1. hobbies and interests
2. collecting

7/6/12 Features, Conceptualiza7on, and Treatment of Hoarding Disorder Overview •  Diagnosis and Features of hoarding •  Cogni7ve behavioral model of hoarding Gail Steketee, PhD and Randy Frost, PhD July 27, 2011 IOCDF Chicago, Ill DSM-­‐V Criteria for Hoarding Disorder – Criterion A •  Persistent difficulty discarding or par7ng with possessions, regardless of whether they are perceived by others to be valuable or not •  Assessment of hoarding •  Interven7on for hoarding DSM-­‐V Criteria for Hoarding Disorder -­‐ Criterion B •  This difficulty is due to a perceived need to save the items and distress associated with discarding them 1 7/6/12 DSM-­‐V Criteria for Hoarding Disorder – Criterion C •  The symptoms result in the accumula7on of possessions that congest and cluTer the ac7ve living areas and substan7ally compromise their intended use. –  If living areas are uncluTered, it is only because of the interven7ons of third par7es (e.g., family members, cleaners, authori7es) DSM-­‐V Criteria for Hoarding Disorder -­‐ Criterion E •  The hoarding is not aTributable to another medical condi7on (e.g., brain injury, cerebrovascular disease, Prader Willi Syndrome). DSM-­‐V Criteria for Hoarding Disorder -­‐ Criterion D •  The hoarding causes clinically significant distress or impairment in social, occupa7onal, or other important areas of func7oning (including maintaining a safe environment for self and others). DSM-­‐V Criteria for Hoarding Disorder -­‐ Criterion F •  The hoarding is not beTer accounted for by the symptoms of another DSM-­‐5 disorder (e.g., OCD, depression, demen7a). 2 7/6/12 Proposed Diagnos7c Specifiers •  With Excessive Acquisi7on "   If symptoms are accompanied by excessive collec7ng or buying or stealing of items that are not needed or for which there is no available space. •  Poor insight Poor insight specifier •  Good or fair insight: Recognizes that hoarding-­‐related beliefs and behaviors (pertaining to difficulty discarding items, cluTer, or excessive acquisi7on) are problema7c. •  Poor insight: •  Absent insight: Poor insight specifier Poor insight specifier •  Good or fair insight: •  Poor insight: Mostly convinced that hoarding-­‐
related beliefs and behaviors are not problema7c despite evidence to the contrary. •  Absent insight: •  Good or fair insight: •  Poor insight: •  Absent insight (Delusional beliefs about hoarding): Completely convinced that hoarding-­‐related beliefs and behaviors are not problema7c despite evidence to the contrary. 3 7/6/12 Irene • 
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53 year old woman 2 children Husband just moved out Hoarding began in childhood Manifesta7ons of Hoarding Acquisi5on Saving Disorganiza5on Compulsive Saving / Difficulty Discarding •  Acquisi7on –  Buying –  Free Things –  Stealing –  Passive •  Types of items –  Clothes, newspapers, books, containers –  DSM-­‐IV – worthless & worn •  ATachments –  Sen7mental –  Instrumental –  Intrinsic 4 7/6/12 Disorganiza7on Epidemiology •  Samuels et al. (2008) = 5.3% US (adjusted) •  Condi7on of Home –  CluTer –  Mixed importance •  Iervolini et al. (2010) = ~2% UK •  Behavior –  Churning •  Mueller et al. (2009) = 4.6% Germany –  Out of sight fear •  Timpano et al. (2011) = 5.8% Germany Low frequency of OCD in hoarding Core beliefs &
vulnerabilities
Information processing Hoarding Sample (n=217) Attachments & Valuation of objects
18% OCD No OCD Nega7ve Reinforcement Emotions
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Frost et al., 2011 5 7/6/12 Biological vulnerability Core Beliefs & Psychological Vulnerabili7es •  Self-­‐worth –  I’m worthless. •  Neural mechanisms •  Mood •  Co-­‐morbidity •  Helplessness –  I have no control. Nothing I do will make a difference. •  Gene7cs Informa7on Processing Deficits •  ATen7on •  Percep7on •  Categoriza7on •  Associa7on •  Memory •  Complex Thinking Emo7onal ATachments and Beliefs • 
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Beauty/aesthe7cs Memory U7lity/opportunity Sen7mental Comfort Safety •  Iden7ty or poten7al iden7ty •  Control •  Mistakes •  Responsibility/waste Decision-­‐making Difficul7es 6 7/6/12 Learning Processes Avoidance condi7oning •  Posi7ve reinforcement (posi7ve emo7ons) •  Nega7ve reinforcement (nega7ve emo7ons) •  No opportunity to test beliefs & appraisals (avoidance) • 
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Distress Decisions ATending to cluTer Feelings of loss Feelings of vulnerability Worries about memory •  Invi7ng people into the home •  Making mistakes •  Losing opportuni7es •  Losing informa7on •  Depression •  Punng things out of sight •  No opportunity to develop alterna7ve beliefs (avoidance) Core beliefs &
vulnerabilities
Information processing Func7onal Analysis of Compulsive Shopping Episode Attachments & Valuation of objects
40 year old professional woman Nega7ve Reinforcement Emotions
Neg.
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Husband & 12 year old son Posi7ve Reinforcement $27,000 credit card debt Clothes buying compulsion Serious hoarding problem 7 7/6/12 Hoarding Interview Compulsive Buying Episode Hoarding Ra7ng Scale hTp://
www.ocfounda7on.org/hoarding/tests.aspx • 
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0-­‐8 scales for 5 items: Difficulty using rooms in your home? Difficulty discarding Problem collec7ng or buying Emo7onal distress Impairment • 
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Home and cluTer Objects and reac7ons Where to start Organiza7onal system Acquiring Reasons for saving Family & friends •  Health & safety •  Problems from hoarding •  Comorbidity (MDD, OCD, ADHD, etc.) •  Family history of hoarding •  Onset & course •  Interven7on efforts Saving Inventory-­‐Revised Cutoff scores •  Excessive Acquisi7on •  Difficulty Discarding •  CluTer •  Total Score 9 14 17 41 8 7/6/12 Ac7vi7es of Daily Living •  Item examples: •  Subscales: –  Kitchen –  Bathroom –  Common Areas Mo7va7on •  What makes people mo7vated to change? –  Importance –  Confidence •  Mo7va7onal Interviewing –  A client-­‐centered, direc7ve method for enhancing intrinsic mo7va7on to change by exploring and resolving ambivalence •  Anosognosia (nosos + gnosis) – Lack of awareness or denial of a disability or deficit – Indifference to consequences •  CluTer Blindness •  Overvalued Ideas Frost et al. (2010) –  Eat at table –  Prepare food –  Use refrigerator Insight Problems •  Defensiveness Ambivalence •  Even people with poor insight are ambivalent –  They know others’ view of the way they live. –  They feel shame when others see their home. •  We must begin here if we hope to get them to change. 9 7/6/12 Style of MI
Principles of MI •  Collabora7on, not confronta7on •  Expressing empathy •  Evoca7on, not educa7on •  Developing discrepancy •  Autonomy, not authority •  Rolling with resistance •  Suppor7ng self-­‐efficacy Strategies for Enhancing Mo7va7on   Ask open-­‐ended ques7ons   Listen with reflec7on   Summarize   Affirm self-­‐efficacy   Ask evoca7ve ques7ons   Explore pros & cons   Ask for elabora7on   Use extreme contrasts   Look forward   Look back   Reframe   Provide feedback   Encourage change talk Components of Treatment of Hoarding • 
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Assessment and case formula7on Mo7va7onal enhancement Skills training – organizing, problem solving Trea7ng excessive acquisi7on Changing ATachments to Things Preven7ng relapse Steketee & Frost, 2007 10 7/6/12 Treatment Format  6 mos -­‐1 yr of treatment, some7mes more in severe cases  Individual or group  Office and in-­‐home sessions (webcam?)  Prac7ce in acquiring loca7ons  Family consulta7on Case Formula7on •  Develop model for understanding client’s problems •  Draw connec7ons of (1) thoughts & beliefs to (2) emo7ons and to (3) behaviors, both ac7ve acquiring & saving and passive avoidance of discarding •  Help client understand why hoarding habits are hard to break because of posi7ve and nega7ve reinforcement  Assistance from a coach  Cleanout with trained staff or coach for extensive cluTer Senng Personal Goals and Values  Ask about personal values  What does the client care most about  Family, friends, honesty, achievements, etc.  Iden7fy and list personal goals  What does the client most want to do in the remainder of his/her life?  Refer back to personal goals and values throughout treatment to clarify ambivalence and increase mo7va7on Example: Sharon’s Goals  To enjoy my instruments again  To create breathing space, order, and beauty in my bedroom (esp. in front of the closet)  To have a living room that a friend or family could enter  To have a safe kitchen with working surfaces  To take a bath  To remove bagged items 11 7/6/12 Skills and Plan for Organizing  Categorize and organize wanted items  Iden7fy categories for types of items  Select loca7ons for item categories  Discuss storage loca7ons and furnishings  Select interim loca7ons during sor7ng Skills for Problem Solving and Decision-­‐
Making  Problem-­‐solving skills  Define the problem, brainstorm solu7ons, select one, try it, assess outcome, revise as needed  Prac7ce decision-­‐making, iden7fy useful rules for acquiring, discarding, keeping, etc.  Categorize unwanted items  Trash, recycle, donate, sell; few undecided  Develop ac7on plan for removing items Rules for Decision Making Skills to Manage ATen7on  Do I need it?  Do I have a plan to use this?  Have I used this in the last year?  Can I get it elsewhere?  Do I have enough space to keep this?  Will genng rid of this help my hoarding problem?   Determine usual aTen7on span   Help client reduce and/or delay distrac7bility   Use 7mer   Control visual field (cover distrac7ng areas)   Discuss ways to create structure   Regular appointments for sor7ng   Establish priori7es   Divide projects into manageable steps 12 7/6/12 Cogni7ve Therapy  During non-­‐acquiring and discarding prac7ce  Iden7fy thinking errors  Iden7fy problema7c beliefs  Evaluate/challenge beliefs  Socra7c ques7oning  Downward arrow for worst fears and core beliefs  Pros and cons, value of 7me vs stuff  Taking another perspec7ve  Behavioral experiments Treatment for Compulsive Acquiring  Iden7fying paTerns of acquiring  Create a hierarchy  Cogni7ve restructuring of beliefs about acquiring  Non-­‐acquisi7on exposures  Drive-­‐by non-­‐shopping  Walk-­‐through non-­‐shopping  Browsing and picking non-­‐shopping  Coping with empty space Gradual Exposure Prac7ce and Homework  Collect box or bag of items from home to bring to office  Work from easier to harder items  Gradually reduce therapist assistance in making decisions  Sort similar items at home between sessions star7ng in easier loca7ons with highest mo7va7on  As person gains skills, bring only difficult items to sort  Make sure sorted items are moved to storage loca7ons or out of home Ques7ons to Challenge Acquiring •  Do I have an immediate use for this? Can I get by without it? •  Do I want it taking up space in my home? •  Is this truly important or do I want it just because I was looking at it? •  What are the advantages and disadvantages of acquiring this? •  Personal rules for acquiring– I must have: –  An immediate use for it –  Time to deal with it appropriately –  Money to afford it comfortably –  Space to put it 13 7/6/12 Roles for Coaches and Family •  Help the client stay focused on sor7ng/
discarding tasks •  Provide emo7onal support •  Help with decisions, but don’t make them for the client •  Be a cheerleader •  Help with hauling •  Accompany the person on non-­‐acquiring trips •  Help them cope with change Downward Arrow Technique •  What would happen if you threw that out? •  Why would that be so bad? •  What would be so bad about that? •  And what would that mean about you? •  So, if you threw this out, then … Coping with Change  Coping with loss  Evaluate true versus imagined loss  Coping with empty space  Developing new uses for spaces  Decorate space  Changing habits  Coping with extra 7me  Plan non-­‐acquiring ac7vi7es  Expand social ac7vi7es Downward Arrow Technique •  What would happen if you threw that out? –  “I’ll never find it again.” •  Why would that be so bad? –  “I would lose an opportunity.” •  What would be so bad about that? –  “I’d be stupid for not taking advantage of an opportunity.” •  What’s the worst part about that? –  “Just that, I’d be a stupid person.” 14 7/6/12 Downward Arrow 2 •  It sounds like you are worried that if you threw this out, that would mean you were a stupid person. Let’s take a look at that idea. –  “I guess I never thought about it. I do worry about doing something stupid.” •  Sounds like you also worry that you might be a stupid person. Does that seem right? Behavioral Experiment Example (top of lost game board box)
•  Predic7on 1: “If I throw this away, it will feel like death.” •  Predic7on 2: “If I throw it away, I will feel this way (like death) forever.” –  “Yeah, I guess so. All through school….” Outcome of Predic7ons •  One minute ayer discarding –  Distress ra7ng at 100, but “It does not feel like death.” •  24-­‐hours ayer discarding –  Distress ra7ng at 10. “It doesn’t bother me much at all.” Conclusions and New Hypotheses •  Conclusion -­‐ Neither predic7on came true. •  New Hypotheses –  The thought of throwing things away is worse than the doing of it. –  If I throw something away that I am deathly afraid of discarding, it will not feel as bad as I think, and the bad feeling won’t last as long as I think. 15 7/6/12 Socra7c Ques7oning: Thinking it Through Logically •  How likely is the feared outcome? •  What evidence is there to support the belief? Taking Another Perspec7ve •  Designed to help clients step outside their own view of the world •  How catastrophic would this be? –  Would your friend (family member) view this situa7on in the same way? –  What would you say to a friend who came to you with this problem? –  What would you say to your son or daughter if they came to you with this problem. •  How well could you cope with not having this? •  How much distress would you feel? •  How long would the distress last? •  Can you tolerate the feeling? •  Is your thinking coming from some7me or someone in your past? Controlled Trial: Saving Inventory-­‐Revised (n=46) Advantages/Disadvantages •  Advantages of Not Acquiring •  Disadvantages of Acquiring –  I can’t afford this right now. –  I don’t have room for this. –  I already have too many like it. % Reduction
–  I’ll have more money for other things. –  I want to be able to choose without feeling compelled. –  It will help me solve my hoarding problem. 0%
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16 7/6/12 Controlled Trial Responders (much or very much improved) Treatment Responders (%) 90 80 70 60 50 Post 40 Followup 30 20 10 0 Self-­‐ra7ng Therapist Steketee et al., 2010; Muroff et al., 2011 Specialized CBT beats the Compe77on 80%
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Average SI-­‐R Changes Before & Ayer Therapy by CBT method 17 7/6/12 Conclusions  Compulsive hoarding is common, chronic, and debilita7ng to the individual and family  Hoarding is associated with unique biological, cogni7ve, and behavioral features  Specialized CBT reduces hoarding symptoms and improves upon previous treatments  Need to refine treatments to increase its impact (e.g., homework completed) and reduce therapy 7me 18