4Case Study Treatmentxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx of Compulsive Hoarding: A Case Study

Lilit Pogosian Albert Einstein College of Medicine Bronx, New York 10461

ABSTRACT in several psychiatric as well as organic disorders rang- ing from obsessive-compulsive personality disorder to The present case report describes an intensive treatment anorexia nervosa, schizophrenia, and certain organic approach combining aggressive pharmacotherapy with brain lesions. However, previous clinical research has daily cognitive behavioral therapy (CBT) directed at help- linked hoarding most commonly with obsessive-compul- ing “Dee,” a 63-year-old female suffering from compul- sive disorder (Maier, 2004). sive hoarding. The successful intervention consisted of individualized exposure and response prevention (ERP), Frost and Hartl (1996) proposed a cognitive-behavioral in addition to to improve insight, model that associated compulsive hoarding with four decrease depressive and general symptoms, main problem areas, including deficits in information and address distorted beliefs. Pretreatment evaluation processing, emotional attachment problems, behavioral included assessment of clutter for all living spaces, includ- avoidance issues, and erroneous beliefs about the nature ing rooms in the house in addition to the car. After the of possessions. Deficits in information processing include six-week intensive treatment program, clutter decreased difficulties in decision-making regarding possessions, dif- substantially in each of the rooms targeted for interven- ficulty in organization and categorization of items, low tion. In addition, Dee’s scores on self-reported measures confidence in memory, and inaccurate judgments about of obsessive-compulsive symptoms and anxiety steadily the importance of remembering certain pieces of infor- decreased during the intervention. Compulsive hoard- mation. These specific deficits lead to the acquisition and ing, when present in patients with obsessive-compulsive saving of items for future use and monetary value. disorder (OCD), has been associated with poor response to both antianxiety medications and typical CBT. This Problems related to emotional attachment include the case report illustrates that specific CBT strategies target- sentimental attachment to physical possessions that ing the characteristic features of compulsive hoarding function as meaningful past events. Behavioral avoid- may provide better results for patients suffering from ance relates to the difficulty patients have discarding compulsive hoarding syndrome. items as a method of avoiding feelings of anxiety about making decisions, feelings of loss, and the tremendous task of actually sorting through and removing years INTRODUCTION of acquired clutter. False beliefs center on emotional attachment to possessions and safety that possessions Obsessive-compulsive disorder (OCD) is currently classi- provide, the reciprocal need to protect items and have fied as a single entity in the Diagnostic and Statistical them available for future use, and beliefs about perfec- Manual of Mental Disorders, fourth edition (DSM-IV) tionism and of failure if an important item is mis- (American Psychiatric Association, 1994). However, it takenly discarded. is becoming evident that several different symptom groups of OCD exist and have been identified as obses- The significance of this theoretical model lies in its sions and compulsions related to checking, symmetry application to intervention (Hartl & Frost, 1999). Past and order, contaminations, and hoarding. Furthermore, studies have consistently shown that patients with com- these symptom groups have been shown to carry differ- pulsive hoarding are more resistant than non-hoarding ent patterns of comorbidity and response to treatment. OCD patients to both pharmacologic and CBT (Steketee and Frost, 2003). At the UCLA Obsessive Compulsive Frost and Hartl (1996) defined clinical compulsive Disorders Intensive Treatment Program, a multi-model hoarding as the acquisition of, and failure to discard, CBT approach has been formulated to target the above- a large number of possessions that appear to be use- mentioned problem areas experienced by compulsive less or of limited value to others. In addition, acquisition hoarders, including difficulties with information pro- of objects is not sufficient to fulfill the criteria of com- cessing, erroneous beliefs about and attachment to pos- pulsive hoarding; as in criteria for most other mental sessions, emotional distress associated with discarding disorders, the behavior must be shown to cause impair- possessions, and avoidance behaviors that limit the dis- ment in everyday functioning as well as psychological tress associated with discarding possessions (Saxena et and emotional distress. Hoarding has been observed al., 2002). Treatment protocol includes comprehensive

8 EJBM, Copyright © 2010 4Case Study xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxTreatment of Compulsive Hoarding: A Case Study education about hoarding, motivational support, aiding approximately 80-90% of the living space. The clutter in organizing, reducing acquisition, assisting discarding, reached as high as four feet in some areas. No rooms and preventing relapse. Importance is also given to set- in the house could be used for their intended purpose, ting concrete goals that focus on improving daily func- especially the kitchen, which was completely unusable tioning such as creating living space for its appropriate secondary to the accumulated clutter. Getting around use. In addition, established rules for therapy require the house was only partially possible by using trails, that the patients make all decisions (save vs. discard) as tables, chairs, couches, and floors were almost com- about their own possessions. Group therapy, including pletely covered with items. In addition, Dee’s car, garage, didactic sessions, provides additional support. and yard were almost completely filled with clutter. Dee’s hoarded possessions included newspapers, maga- The UCLA OCD Intensive Treatment Program consists zines, bills, videos, pictures, clothing items, and musi- of sessions for six weeks, five days a week, Monday cal instruments, books, and notes. Dee’s main hoarding through Friday, from 9:00 a.m. to 1:00 p.m. The patients revolved around musical items accumulated from work also have daily homework assignments as part of and numerous volunteer organizations dating back their treatment. The presented case report describes 15 years. Dee allowed only her cleaning lady into the a 63-year-old divorced female suffering from compul- house. She had not allowed people to visit her home in sive hoarding who was a participant in the UCLA OCD many years, causing her to lose touch with many friends Intensive Treatment Program. and relatives.

During the interviewing process, Dee admitted that she METHOD did not need all possessions that she kept but that she was overwhelmed with the process of sorting through Client Description and discarding items. She also conveyed her fear of “Dee” was a 63-year-old divorced woman who lived throwing away valuable items that might be useful in alone in her house. She described her current hoarding the future or have monetary value. She denied acquir- behavior as “difficulty throwing things away.” She was ing new items. Dee realized that her avoidance and ten- referred to the UCLA Intensive Treatment Program by dency to procrastinate had played a major role in her her daughter, who had been living in New York for the disability. Dee also hoarded activities, which had led to past three decades. her overextending herself to multiple organizations.

Dee’s difficulties with organization and discarding of her Dee’s psychiatric history included two previous episodes possessions had resulted in a clutter-filled environment of , which she described as involving difficulty in her home. As a result, her main disability had been with motivation and getting out of bed. She received complete social isolation due to embarrassment about short periods of supportive during both others seeing her home in this state. She had desired to episodes. The first episode was at the age of 27 and the seek treatment but had not taken that step until urged second at the age of 50, which was related to alcohol by her daughter. use. She had drunk beer or wine daily for ten years, but had been successfully treated in a chemical dependency Dee’s problems with hoarding began in childhood. She program and then attended Alcoholics Anonymous for admitted to hiding things under her bed so her mother six months thereafter. She had been sober for nine years would not discard them. She also recalled being a fear- at time of starting the OCD treatment program. She had ful and anxious child. Dee’s symptoms of hoarding had never been on psychotropic medications. waxed and waned since childhood. Dee’s problems with severe hoarding began to worsen since moving into her Dee met the DSM-IV criteria for OCD and was diagnosed new home 16 years ago, and continued to worsen in with compulsive hoarding syndrome. Physical and labo- the last 10 years. Her family history was significant for ratory findings revealed no abnormalities upon starting hoarding behaviors in her mother and maternal grand- the program. mother. Course of Treatment Dee also described having mild symptoms of depression. The program consisted of intensive, multi-modal treat- She admitted to “crying spells” and “painful emotions” ment in the UCLA OCD Intensive Treatment Program, when thinking about being a failure due to wasted time four hours per day, five days per week, for six weeks. and inability to control her hoarding problem. Her OCD In addition to hoarding-specific CBT, Dee was started mainly revolved around compulsive hoarding behaviors, on escitalopram oxalate (trade name: Lexapro) and her as she denied other symptoms of OCD. dosage was increased from the initial 10 mg to 30 mg per day after the first week. Case Formulation Dee’s house consisted of three bedrooms, two baths, The pretreatment phase began with a thorough assess- and a den. The volume of cluttered possessions took up ment of the amount and type of clutter, beliefs about

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possessions, motivation for treatment, and level of erroneous beliefs that terrible consequences would insight and understanding of the disorder. The first occur if she threw something away. phase of treatment revolved around education regard- ing hoarding behavior, setting goals, and cognitive Outcome and Follow-Up restructuring. A major issue for Dee had been her isola- By the end of the six-week treatment program, Dee had tion from friends and family due to the embarrassment completely cleared her computer room and kitchen of she felt about her cluttered home. Therefore, a major all clutter. She had taken “before” and “after” photos goal for Dee was to reduce the clutter and improve her to track progress and for future encouragement. Her hoarding symptoms so that she would be able to invite pictures served as a reminder of the advantage of set- people to her home. The next phase of treatment was ting and sticking to specific goals. The plan for Dee after exposure and response prevention (ERP), consisting of graduating from the program was to follow up in an sorting through and making a decision on each item, outpatient setting to maintain her gains and continue leading to habituation to discarding previously saved improving. Weekly outpatient follow-up therapy was possessions. Dee decided to start working on the car, set up with a therapist in addition to in-house visits by which she would use on a daily basis to come to the interns twice a week. During in-office visits with the program. Each day, she brought in several boxes of clut- therapist, Dee would continue her ERP process with ter, which she would remove from her car without sort- direct supervision by the therapist. In addition, Dee ing through. Dee spent two and a half to three hours a would meet with her psychiatrist for medication man- day sorting through and discarding clutter that she had agement once every three months. brought in from her car. Her daily homework consisted of putting saved items in their designated places at home. Dee was entirely responsible for deciding the sta- SUMMARY tus of her possessions (save vs. discard) and their place- ment at home if items were to be saved. The therapist Dee presented to the UCLA OCD Intensive Treatment working with Dee did not make any decisions and did Program with symptoms of severe compulsive hoard- not touch her possessions. The role of the therapist in ing as her primary OCD manifestation. Dee’s remarkable the treatment program was to assist in the development improvement during the program had clearly been an of decision-making skills, to provide feedback regarding exception rather than the norm when considering hoard- normal saving behaviors, and to identify and challenge ers’ response to treatment. The success of this hoarding Dee’s erroneous beliefs about her possessions. intervention depended on several factors. Most impor- tantly, Dee was extremely motivated to engage in cog- During the first week of the program, Dee had started nitive restructuring, in addition to making changes in out sorting through one box every hour. She would scan her decision-making process and in her beliefs about the over and read each item and had the greatest difficulty necessity of keeping all of her possessions. She openly deciding on personalized items and any items related to welcomed the support and assistance of her therapist her work or volunteer organizations, including sheets and of the treatment team overall. Secondly, the cogni- of music. After emptying her car of clutter, which lasted tive behavioral approach to Dee’s therapy was tailored more than a week, Dee started on the computer room in to target her compulsive hoarding symptoms. Traditional her house, which took nearly two weeks to completely CBT has focused on cognitive restructuring of maladap- empty of clutter. By the end of the fourth week, Dee had tive thought patterns and behavioral modification. It clearly habituated to the process. She was able to sort has become evident that a crucial component of CBT through one box every 15 minutes and was discarding targeting compulsive hoarders should include instilling 90% of the items. She conveyed less emotional attach- decision-making and organizational skills to support ment to the possessions and expressed the importance of reformed beliefs and altered behavior with the goal of her set goals and her desire to be able to reach them. To decreasing the likelihood of relapse. help Dee with the process of ERP, she was prompted to cognitively reframe her obsessive about discarding Reports and studies have consistently indicated the her possessions. She was often asked, “What’s the worst difficulty of treating compulsive hoarders. With Dee, thing that would happen if you didn’t have this item?” cognitive behavioral strategies targeting her indeci- and “If you needed this information later, how could siveness and maladaptive beliefs regarding possessions you access it if you threw this away now?” Dee herself and avoidance behavior had been effective during the started using certain key phrases such as, “If you have six-week program. Future research is indicated to iden- to ask, it means it’s not that important” and, “When in tify those patients who will benefit from this type of doubt, throw it out.” This type of cognitive restructur- directed cognitive behavior therapy and establish suc- ing was important for Dee, who needed assistance in cessful methods of outpatient follow-up to prevent learning how to think differently about her possessions. relapse and ensure maintenance of gains made during When Dee was asked to think about the consequences intense treatments. of throwing away her clutter, she was challenging her

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REFERENCES Maier, T. (2004). On phenomenology and classification of hoarding: A review. Acta Psychiatrica Scandinavia 110:323-37. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC. Saxena, S., Maidment, K.M., Vapnik, T., Golden, G., Rishwain, T., Rosen, R.M., Tarlow, G., & Bystritsky, A. (2002). Obsessive-compulsive hoarding: Symptom Cermele, J.A., Melendez-Pallitto, L., & Pandina, G.J. (2001). Intervention in severity and response to multi-modal treatment. Journal of Clinical compulsive hoarding: A case study. Behavior Modification 25:214-32. 63:21-7.

Frost, R.O., & Hartl, T. (1996). A cognitive-behavioral model of compulsive Steketee, G., & Frost, R.O. (2003). Compulsive hoarding: Current status of the hoarding. Behavior Research and Therapy 34:341-50. research. Review 23:905-27.

Hartl, T., & Frost, R.O. (1999). Cognitive-behavioral treatment of compulsive hoarding: A multiple baseline experimental case study. Behavior Research and Therapy 37:451-61.

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