4 Case PresentationThe participant is a 65 year old, widowed white female under treatment for severe hoarding behavior, nail biting, and poor social relationships. Her hoarding began when she was about 20 years old, although she recalls excessive collecting as a teenager. When walking, she constantly collects discarded objects, such as soda cans, newspapers, and paper bags, which she says that she “may need sometime.” Her home is extremely cluttered, with objects scattered everywhere in a disorganized fashion; there are piles of clothes, bags, and boxes in all rooms, which she negotiates by making trails to walk through or by jumping over.
5 Case presentation (continued) She said that she tries to throw things away but that she “just can’t decide what to get rid of.” About 6 months ago, she became unable to live in her 6-room house due to the clutter, and she rented an apartment elsewhere. She reports intrusive need for symmetry, constantly rearranging things, and counting objects. She admits to being extremely isolated socially, with few friends or acquaintances, none of whom she will allow into her home. She expressed feelings of shame and embarrassment for the extreme clutter in her home and her excessive accumulation, which she said was “overwhelming my life.”
6 Compulsive hoarding Difficulty discarding possessions Strong urges to save; distress, indecision re discardeven if things appear useless or of limited valueLiving spaces so cluttered that precludes activitiesSignificant distress and impairmentNot due to general medical conditionNot restricted to symptoms of another mental disordere.g., cognitive deficits in dementia
7 Objects hoarded Frost, Steketee, Williams (2000) Possessions hoarded % of N=58Newspapers and magazines89%Other paper rubbish87%ContainersBottles80%Food and food garbage76%Others’ rubbish48%Animals32%Frost, Steketee, Williams (2000)
10 Features Reasons for saving Reactions to intervention “might be useful in future”“can’t decide what to keep and what to throw away”“feelings of security”“sentimental value”very anxious when attempting to discardextremely upset if someone else discardsintervention only if forcedpoor response to treatment
11 Characteristics socially isolated disorganized difficulty making decisionsprocrastination and avoidancepoor insightsocial phobia, depression, generalized anxietyNote: Varies between cases
13 Epidemiology PREVALENCE DESCRIPTIVE ANALYTIC How frequent in the population?DESCRIPTIVEHow related to demographics (age, gender, SES)ANALYTICWhat are risk factors?
14 Baltimore studies Study Years Number Baltimore ECA Study 1981-1982 3,481Baltimore ECA Followup1,920Hopkins Personality Study742
15 Hoarding assessment in HEPS Do you find it almost impossible to throw out worn-out or useless things?Is that true even if they don’t have any sentimental value?Give me some examples.Is this a problem for you or others?Tell me about it.Rating0 (absent); (accentuated); 2(pathological)
16 Male respondent (49 years old) “My room is like a bomb hit it. I’ve got books and papers, stuff in the corner there. I don’t want to throw nothing away. Old suits in my closet, I know I’ll never wear again in my life. Old beat up tennis shoes, think I’ll find a use for them. I never throw a book away. I like to keep articles, the whole paper; it starts building up on me in a hurry. Newspapers knee-high. I keep a whole drawer full of rubber bands; don’t know why, but I do. Lots of junk.”
25 Personality disorders Number of traitsOdds ratioParanoid1.60 **Schizotypal1.49 ***Avoidant1.66 ***Obsessive-compulsive1.76 ***
26 Childhood adversities Death of parentParental sep/divorce%
27 Childhood adversities Psychiatric symptoms, father *Psychiatric symptoms, mother *%Depression, mania, or heavy drinking
28 Childhood adversities Excessive physical discipline *Insecurity from home breakins *%
29 Childhood adversities AdversityOdds ratioParents separated or divorced2.1Death of parent2.3Psychiatric symptoms, father *2.7Psychiatric symptoms, mother *Insecurity from home break-ins *3.9Excessive physical discipline *4.2
30 Possible causes Brain disorder Personality Learned behavior Response to adversity
31 Hoarding behavior in other disorders Physical trauma to brainStrokeTraumatic injuryDementiaFrontotemporal dementiaMental retardationPrader-Willi syndromeAutismSchizophreniaMost hoarding cases do not have these.
32 Information processing deficits Decision-makingCategorizationOrganizationMemory(Frost & Hartl, 1996)
33 Neuroimaging (Saxena et al., 2004) Lower cerebral glucose metabolism in dorsal anterior cingulate gyrus12 hoarding vs 33 nonhoarding OCD; PET; (p<0.001)
34 Anterior cingulate motivation executive control focused attention assigning emotional valence to stimuliproblem solvingdetecting errorsselecting responsesdecision-making
40 Health hazards injury from falling fire hazard contamination from rotting foodallergies from dust pollenanimal wastevermin infestationinability to use rooms (eating, sleeping, bathing)hazards to individual, family, neighborhood
41 Health impacts Tolin et al., 2008 (Psychiatry Research 160:200-211) Nov. 14, 2006 – January 15, 2007864 self-identified hoarding individuals who responded to internet request and completed main questionnaires~94% female; ~90% whitemean age ~49 years old (range, 21-83)665 family informants of hoarding individualsCompared to National Comorbidity Survey
42 Chronic medical conditions BMIChronic conditions%
45 Social impacts Constricted focus Financial burden Social isolation Threat of evictionStrained family relationshipsImpact on family membersThreat to neighborsBurden on social agencies
46 Burden on family members 665 family informants; internet surveyFindingsUnhappy childhoodDifficult having people over to houseStrained relationship with parentsEmbarrassed about homeRejection of hoarding relativeTolin et al., 2008
47 Conclusions from epidemiology Hoarding is serious disorderPrevalence in community is 4-5%Demographic correlates (age, sex, income)Risk correlates: alcohol dependence, personality disorders, and childhood adversitiesBiological basis? Neuroimaging, neurocognitive, and genetic findingsAdverse health and social impactsNeed for more research to elucidate causes
48 Collaboration essential To go from this ……..To this !
50 Resources Public agencies Ad hoc Housing inspection Adult and child protective servicesCourtsFire departmentPolice departmentAnimal protective servicesAd hocMail carriersGas and water meter readersTax assessors
51 Resources Task forces Fairfax County, Virginia: San FranciscoMassachusettsbeverlyhoardingtaskforce.blogspot-- Baltimore County Hoarding Task Force
52 Resources Therapists Clinicians experienced in CBT OCD clinics and practicesHoarding specialists are needed!Greg Chasson, PhDTowson, MD
53 Resources Support groups Professional organizers Clutterers Anonymous sites.google.com/site/clutterersanonymousMessies AnonymousProfessional organizersNational Association of Professional Organizers (NAPO)
54 Resources International OC Foundation www.ocfoundation.org
55 Resources Books Documentary Buried in Treasures (Tolin, Frost, & Steketee)Compulsive Hoarding and Acquiring(Steketee, Frost)Compulsive Hoarding and the Meaning of Things(Frost, Steketee)DocumentaryMy Mother’s Garden (Cynthia Lester)