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Treatment of Hoarding Disorder: From Research to Practical Application UCLA OCD PROGRAM Karron Maidment, RN, MFT UCLA Resnick Neuropsychiatric Hospital Obsessive Compulsive Disorder Clinic
Treatment of Hoarding Disorder:
From Research to Practical
Application
UCLA OCD PROGRAM
Karron Maidment, RN, MFT
UCLA
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
Bags
Books
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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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.
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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.
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
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
2.5
1.5
2.0
1.0
0.5
0.0
Z v
alu
e
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Functional Neuroanatomy of
Compulsive Hoarding Syndrome
(Saxena, Brody, Maidment et al, 2004
Am J Psychiatry)
Anterior
Cingulate
gyrus
L Coronal R
Brain Regions with Lower Glucose Metabolism in Hoarders
than Non-Hoarding OCD
Sagittal
L Transverse R 3.0
2.5
1.5
2.0
1.0
0.5
0.0
Z
va
lue
• 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
Cognitive Behavioral
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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stuff
Self
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
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
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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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
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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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
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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
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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^
^
Problem solving
Establish goal
Come up with a plan
Break it down
Keep it time limited
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Improving Organizational Skills
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
