Transcript Buried in Treasures: Understanding and Treating

Gail Steketee, PhD
Professor and Dean
Boston University School of Social Work
May 30, 2012
◦ Jordana Muroff, PhD
 Boston University School of Social Work
◦ Christiana Bratiotis, PhD
 BUSSW; U. Nebraska at Omaha
◦ Randy Frost, PhD
 Smith College Dept. of Psychology
◦ David Tolin, PhD
 Hartford Hospital, Dept. of Psychiatry
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Identify typical cognitive, emotional and
behavioral features of hoarding and comorbid
conditions.
Apply a theoretical framework to understand
causes and maintaining features for hoarding
problems.
Make decisions about interventions for
hoarding to improve motivation, organizing
and decision-making skills, correct faulty
beliefs, and practice sorting, discarding and
resisting acquiring.
Q&A
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The acquisition of, and failure to discard, a
large number of possessions
Living spaces so cluttered that they cannot
be used as intended
Significant distress or impairment due to
clutter
Frost & Hartl, Behav Res Ther 1996;
34:341-350
Acquisition
Saving
Disorganization
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Buying
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Collecting free
things
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Stealing
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Passive acquiring
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Types of items
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Newspapers, magazines, mail, papers, books
Containers, craft items
Clothing, shoes, furniture,
Household items, appliances, etc., etc.
Emotional attachments
◦ Sentimental
◦ Instrumental/useful
◦ Intrinsic/beautiful
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Condition of Home
◦ Mixed importance
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Behavior
◦ Churning
◦ Out of sight fear
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5% in US (adjusted)
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~2% in UK
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4.6% in Germany
◦ May be twice as common in men
◦ Nearly 3X as common in people age 55 and older
◦ Over 4 times as common among people with low
income (< $20,000)
Wide range of educational
achievement
 Average age at treatment = 50
 Low marriage rate, high divorce rate
 Tend to live alone
 Family history of hoarding is common
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30
26.6
24.1
% Reporting Onset
25
20
13.8
15
10.8
10
5
8.1
3.7
4.8
4.4
2.5
0.7
0
0-5
0.1
0.1
6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60
Age of onset of hoarding symptoms
0.1
61-65
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Social isolation
Strained relationships with family, friends,
landlords, neighbors
Work problems
◦ Interference with major personal or career goals
◦ 6% have been fired because of hoarding
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Legal/financial problems
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Credit card debt
High expenses – buying, storage unit fees
Property damage - loss of investment
Eviction, divorce, bankruptcy
NonHoarding Fire
Hoarding Fire
Ratio
Dollar loss to
owner (USD)
$11,711
$93,784
8x
Containment
to room of
origin
90%
40%
2.25x
Presence of
operating
smoke alarms
66%
28%
2.4x
Source: Melbourne Fire Dept.
OCD = 135
OCD
= 96
Hoarding = 217
Both
= 39
Hoarding
= 178
Frost et al. (2010)
Frost et al. (2010)
*
Frost et al. (2010)
A. Persistent difficulty discarding or parting with
personal possessions, even those of apparently useless
or limited value, due to strong urges to save items,
distress, and/or indecision associated with discarding.
B. The symptoms result in the accumulation of a large
number of possessions that fill up and clutter the active
living areas of the home, workplace, or other personal
surroundings (e.g., office, vehicle, yard) and prevent
normal use of the space. If all living areas are
uncluttered, it is only because of others’ efforts (e.g.,
family members, authorities) to keep these areas free of
possessions.
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C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning (including maintaining a safe
environment for self and others).
D. The hoarding symptoms are not due to a general
medical condition (e.g., brain injury, cerebrovascular
disease).
E. The hoarding symptoms are not restricted to the
symptoms of another mental disorder (e.g., hoarding due
to obsessions in OCD, lack of motivation in MDD,
delusions in Schizophrenia or other Psychotic Disorder,
cognitive deficits in Dementia, restricted interests in
Autistic Disorder, food storing in Prader-Willi Syndrome).
Specify if:
With Excessive Acquisition: If symptoms are accompanied by
excessive collecting or buying or stealing of items that are
not needed or for which there is no available space.
Good or fair insight: Recognizes that hoarding-related
beliefs and behaviors (pertaining to difficulty discarding
items, clutter, or excessive acquisition) are problematic.
Poor insight: Mostly convinced that hoarding-related beliefs
and behaviors (pertaining to difficulty discarding items,
clutter, or excessive acquisition) are not problematic
despite evidence to the contrary.
Delusional: Completely convinced that hoarding-related
beliefs and behaviors (pertaining to difficulty discarding
items, clutter, or excessive acquisition) are not
problematic despite evidence to the contrary.
The Cognitive Behavioral Model
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Hoarding and indecisiveness more
common among family members of people
who hoard
Specific genetic abnormalities have been
found
◦ L/L genotype of COMT Val158Met polymorphism
◦ Chromosome 14
Samuels at al., Behav Res Ther
2007;45:673-686; Lochner et al., J
Clin Psychiatry 2005;66:1155-1160;
Samuels et al., Am J Psychiatry
2007;164:493-499
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Frontal lobe abnormalities may indicate
problems of cognitive processing
◦ Sustained attention – staying on task
◦ Memory strategy – organize visually
◦ Impulse control – resisting acquiring
◦ Decision making – difficulty discarding
◦ Self awareness – insight
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These cognitive impairments may be core
features of hoarding
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Attention
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Perception
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Categorization
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Association
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Memory
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Complex Thinking
Decision-making Difficulties
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Emotional Attachment: identity, loss, mistakes,
comfort
◦ “Throwing this away feels like abandoning a loved one.”
◦ “Throwing this away is like throwing away part of me.”
◦ “I can’t tolerate getting rid of this.”
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Responsibility & Waste
◦ “Throwing this out wastes a valuable opportunity.”
◦ “I’m responsible for the well-being of this possession.”
◦ “I must save this for someone who might need it.”
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Information & Memory
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“I might lose important information if I get rid of this.”
“Saving this means I don’t have to rely on my memory.”
“If I don’t leave this in sight, I’ll forget it.”
“If I don’t keep this, I will lose an important opportunity.”
Control
◦ “No one has the right to touch my things.”
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Aesthetics, Attractiveness, Beauty
◦ “This is beautiful”
◦ “I will never find anything as nice as this again.”
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Positive Emotions
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Pleasure
Excitement
Pride
Relief
Joy
Fondness
Satisfaction
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Negative Emotions
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Grief/loss
Anxiety
Sadness
Guilt
Anger
Frustration
Confusion
Vulnerabilities:
Biology, Family,
MH, Core Beliefs
Cognitive Processes:
Decision-making, Attention,
Memory, Problem solving
Beliefs & Meanings: Identity, Value,
Responsibility, Memory, Control
Negative
Reinforcement
Emotions
Negative
Positive
Saving &
Acquiring
Positive
Reinforcement
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Home and clutter
Objects and
reactions
Where to start
Organizational
system
Acquiring
Reasons for saving
Family & friends
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Health & safety
Problems from
hoarding
Comorbidity (MDD,
OCD, ADHD, etc.)
Family history of
hoarding
Onset & course
Intervention efforts
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0-8 scales for 5 items:
1.
Difficulty using rooms in your home?
2.
Difficulty discarding
3.
Problem collecting or buying
4.
Emotional distress
5.
Impairment
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Retrospective studies
◦ Hoarding predicts poor outcome of SRIs and SSRIs
for OCD clinic patients w hoarding in some
studies, but not others (e.g., Mataix-Cols et al., 1999 vs.
Erzegovesi et al., 2001)
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One prospective study
◦ Hoarding and OCD patients responded similarly to
paroxetine, but both groups improved only
modestly (~30%) (Saxena et al., 2007)
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No studies of stimulants for those with
ADD
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Retrospective studies
◦ OCD patients with hoarding responded
less than non-hoarding pts. to standard
ERP
◦ 31% vs. 59% with clinically significant
change for therapist-directed ERP
◦ 25% vs. 48% response rate for computerassisted self-directed ERP
Abramowitz et al., 2003; Mataix-Cols et al., 2002)
Education and case formulation
 Determine values, set goals
 Enhance motivation
 Train skills for organizing, problem
solving, decision-making
 Practice discarding & non-acquiring
 Challenge thoughts and beliefs
 Prevent relapse
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26 weekly sessions
◦ severe symptoms take more time
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In-home sessions once/month or as often
as feasible
Include practice in acquiring locations
For extensive clutter, consider marathon
sessions with several trained staff members
or coaches
Identify acquiring problems
 Develop a hierarchy - easier to harder
 Modify beliefs about acquiring
 Practice not acquiring
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◦ Drive-by non-shopping
◦ Walk-through non-shopping
◦ Browsing and picking non-shopping
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Organizing
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Managing attention (esp. for ADD)
◦ Categorize and organize wanted items
◦ Categorize unwanted items - trash,
recycle, donate, sell (minimize undecided)
◦ Develop action plan for removing items
◦ Determine usual attention span
◦ Help client reduce/delay distractibility
(e.g., control visual field)
◦ Discuss ways to create daily structure
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Bring boxes from home to sort in the office
◦ Start with easier items
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Talk aloud about how decisions are made to
identify and discuss thoughts and beliefs
Help person establish personal rules for decisionmaking
Practice sorting at home on most important areas
with easiest items first
Move sorted items to destination or out
IMMEDIATELY – no looking back
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Find new routines to replace old habits and
prevent re-accumulation of clutter
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Empty trash
Clean kitchen, do dishes
Sort mail and recycle newspapers daily
Do laundry
Pay bills
Reinforce new behaviors
Cohen’s d
= 1.07
Cohen’s d = 1.81
27% reduction on
hoarding measure
Steketee et al., 2010, Depress & Anx, 27, 476-484
Steketee et al., 2010, Depress & Anx, 27, 476-484
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5 – 8 group members; total n=32
4 groups (n=27) had 16 weekly sessions; 1
group (n=5) had 20 sessions
Mean = 16.6 sessions for all participants
2 hours per session
2 clinical facilitators (training model)
Only 2 home visits per group member
Muroff, Steketee, Rasmussen, Gibson, Bratiotis, Sorrentino
(2009). Depression and Anxiety, 26:634−640.
**
**p<.01
*
*p<.05
Muroff et al., (2009). Depression & Anxiety
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27 people received 20 sessions of group CBT
plus 4 -8 home visits
◦ 14 got 4 home visits by group therapist
◦ 13 got 4 extra visits by undergrad asst.
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13 people received Bibliotherapy (read Buried
in Treasures)
Muroff, Steketee, & Bratiotis, (2010) unpublished
25% gain
9% gain
Muroff, Steketee, & Bratiotis, (2010) unpublished
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17 participants
Average age = 54
88% Women
13 weekly 2-hr group sessions
Facilitated by 2 undergraduate assistants
Used self-help book Buried in Treasures
a
b
c
Pekareva-Kochergina & Frost (2009).
22.6%
50
CBT for Hoarding Delivered
Via Webcam
3/2
1/2
01
7
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CBT elements
Delivered in group format for 20 or more
sessions
Add case management to group therapy:
Assistance with homework in and outside the home
Advocacy and referral as needed
Rewards for decluttering and resisting acquiring
Facilitate connections to others working on
hoarding (via technology?)
◦ Continued assistance over 1-year
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Virtual Hoarding Center www.ocfoundation.org
 Support groups www.messies.com;
www.childrenofhoarders.com
 Mental health therapists
www.ocfoundation.org; www.abct.org
 Professional organizers for chronic
disorganization
www.challengingdisorganization.org
 Hauling - for example: 1-800-GOT-JUNK
 Local health clinic
 Local cleaning services
 Local community task force
Thank you! [email protected]
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