EXAMPLE OF A COMPLETE SYMPOSIUM
Diagnostic and Treatment Issues in Compulsive Hoarding
Convenor and Chair: Randy O. Frost, Smith College, USA
Patterns of comorbidity in compulsive hoarding
Todd Farchione, Boston University; David Tolin, Institute of Living, Hartford, CT; Sanjaya Saxena, UCLA; Karron Maidment, UCLA; Gail Stekteee, Boston University; Randy O. Frost, Smith College; Fugen Neziroglu, Bio-behavioral Institute, Great Neck, NY
Hoarding has been defined as the acquisition of, and failure to discard, possessions that appear to be useless or have limited value. Diagnostically, compulsive hoarding has been closely associated with both obsessive compulsive disorder (OCD); and obsessive compulsive personality disorder (OCPD) and symptoms of this condition can be found among a number of Axis I disorders, as well as in various forms of dementia. While recent research on the features of hoarding and its relationship with other psychiatric disorders has greatly improved our understanding of this condition, the diagnostic picture is far from complete and additional research is clearly needed. Clarifying the diagnostic features of compulsive hoarding is essential to our understanding of this disorder and has important treatment implications. Studies examining comorbidity, or the simultaneous occurrence of two or more disorders in the same individual, indicate that over 50% of patients with a principal anxiety disorder have at least one additional anxiety or mood disorder of clinical severity (Brown and Barlow, 1992). Even higher rates have been reported in investigations that include subclinical comorbid conditions. Results from these studies suggest that comorbidity has important implications for both classification and treatment outcome. Given these findings, examining patterns of comorbidity in compulsive hoarding is expected to shed some light on the diagnostic features of this disorder. In the current investigation, comorbid diagnoses will be examined in a group of patients receiving a principal diagnosis of OCD with primary symptoms of compulsive hoarding. Primary and comorbid diagnoses were assigned on the basis of information obtained through semi-structured or structured clinical interview. Consistent with previous findings from a study by Steketee and colleagues (2000), preliminary results from the current investigation suggest a high rate of comorbidity in this sample, with major depressive disorder and social phobia being most common. In an effort to examine the relationship between compulsive hoarding and OCD, the pattern of comorbidity in this sample will be compared to data obtained from a group of age and gender matched patients with non-hoarding primary OCD. The diagnostic and treatment implication of these results will be discussed.
Compulsive Hoarding – factors in its etiology, phenomenology and treatment; findings from an Australian study
Christopher Mogan and Michael Kyrios, University of Melbourne
Increasing research interest has identified compulsive hoarding as a distinct clinical phenomenon, with increasing agreement that it can be defined as the acquisition and failure to discard possessions that appear to be useless or of limited value, resulting in the clutter of rooms and the overall impairment of personal functioning (Frost and Hartl, 1996). An etiological model that specifies deficits in information processing (memory, decision-making, categorization), emotional attachments, behavioural avoidance, and beliefs about possessions has been posited (Frost and Hartl, 1996). Whilst this model has been supported by findings of differences between hoarders and clinical or non-clinical groups in specific beliefs about possessions, decision-making fears, and performance on tasks of organizational strategy and non-verbal memory in (Hartl et al., 2001; Kyrios et al., 2002; Steketee et al., 2003), there are still many unanswered questions about the etiology, nature and treatment of compulsive hoarding. This paper reports on: (a) a phenomenological study of compulsive hoarders in comparison with groups with non-hoarding Obsessive Compulsive Disorder, Social Anxiety or Panic Disorder, and controls using measures of hoarding behaviours and cognitions, emotional attachment and developmental factors, symptoms of OCD, affect, and personality disorder, and specific meta-memory measures; and (b) a pilot treatment program that tracks cognitive and symptomatic changes. This is the first study of hoarding in the Australian context, and one of the few attempts to replicate the efficacy of clinical interventions.
Group Treatment for Compulsive Hoarding
Jessica R. Grisham, Hyo-Jin Kim, Susan D. Raffa, , and Gail Steketee, Boston University; and Randy O. Frost, Smith College
Individuals with compulsive hoarding problems have been found to respond poorly to both behavioral and pharmacological interventions.The purpose of the current study was to evaluate a cognitive-behavioral group treatment for compulsive hoarding. In particular, we wished to identify which aspects of hoarding were resistant to treatment to further refine therapy for this population. To accomplish this, we compared hoarding-related symptoms before and after a cognitive-behavioral group treatment. The current sample consisted of 14 patients who participated in group therapy for compulsive hoarding at the Center for Anxiety and Related Disorders. Self-report measures of hoarding symptoms at pre-, mid-, and post- treatment were included. Measures included the Saving Inventory Revised (SI-R), the Saving Cognitions Inventory Revised (SCI-R), and the Beck Depression Inventory (BDI). The SI-R is a 23-item scale with a possible score ranging from 0 to 92, comprised of three subscales: clutter, difficulty discarding, and acquisition. The SCI-R was designed to measure hoarding-related thoughts and beliefs about possessions in several domains, including thoughts about control, memory, responsibility, and emotional attachment. Cognitive-behavioral group therapy for compulsive hoarding consists of 20 sessions, weekly for 3 months and then spaced out to twice monthly. In the current sample, treatment began with motivational interviewing and psychoeducation about the primary components of compulsive hoarding, including excessive acquisition, difficulty discarding, and problems with organization. Members also learned cognitive techniques to identify and challenge their hoarding-related thoughts. As the group progressed, members engaged in exposures to discarding their possessions both in session, and outside of session, as weekly homework assignments. In addition, members examined current acquisition behaviors and completed homework assignments related to reducing acquisition. Finally, therapists assisted patients in developing concrete problem-solving and organizational skills related to their possessions. Overall, the data suggest modest improvement in some domains, and limited change in others. Acquisition problems improved more than other areas of hoarding. One possible interpretation is that measures of clutter are less sensitive to change due to the longstanding nature of the problem and large accumulation of belongings, whereas measures of current behavior, such as acquisition, show more immediate improvement. Interestingly, beliefs about responsibility for possessions appear to improve rapidly. This may reflect the emphasis in group therapy on decreasing members’ feelings that they are responsible for their possessions or for excessive preparation in case of any shortages. While the current results suggest some optimism, they also point to slow and limited progress associated with this disorder.
Cognitive Behavioral Group Therapy for Hoarding: A Treatment-Outcome Study
Fugen Neziroglu, Jerry Bubrick and Merry E. McVey-Noble, Bio-Behavioral Institute, Great Neck, New York
Hoarding is a behavior characterized by the compulsive acquisition and/or saving of items without objective value. Currently, hoarding is categorized as a symptom of both Obsessive Compulsive Disorder and Obsessive Compulsive Personality Disorder. It has also been identified as a symptom within anorectic and schizophrenic populations. Though it has been clearly linked with disorders within the Obsessive Compulsive Spectrum, hoarding has more recently been conceptualized as a possible disorder in and of itself. Hoarding, whether as a symptom or syndrome, has been noted to lead to significant functional impairment and subjective distress, posing tremendous difficulties for both the hoarders themselves, and for their families and loved ones. Severe hoarding can lead to limited functional space in the home, isolation and family and marital discord. In addition, the emotional sequelae of pathological hoarding include feelings of extreme anxiety, embarrassment and depression on the part of the hoarder. In the past, two decades, there has been a paucity of clinical and empirical literature on the treatment of hoarding. Recently, a protocol for the group treatment of severe hoarding was developed and piloted at the Bio-Behavioural Institute in Great Neck, New York. The protocol was weekly sessions of 90 minutes for a duration of 12-weeks. Psychoeducation and cognitive behavioural techniques targeting specific reasons for hoarding were implemented. Some reasons for hoarding can be indecisiveness, lack of prioritizing, disorganization, and poor attention span. Finally, group members participated in specific behavioural exercises designed to assist in the discarding of hoarded materials. The group was 12 weeks in duration, and participants included five females and 4 males, age 41 to 63 years. All of the participants had acquired at least some college education and four of the nine had obtained graduate degrees. Despite this, only one of the group members was employed, indicating their severe functional impairment. Regarding the extent of their hoarding, eight out of nine participants reported that they felt they needed additional storage space for their possessions, and five out of the nine reported actually having taken steps to obtain more space. Overall, participants demonstrated improvement on indices of anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-2) and savings behaviour (Savings Behaviour Inventory) at weeks four and eight. However, these measures returned almost to baseline at week 12. Reasons for this phenomenon are explored as well as suggestions are made on how to improve group treatment.