gail steketee, phd professor and dean boston university school of social work may 30, 2012

Gail Steketee, PhDProfessor 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; 34:341-350

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 Fire Ratio

Dollar loss to owner (USD)

$11,711 $93,784 8x

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)

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;45:673-686; Lochner et al., J

Clin Psychiatry 2005;66:1155-1160; Samuels et al., Am J Psychiatry

2007;164:493-499

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

EmotionsNegative 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

PositiveReinforcement

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 = 1.8127% reduction on hoarding measure

Steketee et al., 2010, Depress & Anx, 27, 476-484

Steketee et al., 2010, Depress & Anx, 27, 476-484

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<.05Muroff 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

Muroff, Steketee, & Bratiotis, (2010) unpublished

25% gain 9% 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

ab

c

Pekareva-Kochergina & Frost (2009).

CBT for Hoarding Delivered Via Webcam50 04/

21/23

22.6%

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 www.ocfoundation.org Support groups www.messies.com;

www.childrenofhoarders.com Mental health therapists

www.ocfoundation.org; www.abct.org Professional organizers for chronic

disorganization www.challengingdisorganization.org

Hauling - for example: 1-800-GOT-JUNK Local health clinic Local cleaning services Local community task forceThank you! steketee@bu.edu