Compassion for People Living in Hoarding or Squalid Conditions

Amanda Uhle’s recent book Destroy This House (Summit Books, 2025) opens with an unsettling image of her parents’ home: “The garage in their Pontiac home was filled with food, much of it perishable. Animals got into it. Summer arrived. The toxic smell of rotted food was inescapable.” Uhle hoped someone would intervene, but no one did. Had her parents lived elsewhere, perhaps the story would have ended differently. Gleason and colleagues (2021) address this dilemma directly in “Managing hoarding and squalor,” noting that general practitioners often play a key role in recognizing and managing these situations before they become dangerous.

Many people think hoarding and squalor are the same thing—a cluttered house piled high with stuff and difficult to clean. But while they often overlap, they are separate problems that require different kinds of help.

Hoarding and Squalor: Understanding the Difference

Hoarding disorder is a recognized mental illness listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It centers on emotional resistance to discarding possessions. The distress of throwing things away, even items most would call trash, is intense. Over time, the buildup can make rooms unusable.

By contrast, squalor describes the physical state of a severely unclean environment. It can result from hoarding but also from neglect, poor health, or cognitive decline. About a quarter of people in such conditions have physical issues—limited mobility, incontinence, or significant vision loss—that contribute directly to their living situation.

The risks associated with both hoarding and squalor are serious: Fires spread quickly among piles of debris, emergency responders struggle to access the area, and falls are common. Some people have been crushed under their own belongings. For relatives, this isn’t just unpleasant—it can be life-threatening. Recognizing the danger helps families understand why intervention sometimes cannot wait.

What Hoarding Disorder Looks Like

Between 1.5 and 6 percent of people live with hoarding disorder. It often starts early in life and worsens gradually. According to diagnostic criteria, individuals experience distress when discarding possessions, regardless of actual value, leading to extensive clutter that prevents rooms from being used for their intended purpose.

A major challenge is that about half of those affected do not believe they have a problem. They may admit that others find their homes chaotic, but still see their behavior as reasonable. Comorbidities are common: mood and anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and sometimes obsessive-compulsive disorder (OCD) or autism spectrum disorder. In older adults, medical conditions—such as arthritis, limited mobility, or sleep apnea—can make managing clutter even more difficult.

Hoarding behaviors also appear in people with dementia or in those taking certain Parkinson’s medications that affect dopamine levels, which can trigger impulsive behaviors. This is why careful assessment is needed to determine whether the hoarding is a distinct disorder or part of a broader condition.

Squalor as a Separate Problem

Severe domestic squalor means the home has become so unhygienic that a reasonable outsider would judge it unlivable. About half of those living in such conditions are over 65. One in a thousand older adults is estimated to live this way, though many cases remain undiscovered. Squalor can develop after the death of a spouse, the onset of dementia, or a period of extreme social isolation. Sometimes elder abuse or neglect is also a factor.

Most people living in squalor have some form of psychiatric disorder, but barely half receive mental health services before the problem is discovered. Malnutrition is common, and mortality rates are high. The conditions of these homes are often shocking—accumulated trash, spoiled food, vermin, or even blocked exits—but the underlying causes tend to be medical and psychological, rather than moral.

Hoarding Essential Reads

Animal Hoarding: When Love Becomes Delusional

Are You Buried in Clutter?

The Role of the Brain

Both hoarding and severe squalor share a neurological component: executive dysfunction. The frontal lobes (responsible for planning, organizing, and decision-making) do not function as they should. People in these situations struggle with attention, memory, and prioritization. Viewed this way, hoarding isn’t laziness or apathy. It stems from an impaired brain system. Asking someone with these deficits to “just clean up” makes as little sense as asking someone with a broken leg to “just walk it off.”

The Role of the Doctor

General practitioners rarely receive direct referrals for hoarding or squalor. Most discover it indirectly, through comments from relatives or neighbors, reports from home health workers, or emergency calls. Sometimes physical signs give it away: unwashed clothes, improper hygiene, or patients arriving at appointments carrying large bags filled with random objects.

When suspected, assessment should be broad and multidisciplinary. Ethical complications often arise when people refuse help despite unsafe conditions. In these cases, physicians may need to evaluate decision-making capacity. If a patient lacks this ability and refuses intervention, legal measures such as guardianship, welfare checks, or council inspections may apply, depending on the jurisdiction.

Treatment and Support

Evidence for treating severe squalor remains limited, mainly case studies. For hoarding disorder, the evidence is stronger. Cognitive behavioral therapy tailored for hoarding (CBT-H) has demonstrated the best results. It addresses emotional attachment to objects, avoidance behaviors, and cognitive difficulties through structured goal-setting and the gradual practice in sorting and letting go. While improvement is possible, full recovery is rare, and ongoing support is essential. Motivational interviewing can also help those who are resistant or ambivalent about change.

Medication research is less robust but suggests that some antidepressants, such as paroxetine or venlafaxine, can help. Drugs that improve attention, like methylphenidate or atomoxetine, may benefit certain patients. When another condition, like depression or dementia, is driving the behavior, treating that condition is the first priority.

Coordination Is Key

A cleaning crew

Source: Grok AI image generator / xAI

Lasting improvement requires cooperation among multiple services, including medical care, mental health specialists, social workers, professional cleaners, and occasionally occupational therapists. A case manager is often essential to prevent duplication and confusion. Without long-term follow-up, relapse is a common occurrence. A single cleanup rarely solves the problem unless it is combined with continued behavioral support and monitoring. Within months, many homes return to their previous condition if no ongoing plan is in place.

Families, too, need guidance and empathy. Attempts at forced cleaning or shame-based confrontation usually fail. Success depends on patience, realistic expectations, and sustained collaboration between professionals and loved ones.

Conclusion

Hoarding and squalor are complex, emotionally charged problems. They devastate families and challenge healthcare systems, but they are not hopeless. With a thorough assessment, attention to the underlying psychological and medical factors, and carefully coordinated long-term care, people can live more safely and with greater dignity. Improvement may come slowly, and setbacks are common, but compassion and persistence make all the difference.