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Gail Steketee, PhDProfessor and Dean
Boston University School of Social Work
May 30, 2012
◦Jordana Muroff, PhD Boston University School of Social Work
◦Christiana Bratiotis, PhD BUSSW; U. Nebraska at Omaha
◦Randy Frost, PhD Smith College Dept. of Psychology
◦David Tolin, PhD Hartford Hospital, Dept. of Psychiatry
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
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
Acquisition
Saving
Disorganization
Buying
Collecting free
things
Stealing
Passive
acquiring
Types of items◦ Newspapers, magazines, mail, papers, books◦ Containers, craft items◦ Clothing, shoes, furniture, ◦ Household items, appliances, etc., etc.
Emotional attachments◦ Sentimental◦ Instrumental/useful ◦ Intrinsic/beautiful
Condition of Home
◦ Mixed importance
Behavior
◦ Churning
◦ Out of sight fear
5% in US (adjusted)
~2% in UK
4.6% in Germany
◦ May be twice as common in men◦ Nearly 3X as common in people age 55 and older◦ Over 4 times as common among people with low
income (< $20,000)
Wide range of educational achievement
Average age at treatment = 50 Low marriage rate, high divorce rate Tend to live alone Family history of hoarding is common
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
Source: Melbourne Fire Dept.
Non-Hoarding Fire
Hoarding Fire Ratio
Dollar loss to owner (USD)
$11,711 $93,784 8x
Containment to room of origin
90% 40% 2.25x
Presence of operating smoke alarms
66% 28% 2.4x
Frost et al. (2010)
OCD = 96
Hoarding= 178
Hoarding = 217OCD = 135
Both = 39
Frost et al. (2010)
Frost et al. (2010)
*
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.
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).
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.
The Cognitive Behavioral Model
Hoarding and indecisiveness more common among family members of people who hoard
Specific genetic abnormalities have been found◦ L/L genotype of COMT Val158Met
polymorphism◦ Chromosome 14
Samuels at al., Behav Res Ther 2007;45:673-686; Lochner et al., J
Clin Psychiatry 2005;66:1155-1160; Samuels et al., Am J Psychiatry
2007;164:493-499
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
Attention
Categorization
Memory
Perception
Association
Complex Thinking
Decision-making Difficulties
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.”
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.”
Positive Emotions◦ Pleasure◦ Excitement◦ Pride◦ Relief◦ Joy ◦ Fondness ◦ Satisfaction
Negative Emotions◦ Grief/loss◦ Anxiety◦ Sadness◦ Guilt◦ Anger◦ Frustration◦ Confusion
EmotionsNegative Positive
Beliefs & Meanings: Identity, Value,Responsibility, Memory, Control
Vulnerabilities:Biology, Family,
MH, Core Beliefs
Saving &Acquiring
Cognitive Processes: Decision-making, Attention,
Memory, Problem solving
Negative Reinforcement
PositiveReinforcement
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
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
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
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 computer-assisted self-directed ERP
Abramowitz et al., 2003; Mataix-Cols et al., 2002)
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
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
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
Organizing◦Categorize and organize wanted items◦Categorize unwanted items - trash,
recycle, donate, sell (minimize undecided)
◦Develop action plan for removing items Managing attention (esp. for ADD)
◦Determine usual attention span◦Help client reduce/delay distractibility
(e.g., control visual field)◦Discuss ways to create daily structure
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 decision-making
Practice sorting at home on most important areas with easiest items first
Move sorted items to destination or out IMMEDIATELY – no looking back
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
Cohen’s d = 1.07
Cohen’s d = 1.8127% reduction on hoarding measure
Steketee et al., 2010, Depress & Anx, 27, 476-484
Steketee et al., 2010, Depress & Anx, 27, 476-484
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.
** *
**p<.01 *p<.05Muroff et al., (2009). Depression & Anxiety
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
Muroff, Steketee, & Bratiotis, (2010) unpublished
25% gain 9% gain
17 participants Average age = 54 88% Women 13 weekly 2-hr group sessions Facilitated by 2 undergraduate
assistants Used self-help book Buried in Treasures
ab
c
Pekareva-Kochergina & Frost (2009).
CBT for Hoarding Delivered Via Webcam50 04/
21/23
22.6%
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
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 forceThank you! [email protected]