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Buried in Treasures Understanding and Treating Compulsive

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Buried in Treasures Understanding and Treating Compulsive Powered By Docstoc
					                     Gail Steketee, PhD
                    Professor 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
                    30

                                      26.6

                    25                       24.1
% Reporting Onset




                    20




                    15         13.8

                                                    10.8
                    10
                                                           8.1

                                                                 4.8   4.4
                     5   3.7
                                                                             2.5
                                                                                   0.7
                                                                                         0.1   0.1   0.1
                     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




                         Age of onset of hoarding symptoms
   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
                    Non-       Hoarding Fire                   Ratio
                 Hoarding Fire

Dollar loss to     $11,711        $93,784                       8x
owner (USD)
Containment          90%             40%                       2.25x
to room of
origin
Presence of          66%             28%                       2.4x
operating
smoke alarms



                                Source: Melbourne Fire Dept.
OCD = 135          Hoarding = 217




 OCD        Both              Hoarding
 = 96       = 39              = 178




               Frost et al. (2010)
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               Perception
   Categorization          Association
   Memory                  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      Negative Emotions
    ◦   Pleasure            ◦   Grief/loss
    ◦   Excitement          ◦   Anxiety
    ◦   Pride               ◦   Sadness
    ◦   Relief              ◦   Guilt
    ◦   Joy                 ◦   Anger
    ◦   Fondness            ◦   Frustration
    ◦   Satisfaction        ◦   Confusion
                                    Cognitive Processes:
     Vulnerabilities:
                                 Decision-making, Attention,
    Biology, Family,
                                  Memory, Problem solving
    MH, Core Beliefs



                        Beliefs & Meanings: Identity, Value,
                         Responsibility, Memory, Control



                             Emotions
  Negative
                        Negative   Positive
                                                      Positive
Reinforcement                                      Reinforcement

                         Saving &
                         Acquiring
   Home and clutter        Health & safety
   Objects and             Problems from
    reactions                hoarding
   Where to start          Comorbidity (MDD,
   Organizational           OCD, ADHD, etc.)
    system                  Family history of
   Acquiring                hoarding
   Reasons for saving      Onset & course
   Family & friends        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 = 1.81
                               27% 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<.05
                   Muroff 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
25% gain   9% gain




                     Muroff, Steketee, & Bratiotis, (2010) unpublished
   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
a
         b
                                 c




    Pekareva-Kochergina & Frost (2009).
22.6%




                                          6/1
                                          1/2
             CBT for Hoarding Delivered    01
        50   Via Webcam                     2
   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 force
Thank you! steketee@bu.edu

				
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