psychology of compulsive hoarding - dr christopher mogan
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Psychology of Compulsive Hoarding. Psicología de la acumulación compulsiva.TRANSCRIPT
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The Psychology of Compulsive Hoarding
Dr Christopher Mogan
The Anxiety Clinic, VIC
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The Psychology of Compulsive Hoarding
Dr Christopher Mogan
NATIONAL SQUALOR CONFERENCE
Sydney, November 5-6, 2009
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Hoarding behaviours• Common to hoard ‘stuff’ - keep ‘ just in case’• Compulsive hoarding is more pervasive,
dominating time, space of self & others. Packed garages, backyards, corridors, roof spaces, rooms chaotic & unusable.
• Unable to organize, discard things or prevent clutter, high distress, hazards to health/safety.
• Hoarding largely undiagnosed & untreated.
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Issues in studying hoarding• Causes and phenomenology of
compulsive hoarding remains unclear -no DSM IV criteria
• Estimates of population with OCD range from 0.6% to more than 3%. Hoarding in the OCD population estimated at 30%+.
• Hoarders seen as secretive, resistant to treatment, undiagnosed for years; not a diagnostic criterion for OCD, only OCPD.
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Frost & Hartl (1996) defined Compulsive Hoarding
• The acquisition of and failure to discard possessions that appear to be useless or of limited value.
• Impairment from– the degree of clutter involved making rooms
unusable for their purpose– negative effect on the personal functioning
of the hoarder - reported risks: fire(47%), falls (38%), hygiene (35%). Nil hazards (25%).
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Hoarders & non-hoarders think differently about things
Hoarders have specific problem appraisals:
1. Emotional attachment to objects
2. Memory for possessions and objects
3. Control of possessions and objects
4. Responsibility for possessions and objects
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Other hoarding-related cognitions
– Indecisiveness
– No confidence in memory uncertainty
– Need to keep things ‘in view’
– Comfort from being ‘with’ things
– Fear of forgetting important memories
– Need to be reassured about things
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ETIOLOGY (Causation)Psychoanalytic approachesFreud’s construct of reactive defence against conflict in the anal stage led Fromm to delineate a hoarding character - remoteness, withdrawal from others.. a controlling mode of relatedness - reduce anxiety by control.In Kleinian theory, the unconscious urge is to ‘return’all that had been removed from the mother, yet brings a un-resolvable conflict in the compulsive urge to ‘hold on.’Contemporary P/A theory emphasizes the loss of adaptiveness & mental inflexibility of the hoarder in fearing change/unpredictability
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Neurological approachesHeuristic value based on the reported issues with memory & organization.Research is still developing and findings are inconclusive even with advances in functional & structural imaging.Meta-memory factors suggest memory bias based on appraisal not on deficits.
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Cognitive Behavioural model
• CBT has defined hoarding, developed treatment on a multi-factorial model.
• Information-processing deficits –memory, decision-making, categorizing
• Faulty appraisal of importance of things• Disability associated with clutter, no
insight, emotional & rigid behaviours.
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Some models of HoardingAbnormal Psychology model - focused
Delusional Disorder – e.g. odd and bizarre reasons for keeping things
• Claiming affinity with animals or special relationship with or need for things.
• Deny obvious neglect, harm & chaos; hostile, rejecting of help.
• Function well outside delusional system.
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Squalor modelDementia and other deteriorating models emphasize loss of self-care & organization. Secretive, isolated, uncooperative; decayed food, animal waste, pest infestationHoarder profiles emphasize 65+, single, female.Dementia brings a sudden deterioration to any hoarding situationRequire structure, psychiatric assessment, protective interventions and medication
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3) Addiction model
- Total pre-occupied with hoarding focus- denial, excuses, claims of persecution,
ignoring overall outcome of hoarding. - Impulse control issues in compulsive
acquiring of things or animals.- Significant comorbidities
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4) Attachment model• Emphasizes disorganized early attachment
with compromised chaotic parenting. Animal or object as stable fixtures.
• Compensatory unconditional love for & from animals has explanatory power.
• Consistent with CH where sense of self and grief-like loss connected with things
• Compulsive need to keep animals or objects to protect them, maintain connectedness
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Obsessive Compulsive Disorder Model
• OCD associated with hoarders’ key FELT RESPONSIBILITY to care for possessions including things, animals, memories.
• Harm prevention, special relationships or other symbolic meanings.
• Sense of ‘mission’ whether for animals or responsibility for things
• Avoidance behaviours can reach delusional levels
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Age of onset, course of hoarding
• Chronic and insidious course becoming overwhelming.
• Age of onset in childhood/early adolescence: as young as 10, mild symptoms at 17, moderate in mid-20’s, extreme by mid-30’s.
• Help-seeking not until 50 years and over
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How common is hoarding• As many as 1.2 million problem
hoarders in the USA.• Estimates range from 1 in 350 or 400
people in the UK and Australia.• Number of problem hoarders possibly in
the range of 60,000 to 90,000, but no research data available.
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Phenomenology of hoarding• Examined in a study of known hoarders
in comparison with clinical groups (OCD, anxiety states) and community controls (N= 109).
• Findings consistent with overseas research.
• Hoarding phenomenology is distinct from other clinical and control groups.
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Measuring hoarding?– Savings Inventory – Revised: savings actions, time spent, emotional
responses to saving & discarding, usefulness of saving, interference caused by saving.
– Savings Cognitions Inventory: measuring beliefs associated with possessions - need for things, why cannot throw things away, need to control what happens, to get comfort from things.
– Savings List of things kept.
– Hoarding Rating Scale – Hoarding Interview– Visual Rating of Clutter
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Outcomes• The cognitive, affective and information-
processing factors of CBT model supported.
• Emphasis on severity of clutter, amount saved, and dysfunctional beliefs about things.
• Hoarders compared with other clinical groups and community controls showed significant difference in socio-economic status (income).
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www.theanxietyclinic.com 26
Hoarding-related Early Devel. Influences Inv. (Kyrios, 2005)
Isolated two factors showing hoarders had more issues than non-hoarders:
1) Uncertainty about the self and others e.g. I have never been able to work out people’s reactions to me
2) Warm Family - assessing memories of warmth and security in one’s family e.g.My early childhood featured a constant sense of support
The warm family factor was a significant predictor of hoarding behaviour.
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Predictors of hoarding in Predictors of hoarding in analyses of the data: In order analyses of the data: In order ……
i. Perceived lack of family warmth
ii. Padua Inventory – OCS
iii. Fear of Neg. Eval. – Social Anxiety
iv. Possessions in View Scale
v. Beck Anxiety Inventory
vi. OCPD – Personality Disorder
vii. Frost Indecisiveness Sc – Fear of decision – making
viii.Consequences of Forgetting Scale
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TREATING HOARDING IS COMPLEX
• Hoarders have highly-personalised reasons for Hoarding
• Hoarders have ambivalent and avoidant personality styles
• Uncertainty about self and others leads to object-driven compensatory behaviour
• Treatment – interfering variables are common –Rigidity, Control, Reluctance for treatment
• Fear of making decisions, control and memory and the deep seated beliefs held by hoarders.
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Maintenance Relapse
ContemplationAction
Preparation
Termination
PrecontemplationThe Wheel of Change
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Treatment of hoardingAssessment of hoarders in their context to determine the treatment needs.Liaison with health & welfare agencies –complexities require collaboration.Therapy is not quick-fix, outcomes based on specifying goals. Harm minimization as in drug addiction as a guide.Treatment still being developed..
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Treatment• Learning of skills in managing paper items –
categorizing, judging worth, challenging keeping of everything
• Increasing confidence in discarding sessions in clinic led to systematic practices in home.
• Motivation needs to be very high• Respond to positive reinforcement, sense of
achieving very specific goals
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Quick fix clean-ups• Imposing controls and cleaning up
without respecting the needs of the hoarder lead to rapid relapse and highly reinforced resumption of hoarding.
• Better to understand the personal context, build up rapport and motivation, by targeting small improvements.
• Small goals, active collaboration.
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Myths of saving need challenging
• Someone will find this useful.• I never throw anything away.• I must keep all things that recall this person.• I know exactly where everything is.• How helpful to me is this clutter and mess?• These things are my life…I don’t know why!• Throwing things away is rejecting them• Keeping a things is to accept it into my life.
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Therapy tips• Skills-building is based on practice.
Discard something however small every day- DSD
• Build a relationship affirming the difficult task of CH – Try to keep them attending therapy –motivation as key to change
• Set small targets - safety of self/others• Visualization of de-cluttered room
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FutureResearch needs financial commitmentTraining of associated workers – health, welfare, community carers, state & local jurisdictions -team approach.Leadership for the long term research, planning and resourcing, education, lobbyingSolution not in legislation and enforcement yet they are essential elements, especially when risk extend to children, elderly; and also animals.
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Dr Christopher MoganThe Anxiety Clinic
TMC Suite 6,140 Church St, Richmond 3121
Tel 03-9420 [email protected]