Hoarding Behavior in Elders Presented by: Emily B. Saltz, LICSW Elder Resources www.eldres.com NAPGCM Webinar January 11, 2012
Definition of Hoarding* 1) The acquisition of, and failure to discard a large number of possessions that appear to be useless or of limited value. 2) The living spaces in the home are sufficiently cluttered so as to preclude activities for which those spaces were designed. 3) There is generally significant distress or impairment in functioning caused by hoarding. (Adapted from A Cognitive-Behavioral Model of Compulsive Hoarding by Randy Frost)
DIAGNOSTIC CRITERIA Current: Subset of OCPD in DSMIV DSM-IV lists hoarding of worn out or worthless objects even when they have no sentimental value as a symptom of obsessive-compulsive personality disorder (OCPD).
DIAGNOSTIC CRITERIA Proposed: Accumulation of clutter Difficulty discarding/parting with objects Compulsive acquiring of free or purchased items Distress or interference Duration at least 6 months Not better accounted for by other conditions (OCD, major depression, dementia, psychosis, bipolar disorder) (Frost, Steketee, Tolin & Brown, 2006)
Hoarding vs. Collecting Collecting is a normal and common phenomenon in children. Collecting in adulthood can be a pleasurable activity that does not necessarily include an unwillingness to part with items. Clinically significant hoarding is associated with distress and functional impairment in daily life. Collectors acquires and discards. Hoarders just acquire and rarely discard.
Prevalence and Demographics of Hoarding Prevalence in general population 3-5% Underreported problem only five percent of cases come to attention of authorities. Prevalence among patients with obsessive compulsive disorder is approximately 20-30 percent. Prevalence among patients with dementia is approximately 20 percent. Education ranged widely Typical age of onset was during childhood or adolescence. Strong familial link 80 percent of hoarders grew up in house with someone who had hoarded.
Profile of Hoarders Female, unmarried, lives alone Social Isolation Anxiety, depression and/or personality disorder Poor insight denies problem
Co-Morbid Problems Associated With Hoarding Hoarding is associated with several disorders including: Dementia OCD ADHD Depression Anxiety (PTSD, general) Schizophrenia /psychotic disorders Substance abuse Personality Disorders Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
WHY PEOPLE HOARD Vulnerabilities Information processing deficits Meaning of possessions Emotional Reactions Reinforcement
Symptoms of Hoarding Nearly always accompanied by excessive buying or acquisition of possessions Hoarders can collect things or animals Specialty Hoarders Many hoarders experience significant depression, social phobia, and isolation. Hoarders show poor insight into problems and have poor treatment motivation Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
Symptoms of Hoarding Hoarding is characterized by problems with: Acquisition Discarding Organization Beliefs about possessions Decision-making Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
Deficits Associated With Hoarding Hoarding Stems from Four Types of Deficits Information-processing decision making; categorization/organization; memory. Problems with emotional attachments to possessions objects as extensions of oneself. Behavioral avoidance excessive concern over mistakes. Erroneous or distorted beliefs about nature and importance of possessions. Perfectionism Need for control Responsibility Emotional comfort Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
Animal Hoarding According to HARC (Hoarding of Animals Research Consortium at Tufts University Animal Hoarder is someone who: Accumulates a large number of animals Fails to provide minimal standards of nutrition, sanitation, and veterinary care Fails to act on deteriorating condition of animals Fails to recognize negative impact of animal collection on their own health and well being
Characteristics of Animal Hoarders Believe that they are animals savior May have grown up in chaotic or abusive households Unable to perceive the actual condition of their animals View the world as a very hostile place for both animals and people
Characteristics of Animal Hoarders More than ¾ of animal hoarders are female Nearly half are 60 or older; unmarried Nearly half live alone Dead or sick animals were found in 80% of reported cases Most deny that either the animals or hoarder are suffering from health problems
Barriers to Effective Treatment
Treatment Interventions Medications Psychotherapy Cognitive Behavioral Therapy Harm Reduction Model
Barriers to Effective Treatment with Hoarders Very little data available regarding treatment outcomes with hoarders. Little evidence that antidepressants or other meds used to treat OCD are effective in treatment of hoarding. Hoarders have poor insight into nature of problem (denial). Motivation to change is limited and resistance to treatment is high. Treatment is frequently lengthy (one to two years) Limitations of Cognitive Behavioral Treatment Model
Cognitive Behavioral Therapy Therapist Guide to Compulsive Hoarding (200& Frost and Steketee 26 sessions of weekly treatment over 7-12 months Field Sessions 3 office sessions and one home visit/month Homework each session Some day long cleanouts with therapeutic team
HARM REDUCTION TREATMENT MODEL Three levels of harm: Safety Health Comfort Steps in harm reduction plan: 1. Plan 2. Do 3. Check
HARM REDUCTION TREATMENT MODEL Appropriate for individuals who: Are living in unsafe situations Have little or no insight into problem Not ready for professional treatment May have cognitive impairment or dementia
Hoarding and the Elderly Population Age-related illnesses are not primary cause of hoarding. Hoarding is a common symptom in dementia patients. Memory loss: inability to discriminate between relative importance of articles in home. Forty percent (40%) of hoarding complaints to local health departments involved elder service agencies. Self-neglect associated with hoarding.
Causes of Hoarding in Elderly Compensation for loss Grief reaction death or divorce Avoiding waste Depression era Traumatic event Holocaust Social isolation Finding security Memory problems Paranoia or delusions
Dementia and Hoarding Hoarding is a common symptom in dementia patients. Repetitive and ritualistic behaviors associated with dementia Symptoms of Dementia Hallucinations Paranoia Delusions Misidentification False Ideas
Dementia and Hoarding (cont) Gathering of familiar objects Attempt to regain control Forgetting what is trash Inability to sublimate natural drives sexuality aggression acquisition
Clutter and Hoarding Figure 1: Type and Severity of Clutter (n=62) Percentage of Cases 50 40 30 20 10 Substantial Severe 0 Newspaper Paper Containers Clothing Food Books Trash Types of Hoarded Items
Clutter and Hoarding Figure 2: Extent to which clutter interferes with normal life functioning within the home (n=62) Substantial 50 44 Severe Percentage of Cases 40 30 20 10 38 38 26 12 38 16 13 0 Inhibition of Movement Access to Furniture Access to Food Preparation Interference with Hygiene Types of Interference
Barriers to Effective Treatment with Elderly Hoarders Steketee study (1999) showed that after cognitivebehavioral model of therapy for over one year, 43 percent of subjects had no change after treatment and cleaning out of clutter; 23 percent relapsed. Barriers: Denial and resistance Cognitive impairment/mental illness Lack of family support Lack of trained staff or staff time Client right to self-determination Forced cleaning and excessive use of reasoning are frequently unsuccessful with elderly hoarders
Intervention With Elderly Hoarders Hoarding is a mental health and a public health issue Treatment involves: Mental and physical health assessment Risk reduction Treatment for identified symptoms
Capacity/Risk Model of Intervention Concepts Capacity Risk Three areas of functioning Physical (activities of daily living) Psychological Social (availability of supports, finances) Types of risk Physical/Psychological To self/to others **Model developed by Barbara Soniat, MSW, PhD, National Catholic School of Social Service (NCSSS), Washington, DC.
Evaluating Capacity and Risk Evaluating capacity and risk: High capacity/high Risk = accept clients right to self determination High risk/low capacity = intervention including legal (guardianship, etc) High Risk/Moderate capacity = reduce resistance; reduce risk; increase capacity
No quick fix Intervention Guidelines: The Dos Establish positive relationship Gain person s trust Empathize see their point of view Give choices help maintain a sense of control Help set goals and time frame for getting things done Respect meaning and attachment to possessions
Intervention Guidelines: The Don ts Don t work with hoarders if you feel negatively about this behavior Don t expect miracles overnight Don t overwhelm or threaten Never remove belongings without person being present Don t do a surprise or forced clean-up if at all possible
Intervention Guidelines Hoarding is a mental health and a public health crisis Typically NOT an immediate crisis Interventions without cooperation can be disastrous
Intervention Guidelines: Collaboration Development of hoarding task forces Collaborative intervention: Mental health Adult protective services Code enforcement Building and safety Animal control Criminal justice Zoning/Pest Control Fire prevention Home Care/VNA
Hoarding: Ethical Issues Autonomy vs. beneficence Self determination vs. capacity/risk Privacy vs. Public Health Freedom of choice vs. resistance Process vs. urgency Role as advocate vs. Role as gatekeeper