Buried in Treasures Understanding and Treating Hoarding Disorder
Buried in Treasures: Understanding and Treating Hoarding Disorder Gail Steketee, Ph. D Professor and Dean Boston University School of Social Work May 30, 2012
Collaborators ◦ Jordana Muroff, Ph. D Boston University School of Social Work ◦ Christiana Bratiotis, Ph. D BUSSW; U. Nebraska at Omaha ◦ Randy Frost, Ph. D Smith College Dept. of Psychology ◦ David Tolin, Ph. D Hartford Hospital, Dept. of Psychiatry
Objectives Identify typical cognitive, emotional and behavioral features of hoarding and comorbid conditions. Apply a theoretical framework to understand causes and maintaining features for hoarding problems. Make decisions about interventions for hoarding to improve motivation, organizing and decision-making skills, correct faulty beliefs, and practice sorting, discarding and resisting acquiring. Q&A
Definition of Hoarding The acquisition of, and failure to discard, a large number of possessions Living spaces so cluttered that they cannot be used as intended Significant distress or impairment due to clutter Frost & Hartl, Behav Res Ther 1996; 34: 341 -350
Manifestations of Hoarding Acquisition Saving Disorganization
Acquisition Buying Collecting free things Stealing Passive acquiring
Compulsive Saving & Difficulty Discarding Types of items ◦ ◦ Newspapers, magazines, mail, papers, books Containers, craft items Clothing, shoes, furniture, Household items, appliances, etc. Emotional attachments ◦ Sentimental ◦ Instrumental/useful ◦ Intrinsic/beautiful
Disorganization Condition of Home ◦ Mixed importance Behavior ◦ Churning ◦ Out of sight fear Clutter
Prevalence of Hoarding 2 -5% 5% in US (adjusted) ~2% in UK 4. 6% in Germany ◦ May be twice as common in men ◦ Nearly 3 X as common in people age 55 and older ◦ Over 4 times as common among people with low income (< $20, 000)
Demographics & Features Wide range of educational achievement Average at treatment = 50 Low marriage rate, high divorce rate Tend to live alone Family history of hoarding is common
Social & Functioning Problems Social isolation Strained relationships with family, friends, landlords, neighbors Work problems ◦ Interference with major personal or career goals ◦ 6% have been fired because of hoarding Legal/financial problems ◦ ◦ Credit card debt High expenses – buying, storage unit fees Property damage - loss of investment Eviction, divorce, bankruptcy
Hoarding vs. Non-Hoarding Residential Fires Non-Hoarding Fire Ratio Dollar loss to owner (USD) $11, 711 $93, 784 8 x Containment to room of origin 90% 40% 2. 25 x Presence of operating smoke alarms 66% 28% 2. 4 x Source: Melbourne Fire Dept.
Is Hoarding a subtype of OCD? - Probably not. OCD = 135 OCD = 96 Hoarding = 217 Both = 39 Hoarding = 178 Frost et al. (2010)
Comorbidity in 217 adults with hoarding Dx Frost, Steketee, Tolin, 2011 Frost et al. (2010)
Impulse Control Disorders & ADHD Frost, Steketee, Tolin, 2011 * Frost et al. (2010)
Proposed DSM-5 Criteria for Hoarding Disorder OC Spectrum Committee A. Persistent difficulty discarding or parting with personal possessions, even those of apparently useless or limited value, due to strong urges to save items, distress, and/or indecision associated with discarding. B. The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home, workplace, or other personal surroundings (e. g. , office, vehicle, yard) and prevent normal use of the space. If all living areas are uncluttered, it is only because of others’ efforts (e. g. , family members, authorities) to keep these areas free of possessions.
Proposed Hoarding Disorder Criteria C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). D. The hoarding symptoms are not due to a general medical condition (e. g. , brain injury, cerebrovascular disease). E. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e. g. , hoarding due to obsessions in OCD, lack of motivation in MDD, delusions in Schizophrenia or other Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autistic Disorder, food storing in Prader-Willi Syndrome).
Proposed Hoarding Disorder Criteria Specify if: With Excessive Acquisition: If symptoms are accompanied by excessive collecting or buying or stealing of items that are not needed or for which there is no available space. Good or fair insight: Recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. Poor insight: Mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. Delusional: Completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
Why do people hoard? The Cognitive Behavioral Model
Biology: Genetics Hoarding and indecisiveness more common among family members of people who hoard Specific genetic abnormalities have been found ◦ L/L genotype of COMT Val 158 Met polymorphism ◦ Chromosome 14 Samuels at al. , Behav Res Ther 2007; 45: 673 -686; Lochner et al. , J Clin Psychiatry 2005; 66: 11551160; Samuels et al. , Am J Psychiatry 2007; 164: 493 -499
Neuroimaging findings Frontal lobe abnormalities may indicate problems of cognitive processing ◦ Sustained attention – staying on task ◦ Memory strategy – organize visually ◦ Impulse control – resisting acquiring ◦ Decision making – difficulty discarding ◦ Self awareness – insight These cognitive impairments may be core features of hoarding
Information Processing Problems Attention Perception Categorization Association Memory Complex Thinking Decision-making Difficulties
Hoarding Beliefs Emotional Attachment: identity, loss, mistakes, comfort ◦ “Throwing this away feels like abandoning a loved one. ” ◦ “Throwing this away is like throwing away part of me. ” ◦ “I can’t tolerate getting rid of this. ” Responsibility & Waste ◦ “Throwing this out wastes a valuable opportunity. ” ◦ “I’m responsible for the well-being of this possession. ” ◦ “I must save this for someone who might need it. ”
Hoarding Beliefs Information & Memory ◦ ◦ “I might lose important information if I get rid of this. ” “Saving this means I don’t have to rely on my memory. ” “If I don’t leave this in sight, I’ll forget it. ” “If I don’t keep this, I will lose an important opportunity. ” Control ◦ “No one has the right to touch my things. ” Aesthetics, Attractiveness, Beauty ◦ “This is beautiful” ◦ “I will never find anything as nice as this again. ”
Both Negative and Positive Emotions produce hoarding behaviors Positive Emotions ◦ ◦ ◦ ◦ Pleasure Excitement Pride Relief Joy Fondness Satisfaction Negative Emotions ◦ ◦ ◦ ◦ Grief/loss Anxiety Sadness Guilt Anger Frustration Confusion
Vulnerabilities: Biology, Family, MH, Core Beliefs Cognitive Processes: Decision-making, Attention, Memory, Problem solving Beliefs & Meanings: Identity, Value, Responsibility, Memory, Control Negative Reinforcement Emotions Negative Positive Saving & Acquiring Positive Reinforcement
Assessing Hoarding Severity
Hoarding Interview Home and clutter Objects and reactions Where to start Organizational system Acquiring Reasons for saving Family & friends Health & safety Problems from hoarding Comorbidity (MDD, OCD, ADHD, etc. ) Family history of hoarding Onset & course Intervention efforts
Hoarding Rating Scale (ocfoundation. org) 0 -8 scales for 5 items: 1. Difficulty using rooms in your home? 2. Difficulty discarding 3. Problem collecting or buying 4. Emotional distress 5. Impairment
CBT for Hoarding
Pharmacotherapy Retrospective studies ◦ Hoarding predicts poor outcome of SRIs and SSRIs for OCD clinic patients w hoarding in some studies, but not others (e. g. , Mataix-Cols et al. , 1999 vs. Erzegovesi et al. , 2001) One prospective study ◦ Hoarding and OCD patients responded similarly to paroxetine, but both groups improved only modestly (~30%) (Saxena et al. , 2007) No studies of stimulants for those with ADD
Cognitive-Behavioral Therapy Retrospective studies ◦ OCD patients with hoarding responded less than non-hoarding pts. to standard ERP ◦ 31% vs. 59% with clinically significant change for therapist-directed ERP ◦ 25% vs. 48% response rate for computerassisted self-directed ERP Abramowitz et al. , 2003; Mataix-Cols et al. , 2002)
Specialized CBT for Hoarding (Steketee & Frost, 2007) Education and case formulation Determine values, set goals Enhance motivation Train skills for organizing, problem solving, decision-making Practice discarding & non-acquiring Challenge thoughts and beliefs Prevent relapse
Individual CBT Treatment Format 26 weekly sessions ◦ severe symptoms take more time In-home sessions once/month or as often as feasible Include practice in acquiring locations For extensive clutter, consider marathon sessions with several trained staff members or coaches
Treat Excessive Acquiring Identify acquiring problems Develop a hierarchy - easier to harder Modify beliefs about acquiring Practice not acquiring ◦ Drive-by non-shopping ◦ Walk-through non-shopping ◦ Browsing and picking non-shopping
Train Skills Organizing Managing attention (esp. for ADD) ◦ Categorize and organize wanted items ◦ Categorize unwanted items - trash, recycle, donate, sell (minimize undecided) ◦ Develop action plan for removing items ◦ Determine usual attention span ◦ Help client reduce/delay distractibility (e. g. , control visual field) ◦ Discuss ways to create daily structure
Treat Difficulty Discarding Bring boxes from home to sort in the office ◦ Start with easier items Talk aloud about how decisions are made to identify and discuss thoughts and beliefs Help person establish personal rules for decisionmaking Practice sorting at home on most important areas with easiest items first Move sorted items to destination or out IMMEDIATELY – no looking back
Practice Maintaining the System Find new routines to replace old habits and prevent re-accumulation of clutter ◦ ◦ ◦ Empty trash Clean kitchen, do dishes Sort mail and recycle newspapers daily Do laundry Pay bills Reinforce new behaviors
CBT Delivery and Outcomes for Hoarding
Controlled Trial: Saving Inventory-Revised (SI-R) Cohen’s d = 1. 07 Cohen’s d = 1. 81 27% reduction on hoarding measure Steketee et al. , 2010, Depress & Anx, 27, 476 -484
Controlled Trial Responders Steketee et al. , 2010, Depress & Anx, 27, 476 -484
Group CBT for Hoarding 5 – 8 group members; total n=32 4 groups (n=27) had 16 weekly sessions; 1 group (n=5) had 20 sessions Mean = 16. 6 sessions for all participants 2 hours per session 2 clinical facilitators (training model) Only 2 home visits per group member Muroff, Steketee, Rasmussen, Gibson, Bratiotis, Sorrentino (2009). Depression and Anxiety, 26: 634− 640.
SI-R Outcomes: All vs. 20 -session group ** **p<. 01 * *p<. 05 Muroff et al. , (2009). Depression & Anxiety
Group CBT vs. Bibliotherapy for Hoarding 27 people received 20 sessions of group CBT plus 4 -8 home visits ◦ 14 got 4 home visits by group therapist ◦ 13 got 4 extra visits by undergrad asst. 13 people received Bibliotherapy (read Buried in Treasures) Muroff, Steketee, & Bratiotis, (2010) unpublished
Group CBT vs. Bibliotherapy for Hoarding: SI-R and HRS scores 25% gain 9% gain Muroff, Steketee, & Bratiotis, (2010) unpublished
Biblio-Based Self-Help Program for Compulsive Hoarding R. Frost & A. Pekareva-Kochergina 17 participants Average = 54 88% Women 13 weekly 2 -hr group sessions Facilitated by 2 undergraduate assistants Used self-help book Buried in Treasures
Self help Biblio: SI-R scores a b c Pekareva-Kochergina & Frost (2009).
SI-R Pre-post Mean Changes by modality of CBT
CBT-Webcam: reduction in SI-R total score 22. 6% 50 CBT for Hoarding Delivered Via Webcam 12 /1 7/ 20 21
Next Steps CBT elements Delivered in group format for 20 or more sessions Add case management to group therapy: Assistance with homework in and outside the home Advocacy and referral as needed Rewards for decluttering and resisting acquiring Facilitate connections to others working on hoarding (via technology? ) ◦ Continued assistance over 1 -year ◦ ◦
Referral Options Virtual Hoarding Center www. ocfoundation. org Support groups www. messies. com; www. childrenofhoarders. com Mental health therapists www. ocfoundation. org; www. abct. org Professional organizers for chronic disorganization www. challengingdisorganization. org Hauling - for example: 1 -800 -GOT-JUNK Local health clinic Local cleaning services Local community task force Thank you! steketee@bu. edu
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