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. Author manuscript; available in PMC: 2013 Nov 19.
Published in final edited form as: J Nerv Ment Dis. 2012 Jan;200(1):10.1097/NMD.0b013e31823f678b. doi: 10.1097/NMD.0b013e31823f678b

Prevalence of Hoarding Disorder in Individuals at Potential Risk of Eviction in New York City

A Pilot Study

Carolyn I Rodriguez *,†, Dan Herman *, Jehanny Alcon *, Shaofu Chen *, Audrey Tannen ‡, Susan Essock *, Helen Blair Simpson *,†
PMCID: PMC3833068  NIHMSID: NIHMS526912  PMID: 22210369

Abstract

This study estimated the prevalence of hoarding disorder (HD) in individuals seeking help from Eviction Intervention Services Housing Research Center (EIS), a not-for-profit community organization in New York City (NYC) that aids clients with housing problems including eviction. One hundred fifteen EIS clients were screened for HD. The prevalence of HD among those seeking help from EIS was 22% (clinician-rated) and 23% (self-rated), which is nearly 5 to 10 times greater than the rate of hoarding (2% to 5%) in the general population. Of individuals seeking help from EIS who met the criteria for HD (n = 25), 32% were currently in legal eviction proceedings (i.e., threatened with imminent eviction), 44% had a history of previous legal eviction proceedings, and 20% had been evicted from their home one or more times, yet only 48% were currently seeking mental health treatment. Almost a quarter of individuals seeking help for housing problems from a community eviction prevention organization met the criteria for HD; only about half of these individuals were receiving mental health treatment. Future studies are needed to determine whether HD treatment can reduce the risk of eviction and homelessness in NYC.

Keywords: Hoarding, hoarding disorder, eviction, New York, prevalence

Although the provision of publicly funded health and mental health services to homeless persons has expanded greatly in the past decade, primary prevention of homelessness has received relatively little attention (O’Connell et al., 2005). Evictions are a major proximate cause of homelessness, and numerous studies show that evictions primarily result from tenants’ nonpayment of rent (Stenberg and van Laere, 2009; Van Laere et al., 2009). However, evidence also suggests that, for some housed persons, untreated mental health problems may also increase eviction risk by contributing to behaviors that jeopardize continued tenancy (Crane et al., 2005; Van Laere et al., 2009).

Hoarding disorder (HD; Mataix-Cols et al., 2010) is one mental health condition that may precipitate homelessness by placing housed individuals at risk of eviction (Mataix-Cols D, Grayton L, Bonner A, Luscombe C, Taylor PJ, van den Bree M. A putative link between compulsive hoarding and homelessness: A pilot study [submitted for publication]; Tolin, et al., 2008). Also known as “compulsive hoarding syndrome” (Saxena, 2008), HD is defined as persistent difficulty in discarding personal possessions of limited value, which results in clutter that precludes normal use of living spaces and causes clinically significant distress or impairment (Frost and Gross, 1993; Frost and Hartl, 1996; Mataix-Cols et al., 2010). Once considered a subtype of obsessive-compulsive disorder (OCD), HD is now considered a separable syndrome and has been proposed as a new diagnostic category in DSM-V (Mataix-Cols et al., 2010; Phillips et al., 2010). Epidemiological surveys estimate a 2% to 5% prevalence of HD in the general population (Iervolino et al., 2009; Mataix-Cols et al., 2010; Samuels et al., 2008). Recommended treatment strategies for HD include medication (e.g., paroxetine and venlafaxine) and cognitive behavioral therapy (Saxena, 2008, 2011; Steketee and Frost, 2003).

HD is associated with high levels of disability and impairment (Frost et al., 2000; Tolin et al., 2008). It causes public health problems when clutter attracts pest infestations or obstructs fire exits in apartment buildings, endangering both personal and neighbors’safety (Frost et al., 2000; Frost et al., 1999; Patronek, 1999). These conditions may lead neighbors and landlords to complain, resulting in legal proceedings and eviction (Frost et al., 1999).

Two studies have examined the putative link between HD, eviction, and homelessness. An Internet study of the economic and social burden of HD surveyed 864 individuals with HD and found that 2% reported being evicted and 6% endorsed being threatened with eviction (Tolin et al., 2008). A study in the United Kingdom evaluated the prevalence of HD in 78 randomly selected homeless individuals newly admitted to Salvation Army shelters (Mataix-Cols D, Grayton L, Bonner A, Luscombe C, Taylor PJ, van den Bree M. A putative link between compulsive hoarding and homelessness: A pilot study [submitted for publication]): up to 21% of these individuals endorsed hoarding symptoms and 8% reported that hoarding problems directly contributed to their homeless state. Although these studies suggest that HD may contribute to eviction and homelessness, to our knowledge, no studies have examined the prevalence and correlates of HD in a population seeking housing assistance and at potential risk for eviction.

To begin to address this gap, we evaluated the prevalence of HD in a sample of people seeking services from a not-for-profit community organization focused on helping individuals with housing problems including eviction. In further characterizing this sample, we also assessed sociodemographic correlates, threat of imminent eviction, history of eviction, and mental health treatment utilization.

METHODS

The institutional review board of the New York State Psychiatry Institute approved the study protocol.

Participants were individuals evaluated at the Eviction Intervention Services Housing Resource Center (EIS; Rodriguez et al., 2010), a not-for-profit social service agency in New York City (NYC) that provides legal and housing advocacy for individuals with housing problems including eviction. EIS receives referrals from NYC housing courts, social services agencies, advocacy groups (e.g., Emergency Rent Coalition, a network of community organizations that advocates for vulnerable NYC families), and state government programs (e.g., Family Eviction Prevention Supplement, a program to pay back rent for families receiving public assistance).

All English- and Spanish-speaking adults who met with an EIS staff member between March 2 and 24, 2010, were invited to participate by the EIS staff. Interested participants were introduced to on-site bilingual research staff who conducted all procedures in the subject’s preferred language. Informed consent was obtained after participants were provided written and verbal explanation of the study purpose and procedures. Clients received $25 for study participation.

Clients were also assessed for HD and the severity of clutter, acquisition, difficulty discarding, distress, and impairment using two scales described in detail below: a) the clinician-administered, semistructured Hoarding Rating Scale–Interview (HRS-I; Tolin et al., 2010) and b) a self-rating scale, the Saving Inventory-Revised (SI-R; Frost et al., 2004). The HRS-I is a semistructured interview that assesses severity of clutter, acquisition, difficulty discarding, distress, and impairment, each on a 0 to 8 scale (Tolin et al., 2010). The HRS-I has excellent internal consistency (α = 0.97) and reliably discriminates hoarding from nonhoarding subjects (sensitivity = 0.97, specificity = 0.97; Tolin et al., 2010). Consistent with the literature, we used an HRS-I score of at least 14, the cutoff score with optimal sensitivity and specificity, to define HD status (Tolin et al., 2010). As a secondary measure for HD diagnosis and severity, we used the SI-R (Frost et al., 2004), a 23-item self-report questionnaire used in previous trials (Gilliam et al., 2009; Muroff et al., 2007; Steketee et al., 2010; Tolin et al., 2007). The SI-R discriminates people with HD from OCD patients and community controls and correlates significantly with ratings of clutter and impairment; it has three subscales: Clutter, Difficulty Discarding, and Acquisition (Frost et al., 2004). Internal consistency is excellent for the total score (α = 0.92) and for the three subscales (α = 0.87 to 0.91) (Frost et al., 2004). Consistent with the literature, we used an SI-R score of at least 40, the cutoff score with optimal sensitivity and specificity, to define HD status (Frost et al., 2004). Using a structured diagnostic interview modeled after the National Epidemiologic Survey on Alcohol and Related Conditions (Grant et al., 2003), the research staff asked about age, sex, race/ethnicity, marital status, household composition, and healthcare treatment. Client clinician-administered and self-rating assessments were translated from English to Spanish and were back-translated by a bilingual team of mental health professionals following standard procedures (Brislin, 1986; Canino et al., 1997).

We used a z-test for proportions to compare clinical and demographic correlates between individuals with and without HD. We calculated Cohen kappa to evaluate the level of agreement between clinician-administered (HRS-I) and self-rating (SI-R) assessments of HD.

RESULTS

One hundred twenty-two clients were asked to participate, and 115 did. Most participants were female (94; 82%), Hispanic (65; 57%), single/never married (65; 57%), with more than one child living at home (80; 70%).

Among the 115 participants, 25 (22%) met criteria for HD using the clinician-administered assessment (HRS-I). Using the SI-R, a self-rating assessment, 26 (23%) met criteria for HD. The Cohen kappa coefficient of 0.924 indicates excellent agreement between these two ratings. The 25 individuals who met criteria for HD (as defined by the HRS-I) reported that they were seeking help from EIS for the following reasons: perceived threat of eviction (n = 17 [68%]), problems paying rent (n = 14 [56%]), need for legal representation in housing court (n = 6 [24%]), aid with maintenance issues (n = 14 [56%]), or other dispute with the landlord (n = 9 [37%]).

Demographic and clinical characteristics of individuals with and without HD are presented in Table 1. Individuals with HD were significantly older, more likely to be white, be non-Hispanic, and live alone without children in the household. Individuals with HD also had significantly more lifetime psychiatric hospitalizations, mental health treatment, and use of psychotropic medication. At the same time, only 48% of individuals with HD were currently receiving mental health services.

TABLE 1.

Demographic and Clinical Comparisons of HD vs. Non-HD Clients

Hoarding Nonhoarding
n = 25 (21.70%) n = 90 (78.30%) Test Statistic
n % n % z-test p
Age, yrs
  18–39 5 20 48 53 −2.96 0.0031
  40–59 9 36 34 38 −0.16 0.8729
  60+ 11 44 8 9 4.18 0.0001
Sex
  Female 20 80 74 82.2 −0.25 0.8026
  Male 5 20 16 17.8 — —
Race
  Hispanic 4 16 61 67.8 −4.62 0.0001
  Non-Hispanic 21 84 29 32.2 — —
Ethnicity
  American Indian or Alaska Native 1 4 0 0 1.91 0.0561
  Asian 0 0 0 0 0.00 1.0000
  Black or African-American 5 20 18 20 0.00 1.0000
  Native Hawaiian or other Pacific Islander 0 0 0 0 0.00 1.0000
  White 14 56 11 12 4.69 0.0001
  Other 5 20 61 68 −4.27 0.0001
Marital status
  Married/cohabiting 4 16 21 23.3 −0.79 0.4295
  Widowed/separated/divorced 7 28 18 20 0.86 0.3898
  Single/never married 14 56 51 56.7 −0.06 0.9522
Household residents
  1 14 56 13 14.4 4.34 0.0001
  2+ 11 44 77 85.6 — —
Children in household/under 18
  0 18a 75 16b 18 5.41 0.0001
  1+ 6a 25 73b 82 — —
Eviction risk
  Seeking EIS help for perceived threat of eviction 17 68 76 84.4 −1.85 0.0643
  Currently in eviction proceedings 8c 32 75 83.3 −5.07 0.0001
  Eviction proceedings in past (1+) 11 44 73d 83 −3.94 0.0001
  Evicted in past (1+) 5 20 23 25.6 −0.57 0.5687
Healthcare treatment
  Psychiatric hospitalization (lifetime) 7a 29.2 7 7.8 2.84 0.0045
  Psychiatric hospitalization (12 mos) 0a 0 2 0 −0.74 0.4593
  Mental health treatment (lifetime) 19 76 27 30 4.15 0.0001
  Mental health treatment (12 mos) 12 48 20 22 2.54 0.0111
  Psychotropic medication (lifetime) 16 64 29 32.2 2.88 0.0040
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a

n = 24.

b

n = 89.

c

Self-reported reasons why they were in eviction proceedings included clutter or inability to pay rent.

d

n = 88.

EIS indicates Eviction Intervention Services Housing Research Center; HD, hoarding disorder.

As shown in Table 1, the proportion of those contacting EIS because of a perceived threat of eviction was similar between those with HD (68%) and those without HD (84%). On the other hand, the proportions of those reporting current legal eviction proceedings and reporting a history of previous eviction proceedings differed. Specifically, those with HD had a significantly lower proportion of both current legal eviction proceedings (i.e., actual threat of imminent eviction; 32%) and previous eviction proceedings (44%). The prevalence of previous evictions was similar between both groups.

DISCUSSION

To our knowledge, this is the first study to evaluate HD in a not-for-profit community organization that aids clients with housing problems including eviction. There were three main findings. First, in this sample, the prevalence of HD was approximately 22%. This is 5- to 10-fold greater than the estimated HD prevalence in the general population (2% to 5%; Iervolino et al., 2009; Mataix-Cols et al., 2010; Samuels et al., 2008). These results suggest that community organizations that provide housing assistance may be a fertile site for identifying individuals with HD. This is important because HD clients do not often seek mental health treatment, but they come to the attention of nonmental health agencies (e.g., fire department, police) during emergencies (e.g., pest infestation and fire; Frost et al., 2000; Rodriguez et al., 2010).

Second, the risk of eviction in individuals with HD in this sample was substantial: 32% were threatened with imminent eviction (i.e., currently in legal eviction proceedings), and 20%had been evicted one or more times in their lifetime. This lifetime prevalence of evictions (20%) is 10 times higher than that reported in a sample of individuals with HD surveyed over the Internet (2% reported at least one eviction; Tolin et al., 2008). At the same time, the rate of current and previous eviction proceedings in those with HD was lower than those without HD. We speculate that those with HD (in contrast with those without HD) contact EIS before receiving an eviction notice or a summons for court because of increased anxiety and fear of losing their possessions. This may provide an ideal time to intervene.

Finally, although clients with HD were more likely to have a history of psychiatric hospitalization and previous psychotropic mediation use compared with those without HD, only 48% of those with HD were currently receiving mental health treatment of any kind. Moreover, this is likely an overestimate of those receiving treatment specifically targeted at hoarding problems because HD-focused treatment is typically difficult to access (Rodriguez et al., 2010). Individuals with HD are more likely to be receiving mental health treatments for comorbid psychiatric conditions common in individuals with HD, like major depressive disorder (Frost et al., 2006). Engaging clients with HD in evidence-based, HD-focused treatment as they seek help from housing agencies might reduce their risk of eviction and homelessness, one of the most tragic consequences of this illness.

Our findings need replication given the relatively small sample size, the fact that the data come from only one community organization, and the 1-month sampling period, all of which may create unknown sampling biases. Second, some participants may not have been experiencing HD per se, but from another disorder (e.g., dementia or schizophrenia) that may have led to their hoarding symptoms; this needs to be assessed in future studies.

CONCLUSIONS

These pilot data suggest that individuals seeking help from a not-for-profit community organization aiding clients with housing problems including eviction have a high prevalence of HD. Identifying and treating their HD might decrease their risk of eviction and/or homelessness.

ACKNOWLEDGMENTS

The authors thank Kimberly Glazier for data entry. They also thank the Eviction Intervention Services Housing Resource Center and the clients who participated in this study.

This investigation was supported by a grant from the New York Office of Mental Health Policy Scholar Program and the National Institutes of Mental Health (T32 MH015144-31).

Footnotes

DISCLOSURE

The authors have nothing to disclose.

REFERENCES

  1. Brislin RW. The wording and translation of research instruments. In: Lowner WJ, Berry JW, editors. Field methods in cross-cultural research. Beverly Hills, CA: SAGE; 1986. pp. 137–164. [Google Scholar]
  2. Canino G, Lewis-Fernandez R, Bravo M. Methodological challenges in cross-cultural mental health research. Transcult Psychiatry. 1997;34:163–184. [Google Scholar]
  3. Crane M, Byrne K, Fu R, Lipmann B, Mirabelli F, Rota-Bartelink A, Ryan M, Shea R, Watt H, Warnes AM. The causes of homelessness in later life: Findings from a 3-nation study. J Gerontol B Psychol Sci Soc Sci. 2005;60:S152–S159. doi: 10.1093/geronb/60.3.s152. [DOI] [PubMed] [Google Scholar]
  4. Frost RO, Gross R. The hoarding of possessions. Behav Res Ther. 1993;31:367–382. doi: 10.1016/0005-7967(93)90094-b. [DOI] [PubMed] [Google Scholar]
  5. Frost RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther. 1996;34:341–350. doi: 10.1016/0005-7967(95)00071-2. [DOI] [PubMed] [Google Scholar]
  6. Frost RO, Steketee G, Grisham J. Measurement of compulsive hoarding: Saving inventory-revised. Behav Res Ther. 2004;42:1163–1182. doi: 10.1016/j.brat.2003.07.006. [DOI] [PubMed] [Google Scholar]
  7. Frost RO, Steketee G, Tolin DF, Brown TA. Comorbidity and diagnostic issues in compulsive hoarding; Paper presented at: The Anxiety Disorders Association of America.2006. [Google Scholar]
  8. Frost RO, Steketee G, Williams L. Hoarding: A community health problem. Health Soc Care Community. 2000;8:229–234. doi: 10.1046/j.1365-2524.2000.00245.x. [DOI] [PubMed] [Google Scholar]
  9. Frost RO, Steketee G, Youngren VR, Mallya GK. The threat of the housing inspector: A case of hoarding. Harv Rev Psychiatry. 1999;6:270–278. doi: 10.3109/10673229909000339. [DOI] [PubMed] [Google Scholar]
  10. Gilliam CM, Hannan SE, Norberg MM, Morrison S, Villavicencio AL, Dufresne D. Group cognitive-behavioral therapy for compulsive hoarding: An effectiveness study; Paper presented at: the Annual Meeting of the Association of Behavioral and Cognitive Therapies; New York. 2009. [Google Scholar]
  11. Grant BF, Moore TC, Kaplan K. Source and accuracy statement: Wave 1, National Epidemiologic Survey on Alcohol and Rated Conditions (NESARC) Bethesda, MD: National Insitute on Alcohol Abuse and Alcoholism; 2003. [Google Scholar]
  12. Iervolino AC, Perroud N, Fullana MA, Guipponi M, Cherkas L, Collier DA, Mataix-Cols D. Prevalence and heritability of compulsive hoarding: A twin study. Am J Psychiatry. 2009;2009(166):1156–1161. doi: 10.1176/appi.ajp.2009.08121789. [DOI] [PubMed] [Google Scholar]
  13. Mataix-Cols D, Frost RO, Pertusa A, Clark LA, Saxena S, Leckman JF, Stein DJ, Matsunaga H, Wilhelm S. Hoarding disorder: A new diagnosis for DSM-V? Depress Anxiety. 2010;27:556–572. doi: 10.1002/da.20693. [DOI] [PubMed] [Google Scholar]
  14. Muroff J, Steketee G, Rasmussen J, Gibson A, Frost RO, Tolin DF. Group cognitive and behavioral treatment (CBT) for compulsive hoarding; Paper presented at: the Annual Meeting of the Association of Behavioral and Cognitive Therapies; Philadelphia. 2007. [Google Scholar]
  15. O’Connell JJ, Mattison S, Judge CM, Allen HJ, Koh HK. A public health approach to reducing morbidity and mortality among homeless people in Boston. J Public Health Manag Pract. 2005;11:311–316. doi: 10.1097/00124784-200507000-00009. [DOI] [PubMed] [Google Scholar]
  16. Patronek GT. The hoarding of animals: An underrecognized public health problem in difficult to study population. Public Health Rep. 1999;114:81–90. doi: 10.1093/phr/114.1.81. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Phillips KA, Stein DJ, Rauch SL, Hollander E, Fallon BA, Barsky A, Fineberg N, Mataix-Cols D, Ferrão YA, Saxena S, Wilhelm S, Kelly MM, Clark LA, Pinto A, Bienvenu OJ, Farrow J, Leckman J. Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depress Anxiety. 2010;27:528–555. doi: 10.1002/da.20705. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Rodriguez C, Panero L, Tannen A. Personalized intervention for hoarders at risk of eviction. Psychiatr Serv. 2010;61:205. doi: 10.1176/appi.ps.61.2.205. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Samuels JF, Bienvenu OJ, Grados MA, Cullen B, Riddle MA, Liang KY, Eaton WW, Nestadt G. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther. 2008;46:836–844. doi: 10.1016/j.brat.2008.04.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Saxena S. Recent advances in compulsive hoarding. Curr Psychiatry Rep. 2008;10:297–303. doi: 10.1007/s11920-008-0048-8. [DOI] [PubMed] [Google Scholar]
  21. Saxena S. Pharmacotherapy of compulsive hoarding. J Clin Psychol. 2011;67:477–484. doi: 10.1002/jclp.20792. [DOI] [PubMed] [Google Scholar]
  22. Steketee G, Frost R. Compulsive hoarding: Current status of the research. Clin Psychol Rev. 2003;23:905–927. doi: 10.1016/j.cpr.2003.08.002. [DOI] [PubMed] [Google Scholar]
  23. Steketee G, Frost RO, Tolin DF, Rasmussen J, Brown TA. Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depress Anxiety. 2010;27:476–484. doi: 10.1002/da.20673. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Stenberg S, van Laere I. Evictions—a Hidden Social Problem. Comparative Evidence from Modern Welfare States; Paper presented at: the ISA RC43 Housing Conference.2009. [Google Scholar]
  25. Tolin DF, Frost RO, Steketee G. An open trial of cognitive-behavioral therapy for compulsive hoarding. Behav Res Ther. 2007;45:1461–1470. doi: 10.1016/j.brat.2007.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Tolin DF, Frost RO, Steketee G. A brief interview for assessing compulsive hoarding: the Hoarding Rating Scale-Interview. Psychiatry Res. 2010;178:147–152. doi: 10.1016/j.psychres.2009.05.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Tolin DF, Frost RO, Steketee G, Gray KD, Fitch KE. The economic and social burden of compulsive hoarding. Psychiatry Res. 2008;160:200–211. doi: 10.1016/j.psychres.2007.08.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Van Laere I, DeWit M, Klazinga N. Preventing evictions as a potential public health intervention: Characteristics and social medical risk factors of households at risk in Amsterdam. Scand J Public Health. 2009;37:697–705. doi: 10.1177/1403494809343479. [DOI] [PubMed] [Google Scholar]

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