11/19/2013 THE NATURE AND TREATMENT OF HOARDING DISORDER Randy Frost, PhD Nov. 25 & 26, 2013 Canad Inn Polo Park 1405 St. Matthews Avenue Winnipeg, MB ROAD MAP | Phenomenology | Diagnostic & Assessment | Conceptual Model | Motivation & Treatment | Other Interventions RECENT BOOKS Houghton/Mifflin/Harco urt Oxford University Press Tr ea Tme n Ts Th aT Wo r k Treatment for Hoarding Disorder Treat ment for Second Edition Hoarding Disorder Sec o n d Ed i t i o n WORKBOOK Gail SteKetee theRapiSt Guide Ran d y O. FROSt Gail Steketee Ra n d y O. FROSt 2 1 11/19/2013 OTHER HISTORICAL REFERENCES TO HOARDING | Shakespeare’s Shylock from The Merchant of Venice (1597) | Nikolai Gogol’s Plyushkin from Dead Souls (()1842) | Charles Dickens’ Krook from Bleak House (1850) | George Elliot’s Silas Marner (1861) | Sir Arthur Conan Doyle’s Sherlock Holmes (1890s) MODERN DAY CASES Skokie Hoarder Dies in Home; Removed Via Hole in Roof – “A hoard er was stuck in so much garbage and debris and junk that when she died, she had to be removed through a hole cut into the roof of her hovel.” IndyPosted, July 20, 2010 ANDY WARHOL 2 11/19/2013 WHAT IS COMPULSIVE HOARDING? | The acquisition of, and failure to discard, a large 34:341-350 Frost & Hartl, number of possessions Behav ResTher 1996; | Living spaces that are sufficiently cluttered as to preclude their intended use | Significant distress or impairment caused by the clutter MANIFESTATIONS OF HOARDING Acquisition Saving Disorganization ACQUISITION y Buying y Free Things y Stealing y Passive 3 11/19/2013 COMPULSIVE SAVING / DIFFICULTY DISCARDING | Types of items y Clothes, newspapers, books, containers y DSM-IV – worthless & worn | Attachments y Sentimental y Instrumental y Intrinsic DISORGANIZATION | Condition of Home y Clutter y Mixed importance | Behavior y Churning y Out of sight fear OTHER CORE FEATURES OF HOARDING |Indecisiveness |Perfectionism |Procrastination |Central Coherence 4 11/19/2013 DIAGNOSIS OF HOARDING AND THE DSM HOARDING AND DSM-5: INCLUSION CRITERIA | A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. www.dsm5.or | B. This difficulty discarding is due to a perceived need to save the items and distress associated with discarding them. g | C. The symptoms result in accumulliation of possessions that congest and clutter active living areas and substantially compromise their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). | D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). | E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi Syndrome). | F. The hoarding is not better accounted for by the symptoms of another DSM-5 disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder). 5 11/19/2013 | 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 if: | Good or fair insight: Recognizes that hoarding- related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. | Poor insight: | Absent insight: Specify if: | Good or fair insight: | Poor insight: Mostly convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary. | Absent insight: 6 11/19/2013 Specify if: | Good or fair insight: | Poor insight: | Absent insight (Delusional beliefs about hoarding): Completely convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary. ACQUIRING BEHAVIORS Differences in acquiring process Collectors HD Gather relevant information 95% 35% Planning for acquiring specific objects 75% 35% Getting attached 50% 35% Searching for specific items 95% 18% Feeling rewarded by purchase 95% 77% Organize collected items 95% 47% Share collecting behaviors 90% 53% Mataix-Cols et al., 2012 REASONS FOR DIFFICULTY DISCARDING Collectors HD Useful in future 95% 100% Sentimental attachment 90% 90% Monetary value 50% 59% Avoid waste 10% 55%** Object is unique 55% 69% Misuse of personal information 0% 31%** Part of personal identity 80% 86% Mataix-Cols et al., 2012 7 11/19/2013 KEY DIFFERENTIATING FEATURES Feature Normative Hoarding Disorder collecting Onset & Course Childhood; Childhood; Chronic intermittent Prevalence 70% children; 30% 1-5% adult adult Use of Objects Common Rare Object Content Very focused Unfocused Acquisition Process Structured Unstructured Excessive Possible, but less Very Common Acquisition common Level of High Low Organization Presence of Distress Rare Very Common Social Impairment Minimal Severe Occupational Rare Common Impairment Mataix-Cols et al., 2012 LONDON FIELD TRIAL (MATAIX-COLS ET AL., 2012) | Hoarding vs. Collecting | Near perfect sensitivity (Detecting hoarding when it is there) | Near perfect specificity (Distinguishing hoarding from collecting) | Inter-rater reliability (.97) | 97-100% met criteria for acquisition specifier | Insight Specifier (86% good or fair; 10% poor; 3.4% absent) | Original clutter criterion too strict. FREQUENCY OF ACQUISITION SPECIFIER Frost et al., 2009 Timpano et al., 2011 N=653 N=146 80-86% 67% Frost et al., 2011 Mataix-Cols et al., 2012 N=217 80% N=29 97% 8 11/19/2013 EXCESSIVE ACQUISITION IN HOARDING 8% 4% 60% Excessive Acq 28% Past Acq Avoid No Acq Frost et al., 2013 PERCENTAGE WITH SIGNIFICANT ACQUISITION PROBLEMS Buying 80% Free Things 639 et al., J Frost 70% Both Buying & Free 60% A 50% nxiety Disord2009;23:632- 40% 30% 20% 10% 0% Patient Report PREVALENCE OF HOARDING | Samuels et al. (2008) = 5% in US (adjusted) | Iervolini et al. (2010) = 2.3% (UK) | Mueller et al. (2009) = 4.6% (Germany) | Timpano et al. (2011) = 5.8% (Germany) OCD prevalence = 1-2.5% 9 11/19/2013 12-MONTH PREVALENCE OF PSYCHIATRIC DISORDERS 10% 2005;62:617-6 Kessler et al., 8% 2 A 7; Samuels et al. Samuels 7; 6% Psychiatry Gen rch 4% 2% 0% COMORBID DISORDERS IN HD DX 60% 50% 40% 30% DX 20% 10% 0% MDD GAD SAD ADHD OCD PTSD PERCENTAGE MEETING CRITERIA FOR IMPULSE CONTROL DISORDERS Frost et al. (2 Frost 70 * * * 60 0 50 11) 40 30 Hoarding OCD 20 10 0 10 11/19/2013 HD VS. OCD - % MEETING CRITERIA 35 30 * 25 20 HD 15 OCD 10 5 0 ADHD-Attn ADHD-Hyp PERCENTAGE MEETING DIAGNOSTIC CRITERIA FOR OCPD 35 * 30 25 20 15 10 5 0 Hoarding OCPD* OCPD -no H OCD TRAUMA IN HOARDING AND OCD HD OCD Trauma 24.4% Trauma 49.8% No No Trauma Trauma 11 11/19/2013 CHILDHOOD TRAUMA IN HOARDING AND OCD HD OCD 32.8% 20.9% Trauma Trauma No No Trauma Trauma FREQUENCY OF STRESSFUL LIFE EVENTS IN HD (TOLIN ET AL., 2010) Violence SLE frequency Possessions Relationship Financial 0% 20% 40% 60% 80% 100% Steketee, & Brady (2006) HOARDING IN ANXIETY DISORDER Tolin, Frost, Meunier, PATIENTS (N=139) ADAA 30% 25% ing d 20% 15% % withhoar % 10% 5% 0% Panic Specific OCD Social Anxiety GAD Phobia 12 11/19/2013 Age of Onset in Hoarding 30 26.6 25 24.1 20 (2 al. et Tolin 15 13.8 0 orting Onset orting 10) p 10. 8 10 8.1 % Re 4.8 4.4 5 3.7 2.5 0.7 0.1 0.1 0.1 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Age Range Reported age of onset of compulsive hoarding. COURSE OF COMPULSIVE HOARDING | Saving begins in childhood or adolescence y Clutter does not become severe until adulthood | Chron ic or worsening course | Insight begins later than the symptoms, and fluctuates % OF RESPONDENTS WITH MODERATE TO SEVERE HOARDING 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 years years years years years years years years years years years years years years Tolin DF, et al. Depress Anxiety. 2010. 13 11/19/2013 PROBABILITY OF FULL OR PARTIAL REMISSION OVER 2 YEARS (OCD SUBTYPES) 45% et al. (2 Pinto 40% 35% 30% 25% 0 07), ABCT 07), 20% 15% 10% 5% 0% HOARDING IN CHILDREN | Overlapping ADHD | Reactions to touching/moving objects | Little insight | Abnormal personification | Essentialism HOARDING IN ELDERS | 15% of nursing home residents | 25% of community day care elder participants hoarded small items | Rate of hdihoarding among elders in private and public housing : y Elders at Risk Program, Boston 15% y Visiting Nurses Assn., NYC 10-15% y Community Guardianship, NC 30-35% Frost et al., 1999; Marx & Cohen-Mansfield, 2003 14 11/19/2013 COGNITIVE FUNCTIONING IN ELDERLY HOARDING CLIENTS 26:176-184 Steketee et al. 80% 70% 60% , 50% HealthSoc2001; Wk None 40% Mild Severe 30% 20% 10% 0% Cognitive Problems Memory Problems Poor Insight ELDERLY: PERCENTAGE OF APPLIANCES NOT USEABLE 60% 50% 40% 30% 20% 10% 0% Steketee et al., Health Soc Wk 2001; 26:176-184 HOARDING BEHAVIORS IN OTHER DISORDERS | OCPD | Pervasive Developmental | Schizophrenia Disorder | Dementia/Alzheimer’s | Genetic Disorders and (Prader-Willi Syndrome) Neurodegenerative | Acquired Brain Injury Disorders | OCD | Parkinson’s | Huntington’s 15 11/19/2013 HAZARDS OF HOARDING | Poor Sanitation | Mobility et al. (2 Frost Hazard | Blocked Exits 0 00) | CiCommunity Cost | Homelessness | Fire Hazard DIOGENES SYNDROME | Poor personal hygiene | Domestic squalor | Syllogomania HAZARDS OF HOARDING Frost et al. (2 Frost | Poor Sanitation | Mobility Hazard 0 | Bloc ke d Ex its 00) | Community Cost | Homelessness | Fire Hazard 16 11/19/2013 HAZARDS OF HOARDING | Poor Sanitation | Mobility Hazard | Blocked Exits | Community Cost | Homelessness | Fire Hazard HAZARDS OF HOARDING |Poor Sanitation et al.