CBT for Hoarding Disorder

A Group Therapy Program Therapist's Guide

David F. Tolin, Blaise L. Worden, Bethany M. Wootton, Christina M. Gilliam

• Publisher: Wiley-Blackwell
• Year: 2017
• Print ISBN: 9781119159230
• eBook ISBN: 9781119159254
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Part of a two-component product with a companion client workbook, CBT for Hoarding Disorder: Therapist's Guide guides group leaders through a comprehensive CBT group program for patients struggling with hoarding disorder.

• Provides step-by-step, evidence-based guidance for treating hoarding disorder (HD) with a focus on proven methods for behavior change rather than complex cognitive interventions
• Contains the latest research on HD and emphasizes the cognitive, emotional, and motivational factors involved in discarding and decision-making
• Features an accessible, straightforward client workbook with coping cards that summarize key lessons, homework assignments, motivational tools, and practice exercises for decision-making and emotion regulation skills
• Easy to implement without home visits for professionals and group leaders of all educational backgrounds across a wide variety of treatment settings and disciplines

Part I
Introductory Information for Clinicians

What is Hoarding Disorder?

Diagnosing Hoarding Disorder

Hoarding Disorder (HD) was first afforded diagnostic status in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‐5; American Psychiatric Association, 2013). The DSM‐5 diagnostic criteria for HD include:

1. Difficulty discarding or parting with possessions due to strong urges to save items and/or distress associated with discarding.
2. Clutter that precludes activities for which living spaces were designed.
3. Significant distress or impairment in functioning caused by the hoarding.

Prior to the publication of the DSM‐5, hoarding behaviors were informally considered to be a syndrome or subtype of obsessive‐compulsive disorder (OCD). However, as evidence mounted about the differences between hoarding and OCD (Pertusa et al., 2010), it became increasingly clear that hoarding represented a unique syndrome that had not been adequately categorized. Epidemiological research has suggested that the prevalence rate of HD is between 2 and 5% (Frost, Steketee, & Williams, 2000; Iervolino et al., 2009; Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009; Samuels et al., 2008), making HD a very common condition.

Understanding the Symptoms of Hoarding Disorder

Difficulty discarding.

The hallmark symptom of HD is reluctance to discard personal possessions, including objects that non‐hoarding individuals might consider to be worthless or having little intrinsic value. Although the reasons for saving objects tend to be similar to those described by non‐hoarding individuals (Frost & Gross, 1993), for individuals with HD these beliefs are more intense and rigid, and applied to a greater number of possessions. Attempts to discard usually cause substantial emotional distress, and therefore are frequently avoided.

Excessive clutter.

Excessive clutter is the most visible feature of compulsive hoarding. Unlike normatively “messy” or disorganized individuals, those with HD commonly describe significant difficulty using the living spaces of their homes due to clutter. For example, individuals with HD often have clutter that may cover beds, chairs, or tables, rendering them unusable. In severe cases, the clutter prohibits movement through the house or access to certain parts of the home.

Excessive acquiring.

Although acquiring is not a DSM‐5 diagnostic criterion for HD, research suggests that most individuals with HD do engage in excessive acquiring (Frost, Tolin, Steketee, Fitch, & Selbo‐Bruns, 2009). Excessive acquisition can include compulsive buying, collection of free items, inheritance of items, and rarely, stealing. Many report spending many hours each week searching for and acquiring objects (e.g., excessive shopping, rummaging through trash bins). Individuals with HD therefore may also present with distress related to overspending or debt as a result of compulsive shopping behaviors.

Understanding Hoarding‐Related Impairment

Health risks.

Clutter can lead to substantial personal impairment or injury, and has the potential for fatal consequences. Clutter’s interference with basic home functions such as cooking, cleaning, moving through the house, and even sleeping can make hoarding dangerous, increasing the likelihood of fire, falling, poor sanitation, and pest infestation (Steketee, Frost, & Kim, 2001).

Clutter poses a major fire risk both to those who live in the home and to neighbors. A study analyzing residential fires over a 10‐year period indicated that hoarding accounted for 24% of all preventable fire fatalities (Harris, 2010). Blocked egress, such as doors and windows, may prevent individuals from escaping home fires, and can prevent emergency personnel from entering the home when needed.

Elderly individuals in particular may be injured by falling objects or even trapped by collapse of clutter or other structural elements of the home. Health risks to children who live in the home may include the presence of mold, contributing to respiratory difficulties such as asthma. Children or elderly may become ill from keeping and ingesting expired food. Plumbing or heating may be inoperable; or other repairs may be needed but avoided due to concern about others entering the home.

Due to the potential for harm, clutter may lead to protective removal of children or elderly from the home (Tolin, Frost, Steketee, Gray, & Fitch, 2008). Involvement of government agencies, such as child or elderly protective services, fire marshals, police, or public health departments, is not uncommon. Clutter may also lead to threats of eviction by housing authorities.

Psychological impact.

Individuals with HD are likely to be particularly susceptible to isolation. Embarrassed by their clutter or avoidant of criticism, many individuals with HD avoid inviting friends, family, or repair workers to their homes, contributing to social isolation (Rasmussen, Steketee, Tolin, Frost, & Brown, 2014).

HD may also increase rates of intrafamilial conflict and rejection of the hoarding individual. Family members may be upset by excessive time spent on acquiring or in response to financial debt related to compulsive buying. Family members may become frustrated with the patient’s reluctance or inability to change. In one large survey (Tolin, Frost, Steketee, & Fitch, 2008) of family members of hoarding individuals, scores on a measure of rejection of hoarding individuals were higher than family rejection scores for clients with schizophrenia, especially if the hoarding individual was perceived as having little insight into their problem.

Many individuals with HD describe impaired work and role functioning. Individuals who self‐identified as having HD reported missing more work due to psychiatric reasons than individuals with depression, anxiety disorders, or substance use (Tolin, Frost, Steketee, Gray, et al., 2008).

Hoarding may also have a negative psychological impact on children who are raised in the hoarding environment. In the Tolin, Frost, Steketee, and Fitch (2008) survey, children who identified as having grown up in the home of a parent with HD described lower satisfaction with their childhood than individuals who did not grow up in the cluttered home. Specifically, children raised in the hoarding home reported embarrassment of the home and avoidance of having peers in the home, along with increased conflict within the home.

Financial cost to society.

In addition to the health risks, HD also presents a high financial cost to society. Individuals with HD tend to be high utilizers of services, including medical, mental health, and social welfare services. In one study (Frost, Steketee, & Williams, 2000) approximately 64% of surveyed public health officials reported receiving at least one complaint of hoarding during a five‐year period. The majority (88%) of the cases concerned unsanitary conditions. The City of San Francisco conservatively estimated that HD costs service providers and landlords in that city $6.4 million per year (San Francisco Task Force on Compulsive Hoarding, 2009). The Melbourne Fire Department study found that the average cost of firefighting hoarding‐related fires was eight times greater than that of hoarding‐unrelated fires (Harris, 2010).

Understanding Comorbidity in Hoarding

Management of hoarding cases tends to be complicated by a high presence of co‐occurring mental health and medical concerns. As many as 92% of individuals with HD meet criteria for co‐occurring psychiatric conditions (Frost, Steketee, & Tolin, 2011). As noted previously, the link between hoarding and OCD is not as strong as previously thought, although a significant minority (approximately 18%) of HD clients will also meet diagnostic criteria for OCD (Frost, Steketee, et al., 2011). Depression and anxiety are highly common among those with HD, with Major Depressive Disorder (53%), Social Anxiety Disorder (24%), and Generalized Anxiety Disorder (24%) among the most common co‐occurring diagnoses in treatment‐seeking HD clients (Frost, Steketee, et al., 2011).

Hoarding is also associated with relatively high rates of personality disorders and maladaptive personality traits. Although excessive saving of potentially low‐value items is a criteria for the diagnosis of Obsessive‐Compulsive Personality Disorder (OCPD), most HD clients do not meet criteria for OCPD when the hoarding criterion is removed (Frost, Steketee, et al., 2011). However, Dependent, Avoidant, Paranoid, and Schizotypal Personality Disorders appear fairly common in hoarding samples (Frost, Steketee, Williams, & Warren, 2000; Samuels et al., 2008).

Research increasingly suggests a link between hoarding and Attention‐Deficit/Hyperactivity Disorder (ADHD), or a similar symptom profile. Hoarding clients often report significant problems with attention and executive function that resemble those seen in people with ADHD. Individuals with hoarding symptoms commonly obtain high scores on self‐report ADHD measures, and in one study, 20% of HD clients, compared to 4% of OCD clients and 3% of community controls, met full DSM‐IV‐TR diagnostic criteria for ADHD (Frost, Steketee, et al., 2011). These data comport with those of a study of OCD clients, in which those with hoarding symptoms had a risk of ADHD almost 10 times higher than those without hoarding (Sheppard et al., 2010). Studies of neuropsychological performance in hoarding clients have yielded mixed results, although individuals with HD appear to have more specific deficits in the areas of problem solving, organization, and sustained attention (Woody, Kellman‐McFarlane, & Welsted, 2014).

It is important to be aware that hoarding behaviors such as saving, excessive acquiring, or disorganization may be present in a variety of disorders beyond HD. Hoarding behavior has been noted in clients with OCD (Matsunaga, Hayashida, Kiriike, Nagata, & Stein, 2010) and schizophrenia (Luchins, Goldman, Lieb, & Hanrahan, 1992), as well as after certain neurological insults such as damage to prefrontal and orbitofrontal cortex (Eslinger & Damasio, 1985; Volle, Beato, Levy, & Dubois, 2002) and dementia (Hwang, Tsai, Yang, Liu, & Lirng, 1998). Therefore, in cases of severe clutter and saving behavior, it is important to consider whether alternative diagnoses may better explain the hoarding problem. At this point, this manual has not been tested with individuals without a formal diagnosis of HD.

What Causes Hoarding Disorder?

Our treatment model is based on the idea that the most effective interventions are those that target the active mechanisms of the problem – that is, the reasons why the person engages in the behavior.

Etiology: Why Did These Symptoms Begin?

Research points to certain etiologic factors that might help explain why hoarding occurs in the first place. One such factor is a history of traumatic or stressful life events. Individuals with HD report a high frequency of lifetime traumatic events (Cromer, Schmidt, & Murphy, 2007; Hartl, Duffany, Allen, Steketee, & Frost, 2005; Tolin, Meunier, Frost, & Steketee, 2010), and in many cases, these stressful life events coincide with the onset or worsening of hoarding symptoms. Some have suggested that hoarding behaviors develop, in part, as a means of strengthening one’s sense of safety following a trauma or a chaotic childhood environment (Cromer et al., 2007; Samuels et al., 2008). We note, however, that hoarding is often present in individuals without any reported history of trauma, and most individuals with trauma histories do not engage in hoarding behaviors. Trauma, therefore, seems to have limited explanatory power in our estimation.

Hoarding symptoms appear to have a strong familial component, suggesting influences of both modeling (learning by observing) and genetics. HD likely has a high heritability rate; in one study of rates of HD in twins raised in the same residence, genetic factors were estimated to account for 49% of the variance in diagnostic (HD vs. no HD) status (Iervolino et al., 2009). Most individuals with HD describe at least one first‐degree relative as a “packrat” (Winsberg, Cassic, & Koran, 1999), and family members of individuals who hoard are likely to report indecisiveness (Frost, Tolin, Steketee, & Oh, 2011; Samuels, Shugart, et al., 2007), suggesting that decision‐making problems might be an inherited vulnerability factor. Many clients with HD report being taught or observing in their parent, from early in life, beliefs and behaviors associated with hoarding. For example, their parents would condemn “wasteful behavior,” or the individual would observe excessive acquiring behaviors by the parent. Additionally, certain genetic abnormalities have been identified in famili...

Table of contents

• Cover
• Title Page
• Table of Contents
• Part I: Introductory Information for Clinicians
• Part II: Treatment Manual
• Appendix A: Clock Sign
• Appendix B: “Bad Guy” Reminder Cards for Participants
• References
• Index
• End User License Agreement