Hoarding and the DSM5 Dr Christopher Mogan The Anxiety Clinic, Melbourne PATHWAYS THROUGH THE MAZE Hoarding and Squalor Conference Sydney 2012

DSM5 New and revised 5 th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. DSM is the ‘Good Book’ of mental disorders that started with 106 disorders in 1952, with last revised edition DSM-IV-TR in DSM5 proposes 283 disorders. Hoarding Disorder proposed for inclusion for the first time as a diagnostically distinct entity.

Hoarding - new & separate disorder Despite a long association with OCD, recent research has shown that 80% of hoarders: 1) Do not meet diagnostic criteria for OCD 2) Do not endorse other clinically significant OCD symptoms ( Mataix-Cols, Frost, Pertusa et al, Depress Anxiety,2010) Clinically significant hoarding is prevalent and severe; standardized assessment specifies hoarding as a distinct disorder. Comorbidities are high. Need research prevalence, course, causes, training of workers, outcomes and therapy.

Proposed Criteria for Hoarding Disorder in DSM5: A.Persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions. B. This difficulty is due to strong urges to save items and/or distress associated with discarding. C. The symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible.

C (cont) If all living areas are uncluttered, it is only because of the intervention of third parties (e.g. family members, cleaners, authorities). D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). E. Hoarding symptoms not due to a general medical condition (e.g. brain injury, cerebrovascular disease).

F. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g. hoarding due to obsessions in Obsessive Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another psychotic disorder, cognitive deficit in Dementia, restricted interests in Autistic Disorder, food storing in Prader- Willi Syndrome Specify if: With excessive acquisition: if symptoms are accompanied by excessive collecting or buying or stealing of items that are not needed or for which there is no available space.

7 Specify whether hoarding beliefs and behaviours are currently characterized by: Good or fair insight: Recognizes that hoarding- related beliefs and behaviours (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. Poor insight: Mostly convinced hoarding beliefs and behaviours (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. Absent insight: Completely convinced that hoarding beliefs and behaviours are not problematic (pertaining to difficulty discarding items, clutter, or excessive acquisition) despite evidence to the contrary

Field Trials Review of criteria based on clinical vignette methodology supported the proposed criteria – acceptability, sensitivity and specificity. Criteria endorsed also by sufferers. Second field trial is under way to review these finding in clinical settings. There is a portal on the web for further input. DSM5 scheduled for publication in 2013.

Hoarding Disorder in DSM5 means Guidelines for assessment and diagnosis of HD are specified, accessible and helpful for timely interventions – provide a conceptual model. Formal status of Hoarding Disorder will enhance research, policy development, collaborative practice, legislation and training of workers. Government, community, housing and mental health teams will have a clearer framework. Opportunities to build on shared experiences. Funding packages for the amelioration of the disability of hoarding disorder will be accessible, as funding bodies require DSM status.

The future New chapter open with the inclusion in DSM5, if it actually happens. This is a condition much misunderstood, largely undiagnosed or treated, well known to frontline workers, and emerging as a significant problem. Raising awareness of sub-types - animal hoarding, hoarding in the elderly, children in hoarding households, isolated and depressed hoarders - is the ‘bottom-up’ process that needs energy and leadership at health, legal and government levels. Prevalence estimates at 2%-5% are twice that of OCD, five times Panic Disorder and Schizophrenia.

Dr Christopher Mogan The Anxiety Clinic 140 Church Street Richmond 3121 Vic Tel