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

 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

 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:

Acquisition Saving Disorganization

 Buying  Collecting free things  Stealing  Passive acquiring

 Types of items ◦ Newspapers, magazines, mail, papers, books ◦ Containers, craft items ◦ Clothing, shoes, furniture, ◦ Household items, appliances, etc., etc.  Emotional attachments ◦ Sentimental ◦ Instrumental/useful ◦ Intrinsic/beautiful

 Condition of Home ◦ Mixed importance  Behavior ◦ Churning ◦ Out of sight fear

 5% in US (adjusted)  ~2% in UK  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

 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  Legal/financial problems ◦ Credit card debt ◦ High expenses – buying, storage unit fees ◦ Property damage - loss of investment ◦ Eviction, divorce, bankruptcy

Source: Melbourne Fire Dept. Non- Hoarding Fire Hoarding FireRatio Dollar loss to owner (USD) $11,711$93,7848x Containment to room of origin 90%40%2.25x Presence of operating smoke alarms 66%28%2.4x

Frost et al. (2010) OCD = 96 Hoarding = 178 Hoarding = 217OCD = 135 Both = 39

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.

 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

 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: ; Lochner et al., J Clin Psychiatry 2005;66: ; Samuels et al., Am J Psychiatry 2007;164:

 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  These cognitive impairments may be core features of hoarding

 Attention  Categorization  Memory  Perception  Association  Complex Thinking Decision-making Difficulties

 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.”  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.”

 Information & Memory ◦ “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.”  Aesthetics, Attractiveness, Beauty ◦ “This is beautiful” ◦ “I will never find anything as nice as this again.”

 Positive Emotions ◦ Pleasure ◦ Excitement ◦ Pride ◦ Relief ◦ Joy ◦ Fondness ◦ Satisfaction  Negative Emotions ◦ Grief/loss ◦ Anxiety ◦ Sadness ◦ Guilt ◦ Anger ◦ Frustration ◦ Confusion

Emotions Negative Positive Beliefs & Meanings: Identity, Value, Responsibility, Memory, Control Vulnerabilities: Biology, Family, MH, Core Beliefs Saving & Acquiring Cognitive Processes: Decision-making, Attention, Memory, Problem solving Negative Reinforcement Positive Reinforcement

 Home and clutter  Objects and reactions  Where to start  Organizational system  Acquiring  Reasons for saving  Family & friends  Health & safety  Problems from hoarding  Comorbidity (MDD, OCD, ADHD, etc.)  Family history of hoarding  Onset & course  Intervention efforts

 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

 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)  One prospective study ◦ Hoarding and OCD patients responded similarly to paroxetine, but both groups improved only modestly (~30%) (Saxena et al., 2007)  No studies of stimulants for those with ADD

 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 computer- assisted 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

 26 weekly sessions ◦ severe symptoms take more time  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 ◦ Drive-by non-shopping ◦ Walk-through non-shopping ◦ Browsing and picking non-shopping

 Organizing ◦ Categorize and organize wanted items ◦ Categorize unwanted items - trash, recycle, donate, sell (minimize undecided) ◦ Develop action plan for removing items  Managing attention (esp. for ADD) ◦ Determine usual attention span ◦ Help client reduce/delay distractibility (e.g., control visual field) ◦ Discuss ways to create daily structure

 Bring boxes from home to sort in the office ◦ Start with easier items  Talk aloud about how decisions are made to identify and discuss thoughts and beliefs  Help person establish personal rules for decision- making  Practice sorting at home on most important areas with easiest items first  Move sorted items to destination or out IMMEDIATELY – no looking back

 Find new routines to replace old habits and prevent re-accumulation of clutter ◦ 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 = % reduction on hoarding measure Steketee et al., 2010, Depress & Anx, 27,

 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

 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.  13 people received Bibliotherapy (read Buried in Treasures) Muroff, Steketee, & Bratiotis, (2010) unpublished

25% gain9% gain

 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).

CBT for Hoarding Delivered Via Webcam50 9/7/20159/7/20159/7/ %

 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

 Virtual Hoarding Center  Support groups  Mental health therapists  Professional organizers for chronic disorganization  Hauling - for example: GOT-JUNK  Local health clinic  Local cleaning services  Local community task force Thank you!