Severe Domestic Squalor

“Severe domestic squalor” is not a synonym for anxiety, for depression, or for dementia; it is not a typical subject for psychiatric research in the biology of disorders. On face value, it would appear to be more suited to sociology. In the text Severe Domestic Squalor, by John Snowdon, Graeme Halliday, and Sube Banerjee, experts in this particular field, it is defined as “when a person’s home is so unclean, messy, and unhygienic, that people of similar culture and background would consider extensive clearing and cleaning to be essential” (p. 11). In this text, the authors, who are from the United Kingdom and Australia, first define the problem, logically differentiating from possibly similar-appearing disorders (e.g., hoarding). Important for practicing psychiatrists is the initial review of five series of cases of older people (conducted from 1966 to 2011), with a total of approximately 200 patients. Applicability to DSM is quite limited by both the over 40-year range of the studies and their being conducted outside of the United States. The most recent results are from a study conducted in Australia, which investigated a sample of 120 persons living in moderate or severe squalor. Using DSM-IV criteria, the most common diagnoses were dementia (35%), brain damage as a result of alcohol or substance abuse (24%), and schizophrenia or paranoid state (15%). Frequent overlap was found with hoarding (34%), of which 26% was associated with a personality disorder. These findings are similar to those of earlier studies in that no diagnosable DSM disorder was found in 13% of cases, and in some previous studies, no diagnosable disorder was found in as many as 25% of cases. It is important to realize that it cannot be simply assumed that squalor conditions come generally as a result of an individual having brain damage because the sum total rate is only 30%−60%. Piles of trash and garbage may indicate hoarding in a way that is separate from obsessive-compulsive disorder (OCD) in that this may result from individuals who “collect too much and have difficulty discarding …. Some people … have difficulty with impulse control and acquire more than they discard” (p. 32). The authors carefully differentiate between severities of squalor as well as “dry” and “wet” squalor.

In chapter 4, Mataix-Cols further investigates the relationship between hoarding and squalor. Perhaps this is the most key area for psychiatrists in reading this text. DSM-5 has six criteria for hoarding disorder. It is seen as an independent disorder under the rubric of OCD but separate because patients with hoarding disorder appear to have different biological findings, as well as lack of response to usual pharmacological therapies for OCD (i.e., selective serotonin reuptake inhibitors). In brief, the criteria include 1) “persistent difficulty discarding or parting with possessions, regardless of their actual value”; 2) “this difficulty is due to a perceived need to save the items and to distress associated with discarding them”; 3) the symptoms result in “the accumulation of possessions”; 4) “the hoarding causes clinically significant distress or impairment”; 5) “the hoarding is not attributable to another medical condition”; and 6) “the hoarding is not better explained by the symptoms of another mental disorder” (1). With an estimate of occurrence in 2%−5% of the general population, this is not rare. The authors make some key contrasts between hoarding disorder and excessive acquisition as a result of brain damage (e.g., onset that is sudden with brain damage versus gradual with hoarding disorder, inability to discard items as a key feature in hoarding disorder, indiscriminate acquisition in brain damage, and squalid living conditions frequently found among persons with brain damage). On the other hand, animal hoarding may frequently show overlap between hoarding disorder and squalor. Chapter 5 specifically focuses on animal hoarding, with studies based in North America, when hoarding leads to excessive numbers of animals and failure to maintain standards of care for the animals, combined with denial of the inability to provide care. In such cases, individuals are defined as “exploiters,” “overwhelmed caregivers,” or “rescuers” of the animals; only the last group is seen as likely to have animal hoarding, with a “mission” to take care of the animals, no matter the condition or numbers.

The other sections of the text are of less direct relevance to psychiatrists per se. Chapter 6 reviews available possible rating scales with their degree of validation and reliability with regard to domestic uncleanliness, functionality, hoarding, OCD, cognition, self-neglect, and insight. The use of progressive photos for observer-rated hoarding and clutter may be of theoretical interest but has little practical application. Many of these scales were only used for the measure of squalor in studies conducted in the United Kingdom or Australia; the authors take into account problems with self-rating scales in terms of bias by the person causing the problem, who may wish to minimize the issues. A point is made that almost all of these instruments do not allow adequate measure of uncleanliness and, as just mentioned, have all the disadvantages of being self-ratings.

The sections on interventions (chapter 3), law (chapter 7), ethics (chapter 8), and media portrayal (chapter 9) are more of theoretical interest than practical application. The section on interventions highlights cases in which medical and psychiatric review of the situation are indicated when the situation is first observed. Legal factors, including whether an individual is an owner or renter, are reviewed in terms of Australia and the United Kingdom, with limited U.S. application. However, it appears that the former two countries have a law that is in many ways similar to the “2PC” standard for commitment in the United States. Issues of capacity of the owner and/or tenant are also reviewed. Decisions taking into account ethical considerations focusing on autonomy/capacity or harm to others also show that “the mere presence of mental illness cannot be equated with an absence of decisional capacity” (p. 158). Finally, media portrayals that often focus on the sensationalist content may not be helpful. Some television series that look at problems (e.g., Life Laundry, British Broadcasting Corporation, 2002–2004) and tackle situations step by step in helping hoarders to “make attitudinal shifts, de-sentimentalise, downsize, rationalize, clean, decorate, and sell things” (p. 169) may be quite beneficial to the hoarder, the concerned neighbors, professionals, and the general public to begin to get a handle on these problems.

Thus, Severe Domestic Squalor, although apparently initially a text not relevant to the practice of psychiatry in the United States, is now placed in an ideal position with DSM-5 in understanding and separating hoarding disorder from squalor. One who reads this text will gain an improved picture of true hoarding, its relation to other psychiatric and neurologic conditions, how to evaluate it, and how to proceed to help the individual meeting criteria and suffering as a result of it.