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Hoarding in Older Adults: What You Need to Know! Peggy M.A. Richter, MD, FRCPC Director, Clinic for OCD and Related Disorders Associate Professor of Psychiatry, University of Toronto [email protected] Objectives At the end of this presentation, you will be: • Familiar with the core features of hoarding • Aware of current thinking regarding nature and causes of hoarding • Able to identify appropriate strategies for hoarding Disclosures In the last 3 years: • On National Advisory Board for OCD for Lundbeck • Honoraria from Lundbeck • Research fellow funded by Eli Lilly • Research studies funded by Lundbeck The Collyer Brothers OCD - Diagnosis Obsessions persistent unwanted thoughts, images, or impulses Intrusive, uncontrollable/excessive provoke anxiety Compulsions repetitive behaviours or mental acts performed in response to an obsession, or in ritualistic fashion intended to reduce discomfort or prevent feared event Severity: symptoms must cause OR marked distress occupy > 1 hour/day significantly interfere with functioning Current Obsessions/Compulsions in 182 patients Aggressive Contamination Symmetry Somatic Hoarding Religious Sexual 68.7% 57.7% 53.2% 34.1% 30.2% 24.2% 19.8% Checking 80.7% Washing 63.7% Repeating 55.5% Ordering 40.1% Counting 35.2% Hoarding 28.0% Miscellaneous 59.3% Summerfeldt, Antony, Downie, Richter and Swinson 1997 Is Hoarding OCD? Hoarding ‘Obsessions’ • Intense preoccupation with belongings Hoarding ‘Compulsions’ • Acquisition/sorting /protection of possessions However: • Not intrusive • Not resisted or unwanted • Not distressing However: • Acquisition/collecting of things generally enjoyable • Not generally ritualistic • Not distressing Rachman, Elliott, Shafran & Radomsky, BRAT, 2009 Definition of Hoarding 1. Persistent difficulty discarding or parting with possessions, regardless of their actual value 2. A living space sufficiently cluttered in a manner that precludes activities for which the space was designed 3. Significant distress or impairment in functioning caused by hoarding (including maintaining a safe environment for self and others) 4. Hoarding not caused by other mental disorders (e.g. dementia, BAD, MDE) or a general medical condition (e.g. brain injury, cerebrovascular disease) Specify: With Excessive Acquisition Insight (Good/poor/absent) Frost & Hartl, 1996; Steketee & Frost, 2003; Grisham et al, 2007; DSM-5 Publication Trends in Hoarding Research Mataix-Cols et al, 2010 The OCD Spectrum Hoarding Manifestations of Hoarding: 1. Compulsive Acquiring 2. Saving 3. Disorganization Steketee & Frost, 2007 Manifestations of Hoarding: 1. Compulsive Acquiring • Compulsive buying – Retail/discount – Ebay, web shopping – Home shopping network • Compulsive acquiring of free things – Advertising flyers/handouts – Give-aways – Trash picking, dumpster diving Steketee & Frost, 2007, Frost et al, 2009, Koran et al, 2006 Compulsive Buying (compulsive shopping, oniomania) Characterized by: Preoccupation with shopping, or intrusive buying impulses Clearly buying more than is needed/affordable Distress Interference with functioning Prevalence 2-8% in U.S. Women: clothes, shoes, jewellery, makeup Men: electronics, hardware, car products Odlaug & Grant, 2010; Koran et al, 2006; Mueller et al, 2009 Manifestations of Hoarding: 2. Saving • Reasons for saving – Sentimental “this helps me remember. This represents my life. It’s part of me. – Instrumental “I might need this. I could fix this. Somebody could use this. Think of the potential!” – Intrinsic “Isn’t this beautiful • Hoarders apply these reasons to more things Steketee & Frost, 2007 Manifestations of Hoarding: 3. Disorganization • Condition of the home – Clutter – Mixture of important and unimportant items • Behaviour – Fear of putting things out of sight – Indecisiveness – churning – Categorization problems May be slow at completing tasks, frequently late, use circumstantial/over-inclusive language Steketee & Frost, 2007; Saxena, 2008 Characteristics of Hoarding • Community prevalence 2.3-6% – Prevalence in OCD: 30% – Rate increases with age: 2.3% aged 34-44, 6.2% among age 55 and above • Mean age of onset of hoarding symptoms: 13 – 60% report onset by age 12 • • • • • Course of illness: typically chronic Average age at treatment = 50 Education ranges widely Tend to be single, live alone Low marriage rate, high divorce rate Koran et al, 2006; Mueller et al, 2009; Samuels et al, 2008; Grisham et al, 2006 Steketee & Frost, 2007; Tolin et al, 2010 Characteristics of Hoarders • Squalid conditions uncommon among treatment seekers • Insight is limited; recognition of problem typically develops much later than symptoms • May be precipitated by loss or deprivation – Hartl et al, 2005: hoarders reported greater frequency of traumatic events than controls • Having something taken by force • Rough physical handling • Forced to engage in sexual activity – Cromer et al, 2007: among OCD sufferers, hoarders experienced significantly more traumatic events Hoarding is associated with childhood adversity... -Community-based study of 742 individuals -prevalence of hoarding was 3.7%, 5.3% weighted prevalence Samuels et al, 2008 From: Anderson et al. Reasons to Accumulate Excess. Home Health Care Services Quarterly, 27(3), 2008 > N=18 older adults (> 60, mean age 67.5 years) > Conclusions: Hoarding symptoms typically started early, and always before age 30 Hoarding severity increased with age ~50% had other psychiatric disorders, but only 16% had OCD Compulsive hoarding was grossly underdetected and untreated (only 2/13 received tx for hoarding) Diogenes Syndrome • Also known as – Senile squalor syndrome – Social breakdown syndrome – Syndrome of extreme self-neglect • First recognized in 1966 • Named by Clark et al, 1975 Macmillan & Shaw, BMJ. 1966; Clark et al, Lancet, 1975 Diogenes Syndrome Characterized by: Domestic squalor self neglect Social isolation Hoarding of rubbish (syllogomania) Lack of shame Clark et al, Lancet, 1975; Cybulska & Rucinski Br. J Hosp Med. 1986; Rosenthal et al, Isr J Psych Relat Sci 1999 Features of Diogenes Syndrome • Annual incidence: 5-10/10,000 for >60 yr olds • M= F • Majority live alone, but “squalor a deux” also reported • More prevalent in upper social classes • Clark et al: N=30, most highly successful professionals in earlier life • Only 50% have Axis I Disorder • Often associated with frontal lobe dysfunction (Orrell et al, 1989) Clark et al, Lancet, 1975; MacMillan & Shaw, Br Med J, 1996; Reyes-Oritz, Compr Ther, 2001; Snowdon & Halliday, Int Psychogeriatric, 2011 Outcome of Diogenes Syndrome • Most have significant physical illness cardiac failure pulmonary embolism osteoarthriitis malignancy cervical spondylosis bronchopneumonia Parkinson’s disease gangrene leukemia renal failure • Mortality rate following hospitalization: 50% • 5-year mortality rate: 46% • Follow-up studies show little change in living situations after interventions Clark et al, Lancet, 1975; Ngeh, Ger. Psych 2000; Reyes-Ortiz, 2001; Hanon et al, 2004 Grey Garden Not all hoarders have a mental condition… • Only 50% have an identifiable mental disorder – among cases with severe domestic squalor: dementia (22%) schizophrenia/schizoaffective disorder (21%) substance use disorder (10%) – OCD most common in cases referred to therapists • Frost et al, 2011: studied N=217 hoarders – 18% hoarders had OCD – High comorbidity with depression, anxiety (similar to OCD) – Hoarding associated with ADHD (28% vs. 3% in OCD) “Organic” hoarding versus Hoarding Disorder Mataix-Cols, Pertusa & Snowdon, J of Clinical Psychology: In Session, 2011 The health burden of hoarding What is Hoarding??? • OCD? • complication of multiple aging-related conditions? • independent condition? Why do people hoard? Ethological Cognitive Neurobiology LIFE EXPERIENCE Learning Theory Behavioural “Genetics play a large part in it…for example, if your parents didn’t have any children, you won’t either!” Is Hoarding Genetic? • Hoarding runs in families – 50-85% of hoarders report 1st degree relative who is a “packrat” – 26-54% report family members with OCD • Heritability of hoarding is 71% • In a study of >5,000 twins, genetic factors accounted for 50% of variance, along with nonshared environmental factors, error • Genetic studies suggest hoarding ≠ OCD Saxena, 2008; Mathews et al, 2007; Zhang et al, 2002; Samuels et al, 2007; Iervolino, 2011 - N=3,410 twin participants (2,350 singletons) -completed Hoarding Rating Scale Self-Report -genotyped on Illumina 317 K or 610 K Brain Structures Central to OCD Thalamus Anterior Cingulate Striatum: Corpus Putamen Callosu CaudateAnterior Cingulate Prefrontal Cortex Thalamus from Rosenberg et al., 2000 Do OCD Dimensions Have Differing Neuroanatomical Correlates? Saxena et al, Am J Psych, 2004 From: Anderson et al. Reasons to Accumulate Excess. Home Health Care Services Quarterly, 27(3), 2008 Treatment of Hoarding • Pharmacotherapy • Cognitive-Behavioural Therapy (CBT) • Combined Multi-Modal Treatment Meds OR CBT? • • • • • • Issues to Consider in Initiating Treatment Severity Consider Insight Comorbidity CBT Personality factors For Every Motivation Patient! Availability of treatment OCD: Choice of Medications First Line • SSRIs (Prozac, Luvox, Zoloft, Paxil, Celexa, Cipralex) Second Line • Clomipramine (Anafranil) • Venlafaxine (Effexor) • Mirtazepine (Remeron) Adjunctive Therapy • Antipsychotics (risperidone, olanzepine, quetiapine, *haloperidol) * Only for patients with 2nd Line Adjunctive Therapy poor insight, tics, or schizotypal personality • Topiramate, Pindolol, Memantine, Riluzole • Gabapentin, D-amphetamine, weekly oral morphine, Tramadol, Clonazepam Drug Treatment for Hoarding % ASSUMPTION: •hoarders do less well with tx 60 50 40 EVIDENCE: •results are mixed on OCD-related hoarding (Saxena et al, 2011) •i.e. Saxena et al study •Treated 12 weeks with paroxetine <60 mg daily Compulsive Hoarding Non-hoarding OCD Column1 30 20 10 0 ResponsePartial Response Saxena et al, 2007 Pharmacotherapy General Principles • Treatment goal: improvement, not remission • OCD response may be independent of depression response • Higher dosages better • 6-10 week lag to initial response • Adequate trials require 12-15 weeks • should allow at least 6-10 weeks at maximal dosage CBT for Hoarding OCD: Psychological Treatment Fear responses fade over time if there is no real danger Avoiding feared situations makes the fear stronger Rituals make the fear stronger Staying in the feared situation lessens the fear From Swinson, 2001 Reinforcement process • Immediate positive emotions reinforce acquiring and saving • Immediate negative emotions with discarding lead to avoidance • Avoidance prevents – opportunity to test beliefs – development of alternative beliefs Steketee & Frost, 2007 CBT for Hoarding Core components: Psychoeducation Cognitive strategies to address hoarding beliefs (meaning of possessions) Must target 1. Acquiring 2. Discarding 3. Clutter Organizing/decision making (associated with information processing deficits) Steketee & Frost, 2007; Muroff et al, 2009 Treatment rules • Therapist does not touch possessions without permission • All decisions made by the client • Only Handle It Once • Categories established first • Help client establish own rules for saving and discarding • Clients must think aloud while sorting possessions • Treatment proceeds systematically • In = Out Steketee & Frost, 2007 Assessing Potential Hoarders • Questions to ask someone who acknowledges “clutter”: – Are your belongings in piles along the sides of some/most rooms? How high? – Are you limited to pathways in some rooms? – Or are you walking on “goat paths” over piles? – Are any rooms so cluttered that they’re difficult to use/unusable? i.e. no longer sleeping in bed, kitchen too full to use, no access to bathtub? – Do you feel your clutter is a problem? – Are you willing to work on getting rid of things? Example of hoarding hierarchy Item Fear (SUDS) • Discarding audio recorded information 100 • Discarding children’s old school work 90 • Discarding old cards, letters 70 • Discarding ‘other purchases’ receipts 60 • Discarding old grocery store receipts 50 • Not bringing medical information home 40 • Not bringing home community flyers found in public places 25 E.g. Categorization and sorting • Categorize unwanted items – Trash, recycle donate, sell, undecided – Develop list of items to be removed – Develop action plan for removing items • Define categories for saved objects – Keep similar items together – Choose limited number of locations for each category – Help client select final locations for categories of items Steketee & Frost, 2007 Experiment example – throw out top of lost game board box • Prediction 1 if I throw this away, it will feel like death • Prediction 2 if I throw it away, I will feel this way (like death) forever • One minute after discarding – SUDS 100, but it does not feel like death • 24 hours after discarding – SUDS 10, it doesn’t bother me much at all Steketee & Frost, 2007 Conclusions and new hypotheses • Neither prediction came true • New hypotheses – The thought of throwing things away is worse than doing it – If I throw something away that I am deathly afraid of discarding, it will not feel as bad as I think, and the bad feeling will not last as long as I think Steketee & Frost, 2007 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 Steketee & Frost, 2007 Acquiring Hierarchy Walking out without the object Walking away from item Putting object back Touching object you want Seeing something you want Walking into store Standing outside store Driving past a store 85 80 75 65 50 35 25 10 Treatment of Hoarding • Older studies report poor response to CBT in hoarders • Tolin, Frost, Steketee (2007) reported good results targeting multiple factors: 1. 2. 3. • Disorganization Compulsive acquisition Difficulty discarding Patients received 26 sessions, home visits • Muroff et al (2009) report good outcome with group CBT + 2 home visits Treatment of Hoarding Biblio-based support group helps hoarders! N=18 and N=11 received 13 group sessions reviewing chapters from Buried in Treasures (Tolin, Frost & Steketee, 2007) Hoarding sx ↓ 23-28% 61% rated themselves as “much” or “very much” improved Frost, Pekareva-Kochergina, Maxner, BRAT, 2011 When Hoarding Compromises Safety.... • Forced “clean out” is the last resort – i.e. when poses fire/health hazard (vermin, rodents, toxins, or risk of falls) – POOR outcome long-term • Consider risk management approach if possible – Slow gradual steps to establish trust, working relationship – Gradual reduction of risk Harm Reduction Approach HR focuses on decreasing harmful consequences of high-risk behaviors (rather than stopping behaviors) Family-based HR for hoarders may be advantageous: Many hoarders refuse treatment Over-emphasis on discarding may exacerbate condition The problem is often too big for one person to manage Tompkins, J of Clinical Psychology: In Session, 2011 Massachusetts Department of Developmental Services Risk Management Assessment Tools Suggested Readings • Buried in Treasures – Tolin, Frost & Steketee, Oxford University Press, 2007 • Overcoming Compulsive Hoarding – Neziroglu, Bubrick & Yaryura-Tobias, New Harbinger Press, 2004 • Compulsive Hoarding and Acquiring (client and therapist workbooks) – Steketee & Frost, Oxford University Press, 2007 • Digging Out – Tompkins, New Harbinger Publications, 2009 Target the Whole Picture… • Psychoeducation for the client AND family • Set appropriate expectations re improvement/recovery • Discuss accommodation • Multidisciplinary approach! • Support, support, support case management home making COTA Meals on Wheels support groups day treatment Sunnybrook Clinic for OCD & Related Disorders • Consultation service – General service – Research stream • Group CBT treatment – OCD – TTM & compulsive skin picking – ? Hoarding, BDD, others Referrals: •Laura Toniutti •Ext 6832 •Fax 416-480-6878 OCD Research: •Evan Newton •Ext 3864 • Research – Genetics and neurobiology of OCD & related disorders – Treatment outcome Summary • Hoarding likely common, chronic, frequently severe • Hoarding becoming viewed as an independent disorder which is sometimes associated with OCD • Poor insight, unwillingness to accept help may limit outcome in community • Etiology is poorly understood, multifactorial, may be linked to frontal lobe dysfunction Summary • Treatment may help – Drug treatment – CBT – Combined approaches • Establish realistic treatment goals: improvement, not remission • Long-term treatment often necessary • Consider long-term care/non-drug alternatives in very refractory cases