Lecture 9 - OCD and Hoarding Disorder

Question 1

OCD and Hoarding - Description (5)

Answer 1

• the presence of obsessions/compulsions which cause marked distress, are time consuming, and interfere with functioning. Obsessions – anxiety provoking thoughts, urges, or images which are recurrent, persistent, and seen as intrusive or unwanted. Compulsions – repetitive behaviours or mental acts that the individual feels driven to perform in response to an obsession. Obsessions are neutralised through avoidance (both physical and mental) and performing the compulsions.
  
  • Examples – cleaning (contamination obsessions à cleaning compulsions), symmetry (ordering and counting compulsions), forbidden or taboo thoughts (aggressive, sexual, or religious obsessions), harm (fear of harm to self or loved ones à checking compulsions).
  • Prevalence – 1.2-1.8% 12 months internationally, 1.9% Aus (1.6 males, 2.2 females). 2.3% across the lifespan. Females more common in adulthood, males in childhood.
  • Hoarding Disorder – persistent difficulty discarding or parting with possessions, regardless of their actual value. Possessions congest and clutter the house to the point where rooms can no longer be used for their intended purpose. Collecting, buying, stealing of items which are not needed and they have no room for. Substantial distress to the hoarder or the people around them – insight often impaired and there is a specifier for insight. Prevalence – 2-5% in Aus, twice as prevalent as OCD, more common among males but females present more. 3x as prevalent among older adults. 8.6-40% (20%) of people with OCD have hoarding as well.
    
    • Distinction – both have cognitive focus, obsessive preoccupation, and repetitive behaviours BUT THE FUNCTION OF THE BEHAVIOUR IS DIFFERENT. Obsessions leading to hoarding rather than hoarding for a different reason.

Question 2

OCD and Hoarding Aetiology (7)

Answer 2

• Rachman’s Cognitive Theory of Obsessions – intrusive thoughts are near universally experienced, obsessions result from catastrophic misinterpretations of their significance. Great personal significance attached to thoughts. Very similar to Clark’s cognitive model of panic.
• Salkovski’s Cognitive-Behavioural Model of OCD – appraisal of harm/danger à anxiety à depression, and activation of pre-existing dysfunctional schemata. Impulses are not disturbing unless there is the belief that they might carry through. Putting things right through compulsions and avoiding personal responsibility. Excessive reassurance seeking to spread the responsibility.
  
  • Dysfunctional assumptions interacting with intrusive thoughts – thought-action fusion (having a thought is the same as acting on it, failing to prevent harm is the same as having caused it, not neutralising is the same as wanting the thing that is being neutralised to happen). Compulsions reduce discomfort and seem to have alleviated the threat.
  • Thought-action fusion – increases in personal responsibility and guilt. Inflated sense of personal responsibility, intolerance of uncertainty, overimportance of thoughts, overestimation of threat, need to control thoughts, perfectionism.
• Frost and Hartl’s CB Model of Hoarding – neuropsychological, emotional, and behavioural deficits underlie hoarding. Conditioned emotional responses that have become associated with a person’s thoughts and beliefs about possessions. Avoid anxiety associated with discarding possessions. Possessions seen to be pleasurable or comforting.
  
  • Information processing deficits (frontal lobe dysfunction, can’t concentrate or focus for long enough to commit to throwing something away), problems with emotional attachments to possessions (possessions as extensions of the self or reminders of other people), erroneous beliefs about the importance of possessions (inability to distinguish trash from treasure, immediate reinforcement), emotional distress and behavioural avoidance of discarding possessions (fear of making the wrong decision).
    
    • Risk factors for hoarding – perceived control, intolerance of uncertainty, inhibited self-control, perfectionism, stressful life events, parental modelling, anxiety sensitivity, distress intolerance.

Question 3

OCD and Hoarding - Assessment (11)

Answer 3

• – age of onset, circumstances surrounding onset. The content of obsessions, the degree of insight, the frequency and triggers for obsessions, the feared consequences, what the client believes and the emotions associated with it. Description of compulsive behaviour and ratings of distress, feared consequences, experiences of resistance. Description of avoidance behaviour. Degree of family involvement and impairment.
  
  • Zohar-Fineberg Obsessive Compulsive Screen (ZF-OCS) – wash or clean, check, intrusive thoughts, daily activities taking a long time to finish, concerned about orderliness/symmetry.
  • Yale-Brown Obsessive Compulsive Scale (Y-BOCS) – clinical interview/self-report. Main instrument used. Aggressive, sexual/religious, symmetry/order/counting, contamination/cleaning, hoarding/collecting.
  • Obsessive-Compulsive Inventory (OCI) – washing, checking, doubting, ordering, obsessing, hoarding, and mental neutralising. 0-4 distress rating.
  • Clark-Beck Obsessive Compulsive Inventory (CBOCI) – 25 item screening measure. 10-20 minutes. 11 obsessions/14 compulsions.
  • Hoarding Subscales of OCD Instruments – Y-BOCS gold standard, OCI, etc.
  • Saving Inventory Revised (SI-R) – well-validated self-report. 23 items on 3 subscales (clutter, difficulty discarding, excessive acquisition)
  • Hoarding Assessment Scale – 4 item self-report. Poor insight impedes self-report.
  • Hoarding Rating Scale Interview (HRS-I) – 5 questions on hoarding as well as distress/impairment.
  • Structured Interview for Hoarding Disorder (SIHD) – inclusive criteria / other explanatory disorders.
  • UCLA Hoarding Severity Scale – 10 item semi-structured interview. Indecisiveness, procrastination and slowness.
    
    • Clutter Image Rating (9 pictures/3 rooms, which picture relates to their homes); Activities of Daily Living in Hoarding (ability to eat at the table, use sinks, 5 point scale); Savings Cognitions Inventory (24 item self-report beliefs about obsessions).

Question 4

OCD and Hoarding - Diagnosis (5)

Answer 4

• Obsessions, compulsions or both. Attempts to ignore, suppress obsessions or neutralise them with some thought or action. Compulsions are aimed at preventing or reducing anxiety or distress or preventing some dreaded situation – but they are not connected in a realistic way with what they are trying to use them for or are excessive. Must be time-consuming or cause significant distress or impairment.
  
  • Specifiers – with good/fair insight (OCD beliefs not believed to be true), with poor insight (OCD beliefs probably true), with absent insight/delusional beliefs (convinced that beliefs are true), tic-related.
• Hoarding – difficulty discarding or parting with possessions regardless of their actual value. Perceived need to save the items and distress associated with discarding them. Accumulation of possessions that congest or clutter active living spaces and compromises their intended use. If living areas are uncluttered it is only the result of third parties (cleaners, partners).
  
  • Specifiers – excessive acquisition (gaining of items is frequent and unable to be accommodated), with good/fair insight, with poor insight, with absent insight/delusional beliefs (completely convinced that their beliefs and behaviours are not problematic).
• Differential diagnosis – recurrent thoughts and avoidant behaviours are common to many anxiety disorders. Eating disorders can have obsessions, tic disorders have stereotypical movements but are not used to neutralised obsessions. Delusions but not hallucinations or thought disorder like psychosis. Hoarding can be an aspect of neurodevelopmental or psychotic disorders.
  
  • Comorbidity – 76% have anxiety disorder, 63% have mood/bipolar disorder, 30% have tic disorder. Comorbid OCPD is common (23-32%). Hoarding – 75% have comorbid mood/anxiety, 50% MDD, 20% OCD.

Question 5

OCD and Hoarding - EBT (14)

Answer 5

• Level 1 CBT, Level 2 self-help, Level 4 ACT. Exposure and response prevention is key and recommended for all levels in the NICE guidelines. 10 sessions CBT – assessment & formulation, psychoeducation, cognitive strategies, exposure and response prevention, relapse prevention.
  
  • CBT poor treatment outcomes – hoarding, increased anxiety and symptom severity, unemployment, being single/not married. No impact of medication, age of onset, educational level.
  • Psychoeducation – intrusive thoughts are very common. Need to downwards arrow – accessing appraisals, and interpretations of the intrusions.
  • Cognitive Strategies – overestimation of danger (talking to experts, realistic appraisals), inflated responsibility (pie charting, courtroom procedure), overimportance of thoughts (normalising and surveying), thought-action fusion (having thoughts does not result in actions), intolerance of uncertainty/need for control/perfectionism (cost/benefit analysis).
  • Exposure and Response Prevention – exposed to the situation that triggers the obsessional thoughts, then prevented from engaging in their normal safety behaviours until anxiety habituates. Provides opportunity for disconfirmation and to change appraisals. Compulsions treated as safety behaviours. Exposure hierarchy created, exposure triggers the obsession, compulsion is prevented.
    
    • Need to encourage them to overlearn. Need to choose right kind of exposure (in vivo vs imaginal) for the obsession.
    • Don’t encourage distraction or provide reassurance.
  • Medication – SRIs first line treatment along with ERP. TCAs and SSRIs. Clomipramine (SRI TCA) – superior to SSRIs but has more severe side effects and is less safe.
  • Psychotherapy vs pharmacotherapy – better in combination than medication alone, but ERP may be sufficient without pharmacotherapy.
  • Hoarding treatment – less responsive to OCD specific CBT. Less emphasis on ERP and more emphasis on MI and skills training. Frequent offsite visits for sorting/discarding and non-acquisition training. 26 sessions over 7-12 months. Significant improvements compared to WL, 68% clinician rated improved, 76% self-rated improvement. Has been used in a group format with no home visits with significant reduction in symptoms but lower completion rates.
    
    • MI – express empathy, develop discrepancy, roll with resistance, support self-efficacy – client needs to recognise the need for change and that they can and are able to do something about it.
    • Home visits – client must decide on rules for discarding and acquiring, and needs to make all the decisions. Organising plan established and client must think aloud while deciding.
    • Skills training – personal organising plans. Teaching problem solving skills and categorising and sorting skills. Managing attention and distraction.
      
      • Medication – SSRIs don’t have the same effect, lack of research.

Question 6

OCD and Hoarding - Challenges

Answer 6

• distress intolerance is high in hoarders (BDP and DBT).
  
  • Externalising OCD as a bully – it is something that is forcing you to do all these things. Take back your life. Need to give them something to engage with once their compulsive activities have reduced – lots of time spent doing these activities.