Understanding and Treating Hoarding Disorder Sanjaya Saxena, M.D. - PDF document

Hoarding / Saving Behavior Understanding and Treating Hoarding Disorder Sanjaya Saxena, M.D. Director, UCSD Obsessive-Compulsive Disorders Program Professor, UCSD Department of Psychiatry UCSD School of Medicine La Jolla, CA Hoarding Disorder Hoarding / Saving Behavior DSM-5 Diagnostic Criteria A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. Hoarding is defined as “the acquisition of, and inability to discard worthless B. This difficulty is due to a perceived need to save items and distress associated with discarding them. (or excessive) items even though they appear (to others) to have no value.” C. The symptoms result in the accumulation of possessions that congest and clutter active living areas and substantially compromise their use. If living areas are uncluttered, it is only because of the (Frost & Gross, 1993) intervention of third parties (e.g., family members, cleaners, authorities).

Hoarding Disorder Hoarding Disorder DSM-5 Diagnostic Criteria DSM-5 Diagnostic Criteria Specify if: With Excessive Acquisition: If symptoms are accompanied by D. The hoarding causes clinically significant distress or excessive collecting or buying or stealing of items that are not needed or for impairment in social, occupational, or other important areas which there is no available space. of functioning (including maintaining a safe environment for self and others). Indicate whether hoarding beliefs and behaviors are currently characterized by : Good or fair insight : The individual recognizes that hoarding-related E. The hoarding is not attributable to another medical condition beliefs and behaviors (pertaining to difficulty discarding items, clutter, or (e.g., brain injury, cerebrovascular disease, Prader-Willi excessive acquisition) are problematic. Syndrome). Poor insight : The individual is mostly convinced that hoarding-related F. The hoarding is not better accounted for by the symptoms beliefs and behaviors (pertaining to difficulty discarding items, clutter, or of another mental disorder (e.g., hoarding due to obsessions excessive acquisition) are not problematic despite evidence to the contrary. in Obsessive-Compulsive Disorder, decreased energy in Major Absent Insight (i.e., delusional beliefs about hoarding) : The individual is Depressive Disorder, delusions in Schizophrenia or another completely convinced that hoarding-related beliefs and behaviors (pertaining Psychotic Disorder, cognitive deficits in Dementia, restricted to difficulty discarding items, clutter, or excessive acquisition) are not interests in Autistic Spectrum Disorder). problematic despite evidence to the contrary. Compulsive Hoarding Compulsive Hoarding

Compulsive Hoarding Hoarding Disorder Age at Onset Prevalence Mean: 12-13 years old (Samuels et al, 2002; Lochner et al, 2005; Ayers et al, 2010) • Population prevalence of clinically Mild Moderate Severe significant compulsive hoarding: 3-5% Any 13.4 24.3 33.6 (Samuels et al, 2008; Mueller et al, 2009; Iervelino et al, 2009; Symptom Timpano et al, 2011; Nordsletten et al, 2013) Clutter 16.6 23.8 35.6 = Estimated 7-11 million people in the U.S. Acquiring 18.2 26.6 34.1 Difficulty 16.4 22.6 33.5 Discarding Recognition 30.0 36.7 41.8 (Grisham et al, 2006) Compulsive Hoarding Reasons Given for Hoarding / Saving Behavior Most Commonly Hoarded items Newspapers • Perceived Need for the Items Books - Could use it, fix it, sell it Clothes - Might need it some day Magazines - It’s valuable, was expensive Bills / Receipts / Statements • Emotional Attachment to Possessions Bags, Storage Containers - Sentimental attachments Mail, Catalogs, Ads - Memorabilia Notes and Lists - Reminders of loved ones Memorabilia Same Reasons for Patients with Hoarding Some Idiosyncratic Items Disorder as for Non-hoarding People (Frost & Gross, 1993; Winsberg et al, 1999)

Animal Hoarding Animal Hoarding Hoarding By Cats Hoarding of Cats Compulsive Hoarding Compulsive Hoarding The Behavioral Syndrome Cognitive-Behavioral Model • Obsessional Concerns and Perceived Need to Save • Information Processing Deficits • Clutter - organization • Excessive Acquisition - categorization • “Churning” - memory • Procrastination - focusing attention • Disorganization - of Possessions, Time, Activities, Thoughts • Excessive Emotional Attachment to Possessions • Indecisiveness • Distorted Beliefs about the Importance of • Slowness / Lateness Possessions; Responsibilities • Avoidance • Poor Insight; Over-Valued Ideation. • Perfectionism • Circumstantial, over-inclusive language (Frost & Hartl, 1996; Neziroglu et al, 2012) (Frost et al, 1996; Saxena et al, 2002)

Hoarding Disorder Hoarding Disorder Comorbidity Initial Points to Remember: Point Disorder prevalence (n=217) • Not all Clutter is due to Hoarding Disorder. Major Depression 51% Dysthymia 5% Bipolar Disorder 1% • Compulsive Hoarding is a Neuropsychiatric Disorder. ADHD 28% OCD (non-hoarding) 18% GAD 24% • Hoarding Disorder is NOT merely Laziness, Social Phobia 24% Obstinance, or “Chronic Disorganization”. PTSD 7% Panic Disorder 0% Specific Phobia 14% • Hoarding Disorder can cause severe Functional Eating Disorders 1% Impairment and Disability. EtOH or Drug Abuse 2% Compulsive Buying 61% Kleptomania 10% • People with Hoarding Disorder Need Neuropsychiatric Pathological Gambling 6% Trichotillomania 5% Evaluation and Treatment, Not Just House-Cleaning! OCPD (without hoarding criterion) 18% (Frost et al, 2011) Assessment of Compulsive Hoarding Treatment of Hoarding Disorder Useful Assessment Questions  Medication • Amount and type of clutter?  Cognitive-Behavioral Therapy (CBT) • Health or safety hazards due to clutter? • Urges to save?  Biblio-based Support Groups (using BIT ) • Beliefs & fears about loss of possessions?  Other Psychotherapies: ineffective • Level of insight? • Procrastination, Avoidance?  12 Step Approaches: ineffective • Indecisiveness, Disorganization?  House Cleaning by Others: ineffective • Level of functioning and impairment? • Level of support? (Saxena & Maidment, 2004)

Treatment of Hoarding Disorder Treatment of Hoarding Disorder Prospective Medication Treatment Studies Prospective Medication Treatment Studies Authors Sample size; Measures Treatment % Change in Authors Sample size; Measures Treatment % Change in Age Method Symptom Severity Age Method Symptom Severity Grassi et al, n = 12 UHSS, SI-R, Atomoxetine: UHSS: 41% Saxena et al, n = 32 SADS-L, YBOCS, Paroxetine: YBOCS: 24% 2016 (11 completers) ASRS, HAM-D, 62.7 ± 12.8 mg/day SI-R: 40% 2007 (25 completers) HAM-D, HAM-A, 42 ± 13 mg/day HAM-D: 30% Mean age 46.5 GAF, SDS for 12 weeks ASRS: 19% Mean age 49 GAF, UHSS for 10-12 weeks HAM-A: 25% -Added onto HAM-D: 12% GAF: 14% ongoing meds GAF: 29% Intent-to-Treat UHSS: 24% SDS: 34% Analysis (31% in completers) 6 were full responders; Saxena & n = 24 MINI, UHSS, Venlafaxine XR: UHSS: 36% 3 were partial Sumner, (23 completers) SI-R, YBOCS, 204 +/- 72 SI-R: 32% responders 2014 Mean age 53 HAM-D, HAM-A, mg/day for 12 YBOCS: 39% Rodriguez n = 4 SI-R, ADHDSS Methylphenidate- SI-R: 14% GAF, CGI weeks HAM-D: 46% et al, 2013 Mean age 42.8 ER: 36-54 mg/day ADHDSS: 50% HAM-A: 44% for 4 weeks GAF: 19% -Added onto 2 partial responders ongoing meds 70% Responded CBT for Compulsive Hoarding Cognitive-Behavioral Therapy for Compulsive Hoarding Treatment Sequence Goals 1. Education; improve insight and motivation for treatment. 2. Treatment contract for CBT 1. Eliminate health and fire hazards. 3. Treatment Set-up: Select target area of clutter. Assess items in the area; create hierarchy. 2. Create living and work space. Create realistic categories and storage system. 3. Extinguish fear of discarding unnecessary 4. ERP - Excavation: Patient must make decision to keep or discard each possessions. item and permanently remove it from the pile. 4. Eliminate excessive buying / acquisition. : Saved items must be stored appropriately. : Continue until area is clear, then move to next area. 5. Improve decision-making skills. 5. Plan and implement appropriate use of space. 6. Decrease procrastination and avoidance. 6. Preventing Incoming Clutter by Reducing Excessive Acquisition 7. Improve organizational and time management skills. 7. Cognitive Restructuring 8. Organize possessions for easier access. 8. Organizing: Possessions, Time, Tasks, etc. 9. Prevent future excessive saving / acquisition. 9. Relapse Prevention (Saxena & Maidment, 2004) (Saxena & Maidment, 2004)