Hoarding Disorder: Diagnosis, Assessment, and Effective Treatment Strategies for Mental Health Professionals

Transcription

1 Hoardig Disorder: Diagosis, Assessmet, ad Effective Treatmet Strategies for Metal Health Professioals Movig Home MN DHS Jue 20, 2016 Jaet Yeats, MA LMFT The Hoardig Project Objectives Recogize effective diagosis ad treatmet strategies of hoardig disorder. Describe alterative optios to treatmet other tha a forced cleaout. Apply evidece-based treatmet strategies to address issues of safety i hoardig disorder. Discuss developmet of collaborative etworks i your area to form a commuity respose to hoardig disorder. 1

2 Who We Are 501(c)(3) public charity Missio: To promote a effective, ethical, ad sustaiable respose to hoardig i commuities, through research, educatio ad prevetio, ad collaborative approaches to treatmet. Backgroud o Hoardig Disorder 2

3 What is hoardig disorder? Quick aswer: With the DSM5 hoardig disorder is a diagosis, the commo defiitio has 4 parts: 1. Excessive acquisitio of stuff* 2. Difficulty discardig possessios 3. Livig spaces that ca t be used for their iteded purposes because of clutter 4. Causig sigificat distress or impairmet (Frost & Hartl, 1996 ) *Not uiversal i all people who hoard How may people hoard ad are some people more likely to hoard tha others? Research projects that About 2-5% of the populatio hoard, which is about 15 millio people i the U.S., o the high ed (Iervolio et al., 2009; Samuels et al., 2008) Older people hoard more tha youger people (Samuels, et al. 2008) People with lower icome hoard more tha people with higher icome (Samuels, et al. 2008) Geder differeces? 3

4 What s the differece betwee clutter, collectig, ad hoardig? Clutter: possessios are disorgaized ad may be accumulated aroud livig areas No major difficulty with excessive acquisitio AND o major difficulty discardig items Ca carry o ormal activities i home Collectig: existig ad ew possessios that are part of larger set of items Display does ot impede active livig areas i home Hoardig: possessios become uorgaized piles of clutter Prevet rooms from beig used for ormal activities Motivatio to display items: lost Are there other metal health issues related to hoardig? Yes, hoardig disorder must be cosidered a co-occurrig disorder ad is associated with aother metal health diagosis 92% of the time (Frost et al., 2011) 57% major depressive disorder 29% social phobia 28% geeralized axiety disorder (Frost et al., 2006) 30-40%: OCD (e.g. Samuels et al., 2007) 31%: Orgaic Brai Illess 30%: Persoality Disorders (Mataix-Cols, et al., 2000) 20%: ADHD (e.g. Sheppard et al., 2010) Demetia (Hwag et al., 1999) Eatig Disorders (Frakeburg, 1984) Substace abuse (Samuels et al., 2008) 4

5 Hoardig ad Older Adults Symptoms severity icreased with each decade of life (Ayers et al., 2010) 25% of elderly commuitydwellig day care residets ad 15% of ursig home residets displayed hoardig symptoms (Marx & Cohe-Masfield, 2003) Icreased dysfuctio i several domais of executive fuctioig Metal cotrol, workig memory, ihibitio, ad set shiftig (Ayers et al., 2013) Major cosequeces for older adults: Icreased risk of falls, fire hazards, food cotamiatio, social isolatio, ad medicatio mismaagemet (e.g. Ayers et al., 2010; Frost & Gross, 1993; Kim, Steketee, & Frost, 2001) Icreased risk of medical coditios (e.g. Ayers et al., 2013; Timpao et al., 2011; Toli et al., 2008) What causes hoardig? The BIOPSYCHOSOCIAL Model of Hoardig Disorder states that: Hoardig behavior arises from a variety of exteral ad iteral variables that are biological, psychological, ad social i ature. We ca t talk about oe of these pieces without talkig about the others! Family Cultures Social Biological Psychological Commuities Eviromet 5

6 Is there a family lik to hoardig, ad whe does is start? Family history (Pertusa, et al., 2008; Samuels, et al., 2007) More likely to have 1 st degree relatives with hoardig (12%) or with hoardig symptoms (49%) (Wisberg, Cassic, & Kora, 1999) Social learig (Toli, 2011) Geetic lik (Iervolio et al., 2009; Locher et al., 2005; Samuels, Shugert et al., 2007) Course ad progressio: behaviors begi durig childhood or adolescece (Frost & Gross, 1993; Grisham et al., 2006; Pito, Eise, Macebo, et al., 2007; Samuels et al., 2002; Wisberg et al., 1999) What is the lik betwee Hoardig ad the Brai? Brai fuctioig differeces Occipital ad frotal lobes (Saxea et al, 2004) Abormalities i areas associated with: executive fuctioig, impulse cotrol, ad processig of reward value Maladaptive Cogitive Processes (Grisham, Brow, Savage, Steketee, & Barlow, 2007; Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Hartl, Duffay, Alle, Steketee, & Frost, 2005; Hartl et al., 2004; Lawrece et al., 2006) Iformatio processig difficulties Over-reliace o visual vs. categorical memory cues Attetio: Churig; Clutter blidess = failure to recogize extet of clutter i the home (Steketee & Frost, 2014, p.2-3) Over- or udercategorizatio 6

7 What are the Psychological Factors that cotribute to hoardig? Metal health/emotioal distress (Frost & Hartl, 1996) Co-morbid metal health coditios Uresolved trauma ad loss (Sampso & Harris) People who hoard have specific beliefs about ad attachmet to their possessios (Frost & Hartl, 1996) Feeligs toward object Memory-related cocers Desire for cotrol Resposibility ad waste Aesthetics Hoardig behaviors ca be reiforced over time (Frost & Hartl, 1996) Acquirig thigs makes us feel good, so we wat to do more of it Gettig rid of thigs makes us axious, so we wat to do less of it Coditioed Respose Triggerig Evet Behavioral Reiforcer (/-) Emotioal Respose What are the Social Factors that cotribute to hoardig? Major life evets/trasitios (Grisham, Frost, Steketee, Kim, & Hood, 2000; Kellett, Greehalgh, Beail, & Ridgway, 2010) Higher frequecy of lifetime traumatic evets (Cromer et al., 2007; Hartl et al., 2005) Up to 55% report experiecig a stressful evet at oset of symptoms (Grisham et al., 2006) Burde o families Positive iterpersoal relatioships ca serve as a protective factor agaist hoardig severity (Sampso & Harris, 2012) Social stigma Culture 7

8 What s up with aimal hoardig? Is it the same thig as object hoardig? There are some similarities betwee the two, but they differ i several ways. Research o aimal hoardig is about 20 years behid object hoardig Each situatio is differet Presece of squalor does ot mea aimals are beig hoarded What are the Safety & Health risks associated with hoardig? Fire hazard Blocked exits Safety Risk of falls/items fallig Lack of routie home maiteace Structural damage to buildig from icreased weight ad volume of clutter Risk of evictio ad homelessess Impaired fuctioig Poor hygiee ad groomig, utritio Iattetio to medical eeds Iadequate fiacial maagemet Difficulty cleaig aroud clutter Sleepig o floor istead of bed Metal Health Icreased Health Problems Molds, bacteria, dust, dirt Health Asthma, allergies, headaches Rodet/isect ifestatio Aimal/huma feces/remais (hata virus, tapeworm, psittacosis, cat scratch disease) 8

9 Emotioal/Psychological Impact of Hoardig Clea-outs o Cliets Clea-outs ca do more harm tha good. Ca be traumatizig Emotioal Floodig Eve threats ca be uhelpful Ca rui relatioships ad trust I all three istaces of goig i ad cleaig these places up, withi weeks of relocatig the idividual back ito a clea eviromet, the idividual passed away it was such a dramatic chage for them because we did t realize the impact of the sociological chage. (Brace, 2007) 1 year 2 year 3 year 4 year 5 year 6 year 7 year 8 year 9 year 10 year Cleaout 1 moth 3 moth 6 moth It s ot sustaiable BUT sometimes it s ecessary Diagosis ad Assessmet of Hoardig Disorder 9

10 Hoardig Disorder a. persistet difficulty discardig or partig with possessios, regardless of their actual value b. Difficulty due to a perceived eed to save items ad to distress associated with discardig them c. Difficulty discardig possessios results i accumulatio of possessios that cogest ad clutter active livig areas ad substatially compromises their iteded use. If livig areas are ucluttered, it is oly because of the itervetios of third parties (e.g. family members, cleaers, authorities) d. Hoardig causes cliically sigificat distress or impairmet i social, occupatioal, or other importat areas of fuctioig (icludig maitaiig a safe eviromet for self ad others) e. Not due to medical coditio (e.g. brai ijury, cerebrovascular disease) f. Not due to aother metal health coditio (e.g. OCD, major depressive disorder, schizophreia, eurocogitive disorders, autism) Specify if: a. With excessive acquisitio b. Isight (good, poor, delusioal) Screeig: ASK! First ad foremost, ASK! Make sure to icorporate some form of questio that ca help idicate a problem at home with clutter, excessive acquisitio, or difficulty discardig. Examples: Are ay areas of your home difficult to walk through because of clutter? Are you uable to use ay parts of your home for their iteded purposes? For example, cookig, usig furiture, washig dishes, sleepig i bed, etc? Do you fid the act of throwig away or doatig thigs very upsettig? Do you have strog urges to buy or collect free thigs for which you have o immediate use? Have you ever bee i a argumet with a loved oe because of the clutter i your home? 10

11 Psychological Assessmet Tools Structured Iterview for Hoardig Disorder (Pertusa et al., 2013) Diagostic tool Iterview structured to help guide a cliicia s diagosis through the 6 criteria of hoardig disorder ad its 2 specifiers 11

12 Hoardig Assessmet Tool (Steketee & Frost, 2007) Doe i additio to the physical observatio of home Better uderstad: causes of problem features that might affect itervetio Aveues/impedimets to chage Coducted as a coversatio Ideally coducted by a metal health professioal, but other professioals with good skills i dealig with sesitive issues ca also do this Hoardig Assessmet Tool (Steketee & Frost, 2007) May require multiple visits to office ad/or home Home is ideal Topics addressed: Oset ad duratio of hoardig problem Home eviromet ad cotets Home dwellers thoughts ad feeligs about possessios Curret acquirig Reasos for savig Strategies for orgaizatio Role of family, frieds, commuity members Immediate log-term threats to health or safety Problems resulted from hoardig Previous itervetio attempts Persoal goals ad values with regard to curret ad future use of home 12

13 Hoardig Ratig Scale (HRS) (Toli, Frost, Steketee, 2010) 5-item scale, self-report measure 2-3 miutes Assesses severity of mai features of hoardig Clutter Difficulty discardig Acquisitio Distress Fuctioal impairmet 0 (o problem) to 8 (extreme problem) Hoardig disorder: score at least a 4 or above o clutter ad difficulty discardig, as well as o either distress OR fuctioal impairmet Mild but sigificat hoardig: 16 Moderate: Avg. 24 Severe: Above 30 Examples 1. Because of clutter or umber of possessios, how difficult is it for you to use the rooms i your house? 2. To what extet do you have difficulty discardig (or recyclig, sellig, or givig away) ordiary thigs that other people would get rid of? Cogitive Assessmets The Motreal Cogitive Assessmet The MoCA is a cogitive screeig test desiged to assist Health Professioals for detectio of mild cogitive impairmet. Assessmets like this require a strict protocol ad/or traiig i order to appropriately be used i sessio. 13

14 Assessmets of Home Eviromet ad Fuctioig ICD Clutter-Hoardig Scale (CHS) Assessmet of home s iterior, except where outside structure affects overall safety of iterior Guidelie tool by professioal orgaizers ad related professioals 5 categories: Structure ad Zoig; Aimals ad Pests; Household Fuctios; Health & Safety; Persoal Protective Equipmet (PPE) Available for free dowload: 14

15 Levels of Hoardig (ICD Clutter Hoardig Scale) Clutter Image Ratig (CIR; Frost, Steketee, Toli, & Reaud, 2008) Developed to overcome problems with over- ad uder-reportig 9 pictures for 3 mai rooms Kitche Livig room Bedroom 1= o clutter to 9 = severe clutter Review room ad select picture that looks most like room i the home Score of 4 or more: cliically sigificat clutter problem 15

16 Activities of Daily Livig- Hoardig (ADL-H) Scales (Steketee & Frost, 2007) Extet to which ordiary activities ca be accomplished i the cotext of hoardig problem Specific risks Scorig: Average Sum scores (except NA s) ad divide by umber of scored items Score i the 3 rage: idicate substatial fuctioig impairmet due to clutter How much hoardig iterferes with 16 ordiary activities Ex: bathig, dressig, preparig meals 7 questios: quality of livig coditios Ex: presece of rotte food, isect ifestatio 6 questios: safety ad health Ex: fire hazards ad usaitary coditios 2 subscales scored separately Need for various services providers to have a commo uderstadig of a rage of problems associated with hoardig Checklist that ca be used by ayoe who ecouters a hoardig situatio, regardless of professioal traiig 16

17 Uiform Ispectio Checklist Tufts Aimal Care ad Coditio 17

18 At what poit is this reportable to the authorities? Quick aswer: If there is a threat of edagermet to the health ad safety of: A child/mior Older adult (over 60 with a cogitive, physical, or fuctioal impairmet) Perso with disability or depedecy Aimal you must report (if you are a madated reporter) Buildig codes differ from city to city ad couty to couty, but geeral safety cocers iclude: Health Ex: caot use bathtub/shower/toilet; caot prepare food/use refrigerator/sik; presece of feces or urie; isects/rodets; mold Obstacles Ex: Caot move freely/safely; iability for EMT to eter/gai access; ustable piles/ avalache risk; egresses/exits, vets blocked/ uusable Structure Flammable items by heat source; Storage of hazardous waste/material; Cavig walls; Electrical wires/cords exposed; No heat/ electricity; No ruig water/plumbig problems Treatmet ad Strategies for Metal Health Professioals 18

19 Treatmet Plaig for Hoardig Disorder Combiig strategies from across fields ca help to most holistically treat this metal health ad public safety issue Itegrated treatmet approach (modeled after treatmet for co-occurrig disorders) Prioritize treatmet goals for primary diagoses CBT most Evideced Based Practice Itegrated treatmet for hoardig will iclude differet types of itervetios to support specific treatmet goals Examples: Distress re: discardig items: Exposure treatmets (CBT) Orgaizatio skills: Executive skills buildig (ADHD treatmet) Medicatio for Hoardig Disorder? Commo treatmet goals for Hoardig Disorder Icrease uderstadig of hoardig behavior. Create livig space Icrease appropriate use of space Orgaize possessios to make them more accessible Improve decisio-makig skills Reduce compulsive buyig or acquirig ad replace these behaviors with other pleasurable activities Evaluate beliefs about possessios Reduce clutter level i home eviromet Lear problem-solvig skills Prevet future hoardig 19

20 Treatmet Approaches ad Therapies Motivatioal Iterviewig No-behavioral approaches: Narrative Therapy Ambiguous Loss Theory Behavioral approaches: CBT Exposure Therapy DBT midfuless, axiety maagemet Safety Day harm reductio approach Other Itervetios 20

21 Family Therapy Coachig Role-playig Commuicatio Psychoeducatio Positive family relatioships ca help serve as a protective factor betwee psychological distress ad hoardig severity (Sampso & Harris, 2013). Support group ivolvemet Support Groups Buried i Treasures Peer-led optios Sese of belogig i a commuity No-judgmet Processig People who Hoard Self-awareess Family Members THP Maual Psychoeducatio Commuicatio Self-care Stigma Trauma Ambiguous Loss Treatmet Optios Resources 21

22 Collaborative Approaches to Hoardig Disorder Collaborative Work with Related Professioals Research idicates that idividual treatmet approaches have limited success. (Saxea, Brody, Maidmet & Baxter 2007; Toli, Frost & Steketee 2007) Multidiscipliary approaches atted to the complex ature of hoardig. (Koeig, et al 2010) Why work collaboratively? Ethical right thig to do Effective bio-psychosocial problems Resource-coservig - itegrated care less expesive Cliicia ad professioal-friedly supportive i a situatio which has small successes Idetify stakeholders impacted by hoardig disorder. Housig Public health Metal health Protective services Agig services Legal Fire ad police Medicie Aimal cotrol Orgaizers Cleaig compaies 22

23 Hoardig Task Forces A coordiated pla of itervetio that maximizes resources across agecies is likely to achieve the best possible result with regard to reducig hoardig, beefittig the perso who hoards ad those affected by the problem, ad logterm cost effectiveess. (Bratiotis, Schmalish, & Steketee, 2011) What is a Hoardig Task Force? A orgaized group of professioals workig toward developig a practice of coordiated respose from a variety of commuity fields To provide a directed ad maaged respose to hoardig cases that come to public attetio (IOCDF.org) Objectives: Provide public educatio about hoardig Give out service agecy iformatio Provide support to idividuals, families, ad commuities 23

24 What resources are available? There are several differet resources that are available to people who hoard, their families, ad people who work with them. No-profit agecies: The Hoardig Project Iteratioal OCD Foudatio Istitute of Challegig Disorgaizatio Childre of Hoarders Support Groups The Hoardig Project Childre of Hoarders Readig Resources Treatmet for Hoardig Disorder Workbook (2014), Frost & Steketee. Cliicia s Guide to Severe Hoardig: A Harm Reductio Approach (2014), Tompkis Stuff: Compulsive Hoardig ad the Meaig of Thigs (2010), Frost & Steketee Buried i Treasures: Help for Compulsive Acquirig, Savig, ad Hoardig (2007) Toli, Frost, & Steketee Diggig out: Helpig Your Loved Oe Maage Clutter, Hoardig, ad Compulsive Acquirig (2009), Tompkis & Hartl The Hoardig Hadbook: A Guide for Huma Service Professioals (2011), Bratiotis, Sorretio Schmalisch, & Steketee Loss, Trauma ad Resiliece (2006), Boss Motivatioal Iterviewig: Preparig People for Chage, 2 d ed. (2002), Miller & Rollick Narrative Meas to a Therapeutic Ed (1990), White & Epsto Dirty Secret (2010), Jessie Sholl Comig Clea (2014), Kimberly Rae Miller 24

25 The Hoardig Project Cotact iformatio: Jaet Yeats Jeifer Sampso Max Zubatsky Copyrights The Hoardig Project All rights reserved. REPRINTING: The Hoardig Project grats permissio to copy, reprit, trasmit this powerpoit presetatio for educatioal, ot-forprofit purposes provided credit is give to THP. Requests for permissio to quote copy, reproduce or redistribute all or parts of this guide for commercial purposes should be submitted i writig to 25