1. When Stuff Mounts: Hoarding, Clutter, and Mental Illness
Gregory S. Chasson, Ph.D.
Licensed Psychologist
Assistant Professor
Department of Psychology
Towson University
Principal Investigator
Site for OCD & Autism Research
Co-Owner and Clinical Director
CBT Solutions of Baltimore

2. What is Hoarding Disorder (HD)
Persistent difficulty discarding or parting with possessions, regardless of actual value.
Accumulation of possessions that clutter active living areas and compromising their intended use.
The hoarding causes clinically significant distress or impairment in functioning (including maintaining a safe environment for self and others).
Many have excessive acquisition (excessive collecting, buying or stealing items that are not needed or for which there is no space)
(APA, 2013)

3. Degrees of Clutter Kitchen
Pictures from the Clutter Image Rating scale (Frost, Steketee, Tolin, & Renaud, 2008)

4. Degrees of Clutter Bedroom
Pictures from the Clutter Image Rating scale (Frost, Steketee, Tolin, & Renaud, 2008)

5. Degrees of Clutter Living Room
Pictures from the Clutter Image Rating scale (Frost, Steketee, Tolin, & Renaud, 2008)

6. Impact of Hoarding in MD
Over 200,000 individuals with hoarding difficulties are estimated to reside in Maryland*
But only than a handful of providers are trained to administer evidence-based cognitive-behavioral therapy (CBT) for hoarding, the gold-standard
Huge bottleneck for effective services
Hoarding costs the State of Maryland roughly $45 million per year**
*Extrapolated from Samuels et al, 2008
**Extrapolated from San Francisco Task Force on Compulsive Hoarding, 2009

7. Prevalence Hoarding occurs in 2-5% of adults
Symptoms are usually present at early adolescence
11-20 years
68% before age 20
Late onset is rare
Average age that people seek treatment is 50-60’s
Course tends to be chronic and symptoms worsen over time
(Ayers et al, 2010; Grisham et al, 2006; Samuels et al, 2008; Tolin, Meunier, Frost & Steketee, 2010)

8. Prevalence Continued Studies have been inconsistent regarding gender
According to Timpano et al. (2011), prevalence does not appear to differ between males & females
However, Samuels et al. (2008) found the prevalence of hoarding was about two times as great in men compared to women
Far more women present for treatment

9. Hoarding v. Collecting Hoarding Collecting Chronic Course
Collecting Decreases each decade of life
Object content not as thematic
Thematic object content
Objects rarely used
Objects more likely to be used
Acquisition process is less purposeful & goal-driven
Acquisition process is purposeful & goal-driven
Purpose  control, safety, personal identity
Purpose  hobby/leisure, set completion & public identity
Low organization
High organization
Room functionality compromised
Room functionality not compromised
Distress and impairment
No distress or impairment
Interpersonal conflict
Less interpersonal conflict
(Nordsletten, Fernández de la Cruz, Billotti, & Mataix-Cols, 2012)

10. Risks & Consequences

11. (Lucini, Monk, & Szlatenyi, 2009, Tolin et al., 2010)
Risks & Consequences
Hoarding is associated with substantial functional impairment
Clutter prevents people from using their space for it’s intended purpose & basic activities
Hoarding is responsible for 24% of fire-related deaths.
Fires are 16 times more expensive for fire departments to extinguish when hoarding is at play
Overall property damage is 8 times more costly when hoarding is involved.
(Lucini, Monk, & Szlatenyi, 2009, Tolin et al., 2010)

12. Risk & Consequences Continued
Nearly 40% of people with hoarding tendencies live in poverty
Medical complications are common in hoarding
obesity, asthma, 11-fold increased risk of stroke, medication & dietary mismanagement
Property damage (diminished value of or loss of home investment)
Eviction and/or condemnation of home
Removal of children from the home
(Tolin et al., 2010; Ayers et al., 2010; Steketee et al., 2001; Tolin, Frost Steketee, Gray & Fitch, 2008)

13. Acquisition Compulsive Buying Acquisition of Free Things
Retail, discount, thrift stores
On-line shopping (Ebay, Home Shopping Network, retail/catalogues, etc)
Acquisition of Free Things
Advertisements-flyers/handouts
Give-aways and freebies
“Rescuing”
Trash-dumpster diving
Stealing/Kleptomania—10%

14. Comorbidity Depression (50%) Social Anxiety
Obsessive-Compulsive Disorder (20%)
Attention-Deficit/Hyperactivity Disorder

15. Hoarding Behavior in Other Disorders
Physical trauma to brain
Stroke
Traumatic injury
Dementia
Frontotemporal dementia
Mental retardation
Prader-Willi syndrome
Autism
Schizophrenia
Most hoarding cases do not have these.

16. Understanding the Features of Hoarding: The How & Why
General Conceptual Model:
Genetics
Vulnerabilities (Personal & Family)
Information processing problems
Meaning of possessions/thoughts, beliefs & attachment to possessions
Emotional reactions
Learning processes
(Steketee & Frost, 2014)

17. Neuroimaging
Lower cerebral glucose metabolism in dorsal anterior cingulate gyrus
12 hoarding vs 33 nonhoarding OCD; PET; (p<0.001)
(Saxena et al., 2004)

18. Anterior cingulate motivation executive control focused attention
assigning emotional valence to stimuli
problem solving
detecting errors
selecting responses
decision-making

19. Traumatic life events Childhood adversities Ever in lifetime
Excessive physical discipline
Psychiatric symptoms in parent
Home breakins
Ever in lifetime
Physically handled roughly
Forced sexual activity
Something taken by force

20. (Steketee, Frost, & Kyrios, 2003)
Reasons for Saving
Emotional Attachment: “This item is part of who I am. It represents my life.”
Responsibility: “I might need this. It would be wasteful to get rid of it because someone could use it.”
Control: “People have no right to touch my possessions.”
Memory: “If I get rid of this, I will forget it.”
(Steketee, Frost, & Kyrios, 2003)

21. Treatment

22. (Muroff, Bratiotis, & Steketee, 2011)
Quick Summary
In general, disappointing research evidence for psychopharmacological treatment for hoarding
Standard psychotherapy, including standard cognitive-behavior therapy (CBT), has also yielded disappointing research evidence
BUT, one specific manualized treatment called CBT for Hoarding (Steketee & Frost, 2014) has received some evidence is currently the gold-standard treatment (Steketee et al., 2010)
This manualized treatment is not your standard CBT approach….
(Muroff, Bratiotis, & Steketee, 2011)
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout

23. CBT for Hoarding Protocol
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout

24. FAM Training
Sometimes family members are the most vocal, so I have created a program to leverage this family-member energy
My research lab is conducting a waitlist controlled trial of a family-based approach called Family-As-Motivators Training (FAM Training)
FAM Training is designed to teach family members of loved ones with hoarding 1) how to cope with the hoarding and 2) how to help motivate the loved one to seek treatment
A family member of the loved on with hoarding participates in 10 twice-weekly 50-minute sessions at Towson University
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout

25. FAM Training Pilot
A pilot study of FAM Training yielded highly encouraging results (Chasson et al., in press)
Family members improved in the use of certain coping strategies and in the application of motivational interviewing techniques
They also exhibited increased hopefulness, reported a reduced negative impact of HD on the family, rated a reduction in family enabling of HD behaviors, and displayed boosts in HD and motivational interviewing knowledge.
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout

26. Visit us online at www.soartu.org
FAM Training
FAM Training is free of charge for the family member
Loved one with hoarding must participate in some assessment, but gets $105 for the time and commitment
For more information about the study, please contact Dr. Chasson at (410) or
Visit us online at
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout

27. Thank you!!! Gregory S. Chasson, Ph.D. Licensed Psychologist
Assistant Professor
Department of Psychology
Towson University
(410)
Co-Owner and Clinical Director
CBT Solutions of Baltimore
(443)

28. Who is Dr. Chasson?
Gregory S. Chasson, Ph.D., is an Assistant Professor in the Department of Psychology at Towson University and licensed psychologist specializing in the assessment and treatment of obsessive-compulsive disorder (OCD) and related conditions, including hoarding disorder. During his clinical psychology doctoral training at the University of Houston, he completed a two-year externship and research coordinator position at the OCD Treatment Program of the Menninger Clinic. He also completed three years of pre- and postdoctoral training at Harvard Medical School, where he worked at the OCD Institute at McLean Hospital and OCD and Related Disorders Program at Massachusetts General Hospital. Dr. Chasson currently serves as principal investigator in his research lab at Towson University—the Site for OCD & Autism Research (SOAR)—where he just published a promising pilot study of his Family-As-Motivator (FAM) Training for family members of a loved one with hoarding. He is currently the principal investigator on an externally-funded waitlist controlled trial of FAM Training. Dr. Chasson also co-owns and directs a group cognitive behavior therapy practice in Lutherville that specializes in the assessment and evidence-based treatment of OCD and related conditions, and patients with hoarding make up a significant percentage of the caseload. Other than FAM Training, his research on hoarding has included investigations of cross-cultural manifestations (e.g., China), as well as personality correlates of the condition. He is also contracted to co-author a book for training mental health professionals in the treatment of hoarding: Hoarding Disorder: Advances in Psychotherapy—Evidence Based Practice (Hogrefe Publishing, slated for 2015).
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout

29. References Problems: Not an RCT, rule out placebo effect
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: Fifth edition. Washington, D.C.: American Psychiatric Publishing.
Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. (2010). Age at onset and clinical features of late life compulsive hoarding. International Journal Of Geriatric Psychiatry, 25(2),
Chasson, G. S., Carpenter, A., Ewing, J., Gibby, B., & Lee, N. (in press). Empowering families to help a loved one with hoarding disorder: Pilot study of family- as-motivators training. Behaviour Research and Therapy.
Frost, R.O., Steketee, G., Tolin, D.F., Renaud, S. (2008). Development and validation of the clutter image rating. Journal of Psychopathology and Behavioral Assessment, 30,
Grisham, J. R., Frost, R. O., Steketee, G., Kim, H., & Hood, S. (2006). Age of onset of compulsive hoarding. Journal Of Anxiety Disorders, 20(5),
Lucini, G., Monk, I., & Szlatenyi, C. (2009). An analysis of fire incidents involving hoarding households. [Interactive Qualifying Project, Worcester Polytechnic Institute]
Muroff, J., Bratiotis, C., & Steketee, G. (2011). Treatment for hoarding behaviors: A review of the evidence. Clinical Social Work Journal, 39(4),
Nordsletten, A. E., Fernández de la Cruz, L., Billotti, D., & Mataix-Cols, D. (2012). Finders keepers: The features differentiating hoarding disorder from normative collecting. Comprehensive Psychiatry, 54,
Samuels, J. F., Bienvenu, O., Grados, M. A., Cullen, B., Riddle, M. A., Liang, K., & ... Nestadt, G. (2008). Prevalence and correlates of hoarding behavior in community-based sample. Behaviour Research And Therapy, 46(7),
San Francisco Task Force on Compulsive Hoarding (2009) Beyond overwhelmed: The impact of compulsive hoarding and cluttering in San Francisco and recommendations to reduce negative impacts and improve care. San Francisco, CA: Mental Health Association of San Francisco.
Saxena, S., Brody, A., Maidment, K., Smith, E., Zohrabi, N., Katz, E., & ... Baxter, L. (2004). Cerebral glucose metabolism in obsessive-compulsive hoarding. The American Journal Of Psychiatry, 161(6),
Steketee, G., & Frost, R. O. (2014). Compulsive hoarding and acquiring: Therapist guide (2nd ed.). New York, NY US: Oxford University Press.
Steketee, G., Frost, R.O., & Kyrios, M. (2003). Cognitive aspects of compulsive hoarding. Cognitive Therapy and Research, 27,
Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depression And Anxiety, 27(5),
Timpano, K. R., Exner, C., Glaesmer, H., Rief, W., Keshaviah, A., Brahler, E., & Wilhelm, S. (2011). The epidemiology of the proposed DSM-5 hoarding disorder: Exploration of the acquisition specifier, associated features, and distress. Journal Of Clinical Psychiatry, 72(6),
Tolin, D. F., Frost, R. O., Steketee, G., Gray, K. D., & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160(2),
Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2010). Course of compulsive hoarding and its relationship to life events. Depression And Anxiety, 27(9),
Problems:
Not an RCT, rule out placebo effect
OCD severity and comorbidity confounds results—we know paxil is helpful for OCD—might not generalize to hoarding without OCD
Hoarding reduction measured with a unvalidated instrument
Large number of patients could not tolerate doses; dropout