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Treatment of Hoarding Disorder:

From Research to Practical

Application

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Karron Maidment, RN, MFT

Resnick Neuropsychiatric Hospital

Obsessive Compulsive Disorder Clinic

Hoarding Disorder

Definition

Current research

Treatment and Management

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Hoarding

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

Behavior

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Hoarding Disorder

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

Notes and Lists

Storage Containers

Old Clothes

Memorabilia

(Frost & Gross, 1993; Winsberg et al, 1999)

Research –

3 Perspectives

Cognitive Behavioral

Neurobiology

Neurocognitive

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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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Indecisiveness

Perfectionism

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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Indecisiveness

Perfectionism

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.

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Frost and Hartl 1996

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.

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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

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Indecisiveness

Perfectionism

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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Emotional attachment problems

Erroneous beliefs about the nature of possessions

Frost and Steketee 1999

Neurobiology

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Saxena et al, 2004

Am J Psychiatry

L Transverse R

Right Posterior

Cingulate Gyrus

Brain Regions with Lower Glucose Metabolism

in Hoarding Disorder than in Controls

Functional Neuroanatomy of

Hoarding Disorder

Sagittal 3.0

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Functional Neuroanatomy of

Compulsive Hoarding Syndrome

(Saxena, Brody, Maidment et al, 2004

Am J Psychiatry)

L Coronal R

Brain Regions with Lower Glucose Metabolism in Hoarders

than Non-Hoarding OCD

Sagittal

L Transverse R 3.0

• 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)

Role of the Cingulate Cortex - Attention, Cognition, and Decision-Making

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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)

Role of the Cingulate Cortex - Attention, Cognition, and Decision-Making

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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

Neurobiology

Neurocognitive

Treatment

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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

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

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

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Organizing

Decision making

Initiating/stopping

Decision making

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Discarding Process

Pick a room -

any room

Before photos

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

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

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

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

Improved decision

making about

discarding clutter.

Improved decision

making about the

acquisition of

clutter.

Not so pros

Little likelihood of being able to discard alone.

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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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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Cleared areas must stay clear.

Establish routine for regular ‘sweeps’ of cleared

areas.

- goal directed, time limited

- monitor behavior - make necessary

changes

Organizing Self

Establish times for routine ADL’s

The foundation on which to build the rest of the day

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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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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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Organizing Self

Use a calendar- preferably digital

plan day prioritize activities monitor behavior

adapt behavior

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Problem solving

Establish goal

Come up with a plan

Break it down

Keep it time limited

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Organizing/Prioritizing

Initiating

Stopping

Prioritizing

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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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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Treatment can address

neurocognitive deficits

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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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