Hoarding Disorder: The Next Step
A Neurocognitive Approach to Treatment
Kay Jewels, B.A. Research Assistant, McLean Hospital
Director, The Next Step Program
Donald A. Davidoff Ph.D. Chief, Department of Neuropsychology, McLean Hospital Assistant Professor of Psychiatry, Harvard Medical School
Mental Health Association of San Francisco 18th Conference on Hoarding and Cluttering
March 2018
Disclosure
■ Neither Ms. Jewels nor Dr. Davidoff report that either of them or any member of their immediate families have a significant financial interest in or affiliation with any commercial goods/organization that may have a direct or indirect interest in the scientific program.
■ Neither Ms. Jewels nor Dr. Davidoff will discuss unapproved or investigational use of any products during their presentation at the OCD Annual Meeting.
Hoarding Disorder: The Next Step
A Novel Approach to Treatment Based on an Understanding of the Neurocognitive Deficits of HD
I. Background and Research II. Examples of Cognitive Issues III. The Next Step Program
Importance of Understanding Hoarding Disorder
■ Impact on the Individual ■ Isolation ■ Functional Impairment ■ Family Dysfunction ■ Anxiety & Distress ■ Increased Medical Disability ■ Increased Risk of Physical
Injury ■ Premature Death
■ Impact on Society ■ Safety Hazards ■ Fire Hazard ■ Mold & Toxic Odors ■ Environment for Insects and Rodents ■ Increased Risk of Poverty and Homelessness ■ Public Cost (~$16K to clean each house)
Hoarding Disorder = Public Health Crisis + Mental Health Crisis
Prevalence of Hoarding Across the Life Span
• Hoarding symptom severity increases with age
• Hoarding symptoms are more refractory with age
• Elder individuals with hoarding have a 5 year mortality rate of approximately 50%
Cath 2017; Snowdon 2007; Samuels 2008; Ayers 2010
Historic Conceptualization of Hoarding Disorder (DSM-IVTR)
A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control, at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, characterized by (at least) four of the following:
• Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
• Perfectionism that interferes with task completion
• Excessively devoted to work
• Inflexible about matters of morality, ethics, or values
• Unable to discard worn-out or worthless objects even when they have no sentimental value
• Reluctant to delegate
• Miserly spending style
• Rigid and stubborn
301.4 Obsessive-Compulsive Personality Disorder
Symptoms of Hoarding Disorder
■ Persistent difficulty discarding or parting with possessions ■ Perceived need to save items, regardless of actual value ■ Distress associated with discarding ■ Avoidance of Discarding to manage associated distress
■ Accumulation of possessions ■ Cluttered living areas compromise their intended use ■ Fire Hazards, Health and Safety Violations
■ Significant anxiety or impairment of functioning in social, occupational, or other important areas
Woody et.al. 2014
The Implications of Research (pre-2013)
Deciding to Discard Causes
Anxiety
Anxiety Provokes Distress
Distress Intolerance Predicts Avoidance
Ritual
• Research Prior to 2013 Conflated HD with OCD
• Resulting Treatment Modalities (CBT) not based on Comprehensive Understanding of the Disorder
The Gold Standard Treatment for Hoarding Disorder
CBT has been the traditional treatment of individuals with HD.
It is a short-term, goal oriented treatment that seeks to make
individuals aware of when they make negative interpretations
and of behavioral patterns which reinforce the distorted
thinking. It helps individuals develop alternative ways of
thinking and behaving in order to reduce feelings of distress.
Problem solving and organizational skills are particularly
emphasized. Unfortunately, CBT for geriatric hoarders has
been less than effective.
Steketee & Frost 2007
Ayers 2009
Current Conceptualization of Hoarding Disorder (DSM-5)
A. Persistent difficulty discarding or parting with possessions, regardless of actual value
B. Difficulty due to perceived need to save items and to distress associated with discarding them
C. Results in accumulation of possessions that congest and clutter active living areas and compromises their intended use
D. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
E. Not attributable to another medical condition
F. Not better explained by the symptoms of another mental disorder
Specify if: With excessive acquisition
With good, fair or poor insight With absent insight/delusional beliefs
300.3 Hoarding Disorder
• Attention, including complex attention • Visuospatial Processing • Memory -working memory -visuospatial memory • Executive Functions -planning & organizing -problem solving -conceptualization -categorization -inhibitory control -mental control -cognitive flexibility
Research Indicates Involvement of Multiple Cognitive Processes
Ayers 2013
Woody 2014
In HD, imaging findings implicate areas of the orbitofrontal cortex and dorsal anterior cingulate
Mataix-Cols 2011; Saxena 2008, 2004
Neuroanatomy of Hoarding Disorder
Anterior Cingulate Cortex (ACC)
Mediates a Variety of Higher-level Cognitive and Emotional Functions: • Object Appraisal • Insight • Reward Contingencies • Error Detection • Anticipation of Tasks and Prioritization • Attention/Selective Attention • Visual Memory and Working Memory • Motivation • Intensity of Emotional Response
Posner et.al. 2007
Caveda 2000
Rolls 1996
• Difficulties with sorting
and categorization
• Too many narrowly and
idiosyncratically defined
categories
• Concrete, unrealistic or
illogical groupings
Cognitive Deficits: Conceptualization and Categorization
Ayers 2016, Woody 2014,Timpano 2014,
Wincze 2007, Santostefano 1978
Problems with executive functions can impair decision making including processes such as categorization and object groupings, which are necessary for the organization of tasks involved in decluttering. Problems with memory can heighten fear of making bad choice, i.e. discarding needed objects. Problems with memory may discourage people from using storage systems and places that put object out of sight, like a filing cabinet or closet.
Cognitive Deficits Can Influence Decision-Making
Woody 2014
Lack of Insight
Lack of Distress
Treatment Resistance
• Insight requires higher-order brain networks underlying attention, working memory, and cognitive control.
• The processes are
impaired in those with Hoarding Disorder
Cognitive Deficits Can Result in Lack of Insight
Inflates Perception of Need and
Distress Associated with Discarding
Value Misappraisal
Interferes with the categorization
conceptualization process
Cognitive Deficits: Object Processing
Faulty Object Processing can result in Value Misappraisals:
Cognitive Deficits Can Impact Emotional Regulation
▶ reluctance to accept emotional responses
▶ difficulty regulating behavior when distressed
▶ lack of access to strategies for feeling better when distressed
Tolin 2018
Hoarding: A Neurocognitive Approach to Core Features
Information Processing Deficits • Lack of Insight • Value Misappraisal • Emotional Dysregulation
Recent Improvements in Treatment Strategies for Individuals with HD: Cognitive Rehabilitation
Emphasizing cognitive rehabilitation of cognitive skills
including problem solving, organizational abilities,
prospective memory and cognitive flexibility in the
context of behavioral interventions (exposures) to
discarding and not acquiring produced clinically and
statistically significant reductions in hoarding severity in
a study of geriatric HD. Ayers 2014
Recent Improvements in Treatment Strategies for Individuals with HD: Motivational Interviewing
Adding motivational interviewing and thought
mapping to traditional CBT group treatment of
individuals with OCD facilitates a decrease in
hoarding symptoms Mayer et.al. 2009
The Future: A Comprehensive Approach to HD
HD is not a simple problem of accumulation of objects but is a
complex multifactorial problem involving a unique confluence of
behavioral, emotional, and cognitive factors.
As such, effective strategies to ameliorate the symptoms of HD must
include:
• Therapeutic focus on the excessive emotional attachments to
possessions and subsequent distress and behavioral avoidance
• Correction of erroneous beliefs about the nature and importance
of possessions
• Attention to the observed information processing deficits that
appear to underlie the observed behaviors
• Application of cognitive prostheses to attenuate the impact of the
underlying cognitive deficits.
Cognitive Deficit: Conceptualization & Categorization
Idiosyncratic Grouping
• Difficulties with sorting and categorization
• Too many narrowly and idiosyncratically defined categories
• Concrete, unrealistic or illogical
groupings
Cognitive Deficit: Object Memory and Value Appraisal
Emotional Regulation Deficit
▶ Reluctance to accept emotional responses
▶ Difficulty regulating behavior
when distressed
▶ Lack of access to strategies for
feeling better when distressed
Tolin 2018
The Next Step
The Next Step Program
resolves safety and sanitary
issues, restores functionality to
living areas and reduces distress
utilizing a tripartite approach to
HD consisting of:
• Life Coaching
• Cognitive Behavioral Therapy
• Cognitive Prostheses
The Next Step
The Tripartite Model of Hoarding Disorder
Neurocognitive Substrates of Hoarding Disorder
Core Features of Hoarding Disorder
Symptoms of Hoarding Disorder
• Executive Attention
• Sustained Attention
• Visuospatial Attention
Attention Deficits
• Working Memory
• Visual Memory Deficits
• Verbal Memory Deficits
Memory Deficits • Conceptualization
• Inhibition • Decision Making • Self-Regulation
Executive Dysfunction
• Task Initiation • Task Completion
• Goal Directed Motor Responses
Functional Impairments
Hoarding: Cognitive Deficits Underlie Functional Impairments
Assists with
Increasing Productivity and Reducing Object
Clutter
Reducing Waste and Related
Anxiety
• Planning and Prioritizing the Steps to Goal Completion
• Maintaining Motivation and Sustaining Continued Effort
• Staying on Tasks and Completing Steps
• Organizing and Sorting
• Recycling and Discarding
• Repurposing and Relocating
• Sell items on E-Bay
• Donate to Charity
• Host a Yard Sale
• Give to a Friend • Recycle
The Next Step: Life Coaching
Next Step Includes CBT
CBT ≠ NEXT STEP
But
Clutter
Distress
Avoidance
Attention
Memory
Executive Function
The Next Step: Cognitive Behavioral Therapy Focus
Life coaching, in contrast to CBT alone focuses on: • Reframing the behavior to clarify the impact on
interpersonal and daily life issues
• Utilizing motivational interviewing to clarify individual short and long term goals
• Decreasing the amount and frequency of unproductive behaviors through psychoeducation and retraining around such issues as prioritization and organizational strategies
• Disengaging from false beliefs through the use of rewarding strategies
• Utilizing the therapeutic alliance to convey that two together can do what one alone cannot
The Next Step: Life Coaching
• Keeps it Positive
• Makes it Fun
• Talks it out
Makes it Feel Rewarding
– Remembers Goals
– Highlights Progress
– Gives Recognition
The Next Step: Life Coaching
Breaks the Anxiety Cycle:
Cognitive Prostheses: • Reduces anxiety and fear of forgetting
• Reduces acquiring and saving unnecessary items
• Reduces fear of change
• Reduces negative effects of cognitive deficits
Cognitive Prosthesis: a device that extends the capability of human cognition or sense perception
The Next Step: Cognitive Prostheses
■ Colored Sticker Flags ■ Visual Memory and Prioritization
■ Transparent Storage ■ Visual Memory and Categorization
■ Smart Phone Technology ■ Verbal and Visual Memory
■ Mini GPS Trackers ■ Spatial Memory and Object Location
The Next Step: Cognitive Prostheses
Cognitive Prosthesis: Colored Sticky Flags
• Memory
• Planning
• Prioritization
• Object Location
The Next Step: Example
Cognitive Prosthesis: Transparent Container
• Visuospatial planning
• Conceptualization
• Categorization
• Memory
Cognitive Prosthesis: The Transparent Drawer
A Maintainable Long-Term Organizational Solution that can:
• Keep the Possession in View
• Reduce Object Clutter and Provide Order
• Reduce Anxiety and Fear of Forgetting
• Reduces Resistance to Putting Objects Away
Cognitive Prosthesis: Mini GPS Trackers
• Locate Objects of Importance
• Reduce Fear and Anxiety
• Reduce Reliance on Ineffective Organizational Strategies
• Increase Productivity
Cognitive Prosthesis: Smart Phone Technology
■ Camera ■ Remember Objects with Pictures
■ Notebook ■ Remember Important Information
■ Calendar ■ Remember Important Dates
■ Contacts ■ Remember Important Contacts
Next Step Intervention: Before
Cognitive Prosthesis
Next Step Intervention: After
The Next Step
Before
After
Next Step Intervention: Before
Cognitive Prosthesis
Next Step Intervention: After
The Next Step
After Before
HD is a multifactorial problem involving a cycle of false beliefs, emotional distress and behavioral avoidance. There is increasing evidence that there is a substrate of cognitive processing difficulties underlying this dysfunctional behavior. Any treatment program must address all of these issues simultaneously in order to ameliorate the deleterious impact of HD on an individual’s life. The Next Step Program is a proposed treatment program with a tripartite approach to the problem of HD involving: • Life Coaching • Cognitive Behavioral Therapy and Cognitive Rehabilitation Strategies • Application of Cognitive Prostheses
Conclusions
• What is the exact nature of the cognitive profile of individuals with HD?
• How might these difficulties impact day to day functioning beyond the symptoms of HD itself?
• Does HD represent a neurodevelopmental disorder and is the increase in prevalence over the life span a function of neurodegenerative process?
• What is the role of disgust in HD?
• Can the neuroanatomical structures involved in HD be better defined and even quantified?
• How can we use our knowledge of cognition to further enhance the effectiveness of NSP?
Future Questions and Directions
Thank you
For Further Questions
For further questions or comments, Ms.
Jewels and Dr. Davidoff can be reached at:
McLean Hospital Department of Neuropsychology 115 Mill Street Belmont, MA 02478 (617) 855-2645 [email protected]
Questions?
