Buried in Treasures: The Nature and Treatment of Compulsive Hoarding

Transcription

1 Buried in Treasures: The Nature and Treatment of Compulsive Hoarding David F. Tolin, Ph.D. Director, Anxiety Disorders Center The Institute of Living/Hartford Hospital Disclosures National Institute of Mental Health Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding (Oxford University Press, 2007) DSM-V Criteria for Hoarding Disorder (Proposed) Persistent difficulty discarding or parting with possessions, regardless of whether they are perceived by others to be valuable or not This difficulty is due to strong urges to save items, and/or distress associated with discarding The symptoms result in the accumulation of a large number of possessions that fill up and clutter the active living areas of the home or workplace to the extent that the intended use of at least some of these areas is no longer possible. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 1

2 Prevalence of Hoarding: 2-5% 5% in U.S. (Samuels et al., 2008) 5% in Germany (Mueller et al., 2009) 2% in U.K. (Iervolino et al., 2010) Manifestations of Hoarding Acquisition Saving Disorganization 2

3 Acquisition Buying Free Things Stealing Passive Types of items Compulsive Saving / Difficulty Discarding Attachments Sentimental Instrumental Intrinsic Disorganization Condition of Home Clutter Mixed importance Behavior Churning Out of sight fear 3

4 Is Hoarding A Subtype of OCD? OCD Hoarding Disorders Among Hoarding Participants (N = 217) Frost, Steketee, & Tolin, Depress. Anxiety 2011;28: Insight: Hoarding vs. OCD Hoarding (Tolin et al., 2010) OCD (Foa et al., 1995) 4

5 Neuropsychological Performance: Attention p <.05 p <.05 Grisham et al., Behav Res Ther 2007;45: ; Tolin et al., Psychiatry Res 2011;189: Biphasic Abnormality in ACC/Insula During Discarding Tolin et al., Arch Gen Psychiatry, in press. Neural Activity May Normalize with CBT Tolin et al.,j OCD Relat Disord, in press. 5

6 Cognitive Behavioral Model of Compulsive Hoarding Information processing deficits Problems with emotional attachments Beliefs about possessions Behavioral avoidance Motivational problems Information Processing Deficits Attention Memory Categorization Decision-making Emotional Attachment Emotional Attachment: identity, loss, mistakes, comfort Discarding this possession is like losing a friend. I can t tolerate getting rid of this. Throwing this away is like throwing away part of me. My possessions are part of who I am. 6

7 Beliefs about Possessions Responsibility 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. Memory Saving this means I don t have to rely on my memory. If I don t leave this in sight, I ll forget it. Control If I don t keep control over my stuff, I ll lose control of my life. No one has the right to touch my things. Behavioral Avoidance Avoid Distress Avoid Decision-making Avoid Discarding Avoid Sustained Effort Avoid putting things out of sight Motivational Problems Ambivalence about change Simultaneously want to change and don t want to change Hoarding is wrapped up in interpersonal conflict Decades of digging in heels Chronically overwhelmed Fatigue, stress, low energy 7

8 Cognitive-Behavioral Therapy for Hoarding Assessment Education Motivational Interviewing Organization Decision-making Exposure to non-acquiring and discarding Cognitive restructuring Steketee & Frost, 2007; Tolin et al., Behav Res Ther. 2007;45: Open Trial: Clutter Image Rating * * Pre Post Tolin et al., Behav Res Ther. 2007;45: CBT is Superior to Wait List at 12 Weeks: Saving Inventory-Revised Steketee, Frost, Tolin, Rassmussen, & Brown, Depression & Anxiety 2010;27:

9 CBT Efficacy Continues Through Week 26 Steketee, Frost, Tolin, Rassmussen, & Brown, Depression & Anxiety 2010;27: Psychoeducation Education about cognitive-behavioral model of hoarding Discussion of treatment and its effects Personalized model-building Model-Building Personal and family vulnerability factors Information processing problems Thoughts and beliefs Emotional responses Efforts to obtain pleasure by saving Escape or avoidance of unpleasant emotions Difficulty discarding and clutter 9

10 Working with Hoarding Clients is Tough: Survey of 84 Professionals Tolin, Frost, & Steketee, J OCD Relat Disord, in press. Predicting Professionals Patient Rejection and Working Alliance Problems Patient Rejection (R 2 =.36) Poor insight Poor problem-solving skills Difficulty answering questions appropriately Working Alliance Problems (R 2 =.58) Failure to identify clear goals Arguing, repeatedly questioning, or dismissing Tolin, Frost, & Steketee, J OCD Relat Disord, in press. Motivational Interviewing Style of therapeutic interaction Aimed at increasing readiness for change Recognition of the problem Acceptance of treatment plan Homework compliance Continued attendance 10

11 Why is MI Critical in Hoarding Treatment? Low insight Anosognosia Overvalued ideation Defensiveness Ambivalence regarding change Poor working alliance Treatment noncompliance Attendance Homework General Strategies in MI R E D A SS Roll with resistance Express empathy Develop discrepancy Avoid argumentation Support self efficacy Develop Discrepancy Summarize ambivalence using linking phrases (e.g., on the one hand on the other ) Elicit self-motivational statements Problem recognition Expression of concern Intention to change Optimism (self-efficacy) 11

12 Eliciting Change Talk by Developing Discrepancy What are your client s: Values Desired identity Long-term plans and goals How do clutter, saving and acquiring fit or not fit with these goals and values? Use summarizing statements to show discrepancy, e.g., On one hand on the other hand Eliciting Change Talk: Exploring Pros and Cons Continue to hoard Benefits: -get to keep stuff -avoid decision-making -don t have to do the work of cleaning Costs: -can t find anything -can t have people over -house smells -can t use rooms for intended purpose -friends/relatives get upset -safety hazards Clean house Benefits: -I know what I have and where it is -can invite people over -neighbors will stop complaining -family/friends will be happy -house will be clean -can move around easily Costs: -I ll have to part with my stuff -It will be hard work -emotional stress of discarding Avoiding Argumentation: Emphasizing Personal Choice and Control Client: Are you telling me that I need to throw out all of my stuff? Therapist: Absolutely not. What you do is completely up to you. After all, it s your house, and your stuff, and your life. Nobody can make these decisions for you. 12

13 Organization Training Category reduction Categories and locations for saved items Categories for unwanted items (e.g., trash, recycle, sell, donate) Teach step by step process of moving objects to proper location once decision is made Keep or remove? Not wanted Determine category: Trash, recycle, donate, sell Wanted Determine category: Sort into nearby box Move to final location Trash container Recycle bin Box for charity Box for family/friends Box for sale items Move categorized items to interim location Move to final location Decision-Making Training Challenging questions Therapist initiates Client rehearses 13

14 Challenging Questions How many do I have and is that enough? Do I have enough time and space for it? Have I used it in the past year? Do I have a specific plan to use this within a reasonable time frame? Does this just seem important because I m looking at it now? Is it current, of good quality, etc.? Would I buy it again if I didn t already own it? Do I really need it? Will not having this help me solve my hoarding problem? Treatment for Compulsive Acquisition Identifying patterns of acquisition Cognitive restructuring of beliefs about acquiring Non-acquisition exposures Alternative sources of enjoyment and coping Challenging Questions 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 do I want it just because I was looking at it? What are the advantages and disadvantages of acquiring this? Personal rules for acquiring I must have: An immediate use for it Time to deal with it appropriately Money to afford it comfortably Space to put it 14

15 Exposures for Compulsive Acquisition Non-shopping Excursions Drive-by non-shopping Walk-through non-shopping Browsing and picking non-shopping Treatment for Discarding Select target area and types of possessions Create categories for possessions Sort into discard, recycle, give away, store elsewhere piles Use cognitive strategies during discarding Continue until target area is clear Plan appropriate use of cleared area Plan for preventing new clutter to area Cognitive Restructuring Identify and correct cognitive distortions Need vs. Want Valuing time Downward arrow technique Behavioral experiments 15

16 Cognitive Distortions Distortion All-or-None Thinking Should Statements Fortune-Telling Mental Filtering Catastrophizing Emotional Reasoning Example If I don t do this perfectly, I m a total failure. I should never waste anything. If I thrown these newspapers away, I ll make a mistake and throw out some important information. This newspaper is the most important thing I have to deal with. If I didn t have the information I needed, I d have a complete meltdown and would never be able to recover. My life would be ruined. I must need this object; why else would I feel so anxious about discarding it? Challenging Cognitive Distortions What is the evidence to support this belief? What is the evidence that doesn t support my belief? What s the worst that can happen? What is the probability that this terrible thing will happen? If the terrible thing happens, then what? What is an alternative way to interpret this situation? How might another person view this situation? Downward Arrow If you got rid of this, what would happen? If that happened, why would that be so upsetting? If that were true, what s so bad about that? What s the worst part about that? What does that mean about you? 16

17 Behavioral Experiment Test beliefs against reality Ask client to make specific if-then predictions If I throw this away, X will happen If I throw it away, I will feel X, for X amount of time, with X results Carefully observe actual results Did X happen? Did you feel X, for X amount of time, with X results? Highlight discrepancy between prediction and results Use exercise to challenge beliefs CBT for Hoarding: Summary Ongoing education and model-building Motivational interviewing is critical Hands-on training for organization and decision-making Gradually expose client to non-acquiring and discarding Constant use of cognitive restructuring to challenge maladaptive beliefs 17