Tuesday, May 28, 2013

Hoarders Confess on the Radio: Just another Compulsion?

Spent an hour today chatting on-air with my husband about a new designation in the Diagnostic and Statistical Manual of Mental Disorders, volume 5: Hoarding Disorder.

It was always recognized as a problem, but was listed previously as a type of obsessive-compulsive disorder. This go-round, HD (not "high-definition") merited its own, separate listing. New research has found genetic markers and brain responses that set it apart from the rest of the OCD category, and it often wasn't successfully treated with meds that worked fairly well with other compulsions.

I'm fascinated with the whole idea of compulsions--what causes people to do things that are self-destructive, often as they realize they're harming themselves doing them?

Why do people gobble down boxes of crackers or huge bags of chips when they're not hungry, hating themselves with every bite? Why do people pull out (and sometimes eat!) their hair, a disorder called trichotillomania, or cut themselves uncontrollably, usually termed "self-harm"? What pulls well-to-do people to repeatedly steal stuff they don't want from stores (kleptomania)? And what propels commonly-cited fears of contamination like repetitive hand-washing? Are urges like "sex addiction" related compulsions?

Today on the Michael Medved Show, a caller named Kathy admitted she hoarded garbage. You could hear sadness in her voice--not revulsion or panic or embarrassment--just a near-tears sadness. She holds down a day-job, lives alone in a house, and said she couldn't stand to be there by herself for long enough to remove it. She stayed on the line while the staff found her a local source for help.

But Kathy wasn't the only caller who said she had no one to whom she could turn. Hoarders are often cut off by disgusted relatives, and rather than cultivating friendships tend to withdraw into their fortresses of trash and "treasures." In preparing for the show, I read a Scientific American article describing hoarders who collect their bodily refuse, like fingernails or urine. Animals are another commonly-hoarded item; a woman named Irene Vandyke had 67 dead cats in a freezer, and 100 live ones in crates.

Another caller to the show said he'd been part of a church volunteer crew who spent 8 hours one Saturday cleaning just the outside of a house declared uninhabitable by health authorities. When that happened, the owners just camped (and hoarded) in their backyard, using a fire pit for cooking and warmth.

Researchers have come up with some answers about these disorders, but they're far from definitive. Medications that work for some people just don't for others. Most people with these compulsions wish they could quit, yet even with psychotherapy, may continue. Some, like hoarders, might not even recognize they have a problem, and only when forced to confront it react with anger or anxiety.

I'm convinced that everyone yearns to feel relaxed and "normal" and that despite psychological overlays and triggers, ongoing compulsions are at root physiological. Which brings hope that with continued research, we'll be able to eventually conquer them. Hoarding has been shown in several studies to have a genetic component, with markers seen on various chromosomes, including Chromosomes 14 and 22Q11. It's considered a recessive trait, unlike Obsessive-Compulsive Disorder, which is dominant.

We sound so sure about such pronouncements, but I'm skeptical when, at this point, we claim understanding. We're in the earliest stages of figuring out what goes on in the brain, much less how that activity coordinates with genes and chemicals throughout the body to cause reactions. Some compulsions are actually healthy, and, under the term "instinct" are the means we, and other species, survive.

Brain and body chemicals tell us when we're hungry and sated--have they gone awry for the obese? Are "fight or flight" responses to danger related at all to the chemicals that tell some people to check the stove twenty times to be sure it's off? Or maybe to "scrupulosity," where one is consumed with fears of sinning? I would suspect variants of similar mechanisms at work across all of these, though we don't really know the chemicals or DNA switches or brain activity or combination that's malfunctioning.

In any case, compulsions are unlikely to be someone's "fault." They're imposed on the patient, like cancer is, against his will.  Certainly self-discipline, intervention and learned strategies (such as those in Cognitive-Behavioral therapy) can mitigate biology-based urges (unlike with diseases like cancer that aren't behavioral). But that still leaves so very little in answer to the question, "What drives these people to...?"

[Coming soon: a post in this space in praise of psychologist Carol Tavris and her dubious view of the new DSM-V--and why psychiatrists shouldn't write psychologists' "Bible."]

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