Treatment of Compulsive Hoarding Syndrome

Treatment of Hoarding Disorder: From Research to Practical Application

Karron Maidment, RN, MFT UCLA Resnick Neuropsychiatric Hospital Obsessive Compulsive Disorder Clinic

UCLA OCD PROGRAM Hoarding Disorder

Definition Current research Treatment and Management

UCLA OCD PROGRAM

Hoarding Behavior 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

UCLA OCD PROGRAM Hoarding Disorder

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Hoarding Disorder Most commonly hoarded items:

Newspapers Magazines Bags Books Mail Notes and Lists Storage Containers Old Clothes Memorabilia (Frost & Gross, 1993; Winsberg et al, 1999)

UCLA OCD PROGRAM Research – 3 Perspectives

Cognitive Behavioral Neurobiology Neurocognitive

UCLA OCD PROGRAM Cognitive Behavioral

UCLA OCD PROGRAM Hoarding Disorder – a Cognitive Behavioral Model

Hoarding is part of a discrete clinical syndrome that includes; Indecisiveness Perfectionism Difficulty with organizing Avoidance

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM

Hoarding Disorder – a Cognitive Behavioral Model

Hoarding is part of a discrete clinical syndrome that includes; Indecisiveness Perfectionism Difficulty with organizing Avoidance

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Perfection

Fear of making a mistake Serious negative consequences will result from forgetting All or nothing

Hartl and Frost, 2004

UCLA OCD PROGRAM Hoarding Disorder – a Cognitive Behavioral Model

Hoarding is part of a discrete clinical syndrome that includes; Indecisiveness Perfectionism Difficulty with organizing Avoidance

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Organizational Problems

The apparent chaos is not a reflection of lack of organizing categories, but rather too many.

Frost and Hartl 1996

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM

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

UCLA OCD PROGRAM Hoarding Disorder – a Cognitive Behavioral Model

Hoarding is part of a discrete clinical syndrome that includes; Indecisiveness Perfectionism Difficulty with organizing Avoidance

UCLA OCD PROGRAM Avoidance

Hoarding is an avoidance behavior tied to indecisiveness and perfectionism

Frost and Gross 1993

UCLA OCD PROGRAM Avoidance

Paralysis thru’ analysis

All or nothing behavior

UCLA OCD PROGRAM Hoarding Disorder – a Cognitive Behavioral Model

Emotional attachment problems Erroneous beliefs about the nature of possessions

Frost and Steketee 1999

UCLA OCD PROGRAM Neurobiology

UCLA OCD PROGRAM Functional Neuroanatomy of Hoarding Disorder

Brain Regions with Lower Glucose Metabolism in Hoarding Disorder than in Controls

Sagittal L Transverse R 3.0

2.5

2.0

value

Z 1.5

1.0

0.5

0.0 Saxena et al, 2004 Right Posterior Am J Psychiatry Cingulate Gyrus

UCLA OCD PROGRAM Functional Neuroanatomy of Compulsive Hoarding Syndrome Brain Regions with Lower Glucose Metabolism in Hoarders than Non-Hoarding OCD L Coronal R Sagittal

Anterior Cingulate gyrus

L Transverse R 3.0 2.5

2.0

1.5 Z

value 1.0 0.5

(Saxena, Brody, Maidment et al, 2004 0.0

Am J Psychiatry) UCLA OCD PROGRAM Role of the Cingulate Cortex - Attention, Cognition, and Decision-Making

• 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)

UCLA OCD PROGRAM Role of the Cingulate Cortex - Attention, Cognition, and Decision-Making

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)

UCLA OCD PROGRAM Neuro Cognitive

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Problem Solving

“Executive functions allow us to anticipate outcomes and adapt to changing situations.”

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Treatment for Hoarding Disorder

 Cognitive Behavioral

 Neurobiology Treatment

 Neurocognitive

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Treatment Environment

In Home In outpatient office with in-home support In Intensive Outpatient Clinic

UCLA OCD PROGRAM Treatment of Compulsive Hoarding

 Discarding stuff  Organizing Self  Prevent Incoming  Introduce Alternative Behaviors

UCLA OCD PROGRAM Discarding Process

Ground rules:  Pick a room, any room Decision making  Very systematic Organizing  Can’t put stuff ‘to one side right now’ Decision making  Homework - daily, time limited Initiating/stopping

UCLA OCD PROGRAM Discarding Process

. Pick a room - any room . Before photos

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM

Discarding Process

Recycle

One recycle option only Cannot recycle to save the world K.I.S.(S)

UCLA OCD PROGRAM 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

UCLA OCD PROGRAM Discarding - Rationale

Forces decision making. Reinforces concept of prioritizing - keeping only those things that are important. Acknowledges that some things are not important.

UCLA OCD PROGRAM 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

UCLA OCD PROGR 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.

UCLA OCD PROGRAM Results of Discarding Process

Pros Not so pros  Improved decision  Little likelihood of making about being able to discard alone. discarding clutter.

 Decision making  Improved decision does not generalize making about the well to other areas of acquisition of life. clutter.