Treatment of Compulsive Hoarding

Treatment of
Compulsive Hoarding
Sanjaya Saxena
Karron M. Maidment
Compulsive hoarding and saving symptoms, found in many patients who have obsessive-compulsive disorder (OCD),
are part of a clinical syndrome that has been associated with poor response to antiobsessional medications and cognitive-behavioral therapy (CBT). Specific CBT strategies targeting the characteristic features of the compulsive hoarding
syndrome have had better results. This article provides an overview of the compulsive hoarding syndrome, a review of
treatment approaches and their efficacy, a case presentation, and a detailed discussion of intensive, multimodal CBT for
compulsive hoarding. New insights into the neurobiological characteristics of compulsive hoarding that might direct
future treatment development are also presented.
(Reprinted with permission from the Journal of Clinical Psychology 2004; 60(11): 1143–1154)
focus.psychiatryonline.org
the “compulsive hoarding syndrome” (Saxena et
al., 2002; Steketee & Frost, 2003).
Compulsive hoarding is most commonly driven
by obsessional fears of losing important items that
the patient believes will be needed, distorted beliefs
about the importance of possessions, and excessive
emotional attachments to possessions (Frost &
Hartl, 1996). Hoarders usually fear making wrong
decisions about what to discard and what to keep,
so they acquire and save items to prepare for every
imaginable contingency. Two types of saving have
been identified: instrumental saving, in which possessions fulfill a specific desire or purpose, and sentimental saving, in which possessions represent extensions of the self. By saving possessions, the
compulsive hoarder postpones making the decision
to discard something and, therefore, avoids experiencing anxiety about making a mistake or being less
than perfectly prepared. The most commonly saved
items include newspapers, magazines, old clothing,
bags, books, mail, notes, and lists (Frost & Gross,
1993; Winsberg et al., 1999). Living spaces become
sufficiently cluttered to preclude the activities for
which they were designed, causing significant impairment in social and/or occupational functioning
(Frost & Gross, 1993).
Only a few studies have directly compared patients who have the compulsive hoarding syndrome
to nonhoarding OCD patients; all have found
greater functional disability and more severe psychopathology in hoarders. Compared to nonhoarding OCD patients, hoarders have more severe anxiety, depression, personality disorder symptoms,
and family and social disability (Steketee & Frost,
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INFLUENTIAL
PUBLICATIONS
Although standard diagnostic classifications
consider obsessive-compulsive disorder (OCD)
to be a single entity, clearly several different
symptom dimensions of OCD exist. Four principal OCD symptom factors have been identified
as (1) aggressive, sexual, and religious obsessions
with checking compulsions; (2) symmetry/order
obsessions with ordering, arranging, and repeating compulsions; (3) contamination obsessions
with washing and cleaning compulsions; and (4)
hoarding and saving symptoms (Leckman et al.,
1997). These symptom dimensions appear to be
stable over time and show different patterns of
genetic inheritance, comorbidity, and treatment
response. Thus, OCD appears to be a multidimensional and heterogeneous disorder.
Hoarding is defined as the acquisition of, and
inability to discard, worthless items, though they
appear to others to have no value (Frost & Gross,
1993). Hoarding and saving behavior has been observed in several neuropsychiatric disorders, including schizophrenia, dementia, eating disorders, and
mental retardation, as well as in nonclinical populations, but it is most commonly found in patients
who have OCD. Among OCD patients, 18 – 42%
have hoarding and saving compulsions. Hoarding
and saving symptoms are part of a discrete clinical
syndrome that also includes indecisiveness, perfectionism, procrastination, difficulty in organizing
tasks, and avoidance (Frost & Hartl, 1996; Steketee
& Frost, 2003). OCD patients who have hoarding
and saving as their most prominent and distressing
symptom dimension of OCD and show the other
associated symptoms are thus considered to have
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SAXENA AND MAIDMENT
2003) and lower global functioning (Saxena et al.,
2002). Compulsive hoarders are less likely to be
married than nonhoarders, a finding that indicates
greater social dysfunction (Steketee & Frost, 2003).
A study of elderly hoarders found that hoarding
constituted a physical health threat to 81% of
them, including threat of fire hazard, falling, unsanitary conditions, and inability to prepare food.
Hoarders often have less insight into their symptoms than nonhoarding OCD patients, making
them less likely to seek treatment. Taken together,
the research indicates that compulsive hoarders
have a unique behavioral profile and a characteristic
pattern of symptoms and disability.
Genetic and family studies suggest that compulsive hoarding has a different pattern of genetic inheritance and comorbidity than other OCD symptom factors. The hoarding/ saving symptom factor
shows an autosomal recessive inheritance pattern
and has been associated with genetic markers on
chromosomes 4, 5, and 17 (Zhang et al., 2002).
One study found that 84% of compulsive hoarders
reported a family history of hoarding behaviors in
at least one first-degree relative, but only 37% reported a family history of OCD (Winsberg et al.,
1999). Compared with nonhoarding OCD probands, compulsive hoarders have been found to
have a greater prevalence of social phobia, personality disorders, and pathological grooming disorders and higher rates of hoarding and tics in firstdegree relatives. These studies indicate that the
compulsive hoarding syndrome may represent an
etiologically distinct subgroup or variant of OCD
(Black et al., 1998).
CLINICAL
PICTURE
A thorough assessment of patients’ history and
clinical presentation, with particular attention to
the unique symptoms of the compulsive hoarding
syndrome, is a prerequisite for effective treatment.
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PROCESSING DEFICITS
Compulsive hoarders have great difficulty making decisions and categorizing possessions. Because
every item feels unique, they create a special category for each one and resist storing them together.
Many hoarders also report marked distractibility
and difficulty in maintaining attention on tasks.
AVOIDANCE
BEHAVIORS
In addition to avoiding discarding items and
making decisions, compulsive hoarders may avoid
routine tasks such as sorting mail, returning calls, or
washing dishes. They may even avoid legally necessary tasks such as paying bills, rent, and taxes.
DAILY
FUNCTIONING
Because of their desires for perfection, compulsive hoarders frequently take a long time to complete even small chores. An inordinate amount of
time may be spent “churning”—moving items
from one pile to another but never actually discarding any item nor establishing any consistent organizational system. Daily rhythms are often disrupted. Many compulsive hoarders whom we have
seen sleep most of the day and are awake at night.
Many patients also do not have consistent eating
patterns.
COMPLIANCE
Because of their unstructured days and erratic
sleep/wake cycles, compulsive hoarders often forget
to take their medications or take them at inappropriate times. They may run out of medications or
lose them among the clutter and not renew their
prescriptions for days or weeks.
LEVEL
ABOUT POSSESSIONS
Compulsive hoarders often feel very responsible
for what happens to their possessions and go to
great lengths to avoid being wasteful or irresponsi-
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INFORMATION
MEDICATION
OF CLUTTER
Clutter may extend beyond a patient’s home and
may be found in automobiles, garages, storage lockers, and even storage areas belonging to friends and
family. Living areas may be so cluttered that normal
activities, such as sleeping in a bed, sitting on
couches, or using a kitchen counter, are impossible.
BELIEFS
ble in the disposition of their belongings. Some
believe that every item has special significance.
Hoarders also frequently have unattainable expectations of perfection, believing they must be vigilant in not losing any opportunity to improve preparedness. Compulsive hoarders often believe that
their memory is poor and, therefore, they have to
keep their belongings in sight because they would
not otherwise remember where they were.
OF INSIGHT
Many compulsive hoarders have poor insight
into their disorder, with little awareness of how
much hoarding and clutter have impacted their life.
Poor insight also contributes to low motivation for
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SAXENA AND MAIDMENT
treatment. Despite significant pressure from loved
ones or authorities to get help, many hoarders are
not convinced they truly have a psychiatric disorder. Therefore, they may be quite ambivalent about
engaging in treatment or refuse it outright.
SOCIAL
AND OCCUPATIONAL FUNCTIONING
Many compulsive hoarders have very little family
or social support. The nature of their problem
makes them socially isolated. They are frequently
too embarrassed by their clutter to invite people to
their home, sometimes for many years. Work performance is also often impaired.
TREATMENT
APPROACHES FOR
COMPULSIVE HOARDING
PHARMACOTHERAPY
COGNITIVE-BEHAVIORAL
THERAPY
Hoarding and saving symptoms have been associated with poor response to CBT, but compulsive
hoarders have been underrepresented in most CBT
studies of OCD, limiting the generalizability of the
results. Only a few studies have reported the response of compulsive hoarders to ERP. Most of this
literature is in the form of case reports, the majority
focus.psychiatryonline.org
INTENSIVE
INFLUENTIAL
PUBLICATIONS
Effective treatments for OCD include serotonin
reuptake inhibitor (SRI) medications and cognitive-behavioral therapy (CBT) using the technique
of exposure and response prevention (ERP).
Hoarding and saving compulsions have been
strongly associated with poor response to SRIs
(Black et al., 1998; Winsberg et al., 1999; MataixCols et al., 1999). A small study using open treatment with paroxetine or CBT for OCD patients
found that nonresponders were significantly more
likely to have hoarding/saving symptoms than responders (Black et al., 1998). In a case series, only 1
of 18 compulsive hoarders treated with a variety of
SRIs had an adequate response, and 9 had no response (Winsberg et al., 1999). In an analysis of
large scale, controlled trials of SRI treatment for
patients who have OCD, higher scores on the
hoarding symptom dimension predicted poorer response to SRI treatment, after controlling for baseline severity (Mataix-Cols et al., 1999). Thus, the
hoarding phenotype is a clear predictor of poor response to standard antiobsessional medications.
Despite this fact, no pharmacotherapeutic study
has specifically targeted the compulsive hoarding
syndrome.
of which report a poor outcome and usually emphasize compulsive hoarders’ ambivalence toward
treatment, poor insight, and failure to resist hoarding compulsions. In a controlled trial of CBT for
patients who have OCD, high hoarding symptom
scores predicted premature dropout and poor response to treatment (Mataix-Cols et al., 2002).
There is a paucity of literature on CBT that specifically targets compulsive hoarding. One group of
researchers has developed a CBT treatment strategy
(Hartl & Frost, 1999; Steketee & Frost, 2000) on
the basis of a cognitive-behavioral model that conceptualizes compulsive hoarding as involving four
main problem areas: information processing deficits,
problems in forming emotional attachments, behavioral avoidance, and erroneous beliefs about the nature of possessions (Frost & Hartl, 1996). CBT for
compulsive hoarding is directed toward decreasing
clutter, improving decision-making and organizational skills, and strengthening resistance to urges
to save. Treatment includes ERP, excavation of
saved material, decision-making training, and cognitive restructuring. They first reported the success
of their treatment strategy in a single patient (Hartl
& Frost, 1999). After 9 months of treatment, indecisiveness, hoarding, and OCD symptom severity
were all reduced. Over a 17-month period, five
rooms were excavated. They then reported on seven
compulsive hoarders treated with group CBT sessions and individual home visits. After 20 weeks of
treatment, five of the seven patients had noticeable
improvement, with significantly reduced acquisition of items, increased awareness of irrational reasons for saving, and improved organizational skills
(Steketee & Frost, 2000). Treatment continued for
several of these patients for up to 1 year, with continued improvement. This pilot study also demonstrated the needs to address difficulties with patient
motivation and involve family members in order to
promote progress and reduce risk of relapse. Although clearly effective, this type of treatment is
lengthy and labor-intensive.
MULTIMODAL TREATMENT
Although not all studies agree, recent research
suggests that the combination of medications and
CBT is superior to either alone for OCD. Intensive
treatment approaches combining aggressive pharmacotherapy with daily CBT and psychosocial rehabilitation in controlled settings have been found
to be effective for severe, treatment-refractory
OCD.
The UCLA OCD Partial Hospitalization Program (PHP) is a specialized treatment program that
provides intensive, multimodal treatment for se-
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SAXENA AND MAIDMENT
verely ill patients who have OCD and related disorders. Compared with outpatient treatment, this
program has the advantages of strict enforcement of
compliance with medication and CBT, as well as
massed ERP on a daily basis, 5 days a week. The
UCLA OCD PHP utilizes a modified version of the
treatment approach designed by Frost and colleagues for patients who have the compulsive
hoarding syndrome.
We sought to determine how compulsive hoarders would respond to intensive, multimodal treatment in the UCLA OCD PHP. We studied 190
consecutive patients with DSM-IV OCD, 20 of
whom were classified as having the compulsive
hoarding syndrome. All patients received intensive,
daily CBT (in both individual and group formats),
several hours a day, for approximately 6 weeks, and
the vast majority received medications and psychosocial rehabilitation. All patients were assessed before and after treatment with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton
Depression Rating Scale (HDRS), and Hamilton
Anxiety Scale (Ham-A). The proportions of patients treated with SRIs and antipsychotic medications did not differ significantly between groups.
CBT consisted of individualized ERP, along with
cognitive restructuring to improve insight, decrease
depressive and general anxiety symptoms, and address distorted beliefs. The 20 compulsive hoarders
received CBT focused on the compulsive hoarding
syndrome, along with training in organizational
skills and time management. We compared the response to treatment of compulsive hoarders (n ⫽
20) versus nonhoarding OCD patients (n ⫽ 170).
Hoarders had higher Ham-A scores than nonhoarders, both before and after treatment, but had
similar pretreatment Y-BOCS and HDRS scores.
Both groups improved significantly with treatment, but nonhoarders had significantly greater decreases in Y-BOCS scores than hoarders, indicating
greater improvement of OCD symptoms. Compulsive hoarders continued to have greater overall
symptom severity and functional impairment than
nonhoarding OCD patients at the time of discharge. However, though many hoarders had failed
trials of SRIs or outpatient CBT before admission
to the OCD PHP, they responded better than we
expected to intensive treatment, with a mean 35%
decrease in Y-BOCS score.
MULTIMODAL
TREATMENT FOR
COMPULSIVE HOARDING IN AN
INTENSIVE TREATMENT SETTING
Intensive treatment begins with a thorough assessment of the patient’s amount of clutter; beliefs
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about possessions; information-processing, decision-making and organizational skills; avoidance
behaviors; daily functioning; level of insight; motivation for treatment; social and occupational functioning; level of support from friends and family;
and medication compliance. Before treatment begins, patients must provide baseline photographs of
their cluttered areas.
Education and ERP are major components of
treatment. Patients learn to conceptualize their
hoarding in terms of problems with anxiety, avoidance, and information processing. Patients then
gradually expose themselves to situations that cause
them anxiety (e.g., being required to throw something away or make a decision about what to do
with a specific object). They rate their subjective
level of distress at regular intervals, using a Subjective Units of Distress Scale (SUDS). They are then
supported and instructed to resist the urge to save
or avoid until their SUDS level diminishes by at
least 50%. With repeated practice, ERP extinguishes the fear of losing something important,
thereby reducing the strength of the patient’s urges
to save. Intensive CBT for compulsive hoarding
focuses on four main areas: discarding, organizing,
preventing incoming clutter, and introducing alternative behaviors.
DISCARDING
From the outset, patients are told that ERP will
involve discarding items rather than merely organizing them. Discarding tasks force patients to
make decisions rather than postponing them; the
result is a decrease in the anxiety associated with
decision making. They also help patients learn that
nothing terrible happens when they discard items
that feel valuable. A secondary benefit to discarding
is that patients can learn how to organize their remaining possessions more effectively. When hoarders discard possessions, they typically become anxious, sad, or angry. In our experience, SUDS levels
decrease faster when patients do not see their items
once they are discarded. Discarding tasks may be
performed in the patient’s home or in the therapist’s office. When treatment occurs in the home,
patients are asked to pick one room on which they
would most like to work. They then systematically
work their way around the room, discarding items
or storing them appropriately as they go. They
should not move on to another room until the first
is completely cleared of clutter. Patients who live
too far away from home to make home visits feasible are instructed to take boxes of clutter from their
specified room to the therapist’s office and do the
discarding and sorting there.
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ORGANIZING
Many compulsive hoarders have as much difficulty organizing and storing their possessions as
they have discarding them. Patients must identify
specific places to store saved items and designate
deadlines by which storage will be completed. They
are taught more efficient strategies for organizing
their possessions. Once an area is cleared of clutter,
it must be maintained. Patients are encouraged to
use the cleared area for its intended purpose.
builds awareness of triggers and patterns of acquisition
behaviors. They are encouraged to discontinue many
of their subscriptions to magazines and newsletters. If
patients have difficulty going into stores without buying items, they receive graduated assignments to go to
stores and resist the urge to buy.
INTRODUCING
Hoarding tends to be a full-time occupation. It is
important to replace hoarding behaviors with more
adaptive behaviors. This is done in several ways:
First, although many compulsive hoarders dislike
the idea of schedules, they benefit from structure in
their day. Scheduling the day helps patients develop
the habit of taking medications regularly, going to
sleep at appropriate times, and being active during
the day. These changes can contribute greatly to
improved mood and functioning. Second, patients
are required to perform activities that were previously avoided, such as washing laundry, emptying
the trash, and sorting mail on a regular basis. Patients are encouraged to designate specific days and
times for each activity. As treatment progresses, patients start working toward more long-term structure, which may include part-time work, volunteer
work, or enrollment in classes. It is also important
that they incorporate recreational time in each day.
Compulsive hoarders often report that they never
have time to relax or pursue their hobbies. Therefore, patients are taught to create a realistic schedule
of activities that includes their chores, CBT homework assignments, recreational activities, and eating and sleeping times.
ENDING
TREATMENT
It is highly motivating at the end of treatment to
have “after” photos of the areas on which patients have
worked. When placed next to the baseline photos,
they enable patients to appreciate the improvements
they have made and provide a visual reminder of the
benefit of their hard work. Patients are strongly encouraged to have follow-up CBT on at least a weekly
basis after they complete the intensive treatment program. Without adequate follow up with outpatient
treatment, most patients do not maintain the gains
they have made in intensive treatment.
CASE
PREVENTING
ALTERNATIVE BEHAVIORS
INFLUENTIAL
PUBLICATIONS
There are several ground rules of discarding: The
first is that patients must pick up the first item that
comes to hand in their pile of clutter, rather than
sifting through the pile. The second rule is that they
must make a decision about that item before they
move on to the next item. Patients have three
choices when making a decision about an item—
they can discard it, keep it, or recycle it. The preferred option is that the patient discard the item,
and he or she is actively encouraged to provoke
anxiety by throwing away as many items away as
possible. If patients decide that they must keep an
item, they must decide where the item will be
stored. Recycling items is acceptable, as long as the
recycling options are limited.
ERP is bolstered by cognitive restructuring. Patients are prompted to reframe their obsessive fears
about discarding things. They are asked, “What’s
the worst thing that could happen if you didn’t
have this item?” “What do you think other people
do with similar items?” “If you threw this information away now, how could you access it if you found
that you needed it in the future?” Compulsive
hoarders need assistance in learning how to think
differently about their possessions. When patients
are asked to think about the consequences of
throwing away their clutter, they are challenging
their erroneous beliefs that dire consequences will
occur if they discard something. At the start of
treatment, when patient and therapist look at the
baseline photographs of their clutter, patients are
asked about what their ideal home would look like.
They are asked what percentage of their possessions
would have to be removed in order to achieve that
ideal. Throughout treatment, patients are reminded of how much clutter they have to eliminate
in order to achieve their ideal living environment.
ILLUSTRATION
INCOMING CLUTTER
Clutter should not enter as fast as it leaves. Therefore, patients must work on resisting the urge to acquire new items. Patients are asked to keep a daily log
of every item that they acquire or purchase, which
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PRESENTING
PROBLEM/CLIENT DESCRIPTION
“Sally” was a 50-year-old married woman who
had 3 children and a history of OCD symptoms
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since childhood. Her symptoms had been worsening since her early 20s and currently took the form
of severe compulsive hoarding. Sally also reported
mild depressive symptoms. Her family history was
significant for compulsive hoarding behaviors in
her mother, sister, maternal aunt, middle daughter,
and husband.
Sally first sought treatment when she was 49.
Treatment with paroxetine (Paxil 50 mg/day)
helped relieve Sally’s depression significantly but
did not improve the hoarding. Despite increased
motivation to address her hoarding problem, she
did not know where to begin and was still unable to
discard items. Outpatient CBT was unsuccessful
because Sally usually arrived more than 20 minutes
late at each session. She often had many subjects to
talk about and had difficulty focusing on the process of sorting or discarding her possessions. She
was unable to discard any of her accumulated clutter at home between sessions and was therefore referred to the UCLA OCD PHP for intensive treatment.
CASE
FORMULATION
At the time of admission, every room in Sally’s
house was cluttered, including her children’s bedrooms, garage, and garden. She also had a full storage
locker. Sally’s hoarded possessions included papers,
boxes, bags, arts and crafts supplies, tools, her children’s old schoolwork, toys, and mementos. She had
not allowed people to visit her house in many years,
causing distress to her children. Sally also described
difficulty in making decisions that had been worsening since college. She always felt busy but never productive and never seemed to complete any chore she
set out to do. Sally was frequently late for appointments. At work, she noted that her boss was always
trying to keep her “on task.” Sally met DSM-IV criteria for OCD and major depression and was diagnosed with the compulsive hoarding syndrome. Her
admission Y-BOCS score was 30, and her 21-item
HDRS score was 21. Physical and laboratory exam
results revealed no abnormalities or confounding
medical conditions.
COURSE
OF TREATMENT
Sally received intensive, multimodal treatment in
the UCLA OCD PHP, 4 hours per day, 5 days a
week, for 6 weeks. Her medication was switched
from paroxetine to venlafaxine (Effexor 300 mg/
day). At the start of treatment, Sally estimated that
to make her house look like her ideal home, she
would need to discard 80% of her clutter. Several
neighbors had complained to Sally that they had
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difficulty selling their homes because of her messy
home. Although Sally was aware that her house was
in need of major repairs, she was unable to ask
anyone to appraise her house because of the clutter.
A primary motivation for treatment was to make
the house clean enough to allow workers to enter
and do repairs. She chose to start work on her living
room. Because Sally lived far from UCLA, she
stayed in a local hotel during the week and returned
home on weekends. In the PHP, Sally spent 2 to 3
hours a day sorting through and discarding clutter
that she had taken in from home. Her weekend
homework was to put those items that she had decided to save in their preassigned places, spending
not more than 1 hour per day. Soon Sally was able
to go through one box per hour and discard about
80% of her saved possessions with support and
prompting from staff. When she worked independently, she had more difficulty—throwing away
about 60% of the items. Sally’s two main areas of
difficulty were discarding items related to her children and discarding old tax-related or legal papers.
To address the challenge of discarding her children’s old possessions, PHP staff and Sally met with
her children (all college age or older), who agreed
that Sally could throw away anything that belonged
to them. These included old books, toys, school
reports, and photographs. Her children unanimously agreed that it was “all junk,” and if anything
was important to them, they would remove it from
Sally’s boxes of clutter. Despite this strong endorsement from her children, Sally felt that they were too
young to appreciate the significance of their possessions and would later regret that they were thrown
away. She finally agreed to buy a small trunk for
each child and put items that she wanted to keep in
the trunk, allowing her children to discard them if
they wished. Sally continued to have difficulty with
sorting throughout her treatment.
Sally did much better with tax papers and legal
forms. At first, she was very reluctant to discard any
paper that seemed to be related to legal matters. Because she had become so disorganized over the years,
her husband had taken over the payment of bills and
management of finances. Sally and her therapist met
with Sally’s husband to discuss what would be appropriate to keep and what could be discarded. After several weeks of practice, Sally became proficient at making these decisions for herself and did not feel the need
to defer to her husband on every item.
OUTCOME
AND PROGNOSIS
By the end of treatment, Sally had completely
cleared her living and dining areas (see photos). Her
Y-BOCS score decreased to 16, and her HDRS
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score was 5. She then continued treatment in an
outpatient setting to maintain the gains that she
had made in clearing her living and dining areas
and start sorting through clutter in another room.
Outpatient therapy was set up so that she would
assign one afternoon per week as a “therapy” afternoon. She would talk to her therapist by telephone,
reviewing behavioral goals for the afternoon, and
then work on whatever task was assigned, checking
in with her therapist hourly for the next 3 hours.
Once a month, Sally would take boxes of clutter
from home to her therapist’s office and spend a
3-hour session sorting and discarding items.
At 4-month follow-up, Sally’s Y-BOCS score
had decreased to 14. She was maintaining the gains
she had made during the intensive treatment program and had progressed with consistent outpatient CBT. She no longer acquired unnecessary objects and had cleared two more rooms in her home
(see Figures 1 and 2).
CLINICAL
Baseline Photograph of “Sally’s”
Living Room at the Time of Admission to
the UCLA OCD Partial Hospitalization
Program.
Figure 1.
ISSUES AND SUMMARY
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fered from each other: hoarders had significantly
lower metabolism in the dorsal anterior cingulate
gyrus and thalamus than nonhoarding OCD patients. Across all OCD patients studied, hoarding
severity was significantly correlated with lower activity in the dorsal anterior cingulate gyrus (Saxena
et al., 2004). Our findings suggest that the compulsive hoarding syndrome may be a neurobiologically
distinct variant of OCD.
Diminished activity in the cingulate cortex may
contribute both to the symptoms of the compulsive
hoarding syndrome and to its poor response to
standard antiobsessional treatments. Functions of
the anterior cingulate cortex include focused attention, motivation, executive control, assignment of
emotional valence to stimuli, monitoring of response conflict, emotional self-control, error detection, and response selection. The anterior cingulate
also plays a key role in decision making, especially
in choosing among multiple conflicting options.
The posterior cingulate cortex is involved in the
monitoring of visual events, spatial orientation, episodic memory, and processing of emotional stimuli. Hence, low activity in both the anterior and
posterior cingulate gyrus could mediate the remarkable difficulty in making decisions, attentional
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INFLUENTIAL
PUBLICATIONS
The treatment of compulsive hoarding is extremely difficult. Success depends on the patient’s
having a high degree of motivation and commitment. Home visits are useful both for initial assessment and for in situ ERP exercises. Our experience
suggests that although compulsive hoarders often
have a complex array of symptoms and functional
deficits, they may respond well to a comprehensive,
multimodal approach tailored to the specific features of the compulsive hoarding syndrome. Ideally, multimodal treatment should not only extinguish patients’ obsessional fears and compulsive
saving behaviors, but also give patients a set of organizational and decision-making skills they will
retain forever, thereby reducing the risk of relapse.
There is growing evidence of phenomenological,
genetic, and neurobiological heterogeneity within
the diagnosis of OCD. Recent data regarding the
functional neuroanatomical features of compulsive
hoarding shed light on both the phenomenology
and the poor treatment response of this syndrome.
Our group conducted a positron emission tomography (PET) brain imaging study that measured
cerebral glucose metabolism in patients who have
the compulsive hoarding syndrome, compared to
that in nonhoarding OCD patients and normal
controls. We found that compulsive hoarders had a
unique pattern of brain activity, distinct from that
seen in either nonhoarding OCD patients or normal control subjects. Compulsive hoarders had significantly lower metabolism in the posterior cingulate gyrus and occipital cortex than control subjects.
Hoarders and nonhoarding OCD patients also dif-
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SAXENA AND MAIDMENT
Sally’s Living Room after She
Completed Six Weeks of Intensive,
Multi-Modal Treatment, Including
Cognitive-Behavioral Therapy and
Medication, in the UCLA OCD Partial
Hospitalization Program.
Figure 2.
ers such as donepezil or galantamine, which increase cholinergic neurotransmission in the cerebral cortex, or stimulant medications, which can
increase the functioning of medial prefrontal cortical areas involved in attention and executive functioning. Future cognitive-behavioral approaches
should also target the information-processing deficits that appear to be present in patients who have
the compulsive hoarding syndrome, including
faulty decision making and deficits in organization/
categorization (Frost & Hartl, 1996). These putative deficits must be confirmed by neuropsychological testing, to determine whether the compulsive
hoarding syndrome includes a consistent neurocognitive profile that could be addressed by treatment.
SELECT REFERENCES/RECOMMENDED
READINGS
problems, and other cognitive deficits seen in compulsive hoarders. More-over, lower pretreatment
anterior cingulate gyrus activity has been strongly
associated with poor response to antidepressant
treatment, and lower activity in the posterior cingulate gyrus correlated to a poorer response to fluvoxamine in patients who have OCD. Thus, our
finding of low cingulate activity in patients who
have the compulsive hoarding syndrome is quite
consistent with the poor response to standard treatments for OCD.
Future pharmacotherapeutic approaches should
target brain dysfunctions specifically associated
with compulsive hoarding (Saxena et al., 2004).
Possible strategies might include cognitive enhanc-
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