Barriers Beyond the Clutter: Co-Morbid Issues Complicating Hoarding Disorder Interventions Elspeth Bell, Ph.D. Disclosures
I have nothing to disclose. Objectives
Identify three common psychiatric diagnoses that are often seen in individuals who exhibit hoarding behaviors
Describe why individuals with HD may be more susceptible to chaotic environments
Discuss three strategies for addressing barriers to treating HD Hoarding Disorder: DSM-V Criteria
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.
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. Hoarding Disorder: DSM-V Specifiers
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. Specify whether hoarding beliefs and behaviors are currently characterized by: 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. Co-Morbid Psychiatric Diagnoses
Major Depression (57%)
Social Phobia (29%)
Generalized Anxiety Disorder (28%)
Obsessive Compulsive Disorder (17%)
Attention Deficit Hyperactivity Disorder (ADHD) (16%)
Specific Phobia (12%)
Post-Traumatic Stress Disorder (6%)
Dysthymia (4%)
Panic (2%)
Frost, Steketee, Tolin, & Brown, 2006; Hall, Tolin, Frost, & Steketee, 2013 Psychiatric Diagnoses Impact on HD Exacerbating worries about life and consequences Restricted social supports Difficulty allowing others access to home Seen as resisting help Fear of making mistakes Management of physical space inhibited by obsessions and compulsions Seeking reassurance from others about decisions/choices Distractability and difficulty focusing Poor time management and planning Psychiatric Diagnoses Treatment Interventions
Cognitive Behavior Therapy (CBT) Exposure/Response Prevention (E/RP) Cognitive Reframing
Medications
Coaches and Assistants
Structuring and scheduling
Building decision-making skills Personality Variables
Sensitivity to criticism
Anger
Feeling overwhelmed
Difficulty managing emotions Personality Variables Impact on HD
Feeling (unjustly) criticized by others
Dismissive of others’ concerns regarding clutter
Defensive reactions
Procrastination/Avoidance
Paralyzed to undertake any interventions
Resistant to listen to treatment recommendations Personality Variables Treatment Interventions
Cognitive Behavior Therapy (CBT) Cognitive Reframing Challenging distorted thoughts
Anger management
Building frustration tolerance
Structuring activities into small, discrete steps
Coaching family regarding interactions
Providing concrete feedback regarding behaviors Health and Medical Concerns
Obesity Higher Body Mass Index (BMI)
Diabetes
Arthritis
Joint problems
High blood pressure
Asthma Health and Medical Concerns Impact on HD
Limited strength/endurance
Multiple medical appointments
Exacerbating psychiatric diagnoses Health and Medical Concerns Treatment Interventions
Assess the extent of the health issues
Determine impact of environment on health
Assess appropriateness of living environment
Connecting decluttering efforts with caring for physical well- being
Structuring decluttering efforts to ease health and medical concerns Other Barriers
Financial Challenges Debt Non-payment of bills, taxes Poor follow-through with financial obligations Living Arrangements Home falling into disrepair Unsafe physical environment Interpersonal Factors Hostility Rejection Resentment Hoarding Other Barriers Impact on HD
Financial Problems with meeting obligations Inability to afford services Pressure to keep valued items or sell for profit
Living Arrangements Tensions with landlord Deadlines for removing clutter Threat of eviction
Interpersonal Isolation Threats from members of the community Guilt/Blame/Responsibility Enabling behaviors Other Barriers Treatment Interventions
Financial Budgeting (with family involvement as possible) Automating bill payment Involving financial planners, accountants
Living Arrangements Education of landlords, housing officials Developing housing contracts with involved parties
Interpersonal Family education and therapy (as possible) Connecting with community resources for socialization General Goals of Clutter-Related Interventions
For the Physical Space: For the Individual: • Increase usable living space • Address related medical and • Reduce risks to health and mental health symptoms safety • Develop skills and alternative • Declutter living spaces behaviors • Store kept possessions in • Establish functional support systematic way network • Reduce excessive acquisition • On-going services • Relapse prevention
How do barriers interfere with these goals? Resources
Group Treatment for Hoarding Disorder Muroff, Underwood, and Steketee
Treatment for Hoarding Disorder: Therapist Guide and Workbook Steketee and Frost
The Hoarding Handbook Bratiotis, Schmalisch, and Steketee
Digging Out Tompkins and Hartl Thank You! Elspeth Bell, Ph.D.
5850 Waterloo Road, Suite 140 Columbia, MD 21045
(410) 480-8052
[email protected] www.elspethbellphd.com