people to rate their own clutter severity may not be a reliable way to gauge how bad the hoarding problem actually is.

Cognitive skills linked to clutter awareness

When looking at the cognitive test results, a few key abilities stood out as being related to clutter awareness:

1. Response inhibition: This is the ability to stop yourself from making an automatic response. People who made more errors on a computerized “Go/No-Go” test (which measures this ability) were more likely to underestimate their clutter.

2. Cognitive interference: This involves managing conflicting information. On a “Stroop” test (where you have to name the ink color of words that spell out different colors), people who were faster at naming ink colors relative to reading color words tended to underestimate their clutter more.

3. Cognitive flexibility: This is the ability to switch between different tasks or ways of thinking. There was a trend suggesting that people who performed worse on a test of this skill were more likely to underestimate their clutter.

These findings suggest that difficulties with certain aspects of cognitive control - particularly the ability to inhibit automatic responses and manage conflicting information - may contribute to the lack of awareness seen in hoarding disorder.

Why this matters for understanding and treating hoarding

This research helps clarify several important points about awareness in hoarding disorder:

1. Lack of awareness is common and tends to get worse as hoarding becomes more severe. This explains why many people with significant hoarding problems don’t seek help on their own.

2. Simply asking people to rate their own clutter may not give an accurate picture of how bad the hoarding problem is. Objective assessment by an outside observer is important.

3. Poor awareness in hoarding seems to be related to specific cognitive difficulties rather than just denial or unwillingness to admit to problems. This fits with research on lack of awareness in other mental health and neurological conditions.

4. The cognitive skills linked to awareness in hoarding - like response inhibition and cognitive flexibility - are abilities that can potentially be improved with practice. This suggests possible new treatment approaches.

Understanding these connections could lead to better ways to assess and treat hoarding disorder. For example:

• Treatments might incorporate more practice of cognitive control skills to help improve awareness.
• Helping family members understand that lack of awareness is linked to cognitive difficulties, not stubbornness, could improve support.
• Clinicians might pay special attention to building awareness and insight in patients who show signs of cognitive control difficulties.

Limitations and next steps

It’s important to note that this study only shows correlations - it can’t prove that cognitive control problems directly cause lack of awareness in hoarding. The participants were also mostly older women seeking treatment, so the findings may not apply to all people with hoarding disorder.

Future research could explore whether problems with awareness in hoarding are related to differences in brain activity, particularly in areas involved in error detection and cognitive control. This could provide more insight into the biological basis of awareness difficulties.

Researchers might also look at whether treatments that improve cognitive control skills lead to better awareness and outcomes for people with hoarding disorder. Understanding the brain basis of awareness problems could eventually lead to new treatment approaches, not just for hoarding but for other conditions where lack of insight is an issue.

Conclusions

• People with hoarding disorder often underestimate how cluttered their homes are, especially when clutter is severe
• This lack of awareness is linked to difficulties with cognitive control skills like response inhibition
• Understanding these connections may lead to better ways to assess and treat hoarding disorder
• More research is needed to clarify the brain basis of awareness problems in hoarding and test potential new treatments