Hoarding Disorder E-Book

Gregory S. Chasson

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch
• Veröffentlichungsjahr: 2018

Seitenzahl: 178

Beschreibung

Hoarding Disorder, classified as one of the obsessive-compulsive and related disorders in the DSM-5, presents particular challenges in therapeutic work, including treatment ambivalence and lack of insight of those affected. This evidence-based guide written by leading experts presents the latest knowledge on assessment and treatment of Hoarding Disorder. The reader gains a thorough grounding in the treatment of choice for hoarding – a specific form of CBT interweaved with psychoeducational, motivational, and harm-reduction approaches to enhance treatment outcome. Rich anecdotes and clinical pearls illuminate the science, and the book also includes information for special client groups, such as older individuals and those who hoard animals. Printable handouts help busy practitioners. This book is essential reading for clinical psychologists, psychiatrists, psychotherapists, and practitioners who work with older populations, as well as students.

Leseprobe

Advances in Psychotherapy – Evidence-Based Practice, Volume 40

Hoarding Disorder

Gregory S. Chasson

Illinois Institute of Technology, Chicago, IL

Jedidiah Siev

Swarthmore College, Swarthmore, PA

About the Authors

Gregory S. Chasson, PhD, is a licensed clinical psychologist, Associate Professor in the Department of Psychology at Illinois Institute of Technology, and owner of Obsessive-Compulsive Solutions of Chicago. His research laboratory at Illinois Tech (i.e., Repetitive Experiences and Behavior Lab – REBL) and clinical work focus on obsessive-compulsive spectrum conditions (including hoarding), autism spectrum conditions, and anxiety and traumatic stress. He received his PhD at the University of Houston and completed pre- and postdoctoral fellowships at Harvard Medical School at McLean Hospital and Massachusetts General Hospital, respectively.

Jedidiah Siev, PhD, is a licensed clinical psychologist and Assistant Professor in the Department of Psychology at Swarthmore College, where he directs the Swarthmore OCD, Anxiety, and Related Disorders (SOAR) Lab. Previously, he founded and directed the OCD and Related Disorders Program at Nova Southeastern University, after completing training at the Massachusetts General Hospital and the University of Pennsylvania. Dr. Siev has considerable clinical and research experience with individuals who have hoarding, obsessive-compulsive, body dysmorphic, and anxiety disorders.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Saybrook University, Oakland, CA

Associate Editors

Larry Beutler, PhD, Professor, Palo Alto University / Pacific Graduate School of Psychology, Palo Alto, CA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

David A. Wolfe, PhD, ABPP, Adjunct Professor, Faculty of Education, Western University, London, ON

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://us.hogrefe.com/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2018952155

Library and Archives Canada Cataloguing in Publication

Chasson, Gregory S., 1981-, author

Hoarding disorder / Gregory S. Chasson, Illinois Institute of Technology,

Chicago, IL, Jedidiah Siev, Swarthmore College, Swarthmore, PA.

(Advances in psychotherapy--evidence-based practice ; v. 40)

Includes bibliographical references.

Issued in print and electronic formats.

ISBN 978-0-88937-407-2 (softcover).--ISBN 978-1-61676-407-4 (PDF).--ISBN 978-1-61334-407-1 (EPUB)

1. Compulsive hoarding. 2. Compulsive hoarding--Treatment. 3. Hoarders. 4. Hoarders--Family relationships. I. Siev, Jedidiah, 1977-, author II. Title. III. Series: Advances in psychotherapy--evidence-based practice ; v. 40

RC569.5.H63C43 2018

618.85’84

C2018-904343-1

C2018-904344-X

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

Cover image: © Boogich – iStock.com

© 2019 by Hogrefe Publishing

http://www.hogrefe.com

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Format: EPUB

ISBN 978-0-88937-407-2 (print) • ISBN 978-1-61676-407-4 (PDF) • ISBN 978-1-61334-407-1 (EPUB)

http://doi.org/10.1027/00407-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

|v|Dedication

Dedicated with love to my parents and siblings for instilling in me the critical ingredients of a successful scientist–practitioner. To the memory of my dad, Fred, for modeling a robust work ethic and untiring intellectual curiosity. To my mom, Robin, for teaching me about compassion and the effective navigation of a complex social world. To my brother, Brian, for demonstrating remarkable strength and humor in the wake of adversity. To my sister, Courtney, for reminding me of the benefits of life balance and free thinking.

G.S.C.

Dedicated with love to:

Brendy

– the best writer I know

Shimmy

– who, at age 7, let the world know that “what my father does best is to dilevir the pizza for my birthday”

Ayelet

– who, at age 9, wrote that “my future career is going to be an author and psycoligist because I am good at both and I really like doing them”

Ella

– who, at age 6, described fear accurately: “my heart couldn’t stop beeping”

and

Asher

– who, at age 6, wrote his first hardcover book, “All About Elephants”

J.S.

|vi|Acknowledgments

The authors would like to thank Keith Lit, Ivy Rouder, and Victoria Schlaudt for assistance with clinical examples and manuscript preparation.

Contents

Dedication

Acknowledgments

1 Description

1.1 Terminology

1.2 Definition

1.3 Epidemiology

1.4 Course and Prognosis

1.5 Differential Diagnosis

1.5.1 Obsessive-Compulsive Disorder

1.5.2 Other Conditions

1.5.3 Hoarding Versus Collecting

1.6 Co-Occurring Disorders

1.7 Diagnostic Procedures and Documentation

1.7.1 Structured Diagnostic Interviews

1.7.2 Clinician-Administered Symptom Measures

1.7.3 Self- or Other-Report Symptom Measures

1.7.4 OCD Measures With Hoarding Items

1.7.5 Summary of Diagnostic Procedures and Documentation

2 Theories and Models of the Disorder

2.1 Cognitive Behavioral Model

2.1.1 Vulnerability Factors

2.1.2 Beliefs

2.1.3 Emotions and Reinforcement

2.1.4 Summary of the Cognitive Behavioral Model

2.2 Biological Models

2.2.1 Genetics

2.2.2 Neurobiology

3 Diagnosis and Treatment Indications

3.1 Diagnostic Assessment

3.1.1 In-Office Assessment

3.1.2 Home Visit

3.1.3 Additional Assessment Considerations

4 Treatment

4.1 Methods of Treatment

4.1.1 Cognitive Behavior Therapy for Hoarding Disorder

4.2 Mechanisms of Action

4.3 Efficacy and Prognosis

4.4 Variations and Combinations of Methods

4.4.1 Group-Based Approaches

4.4.2 Technology-Based Approaches

4.4.3 Family Approaches

4.4.4 Other Psychosocial Approaches

4.4.5 Pharmacological Interventions

4.4.6 Multimodal Treatment

4.5 Problems in Carrying Out the Treatments

4.5.1 Treatment Ambivalence

4.5.2 Lack of Awareness

4.5.3 Secondary Gains

4.5.4 Co-Occurring Conditions

4.5.5 Animal Hoarding

4.5.6 Logistical Barriers

4.5.7 Ethical and Legal Barriers

4.6 Multicultural Issues and Other Individual Differences

5 Further Reading

6 References

7 Appendix: Tools and Resources

Example of Exposure and Response Prevention Hierarchy for Hoarding

Types of Cognitive Errors

All-or-None Thinking

Catastrophizing

Emotional Reasoning

Overgeneralization

Unfair Comparisons

“Should” Statements

Mind Reading

Fortune Telling

Personalization or Self-Blaming

Labeling

Selective Attention or Tunnel Vision

Magnification and Minimization

Mental Filter

Discounting the Positive

Sample Thought Record

Accommodation Behavior Contract

|1|1Description

1.1 Terminology

Hoarding disorder is a new disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013, Sect. 300.3), as well as in the International Classification of Diseases, 11th edition (ICD-11; World Health Organization, 2018, Sect. F42, subsection 6B24), where it is included in the respective “Obsessive-Compulsive and Related Disorders” chapter. However, hoarding behavior is not a new or newly discovered phenomenon. The roots of the term hoarding and the presence of hoarding behavior throughout human history are outlined extensively elsewhere (Penzel, 2014). The word hoarding comes from the word hord in Old English, meaning “treasure, valuable stone or store” (Penzel, 2014). According to Penzel, there is evidence of hoarding behavior as early as the very beginning of humankind, and classical literature is peppered with references to hoarding, such as in Dante Alighieri’s well-known poem “Inferno”; Gogol’s main character in Dead Souls from 1842; and Krook, a character in Dickens’ Bleak House from 1862. There are even possible allusions to hoarding in both the Old and New Testaments of the Bible. Specific individuals in history have also been associated with hoarding – for example, the Collyer brothers, Howard Hughes, and the Bouvier Beale mother-and-daughter pair.

Recently, hoarding behavior has received considerable media exposure. Reality television shows such as Hoarders and Buried Alive garner sizable and profitable viewerships. Popular films, like the 2004 Howard Hughes biographical drama The Aviator, have increased the spotlight on hoarding for the public. On the museum circuit, the clutter of Zhao Xiangyuan, the late Chinese citizen from Beijing with hoarding difficulties, has been displayed as an exhibit by her artist son, Song Dong.

The visibility of hoarding behavior throughout history is not reflected in its relative lack of attention in the community of medical and social scientists and theoreticians. Exceptions include early discussions of hoarding by William James (1890), who wrote of instinct and the importance of acquisition behavior in the formation of personal identity; and by Erich Fromm (1947), who introduced the hoarding orientation as one of several personality types, characterizing it as a tendency to view the world as composed of possessions to keep and value.

Hoarding behavior was included in previous versions of the DSM, but only as a single criterion for obsessive-compulsive personality disorder (OCPD), starting in 1980. However, in the early 1990s, Frost and colleagues set the stage for modern theory and research on hoarding behavior when they |2|published seminal research (Frost & Gross, 1993) and articulated a cognitive behavioral model of hoarding (Frost & Hartl, 1996). Since Frost and Gross (1993), the number of research articles in PsycINFO with a keyword hoarding (with human participants set as a parameter of the search) has increased nearly 19-fold, highlighting the increase in scientific attention and growing evidence base.

1.2 Definition

Hoarding disorder is characterized by difficulty parting with items because of the need to save them and distress from discarding them, regardless of their value. Hoarding behavior results in clutter that interferes with the ability to use living spaces as intended, unless someone else intervenes to limit the clutter. The majority (60–90%) of individuals with hoarding disorder engage in excessive acquisition of new objects as well, and the clinician can code this (e.g., for billing or research purposes) by specifying “with excessive acquisition” (Frost, Rosenfield, Steketee, & Tolin, 2013; Frost, Tolin, Steketee, Fitch, & Selbo-Bruns, 2009; Mataix-Cols, Billotti, Fernández de la Cruz, & Nordsletten, 2013; Timpano et al., 2011).

Hoarding disorder is a new diagnosis in DSM-5 and ICD-11; previously, individuals with hoarding would have been diagnosed with obsessive-compulsive disorder (OCD) or OCPD. In fact, before DSM-5, diagnostic criteria pertaining to hoarding behavior were mentioned in only one section of the DSM: the fifth criterion of OCPD, where “[he or she] is unable to discard worn-out or worthless objects even when they have no sentimental value” (American Psychiatric Association, 2000, p. 729). Notably, apparent hoarding behavior (e.g., unwillingness to discard, excessive acquisition) can indicate numerous diagnoses, and hoarding disorder is not diagnosed when the symptoms are better accounted for by another condition, including OCD. For example, an individual with excessive clutter because of obsessions related to contamination or because of the need to complete elaborate compulsions before discarding would be diagnosed with OCD, not hoarding disorder.

Poor insight is common among individuals who hoard, and when coding the diagnosis, the clinician should specify degree of insight. In fact, more than half of individuals with hoarding have poor or delusional levels of insight (Tolin, Frost, & Steketee, 2010). Poor insight can manifest in several ways, including lack of appreciation of the severity of the problem or its impact on related consequences; rigid, fixed, and unreasonable beliefs about possessions; and defensiveness (Frost, Tolin, & Maltby, 2010). Degree of insight is a particular concern with this population because low insight has been associated with lack of motivation, treatment dropout, therapy-interfering behaviors, and poor treatment outcome (Frost et al., 2010).

The DSM-5 criteria for hoarding disorder are provided in Table 1. The ICD-11 criteria for the disorder are similar to those found in DSM-5 and emphasize the accumulation of possessions as a result of difficulty discarding or excessive acquisition, accumulation of belongings that results in the inability to use or remain safe in living spaces, and associated functional impairment

|3|Table 1  DSM-5 Diagnostic Criteria for Hoarding Disorder

Persistent difficulty discarding or parting with possessions, regardless of their actual value.

This difficulty is due to a perceived need to save the items and to distress associated with discarding them.

The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).

The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

Specify if:

With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

Specify if:

With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Note. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders (5th ed., p. 247). © 2013 American Psychiatric Association. All rights reserved.

and/or distress to the self or others. There are, however, some important differences between the DSM-5 and ICD-11 criteria for hoarding disorder. The most critical difference is that DSM-5 requires the presence of difficulty discarding, often considered the hallmark of the disorder. The criteria for ICD-11, however, indicate that one of (a) difficulty discarding, or (b) excessive acquisition is required to explain accumulation of possessions, indicating that a case could be labeled with the diagnosis without the presence of difficulty discarding. In DSM-5, excessive acquisition is a specifier and is not sufficient for a diagnosis of hoarding disorder. Another important difference is that the ICD-11 does not qualify the requirement for clutter by indicating that a lack of clutter could be the result of intervention from others (e.g., parents picking up a child’s clutter). This could make it more challenging for appropriately |4|diagnosing children and other vulnerable populations who present with bona fide hoarding behavior but have guardians who are consistently stepping in to prevent clutter. Another difference between DSM-5 and ICD-11 is that levels of insight are coded in three levels in the former but two levels in the latter, with poor and absent insight collapsed into one level in the ICD-11 hoarding disorder coding scheme.

1.3 Epidemiology

Estimates of the prevalence of hoarding disorder vary considerably, ranging from 1.5% to 5.8% of the population (Nordsletten, Reichenberg, et al., 2013; Samuels et al., 2008; Timpano et al., 2011). Rates are much higher among individuals seeking treatment for anxiety disorders (approximately 12–25%; Tolin, Meunier, Frost, & Steketee, 2011). Research is equivocal about potential gender differences, with some studies finding similar rates among men and women (e.g., Fullana et al., 2010; Nordsletten, Reichenberg, et al., 2013; Timpano et al., 2011), and others finding higher rates in men than women (e.g., Iervolino et al., 2009; Samuels et al., 2008).

1.4 Course and Prognosis

Hoarding disorder tends to have a chronic and gradually worsening course. Typical age of onset is in adolescence. Considering that the disorder usually does not remit spontaneously, over time clutter accumulates, and both symptoms and their sequelae become more severe. Therefore, older adults have higher rates and more severe cases of hoarding (e.g., Nordsletten, Reichenberg, et al., 2013). For this reason, most of the time, those who seek treatment for hoarding are older. Hoarding disorder is also associated with marital status (not being married) and with several negative outcomes, including unemployment and poor reported health (e.g., Nordsletten, Reichenberg, et al., 2013).

1.5 Differential Diagnosis

Prior to DSM-5, hoarding disorder was diagnosed as a subtype of OCD. However, the two differ phenomenologically in several important ways. For example, individuals with hoarding tend not to describe having ego-dystonic obsessions, and hoarding is generally maintained by positive reinforcement as well as negative reinforcement. In contrast to hoarding disorder, however, hoarding behavior – such as refusal to discard – and resultant clutter can reflect several different underlying causes and do not necessarily imply hoarding disorder. As stipulated in diagnostic criteria E and F (Table 1), hoarding disorder is not diagnosed if the behavior is better accounted for by another |5|medical (e.g., Prader-Willi syndrome) or psychiatric disorder (e.g., neurocognitive disorders, such as Alzheimer’s disease).

1.5.1 Obsessive-Compulsive Disorder

OCD is a heterogeneous disorder characterized by intrusive thoughts, images, or urges (i.e., obsessions) and associated compulsions to reduce distress. Obsessional fears and compulsive rituals take many forms and sometimes lead to unwillingness or inability to discard or organize possessions. If the apparent hoarding symptoms are accounted for by OCD, one would diagnose OCD and not hoarding disorder, and the treatment of choice would be a first-line OCD treatment – for example, exposure and response prevention (ERP). However, the differentiation between hoarding disorder and OCD is often unclear, and there is not yet a strong consensus in the field for some ambiguous presentations. Nevertheless, to illustrate, the following are several examples of OCD phenomena that may result in unwillingness to discard and a cluttered living space:

A man with obsessions about symmetry, exactness, and order is overwhelmed at the prospect of cleaning, arranging, and discarding because of perfectionistic or compulsive standards. He therefore avoids or refuses to do so, and his living space becomes extremely cluttered with possessions that would have little value to others.

A woman has obsessions about reading and understanding things sufficiently lest she miss crucial information, and therefore feels compelled to read the wrapper or packaging of everything she owns before discarding it. She accumulates junk mail, privacy notices from financial institutions, cigarette cartons, food cans and boxes, etc., which she refuses to discard without reading every word on them.

A man with contamination obsessions is unwilling to handle possessions he perceives to be unclean, in order to discard them.

1.5.2 Other Conditions