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Welcome. I'm , the host of the "7 Domains of Women's Health." We are continuing our exploration of the 7 Domains of Stuff. If you haven't listened to the first of the series, the "Physical Domain of Stuff," then catch up with it when you can. And we'll be talking about the social, intellectual, financial, environmental, and spiritual domains of stuff in the coming weeks. But today we're going to some of the Emotional Domains of Stuff.

So stuff. It's the inanimate stuff that we have around us. I really like that word "stuff." Anyway, some of these things are necessary to our survival. And some of these things are precious to us as they link us to a person or a memory that's important. But when is too much stuff just too much?

In Sweden, there's a term, "lagom," which we don't have a direct translation for in America, but it means not too much, not too little, but just enough. It's kind of like the Goldilocks framework. I have too much stuff. I have too little stuff. I'm just right.

Many of us have a sense of what is just right, and many of us acknowledge that around us is more stuff than is just right. Having too much stuff around can be a burden. It can be distracting. It can cloud our ability to be calm in the space that is just right.

And that's where a lot of women live. They have their own stuff, their partner's stuff, their kids' stuff, even if their kids have grown up, and the stuff they inherited.

But for some people, the amount of stuff is more than too much. It is more than a distraction. The term "hoarding" is used to describe a person, a hoarder. This degree of keeping stuff can interfere with all the domains of health, the physical, emotional, social, financial, environmental, and spiritual domains.

Dr. Jones: Here in The Scope virtual studio is Ivy, who will be helping us to understand from her experience when too much stuff becomes a significant problem. So thanks for talking with us, Ivy.

Ivy: Thank you for having me. I really appreciate the invitation to be here today.

Dr. Jones: So can you tell me a little bit about your relationship with stuff? Everybody's got stuff. I don't know whether the word . . . it's clothing, it's books, it's stuff. Tell me a little bit about your stuff.

Ivy: So, for me, I think this has been a lifelong attachment battle. Just a lot going on with me. In addition to just being attached to my stuff, I have a concern for the amount of consumption. Especially here in the United States, it's a little bit overwhelming for me just how much comes into our lives on a day-to-day basis.

And I find myself, in addition to wanting to hang on to my stuff, I have a hard time processing all of the incoming boxes, mail, clothing. It's just a little bit too much for me sometimes.

I think if I were on my own, I can handle it. But I am living with a husband, and I'm living with a son, and that brings in a whole new dynamic of where I really need to figure out, "How do I manage this? How do I keep our home in a way that's functional enough for all of us to exist together?"

Dr. Jones: Oh, yeah. Well, you said it's lifelong, and I think that some people who think about . . . we'll call it hoarding, but hoarding is such a horrible term. It's just people who have complicated relationships with too much stuff. It starts as the teenager when you walk in their room, and there's just everything everywhere. But I think we are bombarded with things, advertisements. So, for you, is it an issue of you buying a lot of stuff, or just not getting rid of stuff, or both?

Ivy: For me, I wouldn't say I'm a compulsive shopper. So luckily, I don't have that adding to my stuff, but anything that I've inherited, or people have given me for gifts or even just . . . I mean, it sounds ridiculous, but the boxes that come in from things I've ordered or the container that holds my spinach, I have a really hard time . . . I want to just have the best use of the item. I know we're in a bit of a throwaway society, and it's just hard for me to part with those items, to organize those.

But yes, definitely, if people have given me things, things from my grandmothers, that is very hard for me to move forward. But if I can find someone who I know who can give life to the object, that does make it easier for me to give it away. I do have a hard time donating, giving things away. I do get very attached to each item because of the memory attached to it.

Dr. Jones: Of course. Well, actually, some of your behavior or your keeping hold of boxes or your spinach boxed containers, those plastic containers, I consider that as . . . it's almost a virtue these days. You're using multiple use. You say, "Oh, I don't want to get rid of this box because I might be able to use that box to ship something in, or I might be able to put leftovers in this plastic container."

So the concept of using it again, it's a very farmer thing. Farmers always keep everything. And during the depression, they kept leftover strings and rubber bands because they couldn't afford to get anything, and maybe they could use it again.

Ivy: And I was very close to both sets of my grandparents who did live through the Great Depression and lived through World War II in Germany and here in America. Just hearing their stories, I think something is running really strong in my DNA, and I see it in my uncles, of, "Yes, there is more than one use for this." And finding myself washing plastic forks and trying to remember to bring them with me if I'm eating out.

Dr. Jones: Oh, yeah. Boy, I understand that because I have a special little tray for plastic forks and spoons because I don't want to throw them away. I could use them again.

But somewhere along the line, at least for you, your attachment to things and your need to be able to use stuff more than once, which I think is a significant virtue, at some point, your relationship wasn't serving you. Your perspective wasn't serving you. Or maybe it was serving you, but it wasn't serving your family.

Did you seek professional help? Was there someone who had a specialty in this kind of thing? Or do you think any therapist could help you, or . . .

Ivy: I've done a lot of cognitive behavioral therapy, and I think the tricky part that therapists sometimes don't understand is how to really find the root cause of "Why is all of my stuff making me feel safe?"

And for me, it really is. If I am in a clean space . . . Even when I travel for work, even when I travel, in less than 24 hours, I've already spread out everything in my suitcase. I just like things out almost as if it's a protection, a fortress with all of my stuff. My family and friends have been amazed at how quickly I can turn a space upside down.

And I really love to exist. I feel safe in the chaos, which I know is irrational, but I really do.

Dr. Jones: No, I don't think it's irrational. I think there were times when a very spare cave was one that was empty and cold and having things around and people around to make it . . . It looks cluttered to some, but to some, that feels safe, and it feels warm. It's cozy. It's what's right.

But when it doesn't serve you and your family, that's the hard part, to make those changes.

Ivy: Right. I think definitely for me, if I were living alone, I might be able to exist like this for my entire life. But then again, the burden would fall on my family one day if I haven't managed it. So that's kind of an interesting . . .

I'm actively making a choice, "Okay, I want to have a family. I want to exist with other people," and they've been very patient with me. My entire family, in addition to my husband and my son, my siblings, my parents, they've been very patient with the process. But now that I'm in my 40s, it's gotten to a point where it's just now too much and it's becoming a financial burden.

I do have a storage unit. That's a monthly expense. And there just comes a point where it's like, "Okay, how long am I going to really do this?" I'm very slow moving through it, so I need help, but I'm afraid to ask for help.

Dr. Jones: Sometimes, even when people offer to come and get rid of stuff for you, it's not so easy. You'd say, "Come on in. I'm going to go away for the weekend, and when I come back, I just want all this stuff gone." But that's painful.

Ivy: Yes, definitely. And when I speak with other people who have hoarding tendencies, before we have an item move on, whether we're throwing it away, we're donating it, we really like to hold the item and really pay attention to the details. So it's not so simple as . . .

If I invited my family into my home and said, "Hey, take the next week," they could totally clean the house out for me in one week. But it's my block of I want to see the items. I want to hold it. I want to know what is coming in and coming out of my house.

Again, with so much stuff, and I'm a full-time working mom, when do I find the time to actually sort and go through the stuff and go through my ritual, my process to be able to discard it?

Dr. Jones: This is a very powerful connection, a very human connection between an item and the memories that it holds for you. So, Ivy, if you can go back . . . you may not know exactly the roots of why you became so attached to things, but can you remember the first time you thought that you might be a little bit different in your attachment to things? Was it when you were a kid or a teenager or . . .

Ivy: So I have gone to therapy for several years. I've researched hoarding up and down, reading all of the books, listening to various podcasts. I'm actually very curious about this topic just because I find it so fascinating how people are still researching what is the root cause and what creates a hoarder, essentially.

For me, I can't really pinpoint one trauma or one experience of what happened. Growing up, I shared a room with my sister, which I absolutely loved, and I think we would often blame each other for the messy room. And it wasn't until I moved into my own room where it was kind of like, "Oh, the problem is me." Realizing that I have a hard time organizing my things or giving it away.

So even as a child, I carried my erasers with me in my special purse, and I had special shoes I would wear to special restaurants. There were different attachments I made to items. And if an item went lost or missing, I did have a really hard time with that.

But I think when it really came full circle for me was I was needing to move away for college, and there was just so much stuff, and I didn't know where I was going to store it.

Even after college, coming back home, I needed to extend my stay for another month just to figure out how to either get all of my stuff home or what to do with it.

I often have dreams at night that I'm late for my airplane, and I have so much to pack, and I just can't get all of my stuff with me. So I think that's just been my journey of, "How do I bring all my stuff with me, and why do I need to bring all this stuff with me?"

But it's funny, too, because if you asked me, I would say, "Oh, I'm not an anxious person." But if you asked my husband, he would say, "Oh, you're just living in a constant state of anxiety, and that's why you don't believe you're an anxious person," because this is just how I exist. I think I'm a very friendly, outgoing person, but if you were to come into my home and just start throwing things away, I would cut off the relationship. That's how dramatic it could be.

Dr. Jones: So even as a kid, did your parents say, "You've got to clean up," or, "You've just got to get rid of this," or, "Why can't you do this?" Did your parents recognize that this was an unnaturally tight relationship between you and your things?

Ivy: I think my parents didn't realize the extent of it until I was out of the house, living on my own. They're organized. They helped me stay on top of it. My mom is great at . . . she's really efficient at organizing, about helping me clean my spaces.

When I purchased my first home, got into my career, and then things really got out of control pretty quickly, I think that's when my family, my siblings, and my parents realized, "Oh, wow, we're dealing with more than just someone who likes clutter and someone who's a little messy." I think I always knew it was there, but that's kind of when my family recognized it.

Dr. Jones: Was there an event or an intervention, or was there a time when you realized it brought enough pain in your life that you had to make a change?

Ivy: I mean, I've had this pattern a few times where I've needed to move in order to clean out the house, either to sell it or rent it. And now I've gone through this two or three times. I'm going through it now again, and I'm hoping that this is my final time clearing out a space and not letting it happen again.

I feel like I am now at a point in my life where I can see that it's not serving me anymore, it's not serving my family, and I'm working through it. Today was garbage day, and that's a very stressful day for me for when the garbage needs to go out. So I'm in the process.

I think I finally have the awareness. I think I was in denial for many, many years about how harmful it is to my loved ones. And now I think I finally have the awareness. So sometimes I compare myself . . . I'm like a caterpillar in the chrysalis. I'm working through the process.

Dr. Jones: That's a lovely thought, because the caterpillar eventually comes through as a butterfly, but leaves its container behind and flies away, never seeing it again. It's surrounded by this thing that nurtured it and that it has some kind of biological memories of, and it allowed this transformation, but then you left it behind. That's a great image, I think.

Although it doesn't bother you living by yourself, you did take steps to try to make this clearer to yourself. And when you have to take the garbage out or something, there are ways that help. Are you feeling a little bit better?

Ivy: I think so. I mean, this morning, I was trying to get the garbage and the recycling out, and I was hoping to get through it all. And this is me not throwing it out on a weekly basis. So it does tend to build up.

But for now, it's almost as if I'm afraid to find the root cause of why I am hoarding. I think also that some of my hesitancy to go to therapy more regularly, I think I'm afraid to discover what created this or why I need this to feel safe in my life.

But I do try and cope by blocking out days where I can do the laundry. I just feel like there's so much stuff, and I'm very slow processing it. I'm very detail-oriented, so it's hard for me to just manage day-to-day tasks.

Dr. Jones: Yeah. Well, holding on to stuff is so common. I begin to think of it as a behavior that's on a bell-shaped curve. A lot of people are kind of in the middle, and there are some people who throw everything out. They have to have a completely clean space with nothing in it. And that's at the far end of one scale.

It could be something traumatic that led you to feel comfortable with certain things about you. However, it could be it's just your biology, and keeping things about you is human. We know what civilizations are like by their middens, the concept of a midden, which is where they put their stuff. That's how we learned about past civilizations, because they had stuff.

Ivy: I feel, for me, sometimes my battle with my hoarding tendencies feels bigger than me, even though I can speak about it in a rational way, I can understand why having too much clutter does not create a good rhythm in the home. I can see and I can understand all those things.

But there's a quote I really love from Lao Tzu, and it says, "Nature does not hurry, yet everything is accomplished." And I feel like I live by that, because even though I'm a little bit more slow and detail-oriented, I just think about, even in the springtime, the blossoms blooming in their own time. We can never tell nature to hurry, yet the seasons come and go, and there's always growth.

And so I think that's what I try to remember for myself, is that this might take several years for me to get to a place where I can live more functionally. But I don't always have to feel anxious, and I don't always have to feel in a hurry, but I feel like I will reach my goal at some point. I will be able to grow and to change.

Dr. Jones: So I think that there is a spectrum in nature of spare versus unbelievably on top of each other, and you finding your own path to some kind of even space with you and your family, too.

Ivy: It's interesting with my son because I think when you're a parent who has a hard time getting rid of things, you worry that that will be your child. But I find that he can easily give things away, give gifts to his friends, his own objects.

And it's sometimes interesting, too . . . I grew up in a very tidy home, and sometimes I think your children can swing the other way.

A few weeks ago, I cleared out the entire living room, cleared off the table. And when my son came home from school, he kind of looked around in surprise, and he's like, "This is different. I don't know what to think about it." But then immediately, he went to the table and started doing artwork, and that brought a lot of joy to my heart of, "Oh, if I can open up these spaces for him . . ."

Then on the couch, he organized all of his stuffed animals. And it was just a really beautiful thing to see that when I move my space, it's going to open up space for him to create.

Dr. Jones: Oh, what a joyful day that must have been. What an amazing gift that you gave both of you to be able to have a little more space to become yourselves.

Ivy: Yeah, and I try to go back to that feeling so I can stay the course.

Now, I think the patterns in our lives keep repeating until we can really learn from it and grow from it. I've found that to be true for myself. So I'm excited for when I come out the other end, and I think I will have a lot to offer to people.

I think people who have hoarding tendencies don't like to come to self-help groups. They're afraid to go to therapy. They shut their doors, their windows. They don't want to talk about it. It's a scary thing to face. But through living through it, through my own research, I hope that I can help people in the future. I'm still in the thick of it now, but I'm hopeful that going through this now several times in my life, this process, this pattern, that I can be of help to others.

Dr. Jones: That is beautifully stated, and it's heartfelt. And I wish you all the hopes and joys and sorrows that are going to come with change. And I know that you will be the butterfly that comes out of the cocoon, for sure.

Ivy: Thank you. I really appreciate that.

Dr. Jones: Well, I'm amazed at your journey and your willingness to share and your willingness to do this work, because it's work. And I'm going to thank you for your willingness to share your personal journey about having more stuff or having difficulty getting rid of things that you're attached to.

Ivy clearly is making steps on her own through her own exploration, her own research, her own meditation, cognitive behavioral therapy, and maybe some professional help. But if you find, if you as a listener, or know someone who is really now in a difficult situation because of hoarding or because of their stuff, it's really getting the way of their life, there are psychiatrists who have a special interest in this particular disorder.

Now it has a name in the Diagnostic and Statistical Manual of Mental Disorders. So hoarding disorders is a condition that's understood, and we're going to be talking with a psychiatrist who has a special interest in this field.

Dr. Jones: With us today in the virtual Scope studio to help us think about when too much stuff is just too much is . Dr. Durns is a forensic and clinical psychiatrist at the University of Utah, working in both inpatient and outpatient psychiatry. Dr. Durns, Tyler, thanks for joining me to talk about too much stuff.

Dr. Durns: Thank you for having me.

Dr. Jones: So, Dr. Durns, I think of the things that I have in my life which are very meaningful to me. I have a wedding ring that's around my neck on a chain that I always wear. When I go to the operating room, I put it around my husband's neck until I come out. So there are some things that are precious to me. I know that some other animals collect shiny things, but what is our connection to inanimate objects?

Dr. Durns: It goes back to object relations and what value people see in various objects, right? So people with hoarding disorder often have some additional meaning that they relate to it. This could be sort of almost a memory recall item for some time of importance.

For example, you provided me a microphone for this recording. And if I were to sort of be like, "Well, I want to keep it. This way, I could remember the joy of this experience and being on your podcast," that's where you see some of the differences here.

There's also a sense of pride about this. You'll see this in collectors, for example. Not being, say, a stamp collector myself, if you meet one, they're more than happy and thrilled to walk you through each and every one and its significance.

Whereas with hoarding disorder, there's a lot of shame associated with it. It's not, "Hey, I'm proud of this object," or, "This means something to me that I want to show the world." It really comes from kind of something deeper and much sadder in a way.

Dr. Jones: So there must be something about us as humans. As soon as we settled down to one place, we created beautiful things. So we did things in clay, and we surrounded ourselves with a few things.

I am surrounded with eggs. Because I was a reproductive endocrinologist and I either made eggs, got eggs, or I broke eggs, meaning it was either contraception or in vitro fertilization. Eggs have a profound meaning for me, and they have since I was in my teens. So I have a lot of eggs. And people know if they want to give me a gift, they can give me a little egg. And every egg I have has a story.

So there's something human about collecting stuff. Maybe it's because our brains can make the leap between the concrete and the imagined, and maybe other animals can't do that so well.

Dr. Durns: Well, there's value in sentiment, too, and I think that's a very normal thing. It's sort of when we're attaching that much meaning to everything that it often becomes a problem.

Dr. Jones: Right. And so let's say when you're trying to downsize, as many people my age are, and they have to choose which stuff to keep and which stuff to get rid of, there's often a lot of tears involved, because each one of those things is memories. Maybe it's the whole boxes of your kids' grade school pictures.

But as humans, we collect things which connect us to our past, more our past than our future. And it seems to be inherently human, this process of imagining something, pulling up a memory through an inanimate object.

Dr. Durns: In that sense, stuff more generally, it isn't a bad thing, right? I think there's a lot of be it good memories or even functionality that comes from it. I don't think it's necessarily an aberrant thing to care for items, and it's something we certainly all do. In fact, I'd be worried about somebody who has no sentimental attachment to anything whatsoever.

Dr. Jones: So I think it's hard for us. We discussed in the physical domain, which is the episode before this one, about how stuff fits into Maslow's hierarchy of needs. Some stuff we need just to keep us warm or give us shelter, and some things keep us safe, and some things give us status, and some things connect us with people we love, and some things are aesthetically pleasing. So as you go up, we have a hierarchy of where we are in terms of what our stuff means to us.

When it crosses over to being a burden instead of this fabulous trunk of memories and beauty, well, that's when we need you to help us out. So can you help us define hoarding and hoarding disorder, or maybe help us get rid of some myths?

Dr. Durns: Yeah, I guess a little bit of a review of history is important for some context. There have been references to hoarding or too much stuff dating back to really Dante Alighieri's "Inferno," even. I believe it was the hoarders were condemned to the fourth circle of hell, where they were doomed to bash rocks against wasters and things of that sort.

So this, I guess, phenomenon really started getting more public attention back in the early 20th century. There's this famous case of the Collyer brothers. Hoarding disorder was actually originally called Collyer Brothers Disorder.

And this was really a tragic case where there were these two brothers who were really fairly high-functioning initially in a lot of regards. I believe one was an attorney and the other was a piano repairman.

They sort of became known for hoarding more and more items in their brownstone in New York, and as they did so, became sort of a source of local myth, and people would peek into their windows. People thought they were hoarding gold, and they actually dealt with quite a few break-ins.

Unfortunately, this, of course, led to them being that much more reclusive. And it got to the point where, after Homer Collyer had actually suffered a stroke that left him blind and was sort of left under the care of his brother, they would really only leave the house at night to get food and things of that sort.

It's an especially tragic case because really how the public and the community around them viewed them as, being so intrusive and really alienating them, this led them to eventually stop really having the means to be able to pay for their water, their heat, things like that, sort of living as if they were in the 14th or 15th century.

Dr. Jones: Right. In their very own world.

Dr. Durns: In their very own world and in their very own homes. And this also led to Langley Collyer to kind of set a series of booby traps throughout the house due to intruders. And this really came to public attention because . . . well, there was a call to the authorities eventually, and inevitably, you can probably see where this is going, but of a putrid smell. They eventually went to the home, where they found Homer Collyer, who had passed away approximately 10 to 12 hours before.

And if you're thinking that's not a lot of time for a body to decompose and cause a smell, you're right. So, after finding Homer, they initially suspected Langley, and there was this kind of manhunt. Meanwhile, they were working on excavating over 14 tons of various items throughout their brownstone. Eventually, as they were doing so, they found the body of Langley Collyer, who had unfortunately been crushed under one of his own booby traps.

Dr. Jones: Oh, no.

Dr. Durns: Yeah. And this, of course, leaving Homer, who was entirely dependent on his brother for food and everything, to starve to death. It took, from the estimates I saw, about 2,000 people to help get things out of the home.

So it's been around in popular culture some time, but despite that, was really kind of neglected by the psychiatric community for a very long time, with really the first research in this not taking place until the 1990s. A leading researcher, Randy O. Frost, and two of his students began studying this.

And even still, this was neglected from the DSM, and eventually was adopted as a subtype of OCD. It didn't really make its way into the DSM as a distinct entity until the fifth edition back in 2013.

So now we look at it as something that, while having some related traits and certainly comorbidities that I'm sure we'll get into, is a very distinct entity altogether.

Dr. Jones: Well, sometimes it makes me wonder, for many psychiatric diseases, psychological diseases, how much of the disease is really a problem for the person and how much is it a problem for the rest of us? Maybe it's the rest of us that have this problem with the hoarding disorder, and for some people, they don't think it's a great big problem.

And for a psychiatrist to kind of walk that line between when does somebody think that they're just fine, and their relatives think they're crazy? Or when do people say, "I'm a little bit troubled"? So how do you walk that line between when is something okay, at least to the person who's living it, and when is it not okay?

Dr. Durns: Yeah, you bring up a great point. Psychiatry, I think, certainly has kind of a dark and not great history of sort of trying to define what's normal. I like to think we've moved away from this more recently, and we really try and define all of our disorders as an impairment of function. This could be social functioning, occupational functioning, and so forth.

So to get into, I guess, the criteria as it is now, with that noted qualifier, to qualify for hoarding disorder in general under the DSM, you must have a persistent difficulty discarding or parting with possessions regardless of their value. So this could mean fiscal value or sentimental value.

One kind of common misconception related to this aspect of the criteria is that hoarders just have a bunch of junk everywhere. But that's not necessarily true.

When Randy O. Frost and his team first began studying this, they were sort of expecting that same thing and were really surprised when they were going into people's homes and finding things that are brand new and still in their packages, often purchased because there was some great deal that they felt they couldn't pass up, which is part of the phenomenology of hoarding outside of the criteria.

The next aspect of the criteria is the difficulty is due to a perceived need to save the items and a lot of distress associated with parting with them as well.

So we think about these awful shows that came to light in the early 2000s, where people were distracting their relatives or whatever, and then someone would come in and clear out their entire home as if that would fix the psychological aspect of it, and it really just caused a lot of distress for these people.

And then the next criteria, which I really think of it as there are three primary here, is the difficulty discarding possessions results in accumulation that congests and clutters a living area and substantially compromises their intended use.

When you think about what maybe differentiates someone with hoarding disorder versus someone who has a lot of stuff, really a lot of their stuff, they're not able to use it. In sort of the hoarding disorder community, they talk about these things called goat trails, which are essentially paths that people have to clear in their home just to get around to and from. Things will be poorly taken care of, because how could you take care of so much stuff?

Water heaters will go unchecked or go out. And then, of course, you have the problem of the embarrassment associated with it. So these are people are less likely to come and have that fixed, and end up living in squalor that puts them at physical risk, in addition to really the social impairment from all the isolation and shame.

Dr. Jones: So the concept is that there's an impairment, as we see it, but it's the impairment in the ability of a person to really take care of themselves or meet their fundamental physical needs.

So it's always this difficult line. There are a lot of people who have too much stuff, and it makes me uneasy to be in their home, but they're pretty happy. They can get to the bathroom and cook, and it's not a fire hazard, and there are no rats or anything.

So help me, how do people get to you? Because many folks figure, "This is just who I am, and it's not my problem." So how do they come to you? Do people come to you for help, or did someone bring them in, or . . .

Dr. Durns: Despite the prevalence really being cited consistently at about 1.5% to 4.5% of the population, so being a fairly common illness, it's pretty rare for people to come in actively seeking help for it.

We do know that about 75% of people who qualify for hoarding disorder do have some other comorbidity, depression being the most common, about 50%, and OCD being about 15% to 20%. So they might seek help for these conditions, and the burden really kind of falls to us as clinicians in these cases to make sure we're asking and maybe looking for kind of soft clinical signs that there's this other problem that maybe they're too embarrassed or too ashamed of to ask.

Dr. Jones: Or their mental illness, whether it's addiction or depression, is so overwhelming that they can't clean up. They can't get themselves together to get rid of their stuff. They might think it's okay, but they just are too debilitated by their other psychiatric disorders maybe.

Dr. Durns: Yeah, that's certainly one possible presentation of it. But I think it's important to note, and this is one of the misconceptions, is the sort of classic archetype of someone who has hoarding disorder is an older man or woman who has all these very sentimental objects and things like that.

While it's true that we do see increased prevalence of it reaching the threshold of a disorder when people are older, say, 60 or above, that said, the hoarding behaviors, when they've examined this and followed people longitudinally, really begin often around 15 to 20, so late adolescents and early adults.

But really, in these times of our life, we're often with other people, be it parents, roommates, things like that, people who could sort of keep it in check. And then, of course, you just haven't lived long enough to have enough stuff.

So psychologically, the issue tends to begin quite earlier, even though it doesn't really reach the threshold of impairment until much later.

Dr. Jones: If it shows up for the first time in someone in their late 60s, maybe you're thinking about dementia or another neurologic cognitive disorder where people can't find their stuff. They can't get it away. They don't even know what they have because they're forgetful. Is that a case sometimes?

Dr. Durns: Yeah, absolutely. And it's also often the case that people will sort of downsize their homes as their children move out and things of that sort. So that could kind of aggravate the problem that much more.

Dr. Jones: Oh, yeah. So they move all their stuff from their big house to their little place. Oh, gosh.

Well, are there some examples of conditions that people experience that might tip them over to seeking help

Dr. Durns: Yeah. Depression is certainly the most common one. And again, it's really assessing that and the soft signs here. When people are brought to our attention directly for hoarding disorder, it's often by the authorities or a relative that kind of says, "Hey, enough is enough, and you can't get through your home. It's not safe. We need to do something about this."

Dr. Jones: Yeah. Now it's got a DSM number, so it's recognized as a disease. Can it be treated with drugs? What's the approach to treatment?

Dr. Durns: So unfortunately, to date, there's no FDA-approved medication for this. And we do a lot of off-label prescribing and aren't necessarily strict to the FDA indications.

That said, we're still pretty limited when you look at the data. Of course, treating comorbidities like depression, anxiety, OCD, those things can be of some benefit. But really, the first-line treatment for it is various forms of cognitive behavioral therapy, which is this grab bag that we, I think, misuse the term pretty frequently.

But what this looks like for hoarding disorder is, first, you really have to come at this just like any other disorder with a lot of sincere empathy and really understanding how much pain this is causing them, and really also the pain that led to it in the first place.

And beyond that, it's a lot of offering them skills. So, for example, if somebody comes into an appointment while they're not in a time of acquisition, they're not at a store, they're not feeling tempted, helping them really come up with a list of arguments to themselves on why they shouldn't buy X, Y, or Z items, and having them carry that list with them. That way, when they are in a time of acquisition and they are tempted, they could kind of review these things.

A lot of what we do is supportive treatment for all the distress that comes to it and, of course, helping them build or at least maintain what social relationships they do have so they could still live somewhat fulfilled lives. Ultimately, I think that's what life is about, is our relationships and being able to maintain that.

Dr. Jones: So how can friends and family help?

Dr. Durns: I'll start with how they can't help or shouldn't try to help.

Dr. Jones: Okay. We'll start with that one.

Dr. Durns: I think a lot of well-meaning family members and loved ones will try to help by kind of clearing out stuff, like these TV shows, and say, "Hey, let's just get rid of this." But really, that's just going to be replaced by more stuff, right? So the worst thing you could do is kind of send them away on a trip and then clear out their house while they're gone, because that's just going to cause so much distress.

It's really a lot of supportive interventions and helping them to still have some of these, I guess, social relationships, still maybe even function in their job, still be able to live their life fully. And that could take many forms.

But in addition to that, really just coming at it with a place of empathy and understanding that this isn't really just, "Hey, you have too much stuff. We need to get rid of it." It's, "What does this mean to you? And how can we maybe find a supplement for that that's healthier and doesn't put you at this kind of physical or psychiatric risk?"

Dr. Jones: Does the AA model work in terms of group therapy? Is getting together with other people who struggle and try to realize that this is something they have to deal with every day and they really do want to reconnect with family members a model at all that would work for this?

Dr. Durns: I don't know if the AA model specifically has been studied, but that concept of shared experience and groups or peer support specialists definitely has a lot of encouraging evidence.

And something I'm constantly surprised about in my field . . . Well, I'm very lucky where people come to me and tell me a lot of these very intimate things that they feel are abnormal or are especially embarrassed about, and I'm always kind of shocked at how not unique that is in a lot of ways.

I wish we just had a culture where people were more comfortable being open about their struggles and their hardships, their victories, and all of that, because I think we could all really help each other.

Dr. Jones: Well, if the numbers are somewhere between 1 in 30 and 1 in 50 people could be identified as having hoarding disorder, that means we all know somebody. Whether we know the details of their lives, they're persons just as we are, and recognize that they have stories to tell, things to share.

Well, Dr. Durns, I want to thank you for joining us on the "7 Domains of Stuff," because I think it's really helped me think about how to be, as you mentioned, empathetic and try to see the human side of people with any disorder. But for people who are struggling with isolation because they have too much stuff, it helps me think about it a little bit. I'm very grateful that you joined us. Thank you.

Dr. Durns: I'm grateful you had me.

And for all of our listeners, if this is the first time that you've clicked on our podcast of the "7 Domains of Stuff," we have all seven domains, the physical, the emotional, the social, the intellectual, financial, environmental, and spiritual. We have all these domains of stuff because stuff is a big part of our lives. For women, it flowers our lives, it perfumes our lives, and it complicates our lives.

So check it out. Use it as a conversation starter with people that you know, with other women who might be thinking about their own stuff. Catch all of our "7 Domains" wherever you get your podcasts, and thanks for joining us.