From: Obsessive-Compulsive Disorders: Practical Management, Michael A. Jenike MD (Author)
HOARDING: CLINICAL ASPECTS AND TREATMENT STRATEGIES/Chapter 23
Randy 0. Frost, Ph.D., Gail S. Steketee, Ph.D.
HOARDING SYMPTOMS AND FEATURES
Hoarding behavior is most commonly associated with the collection and storage of food items among rodents, small animals, and birds. Among these creatures, food hoarding is a normal part of the life cycle and can be stimulated in predictable ways.[2-4] Although nonfood hoarding occurs in some nonhuman species, the phenomenon is unusual and not well studied.[5,6] The relationship between nonhuman and human hoarding is uncertain, although Smith has suggested some similarities. Virtually no research exists on the hoarding of food in humans and, until recently, only clinical descriptions of nonfood hoarding among humans could be found. Hoarding behavior has been observed in a variety of disorders, including anorexia nervosa, organic mental disorders, psychotic disorders, obsessive-compulsive personality disorder (OCPD), and mental retardation. However, the majority of research links hoarding to obsessive-compulsive disorder (OCD).
Definition of Hoarding
Although it is widely recognized as a symptom of OCD, hoarding is not described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in this context. DSM-IV presents hoarding in the context of OCPD in which it is defined as the inability to discard worthless or worn-out things, even though they have no sentimental value. Hoarding is defined in the same way on the Yale-Brown Obsessive-Compulsive Scale Checklist (Y-BOCS). Until recently, little attention has been given to this type of compulsion in the research literature, despite the fact that it appears difficult to treat.
Because both the DSM-IV and Y-BOCS definitions of hoarding appear inadequate, Frost and Gross proposed a refined definition of hoarding as, “the acquisition of and failure to discard possessions which appear to be useless or of limited value” (p.367). Several features of this definition are noteworthy.
The definition of hoarding includes acquisition[15-17] because most hoarders actively acquire possessions. We have found that hoarders often buy extra possessions “just in case” they might need them in the future. For example, one of our study participants bought and kept more than 30 bottles of shampoo; if her hoard fell below that number, she felt compelled to buy more. Another participant had rooms full of “gifts” that she had purchased over several decades. She did not know to whom she would give them, but they were “good buys” that she couldn’t pass up. A third had accumulated an entire room full of unworn clothing with the sales tags still attached.
The absence of sentimentality as an exclusion criterion is a second feature of this definition. Although both DSM-IV and the Y-BOCS suggest that hoarding involves only nonsentimental saving, several studies dispute this assumption. For example, Furby found that ordinary people save possessions for either instrumental reasons (i.e., because they have a need for them) or for sentimental reasons (because they are emotionally attached to them). These are the most frequent reasons for saving among hoarders as well. Clinical observations have consistently described hoarding as, in part, an overemotional attachment to possessions.[8,15,19,20] Further, hoarders develop a greater emotional attachment to their possessions than nonhoarders, and these emotional reasons are part of why they hoard . Indeed, this feature appeared so prominently among our study participants, that we made it a major component of our cognitive-behavioral model of hoarding (see following paragraphs, and Frost and Hartl).
One difficulty with our proposed definition is that it does not distinguish between hoarding as a behavior and hoarding as a clinical symptom. That is, how much does one have to hoard to constitute a symptom of OCD? In one of our first hoarding studies, we placed an ad in the local newspaper asking for “packrats” or “chronic savers” to participate in our research, and we received more than 100 calls. Although all these people considered themselves hoarders, our home visits found that many did not have a clinical problem associated with their hoarding. In our subsequent research, we found that the reasons for saving possessions and the types of things saved by hoarders were no different than those of nonhoaders. Hoarders endorsed the same reasons for saving described by Furby as reasons for saving in the general population. We also asked self-identified hoarders and control subjects to rate 80 possessions on the extent to which they saved each one. (The 80-possession list was generated in an earlier investigation of frequently saved things, such as clothes, magazines, and bags, as well as less frequently saved items, such as old appliances, flower pots, and shoe laces.) From this list, we ranked items in each group and calculated a Spearman Rank Order correlation. The correlation between the groups was high (rho = 0.79, p <0.001), suggesting that hoarders save the same kinds of things as nonhoarders, but in larger quantities.
To clarify the distinction between clinical and nonclinical levels of hoarding, Frost and Hartl proposed a three-part definition of clinical hoarding: (1) the acquisition of and failure to discard, a large number of possessions that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and (3) significant distress or impairment in functioning caused by the hoarding. This definition ties the notion of hoarding to clutter, which is the most common associated functional deficit.
Hoarding, Obsessive-Compulsive Disorder, and Obsessive-Compulsive Personality Disorder
Is hoarding a characteristic of OCD, OCPD, or both? Because hoarding is one of the diagnostic criteria for OCPD, it is reasonable to assume that it would be correlated with other OCPD diagnostic criteria and with global measures of OCPD. To test this hypothesis, Frost and Gross administered a self-report measure of hoarding; measures of other OCPD characteristics such as perfectionism, excessive job involvement, restricted affect, rigidity, generosity, and authoritarianism; and a global measure of OCPD to a sample of college students. We found that hoarding was not correlated with a general measure of OCPD, nor was it correlated in the predicted direction with most of the specific OCPD characteristics (the only predicted significant relationship being between hoarding and perfectionism). In a follow-up study, Frost, et al examined hoarding, perfectionism, and general OCPD traits in a group of self-identified hoarders compared with community volunteers matched for age and gender. Although hoarders scored significantly higher on hoarding scale scores and perfectionism, they did not significantly differ from community members on the global measure of OCPD.
A number of studies have attempted to measure the covariation of OCPD symptoms, but only one of these has attempted to objectively measure hoarding behavior. Heatherington and Brackbill told a group of children that they could keep any rocks put into their box from a pile in the experimental room. Rocks were selected based on the assumption that they were “transitional objects” representing money or feces. The number of rocks they kept was the operational definition of hoarding. The number of rocks taken and kept was correlated with other tests of parsimony. Unfortunately, no attempt was made to independently verify the reliability or validity of this measure of hoarding. The findings from our studies, plus the scant evidence on the covariation of hoarding and other OCPD characteristics, lead us to question whether hoarding is truly a symptom of OCPD.
Is hoarding a symptom of OCD? If so, it should be correlated with other measures of OCD. Frost and Gross found that a hoarding scale was significantly correlated with nearly all subscales from three different measures of OC symptoms among college students and a community sample. They also found that self-identified hoarders had significantly higher scores on nearly all OCD subscales compared with a group of matched controls. Subsequently, Frost, et al found that the hoarding scale was significantly correlated with the Y-BOCS total score in a sample of college women. Further, when participants in this study were divided into subclinical compulsives and noncompulsives based on their scores on an obsessive-compulsive inventory, the subclinical compulsives more frequently identified hoarding as a target symptom on the Y-BOCS than noncompulsives.
In another study, we compared the Y-BOCS scores of a sample of self-identified and screened hoarders to a matched control group. The mean Y-BOCS total score for the hoarding group was significantly higher than that of the matched controls. (The mean Y-BOCS total for the hoarding group was 16.5, which indicated a clinical OCD severity in this undiagnosed population.) These findings strongly suggest that hoarding is closely associated with OCD symptomatology.
Associated Features of Hoarding
Prevalence estimates of hoarding symptoms in OCD patients range widely. Rasmussen and Eisen reported that 18% of 200 adult OCD patients had hoarding compulsions. Rapoport found that 11% of 70 children with OCD had hoarding symptoms, and in a later study, it was reported that 42% (10 of 24) of children with OCD had hoarding as a pronounced symptom. However, because no definition of hoarding was provided in these studies, the findings are somewhat unclear. We used the Y-BOCS Checklist and found endorsement of hoarding obsessions in 31% and hoarding compulsions in 26% of 39 outpatients in treatment for OCD. Thus, it appears that hoarding symptoms typically occur in one quarter to one third of OCD patients. No studies have documented the frequency with which hoarding is a primary symptom.
Greenberg suggested that the onset of problematic hoarding occurs in the patient’s early twenties. However, this estimate was based on only four patients, two of whom reported hoarding symptoms in childhood. Among 32 hoarders, Frost and Gross noted that 66% recalled hoarding behavior in childhood and an additional 25% reported onset in the teens or early twenties. A significantly greater number of hoarders reported excessive saving among first-degree relatives (84%) than did nonhoarders (54%). Interestingly, the hoarding patients were more often unmarried compared with nonhoarders in this study–similar to findings from other OCD populations. Nothing is known about the gender ratio of compulsive hoarding, although Frost and Gross found no gender differences on hoarding scale scores.
Although little research exists on the symptom of hoarding, the nature of acquisition tendencies was once a popular topic in psychology. William James believed acquisitiveness was an instinct commonly found in the general population. Other early theorists incorporated hoarding into theories of psychopathology. Fromm described hoarding as one aspect of character, a way in which people related to the world around them. He described a”hoarding orientation’ which represents one type of “nonproductive character” in which security depends on acquiring and saving things. For Freud, the hoarding of money reflected the parsimony component of the anal triad. Jones elaborated on Freud’s notion of hoarding by including the hoarding of other possessions. Bender and Schilder suggested that hoarding in children is a precursor to the development of obsessions. Likewise, Adams described it as a background characteristic from which OCD develops. Other psychoanalytic writers (e.g., Salzman) suggested that hoarding develops from perfectionistic strivings to gain control over the environment. To achieve perfect control, the hoarder must not throw out anything that might be needed in the future. Thus, because one cannot be certain of exactly what might be needed in the future, the safest course of action is to save everything. In a slightly different vein, Rapoport suggested that hoarding is a”fixed-action pattern” (p.280) resulting from evolutionary development. Similar to nesting in animals, this behavior is innate and released by certain hormonal changes.
Despite the longevity of some of these theories, they have failed to generate research that supports or refutes them and have failed to generate treatment programs directed at compulsive hoarding. Prior to 1993, most of the available information on hoarding came from case studies. Greenberg described four cases of compulsive hoarding. In each case, despite debilitating symptoms, patients strongly resisted changing the hoarding behavior, and attempts by family members to discard possessions were met with intense anger and threats of violence. Frankenburg described an anorexic patient who hoarded “bits of paper and Styrofoam, toothpaste tube caps, screws, and nails (p.57).” As with other hoarding patients, she had plans to use each of these possessions, and consistent with Fromm’s observation, she felt “safe” only when she was surrounded by her possessions.
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A COGNITIVE-BEHAVIORAL MODEL OF COMPULSIVE HOARDING
Based on our recent research using nonclinical samples,[15-17] on interviews of people suffering from this condition, and on attempts to change hoarding behavior, we propose a cognitive-behavioral model of compulsive hoarding as a guide for future research and treatment. It is a preliminary model, in that many of the features are hypotheses that are, as yet, untested. The model is phenomenologic in nature, in that it outlines a number of experiential and behavioral features associated with hoarding. We make no assumptions about how these features develop, but hypothesize how they are related to each other and to hoarding behavior.
In this model, we view hoarding as a multifaceted problem that stems from four types of deficits or difficulties: (1) information-processing deficits; (2) problems with emotional attachments to possessions; (3) behavioral avoidance; and (4) erroneous or distorted beliefs about the nature or importance of possessions. These deficits or difficulties overlap in significant ways. Each of these facets is discussed together with the pertinent research in the following paragraphs.
Deficits in information processing in compulsive hoarding encompass three general and overlapping cognitive functions:
(1) decision making;
(2) categorization/organization; and
These deficits appear to be general, because they are not limited to saving or hoarding. These functions are closely related to one another and can be difficult to separate.
The clinical literature suggests that indecisiveness is a hallmark of compulsive hoarding. Case descriptions typically note the difficulty these people have in making general decisions,[20,35] not merely decisions about what to save and what to throw away. In studies of college students, community volunteers, and self-identified hoarders, we have found substantial correlations between general indecisiveness (unrelated to hoarding) and measures of compulsive hoarding.[15,36] Deciding what to wear in the morning, what to order at a restaurant, and what task to perform next are all troublesome decisions for compulsive hoarders. Warren and Ostrom suggested that the indecisiveness shown by compulsive hoarders may be a way of avoiding mistakes. Consistent with this hypothesis, we found hoarding to be correlated with the perfectionistic concern over making mistakes. As with the findings regarding indecisiveness, this relationship existed in student, community, and self-identified hoarder samples. Perhaps hoarding is an avoidance behavior closely related to indecisiveness and perfectionism (i.e., saving a possession allows the hoarder to avoid the decision required to throw it away , thereby avoiding the worry that a mistake has been made). The general indecisiveness displayed by compulsive hoarders forms the backdrop for specific difficulties in deciding whether or not to save a possession, and if saved, where to put it.
Another information-processing deficit that may be related to compulsive hoarding is categorizing and organizing information. Reed has suggested and other investigators[38-41] have found support for the hypothesis that obsessionals have more complex concepts. They define category boundaries so narrowly that few items fit within them, a feature labeled underinclusion, and thus many categories are required to classify personal possessions. This has several implications for compulsive hoarders. First, each possession may be seen as belonging to its own category (i.e., so unique that nothing else is like it and nothing can substitute for it). Such a view makes it difficult to discard anything. Second, because each possession is unique and complex, it is impossible to decide that a class of objects (e.g., old newspapers) is unimportant and can be discarded without closely examining each one. All important aspects of each possession must be examined before discarding. Third, because each possession is unique, it cannot be categorized with similar objects, and thus there is no way to organize possessions.
An example of this phenomenon can be seen in the arrangement of a hoarder’s books. The hoarder begins to read a book but must stop to do something else. The book cannot be returned to the shelf because it is now in a different category–books being actively read. It is placed on the coffee table. Next, a cookbook is consulted for dinner and it too cannot be returned to the shelf because it is being used. It is deposited on the back of the couch. The dictionary used next cannot be reshelved, lest the person forget the word he looked up. This process is repeated until there are books everywhere, none of which can be returned to its shelf because they are all different in their own category. Their new position in the room has meaning because each position represents a different category, and an idiosyncratic sort of organization exists, but the ultimate result is clutter and chaos.
The finite amount of space available means that possessions must be piled on top of one another until there are large mounds of unrelated objects. From this chaos, a sort of temporal organization emerges. The hoarder may have a sense of where things are placed based on when they entered the pile. Hoarders trying to sort through a pile often pick up a possession and, not being sure what to do with it say, “I’ll set it here for now’ placing it somewhere nearby. This is repeated until the piles are so large and numerous that they begin merging (or collapsing) into one large pile. With each new attempt to organize and discard, everything in the pile is examined and moved to the new pile or repositioned in the old pile. The end result is that the pile has been “churned” but no real progress has been made.
Another organizational problem is the mixing of important and unimportant possessions. A typical pile contains everything from paychecks to gum wrappers. We have observed that hoarders have trouble determining the relative importance of possessions, because when a possession is picked up and examined, its value increases. Whatever is “in sight” becomes more important. Judgments about discarding or organizing that are based on the value of a possession are thus difficult to make. When being examined by the hoarder, everything seems “very important.” In the treatment of hoarding, we recommend the creation of a small number of categories into which objects from a hoarding pile can be placed (e.g., save, discard, to go through later). One of our participants created a fourth category, an ” immediate to-go-through” box. In it she placed possessions from a pile on her couch that she deemed essential to go through right away (i.e., before our next session). At the next session she had not gone through the box and could not remember what was in it, so she created another category she called “immediate-immediate to-go-through.” This box contained the same sorts of things that went into the immediate to-go-through box, but these seemed even more important. The only difference between the objects in these two boxes was that she had handled one group of items more recently and they had therefore become more important to her.
The mixing of important and unimportant objects in a hoarding pile creates complications when trying to excavate the pile. The hoarder’s wish to closely review everything before discarding it has some basis in reality. For example, some of our research participants found envelopes full of cash (up to $100) among decades-old newspapers. Such occurrences reinforce the hoarder’s belief that he must carefully scrutinize everything before discarding it.
Some evidence suggests that OCD patients and nonclinical compulsive checkers suffer from subtle memory deficits.[42-44] In addition, OCD patients and nonclinical checkers show less confidence in their memories.[44,45] Similar memory problems have been observed with compulsive hoarders. Frost and HartI suggested that two aspects of memory are salient: (1) confidence in memory and (2) beliefs about the importance of remembering or recording information. For example, one of our participants saved newspapers because she was convinced she would not remember the information they contained. Saving the newspapers allowed her to feel that she still retained the information, even though she could not remember it. Frost and Longo recently examined several hypotheses regarding memory functioning in compulsive boarders. Participants scoring high or low on the hoarding scale were given the Wechsler Memory Scale-Revised and a measure of the extent to which they would rely on (have confidence in) their memory. The findings failed to reveal any actual memory deficits, but did reveal significantly lower confidence in memory among hoarders.
Beliefs about memory have been hypothesized to influence memory processes themselves (e.g., Andersson). In the case of hoarding, these beliefs may be important determinants of saving behavior. In addition to believing that things must be saved lest they be forgotten, hoarders also seem to believe that if an object is out of sight, it will be forgotten. The concern reported by one of our participants about using a filing system was, “If I put it with this stuff [into a filing system], I won’t remember it!” This suggests that visual cueing is an important memory aid for compulsive hoarders, and this element may explain why hoarders create piles of objects in living areas and why things in sight take on greater value. Difficulties like these suggest that hoarding is a problem not only of saving, but also of organizing possessions.
Why hoarders believe it is important to remember everything is unclear. It may be that they believe the negative consequences of not remembering are more likely and more severe than do nonhoarders. The high levels of perfectionism seen among compulsive hoarders may be partly responsible for these beliefs. Perhaps forgetting is interpreted as a mistake or failure that provokes distress. Lack of confidence in memory among compulsive hoarders may manifest itself in checking rituals. The extent to which the hoarding or checking is the primary symptom may be difficult to determine. Further research on the relationship between checking and hoarding is necessary to sort out these questions.
Emotional Attachment Problems
We have already noted that hoarded items are saved for both nonsentimental and sentimental reasons. Case studies and anecdotal reports of compulsive hoarding frequently note extreme emotional attachments to possessions.[8,19,20,34] From these accounts, it appears that many hoarders see their possessions as extensions of themselves. When other people touch or move them, the hoarder feels violated.
Several empirical studies also have demonstrated the extent to which possessions are saved for sentimental reasons. Frost and Gross found that hoarders reported more sentimental saving than nonhoarders, and greater emotional attachment to possessions. In a subsequent study, Frost, et al found evidence for two types of excessive emotional attachment to possessions among compulsive hoarders: sentimental and security-based. In the former, possessions serve as meaningful reminders of important past events. They become extensions of the self not to be discarded without careful consideration, because getting rid of such a possession feels like the loss of a close friend. Possessions also provide a source of comfort and security, signaling a safe environment (see Fromm).[48,49] For example, after a particularly stressful day, one hoarder remarked, “I just want to go home and gather my treasures around me.” The thought of throwing away these possessions violates this feeling of safety. In a test of these emotional attachment hypotheses, Frost, et al found that among both college student and community samples, hoarding severity was correlated with a measure of sentimental attachment to possessions and the extent to which possessions provided emotional comfort.
Such attachment also appears to occur among hoarders when they are acquiring new possessions. Buying objects seems to provide hoarders with some degree of comfort, even if the items are frivolous. The relationship between compulsive hoarding and compulsive shopping is unclear, although such a relationship has been hypothesized.
A third prominent feature of compulsive hoarding is behavioral avoidance. Saving possessions allows the hoarder to avoid the loss of objects that may be needed someday, that may be of use to others, or that are aesthetically pleasing. Hoarding also prevents emotional upset associated with discarding (losing) possessions with sentimental or safety signal value. Although it is clear that these situations are avoided, it is still not entirely clear why. Perhaps the significant variable here is the fear of losing something that is not entirely tangible. Hoarders who save newspapers, for instance, fear losing not so much the paper itself or the stories that they have read, but information that may be there. O’Connor and Robillard described people with OCD as creating a fiction (“I may be contaminated”) and trying to bend the real world to match the fiction (trying to wash away germs that are not there). This idea is applicable here. Hoarders may manufacture an idea that something very important is embodied in this possession. With newspapers, it may be information. With junk mail, it may be opportunities. Used envelopes may represent a part of their life. Saving these things means avoiding such losses. Likewise, excessive buying of unneeded items may seem to prevent the loss of a good bargain. Relatedly, one of our research participants noted that imagining all the newspapers that are published in the world made her very uncomfortable because of all the information that is lost to her forever.
In addition, hoarders save to avoid decision making–a difficult and unpleasant chore–perhaps because of their excessive concern over mistakes. The overly complex concepts of compulsive hoarders require consideration of many details and for some extensive checking and reading rituals. Simply saving the item avoids this time-consuming and onerous process. In some instances, decision making is more troublesome than actually discarding the possession. On several occasions, we have observed patients with very high anxiety in anticipation of making a decision to discard something, but once the decision is made, the anxiety subsides quickly and thoughts about the object itself play a very small role.
As mentioned earlier hoarding involves not only the inability to discard objects of limited value, but also a problem in organizing possessions. Without a workable organizational scheme, decisions about where to put things are problematic, especially when coupled with fears of losing information, opportunities, or parts of oneself. Putting everything in a pile to be sorted later avoids this problem, and leaving things in sight avoids the worry that they will be forgotten if they are filed away. Unfortunately, however, the creation of an effective filing system may not resolve fears of loss, as in the case of one client who still reported feeling that filed papers were lost to her despite her newfound ability to locate them using her organizing scheme.
Beliefs About the Nature of Possessions
Underlying many hoarding behaviors is a set of beliefs about the nature and meaning of possessions. Many of these beliefs are experienced by patients with other OCD symptoms (see Chapter 18), but in patients with hoarding tendencies, they have a specific connection to possessions. Several of these beliefs have already been mentioned:
(1) beliefs about the necessity of perfection and excessive concern over mistakes;
(2) beliefs about responsibility;
(3) beliefs about control over possessions;
(4) beliefs about emotional attachments to possessions; and
(5) beliefs about memory.
Each of these beliefs is related to an overestimation of catastrophe or loss. Distorted beliefs about the probability and severity of negative consequences if possessions are discarded or placed out of sight may be a key feature connecting these distorted thoughts. For example, beliefs about memory and the usefulness of keeping important things in sight also appear to influence hoarding behavior. Other types of beliefs are discussed in the following paragraphs.
As mentioned previously, compulsive hoarders score higher on measures of perfectionism, especially concern over mistakes. It also has been suggested that hoarders have a fundamental belief that perfection is not only possible, but expected. For example, Frost and Hartl described a woman who reported two concerns when trying to discard newspapers. First, she was concerned that she had not read them thoroughly, and second, she couldn’t remember what she had read. She believed that it was possible to read the paper and remember everything “perfectly.” Failure to do so seemed a catastrophe. Saving the newspapers allowed her to continue the fiction (erroneous belief) that perfect paper reading was possible and to avoid the failure associated with not reading the paper perfectly.
Need for Control
Frost, et al found hoarding to be associated with an exaggerated need for control over possessions. Hoarders were less willing to share possessions with others or to have others touch or use their possessions. Unauthorized touching or moving of possessions can prompt extreme anger among compulsive hoarders. This need for control may be associated with other features. For instance, if someone else touches a possession, it may remove some of the safety signal value of the possession, similar to an object becoming contaminated. Because possessions are often believed to be extensions of the self, it may seem to the hoarder that he is personally being violated when someone touches his things. This feature has obvious implications for treatment, which will be discussed shortly.
Beliefs about the nature of responsibility toward possessions also may play a role in the development and maintenance of hoarding behavior Frost, et al reported that hoarders felt more responsible for preparing to meet future needs than did nonhoarders. This behavior also was reflected in the fact that hoarders carry more”just-in-case” items in their pockets, purses, and cars than do nonhoarders. If they can imagine a situation in which an object they possess (or could possess) can be used, hoarders appear to feel responsible for attaining and saving that object in case that situation arises.
A second type of responsibility is for the proper care and use of possessions. Discarding a possession that still has a use–even a remote one–leads hoarders to feel guilty about waste. Frost, et al found that hoarders reported these thoughts more frequently than did nonhoarders. Specifically, thoughts such as, “Ownership carries with it a responsibility to use a possession properly,” “I must take precautions to protect my possessions from harm,” and “I feel guilty if I don’t use something for a long time,” were reported more frequently by hoarders than by nonhoarders.
In addition to these beliefs, a fourth set of beliefs has to do with beliefs about emotional comfort. Beliefs such as, “Without my possessions, I will be vulnerable,” “Throwing something away means losing a part of my life,” and “My possessions provide me with emotional comfort,” characterize compulsive hoarders and undoubtedly make discarding possessions more difficult.
TREATMENT FOR COMPULSIVE HOARDING
At present, very little information is available about the treatment outcomes of patients with hoarding problems. Most single-case and anecdotal reports[9,19] have been descriptive rather than treatment -oriented, noting a tendency among hoarders to be disinterested in changing their behaviors. Occasionally, treatment outcome studies of patients with OCD have made passing reference to the difficulty in treatment of hoarding or to refusal, dropout, or treatment failure of those patients with hoarding symptoms. However, Baer and Foa and Wilson anecdotally described cases of women with hoarding symptoms who made substantial progress in reducing these symptoms by using a behavioral program of gradual exposure to discarding.
Based on an early version of our hoarding model, Frost and Hartl developed a preliminary treatment strategy and applied it in a single case study, using a multiple-baseline design.
A 53-year-old woman had suffered from compulsive hoarding since childhood. She had one drug trial–a serotonin reuptake inhibitor (SRI) with limited success–and side effects resulted in discontinuation. Her hoarding behavior was so severe that no room in her house could be used in any normal way. Because her kitchen table was covered, her family ate with their plates on their laps. Several rooms had only small pathways, with possessions piled halfway to the ceiling everywhere else.
Our treatment strategy had three main components. The first of these was training in decision making and organizational skills for the management of possessions. For many hoarders, the idea of trying to discard possessions is too frightening, but being more organized and decisive is a goal they will agree to and strive to achieve. In this case, decision-making training involved category creation and moving designated possessions to storage with a goal of creating uncluttered living space. This training was performed in the context of weekly excavation sessions with homework between sessions. The second component was exposure to discarding and the associated experiences that saving things allowed her to avoid (i.e., decision making, emotional upset, etc.). Cognitive restructuring of hoarding-related beliefs was the third component of the treatment. Excavation sessions provided an in vivo context for cognitive restructuring of beliefs related to saving behaviors (i.e.; perfectionism, responsibility, control over possessions, memory, and emotional attachment to possessions).
Treatment progressed with each room being completed before moving to the next. Within each excavation session, a four-step process was used, which included identifying a target area to work on, creating a small number of categories into which possessions were placed, excavation of the area, and physical moving of the items in each category to their proper destination. To assess the severity of hoarding, we calculated two clutter ratios (CRs) for each room in the house before treatment and again when each room was excavated. Floor CRs were calculated by dividing the square footage of floor space that was cluttered by the square footage of total floor space not occupied by furniture. Furniture CRs were calculated by dividing the square footage of cluttered furniture tops by the total square footage of furniture tops minus decorative items. To gain some perspective on normal CRs, a small pilot study was undertaken in which CRs of four nonhoarding individuals were calculated. The mean CRs from this sample for both floor and furniture tops were less than 0.05.
At pretest, this patient’s floor CRs ranged from 0.23 to 0.78 with a mean of 0.54. Furniture CRs ranged from 0.53 to 1.0 with a mean of 0.85. Over 18 months and 35 sessions, seven rooms were excavated. When each room was excavated, the CRs declined substantially. Immediately after excavation, the mean CR for floors for all seven rooms was 0.02 and for furniture tops it was 0.05–ratios that were quite normal. The CRs of rooms completed early in the treatment were maintained throughout the 18 months.
The results of this case study indicate that it is possible to significantly alter severe hoarding behavior using a framework consistent with the cognitive-behavioral model outlined earlier. Based on this model of hoarding and the results of this case study, we have generated a treatment program for compulsive hoarding. We are in the process of refining and testing the intervention, which can be administered either by an individual therapist treating a patient in the home or in a group format supplemented with a paraprofessional helper holding excavation sessions in the patient’s home. The treatment assumes that the therapist is familiar with this cognitive-behavioral model of compulsive hoarding, and that the patient accepts the basic goals and procedures of treatment. Outlined below are the assessment procedures, treatment goals, treatment rules, a description of the excavation sessions, and a brief overview of cognitive restructuring.
A great deal of information about the patient’s hoarding behavior is essential for designing this treatment program. Much of this information can be gathered from initial interviews. The types of information needed include the following:
* What types of possessions are saved?
* What are the reasons for saving each type of possession?
* Where are saved items kept? Is there some form of organization?
* What is the actual amount of clutter? Spaces in the house should be evaluated in terms of their usability. Note parts of the house that are unusable because of clutter.
* Are family members involved? How does the problem affect relationships with family or friends?
* How are items acquired? Note how new items enter the house and where they go when they do.
* Does the patient have decision-making problems? A careful analysis of the nature and extent of decision-making problems and the creation of effective decision-making strategies are crucial.
* What avoidance behaviors are evident? A careful analysis of all of the things that are avoided by saving is necessary.
* How much anxiety or discomfort regarding hoarding is experienced during a typical day and during attempts to organize and discard possessions? This information is critical for setting up excavation sessions and hierarchies for discarding, and for determining the course of habituation to discarding.
* What is the patient’s hoarding history and previous treatment? Circumstances surrounding the onset of hoarding and the results of previous attempts at treatment for the problem behavior may be helpful.
In addition to this information, standardized assessments also are useful. The Y-BOCS provides an overall index of severity of the problem. We recommend the use of a modified Y-BOCS in which the clinician inquires about the hoarding symptoms rather than all OCD symptoms. We also have developed a Hoarding Severity Scale and a Hoarding Cognitions Inventory to provide additional information on the severity and range of thoughts and beliefs associated with hoarding. (These scales are available from the authors.) Psychomatic data supporting the reliability and validity of these measures are pending.
Finally, a behavioral assessment of hoarding severity is necessary. As noted earlier, we have used CRs to provide baseline information about the severity of the hoarding problem and to track the progress during treatment. As described earlier, two clutter ratios are useful, one for floor space and one for furniture tops. Photographs or videotapes of rooms also can help in the calculation of these ratios after the initial room measurements are made.
A careful discussion of concrete goals is essential prior to beginning treatment. Most severe hoarders are reluctant to enter a treatment program in which the only goal is to discard the possessions they have spent their lives collecting. Thus, in this treatment program, the discarding of possessions is a lesser goal at the outset of treatment and gains importance as it becomes apparent to the patient that the most important goals cannot be reached without discarding. The first and primary goal of this treatment program is the *creation of uncluttered living space*. The most troublesome aspect of compulsive hoarding is that clutter interferes with the ability to use interior living spaces. Most people who suffer from compulsive hoarding can readily agree to such a goal. Even if no change occurs in the acquisition and saving by a hoarding patient, if he is able to maintain uncluttered living spaces in his home, the treatment will have been useful.
A related goal is to *increase the appropriate use of space*. Severe hoarders may not have used most parts of their houses for years. Establishing a regular pattern of use will facilitate the maintenance of a clutter-free house. For instance, patients must learn to use the kitchen table for food preparation or sit-down meals. If it is not used in this way, the table may once again become a space to store hoarded objects.
To excavate and maintain an uncluttered home, it is necessary for a hoarder to *improve decision-making skills*, and to *develop an organizational plan* for the home. The strategy we have adopted is to create with the patient a small number of categories for each type of possession. Then all possessions are placed into one of these categories. Each category has a designated location once excavation is performed. For example, because most compulsive hoaders have difficulty with books, we often begin with books and require that every book in a room go into one of three categories: (1) sell or donate; (2) store; and (3) display. The sell-or-donate books are placed in a box and moved to a designated location out of the main living area. The books to be stored are also placed in a box, labelled, and placed in a designated storage location. Books to display are put on a bookshelf. If the display category is larger than the bookshelf, the extra books are treated like books to store, but are labelled “display” so they may be readily identified when bookshelf space becomes available. Limiting the number of categories makes these first decisions easier and the organizational plan clear. Other types of possessions usually require more elaborate filing systems (e.g., letters, documents, etc.).
*Discarding unneeded possessions* is a more difficult goal. Most hoarders recognize that they must be more selective about what they keep, but fear they will lose control over what is saved and what is discarded. This is especially problematic in cases in which family members have discarded some possessions against the patient’s wishes. In this treatment, we emphasize that the volume of possessions does not matter. What matters instead is that appropriate living space exists in the home. In their efforts to achieve the first several goals, hoarders begin to change their perspective about how much they”need” to keep. One strategy we have found helpful is asking hoarders to think about the clutter in their house as a loss of control. Then, we request that they think about “temporarily suspending” their normal saving behavior to gain control over the clutter. This allows them to view the discarding of possessions as serving a greater purpose (i.e., giving them a sense of control over the hoarding). As the patient gains some experience at discarding, the prospect of discarding unneeded possessions becomes a more palatable therapeutic goal.
*Reducing the accumulation of new possessions* is a necessary goal of this treatment. Because many hoarding patients engage in compulsive shopping or trash picking in an effort to accumulate new possessions, it is important to understand the value that these possessions have for the hoarder. Understanding the instrumental or sentimental value of each type of acquisition enables the therapist to design specific exposure and response prevention (ERP) strategies as well as cognitive interventions. If the patient accumulates possessions from certain places (e.g., tag sales, dumpsters), the therapist can accompany the patient to these sites, identify desired items, and stay until the patient habituates to the feeling of”needing” to acquire the possession. It is important to emphasize the distinction between objective need and the feeling of need. If a patient can learn this distinction, managing the “feeling” of need may be easier.
Familiarizing patients with the nature of OCD hoarding and the model on which this treatment is based helps them develop confidence in their ability to tolerate the discomfort associated with hoarding. Education regarding OCD hoarding also gives patients a sense of optimism and empowerment. Finally, *developing skill of self-instruction and cognitive correction* of faulty thinking about saving possessions is an essential part of this treatment. The exact nature of these skills and suggestions for developing them are presented in the following paragraphs.
The history of interpersonal relationships for someone with a hoarding problem is invariably intertwined with the relationships they have with their possessions. Most hoarders have had family or friends attempt to “help” them with their hoarding problem and actively resist this help because they usually involve offers to make decisions about what to save and to do the discarding for the hoarder. In considering treatment, the hoarder often has only these negative experiences of “helpers” on which to reflect. To make the treatment and the therapist’s role clear, specifically defined rules of behavior for the therapist are necessary. Likewise, to make the importance of the procedures clear, a defined set of rules for the patient to follow is necessary. We propose the following six treatment rules.
1. *The therapist may not touch or throw away anything without explicit permission*. Knowing that the therapist will not touch a possession without permission helps to develop trust and confidence in a cooperative patient-therapist relationship. This is not an easy rule to follow. The impulse to pick things up and discard or organize them is strong when the goal is to remove clutter. However, if the rule is violated, the trust between the therapist and patient also will be violated. There may be some exceptions to this rule if the patient has contamination fears or obsessions about others disturbing their possessions. In this case, a change in the rule should be negotiated and the rationale for doing so should be clear to both patient and therapist.
2. *All decisions regarding saving, discarding, and organizing are made by the patient*. Because part of the problem of compulsive hoarding has to do with inability to make decisions of this sort, making decisions for these patients will not help. Indeed, one of the goals for the treatment is to teach the patient how to make decisions.
3. *Any possession touched by the patient during an excavation session should be placed in a final location*. The excavation sessions should enable the patient to learn the most efficient way of organizing and discarding to prevent behaviors that have led to the clutter problem. One of the most prominent of these is “churning.” We use the Only handle It Once (OHIO) rule: Whenever a possession is picked up, it cannot go back onto the pile. It must go into one of the categories generated prior to the excavation (or in some cases, a new category).
4. *Categories for possessions must be established before handling them*. Before each excavation session, a small number of categories must be established by the patient and therapist. This is essential
for the development of efficient decision making and organization of possessions.
5. *Treatment should proceed systematically*. Like the excavation sessions themselves, it is important that the treatment sequences be systematic and well organized, so the patient will know what needs to be done and when. Many hoarders spend hours trying to organize and discard with little success, because their efforts are unfocused and produce little visible benefit. They may spend 30 minutes in one room and 30 minutes in another room and in the end see no progress. Thus, it is important that treatment should focus on one area or room until it is complete before moving to the next. More easily categorized objects (e.g., books) should be first, and should progress to more difficult ones (documents). Focus first on spaces in which progress will be readily observable and have the most desired functional effect for the patient (e.g., able to eat comfortably or sit in favorite chair).
6. *Flexible and creative strategies are to be applied as needed to make steady progress*. There will invariably be unforeseen problems in trying to excavate a house full of possessions. It may be necessary, for instance, to temporarily redefine some areas of the home as storage rather than living space, until more actual storage space becomes available later in the treatment.
Before beginning the first excavation session, the patient should understand the model of hoarding and the objectives of the treatment. The excavation sessions are designed to create in vivo opportunities for the patient and therapist to encounter each of the problems outlined in the model. These sessions have clear-cut steps to help the patient structure similar excavation homework between sessions. Such structure helps the patient avoid some of the difficulties encountered in previous attempts to clear the house. The specific steps for each excavation session are outlined in the following list.
–Step 1. Select a target area (e.g., kitchen table).
–Step 2. Assess types of possessions in the target area.
–Step 3. Determine hierarchy of items within target area.
–Step 4. Select type of possession with which to begin.
–Step 5. Create categories and a filing system for this possession type.
–Step 6. Begin excavating.
–Step 7. Continue until target area is clear.
–Step 8. Plan for appropriate use of cleared space.
–Step 9. Plan for preventing new clutter to this area.
During excavation sessions, there is ample time to explore the belief systems underlying hoarding behavior. The therapist should encourage the patient to verbalize thoughts and feelings when excavating to understand specific decision-making problems and erroneous beliefs regarding saving and discarding. A “stream of consciousness” instruction facilitates this process. It is important to help the patient recognize his characteristic thought processes and develop ways of challenging these beliefs. The most common themes encountered are perfectionism, responsibility, control, emotional attachment, and beliefs about memory. A variety of techniques are useful here to challenge these thoughts and the excessive value placed on possessions. These cognitive techniques are described elsewhere (see Chapter 18).
During these sessions, it is important that the therapist not express disappointment or negative feedback regarding decisions made by the patient. Such expressions are likely to increase shame and disappointment and decrease motivation. It also is important not to engage in extended arguments with the patient about a decision to save something. A Socratic approach that encourages the patient to question his or her reason for saving something is preferable. These instances also may provide opportunities to remind patients of the goals in treatment, especially the need to create usable living spaces and to establish decision-making rules and categories for saving.
Behavioral experiments to test the patient’s beliefs and reactions also are helpful in the process of cognitive restructuring. Most hoarders show excessive attachment to possessions that have little instrumental value and are not reminders of special times. They believe they will not be able to tolerate discarding such a possession. A behavioral experiment to test this hypothesis by discarding such an item reveals not only the strength of this feeling, but also the amount of time it takes to habituate to a decision to discard such a possession. The outcome of such an experiment also will clearly show the patient that his or her”feeling” of being unable to stand it is inaccurate.
Obsessive-compulsive hoarding is a little-studied phenomenon. This chapter reviews the existing literature on this topic, presents a cognitive-behavioral model of compulsive hoarding, and outlines a treatment program for this problem. The literature review suggests a change in the definition of compulsive hoarding most commonly used so as not to exclude possessions saved for sentimental reasons.
Compulsive hoarding was defined here as having three parts:
(1) the acquisition of and failure to discard, a large number of possessions that appear to be useless or of limited value;
(2) living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and
(3) significant distress or impairment in function caused by the hoarding.
The cognitive-behavioral model of compulsive hoarding emphasizes four major factors:
(1) information-processing deficits;
(2) problems with emotional attachments to possessions;
(3) behavioral avoidance; and
(4) erroneous or distorted beliefs about the nature or importance of possessions.
The individual and group treatment program outlined emphasizes the creation of uncluttered living space, the appropriate use of uncluttered space, improvement in decision-making skills, and the creation of an organizational plan for possessions. As treatment progresses, more emphasis is placed on discarding and reducing accumulation. The treatment is conducted in the context of highly structured excavation sessions during which exposure and cognitive restructuring can take place.
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Third Edition (1998)
Michael A. Jenike, M.D.
Director, Obsessive-Compulsive Disorders
Clinic and Research Unit
Massachusetts General Hospital
Professor of Psychiatry, Harvard Medical School,
Lee Baer; Ph.D.
Director, Psychological Research
Obsessive-Compulsive Disorders Clinic and Research Unit
Massachusetts General Hospital
Associate Professor of Psychology
Department of Psychology, Harvard Medical School
William E. Minichiello, Ed.D.
Director, Psychological Clinical Services, Behavior Therapist
Obsessive-Compulsive Disorders Clinic and Research Unit
Massachusetts General Hospital
Assistant Professor of Psychology, Department of Psychiatry
Harvard Medical School, Boston, Massachusetts