Nisan Steinberg, PhD, JD – Brain Blogger Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 When Hoarding Becomes Dangerous Tue, 10 Feb 2015 12:00:05 +0000 Hoarding behavior demands intervention when it causes clinically significant distress for a person, or impairment in his or her social or occupational functioning. Governmental authorities may step in when the hoarding behavior endangers the health and safety of the hoarder and others in the community.

In front of her office was a gleaming white utility truck, bearing the motto With Respect and Compassion. Kathie Jo Kadziauskas-Hobbs, the principal of AAA Hoarding and Biohazard Removal, headquartered in Camarillo, California, was first called a few years back to deal with complicated hoarding situations, after establishing her reputation as an expert in the crime scene clean-up field.

Ms. Kadziauskas-Hobbs is an aficionado of antiques, folk art, and classic vehicles; she granted an interview in an exotic room, draped by a large multicolored silk kimono on one wall, bearing beautiful oriental paintings on another, and sporting, in a corner, a silver saxophone and an antique barber chair upholstered in wine-colored velvet.

The eclectic Ms. Kadziauskas-Hobbs wants family members to intervene early when they see a loved one begin to exhibit troubling hoarding behavior — preferably at Levels I or II of the Clutter-Hoarding Scale, a widely used home-descriptive scale devised by the Institute for Challenging Disorganization (ICD) — so that therapeutic counseling or professional in-home help can begin, and Kadziauskas-Hobbs’ services will not be needed.

Level I is an essentially normal domestic situation: clutter in the home is not excessive; all doors, stairways and windows are accessible; the utilities and plumbing are functional; there is appropriate animal control; and household sanitation is safely maintained.

At Level II, housekeeping and maintenance are inconsistent, and a bit of help might be needed from professional home organizers or other professionals who have additional knowledge and understanding of chronic disorganization. Clutter may impede the function of key living areas or block a major exit from the home; one or more appliances or utilities may not be functional for more than a season; there may be visible or malodorous pet waste present in inappropriate places, or perhaps some evidence of insect pests or vermin.

Kadziauskas-Hobbs is not typically called in until the hoarding problem has progressed to Levels III-V of the Clutter-Hoarding Scale:

At Level III, the hoarding situation has progressed such that items normally stored indoors may overflow to clutter the shower, bathtub, or the outside of the home; several appliances may not be fully functional; animal sanitation is clearly inadequate, and the animal population in the home may violate local legal limits; expired medications or hazardous materials may be accumulating in a disordered, cluttered home, perhaps strewn with dirty laundry or smelling from overflowing garbage receptacles.

By Level IV, clutter inhibits access to exits, entrances, hallways and stairs; animal behavior may be destructive and sanitation poor; the smell of mold or mildew or rotting food or backed-up plumbing is striking; there is typically structural deterioration of parts of the home; the dishes are unusable; non-food items may be stored in the refrigerator; the use of other appliances may be inappropriate or even dangerous. There may be no linens on beds. The hoarder may be sleeping on a bare infested mattress, couch, or chair, or on the floor.

A Level V home is extremely cluttered; key living spaces are unusable; all the rooms are used for non-intended purposes; the toilets, sinks and tubs are not functioning, and human urine and excrement are where they do not belong. The structure may be severely damaged, with pervasive mold and/or mildew, moisture or standing water, and is typically heavily infested with insects, spiders, mice, rats, snakes, and other vermin. Any animals in the home are at risk and may be dangerous to people due to the animals’ behavior, ill health, and numbers. At Level V, it is not unusual for the hoarder to be involved in legal proceedings, such as a conservatorship, guardianship, eviction or condemnation proceedings.

If Kadziauskas-Hobbs’ services are retained by the hoarder and his family instead of by third parties or governmental authorities, the hoarder and family can exercise the greatest possible control in the remediation process and protect the hoarder’s ability to stay in his or her home, which are typically their foremost priorities. In a conversation with Kadziauskas-Hobbs before the removal work begins, the hoarder and the family will have an opportunity to instruct her about things of value she should look for and save for them — memorabilia of a dead spouse, family photographs, autograph albums, diaries, or other personal documents. Kadziauskas-Hobbs’ tact in working with the hoarder is one of her most important skills.

If the family neglects the problem, a landlord, Adult Protective Services, or a public administrator or guardian may call Kadziauskas-Hobbs in first; or Code Enforcement may issue an abatement warrant and hire her firm. Then, the hoarder and the family will have far less control. The third party or governmental agency, as the client, will provide the removal instructions, typically with emphasis strictly on the most economical, speediest possible remediation of health and safety code violations, rather than careful searching for, and preservation of, valued personal items.

Kadziauskas-Hobbs recommends to family members that the hoarder not be present when she and her crews are working on-site, in order to prevent additional unnecessary distress to the hoarder. However, sometimes law enforcement has been required to physically restrain a hostile hoarder during the removal work, in situations where the dwelling is subject to a court-ordered abatement warrant.

In California, the Trauma Scene Waste Management Act regulates waste management with respect to large quantities of spilled human blood or body fluids, but the state does not otherwise regulate hoarding and biohazard removal companies, except as to such medical waste, and the conventional rules of occupational safety and health.

Nevertheless, Kadziauskas-Hobbs requires her crews of two to eight individuals to undergo OSHA Blood-borne Pathogens training, to wear full biohazard suits on the job, including masks and disinfectable gloves and boots, and to use the same bacteriocides that crime scene crews do. She and other reputable operators recognize that a hoarding scene often involves biohazards, such as decomposing animal bodies and infectious biomaterials. These materials are too hazardous to be adequately handled with a pair of kitchen gloves and a bucket of bleach, to then be tossed in a dumpster. Her crews are trained to disinfect and dispose of contaminated mattresses, couches, and other large furnishings that medical waste companies will not handle.

As the DSM-5 informs, hoarding behavior can be a symptom of many different medical conditions and mental disorders, such as a brain injury, cerebrovascular disease (e.g. a cerebrovascular dementia), Prader-Willi syndrome-related food hoarding, and Obsessive-Compulsive Disorder (OCD). Hoarding may be a sign of decreased energy in major depressive disorder, or of delusions in schizophrenia or another psychotic disorder. Cognitive deficits resulting from a major neurocognitive disorder, such as fronto-temporal dementia or Alzheimer’s disease, or restricted interests in autism spectrum disorder, can also lead to hoarding behavior.

Since 2013, if none of the aforementioned conditions or disorders applies, then a separate Hoarding Disorder with its own ICD-9-CM and ICD-10-CM diagnostic codes, can now be applied. This enables a sufferer or his family to potentially access legal help with respect to coverage under mental health care insurance and government benefits, such as state disability and Medicare. The ICD diagnostic codes can also be important in making claims for property insurance benefits. For example, coverage for professional remediation/hoarding removal costs may now be available under provisions of some property insurance policies. In some states, such as California, an elected insurance commissioner is empowered to oversee compliance with such provisions.

Family members need to stay connected and alert to behavioral changes of their loved ones, including unusual collecting behaviors. Many counties and cities in the United States have a Hoarding Task Force, a valuable multi-agency resource to provide public education about hoarding, give out service agency information, offer training, and give support to families.

The nature of the underlying medical condition or mental disorder may lead to characteristic kinds of hoarding. For example, when hoarding is associated with OCD, a specific obsession can lead to collecting of items, such as feces, urine, hair, nails, trash, dead animals, or rotten food. With a major neurocognitive disorder, the onset of hoarding behavior is typically more gradual and may be accompanied by self-neglect and severe domestic squalor, alongside other neuropsychiatric symptoms, e.g. disinhibition, gambling, rituals/stereotypes, tics, and self-injurious behavior.

To Kathie Jo Kadziauskas-Hobbs and her colleagues in the business of hoarding and biohazard removal, advance knowledge of the particular clinical diagnosis may be helpful before they walk into a situation, but it is not for them to make a diagnosis or offer therapeutic counseling.

Kadziauskas-Hobbs often encounters families who know far less about their hoarding family member than she and her crews have discovered from the clues they find on the job site. She learns what the hoarder reads, eats, and wears. In profile, the hoarders Kadziauskas-Hobbs encounters tend to be female, above 50 years of age, surrounded by evidence they are well-educated, well-traveled, and had a professional career. They were interesting people. Then one day something caused the hoarding to start. Families need to be connected and involved with their loved ones, if that day comes.


Schmalisch, C.S. Hoarding and the Legal System. Accessed 3 February 2015.

New York Daily News (October 8, 2012).Las Vegas officials swarm home in ‘very tragic’ hoarding case, Associated Press. Accessed 3 February 2015.

Trauma Scene Waste Management Act, California Health and Safety Code Section 118321 et seq.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

World Health Organization, International Classification of Diseases (ICD),

Centers for Disease Control and Prevention, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

Christiana Bratiotis, Hoarding Task Forces,

Image via THPStock / Shutterstock.

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Eric McCormack Moderates Real-Life Discussion of Mental Illness on Campus Thu, 22 Jan 2015 17:10:03 +0000 Eric McCormack is an articulate actor who played the fictional Dr. Daniel Pierce, a crime-solving schizophrenic neuropsychiatrist in the dramatic television series Perception.

As McCormack is careful to clarify, “I’m not a professor, nor am I a person living with paranoid schizophrenia… I just play one on TV.”  McCormack largely modeled his character after the real-life Elyn Saks, a highly successful academic who battles schizophrenia. Late last year, McCormack joined Professor Saks to moderate a panel discussion at USC’s Gould School of Law: “In Real Life and as Seen on TV: Stories of Mental Health on Campus,” sponsored by the Saks Institute for Mental Health Law, Policy, and Ethics.

The event also featured Jessie Close (sister of actress Glenn Close) and law student Sam Brown. They told their personal stories in an effort to spur the discussion about the problems of stigma and shame (i.e., “self-stigma”) among sufferers of mental illness, particularly college students, and how the media and university community have the power to harm or help. McCormack remarked:

“The stigma of mental illness…is the result of fear and ignorance.  People fear and despise what they don’t understand. And when the media only discuss schizophrenia after there has been a mass shooting, it only increases that fear and that ignorance.”

McCormack further noted the media’s contribution to the stigma around mental illness; a TV show like Criminal Minds or The Blacklist, in which the focus each week is someone with “something wrong upstairs,” risks sensationalizing and trivializing mental illness. He asked the panelists whether the media had contributed to their own sense of shame about their mental illnesses.

Brown admitted to being affected by media reports about mass shootings and drama shows, but he could not suggest a satisfactory solution for the media.

 “I don’t think it makes good news, when mentally ill people take their medication and go on with their day,” Brown reasoned.

Elyn Saks thought the media had improved in the area of mental illness over the years compared to the 1960s and ‘70s.

“When I look back, there weren’t that many shows that portrayed mental illness. We have that now…It’s really good to portray the illnesses accurately and sensitively, and I think we’re doing that more than we used to.

Saks thought that one way the media can reduce the stigma associated with mental illness is that if there were violence committed by a mentally ill person, it should be put in context.  She noted that only a small percentage of violence is committed by mentally ill people, and people with mental illness are much likelier to be victimized, e.g., 20 times likelier to be murdered.  She also proposed telling success stories that humanize the mentally ill, for example, McCormack’s character Daniel Pierce:  He’s got schizophrenia.  He struggles with it.  He doesn’t completely accept it.  He functions with it.

McCormack asked how the shame of mental illness could be mitigated, especially in a campus setting.  All the panelists agreed that early detection could save students from much of that shame.

When Close was first diagnosed with bipolar disorder, she called her sister Glenn Close, who was much relieved:

“Oh, thank God it’s actually something, and you’re not just crazy!’”

Professor Saks suggested mental health education in high schools, so that people know what some of the signs and symptoms are.

Being diagnosed with a mood disorder forced Brown to accept that, “this was a part of me; my mood was myself…my personality…I was going to have to deal with it.”  His condition did not prevent Brown’s graduation from UCLA in 2007.  He first encountered stigmatization, when he was no longer wanted at a camp where he had previously enjoyed a summer job for several years. Due to his experience with the camp, he had decided to be tight-lipped about his condition at law school, first “coming out” at this public panel discussion event.

Recently married, law student Brown revealed that he would tend to tell his dates early on about his mental illness. “It’s important to tell; you need someone to know who you are quickly.  It’s not something you are going to hide.”  Brown cautioned that the person with mental illness can become the monopolizer of “complicated” in the relationship, potentially a source of tension for a new couple.

Saks further illustrated the problem of self-stigma from her own life.  She shared how she had once received a message T-shirt about schizophrenia as a gift.  Saks thought, “Do I really want to wear a T-shirt that identifies me as having schizophrenia?”  Then she thought:

“I’ve also had cancer.  People wear armbands and pins and T-shirts in pride, with solidarity and without shame…and that’s the way it should be with schizophrenia also, but it’s not.  And I myself am guilty of those negative shameful feelings.”

However, Brown was most concerned about stigma placed on the mentally ill by others:

“When I first got out of the hospital, my family and friends were so on-the-ball, as if nothing had happened to me, nothing’s changed.  So I came out with this open attitude about it.  I probably told too many people…I probably told girls too quickly when I was courting them…The people around you, your friends, your family, because they love you, are going to be most willing to accept [mental illness].”

Brown, who plans to practice employment law when he graduates and wrote a soon-to-be published article on “moral fitness” in bar applications, continued about stigma:

“The things that terrify me are employers, law school admissions, the California state bar; to be a lawyer in the state of California you need to tell them that you had a mental illness.  You need to waive your medical privacy.”

Even physicians with lives in their hands are not legally required to do this.

Brown challenged those of us who have been in a hiring situation:

“Are you going to be able to hear about the mental illness of someone applying for a job and say that it just doesn’t matter…It’s the people in real positions of power and the way they treat you that can really knock you down a peg, or lift you up.”

Brown would not want universities to aggressively pursue proposals, such as requiring students to take a mental health test in order to return to school after a break of a semester or quarter, or to condition a student’s return on his continuing to go to therapy.  Although such proposals may be well-intentioned, Brown suggested, “We don’t want a campus where someone feels afraid to “come out’” as a person suffering mental illness.

Brown recognized that some people with mental illness prefer to compartmentalize their illness, to take their medications and see their doctors regularly, but prefer not to identify with their illness. However, he believes that a community is important. Brown advocates developing a strong group identity for people with mental illness.  He compared it to cancer survivors having a strong group identity.  Brown thought it would be positive for the university to foster a sense of community pride in overcoming adversity, not just mental health awareness week when students make sure they’re not sick.

Saks spoke from deep personal experience:

“The worst thing about stigma is that it deters people from getting care, and they shouldn’t have to suffer, but they will unless they get care.”

Close urged students living with mental illness to take care of themselves, find a therapist or counselor they can talk to, and, above all: “Stay in school!”  Despite the obstacles and interruptions that may occur in a one’s studies, “Try, try, try again,” she concluded.

Finally, McCormack commended the panelists for being open about their mental illness in order to further vital public education:

“We educate people about what to do if someone has a heart attack, but we don’t tell them what to do if they suddenly [encounter] a psychotic…and of, course, what are they going to do but back away and fear for their life, as opposed to thinking, ‘How can I help this person?’…It’s hard to teach empathy.”

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