The Hoarding of Animals: An UpdatePublished on Physicians Practice (http://www.physicianspractice.com)

The Hoarding of Animals: An UpdateApril 30, 2015By Randy O. Frost, PhD [1], Gary Patronek, VMD, PhD [2], Arnold Arluke, PhD [3], and Gail Steketee,PhD [4]

The authors provide information about the human-animal bond that may provide a starting point forunderstanding the development of animal-hoarding disorder.

When “People Who Hoard Animals” was published in Psychiatric Times in 2000, we were justbeginning our study of this poorly understood behavior.1 Since then, hoarding disorder (HD) hasbeen a subject of considerable research and has become an official diagnosis in DSM-5. DSM-5criteria for HD do not specify the types of possessions that are necessary for this diagnosis. Becauseanimals are legally considered property (ie, possessions), the hoarding of animals would appear toqualify as HD, although this question is not yet resolved in the psychiatric literature.

In light of this development, a review of the existing literature and a new look at animal hoarding iswarranted. In this article, we provide an overview of what we have learned in the past 15 yearsabout this behavior with respect to phenomenology, etiology, and treatment. At the outset, it isimportant to note that our knowledge of this condition is based on a limited number of studies.Consequently, what is described here should be viewed as a set of working hypotheses.Prevalence

Although animal hoarding technically fits the criteria for HD, DSM-5fell short of listing it as an official subtype, and Mataix-Cols2 has rightly noted that its diagnosticclassification remains unclear on the basis of the available evidence. DSM-5 describes animalhoarding as a condition associated with HD and defined by “the accumulation of a large number ofanimals and a failure to provide minimal standards of nutrition, sanitation, and veterinary care andto act on the deteriorating condition of the animals (eg, disease, starvation, death) and theenvironment (eg, severe overcrowding, extremely unsanitary conditions).” Estimates from surveys ofanimal control agencies and humane societies suggest that there are approximately 3000 reportablecases of animal hoarding annually in the US.3The most dramatic feature of this behavior is the effect it has on the home environment. Largenumbers of animals, often sick, dying, or dead, are crammed into living areas of the hoarder’s home.Often urine and feces cover the floors and/or walls, creating high concentrations of ammonia andaerosolized organic contaminants that pose serious health risks to occupants.4,5 In a study ofcomplaints to health departments, animal hoarding was found to result in significantly moreunsanitary conditions than did object hoarding and posed significantly more threat to the health ofhuman occupants of the home and to the community at large.6 Surveys of caseworkers dealing withthis problem indicate that a lack of appropriate sanitation appears in 70% to more than 90% ofanimal-hoarding cases, and together with the large number of animals involved, increases thelikelihood of zoonotic diseases for the occupants and the community.4,7

Case reports indicate that between 31% and 100% of individuals who hoard animals also hoardinanimate possessions.7,8 In these cases, the clutter and unsanitary conditions severely interfere withnormal activities of daily living, such as sleeping in a bed, bathing, finding important objects, andpreparing food. Often major appliances, toilets, showers, and tubs are not in working order. Inabilityto care for the hoarded animals and to maintain basic personal hygiene make this a problem ofanimal abuse as well as of the hoarder’s self-neglect. From a resource perspective, animal-hoardingcases require more agency involvement for resolution than do object-hoarding cases, and legal

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The Hoarding of Animals: An UpdatePublished on Physicians Practice (http://www.physicianspractice.com)

proceedings can result in substantial costs.6Types of animal hoardingPatronek and colleagues9 have suggested 3 ways to classify persons who hoard animals:overwhelmed caregivers, rescuers, and exploiters. The overwhelmed caregiver is an individual whoowns a large number of animals that were reasonably well cared for until a change in circumstancesimpaired the individual’s ability to provide proper care for them. Most often, the circumstancesinvolve loss of resources, such as death of a spouse, loss of a job, or failing health. These individualsoften initially make attempts to provide adequate care but eventually become overwhelmed, andliving conditions deteriorate. Their acquisition of animals tends to be passive, with new animalscoming from breeding among the animals they have. Overwhelmed caregivers of-ten exhibit someawareness of their problems with animal care and tend to minimize rather than deny them. Isolationmay be a factor in their reluctance to seek help. When they are confronted by authorities, they havefewer problems complying with intervention than rescuers or exploiters.A strong sense of mission to save animals from a presumed threat characterizes the more seriousrescuers or those who are mission-driven. These individuals vehemently oppose euthanasia andshow strong fears about the death of their animals, even though they fail to recognize the poorquality of the care they are providing. They believe only they can adequately care for their animals.Even as they become overwhelmed, they continue to collect new animals, often relying on a largenetwork of enablers who facilitate their acquisition of more animals. Their acquisition methods tendto be more active than passive, often involving going in search of animals they perceive to be inneed of rescue. Mission-driven animal hoarders or rescuers go to great lengths to avoid authoritiesand actively prevent outside influence over their growing population. These individuals now oftenpresent themselves as organized institutional personnel, often masquerading as representatives of alegitimate shelter or sanctuary that cares for hundreds of animals.Animal-hoarding cases typified by exploiters are the most serious and difficult to resolve. Theyinvolve individuals with sociopathic characteristics who acquire animals to serve their own needs,with little true attachment to them. These individuals appear indifferent to the suffering of theiranimals, and they lack empathy for humans and animals. They display extreme denial of anyproblems and flatly reject authority or any outsider’s legitimate concerns. As do the mission-drivenanimal hoarders, exploiters believe their knowledge is superior to anyone else’s, and they display anextreme need to exert control over their animals. Exploiters display many characteristics ofantisocial personality disorder, including superficial charm and charisma; they are manipulative andcunning, narcissistic, and appear to lack guilt or remorse. The absence of emotional attachment totheir animals suggests that these individuals may not fit the diagnostic criteria for HD.Very little research has been done to verify these classifications of animal hoarding. However, in areview of a small number of cases, Reinisch10 classified 40% as overwhelmed caregivers, 20% asmission-driven hoarders, and 40% as exploiters.Typical characteristics ofanimal hoardersThe majority of studies that examined the phenomenology of animal hoarding are detailed casereports prepared by animal control agencies and humane societies. In the two largest reports, thefindings regarding sex and age were remarkably similar. Patronek4 reported that 76% of 54 hoarderswere female, and nearly half of the 54 were 60 years or older. A report by the Hoarding of AnimalsResearch Consortium (HARC) detailed 71 cases.7 Eighty-three percent of these cases were women;the average age was the mid-50s. Animal-hoarding behavior appears to develop in middle age orlater, although research is lacking on this point.11 From half to nearly three-quarters of theindividuals in these studies were single, widowed, or divorced. Interestingly, over half of the HARCsample lived with other individuals, including children and elders. Smaller case studies have reportedsimilar sex and age distributions12,13; a recent Spanish study found a similar age distribution but amore equal sex representation.14

Most of the few studies on animal hoarding outside North America are case studies that documentthe existence of animal hoarding or describe the characteristics of hoarders within particularcountries. For example, Svanberg15 reported media and government reaction to a Swedish womanwho “rescued” 150 swans over several years by bringing up to 10 at a time to her one-roomapartment. Also in Sweden, Zak16 described the case of a hoarder with 80 dogs, 1 cow, 2 pigs, 1rabbit, and some poultry in unsatisfactory conditions, without any veterinary care. Other studieshave detailed the condition of animals and characteristics of the owners in Spain, New South Wales,and Serbia14,17,18; these reports were similar to those from the US.As noted, a recent study by Ockenden and colleagues12 in Australia found demographic similaritieswith US animal-hoarding cases, but the affected animals were in better condition than their

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The Hoarding of Animals: An UpdatePublished on Physicians Practice (http://www.physicianspractice.com)

American counterparts. To provide insight into the development of animal hoarding, Ramos andcolleagues19 examined Brazilians who own large numbers of animals that are adequately cared for innormally functioning homes. These individuals showed more intense attachments to their pets thanowners of just 1 or 2 animals; these types of attachments were suggested to be precursors to animalhoarding.Types of animals most likelyto be hoardedDetails regarding the number and kinds of hoarded animals generally have been consistent acrossstudies. Cats are the most frequently reported type of animal hoarded, followed by dogs, although ina study from Spain, there was a higher frequency of dogs than cats among the animal-hoardingcases.14 Farm animals and birds were also reported with some frequency (11% to 17% in somestudies20). In the study by Patronek,4 in 35% of the cases, only a single species was hoarded; in 31%of the cases, 2 species were hoarded; and in 33% of the cases, more than 2 species were hoarded.Calvo and colleagues14 reported that 79% of cases involved a single species. The typical number ofanimals in these cases ranged from 10 to more than 900. Women were more likely than men to havemore than 100 animals, and middle-aged persons (aged 50 to 64 years) had significantly moreanimals than did those who were younger or older.7Underlying psychopathologyA comparison of animal and object hoarding outlined similarities, including a chronic coursecharacterized by an exaggerated need to control, an exaggerated sense of responsibility, andintense emotional attachments to hoarded objects or animals.11 Both types of hoarding are alsocharacterized by poor insight and great difficulty in parting with objects or animals. In both objecthoarding and animal hoarding, the urge to save/acquire is intense, as is the distress whenpossessions are removed. A result of these behaviors is a seriously compromised living environment;in most cases, hoarding of animals results in more severe personal and public health consequences.There are some notable differences between object and animal hoarding. In one study, mostanimal-hoarding cases involved squalid living conditions, while only a minority of object-hoardingcases did so.21 A review of the sex ratio indicates that it is relatively even for object hoarding,whereas animal hoarders are predominantly female.22 Although both conditions are characterized bypoor insight, animal hoarders often exhibit delusional beliefs about special abilities to communicatewith, understand, and care for animals.23

There is little documentation of the clinical trajectory of animal hoarding, although anecdotal reportsare available and one book provides an in-depth self-report.24 Steketee and colleagues8 examinedthe characteristics and antecedents of hoarding behaviors by interviewing 16 individuals who fit thecriteria for animal hoarding and 11 individuals who owned many animals but did not meet hoardingcriteria. Both groups comprised mainly white, middle-aged women who owned an average of 31animals. Interestingly, individuals in both the hoarding and nonhoarding groups reported stressfulchildhood and adult life events as well as strong feelings about animals, such as urges to rescue,take care of, and be close to them. However, those who hoarded animals more often attributedhuman characteristics to animals and reported having had more problems with early attachments tocaregivers and chaotic childhood environments. They also had more dysfunctional currentrelationships and mental health concerns. This report and clinical impressions suggest the followingrecurring themes among individuals with animal-hoarding disorder:• Unshakable belief that they are saving, rescuing, or caring for their animals, which they see asbeing well and happy• Profound compulsion to maintain or increase the collection of animals despite ample evidence oftheir failure to provide adequate care• Childhood history of parents who were unstable, neglectful, abusive, absent, and/or inconsistent,often with chaotic, transient lifestyles• Difficulty in establishing and maintaining stable interpersonal relationships as an adult• Trauma in childhood and/or adulthood: often multiple, severe traumatic events, such as sexualabuse or assault, parental abandonment, or death or unexpected loss of loved onesUnfortunately, there are no articles that describe the clinical characteristics of animal hoardersbased on formal psychological/psychiatric evaluations. Nonetheless, these themes suggest thatinformation about the human-animal bond may provide a starting point for understanding thedevelopment of animal-hoarding disorder.Nathanson and Patronek25 have proposed an attachment-based explanatory model. Consistent withthis approach, a psychodynamic theory proposed by Brown26-28 suggests explanations for theunderpinnings of a “normal” human-animal bond and shows how these concepts may be relevantwhen the bond goes awry, as occurs in animal hoarding. Brown grounds her theory in the

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The Hoarding of Animals: An UpdatePublished on Physicians Practice (http://www.physicianspractice.com)

well-established importance of attachment security during development and the knowledge thatwhen needs are not met during this critical period, particularly when accompanied by trauma,disorders of the self and dysfunctional attachment styles can result.Attachment to companion animals can be profound, even for nonhoarding pet owners. Individualswho hoard animals show difficulty in letting go of them, even after they are dead. Their attachmentsare rigid and extreme, frequently at the expense of the well-being of the animals. Brown suggeststhat in animal-hoarding disorder, companion animals provide critical self-object functions, even intoadulthood. Accordingly, reliance on an animal(s) can become intense and crucial to a person’s senseof well-being, with loss or potential loss of the animal(s) creating a sense of fragmentation,disintegration, and depression.Many aspects of Brown’s hypothesis are also consistent with Flores’s29 framing of addiction ashaving its roots in attachment disorder, whereby the addictive behavior represents attempts atself-repair. Indeed, in “People Who Hoard Animals,” similarities in animal hoarding and addictivebehavior were noted.1 The powerful positive feedback persons with animal-hoarding disorder mayreceive from their imagined role as animal caregiver is consistent with this approach and mayexplain what drives the hoarding behavior.Building on this work, Patronek and Weiss30 explored the application of Allen and Fonagy’s31 work onmentalization theory as a way to further understand the various features of animal hoarding.Mentalization has been described as a form of emotional knowledge that involves being able toappreciate the reality of others and as a dynamic skill that is compromised by intense emotionsassociated with attachment relationships.31-34 Allen35 describes how adults with a history ofchildhood attachment trauma fail to understand how others (people and animals) think and feel.Impaired mentalization may be one mechanism that helps maintain hoarding behavior.30 Althoughproblems in mentalization in persons with animal-hoarding disorder remain to be examined, thepossibility of deficits in this area has important implications for therapy.Research in other spheres may play a crucial role in the developing science of animal hoarding. Forexample, complex feedback mechanisms involving the oxytocinergic system have been linked notonly to a history of childhood adversity but also to human-animal interactions.36,37 Oxytocin maypromote a tendency to “tend and befriend” animals and increase defensive behavior againstperceived threats from outsiders. Tending and befriending is a more typical response to stressamong women than men, which would be consistent with the sex disparity seen in animalhoarding.38 While it is speculative, this account suggests avenues for neurobiolog-ical research intoanimal-hoarding disorder.Legal issuesAnimal hoarding poses some unique legal issues, above and beyond those typically encountered inextreme object hoarding, because the conditions observed in these cases often violate state criminalstatutes prohibiting cruelty to animals. Unlike civil child protection laws, however, animal crueltystatutes do not provide an avenue for intervention until a crime can be proved. Thus, in the absenceof voluntary cooperation or the presence of children or dependent adults whose welfare may becompromised, intervention may be delayed until environmental conditions deteriorate substantially.Ultimately, despite potential mental illness that contributes to the behavior, a person withanimal-hoarding disorder may be prosecuted and subjected to criminal penalties, including fines, jail,and/or forcible removal of animals and/or prohibitions or limitations on future ownership orcaregiving, with no provision for mental health treatment.The animals are often in legal limbo for months to years during protracted legal proceedingsbecause, under the law, they are treated primarily as evidence rather than as victims of a crime.39

There is also no legal mandate that the interests of the animals must be considered during casedisposition. To avoid this, some agencies may not prosecute but, instead, may attempt to negotiate,even if the proposed solutions are suboptimal for animals and people.20

EvaluationClinical evaluation of a person with animal-hoarding disorder can take 2 primary forms: psychiatricevaluation for purposes of therapy and forensic evaluation for the courts. For the former, werecommend that the clinician be skilled in evaluating a broad spectrum of behavioral disorders andfamiliar with published guidelines for assessing and treating object hoarding.22 Given the potentialfor deep attachment to animate beings who often provide reciprocal interaction, there may be limitsto how far we can extrapolate from object hoarding. Thus, it is important for the therapist to beknowledgeable about the human-animal bond and to explore those issues with the individual.40 Thepotential for self-neglect should also be explored.With respect to forensic evaluation, several dozen states have legislated mandatory or discretionary

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The Hoarding of Animals: An UpdatePublished on Physicians Practice (http://www.physicianspractice.com)

evaluation of persons convicted of animal maltreatment, including animal hoarding. However,legislatures provide little guidance on what the goals of such an evaluation might be (eg, detectionof danger to public safety, detection of mental illness, identification of being dangerous to self andothers, identification of competency/capacity to care for animals). Limited forensic instruments areavailable for these purposes, and none has yet been validated. (One such instrument has been usedfor several years at the University of Denver and will be described in an upcoming book by Levitt,Grisso, and Patronek.41)TreatmentMany studies of animal hoarding report recidivism rates from 60% to 100%.12 Recidivism in thiscontext refers to the frequency with which people reacquire multiple animals after having animalslegally removed. This differs from the concept of relapse, which refers to the return of symptomsafter someone has been successfully treated for a disorder. Nothing is known about relapse inanimal hoarding, since no studies of treatment outcomes have been done. However, there are somecase examples of individuals who have stopped hoarding animals and have been able to keep fromreacquiring them.23

As noted earlier, although courts may mandate counseling, no validated therapy for animal-hoardingdisorder is available. In addition, most individuals who have been adjudicated for animal hoardingare reluctant to participate in therapy, making this strategy difficult to enforce. Similar tononvoluntary clients who are prosecuted in housing courts for object hoarding, the most appropriatemethod for initial engagement of persons with animal-hoarding disorder may be through communitytask forces composed of a mix of service professionals (housing, police, fire, public health, mentalhealth, legal). Members of such multidisciplinary task forces can work together to engage offendersin identifying goals that matter to them while requiring compliance with nonhoarding behaviors. Ofcritical importance is determining whether to limit the number of animals or require abstinence (eg,because of overt cruelty rather than neglect).Essential to this process is determining how to provide basic social support that meets the need forbonding that was previously filled by animals. According to Fonagy and colleagues,42 it is importantthat therapists avoid demanding a level of mentalizing from patients that is beyond their ability. Arelatively high level of metacognition (ie, the ability to reflect on one’s own thought process or thatof others) is required before a patient’s own distorted thinking can be challenged and distinguishedfrom reality. Our clinical experience strongly suggests that animal hoarders often show profounddeficits in this area.Quick fixes for these cases are unlikely; court-mandated therapy must be applied carefully to avoidextending the period of legal limbo for animals or putting animals at future risk. Given thelong-standing nature of the hypothesized psychopathology underlying animal hoarding, even in anideal situation with a cooperative and receptive patient, a longer-term therapeutic undertaking withperiodic checks on compliance would be expected. Disclosures: Dr Frost is Harold and Elsa Siipola Israel Professor or Psychology at Smith College, Northampton,Mass. Dr Patronek is Adjunct Assistant Professor at the Cummings School of Veterinary Medicine,Tufts University, North Grafton, Mass. Dr Arluke is Professor of Sociology at Northeastern University,Boston. Dr Steketee is Professor in the School of Social Work at Boston University. The authors reportno conflicts of interest concerning the subject matter of this article. References: 1. Frost R. People who hoard animals. Psychiatr Times. 2000;17(4):25-29. http://www.psychiatrictimes.com/obsessive-compulsive-disorder/people-who.... Accessed March 7,2015.

2. Mataix-Cols D. Clinical practice. Hoarding disorder. N Engl J Med. 2014;370:2023-2030.

3. Patronek GJ. Animal hoarding: its roots and recognition. DVM360. August 1, 2006. http://veterinarymedicine.dvm360.com/animal-hoarding-its-roots-and-recog.... Accessed March 7,2015.

4. Patronek GJ. Hoarding of animals: an under-recognized public health problem in a difficult-to-studypopulation. Public Health Rep. 1999;114:81-87.

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5. Douwes J, Thorne P, Pearce N, Heederik D. Bioaerosol health effects and exposure assessment:progress and prospects. Ann Occup Hyg. 2003;47:187-200.

6. Frost RO, Steketee G, Williams L. Hoarding: a community health problem. Health Soc CareCommunity. 2000;8:229-234.

7. Health implications of animal hoarding. Health Soc Work. 2002;27:125-136.

8. Steketee G, Gibson A, Frost RO, et al. Characteristics and antecedents of people who hoardanimals: an exploratory comparative interview study. Rev Gen Psychol. 2011;15:114-124. http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2011-09729-001. Accessed March 7,2015.

9. Patronek GJ, Loar L, Nathanson JN, eds. Animal Hoarding: Structuring Interdisciplinary Responsesto Help People, Animals, and Communities at Risk. Hoarding of Animals Research Consortium. 2006. http://www.tufts.edu/vet/hoarding/pubs/AngellReport.pdf. Accessed March 7, 2015.

10. Reinisch AI. Characteristics of six recent animal hoarding cases in Manitoba. Can Vet J.2009;50:1069-1073.

11. Frost RO, Patronek G, Rosenfield E. Comparison of object and animal hoarding. Depress Anxiety.2011;28:885-891.

12. Ockenden EM, De Groef B, Marston L. Animal hoarding in Victoria Australia: an exploratory study.Anthrozoos. 2014;27:33-47.

13. Worth D, Beck AM. Multiple ownership of animals in New York City. Trans Stud Coll PhysiciansPhila. 1981;3:280-300.

14. Calvo P, Duarte C, Bowen J, et al. Characteristics of 24 cases of animal hoarding in Spain. AnimalWelfare. 2014;23:199-208.

15. Svanberg I. The social construction of the swan lady: a case of animal hoarding in Sweden.Unpublished paper. Uppsala Centre for Russian and Eurasian Studies. 2011.

16. Zak P. Dogs (and cats) can love. The Atlantic. April 22, 2014. http://www.theatlantic.com/health/archive/2014/04/does-your-dog-or-cat-a.... Accessed March 7,2015.

17. Joffe M, O’Shannessy D, Dhand NK, et al. Characteristics of persons convicted for offencesrelating to animal hoarding in New South Wales. Aust Vet J. 2014;92:369-375.

18. Vucinic M, Radisavljevic K, Vukmirovic N. Some cases of animal hoarding from Serbia. In:Proceedings from the 21st International Conference on Animal Protection and Welfare; October 9,2014; Brno, Czech Republic.

19. Ramos D, da Cruz NO, Ellis SLH, et al. Early stage animal hoarders: are these owners of largenumbers of adequately cared-for cats? Hum Animal Interact Bull. 2013;1(1):55-69.

20. Berry C, Patronek GJ, Lockwood R. Animal hoarding: a study of 56 case outcomes. Animal Law.2005;11:167-194.

21. Rasmussen JL, Steketee G, Frost RO, et al. Assessing squalor in hoarding: the Home EnvironmentIndex. Community Ment Health J. 2014;50:591-596.

22. Steketee G, Frost RO. Phenomenology of hoarding. In: Frost RO, Steketee G, eds. Handbook ofHoarding and Acquiring. New York: Oxford University Press; 2014:19-32.

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23. Frost RO, Steketee G. Stuff: Compulsive Hoarding and the Meaning of Things. New York:Houghton Mifflin Harcourt. 2010:118-133.

24. Arluke A, Killeen C. Inside Animal Hoarding: The Case of Barbara Erickson and Her 552 Dogs.West Lafayette, IN: Purdue University Press; 2009.

25. Nathanson JN, Patronek GJ. Animal hoarding: how the semblance of a benevolent missionbecomes actualized as egoism and cruelty. In: Oakley B, Knafo A, Madhavan G, Wilson DS, eds. Pathological Altruism. New York: Oxford University Press; 2012:107-115.

26. Brown SE. The human-animal bond and self-psychology: toward a new understanding. SocAnimals. 2004;12:67-86.

27. Brown SE. Companion animals as self-objects. Anthrozoos. 2007;20:329-343.

28. Brown SE. Theoretical concepts from self-psychology applied to animal hoarding. Soc Animals.2011;19:175-193.

29. Flores PJ. Addiction as an Attachment Disorder. Lanham, MD: Jason Aronson; 2004.

30. Patronek GJ, Weiss KJ. Animal hoarding: a neglected problem at the intersection of psychiatry,veterinary medicine, and law. Findings from the Henderson House Workgroup. Poster presented at:American Psychology-Law Conference; 2012; San Juan, Puerto Rico. Poster 117-64. http://www.tufts.edu/vet/hoarding/pubs/APLS2012.pdf. Accessed March 7, 2015.

31. Allen JG, Fonagy P, eds. Handbook of Mentalization-Based Treatment. Chichester, UK: Wiley;2006.

32. Bateman A, Fonagy P. Mentalization-Based Treatment for Borderline Personality Disorder: APractical Guide. Oxford, UK: Oxford University Press; 2006.

33. Fonagy P, Gergely G, Jurist E, Target M. Affect Regulation, Mentalization, and the Development ofthe Self. New York: Other Press; 2002.

34. Fonagy P, Target M. The mentalization-focused approach to self-pathology. J Pers Disord.2006;20:544-576.

35. Allen JG. Mentalizing in practice. In: Allen JG, Fonagy P, eds. Handbook of Mentalization-BasedTreatment. Chichester, UK: Wiley; 2006.

36. Pierrehumbert B, Torrisi R, Laufer D, et al. Oxytocin response to an experimental psychosocialchallenge in adults exposed to traumatic experiences during childhood or adolescence. Neuroscience. 2010;166:168-177.

37. Miller SC, Kennedy C, DeVoe D, et al. An examination of changes in oxytocin levels in men andwomen before and after interaction with a bonded dog. Anthrozoos. 2009;22:31-42.

38. Taylor SE, Klein LC, Lewis BP, et al. Biobehavioral responses to stress in females:tend-and-befriend, not fight-or-flight. Psychol Rev. 2000;107:411-429.

39. Bernstein M, Wolf BM. Time to feed the evidence: what to do with seized animals. EnvironmentalLaw Reporter. 2005;35:10679-10689. http://elr.info/sites/default/files/articles/35.10679.pdf. AccessedMarch 7, 2015.

40. Patronek GJ, Nathanson JN. A theoretical perspective to inform assessment and treatmentstrategies for animal hoarders. Clin Psychol Rev. 2009;29:274-281.

41. Levitt L, Grisso T, Patronek GJ, eds. Animal Maltreatment: Forensic Mental Health Issues andEvaluations. New York: Oxford University Press. In press.

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42. Fonagy P, Bateman A, Bateman A. The widening scope of mentalizing: a discussion. PsycholPsychother. 2011;84:98-110. DOI: 10.1111/j.2044-8341.2010.02005.x. Accessed March 7, 2015. Source URL: http://www.physicianspractice.com/addiction/hoarding-animals-update

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