03 - hoarding disorder - caleb lackhoarding disorder a new syndrome? • not included in the dsm-iv...
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7/20/16
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HoardingDisorder
ANewSyndrome?
• NotincludedintheDSM-IV
• HoardingsymptomsarelistedunderOCPD– “Inabilitytodiscardworn-outorworthlessobjectsevenwhentheyhavenosenMmentalvalue”
• NotlistedatallinICD-10
Mataix-Colsetal.(2010)
OperaMonalDefiniMon
A. PersistentdifficultydiscardingorparMngwithpossessions,regardlessofthevalueothersmayaVributetothesepossessions
B. Thisdifficultyisduetostrongurgestosaveitemsand/ordistressassociatedwithdiscarding
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OperaMonalDefiniMon
C. ThesymptomsresultintheaccumulaMonofalargenumberofpossessionsthatfillupandcluVeracMvelivingareasofthehomeorworkplacetotheextentthattheirintendeduseisnolongerpossible.IfalllivingareasareuncluVered,itisonlybecauseoftheintervenMonsofthirdparMes(e.g.,familymembers,cleaners,authoriMes).
OperaMonalDefiniMonD. Thesymptomscauseclinicallysignificant
distressorimpairmentinsocial,occupaMonal,orotherimportantareasoffuncMoning(includingmaintainingasafeenvironmentforselfandothers)
E. ThehoardingsymptomsarenotduetoaGMC
F. Thehoardingsymptomsarenotrestrictedtothesymptomsofanothermentaldisorder
HoardingSpecifiers• WithExcessiveAcquisi/on:IfsymptomsareaccompaniedbyexcessivecollecMngorbuyingorstealingofitemsthatarenotneededorforwhichthereisnoavailablespace.
• Goodorfairinsight:Recognizesthathoarding-relatedbeliefsandbehaviorsareproblemaMc.
• Poorinsight:Mostlyconvincedthathoarding-relatedbeliefsandarenotproblemaMcdespiteevidencetothecontrary.
• Absentinsight:Completelyconvincedthathoarding-relatedbeliefsandbehaviorsarenotproblemaMcdespiteevidencetothecontrary.
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HoardingandOCD
• Hoardingsymptomsseenin18-40%ofOCDcases;onlyclinicallysignificantin<5%
• Resembleeachotherphenomenologically
• ComorbidratesofOCDin16-35%ofcompulsivehoarders
Mataix-Colsetal.(2010)
Hoardingvs.OCD
• Inhoarding,don’tseedistressing,repeMMve,intrusivethoughts(obsessions)
• Thoughtsofpossessiondonottriggerrituals
• Whenconfrontedwithdiscarding,angerandgriefareaslikelyasanxiety
Mataix-Colsetal.(2010)
Hoardingvs.OCD
• ConMnuallyworseningpaVernofsymptoms,withlateonsetofdistress/disability
• LackofinsightcomparedtoOCD
• Acquiringandsavingareojenpleasantevents,whereO/Carealwaysnega/ve
Mataix-Colsetal.(2010)
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Hoardingvs.Squalor
• “Diogenessyndrome”associatedwithself-neglectanddomesMc-neglect
• MostwithHDdonotshowthis,maybeasubsetofindividuals– 17%hoarders,32%residences“extremelyfilthy”
Sketekeeetal.(2001)
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AnimalHoarding
• Largenumberofanimalsand1. Failuretoprovideminimalstandardsof
nutriMon,sanitaMon,andveterinarycare2. FailuretoactonthedeterioraMngcondiMonof
theanimalsandtheenvironment3. LackofawarenessofthenegaMveeffectsofthe
collecMonontheirownhealthandwell-beingandonthatofotherfamilymembers
Patronek&Nathanson(2009)
AnimalHoarding
• MaybemorerelatedtoDiogenessyndromethancompulsivehoarding– Squalor,neglectofself
• Muchmoreresearchneeded
Patronek&Nathanson(2009)
Prevalence
• 2-5%ofgeneralpopulaMon
• Ojenonlydiagnosedlaterinmiddletolateadulthood(50+years)
• 60%+engageinexcessivebuying,over50%inacquiringfreethings
etal.(2010)
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Prevalence
• Differingstudiesusingdifferentmethodshavefoundquitedifferentrates
Pertusaetal.(2010)
Course
• RetrospecMvereportsoffirstsymptomsinadolescence,firstinterferenceinmid-30s
• ChronicandunremiongcourseforvastmajorityofpaMents
Mataix-Colsetal.(2010)
GenderDifferences
• Clinicalsamplesarepredominatelyfemale
• Epidemiologicalstudiesaremixed,withtwofindinghighermalesrates
• Similarphenomenologyacrossgenders
Mataix-Colsetal.(2010)
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SES&CulturalDifferences
• Appearstobeauniversalphenomenon
• EasternandWesternhoardersarequitesimilaracross– ClinicalcharacterisMcs– Itemsbeinghoarded– ExtentofcluVer
Mataix-Colsetal.(2010)
Comorbidity
• HighoverlapwithMDD(57%),SAD(29%),andGAD(28%)
• Lessthan20%havecomorbidOCD
Frostetal.(2006)
ImpactofHoarding
• AssociatedwithsubstanMaldistress/disability
• CluVerpreventsnormaluseofspacetoaccomplishbasicacMviMes(cooking,cleaning,moving,sleeping)
• Putspeopleatriskforfire,falling,poorsanitaMon,andhealthrisks
Mataix-Colsetal.(2010)
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ImpactofHoarding
• Workimpairmentgreaterthanallotheranxiety,mood,andsubstanceusedisorders
• 8-12%evictedorthreatenedduringlife
• Ojenleadstofamilyandneighborconflict
Mataix-Colsetal.(2010)
Let’sWatchSome
• hVps://youtu.be/NKKYuPLDWKA
• Whilewewatch,thinkaboutwhatwe’vetalkedaboutinclass
• IsthedepicMonaccurate?Isthetreatmentaccurate?Likelytohelp?
EMology
• Highincidenceof“packrats”infirstdegreerelaMvesofhoarders
• HoardinginOCDshowshigherthanexpectedfamilyratesofhoarders
• GeneMcfactorsaccountforabout50%ofvarianceinhoardingbehaviors
Mataix-Colsetal.(2010)
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EMology
• Inanimalstudies,implicaMonofsubcorMcallimbicstructuresandtheventro-medialprefrontalcortex
• SomeevidencefromlesionstudiesinhumansimplicaMnganteriorventromedialprefrontalandcingulatecorMces
Mataix-Colsetal.(2010)
EMology
• SavingandacquiringbehaviorsareojenposiMvelyreinforcedincompulsivehoardingbyposiMvefeelings
• Feelingsofpleasure,safety,andcomfortareprovidedbyacquiringnewitemsorfantasizingaboutexisMngones
Mataix-Colsetal.(2010)
Meetthe“BadGuys”
• “It’sjustnotmypriority”(lowmoMvaMontochange)
• Overthinkingandconfusingone’sself
• Avoidanceandmakingexcuses
• PrioriMzingshort-termreinforcement
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Meetthe“BadGuys”
• Unhelpfulbeliefsthatgetintheway– Seeinguselessobjectsasusefulorneeded– PerfecMonism&fearofmakingmistakes– Exaggeratedsenseofresponsibility– AVachmentandanthropomorphizingobjects– SeeingobjectsaspartofyouridenMty– UnderesMmaMngtheirmemory– Seeinghoardingasbeingundertheircontrol
EMology
• Avoiddiscardingpossessionsandendupstoringthemasawaytoavoid– Theexperienceofloss– Havingtomakeananxiety-provokingdecision– Makingamistakeregardingapossession
• CluVerisafuncMonofbothvolumeofthingsandorganizaMondeficits
Pertusaetal.(2010)
Treatment
• Giventhenewnessofthisareaofresearch,limitednumberofoutcomestudies
• SRIeffecMvenessinOCDpaMentswithhoardingismixed(someless,someequal)
• OnestudyusedparoxeMneandfounda25%decreaseinhoardingsymptoms
Pertusaetal.(2010)
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Treatment
• Poorinsightmaycausetreatmentrefusal,lackofcooperaMon,dropout,andpooroutcomes
• AspecificallydevelopedCBTtreatmenthasshownsomepromise,withdecreasesof23-37%and70%responserate
Pertusaetal.(2010)
CBTforHoarding
• Includesofficeandin-homesessions
• Focuseson– MoMvaMonalinterviewing– Skillstraining(organizing,decisionmaking,problemsolving)
– ExposuretosorMng,discarding,andnotacquiring– CogniMverestructuring
Sketekee&Frost(2008)
CogniMveTherapy
• UsedbecausehoardinginvolvesfalsepercepMonsofthreatandworrisomereacMonspredicMngnegaMvefutureevents
1. IdenMfyhowthepaMentisthinkingandthebeliefsaboutself,world,andfuturethatunderliethosethoughts
– The“badguys”wediscussed!
Borkovecetal.(2004)
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CogniMveTherapy
2. EvaluatetheaccuracyofthosecogniMonsthroughexaminaMonoftheirlogic,probability,andpastevidence
3. GeneratealternaMve,moreaccurateinterpretaMons,predicMons,andwaysofbelieving
Borkovecetal.(2004)
CogniMveTherapy
4. UsethesenewperspecMveswheneverworryisdetectedandengageindeliberatebehavioralexperiments
• Canalsousea“WorryOutcomeDiary”toassistingatheringevidencefor/against– Allowsonetotrackwhetherornotthefearedoutcomeactuallyhappened
Borkovecetal.(2004)
ChallengingThoughts
• CanIsaythatthisstatementis100%true,withoutanyexcepMons?
• Whatisthelikelihoodorprobabilityofthishappening?– Ratethistwice,onceemoMonallyandonceobjecMvely
• Doesthisstatementfitwithalltheavailableevidence?
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ChallengingThoughts
• AmIignoringanysafetyfactors?
• Doesthisalwaysapply?AretherecondiMonsunderwhichthismightnotapply?
• Isthereagrayareatothisstatement(notjustablackandwhitething)?
• Isthisbasedonfactorfeeling?Havemyfeelingseverturnedouttobewrong?
ChallengingThoughts
• HowmuchcontroldoIactuallyhaveinthissituaMon?– AmItakingresponsibilityforthingsoverwhichIhavenocontrol?
– AmIignoringaspectsofthesituaMonthatIcancontrol?
• IsmyexpectaMonforthisoutcomerealisMcorevenpossible?
TheThoughtRecord
• ThisisaphysicalmanifestaMonofthethoughtchallengingprocess
• OjenusedearlyintherapytohelpclientgeneralizeCRskillsoutsideoftherapy
• Shouldbecustomizedfortheageand/ordevelopmentalleveloftheclient
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Exa
mpl
e of
an
adul
t tho
ught
reco
rd THOUGHT RECORD
Trigger: __________________________________________________________ Cognitions (images, thoughts, assumptions, and/or beliefs):_________________ _________________________________________________________________ Strength of belief in cognitions (on a 1-7 scale): __________________________ Challenges to cognitions: _____________________________________________ _________________________________________________________________ Types of thinking errors: ____________________________________________ _________________________________________________________________ Alternative viewpoints: • Worst outcome: _________________________________________________ • Best outcome: __________________________________________________ • Most realistic outcome: ___________________________________________ What effect does this thought have on the way I feel? _____________________ _________________________________________________________________ Rational responses: Even though I feel that ________________________________________ is true, (thoughts or assumptions) the reality is that ___________________________________________________. (answers to challenges and alternative viewpoints)
UsingtheThoughtRecord
• Whenteachingclients,itisimportanttomakesurethattheyarerecognizingthoughtsandemoMonsaccurately
• PracMceinsessionwithtwo-threerecordsbeforeclientsdothemontheirown
• ReviewtherecordstheydidashomeworkthenextweekandmakecorrecMonsasneeded
• It’sMmetorestructureyourselfcogniMvely!
• Youwillcomplete2thoughtrecordsdaily(6total)andturntheminFriday
• Usethoughtchallengingandthelistofcommonthinkingerrorstohelp!
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