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The Psychology of Compulsive Hoarding Dr Christopher Mogan The Anxiety Clinic, VIC
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The Psychology of Compulsive Hoarding
Dr Christopher Mogan
The Anxiety Clinic, VIC
The Psychology of Compulsive Hoarding
Dr Christopher Mogan
NATIONAL SQUALOR CONFERENCE
Sydney, November 5-6, 2009
Hoarding behaviours• Common to hoard ‘stuff’ - keep ‘ just in case’• Compulsive hoarding is more pervasive,
dominating time, space of self & others. Packed garages, backyards, corridors, roof spaces, rooms chaotic & unusable.
• Unable to organize, discard things or prevent clutter, high distress, hazards to health/safety.
• Hoarding largely undiagnosed & untreated.
Issues in studying hoarding• Causes and phenomenology of
compulsive hoarding remains unclear -no DSM IV criteria
• Estimates of population with OCD range from 0.6% to more than 3%. Hoarding in the OCD population estimated at 30%+.
• Hoarders seen as secretive, resistant to treatment, undiagnosed for years; not a diagnostic criterion for OCD, only OCPD.
Frost & Hartl (1996) defined Compulsive Hoarding
• The acquisition of and failure to discard possessions that appear to be useless or of limited value.
• Impairment from– the degree of clutter involved making rooms
unusable for their purpose– negative effect on the personal functioning
of the hoarder - reported risks: fire(47%), falls (38%), hygiene (35%). Nil hazards (25%).
Hoarders & non-hoarders think differently about things
Hoarders have specific problem appraisals:
1. Emotional attachment to objects
2. Memory for possessions and objects
3. Control of possessions and objects
4. Responsibility for possessions and objects
Other hoarding-related cognitions
– Indecisiveness
– No confidence in memory uncertainty
– Need to keep things ‘in view’
– Comfort from being ‘with’ things
– Fear of forgetting important memories
– Need to be reassured about things
ETIOLOGY (Causation)Psychoanalytic approachesFreud’s construct of reactive defence against conflict in the anal stage led Fromm to delineate a hoarding character - remoteness, withdrawal from others.. a controlling mode of relatedness - reduce anxiety by control.In Kleinian theory, the unconscious urge is to ‘return’all that had been removed from the mother, yet brings a un-resolvable conflict in the compulsive urge to ‘hold on.’Contemporary P/A theory emphasizes the loss of adaptiveness & mental inflexibility of the hoarder in fearing change/unpredictability
Neurological approachesHeuristic value based on the reported issues with memory & organization.Research is still developing and findings are inconclusive even with advances in functional & structural imaging.Meta-memory factors suggest memory bias based on appraisal not on deficits.
Cognitive Behavioural model
• CBT has defined hoarding, developed treatment on a multi-factorial model.
• Information-processing deficits –memory, decision-making, categorizing
• Faulty appraisal of importance of things• Disability associated with clutter, no
insight, emotional & rigid behaviours.
Some models of HoardingAbnormal Psychology model - focused
Delusional Disorder – e.g. odd and bizarre reasons for keeping things
• Claiming affinity with animals or special relationship with or need for things.
• Deny obvious neglect, harm & chaos; hostile, rejecting of help.
• Function well outside delusional system.
Squalor modelDementia and other deteriorating models emphasize loss of self-care & organization. Secretive, isolated, uncooperative; decayed food, animal waste, pest infestationHoarder profiles emphasize 65+, single, female.Dementia brings a sudden deterioration to any hoarding situationRequire structure, psychiatric assessment, protective interventions and medication
3) Addiction model
- Total pre-occupied with hoarding focus- denial, excuses, claims of persecution,
ignoring overall outcome of hoarding. - Impulse control issues in compulsive
acquiring of things or animals.- Significant comorbidities
4) Attachment model• Emphasizes disorganized early attachment
with compromised chaotic parenting. Animal or object as stable fixtures.
• Compensatory unconditional love for & from animals has explanatory power.
• Consistent with CH where sense of self and grief-like loss connected with things
• Compulsive need to keep animals or objects to protect them, maintain connectedness
Obsessive Compulsive Disorder Model
• OCD associated with hoarders’ key FELT RESPONSIBILITY to care for possessions including things, animals, memories.
• Harm prevention, special relationships or other symbolic meanings.
• Sense of ‘mission’ whether for animals or responsibility for things
• Avoidance behaviours can reach delusional levels
Age of onset, course of hoarding
• Chronic and insidious course becoming overwhelming.
• Age of onset in childhood/early adolescence: as young as 10, mild symptoms at 17, moderate in mid-20’s, extreme by mid-30’s.
• Help-seeking not until 50 years and over
How common is hoarding• As many as 1.2 million problem
hoarders in the USA.• Estimates range from 1 in 350 or 400
people in the UK and Australia.• Number of problem hoarders possibly in
the range of 60,000 to 90,000, but no research data available.
Phenomenology of hoarding• Examined in a study of known hoarders
in comparison with clinical groups (OCD, anxiety states) and community controls (N= 109).
• Findings consistent with overseas research.
• Hoarding phenomenology is distinct from other clinical and control groups.
Measuring hoarding?– Savings Inventory – Revised: savings actions, time spent, emotional
responses to saving & discarding, usefulness of saving, interference caused by saving.
– Savings Cognitions Inventory: measuring beliefs associated with possessions - need for things, why cannot throw things away, need to control what happens, to get comfort from things.
– Savings List of things kept.
– Hoarding Rating Scale – Hoarding Interview– Visual Rating of Clutter
Outcomes• The cognitive, affective and information-
processing factors of CBT model supported.
• Emphasis on severity of clutter, amount saved, and dysfunctional beliefs about things.
• Hoarders compared with other clinical groups and community controls showed significant difference in socio-economic status (income).
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Hoarding-related Early Devel. Influences Inv. (Kyrios, 2005)
Isolated two factors showing hoarders had more issues than non-hoarders:
1) Uncertainty about the self and others e.g. I have never been able to work out people’s reactions to me
2) Warm Family - assessing memories of warmth and security in one’s family e.g.My early childhood featured a constant sense of support
The warm family factor was a significant predictor of hoarding behaviour.
Predictors of hoarding in Predictors of hoarding in analyses of the data: In order analyses of the data: In order ……
i. Perceived lack of family warmth
ii. Padua Inventory – OCS
iii. Fear of Neg. Eval. – Social Anxiety
iv. Possessions in View Scale
v. Beck Anxiety Inventory
vi. OCPD – Personality Disorder
vii. Frost Indecisiveness Sc – Fear of decision – making
viii.Consequences of Forgetting Scale
TREATING HOARDING IS COMPLEX
• Hoarders have highly-personalised reasons for Hoarding
• Hoarders have ambivalent and avoidant personality styles
• Uncertainty about self and others leads to object-driven compensatory behaviour
• Treatment – interfering variables are common –Rigidity, Control, Reluctance for treatment
• Fear of making decisions, control and memory and the deep seated beliefs held by hoarders.
Maintenance Relapse
ContemplationAction
Preparation
Termination
PrecontemplationThe Wheel of Change
Treatment of hoardingAssessment of hoarders in their context to determine the treatment needs.Liaison with health & welfare agencies –complexities require collaboration.Therapy is not quick-fix, outcomes based on specifying goals. Harm minimization as in drug addiction as a guide.Treatment still being developed..
Treatment• Learning of skills in managing paper items –
categorizing, judging worth, challenging keeping of everything
• Increasing confidence in discarding sessions in clinic led to systematic practices in home.
• Motivation needs to be very high• Respond to positive reinforcement, sense of
achieving very specific goals
Quick fix clean-ups• Imposing controls and cleaning up
without respecting the needs of the hoarder lead to rapid relapse and highly reinforced resumption of hoarding.
• Better to understand the personal context, build up rapport and motivation, by targeting small improvements.
• Small goals, active collaboration.
Myths of saving need challenging
• Someone will find this useful.• I never throw anything away.• I must keep all things that recall this person.• I know exactly where everything is.• How helpful to me is this clutter and mess?• These things are my life…I don’t know why!• Throwing things away is rejecting them• Keeping a things is to accept it into my life.
Therapy tips• Skills-building is based on practice.
Discard something however small every day- DSD
• Build a relationship affirming the difficult task of CH – Try to keep them attending therapy –motivation as key to change
• Set small targets - safety of self/others• Visualization of de-cluttered room
FutureResearch needs financial commitmentTraining of associated workers – health, welfare, community carers, state & local jurisdictions -team approach.Leadership for the long term research, planning and resourcing, education, lobbyingSolution not in legislation and enforcement yet they are essential elements, especially when risk extend to children, elderly; and also animals.
Dr Christopher MoganThe Anxiety Clinic
TMC Suite 6,140 Church St, Richmond 3121
Tel 03-9420 [email protected]
