Hoarding Disorder Case Study

welcome to my scientifically informed insider look at mental health topics if you find this video to be interesting or helpful please like it and subscribe to my channel Louis is dr. Grande today's question asks I can analyze case study involving hoarding disorder so a case study or a case report is completed when a counselor wants to document a client's course of treatment right so what the symptoms were and how the treatment progressed things like that this is done with the clients consent and details are changed to protect the clients identity case reports appear in a variety of places the one I'm using for this video was published in a journal and I'll put the reference to the article in the description for this video so first I'll talk a little bit about hoarding disorder including going over the definition and then I'll take a look at this case study hoarding disorder was first introduced as an official mental disorder in 2013 with the publication of dsm-5 Diagnostic and Statistical Manual version 5 before that the symptoms of hoarding were recognized but it was thought that they were really a possible expression of obsessive compulsive disorder OCD or perhaps related to psychosis in some cases we see people speculated that they may be connected to obsessive compulsive personality disorder OCPD one of the symptoms for that disorder is an inability to throw out worthless items so we see a bit of a connection there now the criteria for hoarding disorder in dsm-5 is fairly straightforward we see a persistent difficulty discarding possessions regardless of their value the difficulty is due to a perceived need to save the items or to de-stress associated with discarding the items the difficulty results in the accumulation of possessions and that causes congestion in the living areas now there's an exception with this particular criterion if like relatives come in and clean out somebody's house they could still meet this criterion right so if they had not intervened would the house be cluttered next we see clinically significant distress so if somebody accumulates a lot of items and doesn't cause them dysfunction it's not a disorder we see the difficulty can't be better explained my medical condition or better explained by another mental disorder like OCD major depressive disorder or schizophrenia about eighty-five percent of individuals with the disorder are eligible for a specifier called excessive acquisition so a specifier modifies the primary diagnosis right so it would be hoarding disorder with excessive acquisition if somebody had that it's most commonly seen in the form of buying next we would see acquiring free items and sometimes we see stealing but this is fairly uncommon there are some other specifiers as well for hoarding disorder and all of them have to do with insight better insight is associated with a better prognosis so looking at these three specifiers we see with good or fair insight so the person recognizes that the hoarding related beliefs and behaviors are problematic then we have with poor insight so the person mostly believes that the beliefs or behaviors are not problematic and then we see with absent insight delusional beliefs so the person is completely convinced the hoarding related behaviors are not problematic so now taking a look at some other characteristics of chording disorder they kind of tie to this particular case that I'm looking at we see that perfectionism avoidance being disorganized procrastinating being highly distractible and indecisiveness are all tied to hoarding disorder which of course is an interesting mix of characteristics perfectionism is associated with high conscientiousness if you're indecisive and disorganized that would be associated with low conscientiousness so we see kind of splitting that trait we see that high extraversion is related to hoarding disorder which is somewhat surprising we would tend to think there would be really no association with extraversion and high in eroticism is associated with the disorder and this part isn't really surprising at all someone over the age of 55 is three times more likely to have chorong disorder as compared to somebody between the ages of 34 and 44 females with hoarding disorder are more likely to seek treatment than Mae and females are at a greater risk to have that excessive acquisition specifically through the buying form right so the excessive acquisition specifier and the acquisition is through excessive buying also we see that individuals with this disorder tend to live alone now this one's not really clear in terms of why this is the case my thinking is that if somebody has these tendencies and they happen to live alone there's a greater chance that those symptoms would manifest if they live with somebody else that other person might prevent the acquisition of items right so that might explain this association between living alone and the disorder so this case study was published in 2001 and even though the DSM for text revision came out in 2000 my guess is the events in this case study took place before 2000 which is why they used DSM 4 in the case report DSM 4 was published in 1994 even going back this far many theorists considered hoarding behavior to be indicative of a separate syndrome it was typically referred to as compulsive hoarding so now taking a look at this particular case the client in this case was a 72 year old divorced Caucasian female I will refer to her as Tracy Tracy was initially encountered when she was referred to an outpatient group for women at intake she presented with symptoms of depression memory problems difficulty concentrating and trouble finding the right words a neuropsychological assessment was conducted but no evidence of dementia or a neurological problem was identified the symptoms were attributed to the depression and anxiety she was experiencing Tracy worked part-time as a sales clerk and lived independently in her own home she described herself as a pack rat but did not elaborate beyond that initially as I mentioned Tracy was divorced her marriage lasted 15 years and she had two daughters from that marriage her husband was physically and emotionally abusive Tracy reported that she started drinking alcohol to manage her feelings and she became addicted she went to Alcoholics Anonymous for several years after her and stayed sober for more than two decades her relationship with her daughter's was damaged because of her alcohol use Tracy had two main stressors on her mind at the time of intake her younger daughter's marriage was coming up and she was anxious about seeing her ex-husband at the wedding that stressor resolved through the group therapy that she was receiving the second stressor was her experience of loss when her eldest daughter son-in-law and grandchildren moved to another state her daughter had invited them to move out with her and reside in a nearby senior living community Tracy felt she couldn't do that because she was trapped in her home by all of her possessions so we see here that Tracy actually asks for help at this point with compulsive hoarding which she had been struggling with for 10 years it's worth noting that she did not meet the criteria for OCD or OCPD stressing the importance of hoarding disorder as a separate diagnosis which again would become available and the sm5 fortunately these counselors recognized Tracy's needs even without the diagnosis being available in DSM for now typically if somebody has OCD and they manifest hoarding behavior the behavior is highly distressing to them they're not satisfied with it there's no pleasure in it and excessive acquisition is usually absent so the clinical picture is a lot different when we see OCD even still 20% of individuals with hoarding disorder meet the full criteria for OCD so OCD and hoarding disorder can become orbit now Tracey's behavior was satisfying to her however it was associated with a lot of shame we see that she didn't ask for help until she'd been in group therapy for 12 weeks and individual therapy for six weeks so it took her a while to talk about the subject Tracy had collected a wide variety of items in her home including furniture kitchenware paperwork books figurines and clothing she considered many of the items to be sentimental so as she was thinking about one particular item that might bring back memories associated with when she obtained it or when she used Tracy would go shopping when she felt down or lonely and would buy a large quantity of items even though she didn't need them so Tracy's goal was really around that second stressor I talked about as I mentioned the first one had resolved so her goal was to clean out her house sell it and then move to where her eldest daughter left so the next stage in terms of treatment here was the intervention which is fairly common with hoarding disorder one of the keys of course with the intervention is having permission to carry it out many people with this disorder will not permit an intervention right because of the stage people are coming into the house and clearing out all the stuff so just the fact that Tracy agreed to the intervention was a good sign that she would recover the agency took a proactive approach and also tried to maintain Tracy's sense of personal empowerment they indicated to her that she was in charge of how the cleaning of the house took place she would be supported throughout the process and agency staff would be active participants in the physical work of identifying and discarding items now when I read this in the case report I was thinking how many agencies would allow their staff to participate in the actual cleaning part right so I know this took place a while ago perhaps it was a bit more common to do this back then but even still I was surprised by this part a little bit another important point the intervention isn't the only aspect of treatment we see that a client can allow an agency to clean out their house but that doesn't mean the underlying reasons for the hoarding behavior have been addressed as the agency staff prepared for the intervention they first wanted to determine if there had been any prior attempts to remove the clutter and to what extent Tracy's house was cluttered this was a smart move not just rushing in and trying to clean things out but rather taking a step back and trying to identify obstacles and figure out the extent of the problem as far as prior attempts attempts had been made but they had failed they only led to frustration and anxiety looking at the extent of the clutter about 75% of the space was occupied by clutter there was only enough space for one person at kitchen table and one person on the sofa Tracy had piles of newspapers magazines knickknacks plates glasses old toys books boxes and furniture some of those items I talked about before there were items in just about every room in the house two bedrooms were used only to store items most of the windows were completely or partially blocked there were narrow pathways available to walk throughout the house this is actually pretty common with hoarding I've seen this a few times this can also be quite dangerous outside of the obvious risk of fire there are tripping hazards and I've even heard situations where people were trapped by an avalanche of items like books or newspapers so really quite frightening they found five-year-old Easter baskets that she had purchased that still had wrapped candy in them another one of the risks we see here food going bad the walls in one of the bedrooms had damaged consistent with small roads right so actually we see quite a few hazards with this behavior after this assessment the agency staff started with the planning stage they talked about the option of donating and recycling some of the items which i think is much more acceptable to people most of the time than just throwing something out because it feels like there's some sort of good that comes out of it like all the behavior wasn't just for nothing Tracy struggled during the stage she had difficulty deciding what would be thrown out she also had difficulty knowing where to start this is also fairly common but not just with hoarding behavior when we see any situation that potentially involves an overwhelming amount of change people just don't know where to make the first step they don't know what to do to get the ball rolling so this is where the counselors can really help in terms of kind of pointing out the first step now Tracy did some role-playing with the counselors they went through some scenarios where they might disagree on a particular item that was being considered for removal they wanted to set an expectation that this would be a difficult process with tough decisions but ultimately Tracy was in charge all right so that's the tone that they were setting here I think this was another smart move setting the expectation that there would be some arguments back fourth it wasn't going to be all happy right there was gonna be some struggle here there was gonna be a debate and that process was okay right they really normalized disagreeing and having that debate after this they had to get to the actual removal of the items the team comprised her individual counselor her group counselor another counselor from the agency and Tracy's case manager when the team arrived Tracy had already marked some clothing for donation the clothes had tags on them and they never been worn I've seen this several times as well you'll see these closets full clothes with the tags on them they're really in perfect condition unless there's been some sort of damage caused by water or creatures or something like that but typically you'll see just all the clothes lined up the tags on them and it just seems like such a waste they were purchased and never used at all it's almost like they're just there for a sense of security like the person has another outfit to wear if they need it but they never go ahead and do that another behavior I've seen that wasn't really talked about in this case report is individuals buying multiple sets of the same type of clothing right so if it's a particular shirt or a dress they'll buy several of that shirt or several that dress and only wear one almost like again they want to have several backups so either way back to Tracy we see she started designating other items that could be donated and recycled and indicated that she was relieved that the items had someplace to go connecting back to what I said earlier that's some good coming from the clean-out so these items may still have some use so Tracy was off to a good start but it wasn't all smooth sailing she struggled with getting rid of some items especially where there was some type of emotional connection here we see the team took pictures of the different possessions and made a scrapbook so they were trying to preserve the memory really honored the emotional connection to the items without actually keeping the items I thought this was also a clever move this would have been much easier these days and the case report we see they used a Polaroid camera nowadays somebody could use a smartphone which would be cheaper easier and more efficient another strategy they used was being open to the possibility that they were making mistakes by throwing out some of the items this is actually a reasonable assumption even though most of the items were not useful to Tracy and variably during an intervention like this people will throw out items that actually would have some use for them in the future here they emphasize the ability to rectify any mistakes if an item was thrown out that she needed she could replace it at a later date it was worth taking that risk to get the house cleaned out to meet the ultimate goal obviously this is a harder sell when talking about something that is in fact irreplaceable so when all this was said and done Tracy had donated recycled or discarded 85 boxes of books 25 bags of clothing 10 boxes of toys 10 boxes of collectibles and more than 20 bags of garbage that reduced the amount of clutter in the house by half now when I first read that I was a bit surprised I thought with all those quantities going out the reduction would have to be more dramatic than that but that was just half the clutter I thought for sure it was gonna be something like down to 10% right but of course half is still a significant improvement as I mentioned before the intervention with hoarding disorder is not everything the underlying reasons have to be addressed and the client has to maintain the gains that were made well in this case due to a restructuring that occurred at the agency Tracy was actually disconnected from all counselling services it's not clear from the report if she was referred to another agency or if she declined a referral evidently she still had case management services and a case manager indicated that within three months Tracy had disposed of the rest of the items and her home was being repaired six months later she moved into a condominium near her daughter the new case manager indicated that Tracy was working part-time and was having no significant symptoms of depression or anxiety often when I read these case studies I look at the treatment that was selected and I think okay that was appropriate of course that kind of makes sense if the people selected the case for a case report they're going to usually pick situations where their treatment was appropriate but even still I usually find a number of things that I would have done differently with this particular case report though I was pretty happy with pretty much all the strategies they used they were quite clever and they really thought things out pretty well I really admire to the dedication and the hard work that the counselors and the case manager invested here now of course these strategies would be unlikely to achieve success with somebody who had a lack of insight if the client didn't understand that the cutter was interfering with their goal there would be no reason to remove the clutter but for somebody with enough insight to appreciate the consequences of the hoarding behavior I think these treatment strategies really make a lot of sense I know whenever I review case studies there will be a variety of opinions please put any opinions and thoughts in the comment section they always generate an interesting dialogue as always I hope you found my analysis of this topic to be interesting thanks for watching

Channel: Dr. Todd Grande

Views: 364,671

Keywords: hoarding disorder, compulsive hoarding, persistent difficulty discarding possessions, accumulation of possessions, clinically significant distress, OCD, OCPD, obsessive-compulsive, major depressive disorder, MDD, schizophrenia, delusions, psychosis, intervention, diagnostic and statistical manual

Id: bSQr9pADsL8

Length: 18min 52sec (1132 seconds)

Published: Sat Mar 28 2020