CBT Solutions of Baltimore Presents: Underneath It

When Stuff Mounts:
Hoarding, Clutter, and Mental Illness
Gregory S. Chasson, Ph.D.
Licensed Psychologist
Assistant Professor
Department of Psychology
Towson University
Principal Investigator
Site for OCD & Autism Research
Co-Owner and Clinical Director
CBT Solutions of Baltimore
What is Hoarding Disorder (HD)
 Persistent difficulty discarding or parting with
possessions, regardless of actual value.
 Accumulation of possessions that clutter active living
areas and compromising their intended use.
 The hoarding causes clinically significant distress or
impairment in functioning (including maintaining a safe
environment for self and others).
 Many have excessive acquisition (excessive collecting,
buying or stealing items that are not needed or for
which there is no space)
(APA, 2013)
Degrees of Clutter
Degrees of Clutter
Pictures from the Clutter Image Rating scale (Frost, Steketee, Tolin, & Renaud, 2008)
Degrees of Clutter
Living Room
Pictures from the Clutter Image Rating scale (Frost, Steketee, Tolin, & Renaud, 2008)
Impact of Hoarding in MD
 Over 200,000 individuals with hoarding difficulties are estimated to
reside in Maryland*
 But only than a handful of providers are trained to administer
evidence-based cognitive-behavioral therapy (CBT) for hoarding, the
 Huge bottleneck for effective services
 Hoarding costs the State of Maryland roughly $45 million per year**
*Extrapolated from Samuels et al, 2008
**Extrapolated from San Francisco Task Force on Compulsive Hoarding, 2009
 Hoarding occurs in 2-5% of adults
 Symptoms are usually present at early adolescence
 11-20 years
 68% before age 20
 Late onset is rare
 Average age that people seek treatment is 50-60’s
 Course tends to be chronic and symptoms worsen over time
(Ayers et al, 2010; Grisham et al, 2006; Samuels et al, 2008; Tolin, Meunier, Frost &
Steketee, 2010)
Prevalence Continued
 Studies have been inconsistent regarding gender
 According to Timpano et al. (2011), prevalence does not
appear to differ between males & females
 However, Samuels et al. (2008) found the prevalence of
hoarding was about two times as great in men compared
to women
 Far more women present for treatment
Hoarding v. Collecting
Chronic Course
Collecting Decreases each decade of
Object content not as thematic
Thematic object content
Objects rarely used
Objects more likely to be used
Acquisition process is less purposeful &
Acquisition process is purposeful &
Purpose  control, safety, personal
Purpose  hobby/leisure, set
completion & public identity
Low organization
High organization
Room functionality compromised
Room functionality not compromised
Distress and impairment
No distress or impairment
Interpersonal conflict
Less interpersonal conflict
(Nordsletten, Fernández de la Cruz, Billotti, & Mataix-Cols, 2012)
Risks & Consequences
Risks & Consequences
 Hoarding is associated with substantial functional
 Clutter prevents people from using their space for it’s
intended purpose & basic activities
 Hoarding is responsible for 24% of fire-related deaths.
 Fires are 16 times more expensive for fire departments to
extinguish when hoarding is at play
 Overall property damage is 8 times more costly when hoarding
is involved.
(Lucini, Monk, & Szlatenyi, 2009, Tolin et al., 2010)
Risk & Consequences Continued
 Nearly 40% of people with hoarding tendencies live in poverty
 Medical complications are common in hoarding
 obesity, asthma, 11-fold increased risk of stroke,
medication & dietary mismanagement
 Property damage (diminished value of or loss of home
 Eviction and/or condemnation of home
 Removal of children from the home
(Tolin et al., 2010; Ayers et al., 2010; Steketee et al., 2001;
Tolin, Frost Steketee, Gray & Fitch, 2008)
 Compulsive Buying
 Retail, discount, thrift stores
 On-line shopping (Ebay, Home Shopping Network,
retail/catalogues, etc)
 Acquisition of Free Things
Give-aways and freebies
Trash-dumpster diving
 Stealing/Kleptomania—10%
 Depression (50%)
 Social Anxiety
 Obsessive-Compulsive Disorder (20%)
 Attention-Deficit/Hyperactivity Disorder
Hoarding Behavior in Other
 Physical trauma to brain
 Stroke
 Traumatic injury
 Dementia
 Frontotemporal dementia
 Mental retardation
 Prader-Willi syndrome
 Autism
 Schizophrenia
 Most hoarding cases do not have these.
Understanding the Features of
Hoarding: The How & Why
General Conceptual Model:
 Genetics
 Vulnerabilities (Personal & Family)
 Information processing problems
 Meaning of possessions/thoughts, beliefs & attachment
to possessions
 Emotional reactions
 Learning processes
(Steketee & Frost, 2014)
Lower cerebral glucose metabolism in dorsal anterior cingulate gyrus
12 hoarding vs 33 nonhoarding OCD; PET; (p<0.001)
(Saxena et al., 2004)
Anterior cingulate
 motivation
 problem solving
 executive control
 detecting errors
 focused attention
 selecting responses
 assigning emotional valence
to stimuli
 decision-making
Traumatic life events
 Childhood adversities
 Excessive physical discipline
 Psychiatric symptoms in parent
 Home breakins
 Ever in lifetime
 Physically handled roughly
 Forced sexual activity
 Something taken by force
Reasons for Saving
 Emotional Attachment: “This item is part of who I am. It
represents my life.”
 Responsibility: “I might need this. It would be wasteful to
get rid of it because someone could use it.”
 Control: “People have no right to touch my possessions.”
 Memory: “If I get rid of this, I will forget it.”
(Steketee, Frost, & Kyrios, 2003)
Quick Summary
• In general, disappointing research evidence for psychopharmacological
treatment for hoarding
• Standard psychotherapy, including standard cognitive-behavior therapy
(CBT), has also yielded disappointing research evidence
• BUT, one specific manualized treatment called CBT for Hoarding
(Steketee & Frost, 2014) has received some evidence is currently the
gold-standard treatment (Steketee et al., 2010)
• This manualized treatment is not your standard CBT approach….
(Muroff, Bratiotis, & Steketee, 2011)
CBT for Hoarding Protocol
FAM Training
• Sometimes family members are the most vocal, so I have created a
program to leverage this family-member energy
• My research lab is conducting a waitlist controlled trial of a family-based
approach called Family-As-Motivators Training (FAM Training)
• FAM Training is designed to teach family members of loved ones with
hoarding 1) how to cope with the hoarding and 2) how to help motivate
the loved one to seek treatment
• A family member of the loved on with hoarding participates in 10 twiceweekly 50-minute sessions at Towson University
FAM Training Pilot
• A pilot study of FAM Training yielded highly encouraging results (Chasson
et al., in press)
• Family members improved in the use of certain coping strategies and in
the application of motivational interviewing techniques
• They also exhibited increased hopefulness, reported a reduced negative
impact of HD on the family, rated a reduction in family enabling of HD
behaviors, and displayed boosts in HD and motivational interviewing
FAM Training
• FAM Training is free of charge for the family member
• Loved one with hoarding must participate in some assessment, but gets
$105 for the time and commitment
For more information about the study, please contact Dr. Chasson at
(410) 704-3261 or
[email protected]
Visit us online at www.soartu.org
Thank you!!!
Gregory S. Chasson, Ph.D.
Licensed Psychologist
Assistant Professor
Department of Psychology
Towson University
(410) 704-3261
[email protected]
Co-Owner and Clinical Director
CBT Solutions of Baltimore
(443) 470-9815
Who is Dr. Chasson?
Gregory S. Chasson, Ph.D., is an Assistant Professor in the Department of Psychology at
Towson University and licensed psychologist specializing in the assessment and treatment
of obsessive-compulsive disorder (OCD) and related conditions, including hoarding
disorder. During his clinical psychology doctoral training at the University of Houston, he
completed a two-year externship and research coordinator position at the OCD
Treatment Program of the Menninger Clinic. He also completed three years of pre- and
postdoctoral training at Harvard Medical School, where he worked at the OCD Institute
at McLean Hospital and OCD and Related Disorders Program at Massachusetts General
Hospital. Dr. Chasson currently serves as principal investigator in his research lab at
Towson University—the Site for OCD & Autism Research (SOAR)—where he just published
a promising pilot study of his Family-As-Motivator (FAM) Training for family members of a
loved one with hoarding. He is currently the principal investigator on an externallyfunded waitlist controlled trial of FAM Training. Dr. Chasson also co-owns and directs a
group cognitive behavior therapy practice in Lutherville that specializes in the
assessment and evidence-based treatment of OCD and related conditions, and patients
with hoarding make up a significant percentage of the caseload. Other than FAM
Training, his research on hoarding has included investigations of cross-cultural
manifestations (e.g., China), as well as personality correlates of the condition. He is
also contracted to co-author a book for training mental health professionals in the
treatment of hoarding: Hoarding Disorder: Advances in Psychotherapy—Evidence Based
Practice (Hogrefe Publishing, slated for 2015).
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: Fifth edition. Washington, D.C.: American Psychiatric Publishing.
Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. (2010). Age at onset and clinical features of late life compulsive hoarding. International Journal Of
Geriatric Psychiatry, 25(2), 142-149.
Chasson, G. S., Carpenter, A., Ewing, J., Gibby, B., & Lee, N. (in press). Empowering families to help a loved one with hoarding disorder: Pilot study of familyas-motivators training. Behaviour Research and Therapy.
Frost, R.O., Steketee, G., Tolin, D.F., Renaud, S. (2008). Development and validation of the clutter image rating. Journal of Psychopathology and Behavioral
Assessment, 30,193-203.
Grisham, J. R., Frost, R. O., Steketee, G., Kim, H., & Hood, S. (2006). Age of onset of compulsive hoarding. Journal Of Anxiety Disorders, 20(5), 675-686.
Lucini, G., Monk, I., & Szlatenyi, C. (2009). An analysis of fire incidents involving hoarding households. [Interactive Qualifying Project, Worcester
Polytechnic Institute]
Muroff, J., Bratiotis, C., & Steketee, G. (2011). Treatment for hoarding behaviors: A review of the evidence. Clinical Social Work Journal, 39(4), 406-423.
Nordsletten, A. E., Fernández de la Cruz, L., Billotti, D., & Mataix-Cols, D. (2012). Finders keepers: The features differentiating hoarding disorder from
normative collecting. Comprehensive Psychiatry, 54, 229-237 .
Samuels, J. F., Bienvenu, O., Grados, M. A., Cullen, B., Riddle, M. A., Liang, K., & ... Nestadt, G. (2008). Prevalence and correlates of hoarding behavior in
community-based sample. Behaviour Research And Therapy, 46(7), 836-844.
San Francisco Task Force on Compulsive Hoarding (2009) Beyond overwhelmed: The impact of compulsive hoarding and cluttering in San Francisco and
recommendations to reduce negative impacts and improve care. San Francisco, CA: Mental Health Association of San Francisco.
Saxena, S., Brody, A., Maidment, K., Smith, E., Zohrabi, N., Katz, E., & ... Baxter, L. (2004). Cerebral glucose metabolism in obsessive-compulsive hoarding. The
American Journal Of Psychiatry, 161(6), 1038-1048.
Steketee, G., & Frost, R. O. (2014). Compulsive hoarding and acquiring: Therapist guide (2nd ed.). New York, NY US: Oxford University Press.
Steketee, G., Frost, R.O., & Kyrios, M. (2003). Cognitive aspects of compulsive hoarding. Cognitive Therapy and Research, 27, 463-479.
Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder.
Depression And Anxiety, 27(5), 476-484.
Timpano, K. R., Exner, C., Glaesmer, H., Rief, W., Keshaviah, A., Brahler, E., & Wilhelm, S. (2011). The epidemiology of the proposed DSM-5 hoarding disorder:
Exploration of the acquisition specifier, associated features, and distress. Journal Of Clinical Psychiatry, 72(6), 780-786.
Tolin, D. F., Frost, R. O., Steketee, G., Gray, K. D., & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160(2),
Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2010). Course of compulsive hoarding and its relationship to life events. Depression And Anxiety, 27(9),

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