Kathleen Louden

April 08, 2014

CHICAGO — The extent to which family members tolerate and accommodate an individual's hoarding behavior is linked to severity of the disorder and is also an indicator of relationship conflict and the patient's level of functional impairment, new research shows.

Using a mediation model, new findings show that family accommodation ― such as not bringing outsiders into the home, allowing the saving of possessions, or taking on the responsibilities of the hoarder ― influences hoarding symptom severity and family conflict.

Family accommodation also influences the relationship between hoarding symptom severity and the hoarder's ability to function on a daily basis.

"We have evidence to suggest that family accommodation plays a role in the relationship between hoarding symptom severity and impairment in activities of daily living [ADL]," lead author Valerie Vorstenbosch, PhD, a postdoctoral fellow at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, told Medscape Medical News.

Clinicians have long believed that family members' accommodating behaviors help maintain the severity of a patient's hoarding symptoms, but currently, there is a lack of research examining this relationship, said Dr. Vorstenbosch.

She said these findings suggest that family accommodation may be one mechanism through which the severity of hoarding symptoms influences both relationship conflict and ADL impairment.

The findings were presented here at the Anxiety and Depression Association of America (ADAA) Conference 2014 during a symposium devoted to new research exploring hoarding and family relationships, a topic all of the panelists suggest has been understudied.

Separate DSM-5 Diagnosis

Dr. Vorstenbosch and her colleagues studied 52 pairs: hoarders and their intimate partner or another close family member who spent at least 4 hours a week with the hoarding-identified individual and who did not have hoarding symptoms themselves. Most (71%) of the dyads lived together, she said.

Hoarding was determined by a score of 14 or higher on the Saving Inventory–Revised. The inventory assesses clutter, difficulty discarding, and excessive acquisition.

"Hoarding disorder" was defined last year in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), as "persistent difficulty discarding or parting with possessions" regardless of their actual value, extensive clutter in the home and workplace, and symptoms that impair function, including "maintaining a safe environment."

The new edition of the manual made hoarding a separate diagnosis from obsessive-compulsive disorder (OCD).

In the study, each dyad member evaluated the nonhoarding significant other's family accommodation using an 11-item clinician-rated interview that the investigators adapted from the Family Accommodation Scale for OCD.

The scale measured perceived frequency of accommodating behaviors and distress associated with accommodating behaviors. Those scores were combined to yield a total score.

Dr. Vorstenbosch said the reported perceptions of both dyad members showed that the more severe the hoarding symptoms, the greater the family accommodation and the greater the relationship conflict. Conflict was assessed using the Quality of Relationships Inventory.

"The family feels they are accommodating more, but they are having more stress," said Dr. Vorstenbosch.

Treatment Implications

The extent to which the severity of hoarding symptoms was associated with functional impairment reportedly differed depending on whose perceptions were assessed.

Data showed that the association between hoarding symptom severity and hoarders' ADL impairment was significantly reduced when family accommodation was included in the mediation model for hoarding-identified participants, but not their significant others.

Dr. Vorstenbosch cautioned that she could not make causal statements about the findings because of the study's cross-sectional design and measurement at only 1 time point. They could not address, for instance, whether symptom severity preceded relationship conflict or vice versa.

Dr. Vorstenbosch told conference delegates that her group's findings have treatment implications, especially because previous research shows that family accommodation was linked to poorer treatment outcomes for individuals with OCD.

She recommended that providers target family accommodation using a couple-based or family-based therapy for hoarding.

"To my knowledge, family-based interventions are not readily available, other than often including loved ones in treatment as a coach for the person who hoards," Dr. Vorstenbosch told Medscape Medical News.

She suggested that family therapy should seek to understand how each person's behaviors influence the relationship and how each person could help to decrease hoarding symptoms and accommodation.

Hoarding Spans Generations

A second study presented during the symposium showed that hoarding even has negative effects on adult offspring of hoarders.

Adult offspring reported interpersonal problems with their parent who hoards, especially feeling submissive and nonassertive with the parent — "the opposite of what you'd expect," said investigator Amy Przeworski, PhD, of Case Western Reserve University in Cleveland, Ohio.

Another panelist, Gail Steketee, PhD, of Boston University in Massachusetts, reported her research showing that people with hoarding disorder tend to have other family members across generations who hoard.

Compared with men, women reported significantly higher rates of having any first-degree relative who hoarded, she said.

Symposium discussant Kiara Timpano, PhD, of the University of Miami in Coral Gables, Florida, commented that hoarding "affects many more individuals than we ever expected. It also impacts their families and the communities where they live."

Dr. Timpano, who was not involved with any of the studies presented, told conference delegates that the biggest message from the symposium is likely the importance of including family members in treatment.

"But," she continued, "we need to ask when would it be best to include them, and how can we include family in the most effective way."

She said a strength of Dr. Vorstenbosch's study was its inclusion of both hoarders and family members. Dr. Timpano also noted that there are many types of family accommodation — both positive and negative — and that accommodation is not always helpful to the person who hoards.

"Sometimes what family members think is helpful is actually not helpful," she told Medscape Medical News.

The study conducted in dyads showed that the relationship between family accommodation and hoarding is complex, Dr. Timpano said.

"Family members can impact hoarding severity [through accommodation], especially if they feel frustrated, but hoarding severity can also affect how the family functions," she said. "It's a bidirectional relationship."

Multiple factors contribute to the severity of hoarding disorder, according to Dr. Timpano.

"There are emotional processes, personality and biological factors, and cognitive processes. Hoarding is a perfect storm of all these things," she said.

Dr. Vorstenbosch was a graduate student at Ryerson University, Toronto, while conducting this research. A grant from the Ryerson University Health Research Fund supported this study. Dr. Vorstenbosch, her copanelists, and Dr. Timpano report no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2014. Abstract 371R. Presented March 28, 2014.

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