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BURIED IN TREASURES: UNDERSTANDING AND INTERVENING WITH HOARDING DISORDER

August 4, 2020

Jennifer Baker, LICSW

Objectives

• Describe the etiology and manifestation of hoarding

• Explain the diagnostic criteria and course of hoarding disorder

• Identify behavioral, cognitive, and emotional strategies for intervening at individual and community level

Hoarding Disorder: Diagnostic Categorization 1

A. Difficulty discarding/parting with objects

B. Difficulty discarding due to urges to save

C. Symptoms result in accumulation of possessions that

clutter living areas

D. Distress or interference

E. Not better accounted for by medical condition

F. Not better accounted for by other mental illnesses

Diagnostic Specifiers: (With) excessive acquisition, poor insight

What Hoarding Is Not 2, 3

Animal Hoarding • Accumulation of more animals than a typical pet owner, not a

breeder

• Failure to provide adequate care or conditions for the animals

• Reluctance to place animals in others’ care

Squalor • Filth or degradation from neglect

• Diogenese Syndrome

• Home Environment Index – available upon request

Why Do People Hoard • Tendency toward being reductionist in assessment;

want a single causal factor

• Complex interplay of: • Evolutional biology • Neurobiology • Genetics • Thoughts • Emotions • Life experiences

• Ultimately, hoarding is an anxiety-based disorder

Lifetime Mental Illness Co-morbidity 4, 5

(N=217)

• Major Depressive Disorder (MDD) 69.1% • Social Phobia 28.1% • Generalized Anxiety Disorder (GAD) 24.9% • Obsessive Compulsive Disorder (OCD) 17.0% • Specific Phobia 16.1% • Post Traumatic Stress Disorder (PTSD) 12.4% • Substance Abuse 12.0% • Bipolar Disorder 1.4% • Panic Disorder 1.4% • Eating Disorder 1.4%

Attention Deficit Disorder (ADD) 20%

Executive Functioning in People who Hoard

• Impairment carrying out daily life activities due to difficulties with: • Categorization/association

• Perception and Insight

• Decision-making

• Attention

• Complex thinking

• Prospective memory

Manifestations of Hoarding

• Saving: Sentimental, instrumental, intrinsic

• Acquisition: Buying, stealing, passive acquisition, free things

• Clutter/Disorganization: Random piles, churning, goat paths

Hoarding Specific Assessments 6

• Clutter Image Rating • Visual rating scale that uses 9 photos in three different rooms

to assess severity of hoarding and insight

• Evaluate on volume of clutter

• 4 or greater is clinically significant

• http://www.hoardingconnectioncc.org/Hoarding_cir.pdf

• HOMES Multi-disciplinary Risk Assessment • Identifies safety concerns related to Health, Obstacles, Mental

Health, Endangerment, and Structure

• Considers occupants and their capacity to address the problem

• http://www.mass.gov/eohhs/docs/dmr/awp/hpci-risk-hoarding.pdf

Clutter Image Rating: Living Room Please select the photo below that most accurately reflects the amount of clutter in your room.

3

Intervention Options 7

• Supportive, step-by-step reduction of clutter • Behavioral coach, in-home (harm reduction approach) • Mental health treatment (specialized CBT for hoarding) • Buried in Treasures peer led groups • Support groups (online or in person)

• Medications • Supported clean-out • Clean out without control/presence • Eviction/Condemnation

Inappropriate intervention WILL result inaccumulation of clutter (or worse)

Working as a Team 7

• Helping can be expensive, difficult and time consuming• No discipline has all the expertise needed • Use a coordinated service plan

• Delineate expectations and consequences • Break into small goals with clear deadlines • Address acquiring early • Provide verbally and in writing

• Use carrot/stick approach • Follow up is essential

• In-home coach • Virtual home tours/sorting sessions

• Use caution when working with family/friends

Effective Helping Strategies 8,9

• Mirror the language used by the person with the hoarding problem (non-judgmental)

• Do not touch belongings without permission

• Find some aspect of the home that you genuinely appreciate and offer a compliment

• Start in small areas or areas of high motivation

• Work with the person instead of ‘doing for’ them

• Genuinely praise success, however small

• Use a timer and take frequent breaks

• Use decision-making questions and 3-pile sorting

Harm Reduction: A Focus on Safety 8,9

• Move flammable items away from heat sources

• Maintain clear routes to doors and windows

• Stack clear bins to store items and frame paths

• Use existing organizational systems or create new ones

• Collaborate on food safety guidelines such as discardingitems after expiration dates or when obviously spoiled

• Use “OHIO” – Only Handle It Once

• Employ the concept of “sacred space”

• Engage supportive allies

• Identify motivating factors such as the ability to enjoy cherished activities or to spend time with family or friends

Remember!

• Be patient: hoarding disorder is an anxiety-based disorder

• Be realistic: it took years for the home to become cluttered and recovery will take time

• The ultimate goal is HOUSE FUNCTIONAL, not HOUSEBEAUTIFUL

References 1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders. (5th ed.). Arlington, VA: American Psychiatric Association. 2. Patronek, G. J., Loar, L., & Nathanson, J. N. (2006). Animal Hoarding: Strategies for

Interdisciplinary Interventions to Help People, Animals, and Communities at Risk. Boston, MA: Hoarding of Animals Research Consortium Available at: http://www. tufts.edu/vet/cfa/hoarding/pubs/AngellReport.pdf

3. Rasmussen, J., Steketee, G., Frost, R., Tolin, D., & Brown, T. (2013). Assessing Squalor in Hoarding: The Home Environment Index. Community mental health journal. 50. 10.1007/s10597-013-9665-8.

4. Frost, R. O., Stekette, G., & Tolin, D. F. (2011). Comorbidity in hoarding disorder. Depression and Anxiety, 0, 1-9.

5. Morein-Amir, S, M Kasese, SR Chamberlain, E Trachtenberg. (2020). Elevated levels of hoarding in adhd: A special link with inattention. MedRxiv. 10.1101/2020.06.09.20126490.

6. Frost RO, Steketee G, Tolin DF, Renaud S. Development and validation of the Clutter Image Rating. 2006.

7. Bratiotis, C., Schmalisch C. S., & Steketee, G. (2011). The hoarding handbook: A guide for human service professionals. New York, NY: Oxford University Press.

8. Tompkins, M. A. (2011). Working with families of people who hoard: A harm reduction approach. Journal of Clinical Psychology: In Session, 67(5), 497 – 506.

9. Tompkins, M. A. & Hartl, T. L. (2009). Digging Out: Helping Your Loved One Manage Clutter, Hoarding, and Compulsive Acquiring. Oakland, C.A.: New Harbinger Publications.

Contact Information

Jennifer Baker, LICSW

Jennifer.baker@alegent.org

402-398-5934

Questions?