Hoarding Disorder: The Next Step

Transcription

1 Hoarding Disorder: The Next Step A Neurocognitive Approach to Treatment Kay Jewels, B.A. Research Assistant, McLean Hospital Director, The Next Step Program Donald A. Davidoff Ph.D. Chief, Department of Neuropsychology, McLean Hospital Assistant Professor of Psychiatry, Harvard Medical School Mental Health Association of San Francisco 18 th Conference on Hoarding and Cluttering March 2018

2 Disclosure Neither Ms. Jewels nor Dr. Davidoff report that either of them or any member of their immediate families have a significant financial interest in or affiliation with any commercial goods/organization that may have a direct or indirect interest in the scientific program. Neither Ms. Jewels nor Dr. Davidoff will discuss unapproved or investigational use of any products during their presentation at the OCD Annual Meeting.

3 Hoarding Disorder: The Next Step A Novel Approach to Treatment Based on an Understanding of the Neurocognitive Deficits of HD I. Background and Research II. Examples of Cognitive Issues III. The Next Step Program

4 Importance of Understanding Hoarding Disorder Impact on Society Safety Hazards Fire Hazard Mold & Toxic Odors Environment for Insects and Rodents Increased Risk of Poverty and Homelessness Public Cost (~$16K to clean each house) Impact on the Individual Isolation Functional Impairment Family Dysfunction Anxiety & Distress Increased Medical Disability Increased Risk of Physical Injury Premature Death Hoarding Disorder = Public Health Crisis + Mental Health Crisis

5 Prevalence of Hoarding Across the Life Span Hoarding symptom severity increases with age Hoarding symptoms are more refractory with age Elder individuals with hoarding have a 5 year mortality rate of approximately 50% Cath 2017; Snowdon 2007; Samuels 2008; Ayers 2010

6 Historic Conceptualization of Hoarding Disorder (DSM-IVTR) Obsessive-Compulsive Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control, at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, characterized by (at least) four of the following: Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost Perfectionism that interferes with task completion Excessively devoted to work Inflexible about matters of morality, ethics, or values Unable to discard worn-out or worthless objects even when they have no sentimental value Reluctant to delegate Miserly spending style Rigid and stubborn

7 Symptoms of Hoarding Disorder Persistent difficulty discarding or parting with possessions Perceived need to save items, regardless of actual value Distress associated with discarding Avoidance of Discarding to manage associated distress Accumulation of possessions Cluttered living areas compromise their intended use Fire Hazards, Health and Safety Violations Significant anxiety or impairment of functioning in social, occupational, or other important areas Woody et.al. 2014

8 The Implications of Research (pre-2013) Research Prior to 2013 Conflated HD with OCD Resulting Treatment Modalities (CBT) not based on Comprehensive Understanding of the Disorder Deciding to Discard Causes Anxiety Distress Intolerance Predicts Avoidance Ritual Anxiety Provokes Distress

9 The Gold Standard Treatment for Hoarding Disorder CBT has been the traditional treatment of individuals with HD. It is a short-term, goal oriented treatment that seeks to make individuals aware of when they make negative interpretations and of behavioral patterns which reinforce the distorted thinking. It helps individuals develop alternative ways of thinking and behaving in order to reduce feelings of distress. Problem solving and organizational skills are particularly emphasized. Unfortunately, CBT for geriatric hoarders has been less than effective. Steketee & Frost 2007 Ayers 2009

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11 Current Conceptualization of Hoarding Disorder (DSM-5) Hoarding Disorder A. Persistent difficulty discarding or parting with possessions, regardless of actual value B. Difficulty due to perceived need to save items and to distress associated with discarding them C. Results in accumulation of possessions that congest and clutter active living areas and compromises their intended use D. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning E. Not attributable to another medical condition F. Not better explained by the symptoms of another mental disorder Specify if: With excessive acquisition With good, fair or poor insight With absent insight/delusional beliefs

12 Research Indicates Involvement of Multiple Cognitive Processes Attention, including complex attention Visuospatial Processing Memory -working memory -visuospatial memory Executive Functions -planning & organizing -problem solving -conceptualization -categorization -inhibitory control -mental control -cognitive flexibility Ayers 2013 Woody 2014

13 Neuroanatomy of Hoarding Disorder In HD, imaging findings implicate areas of the orbitofrontal cortex and dorsal anterior cingulate Mataix-Cols 2011; Saxena 2008, 2004

14 Anterior Cingulate Cortex (ACC) Mediates a Variety of Higher-level Cognitive and Emotional Functions: Object Appraisal Insight Reward Contingencies Error Detection Anticipation of Tasks and Prioritization Attention/Selective Attention Visual Memory and Working Memory Motivation Intensity of Emotional Response Posner et.al Caveda 2000 Rolls 1996

15 Cognitive Deficits: Conceptualization and Categorization Difficulties with sorting and categorization Too many narrowly and idiosyncratically defined categories Concrete, unrealistic or illogical groupings Ayers 2016, Woody 2014,Timpano 2014, Wincze 2007, Santostefano 1978

16 Cognitive Deficits Can Influence Decision-Making Problems with executive functions can impair decision making including processes such as categorization and object groupings, which are necessary for the organization of tasks involved in decluttering. Problems with memory can heighten fear of making bad choice, i.e. discarding needed objects. Problems with memory may discourage people from using storage systems and places that put object out of sight, like a filing cabinet or closet. Woody 2014

17 Cognitive Deficits Can Result in Lack of Insight Insight requires higher-order brain networks underlying attention, working memory, and cognitive control. The processes are impaired in those with Hoarding Disorder Lack of Insight Lack of Distress Treatment Resistance

18 Cognitive Deficits: Object Processing Faulty Object Processing can result in Value Misappraisals: Inflates Perception of Need and Distress Associated with Discarding Value Misappraisal Interferes with the categorization conceptualization process

19 Cognitive Deficits Can Impact Emotional Regulation reluctance to accept emotional responses difficulty regulating behavior when distressed lack of access to strategies for feeling better when distressed Tolin 2018

20 Hoarding: A Neurocognitive Approach to Core Features Information Processing Deficits Lack of Insight Value Misappraisal Emotional Dysregulation

21 Recent Improvements in Treatment Strategies for Individuals with HD: Cognitive Rehabilitation Emphasizing cognitive rehabilitation of cognitive skills including problem solving, organizational abilities, prospective memory and cognitive flexibility in the context of behavioral interventions (exposures) to discarding and not acquiring produced clinically and statistically significant reductions in hoarding severity in a study of geriatric HD. Ayers 2014

22 Recent Improvements in Treatment Strategies for Individuals with HD: Motivational Interviewing Adding motivational interviewing and thought mapping to traditional CBT group treatment of individuals with OCD facilitates a decrease in hoarding symptoms Mayer et.al. 2009

23 The Future: A Comprehensive Approach to HD HD is not a simple problem of accumulation of objects but is a complex multifactorial problem involving a unique confluence of behavioral, emotional, and cognitive factors. As such, effective strategies to ameliorate the symptoms of HD must include: Therapeutic focus on the excessive emotional attachments to possessions and subsequent distress and behavioral avoidance Correction of erroneous beliefs about the nature and importance of possessions Attention to the observed information processing deficits that appear to underlie the observed behaviors Application of cognitive prostheses to attenuate the impact of the underlying cognitive deficits.

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25 Cognitive Deficit: Conceptualization & Categorization

26 Idiosyncratic Grouping Difficulties with sorting and categorization Too many narrowly and idiosyncratically defined categories Concrete, unrealistic or illogical groupings

27 Cognitive Deficit: Object Memory and Value Appraisal

28 Emotional Regulation Deficit Reluctance to accept emotional responses Difficulty regulating behavior when distressed Lack of access to strategies for feeling better when distressed Tolin 2018

29 The Next Step

30 The Next Step The Next Step Program resolves safety and sanitary issues, restores functionality to living areas and reduces distress utilizing a tripartite approach to HD consisting of: Life Coaching Cognitive Behavioral Therapy Cognitive Prostheses

31 The Tripartite Model of Hoarding Disorder Neurocognitive Substrates of Hoarding Disorder Core Features of Hoarding Disorder Symptoms of Hoarding Disorder

32 Hoarding: Cognitive Deficits Underlie Functional Impairments Executive Attention Sustained Attention Visuospatial Attention Attention Deficits Memory Deficits Working Memory Visual Memory Deficits Verbal Memory Deficits Conceptualization Inhibition Decision Making Self-Regulation Executive Dysfunction Functional Impairments Task Initiation Task Completion Goal Directed Motor Responses

33 The Next Step: Life Coaching Assists with Increasing Productivity and Reducing Object Clutter Reducing Waste and Related Anxiety Planning and Prioritizing the Steps to Goal Completion Maintaining Motivation and Sustaining Continued Effort Staying on Tasks and Completing Steps Organizing and Sorting Recycling and Discarding Repurposing and Relocating Sell items on E-Bay Donate to Charity Host a Yard Sale Give to a Friend Recycle

34 Next Step Includes CBT But CBT NEXT STEP

35 The Next Step: Cognitive Behavioral Therapy Focus Memory Attention Executive Function Clutter Distress Avoidance

36 The Next Step: Life Coaching Life coaching, in contrast to CBT alone focuses on: Reframing the behavior to clarify the impact on interpersonal and daily life issues Utilizing motivational interviewing to clarify individual short and long term goals Decreasing the amount and frequency of unproductive behaviors through psychoeducation and retraining around such issues as prioritization and organizational strategies Disengaging from false beliefs through the use of rewarding strategies Utilizing the therapeutic alliance to convey that two together can do what one alone cannot

37 The Next Step: Life Coaching Breaks the Anxiety Cycle: Keeps it Positive Makes it Fun Talks it out Makes it Feel Rewarding Remembers Goals Highlights Progress Gives Recognition

38 The Next Step: Cognitive Prostheses Cognitive Prosthesis: a device that extends the capability of human cognition or sense perception Cognitive Prostheses: Reduces anxiety and fear of forgetting Reduces acquiring and saving unnecessary items Reduces fear of change Reduces negative effects of cognitive deficits

39 The Next Step: Cognitive Prostheses Colored Sticker Flags Visual Memory and Prioritization Transparent Storage Visual Memory and Categorization Smart Phone Technology Verbal and Visual Memory Mini GPS Trackers Spatial Memory and Object Location

40 Cognitive Prosthesis: Colored Sticky Flags Memory Planning Prioritization Object Location

41 The Next Step: Example

42 Cognitive Prosthesis: Transparent Container Visuospatial planning Conceptualization Categorization Memory

43 Cognitive Prosthesis: The Transparent Drawer A Maintainable Long-Term Organizational Solution that can: Keep the Possession in View Reduce Object Clutter and Provide Order Reduce Anxiety and Fear of Forgetting Reduces Resistance to Putting Objects Away

44 Cognitive Prosthesis: Mini GPS Trackers Locate Objects of Importance Reduce Fear and Anxiety Reduce Reliance on Ineffective Organizational Strategies Increase Productivity

45 Cognitive Prosthesis: Smart Phone Technology Camera Remember Objects with Pictures Notebook Remember Important Information Calendar Remember Important Dates Contacts Remember Important Contacts

46 Next Step Intervention: Before

47 Cognitive Prosthesis

48 Next Step Intervention: After

49 The Next Step Before After

50 Next Step Intervention: Before

51 Cognitive Prosthesis

52 Next Step Intervention: After

53 The Next Step Before After

54 Conclusions HD is a multifactorial problem involving a cycle of false beliefs, emotional distress and behavioral avoidance. There is increasing evidence that there is a substrate of cognitive processing difficulties underlying this dysfunctional behavior. Any treatment program must address all of these issues simultaneously in order to ameliorate the deleterious impact of HD on an individual s life. The Next Step Program is a proposed treatment program with a tripartite approach to the problem of HD involving: Life Coaching Cognitive Behavioral Therapy and Cognitive Rehabilitation Strategies Application of Cognitive Prostheses

55 Future Questions and Directions What is the exact nature of the cognitive profile of individuals with HD? How might these difficulties impact day to day functioning beyond the symptoms of HD itself? Does HD represent a neurodevelopmental disorder and is the increase in prevalence over the life span a function of neurodegenerative process? What is the role of disgust in HD? Can the neuroanatomical structures involved in HD be better defined and even quantified? How can we use our knowledge of cognition to further enhance the effectiveness of NSP?

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57 Thank you

58 For Further Questions For further questions or comments, Ms. Jewels and Dr. Davidoff can be reached at: McLean Hospital Department of Neuropsychology 115 Mill Street Belmont, MA (617)

59 Questions?

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