Childhood Trauma: Vulnerability Factor in Geriatric Hoarding Disorder

Introduction Hoarding disorder (HD) is characterized by difficulty discarding possessions despite no real or perceived value which consequently leads to clutter and distress. Older adults with HD face significant perils such as increased risk for social isolation, falls, fire, cognitive impairment, and medical complications. Despite the fact that HD is three times more common in older adults than in younger adults, the pathophysiology, clinical characteristics, and evidence-based treatments of HD in older adults are poorly understood. Proposed risk factors for HD include family history of HD, environmental factors such as traumatic life events, early childhood adversity, personality structure, poor executive functioning, and neurocognitive disorders. Here we present a case of a 79 y/o female, Jewish Polish immigrant living in New York, single, divorced, childless, with master's degree in economics and vast work experience in banking and in the tourism industry. Medical history of hypertension and a psychiatric history of Major Depressive Disorder and Generalized Anxiety Disorder. She has responded well to long-term outpatient psychiatric treatment with combined medication management and psychotherapy with improvement in mood but has residual persistent feelings of fatigue and lethargy that disrupt her optimal desired functionality which she attributes to her mother's death 6 years ago. Despite adequate resolution of normal grief, patient's symptoms persist along with self-deprecating attitude. PHQ9 score of 8 and GAD 7 score of 6. She has no evidence of cognitive impairment and her MOCA score is 28/30. Upon exploration of patient's persistent weariness, it becomes evident her marked concerns regarding clutter in her two-bedroom apartment, including furniture, books, linens, clothes, and old newspapers. She reports persistent difficulty parting with possessions, regardless of their actual value, which is due to perceived need to save the items and distress associated with discarding them. The clutter causes clinically significant distress including maintaining a safe environment for self and fulfills DSM-V diagnosis of (HD). The Clutter Image Rating Scale was used to assess clutter volume in the home with mean score of 4 which warrants clinical concern. Interestingly, she describes hoarding symptoms beginning when she was 73 y/o after mother's death. As proposed by patient, difficulties discarding items at home rely specifically on extreme poverty experienced during childhood while living in Poland during World War II era. Although patient wishes to discard unnecessary items, she has difficulty doing so since she feels guilty. In turn, she struggles with depressive and anxiety symptoms which negatively impact her quality of life. This case exemplifies the possible relationship of childhood trauma as vulnerability factor for geriatric HD. Given the high prevalence of HD in elderly patients, high clinical suspicion regarding trauma or childhood adversity must be present in these cases. Recognition of the relationship between trauma and HD can in turn more properly address other comorbidities such as depression and anxiety. Also, recognition of this relationship can tailor treatment plan for HD more appropriately since relinquishing patient's items may induce reactivation of trauma symptoms.