gail steketee, ph.d. dean and professor boston university school of social work

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When Homes are Buried in Treasures: Aging and Hoarding Behavior The Tenth Annual University of Maine Geriatrics Colloquium Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

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Page 1: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

When Homes are Buried in Treasures: Aging and Hoarding

Behavior

The Tenth Annual University of Maine Geriatrics Colloquium

Gail Steketee, Ph.D.Dean and Professor

Boston University School of Social Work

Page 2: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Disclosures: Books by Oxford &

Houghton-Mifflin-HarcourtGrant Funding from

IOCDF, NIMH

Page 3: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 4: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding disorder (HD) diagnosis

Hoarding symptoms and features, safety risks

Assessing hoarding Model for understanding

HD Treatment strategies

Road Map for HD

Page 5: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 6: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 7: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 8: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 9: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 10: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.  B. Due to a perceived need to save the items and distress associated with discarding them.C. Possessions clutter active living areas and compromise their intended use. Living areas may be uncluttered due to intervention by others (e.g., family members, cleaners, authorities).

DSM-5 Criteria for Hoarding Disorder (HD) (APA, 2013)

Page 11: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

D. 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. Not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi Syndrome).F. Not better accounted for by symptoms of other disorders, such as OCD, Depression, Schizophrenia, Dementia, Autism Spectrum.

DSM-5 Criteria for HD (cont.)

Page 12: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

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.”

Acquisition Specifier

Page 13: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 14: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

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: Mostly convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary.

Absent insight (Delusional beliefs about hoarding): Completely convinced that hoarding-related beliefs and behaviors are not problematic despite evidence to the contrary.

Insight Specifier

Page 15: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Feature Collecting Hoarding Object content

Focused; cohesive themes, few obj types

Unfocused; lacks theme, many different objects

Acquisition process

Structured, planned and focused searches

Unstructured; little planning or focused searching

Excessive acquisition

Less common; mainly purchased items

Very common (~90%), free and purchased items

Level of organization

High; items arranged, stored and/or displayed

Low; disorganized clutter

Presence of distress

Rare;(e.g., finances); generally pleasurable

Common due to clutter, diff. discarding, not acquiring

Social impairment

Minimal; social activities often part of collecting

Mild to severe; relationship conflict, social withdrawal

Occupational interference

Rare Common

* Adapted from Nordsletten, Fernández de la Cruz, Billotti, Mataix-Cols (2013). Finders keepers: the features differentiating hoarding disorder from normative collecting. Comprehensive Psychiatry, 54, 229-37.

Page 16: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Reasons for Saving - same as for all of us

Sentimental – “This represents my life. It’s part of me.” Instrumental – “I might need this. Somebody could use

this.” Intrinsic – “This is beautiful. Think of the

possibilities!”

Page 17: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Homes cluttered

with objects of

mixed value

Churning

behavior

Out of sight

fears

Disorganization

Page 18: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding Consequences in Older Adults

◦Chronic and age-related medical illnesses (Ayers et al., 2010; Ayers et al., 2014).

◦Medication and diet mismanagement leads to worsening medical conditions (Ayers, Schiehser, Liu, & Wetherell, 2012a; Diefenbach, DiMauro, Frost, Steketee, & Tolin, 2012; Kim et al., 2001).

◦Significant impairment in activities of daily living - move about in the home, find important items, eat at a table, use the kitchen sink, prepare food, sleep in a bed(Ayers et al., 2012; Diefenbach, et al., 2012; Steketee, Schmalisch, Dierberger, DeNobel, & Frost, 2012).

◦Premature relocation to senior housing or eviction; risk of homelessness (Whitfield, Daniels, Flesaker, & Simmons, 2011)

Page 19: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Frost et al. (2000)

Mobility Hazards

Page 20: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding related Consequences

Social isolation (Ayers et al., 2010; Kim et al., 2001)

Strained relationships (Tolin et al., 2008)

◦Family, friends◦Landlords, neighbors

Legal and financial problems◦Credit card debt◦High expenses – buying, storage unit fees◦Property damage - loss of home

investment

Page 21: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Death in house fires - 6%

8 times the cost of ordinary fires

77% are men Nearly 40%

are 65 or older

Frost et al. (2000)

Profiles of Hoarding Fires

Page 22: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

North America◦ US, Canada

Europe ◦ UK, France, Germany, Netherlands, Italy◦ Poland, Turkey

Africa◦ Egypt, South Africa

South America◦ Brazil, Costa Rica

Asia◦ Japan, Singapore

Hoarding Crosses Cultures

Page 23: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Recent estimates- 4-5% in adults◦ US – 5% Samuels et al. (2008)◦ UK – 2% Iervolino et al. (2010)◦ German – 4.6% Mueller et al. (2009)

More common among older people and those with low incomes

Among elder service organizations:◦ 15% at Elders at Risk Program, Boston 15%◦ 10-15% at Visiting Nurse Assn., NYC◦ 30-35% at Community Guardianship, NYC

Epidemiology

Page 24: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

0

5

10

15

20

25

30

3.7

13.8

26.6

24.1

10.8

8.1

4.84.4

2.5

0.7000000000000010.10.10.1

<5 10 15 20 25 30 35 40 45 50 55 60 65

2/3 of hoarding begins before age 20

Page 25: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

0-5

10-J

un

15-N

ov

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

56-6

0

61-6

5

66-7

0 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Tolin DF, et al. Depress Anxiety. 2010.

Hoarding becomes moderate to severe after age 30

Page 26: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Frequency of Hoarding in Older Adults 15% of nursing home residents and 25% of

community day care elder participants hoarded small items (Marx & Cohen-Mansfield, 2003)

Rate of hoarding among elders in private and public housing is unknown, but some frequency counts are available:◦ Elders at Risk Program, Boston 15%◦ Visiting Nurses Association., NYC 10-15%◦ Community Guardianship, NC 30-35%

Some of the worst cases are reported among elderly people

Page 27: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Major Dep.

GAD Social Phob

PTSD Sub. Abuse

ADD0

10

20

30

40

50

60

Frost et al. (2010)

Most people with HD also have other MH problems (n=217)Frost, Steketee, Tolin et al., 2011

Page 28: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding often goes unreported: n=139 anxiety clinic patients

Panic Specific Phobia OCD Social Anxiety GAD0%

5%

10%

15%

20%

25%

30%

% o

f A

Ds

wit

h h

oar

din

g

0% 0%

11%

14%

27%

Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2011). Journal of Anxiety Disorders, 25, 43-48.

Page 29: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Health Threats in 62 Elders who Hoard (seen by 40 Caseworkers)

Fire Falling Unsanitary Medical Ambulation0%

10%

20%

30%

40%

50%

Kim, Steketee, & Frost (2001). Health & Social Work. 26:176-184

Page 30: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

% with unusable appliances in 62 older adults (Case Worker Interview)

Stove/O

ven

Fridge/F

reeze

r

Kitchen S

ink

Bathtu

b

Bathro

om S

ink

Toilet

Heat0%

10%

20%

30%

40%

50%

60%

Steketee et al., Health Soc Wk 2001; 26:176-184

Page 31: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Cognitive Problems did not Explain Hoarding in Elders

Cognitive Prob-lems

Memory Prob-lems

Poor Insight0%

10%

20%

30%

40%

50%

60%

70%

80%

None

Mild

Severe

Kim, Steketee, & Frost (2001). Health & Social Work. 26:176-184

Page 32: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Kim, Steketee, & Frost (2001). Health & Social Work. 26:176-184

Previous Interventions for Elders rarely worked

Clear

ing

Partia

l Cle

arin

g

Clean

ing A

ssis

tance

Hoarder

Family

Mem

ber

Outs

ide

Agency

Sustai

ned Im

prov.

Impro

v. &

Rel

apse

No Chan

ge

Clutte

r Wors

ened

No Info

0%

10%

20%

30%

40%

50%

60%

70%

80% Intervention By Whom Outcome

Page 33: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Community Challenges Increased social service provider load for:

◦Public health departments◦Housing and inspection services◦Housing managers & landlords◦Elder service agencies◦Mental health department◦Health care organizations

The time and money required to resolve serious hoarding cases strains agency resources

Page 34: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Concerns/barriers in treating late life hoarding Possible cognitive impairment Need for assistance in physical ADLs

◦ Care and moving of the body◦ Walking, bathing, dressing, toileting, brushing

teeth, eating Need for help with instrumental ADLs

◦ Activities that support independent living◦ Cooking, cleaning, driving, communication via

phone or computer, shopping, tracking finances, managing medications

Page 35: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Concerns/barriers in treating late life hoarding Not familiar/comfortable with psychiatric

treatment Role of family members and other social

supports Limited/fixed income Multiple medications/multiple medical

providers Possible negative life events (i.e., death of

spouse) Risk of losing independent living status

Page 36: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Frost et al. (2000)

79% of cases involved multiple agencies

Community Costs

Sanitation problems

Page 37: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Diagosis◦ Structured Interview for Hoarding Disorder (SIHD)◦ Other MH conditions: SCID, ADIS, MINI

Clinical Hoarding Interview (Steketee & Frost, 2014)

Hoarding Rating Scale (HRS) Saving Inventory-Revised (SI-R) Clutter Image Rating (CIR) Activities of Daily Living-Hoarding (ADL-H) Risk & Safety

◦ Home visit, HOMES, Home Environment Index Family accommodation and burden

Hoarding Assessment Instruments

Page 38: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

0 1 2 3 4 5 6 7 8Not at all Mild Moderate Severe ExtremelyDifficult

Difficult

1. Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home?

2. To what extent do you have difficulty discarding (or recycling, selling, giving away) ordinary things that other people would get rid of?

3. Do you currently have a problem with collecting free things or buying more things than you need or can use or can afford?

4. To what extent do you experience emotional distress because of clutter, difficulty discarding or problems with buying or acquiring things?

5. To what extent do you experience impairment in your life (daily routine, job / school, social activities, family activities, financial difficulties) because of clutter, difficulty discarding, or problems with buying or acquiring things?

Hoarding Rating Scale (HRS)

Tolin, D.F., Frost, R.O., & Steketee, G. (2010). Psychiatry Research, 30, 147-152.

Page 39: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work
Page 40: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

ADL-Hoarding (ADL-H)Activities affected by

hoarding problem

Can do

easily

little

difficulty

moderate

difficulty

great

difficulty

Unable

to do

1. Prepare food 1 2 3 4 5

2. Use refrigerator 1 2 3 4 5

3. Use stove 1 2 3 4 5

4. Use kitchen sink 1 2 3 4 5

5. Eat at table 1 2 3 4 5

6. Move around home 1 2 3 4 5

7. Exit home quickly 1 2 3 4 5

8. Use toilet 1 2 3 4 5

15. Find important things (bills, tax forms, etc.)

1 2 3 4 5

Frost, R.O., Hristova, V., Steketee, G., & Tolin, D.F. (2013). Activities of Daily Living in hoarding disorder (ADL-H). Journal of Obsessive Compulsive and Related Disorders, 2, 85-90.

Page 41: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Safety Fire hazards, blocked exits, cluttered

stairways, room for emergency personnel & equipment

Squalid conditions Rotten food, insects, animal waste Cleaning and hygiene behavior

Structural damage Home Environment Index HOMESFrost & Hristova, J Clin Psychol 2011;67:456-466; Rasmussen,, Steketee, Frost, Tolin, & Brown (in press). Community Mental Health

Journal.

Assessing Risk

Page 42: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Additional geriatric specific assessments:◦ Depression and anxiety measures normed for use

with older adults Geriatric Depression Scale Geriatric Anxiety Scale

◦ Neurocognitive functioning (Montreal Cognitive Assessment, Delis-Kaplan Executive Functioning System)

◦ Additional Functional Measures (Functional Disability Index)

Geriatric-specific Assessment

Page 43: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

EmotionsNeg. Pos.

Attachments & Valuation of objects

Core beliefs &vulnerabilities

Saving &Acquiring

Information processing

Negative Reinforcement

PositiveReinforcement

Steketee, G., & Frost, R.O. (2003). Clinical Psychology Review, 23, 905-927.

MODEL FOR HOARDING DISORDER

Page 44: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Genetics◦ Family history of hoarding◦ Linkage studies◦ Twin study

Neural mechanisms ◦ FMRI studies◦ PET studies◦ Brain damage studies

Evolutionary biology◦ Hoarding by animals◦ Nesting behavior

Biological vulnerability

Page 45: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Core Beliefs - low self-worth; helplessness

Intermediate Beliefs - perfectionism Depressed mood Mental health co-morbidity Early history of loss or traumatic

events Poor health or disability Physical constraints

Psychological and Physical Vulnerabilities

Page 46: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Attention

Categorization

Memory

Perception

Association

Complex

Thinking

Information Processing

Decision-making Difficulties

Page 47: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Beauty/aesthetics Memory Utility/opportunity Sentimental Comfort Uniqueness

Identity/potential identity

Need for control Concern over

mistakes Responsibility/

waste Completeness Safety

Emotional Attachments and Beliefs

Page 48: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Emotions Positive Emotions

◦ Pleasure◦ Excitement◦ Pride◦ Relief◦ Joy ◦ Fondness ◦ Satisfaction

Negative Emotions◦ Grief/loss◦ Anxiety◦ Sadness◦ Guilt◦ Anger◦ Frustration◦ Confusion

Page 49: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Distress Decisions Attending to clutter Feelings of loss Feelings of

vulnerability Worries about

memory

Inviting people into the home

Making mistakes Losing opportunities Losing information Depression Putting things out of

sight

Avoidance

Page 50: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

EmotionsNeg. Pos.

Attachments & Valuation of objects

Core beliefs &vulnerabilities

Saving &Acquiring

Information processing

Negative Reinforcement

PositiveReinforcement

Steketee, G., & Frost, R.O. (2003). Clinical Psychology Review, 23, 905-927.

MODEL FOR HOARDING DISORDER

Page 51: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Steketee et al., Health Soc Wk 2001; 26:176-184

Cleanouts - Case Worker reports about Hoarding in Older Adults

0%5%

10%15%20%25%30%35%40%45%50%

Sust. Impr. Impr. &Relapse

No Change ClutterWorsened

Page 52: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding predicted negative outcome of SSRIs in OCD Mataix-Cols et al. (1999)

Hoarding and non-hoarding OCD patients respond similarly to paroxetine◦ (But neither group improved greatly – 28% vs

32% responder rate) Saxena et al., (2007)

Recent findings indicate that venlafaxine may be beneficial for HD Saxena et al. (2013)

Pharmacotherapy

Page 53: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Specialized CBT for Hoarding

Education and case formulation Determine values, set goals Enhance motivation Train skills for organizing, problem solving, decision-making

Practice discarding & non-acquiring

Evaluate thoughts and beliefs Maintain new behaviors

Page 54: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Individual, group or web-based Sessions and practice in office and at home

Practice in acquiring locations Family consultation Use of a coach Structured cleanout for severe clutter - later in treatment using experienced staff

Treatment Format

Page 55: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Motivational Interviewing to tip the balance and resolve ambivalence

Benefits of change seem small

Costs of change seem heavy

Page 56: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Values◦What you care most about?

Personal goals◦What do you most want to do in the

remainder of your life? Short-term goals

◦What would you like to accomplish in the next year?

Establish Personal Values and Goals

Page 57: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

To enjoy my instruments again To create breathing space, order, and

beauty in my bedroom (esp. in front of the closet)

To have a living room that a friend or family could enter

To have a safe kitchen with working surfaces

To take a bath To remove bagged items

Example: Sharon’s Goals

Page 58: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Problem solvingSorting OrganizingDecision making

Skills Training

Page 59: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Determine usual attention span Help client reduce and/or delay

distractibility◦ Use timer◦ Control visual field (cover distracting

areas) Discuss ways to create structure

◦ Regular appointments for sorting ◦ Establish priorities◦ Divide projects into manageable steps

Skills to Manage Attention

Page 60: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Do I have an immediate use for this? Can I get by without it? Do I want it taking up space in my home? Is this truly important or does it just

seem so because I am looking at it? What are the advantages and

disadvantages of acquiring this? Develop personal rules for acquiring -

must have:◦ An immediate use for it◦ Time to deal with it appropriately◦ Money to afford it◦ Space to put it

Acquiring Questions and Rules

Page 61: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Bring box from home to sort in the office Start with easier items, set aside harder

ones Ask client to talk aloud about decisions to

keep or remove (recycle, give away, trash, sell)

Gradually reduce assistance with decisions Weekly practice at home on most

important areas, work on easiest items first Move sorted items to destination ASAP – no

looking back

Treating Difficulty Discarding

Page 62: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Some office, but mostly home visits for 1.5 – 2 hours

~40 sessions over 12 months Team approach - agency clinicians,

trained staff member Flexible treatment – interweave skills training, exposure practice, cognitive training

Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.

Brookline Flexible CBT for Hoarding with older adults

(modified from Steketee & Frost 2007 manual)

Page 63: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Excluded patients with dementia and serious personality disorders

9 began; 6 completed (5 F, 1 M) Average age = 72 (range 56 – 86) Only 1 had no MH problems; 5 had

depression, 1 PTSD, 1 ADHD 5 lived alone; 1 lived with roommates Physical health problems included

diabetes, overweight, arthritis, chronic bronchitis, glaucoma, Parkinson’s

Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.

Brookline Study Recruitment

Page 64: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.

Humor and inspirational quotations Schedule sorting times Listen to music while sorting Review progress via before and after

photos Review life goals, esp. as priorities change

with declining health Reward self for work done - but not with

new items! Balance homework with leisure

Engagement Strategies

Page 65: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Average reduction in clutter = 28%Range = 17% to 46%

ClientsCIR %

Reduction

1 17%

2 20%

3 25%

4 29%

5 36%

6 46%

Mean 28%

Turner, Steketee, & Nauth (2010). Cog. & Behav. Pract., 17, 449-457.

Page 66: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Ayers et al. 2010, unpublished

N=12 Standard CBT methods for 26 weekly

sessions; less flexible therapy Only 3 (25%) improved by 30% or more, but

one relapsed; 9 (75%) did not improve noticeably

Responders had previous psychotherapy, high homework compliance and lower mean age (68 v. 76)

Why the poor response?

Ayers et al. CBT with Older Adults

Page 67: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

More health problems and safety risks like falling and fire danger

Low insight, motivation and ambivalence required strong relationship building

Deprivation history exacerbated some clients’ worries about “saving necessities”

Downsizing homes provoked special challenges:◦Who should receive cherished objects◦How to physically remove items

Cognitive therapy was less useful for those with some cognitive decline

Aging Can Complicate Treatment

Page 68: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Emphasize behavioral more than cognitive therapy methods

Teach skills to improve cognitive functioning◦ e.g., use calendar, to do lists & memory cues,

prepare to organize, encourage flexible thinking, train problem solving

Practice in session; arrange for help with homework

Train new behavior habits to prevent relapse

Modified CBT for Older Adults

Page 69: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Cognitive Flexibility Training

Brainstorming Strategy

verbalization Hypothesis testing

by looking for disconfirming evidence

Set shifting/ maintenance

Page 70: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Ayers et al., 2014 pilot study

9 women, 2 men Mean age = 66, range 60-85 24 wks. individual therapy by licensed

psychologists First 6 sessions on executive functioning Next 16 sessions on exposure for

discarding and acquiring ◦Approximately 12-25% home visits

Final 2 sessions on relapse prevention

Page 71: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Results

Significant and large improvement in measures of hoarding severity

8 of 11 = treatment responders 3 partial responders:

◦narrowly missed full response criteria◦3 had comorbid MDD; 2 had OCD. ◦Had highest hoarding severity scores before treatment (SI-R = 75, 71, 67).

Page 72: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding Severity Changes

Measure

% Improvement n=11

SI-R 38%

CIR 26%

Page 73: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Case example - bedroom

Bedroom at initial home visit (unable to sleep in bed)

Bedroom at session 18

Page 74: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Next steps in treatment for older adults with HD (Ayers et al.)

Randomized controlled trial in progress 33 participants are enrolled

22 women; 11 men mean age 68; 12% ethnic minority

◦16 assigned to TAU (case management) (2 refused final assessments; 1 hospitalized for

psychiatric symptoms)◦17 assigned to CREST condition (cog. rehab.)

No participants dropped out Real world effectiveness

Page 75: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Hoarding Disorder is common, chronic, and debilitating for sufferers and family members

Hoarding has unique biological, cognitive, emotional, and behavioral features

Medications for OCD have not been very helpful

Specialized CBT reduces hoarding symptoms in adults but requires modification for older adults

Conclusions

Page 76: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

Structured assignments (esp. sorting) with daily goals, scheduling and in-home coaches were very helpful

Patients with comorbid disorders and severe HD may require more intensive therapy

Group therapy increases social support, but it is not clear how to use this for older adults

How can we promote social support when therapy ends?

More studies are needed with larger and more diverse clients

Successes with CBT for Elders

Page 77: Gail Steketee, Ph.D. Dean and Professor Boston University School of Social Work

www.ocfoundation.org/hoarding◦ Information, measures, therapy manuals,

referral, resources, hoarding task forces, therapy referrals

www.abct.org therapy referralswww.messies.com; www.childrenofhoarders.com

◦Support groups http://www.challengingdisorganization.org/

◦Professional organizers who specialize in chronic disorganization

Find local cleaning co. with sensitivity and expertise in hoarding

Gail Steketee: [email protected]

Referral Options