03 - Hoarding Disorder - Caleb LackHoarding Disorder A New Syndrome? • Not included in the DSM-IV • Hoarding symptoms are listed under OCPD – “Inability to discard worn-out

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HoardingDisorder

ANewSyndrome?

•  NotincludedintheDSM-IV

•  HoardingsymptomsarelistedunderOCPD– “Inabilitytodiscardworn-outorworthlessobjectsevenwhentheyhavenosenMmentalvalue”

•  NotlistedatallinICD-10

Mataix-Colsetal.(2010)

OperaMonalDefiniMon

A.  PersistentdifficultydiscardingorparMngwithpossessions,regardlessofthevalueothersmayaVributetothesepossessions

B.  Thisdifficultyisduetostrongurgestosaveitemsand/ordistressassociatedwithdiscarding

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OperaMonalDefiniMon

C.  ThesymptomsresultintheaccumulaMonofalargenumberofpossessionsthatfillupandcluVeracMvelivingareasofthehomeorworkplacetotheextentthattheirintendeduseisnolongerpossible.IfalllivingareasareuncluVered,itisonlybecauseoftheintervenMonsofthirdparMes(e.g.,familymembers,cleaners,authoriMes).

OperaMonalDefiniMonD.  Thesymptomscauseclinicallysignificant

distressorimpairmentinsocial,occupaMonal,orotherimportantareasoffuncMoning(includingmaintainingasafeenvironmentforselfandothers)

E.  ThehoardingsymptomsarenotduetoaGMC

F.  Thehoardingsymptomsarenotrestrictedtothesymptomsofanothermentaldisorder

HoardingSpecifiers•  WithExcessiveAcquisi/on:IfsymptomsareaccompaniedbyexcessivecollecMngorbuyingorstealingofitemsthatarenotneededorforwhichthereisnoavailablespace.

•  Goodorfairinsight:Recognizesthathoarding-relatedbeliefsandbehaviorsareproblemaMc.

•  Poorinsight:Mostlyconvincedthathoarding-relatedbeliefsandarenotproblemaMcdespiteevidencetothecontrary.

•  Absentinsight:Completelyconvincedthathoarding-relatedbeliefsandbehaviorsarenotproblemaMcdespiteevidencetothecontrary.

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HoardingandOCD

•  Hoardingsymptomsseenin18-40%ofOCDcases;onlyclinicallysignificantin<5%

•  Resembleeachotherphenomenologically

•  ComorbidratesofOCDin16-35%ofcompulsivehoarders

Mataix-Colsetal.(2010)

Hoardingvs.OCD

•  Inhoarding,don’tseedistressing,repeMMve,intrusivethoughts(obsessions)

•  Thoughtsofpossessiondonottriggerrituals

•  Whenconfrontedwithdiscarding,angerandgriefareaslikelyasanxiety

Mataix-Colsetal.(2010)

Hoardingvs.OCD

•  ConMnuallyworseningpaVernofsymptoms,withlateonsetofdistress/disability

•  LackofinsightcomparedtoOCD

•  Acquiringandsavingareojenpleasantevents,whereO/Carealwaysnega/ve

Mataix-Colsetal.(2010)

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Hoardingvs.Squalor

•  “Diogenessyndrome”associatedwithself-neglectanddomesMc-neglect

•  MostwithHDdonotshowthis,maybeasubsetofindividuals– 17%hoarders,32%residences“extremelyfilthy”

Sketekeeetal.(2001)

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AnimalHoarding

•  Largenumberofanimalsand1.  Failuretoprovideminimalstandardsof

nutriMon,sanitaMon,andveterinarycare2.  FailuretoactonthedeterioraMngcondiMonof

theanimalsandtheenvironment3.  LackofawarenessofthenegaMveeffectsofthe

collecMonontheirownhealthandwell-beingandonthatofotherfamilymembers

Patronek&Nathanson(2009)

AnimalHoarding

•  MaybemorerelatedtoDiogenessyndromethancompulsivehoarding– Squalor,neglectofself

•  Muchmoreresearchneeded

Patronek&Nathanson(2009)

Prevalence

•  2-5%ofgeneralpopulaMon

•  Ojenonlydiagnosedlaterinmiddletolateadulthood(50+years)

•  60%+engageinexcessivebuying,over50%inacquiringfreethings

etal.(2010)

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Prevalence

•  Differingstudiesusingdifferentmethodshavefoundquitedifferentrates

Pertusaetal.(2010)

Course

•  RetrospecMvereportsoffirstsymptomsinadolescence,firstinterferenceinmid-30s

•  ChronicandunremiongcourseforvastmajorityofpaMents

Mataix-Colsetal.(2010)

GenderDifferences

•  Clinicalsamplesarepredominatelyfemale

•  Epidemiologicalstudiesaremixed,withtwofindinghighermalesrates

•  Similarphenomenologyacrossgenders

Mataix-Colsetal.(2010)

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SES&CulturalDifferences

•  Appearstobeauniversalphenomenon

•  EasternandWesternhoardersarequitesimilaracross– ClinicalcharacterisMcs–  Itemsbeinghoarded– ExtentofcluVer

Mataix-Colsetal.(2010)

Comorbidity

•  HighoverlapwithMDD(57%),SAD(29%),andGAD(28%)

•  Lessthan20%havecomorbidOCD

Frostetal.(2006)

ImpactofHoarding

•  AssociatedwithsubstanMaldistress/disability

•  CluVerpreventsnormaluseofspacetoaccomplishbasicacMviMes(cooking,cleaning,moving,sleeping)

•  Putspeopleatriskforfire,falling,poorsanitaMon,andhealthrisks

Mataix-Colsetal.(2010)

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ImpactofHoarding

•  Workimpairmentgreaterthanallotheranxiety,mood,andsubstanceusedisorders

•  8-12%evictedorthreatenedduringlife

•  Ojenleadstofamilyandneighborconflict

Mataix-Colsetal.(2010)

Let’sWatchSome

•  hVps://youtu.be/NKKYuPLDWKA

•  Whilewewatch,thinkaboutwhatwe’vetalkedaboutinclass

•  IsthedepicMonaccurate?Isthetreatmentaccurate?Likelytohelp?

EMology

•  Highincidenceof“packrats”infirstdegreerelaMvesofhoarders

•  HoardinginOCDshowshigherthanexpectedfamilyratesofhoarders

•  GeneMcfactorsaccountforabout50%ofvarianceinhoardingbehaviors

Mataix-Colsetal.(2010)

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EMology

•  Inanimalstudies,implicaMonofsubcorMcallimbicstructuresandtheventro-medialprefrontalcortex

•  SomeevidencefromlesionstudiesinhumansimplicaMnganteriorventromedialprefrontalandcingulatecorMces

Mataix-Colsetal.(2010)

EMology

•  SavingandacquiringbehaviorsareojenposiMvelyreinforcedincompulsivehoardingbyposiMvefeelings

•  Feelingsofpleasure,safety,andcomfortareprovidedbyacquiringnewitemsorfantasizingaboutexisMngones

Mataix-Colsetal.(2010)

Meetthe“BadGuys”

•  “It’sjustnotmypriority”(lowmoMvaMontochange)

•  Overthinkingandconfusingone’sself

•  Avoidanceandmakingexcuses

•  PrioriMzingshort-termreinforcement

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Meetthe“BadGuys”

•  Unhelpfulbeliefsthatgetintheway– Seeinguselessobjectsasusefulorneeded– PerfecMonism&fearofmakingmistakes– Exaggeratedsenseofresponsibility– AVachmentandanthropomorphizingobjects– SeeingobjectsaspartofyouridenMty– UnderesMmaMngtheirmemory– Seeinghoardingasbeingundertheircontrol

EMology

•  Avoiddiscardingpossessionsandendupstoringthemasawaytoavoid– Theexperienceofloss– Havingtomakeananxiety-provokingdecision– Makingamistakeregardingapossession

•  CluVerisafuncMonofbothvolumeofthingsandorganizaMondeficits

Pertusaetal.(2010)

Treatment

•  Giventhenewnessofthisareaofresearch,limitednumberofoutcomestudies

•  SRIeffecMvenessinOCDpaMentswithhoardingismixed(someless,someequal)

•  OnestudyusedparoxeMneandfounda25%decreaseinhoardingsymptoms

Pertusaetal.(2010)

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Treatment

•  Poorinsightmaycausetreatmentrefusal,lackofcooperaMon,dropout,andpooroutcomes

•  AspecificallydevelopedCBTtreatmenthasshownsomepromise,withdecreasesof23-37%and70%responserate

Pertusaetal.(2010)

CBTforHoarding

•  Includesofficeandin-homesessions

•  Focuseson– MoMvaMonalinterviewing– Skillstraining(organizing,decisionmaking,problemsolving)

– ExposuretosorMng,discarding,andnotacquiring– CogniMverestructuring

Sketekee&Frost(2008)

CogniMveTherapy

•  UsedbecausehoardinginvolvesfalsepercepMonsofthreatandworrisomereacMonspredicMngnegaMvefutureevents

1.  IdenMfyhowthepaMentisthinkingandthebeliefsaboutself,world,andfuturethatunderliethosethoughts

–  The“badguys”wediscussed!

Borkovecetal.(2004)

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CogniMveTherapy

2.  EvaluatetheaccuracyofthosecogniMonsthroughexaminaMonoftheirlogic,probability,andpastevidence

3.  GeneratealternaMve,moreaccurateinterpretaMons,predicMons,andwaysofbelieving

Borkovecetal.(2004)

CogniMveTherapy

4.  UsethesenewperspecMveswheneverworryisdetectedandengageindeliberatebehavioralexperiments

•  Canalsousea“WorryOutcomeDiary”toassistingatheringevidencefor/against– Allowsonetotrackwhetherornotthefearedoutcomeactuallyhappened

Borkovecetal.(2004)

ChallengingThoughts

•  CanIsaythatthisstatementis100%true,withoutanyexcepMons?

•  Whatisthelikelihoodorprobabilityofthishappening?– Ratethistwice,onceemoMonallyandonceobjecMvely

•  Doesthisstatementfitwithalltheavailableevidence?

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ChallengingThoughts

•  AmIignoringanysafetyfactors?

•  Doesthisalwaysapply?AretherecondiMonsunderwhichthismightnotapply?

•  Isthereagrayareatothisstatement(notjustablackandwhitething)?

•  Isthisbasedonfactorfeeling?Havemyfeelingseverturnedouttobewrong?

ChallengingThoughts

•  HowmuchcontroldoIactuallyhaveinthissituaMon?– AmItakingresponsibilityforthingsoverwhichIhavenocontrol?

– AmIignoringaspectsofthesituaMonthatIcancontrol?

•  IsmyexpectaMonforthisoutcomerealisMcorevenpossible?

TheThoughtRecord

•  ThisisaphysicalmanifestaMonofthethoughtchallengingprocess

•  OjenusedearlyintherapytohelpclientgeneralizeCRskillsoutsideoftherapy

•  Shouldbecustomizedfortheageand/ordevelopmentalleveloftheclient

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Exa

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rd THOUGHT RECORD

Trigger: __________________________________________________________ Cognitions (images, thoughts, assumptions, and/or beliefs):_________________ _________________________________________________________________ Strength of belief in cognitions (on a 1-7 scale): __________________________ Challenges to cognitions: _____________________________________________ _________________________________________________________________ Types of thinking errors: ____________________________________________ _________________________________________________________________ Alternative viewpoints: • Worst outcome: _________________________________________________ • Best outcome: __________________________________________________ • Most realistic outcome: ___________________________________________ What effect does this thought have on the way I feel? _____________________ _________________________________________________________________ Rational responses: Even though I feel that ________________________________________ is true, (thoughts or assumptions) the reality is that ___________________________________________________. (answers to challenges and alternative viewpoints)

UsingtheThoughtRecord

•  Whenteachingclients,itisimportanttomakesurethattheyarerecognizingthoughtsandemoMonsaccurately

•  PracMceinsessionwithtwo-threerecordsbeforeclientsdothemontheirown

•  ReviewtherecordstheydidashomeworkthenextweekandmakecorrecMonsasneeded

•  It’sMmetorestructureyourselfcogniMvely!

•  Youwillcomplete2thoughtrecordsdaily(6total)andturntheminFriday

•  Usethoughtchallengingandthelistofcommonthinkingerrorstohelp!