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Subjective Units of Distress (SUDS)

Education and Exposure Response Prevention are major components of treatment.

Patients learn to conceptualize their hoarding in terms of problems with anxiety, avoidance, and information processing. Patients then gradually expose themselves to situations that cause them anxiety (e.g., being required to throw something away or make a decision about what to do with a specific object).

They rate their subjective level of distress at regular intervals, using a Subjective Units of Distress Scale (SUDS).

They are then supported and instructed to resist the urge to save or avoid until their SUDS level diminishes by at least 50%.

With repeated practice, ERP extinguishes the fear of losing something important, thereby reducing the strength of the patient’s urges to save.

Intensive CBT for compulsive hoarding focuses on four main areas: discarding, organizing, preventing incoming clutter, and introducing alternative behaviors.

-Treatment of Compulsive Hoarding, 2007. Sanjaya Saxena, and Karron M. Maidment

When patients throw something away, they typically become anxious for awhile. Patients are asked to rate their anxiety — Subjective Units of Distress (SUDS) — and then monitor it as it decreases over time. The anxiety may stay for a few minutes or even a few hours but it does decrease. It seems to decrease faster when the patient does not see the discarded item once it is thrown away.

The discarding process helps the patient in two ways. First of all, it forces the patient to make decisions, rather than postpone them, and results in a decrease in the anxiety associated with making decisions. Secondly, it helps the patient to see that nothing terrible happens when s/he throws things away that feel valuable. This directly addresses the patient’s obsessive fears of losing valuable or necessary items.

To help patients throw things away, they are prompted to cognitively reframe their obsessive fears about discarding things.

They are asked:

  • What’s the worst thing that would happen if you didn’t have this item?


  • What do you think other people do with similar items?


  • If you needed this information later, how could you access it if you threw this away now?

This process is essential. People who hoard need assistance in learning how to think differently about their possessions. When patients are asked to think about the consequences of throwing away their clutter, they are challenging their erroneous beliefs that dire consequences will occur if they throw something away.

-From Karron Maidment, UCLA OCD Research Program

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