Treatment of Late Life Compulsive Hoarding

This study will examine a new behavioral treatment for older adults with compulsive hoarding.

What is involved?

Participants will be randomized to a new behavioral treatment for compulsive hoarding or case management. There are no fees or costs associated with participation. This is a non-medication study.

Who is eligible?

To participate, you must be over the age of 60, have significant hoarding symptoms, and live in San Diego, California.

Who do I contact?

Please call Catherine Ayers, Ph.D., ABPP at 858-552-8585 Ext.  2976 for more information.

VA Career Development Award: Treatment of Late Life Compulsive Hoarding (Ayers PI; CSRD-068-10S)

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Group Treatment for Compulsive Hoarding

This study will examine group treatments for adults with compulsive hoarding.

What is involved?

Participants will be randomized to a new behavioral treatment for compulsive hoarding or traditional exposure therapy for discarding. There are no fees or costs associated with participation. This is a non-medication study.

Who is eligible?

To participate, you must be over the age of 18, have significant hoarding symptoms, and live in San Diego, California.

Who do I contact?

Please call Catherine Ayers, Ph.D., ABPP at 858-552-8585 Ext.  2976 for more information.

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Neuropsychiatric Features of Animal Hoarding

This study will examine neurocognitive and psychiatric characteristics of people who hoard animals.

What is involved?

Participants will complete a series of questionnaires and will be given feedback upon completion. There are no fees or costs associated with participation.

Who is eligible?

To participate, you must be over the age of 18, have a problem with animal hoarding, and live in Southern California.

Who do I contact?

Please call Catherine Ayers, Ph.D., ABPP at 858-552-8585 Ext.  2976 for more information.

Are you a:

• Packrat?
• Hoarder?
• Clutterer?

The UCSD Obsessive-Compulsive Disorders (OCD) Program is looking for people with problems with hoarding, saving, or clutter to take part in a study that is providing:

• Diagnostic Evaluation
• Brain Imaging Scans
• 12 weeks free medication treatment
• Neuropsychological Evaluation

Healthy Females age 45-65 years wanted for research.

Participants will receive:

• PET and MRI scans of brain
• A Psychiatric Evaluation
• A Neuropsychological Evaluation
• Payment for Participation

You may be eligible if you:

• have NO history of psychiatric disorders
• are in good physical health
• are NOT taking any medications that affect the brain

Study Conducted by Sanjaya Saxena, M.D.
UCSD Obsessive-Compulsive Disorders Program
Department of Psychiatry
UCSD School of Medicine

For more information, please call
(858) 534-8056

There are a number of things that make us humans vulnerable to anxiety and worry. But one of the common attitudes among people who deal with anxiety is having a need for certainty.

It is almost as though we are requiring 100 percent certainty that we will encounter zero risk. Well, this is just too much to ask out of life. People with anxiety, phobias, and panic ask questions such as, Can I know for certain I won’t have panic symptoms when I go to that job interview? Can I know for sure that I won’t have to leave if I do go to the interview? Can I know for certain that I won’t feel trapped? Can I know for sure that I won’t cause an embarrassing scene?

If the theory that some people’s brains causes them to feel a strong and inappropriate need for certainty is true, then tackling this problem involves changing those demanding thoughts. So, that means you work to find a way to accept the outcome that you fear. When you have faced this scenario in the past you have probably tried to reassure yourself or get reassurance from someone else. The problem with that is that it’s helpful for about 5 seconds. No amount of reassurance will ever be enough because you still don’t know for certain that whatever you fear is not going to occur. So that nagging anxiety voice will continue to haunt you.

The attitude to aim for instead is, I can tolerate uncertainty. Examples include: “I accept the possibility of a panic attack/plane crash/making a wrong decision, etc., happening.”

For a fear of leaving a situation, you might say to yourself, “I accept the possibility that I might have to leave the restaurant. I imagine that I might feel embarrassed but I’m willing to tolerate that now.”

In the case of fear of a plane crash, you could say, “I accept the possibility that this plane could crash. I’m going to act, think, and feel as if this plane is 100% safe. I accept the risk that I could be wrong.”

Lastly, in the case of fear of a wrong decision, “I accept the possibility that this may not be a perfect decision and I will deal with the consequences that come with it. Yet, I have made a thoughtful decision weighing all the information that I have at this time and therefore making the best decision I’m capable of. I accept and can tolerate that I may be wrong.”

The bottom line is this: When you accept the possibility of a negative outcome, you avoid the need for absolute certainty for your future safety either physically or psychologically. Your responsibility is to lower your risk of problems as much as makes common sense but then to accept the remaining risk that is not under your control.

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Comment from Lori: This difficulty with uncertainty is especially challenging for those with OCD. As Dr. Chapman noted, reassurance seeking or other attempts to gain certainty are only momentarily helpful; and they can perpetuate the vicious cycle of OCD.

Hypochondriasis is a “preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.” These fears continue even after appropriate medical evaluation shows no illness and, for a diagnosis of hypochondriasis, must cause clinically significant distress or impairment in functioning (American Psychiatric Association, 2002, p 507).

Hypochondriasis develops in the context of a biological predisposition to anxiety, difficult illness or death related experiences and stressful life events (Walker & Furer, 2008) and may be a way of avoiding more pressing issues (Taylor, Asmundson, & Coons, 2005). Research indicates that cognitive behavioral therapy (CBT) is an effective treatment.

The elements included in CBT for hypochondriasis differ. Common techniques include education about symptoms, education about the selective perception of symptoms (bodily sensations increase due to focus, presence of anxiety, and vigilance for new symptoms), persuasion, exposure response prevention, and the prevention of reassurance seeking (Magariños, Zafar, Nissenson, & Blanco, 2002).

Taylor, Asmundson, and Coons (2005) add a reminder about the importance of a medical evaluation first, list relaxation training as well as cognitive restructuring as useful (i.e. keeping negative thought records which are then used to help teach the development of more rational responses). They also include the element of therapist openness, acceptance, warmth and empathy as especially important for hypochondriacs because they generally feel they are not understood by professionals. The importance of eliminating checking behavior, avoidance and other maladaptive behaviors, including conversations about illness, is emphasized. Stimulus control is mentioned as a way to reduce worry (what triggers worry and how it is reinforced).

Another treatment for hypochondriasis that is being researched is interoceptive exposure which, for hypochondriasis, is defined as producing bodily sensations, focusing on the sensations without trying to end them, trying to maintain the sensations and repeating this process until there is no distress from the symptom. A drawback to this approach is that it is difficult to deliberately produce some sensations at will. Techniques that have successfully overcome this difficulty are to 1) focus one’s attention on the associated part of the body, 2) capture the opportunity to focus when the sensations occurs, and 3) use imaginal exposure by creating narratives about the feared symptoms, illness, and outcome (Walker & Furer, 2008).

Other important behavioral techniques that are closely tied to interoceptive exposure are the use of behavioral experiments (i.e. having a healthy patient who fears heart problems do aerobic exercise), response prevention for bodily checking and reassurance seeking, exposure to illness related situations (i.e. hearing or reading about an illness), reduction of safety behaviors (i.e. carrying a cell phone to call for help) and reduction of cognitive distraction during exposure.

For patients with hypochondriasis, distress about bodily sensations can be a vicious cycle. Autonomic arousal due to fear intensifies sensations which then in turn increase fear (Barlow, 2008). Often those who are finally referred by their primary care doctors for psychological treatment are difficult cases due to poor insight and length of illness. It is not unusual for fears about illness to even reach delusional states. An additional challenge in treating this disorder as a non-medical provider is the risk that there is underlying physiological pathology, thus contact with the primary care physician is critical, especially if new concerns arise.

REFERENCES

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4^th Edition). Washington, DC: American Psychiatric Association.

Barlow, D. (2008). Clinical Handbook of Psychological Disorders-A Step-by-Step Treatment Manual (4^th Edition). New York, NY: The Guilford Press.

Magariños, M., Zafar, U., Nissenson, K., Blanco, C., (2002). Epidemiology and treatment of hypochondriasis. Therapy in Practice, 16(1), 9-22.

Taylor, S., Asmundson, G., Coons, M., (2005). Current directions in the treatment of Hypochondriasis. Journal of Cognitive Psychotherapy: An International Quarterly 19(3), 285-304.

Walker, J., Furer, P., (2008). Interoceptive exposure in the Treatment of Health Anxiety and hypochondriasis. Journal of Cognitive Psychotherapy: An International Quarterly, 22(4), 366-378. doi: 10.1891/0889-8391.22.4.366

Rachael Hatton, Marriage and Family Therapist Intern

New treatment groups for adult OCD, teen OCD, adult trichotillomania, and adult hoarding are now forming in San Diego. These groups will be led by Rachael Hatton, MFTI, under Lori’s supervision. Rachael is a behavioral therapist specializing in treating OCD and related disorders.

The cost is $350, and  includes one individual intake session and 12 weekly group sessions.

To register, contact Rachael at rmzhatton@yahoo.com or Lori at llrwalker@sbcglobal.net.

Rachael has a master’s degree in Human Development and Family Studies with an emphasis in Marriage and Family Therapy from the University of Connecticut and a bachelor’s degree in Psychology from the University of California San Diego. Learn more about Rachael at www.rhattontherapy.com.

Dad to Dad: Parenting a Child with Trichotillomania

Trichotillomania (Hair Pulling Disorder) is an OCD Spectrum Disorder, which shares some common characteristics with OCD.

Contact number: 760-525-1645

Michael_Gutierrez@Cox.net

This 12-step support group serves to identify obsessive/compulsive behavior and provides members an opportunity to share experiences and feelings.

Introduction

Compulsive hoarding can be defined as behavior leading to an over-accumulation of possessions that negatively impacts life. There are multiple issues that come together to create hoarding. It has a poor prognosis and can cause extreme distress for the sufferer as well as family and friends. Hoarding can create safety hazards, interfere with the ability to complete daily tasks, cause financial and legal problems, social isolation, and relational difficulties.

Hoarding is not solely a psychological problem that can be addressed by challenging thoughts and belief, addressing early learning patterns, or working through difficult emotions. It has genetic and biological underpinnings that cannot be ignored. It is a very complex illness where multiple vulnerability factors and information processing deficits converge to create a painful and debilitating disorder. A relationship has been established between hoarding and obsessive compulsive disorder, and it is often comorbid with social phobia, depression, attention deficit hyperactivity disorder, impulse control disorders, and personality problems (Stekette, 2007, p. 5-8 ).

Psychosocial contributors to hoarding can include family rules and values, early associations, learning, and various forms of behavioral reinforcement. These will not be discussed here. Rather, we will look at genetic and biological vulnerability factors that impact brain function. These will include mental health concerns such as obsessive compulsive disorder, depression, or trauma, as well as other medical concerns that limit mobility or cause fatigue. Later we will look at deficits that impair information processing, then consider the role of compulsive acquiring. This article will show the complex interaction between brain function, the environment, physiological illness and hoarding symptoms.

Vulnerability Factors that Involve Brain Function

Obsessive-Compulsive Disorder

Obsessive compulsive disorder (OCD) is diagnosed in the presents of obsessions, compulsions or both. Examples of obsessive thoughts contributing to hoarding include: one’s environment must be perfect; one must not make mistakes; one must not waste; everything must be used for a purpose. Compulsions may include things like detailed and perfectionistic ordering, arranging, or organizing to the point of overwhelm and shut down; excessive recycling; and attempting to find the perfect home for any possessions that are being parted with, no matter how much time or energy is involved. A large percentage of hoarders also have other symptoms of OCD.

The cause of OCD is not clearly understood. However, OCD has been shown to be genetically predisposed (Chansky, 2000, p. 30). Gene expression or activation in general can be an internal process or may be impacted by the environment. Factors that have been shown to activate gene expression include psychoactive drugs or chemicals, stress hormones, thyroid hormones, and sex hormones (Preston, 2005, p. 34). The interplay between the genetic predisposition to OCD and environmental factors is being researched extensively. Anecdotal stories and observations from this author’s practice include OCD onset after LSD use, puberty, trauma, strep infection (PANDAS), and severe stressors. Traumatic brain injury (TBI) has also been show to trigger OCD symptoms which have been correlated with brain lesions in inhibitory brain structures (Grados, 2003, p. 7).

The areas of the brain implicated in OCD are the prefrontal cortex, hypothalamus, amygdala, cingulate, and basal ganglia. The prefrontal cortex has been specifically implicated in hoarding due to its function in behavioral monitoring and organization of complex information processing. It is also associated with impulse control (Preston, 2005, p. 37; An, 2009, p. 318-331). The cingulate is part of the autonomic pathway which controls response to external and internal stimuli as part of the fight or flight response to emergencies. The basal ganglia inhibits unwanted movement patterns and speech and is more likely associated with other obsessive compulsive spectrum disorders.

Depression

Depression is a vulnerability factor for hoarding due to its impact on motivation, energy levels, ability to concentrate, memory, anxiety level, and sleep. These factors then impact general functioning. At times depression can be a reaction to grief, loss, rejection, or other psychological factors but often there is biochemical dysfunction.

Some common drugs that can cause depression are high blood pressure medicine, corticosteroids and other hormones, anti-parkinson drugs, anti-anxiety drugs, birth control pills and alcohol.

The prefrontal cortex, hypothalamus, amygdala, and hippocampus have been implicated in depression. The hypothalamus in particular plays a large part in common symptoms of depression since it regulates the autonomic nervous system, sleep-cycles, hunger, sex drive, and also influences the immune system (Preston, 2005, p. 37). The link is clear since common symptoms of biological depression include sleep disturbance, appetite disturbance, fatigue, decreased sex drive, restlessness or psychomotor slowing, impaired concentration, forgetfulness, and inability to experience pleasure (Preston, 2009, p.6).

Causes of depression that can be linked to the hypothalamus include: hypothyroidism which is attributed to 5-10% of major depressions; difficulties in menopause; post-partum hormonal changes; and premenstrual syndrome (Preston, 2009, p. 3-4).

Post traumatic stress disorder (PTSD)

PTSD is classified as an anxiety disorder and can result from many types of trauma including early deprivation and loss, either physical or psychological. Sometimes early loss or deprivation can contribute to the onset of hoarding behaviors. Secondary loss of possessions for hoarders during “clean-outs” may create additional trauma that reinforces the need to hold on even tighter. At times late onset of hoarding can be precipitated by trauma (Stekette, 2007, p. 7). The brain structures implicated in anxiety disorders include the hypothalamus, amygdala, and cingulate. The amygdala can be responsible for intense emotions and “elicits and controls aggression” and “primitive threat appraisal” (Preston, 2005, p. 37). It “integrates information from the senses and from within the body with past experiences.” (Woolsey, 2008, p. 220)

General medical conditions

Any medical condition that impacts overall functioning can be a vulnerability factor for hoarding. An example of this would by post concussion syndrome which impacts the hippocampus and can last for up to a year after a minor head trauma. Symptoms include headaches, dizziness, fatigue, irritability, anxiety, insomnia, loss of concentration and memory, noise and light sensitivity. If other vulnerability factors are present, any medical condition may be enough to tip the scales and minor problems with discarding and clutter can become more severe.

Information Processing Difficulties Due to Brain Function

Attention Deficit Disorder (ADHD) has been shown to contribute to hoarding and clutter problems with common symptoms being difficulty paying attention to details, being easily distracted by irrelevant stimuli, difficulty performing tasks that require concentration, frequent shifts from one uncompleted activity to another, procrastination, disorganized work habits, forgetfulness in daily activities, frequent shifts in conversation, not listening to others, not keeping one’s mind on conversations, and restlessness. Both the prefrontal cortex, discussed previously, and the brain stem, specifically the reticular system, are implicated in ADHD. The reticular system is the stimulus filter or gate (Preston, 2005, p. 37). If irrelevant stimuli are not filtered, information overload can be responsible for difficulty managing tasks and possessions.

Memory problems also can contribute to hoarding and clutter because frequently items are left in view so they are not forgotten or duplicates of items are purchase due to difficulty finding them. “The hippocampus processes experience into memories and is involved in the recall of spatial locations.” (The Brain Atlas, 2008, p. 218) Various learning disabilities can also contribute to clutter, disorganization, and time management problems.

Hoarding worsens with age possibly due to cognitive decline and memory loss (Dudley, 2007). Cognitive decline can be caused by dementia and other confusional states linked to dysfunction of the cortex. The cause of dementia includes disease, infection, stroke, head injury, drugs, and nutritional deficiencies.

Compulsive Acquiring

Frequently those that hoard also compulsively acquire. Common methods of acquiring include buying from stores, yard sales, the internet, picking up discarded items, and more infrequently stealing (Stekette, 2007, p., 168). Compulsive acquiring is considered an impulse control disorder and indicates pathology in the prefrontal cortex and amygdala (both discussed previously), as well as the septum. The septum is the emotional and stimulus gate and contains the pleasure centers (Preston, 2005, p. 37). Often acquiring is done to alter negative mood states, decrease anxiety, or relieve tension and can be treated similarly to other addictive behavior.

In conclusion it is clear that brain function is an important element in understanding compulsive hoarding, and is a part of vulnerability factors such as OCD, depression, and trauma. Information processing difficulties stemming from ADHD, learning disabilities, or cognitive decline are also linked to brain function. Additionally, as we have noted, brain function plays a role in compulsive acquiring. Treating hoarding is a complex task that must include medical evaluation, psychiatric evaluation, compensatory skill building, exposure therapy, as well as addressing distorted thoughts and beliefs, facing issues of grief, loss, trauma, and increasing social support.

REFERENCES

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.

An, S. K., Mataix-Cols, D., Lawrence, N. S., Wooderson, S., Giampietro, V., Speckens, A., Brammer, M. J., Phillips, M. L., (2009). To discard or not to discard: The neural bases of hoarding symptoms in obsessive-compulsive disorder. Molecular Psychiatry, 14, 3, 318-331.

Chansky, T., (2000). Freeing your child from obsessive-compulsive disorder. New York, NY: Three Rivers Press.

Dudley, D., (2007). Conquering clutter. AARP Magazine, 1, 2.

Grados, M., (2003). Obsessive-compulsive disorder after traumatic brain injury. International Review of Psychiatry, 15, 4, 350-358.

Preston, J., Johnson, J., (2009). Clinical psychopharmacology made ridiculously simple (6 ed.). Miami, FL: MedMaster Inc.

Preston, J., O’Neal, J. O., Talaga, M., (2005). Handbook of clinical psychopharmacology for therapists (45^th ed.). Oakland, CA: New Harbinger publications, Inc.

Steketee, G., Frost, R., (2007). Compulsive Hoarding and Acquiring, Therapist Guide. New York, NY: Oxford University Press.

Woolsey, T., Hanaway, J., Mokhtar, G., (2008). The brain atlas (3^rd ed.). Hoboken, NJ: John Wiley & Sons, Inc.