Treatment of Compulsive Hoarding Syndrome

Treatment of Hoarding Disorder:
From Research to Practical
Application
Karron Maidment, RN, MFT
UCLA
Resnick Neuropsychiatric Hospital
Obsessive Compulsive Disorder Clinic
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Hoarding Disorder
Definition
Current research
Treatment and Management
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Hoarding Behavior
Hoarding Behavior should be distinguished
from Hoarding Disorder:
• Dementia
• Psychosis
• Eating Disorders
• Major Depression
• Normal population
People with Clinically Significant Hoarding
Behaviors Need Diagnostic Evaluation
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Hoarding Disorder
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Hoarding Disorder –
Clinical Criteria
 Persistent difficulty discarding or parting with possessions
regardless of their actual value.
 This difficulty is due to a perceived need to save the items, and to
distress associated with discarding them.
 The difficulty discarding possessions results in the accumulation
of possessions that congest and clutter active living areas and
substantially compromise their intended use.
 The hoarding causes clinically significant distress or impairment
in functioning.
DSM -5 American Psychiatric Association 2013
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Hoarding Disorder
Most commonly hoarded items:
Newspapers
Magazines
Bags
Books
Mail
Notes and Lists
Storage Containers
Old Clothes
Memorabilia
(Frost & Gross, 1993; Winsberg et al, 1999)
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Research –
3 Perspectives
Cognitive Behavioral
Neurobiology
Neurocognitive
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Cognitive Behavioral
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Hoarding Disorder –
a Cognitive Behavioral Model
Hoarding is part of a discrete clinical syndrome that includes;
Indecisiveness
Perfectionism
Difficulty with organizing
Avoidance
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Indecisiveness
 Compulsive Hoarders have difficulty making
decisions about everything, not just saving items.
 Excessive concern with making a mistake.
Frost and Hartl ‘96, Grisham et al 2010
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Indecisiveness
Compulsive hoarders have an overly
complex way of thinking. This makes
decision making time consuming and
onerous.
Ayers et al 2013. Grisham et al 2010
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Indecisiveness
Saving allows the person with
hoarding to avoid the decision
required when discarding a
possession, and thus avoid the
worry about making a mistake by
throwing something away.
Frost and Gross 1993
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Hoarding Disorder –
a Cognitive Behavioral Model
Hoarding is part of a discrete clinical syndrome that includes;
Indecisiveness
Perfectionism
Difficulty with organizing
Avoidance
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Perfection
 Every activity has to be done perfectly.
 Need to remember everything, perfectly.
 Possessions are perfect and therefore
irreplaceable
Frost and Steketee 1999. Frost and Gross 1993
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Perfection
Fear of making a mistake
Serious negative consequences will result
from forgetting
All or nothing
Hartl and Frost, 2004
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Hoarding Disorder –
a Cognitive Behavioral Model
Hoarding is part of a discrete clinical syndrome that includes;
Indecisiveness
Perfectionism
Difficulty with organizing
Avoidance
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Organizational
Problems
Categorization
“Because each possession is so unique, it can not be
categorized with similar objects, and thus there is
no way to organize possessions”
Frost & Hartl, 1996
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Organizational Problems
The apparent chaos is
not a reflection of
lack of organizing
categories, but rather
too many.
Frost and Hartl 1996
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Organizational
Problems
‘Churning’ occurs when a decision cannot be made about a
unique item. It will be ‘put to one side for now.’ This results
in piles of clutter.
Frost and Hartl 1996
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Organizational
Problems
Visual Cues
The sight of a possession will increase its value. Thus, important
objects are saved along with unimportant objects because everything
‘looks’ important.
 Fear of filing something away for fear of forgetting the file heading
Frost and Hartl 1996
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Hoarding Disorder –
a Cognitive Behavioral Model
Hoarding is part of a discrete clinical syndrome that includes;
Indecisiveness
Perfectionism
Difficulty with organizing
Avoidance
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Avoidance
Hoarding is an
avoidance
behavior tied to
indecisiveness and
perfectionism
Frost and Gross 1993
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Avoidance
Paralysis thru’ analysis
All or nothing behavior
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Hoarding Disorder –
a Cognitive Behavioral Model
Emotional attachment problems
Erroneous beliefs about the nature of possessions
Frost and Steketee 1999
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Neurobiology
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Functional Neuroanatomy of
Hoarding Disorder
Brain Regions with Lower Glucose Metabolism
in Hoarding Disorder than in Controls
Sagittal
L
Transverse
R
3.0
Z value
2.5
2.0
1.5
1.0
0.5
0.0
Right Posterior
Cingulate Gyrus
Saxena et al, 2004
Am J Psychiatry
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Functional Neuroanatomy of
Compulsive Hoarding Syndrome
Brain Regions with Lower Glucose Metabolism in Hoarders
than Non-Hoarding OCD
L
Coronal
R
Sagittal
Anterior
Cingulate
gyrus
L
Transverse
3.0
R
2.5
Z
value
2.0
1.5
1.0
0.5
(Saxena, Brody, Maidment et al, 2004
Am J Psychiatry)
0.0
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Role of the Cingulate Cortex Attention, Cognition, and Decision-Making
• Functions of the dorsal anterior cingulate cortex: attention,
motivation, executive control (planning, time sequencing,
etc.), assigning emotional valence, error detection, and
response selection, especially choosing between multiple
conflicting options.
• Functions of the posterior cingulate cortex: episodic
memory, monitoring visual events, spatial orientation, and
processing of emotional stimuli.
•
(Saxena, Brody, Maidment et al, 2004)
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Role of the Cingulate Cortex Attention, Cognition, and Decision-Making
Summary
Dysfunction of the cingulate cortex could mediate
the remarkable decision-making and attentional
difficulties seen in patients with Hoarding
Disorder
(Saxena, Brody, Maidment et al, 2004)
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Neuro Cognitive
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Compulsive Hoarders have
problems with….
Executive Functions
Necessary for goal directed behavior.
 Ability to initiate and stop actions.
 Monitor and change behavior as needed.
 Plan future behavior when faced with novel
tasks and situations.
Encyclopedia of Mental Disorders
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Problem Solving
“Executive functions allow us to anticipate outcomes
and adapt to changing situations.”
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Compulsive Hoarders have
problems with….
Abstract concepts
Problem solving
Planning
Learning new information
Maintaining new skills
McMillan et al 2012.Grisham et al 2007.Mackin et al 2011. Ayers et al 2013
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Treatment for Hoarding Disorder
 Cognitive Behavioral
 Neurobiology
Treatment
 Neurocognitive
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Treatment for Hoarding
Disorder
A multi model approach is essential to the effective
treatment of Hoarding Disorder;
 Therapist for CBT
 Psychiatrist for meds
 Professional organizer specializing in clutter, equivalent helper
 Adult Protective Services for health, safety, referrals
 Code Enforcement for health and safety
 Advocacy agency for financial advice/assistance
 General Practitioner for medical problems
 Family for support
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Treatment Environment
In Home
In outpatient office with in-home support
In Intensive Outpatient Clinic
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Treatment of Compulsive
Hoarding
 Discarding
 Organizing
 Prevent Incoming
stuff
Self
 Introduce Alternative Behaviors
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Discarding Process
Ground rules:
 Pick a room, any room
 Very systematic
 Can’t put stuff
‘to one side right now’
 Homework daily, time limited
Decision making
Organizing
Decision making
Initiating/stopping
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Discarding Process
 Pick a room any room
 Before photos
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Discarding Process
Ground Rules
Take the first item that comes to hand
Make a decision
a) Recycle
b) Discard
c) Keep
Final decision is always with the patient
Helper does not touch patient’s stuff without
permission
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Discarding Process
Recycle
One recycle option only
Cannot recycle to save the world
K.I.S.(S)
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Discarding Process
Keep
Put saved item in its correct place immediately
Don’t put ‘to one side for now’
If saved items turn up back in ‘sorting’ pile, they
must be discarded
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Discarding - Rationale
Forces decision making.
Reinforces concept of prioritizing - keeping only
those things that are important.
Acknowledges that some things are not important.
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Discarding - Rationale
Addresses executive functioning:
A goal directed behavior.
A process that involves initiating and
stopping.
Introduces a different way of doing
something.
Prevents future negative consequences
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OCD
PROGR
AM
Additional Benefits of discarding
clutter
 Cleared, functional space.
 Daily visual reminder of accomplishment.
 Less pressure from friends, family, outside agencies.
 Opportunity to organize remaining stuff.
 Opportunity to develop skills to maintain cleared areas.
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Results of Discarding Process
Pros
Not so pros
 Improved decision
making about
discarding clutter.
 Little likelihood of
being able to discard
alone.
 Improved decision
making about the
acquisition of
clutter.
 Decision making
does not generalize
well to other areas of
life.
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Improving Organizational Skills
Organizing Stuff
Create and implement efficient system for filing and
storing items that does not rely on visual cues or
memory.
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Improving Organizational Skills
Organizing Stuff
Stay with the system.
Everything is put in its proper place.
Don’t leave things out as a reminder
Prevent over - categorization
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Improving Organizational Skills
Cleared areas must stay clear.
 Establish routine for regular ‘sweeps’ of cleared
areas.
- goal directed, time limited
- monitor behavior - make necessary
changes
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Improving Organizational Skills
Organizing Self
Establish times for routine ADL’s
The foundation on which to build the rest of the day
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Improving Organizational Skills
Baseline Routine Activities:
 Personal hygiene daily
 Empty trash daily
 Do dishes daily
 Sort mail daily
 Laundry x 1 per week
 Bills x 1 per week
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Improving Organizational Skills
Incorporate structure and routine into the day
 Establish ‘baseline’ routine activities
 Incorporate recreational time into each day
 Plan long term structure, e.g. work, school,
volunteering, day care.
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Improving Organizational Skills
Organizing Self
 Use a calendar- preferably digital
plan day
^
prioritize activities
monitor behavior
^
adapt behavior
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Improving Organizational Skills
Problem solving
Establish goal
Prioritizing
Come up with a plan
Organizing/Prioritizing
Break it down
Initiating
Keep it time limited
Stopping
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Results of Improved
Organizational Skills
Reduced time for hoarding behavior.
Improved sleep, mood, energy.
 Improved efficiency /functionality
Improved general decision making.
Improved problem solving.
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Treatment can address
neurocognitive deficits
Abstract concepts
Focus on behavioral. Minimize cognitive.
Learning new information / Maintaining new skills
A lot of repetition. Keep tasks small, concrete and time limited.
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Understanding and Treating
Compulsive Hoarding Syndrome
Remember
Hoarding Disorder is a Neuropsychiatric Disorder.
- It is not laziness or a character flaw.
- It is due to distinct brain abnormalities.
- It will not improve without treatment.
- Simply throwing away or organizing a hoarder’s
possessions will not solve their problems.
(Saxena et al, 2004)
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The End
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