ABPSYCH Quiz 6: PT 3

Etiology: Environmental factors 1. Elevated rates of traumatic events

1.Elevated rates of traumatic events -More than OCD patients (more trauma in hoarding than in OCD patients.) -Total # of events correlate with severity of hoarding -52% link b/w stress (20% trauma & 32% chronic stress) & hoarding ONSET (early onset hoarders there is less of a relationship w trauma) -Less identifiable stressor with early onset HD (0-10yrs), diff subtypes? -Trauma may also trigger recurrence or worsening of sxs -BUT NOT more PTSD: buffering effect of possessions: comfort & security?

HD: Diagnostic Criteria

A.Persistent diff discarding possessions, regardless of value B.Related to perceived need to save items or distress at discarding them C.Results in accumulation of clutter & congestion of living areas, compromising normal use (if clear only due to a 3rd party, still meet) D.Significant distress or impairment (incl. maintaining safety)-Inpairment can be filled by the environment beinf unsafe, not sanitary or dangerous bc fire hazard E.NOT another med condition (brain injury/ neurocognitive) F.NOT another mental health condition (OCD, MDD, Schizophrenia, ASD...) Specify: with excessive aquisition (not needed, no space, $ or free) buying/free stuff acquired Specify: insight absent or delusional ; poor ; good or fair

Etiology: Environmental factors 2. Material deprivation in childhood

Many people with HD consider it as a cause of their beh' (not having stuff in childhood. When u ask this is typ what they will tell u. but we don't actually have data showing this, but not for all hoarders.....maybe there are subtypes nof ppl who hoard for diff reasons.)---- NO evidence currently show link, but few studies 20% HD experienced 'lack of adequate shelter'; 8-12% eviction/or threat of eviction (ather than showing tht there was a lack of stuff, this studied showed 20% of hoarder who said they exper. Lack of stuff had exper homelessness in the past. And on top of tht there was another 8-12% who had either been evicted from home/ been evicted) Emotional deprivation rather than material deprivation? .......so is this material in olace of emotional depreivation?- possibly emo. Depriv rather than material dep.

Content of Hoarding

No proper studies looking at this, they only way to know then is looking at anechdotal information. This data is from people who aren't doing empirical research/their job isn't to collect data but they do have data bc its like a side effect of wht they do (extrme cleaning companies) •No def in DSM-5 & few published studies Their data suggests that theres these 5 areas that people tend to hoard: 1.Shopper hoarder: often unused, 'a good deal', like stockpiling but less purposeful, addiction?, DSM-III 'Impulse-control NOS'-1. whether this is more of an addiction//impulse control rather than hoarding. 2.Specialized hoarder: may resemble collecting but less organized/purposeful 3.Food hoarder: often unused, may resemble stockpiling but less purposeful, food safety issues/more chaotic 4.Garbage hoarder: may include food waste/filth or broken objects, hygiene 5.Paper/recycling hoarder: may cumulate for years, clutter, fire hazard Bibliomania: Books but no intrinsic value, poss multiple copies

Hoarding: Age

Studies suggest ONSET 11-15yrs, impairment by mid-30 Studies suggest that onset happens in around teenage years ...more ppl start hoarding in teenage phase and early adult phase AND then it tapers off -WHats interesting Is that impairment may not be sig. till person is in their late 30s. WHY? -as a child u prob limited to ur bedroom/where u can do so. College age u have more freedom to accumulate. And then by the time u live in ur own home and can do whathever u want bc no one is saying anything to u that will take time to where its gonna be a problem.... -so late 30s impairment makes sense bc it can take decades to build up to a problem -SXS worsen w every decade of life, bc its difficult to discard the stuff and so ppl accumulate

Hoarding: Cross-Cultural

Very few actual studies and most are only in context of OCD bc it wasn't a stand-alone disorder until recently •Universal phenomenon, sxs found in Africa, Asia, and SAmerica BUT few non-Western studies & most only in the context of OCD •HD in OCD (Y-BOCS): India, Japan, Turkey & Brazil: 11-49%,lower for hoarding specific measure: India & Brazil 10-17% (hoarding sxs on the ybocs have been shown across continents but they are higher numbers than u would find now if u were just looking at general hoarding.....but not rlly reliable) Take home: does exist in all cultures •Phenomenological diffs?: mixed findings but possibly if so, WHY? $, space, culture (idioms of distress)-- are there diff in what it may look like and what types of content do they hoard...but rlly needs more studies (phenomenological diffs) Rlly understudied area •Assessment: few assessment instruments Few studies: only in nonclinical samples, only 1 measure SI-R •Treatment: no studies to date

Differential Diagnosis of HD:

When diagnosing hoarding disorder, what's most important to look at is whether it is primary or secondary hoarding-is it the main issue or is it part of another disorder? Have to look at WHY their is clutter for example...could be dep.....have to rule in and rule oUT

Hoarding: Gender/Age & Ethnicity

[Mixed findings in gender and a lot is due to the fact that hoarding was generally only talked abt in relation to OCD profile]. •Gender: mixed findings, poss due to focus on OCD samples Men > women: population samples Women > men: clinical samples Some studies: no differences (data at the moment maybe more males than females in population samples but maybe more females than males in clinical samples....some studies say no diff...so mixed findings) •Ethnicity: sparse findings, lack of studies -HD exists across ethnicities -Findings suggest: same or possibly slightly lower in AA, Hispanic & Asian populations -Treatment response: very few data (samples 90%+ Euroamerican) (Very diff to get data across ethnicities, lack of studies. Def need for more research. Diff findings. Very unclear and most studies have only been done w Americans of European descent, so we don't know much)

Etiology: Biological factors

•Distinct Fronto-limbic circuits (Frontal lobe talking to the limbic sys., to the amygdala part.) 1.Cingulate cortex: hyper-activation: decision making (there appears to be hyper activation so theres a lot of activation happening in the cortex at the moment of making the decision to acquire something) 2.Ventromedial prefrontal cortex, & limbic structures: hyper-activation, related to object significance, information processing deficits (there's hyper hyperactivation in relation to the object ---SO ppl who tend to hoard, the object itself tends to give them more satisfaction/more significance/triggers more reaction in brain,,,so this is def some type of diff in info. processing •Different than OCD (This is Diff than whats going on in OCD. This is part of the argument to say that hoarding is its own thing it is not just a sxs of OCD,,,its its own beast.) Impairments: memory, planning, strategizing, decision making & problem solving, impulsivity, delayed gratification, behavioral disinhibition (Diff in Impairments (may help to explain overlap we see in ppl who have ADHD) Dysfunctional beliefs: heightened sense of responsibility for objects, fears of waste, fears of losing information, need for control of belongings, intense emotional attachment to possessions (diff in Dys. Beliefs: may be kind of related to diff in info procc in the PFC and the amyg.....alot of emo. Attachment to objects)

Etiology: Biological factors CONTINUE

•Family studies: HD sxs common among 1st-degree relatives •Twin studies: heritability 51%, so moderate genetic contribution, environmental factors also important •Gene studies: genetic correlations (2016 study) between: -Hoarding & obsessive-compulsive sxs (r = 0.41) -Hoarding & tics (r = 0.35), -Obsessive-compulsive sxs and tics (r = 0.37) So poss some shared genetic contributions, but so far unknown (So possible there are shared genetics going on between these disorders but that is it.,,,,we just don't know) •Animal studies: limbic areas (dopamine deficits), vmPFC lesions induce HD

Assessment: Interview measures

•Hoarding Rating Scale-Interview (HRS-I) 5-item brief interview, covering clutter, diff discarding, acquisition, distress, & impairment Score 14+ clinical, high sensitivity & specificity BUT not diagnostic for DSM-5 as does not assess specific reasons for hoarding & difficulty discarding •Structured Int. for Hoarding Disorder (SIHD) DSM-5 diagnostic criteria BUT not measure or quantify sxs severity & associated features Isn't a best interview right now, your best bet is to use the SCID!!!

Special Case: Animal hoarding

•Keeping lots of animals, no proper care, whilst denying this inability (Not rlly recognized as a spefici area in the dsm ....only way animal hoarding is delt w is from a legal POV) •US: legal consequences only, animal cruelty laws: misdemeanor poss higher some states •Consequences for health & safety of both animals & humans •Usually specialize in one species, majority also hoard objects (-usually ppl who hoard animals also hoard other objects. So theres this excessive kind of acquisition of getting more/keep growing more stuff. May be diff to diagnose this bc it can be very "mission-driven/rescuing",,diff to see it as a prob......of understanding motivations underneath) •Excessive acquisition: 'mission-driven, rescuing' OR breeding •May occur within the context of Diogenes syndrome - senile squalor syndrome (not in DSM but medical dxs): extreme self-neglect, squalid living conditions, social withdrawal & denial of problem (Not a mental disorder not in DSm but it is in the ICD bc it's a medical cond. And this is where older persons become senile and may lose control after looking over themselves. ,,, can get caught up in this situation.) May be a distinct syndrome or a specific subtype of HD (Questions on whether this is a distinct syndrome or a hoarding)

Hoarding Treatment

•Meds = SSRIs: 50% less responsive than OCD (= 50% of 50%!) -Generally, professionals typ do everything that you would do for OCD+try anf get improvement their: poss meds (50% less than OCD+for OCD they are only working about 50%). Therapy: CBT-ERP-HRT (mix of each, whatever they think might work) HRT: idea of trying to change ur response to the trigger (used for skin picking+trichotillomania) =----3 techniques: 1) awareness training (identifying high-risk situations), 2) developing a competing response until the urge passes &3) stimulus control (eliminating cues for pulling and picking) ---if there's an urge to acquire something, trying to find something else that the person can do at that specific moment to that they can fight the urge until it passes •HD shown lower response to ERP alone than OCD does •No RCT to date that compare SSRIs to therapy in HD (couldn't find any studies that show efficacy of a HD with meds and w//out and w therapy....Dr. Starrs says given the low efficacy w meds w OCD she says she would not recommend just treating HD with meds alone

Hoarding: Prevalence & Comorbidity

•Prev: range 1.5-6% in pop samples (we generally think 5%) •Comorbidity: No gender diffs Big Comorbid findings: •MDD: 51% ; •ANX: GAD: 24.4%, Social Phobia: 23.5% •ADHD: 40%, > inattentive (in comorbidities the pattern is highest in depression (MDD) and then anxiety disorders,,,,and then ADHD (inattentive type) which may be related to the kind of impulsivity) Not solid findings: •overlap in OCD and HD: unclear due to dxs overlap: 1st study post-DSM-5: around 18%, 2x more men, prelim finding •OCPD: higher only when incl. HD sxs

changes in DSM-5 CONT

•Previously criterial sxs of OCPD: Obsessive-Compulsive Personality Disorder (used TO BE a criterial sxs of OCPD: But when u work w people w ocpd when they hoard, its more related to their obsession rather than primary hoarding has a diff quality to it. -----but criteria has changed in OCPD so u could have ocpd and hoarding dis) -OCPD: primarily perfectionism, neatness, order, rigidity, attention to detail, need for control.... -"unable to discard worn-out or worthless objects even when they have no sentimental value" -BUT different quality than in HD -Weak correlations for HD with other OCPD criteria •Relationship between HD & OCDP possibly artefact due to overlapping criteria (poss this issue in comoribity could be due to the overlapping kind of sxs and that's it's the ocd diagnosis tht needs to be clarifying)

Changes in DSM-5

•Previously viewed as a SYMPTOM of OCD in DSM -BUT not all hoarding meets OCD criteria Received Anxiety disorder NOS or no diagnosis! -Only mentioned in DSM-IV: because of the Y-BOCS items (Hoarding used to be viewd as a sxs of OCD but this was a prob bc all ppl who hoard didn't meet OCD criteria---Hoarding wasn't a primary part of diagnoses in ocd---They ended up being given weird/unspecified anx. Disorder which wasn't helping person) •Studies using Y-BOCS -HD in OCD: 18-40% prevalence but only 5% clinically significant -Community self-id' HD samples report higher OCD sxs & more distress (So now its viewed as a distinct disorder,,,,can add hoarding to some other r disorders --so it can be primary or secondary---) -Att! Hoarding itself not distressing: discarding is distressing •Current view: either a distinct disorder, or a comorbid condition

Assessment: Self-report measures

•Saving Inventory-Revised (SI-R) 23-items, 3 subscales 1) difficulty discarding, 2) excessive clutter & 3) excessive acquisition Good psychometrics clinical & nonclinical pops. Score of 42+ indicates clinical severity •Hoarding Rating Scale-Self Report (HRS-SR) 5-item scale assessing clutter, diff discarding, acquisition, distress, & impairment BUT not perceived need to save items, reasons for difficulty discarding, or associated features, so NOT DIAGNOSTIC -good for screening patients, both

Hoarding: Stigma and Ethics

•Stand alone disorders vs. sxs of OCD •Misconceptions in the general public •Length of time until treatment •Serious health & safety concerns for self, family, pets, neighbors Possible losing home: eviction •Clutter impacting home quality of life: self & family members •Financial impact: never ending cost of stuff •Treatment, esp. discarding is highly distressing (accumulating ego-syntonic, discarding ego-dystonic) Underlying beliefs, emotions & trauma Focus on quality of life for self, family (incl. pets) -Think about quality of life and how to slow get gains for this person in improving their quality of life

HD: Hoarding Disorder

•aka Compulsive Hoarding: excessive, impulsive, pathological (Idea is person is accumulating stuff of some kind and getting rid of the stuff is v distressing.) •Chronic need to accumulate & distress about discarding -Primary Hoarding: the main disorder -Secondary Hoarding: developmental, neurological, psychiatric conditions (The old idea was that hoarding was just part of other disorder, but now we recognize that there's a primary hoaring disorder but it CAN BE a seconday sxs.) •Results in clutter & chaotic environment, may be UNSAFE (Concerning bc it results in clutter and chaos and can create unsafe environment. So its important to catch before this happens) There are some ppl that accumulate stuff and ARE NOT hoarders::: Diff: stockpiling is accumulating a reserve but its usually organized, has a purpose,,,not clutter.Goes w the survival plan. And odesnt ivvolve a stress.impairment • Stockpiling: accumulating a reserve supply, organized, purposeful, usually without clutter, distress or impairment •vs Collecting: organized, targeted, systematic, usually without clutter, distress, or impairment (This collecting is organized and targeted and systematic. Usually doesn't involve clutter. Its possible tht there may be a grey area there.) •Insight: may be poor with impairment apparent only to others (may be poor, ppl may have great diff in recognizing the extent of their problem)