and let you know that the slides for this session are connected to the app and also available at the clinical updates toolkit on the APA website. So we have three speakers today, and I will read very brief introductory comments of our speakers, and then they will take over. Dr. Carolyn Rodriguez is Associate Dean for Academic Affairs at Stanford University School of Medicine, and a consultation liaison psychiatrist at Palo Alto Veterans Affairs Hospital. Dr. Randy O. Frost is the Harold and Elsa Cipolla Israel Professor of Psychology at Smith College. He's an expert in obsessive-compulsive disorder, hoarding, and the pathology of perfectionism, and has published more than 100 scientific papers on these topics. Dr. Michael G. Wheaton, Assistant Professor of Psychology, joined Barnard's faculty right up the street here. Prior to coming to Barnard, Dr. Wheaton was a postdoctoral clinical researcher at the Anxiety Disorders Clinic of New York State Psychiatric Institute, and he previously taught at Yeshiva University. So, where are we starting? Thank you, Ron. We're going to cover three things today as we go through our clinical update regarding hoarding disorder. We're going to spend some time talking about what is hoarding, looking at symptoms and diagnoses. We're going to touch on why people hoard. We're going to talk about a conceptual model that organizes our current level of knowledge about hoarding and tries to integrate it into some fashion so that we understand where we're going with the research on this topic. And then finally, we're going to talk about how we treat hoarding disorder. So, let's start with what is hoarding. The DSM-5, as you probably know, lists hoarding as one of the new diagnoses in the 2013 version. I'm going to go through it quickly because we have a lot of other stuff to get to. This is sort of the overview of it. There are four inclusion criteria. One is persistent difficulty discarding or parting with possessions regardless of their actual value. Now, we'll talk about that issue, that little phrase, in a few minutes and what that means and why it was included here. The second diagnostic criteria is this is due to perceived need to save the items and distress associated with discarding them. This is the key feature of the disorder, this difficulty discarding. This criteria is designed to separate it from saving issues that are more motivational. For instance, in depression, people don't have the energy to get rid of things or to discard things. The third criteria is the accumulation of possessions that clutter active living areas of the home, which is a key piece of this, and substantially compromise their intended use. This diagnostic criteria is not really about the behavior. It's about the consequences of the behavior. In a sense, it's a step down in terms of an inclusion criteria. It's the product of the problem. It's not necessarily a problem in itself except that this is what interferes with people's ability to live comfortably. There's a caveat here is that if the living areas are uncluttered, it's only because of the behavior or interventions of third parties like family members, cleaners, authorities, health departments who come in and clean out the house of a particularly difficult hoarding case. The fourth inclusion criteria is that this causes significant distress or impairment in social, occupational, or other important areas of functioning, including maintaining a safe environment for self or others. Again, this is a consequence of the behaviors we're going to be talking about. Two inclusion criteria here are pretty common in the diagnostic code for other disorders in this section. It's not attributable to another medical condition, and it's not better accounted for by another DSM-5 disorder. We're going to have a lot of time to talk about that, but there are cases of OCD that look much like hoarding disorder but wouldn't qualify for hoarding disorder. The same is true for autism spectrum disorder, psychotic disorder, and sometimes dementia. There are two diagnostic specifiers. Once the diagnosis is made, you specify whether or not this is accompanied by excessive acquisition. I'm going to postpone that and talk about acquisition in a moment and move on to the second diagnostic specifier, which is insight. This insight specifier is common to the disorders in anxiety and obsessive-compulsive disorder section, good or fair, poor or absent. Interestingly, there's a problem here we have with determining insight in hoarding. When we look at the research that's been done in research samples, that is people who show up for treatment or people who we solicit to volunteer for our studies, in these samples about 16% of them are judged to have absent insight. But in community samples, now these samples involve samples that are drawn from health departments, elder service agencies, where people aren't coming in for treatment, but they are identified by other people. And here, about 50% of the cases in these studies are judged by these authority figures, the workers, as having absent insight. Now, the problem is that it's not entirely clear in a hoarding disorder what absent insight is. Now, when we think about insight, we think about the classic notion of insight, which is anosognosia, the inability to recognize a problem. And for many people with hoarding disorder, it kind of looks that way. But there are a couple of reasons why it might not be a true anosognosia. The first of those is a phenomenon that we see frequently in hoarding, which we call clutter blindness. And this is a case where an individual pretty much habituates to the level of clutter in their home. So when you visit them in the home, or when you talk about their home, they say, my home is fine, I get along fine, all the stuff doesn't bother me, and so forth. But when that happens, often we have a real funny phenomenon when we show them a picture of their home. When they're in the clinic, we show them a picture of their home. They look at it, and it is as though they're viewing their home for the first time. It's a two-dimensional representation of the clutter, and for some reason, they look at that, and many of them don't even recognize that as their home. That's not my home, that looks terrible. And so that's a piece of this puzzle of what is insight. Is it the case that what we think of as absent insight is simply a matter of having habituated to living and being comfortable in that environment? And the other problem with determining insight has to do with the defensiveness and resentment that we see among many of the cases of hoarding disorder. If you've treated some of these folks, you probably have seen this. We have to keep in mind that most of the time when we see patients with hoarding disorder, they have suffered decades' worth of criticism from family members, from friends, from authorities, and so forth, and that's left them very defensive. And so what we see here with respect to admitting or recognizing the problem is a high level of fear, shame, feelings of being overwhelmed with trying to cope, and also a sense of hopelessness. So the judgment of what is absent insight is a little bit complicated in hoarding disorder. So what I want to do now is I want to walk you through the home of a person with a moderate hoarding problem. This is one of our early cases, and I want you to notice a couple of things. First of all, if you notice all the stuff on this kitchen table, you'll see a wide variety of things. It looks like there's a milk carton, egg cartons, newspapers, ribbons, light bulbs, phone books, and so forth. A seemingly random assortment of things. Keep that in mind because that's a clue. It tells us something about something that's going on. We'll come back to that. This is her dining room, and you can see it's a slightly different kind of stuff, mostly clothes, but there are also toys, books, and the lids for containers you see up here in the sort of middle left-hand side of the picture. And that tells us a couple of things. First of all, those blue lids there are for storage containers. So what that tells us is that this woman has been trying to do something but clearly failing because the material that she's collected to try to deal with this problem ends up in the pile. This is the same room from another vantage point, and I show it because the door that you see is the door to her home. And so if there were a fire, she would have difficulty getting out. The rest of the phenomenon is pretty much the same, a wide assortment of things. Again, here we see the room where she spends most of her time, and what she said to me is that she sits there for three hours almost every day trying to sort through her stuff, again, telling us that she's trying to do something, but it is wildly ineffective, and that's another key to what's going on with hoarding problems. Now here we see up in her upstairs hallway bags filled with gifts. These are things that she's purchased over the last decade, and the idea for her is that these gifts are not really part of the problem because they belong to someone else. She just hasn't given them out yet. The same thing happens every time. She's out shopping, she sees something, and she thinks, that would make a great gift for someone. She buys it, puts it in the bag, and it ends up here for decades. You also see clutter outside the home in approximately a third to a quarter of the cases. These are the ones that are more likely to be identified by the health department and something done because of complaints from neighbors. We also see that whatever space is available to the person gets filled, and sometimes that involves cars as well. Now we've had this sort of picture, and this is one of our early cases. This is a woman who came to me because her husband told her that she had to clean up the house or he was leaving, and she couldn't do it, so he left. Now she's concerned about losing her children in the upcoming divorce, so she came to me for help. So what I want to do is I want to start breaking down what we're seeing here, the manifestation of hoarding that we see, and this goes beyond the DSM criteria, which is sort of surface level. There are three main manifestations. The first is acquisition. This stuff has to come in somehow, so we want to take a look at that. The second is saving behavior because that's really what we're dealing with here Is it saving behavior? Is it difficulty discarding? So that's the second thing. And the third feature that is prominent here is disorganization. I want to talk a little bit about each of those specifically. So there are four ways in which we acquire possessions. Buying, acquiring free things, stealing, or passive acquisition. Junk mail that comes into our home, for instance. What we see in hoarding is the primary means of acquisition include buying and acquiring free things. And I'll show you some data. This is one of our studies looking at excessive acquisition in hoarding, and what we found with the hoarding cases in this sample, a fairly large sample, is 60% reported excessive levels of acquisition. 28% reported that currently they didn't have excessive levels of acquisition, but they had in the past 4% who said they didn't have current problems nor past problems, but what they did was avoid places to go where they might acquire things. One of the things we find with cases coming in is people, when they say, I don't have an acquisition problem, it's largely because they're avoiding places to go. Now the woman whose home we toured just a moment ago could not come to New York City because if she came to New York City, invariably she would see a news kiosk on the street and she would think to herself, look at all those newspapers and all those magazines. Somewhere in all of that, there's a piece of information that could change my life. How can I walk away without it? And she started by simply crossing the street and looking away, but that got too hard, so she stopped coming to the city altogether. And that's quite common here. So in the end, if you look at this pie chart, only about 8% of this sample of people with hoarding problems had no evidence of excessive acquisition of one sort or another. So that specifier is going to be attributable probably to about 90 to 95% of people with hoarding disorder. So it's something to look at because many times when people come in for treatment, they deny that it's a problem. Now the most frequent means of acquisition is buying, but collecting free things also is prominent. This is a separate sample that we're looking at, and you can see compulsive buying is the highest level of acquisition, followed by free things, but most people, well above 50%, engage in both buying behavior and collecting free things to an excess. The second manifestation is the saving behavior or difficulty discarding. Two issues really to deal with here. First has to do with the type of items. Type of items, most people say the highest frequency items, clothes, newspapers, books, containers. When you compare that with the population who does not have hoarding problems, these things are also at the top of the list. So the nature of the items that are saved typically is not that much different than it is for people who don't hoard. It's just that people who hoard save more of them. Now, remember in the diagnostic criteria, this phrase, regardless of their actual value, that comes about because there's a diagnostic criteria in obsessive-compulsive personality disorder that has to do with an inability to discard worthless and worn-out things. One of the initial myths about hoarding disorder was that that's for people who collect things that are worthless and worn out. It's simply not true. People who hoard collect everything. We've got cases of people whose homes are filled with brand-new things, clothes with a tag still on, appliances not out of the box, and so forth. So it's really a collection of everything. And so it's not really a disorder having to do with worthless and worn-out things. When we look at types of items, we try to see whether there are different types of hoarding based on the items, and the only thing that comes up here that's different in some way is the hoarding of animals. We're not going to talk about that. It's a complicated subject, but it may be closer to a delusional disorder than a hoarding disorder, but it probably still fits within the hoarding disorder category. The other issue related to saving has to do with the nature of the attachment people have to these things. And when we look at what kinds of attachments people have to their objects, again, the nature of the attachments are no different than the nature of all of our attachments to things. We get attached to things for sentimental reasons, we get attached to things for instrumental reasons, meaning they're useful to us, or we get attached to things simply because we like them, like a picture on the wall and so forth. That's exactly the same for people with hoarding and not. Now, we'll dive into the more specific kinds of motivational issues with respect to hoarding and saving behavior in a few minutes, so we'll come back to that. The third manifestation has to do with disorganization. There are two ways in which disorganization shows up here. One is in the condition of the home. This clutter is a manifestation of the disorder. There's a mixture of important and unimportant things. So somewhere in this pile is a diamond ring she lost a couple of months ago, a letter from her insurance company that she needs to find because of an accident that she had, and probably the sort of funniest of these is when I would go to her home and we would work on getting rid of things, that she had piles and piles of newspapers. One day when I arrived, she said, today I think I can throw out a whole New York Times without looking at it. And she picked it up off the pile and she shook it, and I just want to make sure there's nothing important here. She shook it and out fell an ATM envelope with $100 in cash. Not a good therapeutic moment. And I wondered later whether she planted it there. But I don't think she did. So the condition of the home is a part of this disorganization. Now, we will see some cases of hoarding that involve squalor. Only 10% to 15%, but it is there. Now, squalor is an interesting topic because there are people who live in squalor who don't hoard. So there's some kind of overlap there. The other kind of disorganization we see is disorganization of behavior. Churning behavior is something we see frequently when we're trying to work with someone. So this woman would sit, and this is where this three hours of work came in. She sat on that couch and she would pick an item up and try to decide something about it and basically set it back down and go on to the next item because this item was too difficult. She'd set it down. And so the pile got churned without anything really being given away or thrown out. The other feature here of behavioral disorganization has to do with the fear that these folks have of putting things out of sight. I didn't show you her bedroom, but it looked like much of the rest of the house. Clothes on top of the dresser all the way to the ceiling, but her dresser drawers were empty. And what she said was, if I put my clothes in the drawer, I won't be able to see them. If I can't see them, they'll be lost to me. So keep that in mind because here we're seeing manifestations of a tendency to rely on visual cues for memory, and that's an important component of hoarding disorder. All right, so now I'm going to turn it over to Carolyn who's going to talk more about prevalence and demographics. Thank you so much, Randy. I'll just bring this microphone down. So my name is Carolyn Rodriguez. I'm at Stanford University. Pleasure to be with you today. This slide is just to show what you may already know, that hoarding disorder isn't just in the United States. It's something that happens across cultures and countries. People have done studies at a lot of different areas. But what I wanted to say is here that meta-analysis, which is probably our best estimate of the prevalence of hoarding disorder, is about 2.5%. A question that we get commonly is, what's the comorbidity with hoarding disorder? And the top one is major depression. You see here approximately 50%, but also GAD and others here. OCD, interestingly, is a little bit less than 20%, and PTSD as well we see. One of the interesting things is, you know, a study that was done on trauma and hoarding disorder shows that if you compare individuals with hoarding disorder and individuals with obsessive-compulsive disorder, the number of traumatic incidences is higher in self-reported by hoarding disorder individuals than OCD, and yet the prevalence of the diagnosis of PTSD is the same between the two disorders as a comorbidity. And one of the things that Randy has talked about previously is that maybe hoarding disorder is protective for development of PTSD. It's an interesting thing. We need more research out there in this phenomenon. For those of you that treat individuals with anxiety disorders, this is the percentage with hoarding disorder. So GAD is very, very common. In terms of the onset of hoarding disorder, even though we see it more commonly in the next slide I'll show you in older adults, the hoarding behavior itself, the onset is early, with an average of 17 years old. And as you can see in this slide, a study by David Tolan et al has shown that hoarding severity increases with age and the prevalence with each decade of life. So as you may already be aware, but just to emphasize it here, there are a lot of hazards of hoarding disorder, including poor sanitation and mobility hazards. And often, sometimes individuals with hoarding disorder, they first come to medical attention when they've had a fall in their home and they have to call the emergency services. And then it's a big problem when the emergency services can't get into the home to help the patient get to the hospital. Similarly, blocked exits are a big fire hazard and it has a high community cost in terms of using resources in order to be able to decrease bulk and make homes more livable. This can result in high eviction rates here in New York. We did some work with eviction prevention agencies. And as you can imagine, an apartment building, this comes to the attention of landlords and neighbors very, very quickly. And sometimes individuals can become homeless. And so we found that the rates of individuals with hoarding disorder in eviction prevention agencies was very, very high. This is a picture of a home that has burned down because of hoarding disorder. Fire hazards, again, very, very challenging problem. And they can be a big impairment in terms of work and family conflict. So I'm gonna pass it back now to Randy. Thank you, Carolyn. So one of the things we're gonna do now is talk about a conceptual model, a way of organizing what we know about hoarding disorder in such a way that it might help us understand why it happens, and at least give us a roadmap for how to go about doing research on this. And the idea here is that there are a variety of things that contribute to the development of hoarding. Some background vulnerabilities, like some of the things Carolyn talked about just a few moments ago, like trauma and so forth. Beyond that, these things are related to information processing deficits that have been identified in hoarding disorder. Attachments and saving beliefs. Hoarding disorder, really important, and they're especially important when we get to the clinical, the treatment aspect, because this is what we face when we try to treat someone, is their beliefs and their emotional attachments to the objects are what's preventing them from letting it go. So it's important for us to understand those. And the way in which these things are wrapped up with reinforcement patterns for these folks all lead to these acquiring saving behaviors, which then lead to the clutter and the dysfunction in the home. So let's start with the general vulnerabilities. Now, there are a number of them, but these are some of the ones that are most important, and at the same time, puzzling. And the first puzzling one is poor health and disability. A number of studies now have replicated the finding that people with hoarding disorder have higher levels of body mass index, more overweight. They suffer from poor health and disability. All kinds of chronic illnesses, heart disease, cancers of some kind, fibromyalgia, just a long list of these chronic disorders seem to be characteristic of folks, and we have no idea why. It might suggest that maybe there's some kind of systemic phenomena going on that leads to these disorders and hoarding behaviors at the same time. We don't know. A second vulnerability is perfectionism. It might be somewhat unexpected. And this is especially important with respect to how people respond to treatment. A couple of studies have shown that those people who are more highly perfectionistic don't do as well in treatment for hoarding disorder. The third is genetic vulnerabilities. There are twin studies, some linkage studies, some family studies showing that hoarding behavior is partly genetically influenced. And some studies suggest as much as 50% of the variants of hoarding behavior may be genetically influenced, at least. And finally, we see a number of studies showing high levels of emotional dysregulation. I want to focus a little bit on that right now because it's important for understanding this model. There are high levels of anxiety sensitivity in people with hoarding disorder. People with hoarding disorder have a very low tolerance for distress, and these things are related to what's referred to in the literature as negative urgency, that is the tendency to engage in rash and regrettable acts when they're aroused. So what happens? They get anxious, they can't tolerate, they got to do something, and they have to do it quickly and right away. And finally, there are high levels of experiential avoidance, the tendency to avoid negative emotional states. Now, this is quite important from the standpoint of understanding what happens when we try to help someone get rid of something, and we'll come around to that as we move on. There are information processing deficits that have been established through the research for these folks. There are problems with attention, high levels of ADHD, a tendency to focus on unique and unusual details of objects, and a tendency to miss the global concepts related to them for instance, the woman whose home we toured at the beginning, as I showed up one day, her eyes lit up, and she said, I've got to show you something. And she went to the other room, she came back, and she had this large, clear plastic bag filled with bottle caps. And she said, look at these bottle caps, aren't they beautiful, look at the shape and the color and the texture. And I'm thinking, I shouldn't have dropped out of art appreciation in high school, because when I look at the bottle caps, I think, where's the trash can? And it speaks to not only this kind of attentional focus on these unique details, but also on this notion of an appreciation for the physical beauty of objects that most of us don't have. Categorization, it appears as though in categorizing objects, there's a tendency to use narrow category boundaries. That is, each object is so unique and so different from every other object, that it can't be classified with those objects and put away in some kind of organized fashion. And so that's why things may end up in the middle of the room in a great big pile. Memory, people with hoarding disorder complain often about their memories. Not entirely clear they have real memory issues, but they do appear to rely on visual cueing for memory. Again, something that might explain why things are out in the middle of the room instead of put away somewhere. Perception, this notion of clutter blindness is an example of a perceptual issue. Association, with this woman in the bottle caps, you notice that her association with these bottle caps is florid. She's looking at shape, the color, the texture. She's thinking about how all these things go together. Her thoughts are very complex. The associations she has are numerous. When I look at those bottle caps, I only have one association with a trash can. So her thought process is influenced by the amount of information that she's using to think about each of these objects. All of that leads to a very complex way of thinking. And one of our clients described it this way. He said, my brain is like a tree with many branches and there are just too many branches for me to navigate. I go down one branch and it branches into three or four and pretty soon I get lost. And that's kind of the experience that we see with people with hoarding problems. The next feature of this conceptual model is the nature of the emotional attachments and beliefs that are related to these objects. And they seem to classify themselves into four different categories. The first has to do with notions of identity and opportunity. And here, saving for this reason is motivated by a fear of loss. The second is feelings of safety and comfort. And here, the motivation seems to be distress. Responsibility and waste. Here, the motivation seems to be guilt. And beauty and aesthetics. Here, the motivation is more positive, by pleasure. Now, what I'm gonna show you now are sort of examples of this. And this is a case of a woman who came to the International OCD Foundation meeting one year and had contacted me before and so I suggested that she show up. She came to my talk and I had a video of a student of mine who played the role of someone with a hoarding problem and we did a role play. And she came up to me afterwards and said, that was terrible. And she said, if you want to know what it's really like, if you wanna show people what it's really like, let me do it. And so we made this arrangement. She lives out on the West Coast, I'm on the East Coast. And she would make these videos, one to two minutes long of her looking. And the idea was this, okay, you take an object and spend a few minutes talking about it and then make a decision about whether to get rid of it. And this is the product of some of those. And the first one has to do with acquiring and saving behavior motivated by fear of loss. And here we see a couple of themes. One is the theme of opportunity. In some ways, I've thought about hoarding disorder as a disorder of opportunity. What would it be like if you couldn't give up any opportunity? All of us, as we move through life, there are opportunities we give up to pursue others. But what if you couldn't allow yourself to lose any of those opportunities? You would get stuck. And that's a little bit about what we see here. And there are two ways in which this shows up for opportunity and identity. One is having an opportunity for a fantasized future because of this object. And secondly, to preserve an idealized past. So let's take a listen. And this woman's name is Marnie. The OCD newsletter for me is stacked with information. A piece of paper that has something in it that will change my entire life. And that piece of paper is the best opportunity I've ever had. And that opportunity is lost now because I didn't carefully go through it. Maybe this article in it is gonna inspire me to write this screenplay. And the screenplay is gonna be the best screenplay. And it's gonna change my whole world. And I'll go from the smaller type house to a mansion in Bel Air. And it's all because I haven't read this one article. So you see the exaggerated sense of the opportunity provided here. And what this is gonna do for her future and who she's gonna become. And similar with the preservation of the past. Okay, so I know that it would make sense to get rid of this little baby carriage that Kennedy kept for twin dolls. And it's disgusting and it's got dirt all over it. And it looks, it might even, I don't know. It's all a mess. To me, it's gorgeous and needs to be here. So I remember always how she played with it. And if I give it up, I feel like, I don't know. I feel like, I feel so sad. And I feel like I'm losing that time when she used to play with it. Like it gets erased from my memory. And I'm wearing gloves, not because of OCD, but because I have pink eyes. So I might as well put that out there. So the deal is mainly, I don't wanna let it go. And I'm angry that I have to let it go. And I'm sad and it feels like I'm saying F you to her childhood, but I'm gonna throw it away. I thought it was good for goodwill, but apparently it's pretty disgusting. So in my eyes, it's gold. In everyone else's eyes, it's trash. So I'm gonna get rid of it and see how I feel. I'm definitely pissed off and disturbed. And as Dr. Frost says, that means that that's a good thing. So if I work through it, it's good. If I succumb to it and keep it, I'm not gonna change. So here we go. Okay, so in essence, I feel like in getting rid of this, I am dumping my daughter's childhood. I am no longer going to be able to remember anything about my daughter's childhood. That is my feeling. I know it's not rational because that's what I'm supposed to ask. Is that rational? No, it's not rational. But the feeling is so strong, I could just, I feel like I could just die. And this is all part of, if I'm not feeling anxiety, I'm not changing. So I feel anxiety and I'm pissed, but I'm gonna do it because I don't want everyone living in my shit anymore. So you see here a couple of things that are characteristic. One is the wide variety of emotion. It's not just anxiety, it's not just distress, it's anger, it's hatred, it's fear. It's a whole host of things that go on with her when she's trying to let go of these things. The other thing you notice here is that she relies on this object as a visual representation of her past. And part of her fear is that she's gonna lose that personal history. She's gonna, in a sense, lose her identity. And so that's all a piece of this and it sort of gets all convoluted together. The other thing you see here is the statement that she made at the end. And this is a statement we hear again and again from people with hoarding disorder when they try to let something go. I just feel like I want to die. And that is characteristic of people with this disorder, particularly people who have it in a more severe form. And that is tied in with the comfort and safety related attachments. That the acquiring saving behavior is motivated by distress that's associated with either not acquiring something or letting something go. Think back to the vulnerabilities we talked about. Anxiety sensitivity, intolerance of uncertainty, experiential avoidance. These things tie into this fear of distress. And so what's gonna happen? The woman whose home we toured at the beginning, she was an art history major in college. And she kept, 30 years later, she still had her art history books. And so we were working on these books and her task was to put them into two boxes. One box to sell and one box to keep. And to sell or donate. And she took one of her books, and she hadn't looked at it in 30 years, and she put it in the sell box. And she said, I just feel like, I feel like I want to die. And she kept going. And 10 minutes later, I asked her how she felt about it. And she said, it's okay, not bad. So she got through that difficult period, that difficult emotional period, and then she was okay. Another example of that was, and again, that had to do with her identity as an art history sort of person. Another example of that, when I was working with her on papers and she pulled out an envelope from an ATM machine. ATM machines used to spit out money with envelopes. And it was about five or six years old, and she had written on the envelope how she spent the money. It was like grocery store items, drug store items, and so forth. And nothing unusual. And she put it in the recycle box. And she started to cry. And she said, it feels like I'm losing that day in my life. And if I lose too much, there'll be nothing left of me. So this item had somehow contained a piece of herself, piece of her identity, piece of her personal memory, in much the same way it did with Marnie. Now, you can see this distress with Marnie, but she had a level of distress for something that was much more difficult than the things she dealt with beginning. I've held onto this. I got the guy waiting outside for donations for the little children. I don't want to let go of this. I'm so sad and so angry. And I want to hold on and talk to you about it. Called you twice, called Karen twice. And I'm just going to take the risk of letting it go. This I've been holding onto and I'm really upset. I feel like the smart thing to do is give it away, but my stomach is in more than knots. I am at a 10 and I'm pissed off and I'm scared. And I'm scared how I'm going to feel after it's gone. Like I lost my kid and I lost everything. And I feel awful and I kind of hate you. Okay, Randy, I'm watching the guy go out of our driveway and I'm really sad. And I hope I didn't make a mistake. I know it's always best if it serves others and I just saw him go and my heart is broken. I'll survive it, but that was definitely a 10 and I just feel like there was a death that just happened. So you see again, the intensity of this motion and unless she's doing this, unless she's doing this project, she wasn't going to throw that away. So that's the key here. We have to get them to the point they're motivated to do this in order to let go of this stuff because it's painful. The third of these types of motivation has to do with responsibility related attachments. Here the acquiring and saving behavior is motivated by guilt and guilt on two levels really, a fear of wasting things and a fear of causing harm to an object. And from the research, it looks like a fear of waste might be the strongest predictor of the severity of hoarding problems compared to other things. And in fact, so much so that in one of our recent studies, we developed this notion of what we called material scrupulosity. That is a kind of OCD level scrupulosity about material objects and letting them go. Because it can be so extreme. But let me show you an example of Marty and this has to do with a fear of harm. This is, my daughter wore this all the time. I don't want to let it go. I look in it, I don't even know what I'm looking for, but I'm looking in it for something. I can't tell you what it is. All I know is my heart is in my, it's so heavy letting go of this. It's all stained, I'm so glad it's at least stained because it makes it easier to let go of. It's gonna go in the trash right now. This is like, it feels like a sin and I feel like I'm just gonna wither away like the Wicked Witch of the West and just go into the ground and that's how I feel and my thought is I'll never survive this intense pain but rationally, I need to have a nice home and Dr. Frost, I'm gonna do it because I believe that someday I can live in a nice environment if I just keep letting go of stuff even though my head says don't do it, don't do it. Okay, one other thing, I feel like as insane as it is, I feel like this is a friend of mine and I'm putting my friend in the garbage and killing her. That's my feeling. I know it's not a fact. So here, she can separate this feeling and it's not real but yet, it still pulls at her. You can see the difficulty she has with this and the final type of interaction is joy or aesthetic-based attachments. I sort of think about this as sort of awe-inspired, an attraction to beauty, to the physical nature of objects and I sometimes think of this as maybe a form of creativity and in some sense, it might be a special form of giftedness among people with hoarding, this ability to see the pleasure and the aesthetic qualities of possessions that most of us either have lost or like me, perhaps never had. But is that related to creativity? Well, most people, when they think about creativity, think about people who produce something in a creative way. Well, most people with hoarding disorder have such trouble with organizing all their things that they can't get to the point of creating something. They can see something that could be used to create something like these bottle caps but she couldn't, she had no way of putting it all together so it may be a form of giftedness that has to do with a recognition. Now, there are some people who had some hoarding-like tendencies that have become great artists. Andy Warhol is a good example but for the most part, people with hoarding disorder don't ever get that far and here is a description of Marnie's pleasure-related saving. All right, Randy, this is interesting because I just think it's so pretty. It's the prettiest piece of like string that goes on gifts or anything. It's metallic, green metallic and it's just so pretty. I know that I need to let go of it because there's no place for it but these are the things that make me nuts. I can think of a million things to do with it. That's part of this disorder that we are creative but damn, I wanna keep it and it's not even that it's wasteful, it's just why would I wanna toss something so beautiful away that gives me joy but it always comes back to what's my larger objective and that's to not live in chaos so I'm gonna get rid of it. All right, so how do these attachments and beliefs, how do they reinforce what? And what's the reinforcement pattern here? Well, simply to begin with, seeing new items provokes positive feelings like this green string that reinforce acquiring and saving behavior. Resisting acquiring, on the other hand, provokes negative emotions and that negatively reinforce acquiring behavior so people will avoid not acquiring in order to soothe themselves. Same with trying to discard. Trying to discard provokes negative emotions that negatively reinforce saving behavior and the result of these features is that once possessions enter the home, they are seldom or never used or reviewed. You simply stay on the floor or stay in the spot where they were placed. There's no opportunity there for them to determine the true value these possessions have in their lives. Now, what's happened with Marnie and these tapes is that there's something to be said about the power in telling the story of a possession so Marnie, with these segments, shared them with me and she's done over 200 of them over the last couple of years and sent them to me and there's something about the communication there. She's communicating with me through these things and what she's also doing is she's processing the importance of these objects, identifying the attachments, making the decisions about getting rid of them and she has kept only one or two items out of these 200 that she's done and reflected with the lessons learned. Now, here's an example of how that happened. So what we did as she got better at doing this, then we put it into a process for her into a processing video and this is a little bit longer but you get a sense of what it's like. Now, these are books for my daughter that she might like and she has a hard time picking books. So it has one, two, three, four books that I feel I have to put on her desk because it's like my anxiety's up to about a seven in that it needs to go on her desk so she has the opportunity to read them to see these four books that she might love and therefore change her world and maybe even inspire her to become a writer. So the deal is if I don't put this on her desk, in essence, I've stunted her future. I feel like if I don't put this on my daughter's desk, I am a bad mom and she had an opportunity to be a great writer and I've blown it. So I'm going to rip it up. And my anxiety's at about an eight. It doesn't help that my dog is panting next to me. That just is making me more anxious. Okay, so I've ripped it up and part of me's saying, ooh, I still have the video. I could repeat it, I could watch it and find out what those books are so that I could give them to my daughter so that she can become a great writer. But I wanna be different and I wanna live my life so I'm not gonna do that. Timer, I can't even talk, I'm so nervous. The timer just went off and that was in regards to, what was I supposed to do? What was the timer, Becky, for what? I set a timer for checking in on how I feel about, I think the recycling? What did I throw out first? See, this is very interesting. I can't even remember what it was that I was so upset about that I needed to set a timer. The book list. The book list, that's right, thank you. So where am I at with the book list? It's now 10 minutes later and it's probably down to already like a four, maybe even a three. So the deal is if I can sit 10 minutes, then I can let things go. I guess that's the deal, 10 minutes. I don't know if I've rationalized it or not but the truth is if I were to give that book list to my daughter, she's a teenager now, she would throw it out. Even if the books were brilliant because she doesn't want my advice. So that whole drama was created in my brain and it's feelings are not facts and there was not one fact in that anxiety. There wasn't a fact. Okay, reporting back about a couple things. One is, see, it's so funny. I can barely remember it. That's how much of a non-issue it is when I give it time to settle down. The book thing, I'm excited one now. I don't really care. I mean, I really don't care. That's a miracle and that's wild. See, it's really funny that the things that I felt so strongly about when I was in it, now, I mean, I get it. I get it now, Randy. If you wait it out and sit with the discomfort, it'll start to diminish. Okay, bye. All right, so with this process, she has worked through much of the clutter in her home and is in pretty good shape now. And now, if when she tries to throw something away, you don't see the emotion, the way you do in these early films. Okay, so let me now turn this over to Mike who's gonna talk about interventions. Okay, so really glad to be here and I wanna thank Carolyn for having me to participate in this talk. So we're gonna transition to talk about interventions for hoarding. Carolyn will cover medications, but I'm gonna talk about the recommended form of psychotherapy for hoarding disorder is a form of cognitive and behavioral therapy. And how I came to this work, I started my graduate training in clinical psychology in 2007 back in DSM-IV-TR days. When there was no hoarding disorder, hoarding symptoms were typically thought of within the realm of OCD. And the training that I was receiving was as a CBT therapist for OCD. And both my experience clinically and the research was suggesting that the typical forms, the variants of CBT that were developed for OCD, namely exposure and ritual prevention were not sufficient to treat hoarding problems. It could maybe help a little bit, but it was really a different kind of issue that was happening. And so Dr. Frost is really one of the people who pioneered the specific form of cognitive behavioral therapy that is effective for hoarding. So just going over what's involved in CBT for hoarding. So typically it begins with a very careful and thorough assessment of the hoarding issues. And then an individualized case formulation using some of the same language and even the same figure that was presented in the slides to develop a conceptualization of why clutter develops, that we go over with the individual. The idea being that we want to establish the patterns of thinking and behaving in their own life that have led to the clutter problems. Because for a lot of people that I've seen clinically, at the beginning, they kind of are baffled by the state that they find themselves in. It's like, how did it get this bad? And there definitely is clutter blindness, unawareness of the problem. But when people are aware of the problem, there's often a great deal of embarrassment, shame, self-judgmental thoughts and attitudes of people. In particular, I have a woman I'm treating right now who will say things to me like, this is not normal, it's like this. How did I get like this? What type of person am I that I have these issues? So we go through a case formulation model with the person to try to make it explicable rather than inexplicable how this clutter developed. And because the idea being if we can see, okay, well there was a function to the saving behavior. Maybe it saved you to escape the distress that you would have experienced with parting with this. It functioned in that moment. Maybe it was maladaptive in the long run, but we have an explanation for how we got here. That can also help put the idea in the mind that change is possible. So another big component of CBT for hoarding is working on motivation. Just as with motivational interviewing for substance use problems, the idea is that the motivation for change can't come from without, it has to come from within. Often people with hoarding problems do have family members or friends sort of exerting pressure on them to change from the outside and typically that won't work. Just going in and clearing out someone's house without their permission, without their awareness will not really solve the issue because the issue are these internal states of patterns of behavior and thinking that need to change. So the desire for change has to come from within with motivation consisting of obviously feeling capable of making change, which hopefully by orienting the person to the treatment and giving a good overview of the formulation that they feel like change is possible. Then also motivation for change is a function of the importance of change, the reasons why change is desirable. And so treatment with CBT focuses on that, trying to help the person to articulate their values, what's really important to them. This is done early on in treatment and typically people report that what they value are things like friends and family, social connections, and then we'll try to talk through the ways in which the clutter issues are not in line with that value. As Dr. Frost mentioned, maybe family members don't want to come to visit you with the grandchildren if they feel like it's not safe for them to be in the home. Or you wish that you could have friends over for a dinner party, but you're so embarrassed of the clutter that you're not able to have them over. So we try to cultivate basically a discrepancy in between the current state of affairs and the person's long-term goals and values and try to have them be the ones to talk about reasons for change and to cultivate a desire for change. As often people are in a state of ambivalence of I'd like to change, but change also seems hard and maybe it's not so bad, maybe it's sort of tolerable the way that it is, and pushing them by giving them the reasons to change can make them respond on the other side of the ambivalence to articulate the reasons why it really isn't so bad. So instead we want to use motivational interviewing techniques to try to get the change to come from within. That's a core component of CVT. Then there's also work on organization and training in making decisions on how to categorize possessions. People with hoarding problems, as Dr. Frost just mentioned, maybe categorize items differently and maybe their storage system is very different than how other people would store things. Sometimes with hoarding problems, things are being stored sort of chronologically. I keep things wherever I was when I got it, I kind of set it down, and so that pile over there is the things that were arriving to my home last summer, and that can sort of shift as time is going on. So we would work on how to appropriately categorize items that you want to keep, and then if you desire to keep it, having a place for it. And as Dr. Frost mentioned, sometimes people with hoarding problems actually have storage space that they're not optimally using. I've had clients where instead of using the pantry to store cans of food items, the pantry's sort of bare, and the food items are being stored just on the countertop, just as Dr. Frost said, well then I know I have it, I can see it. So organizational skills training could help the person to learn how to be organized. And then another obviously key component, as was evident in the processing videos with Marnie, is trying to change attachments to possessions. Sometimes this involves kind of standard Beckian cognitive therapy, challenging thoughts and beliefs and interpretations. Sometimes we use something called the downward arrow to think about how bad would it be to waste something, to distinguish between a need and a want to save a possession. And then we also use behavioral experiments, just as in the video, to say try to make the thoughts that you're having into testable hypotheses If I were to throw this out, I couldn't stand it. The distress would last forever. If we think of it as a scientist would have, how can we make that a testable hypothesis and then test it out, and see how the distress changes with time. Maybe it feels like it will be unending distress, but actually the behavioral experiment reveals that it wasn't quite so bad. And then lastly, it's very important to work on changing acquisition patterns. If a person is discarding items, but also still acquiring, you wouldn't expect very much change to happen. So this can typically begin in the office with working with the person to articulate rules for acquiring things. That we might want to have them write down on an index card, or maybe even something that they could laminate and have in their pocket for, here are your rules for when to acquire something. It shouldn't be based on just, I had the urge to get it, so I got it. It should be more, here are the reasons. Do I really need it? Do I have space for it? Do I already have something similar to this? And only if the answers are yes, acquiring it. And then in addition, a lot of what would have to happen is working on the urge to acquire, and maybe for people without hoarding problems, it's relatively easy to have the urge to get something, but then to give it a second thought, now I don't really need that. It would be nice to have, but it's kind of expensive, maybe I don't want it. People with hoarding problems may not have that experience. They may have, I have the urge to get it, I have to get it. And sometimes the urge to get it, sometimes it's gratifying, it's enjoyable to get something, but sometimes it's also that when I have this urge to get it, if I don't get it, it feels like a loss. It feels like I'm losing an opportunity, and it's very distressing, and so the acquisition is actually being negatively reinforced, because acquiring the item relieves that distress. So we sometimes think of it as being the urge to acquire as something that we can ride the wave to, see if the urge dissipates. It's sort of similar in the way as the urge to wash your hands would dissipate if you were doing exposure for OCD. Make it more doable, we'll sometimes make it hierarchical, develop what we would call a non-acquisition hierarchy of what are the places that you would typically feel the urge to acquire, and then organize it from easy to hard in terms of practicing. So maybe the first, we would call them non-acquisition trips. Sometimes these are being practiced with the therapist going with the person. And sometimes they're doing it on their own. But basically it might be, the first step might be a drive-by non-acquisition trip, where the person stays in their car, but drives by the flea market without going inside, and has the urge to go inside, but sees that the urge dissipates. Then we'd move up the non-acquisition hierarchy to a walkthrough of walking through a store, feeling the urge to look at all the items, but like walking out without, and feeling that urge hopefully dissipate. And maybe at the top of the list would be a browsing non-acquisition. Actually being in the store, picking an item, really desiring that item, having a strong urge to have it, putting it back on the shelf, and walking away without purchasing it. Again, riding the wave of distress that would come from that. So there's more elements in the CBT protocol, but just in the interest of time, we'll move on to showing some data about it. So this is a trial that Randy was involved in, along with Gail Steketee and others, a waiting list control trial of individual CBT for hoarding disorder, where 46 individuals with hoarding problems were randomized to either receive this individual CBT or a waiting list for 12 weeks. After 12 weeks, there's already starting to be a separation in terms of reduction in hoarding severity. And the waiting list closed at 12 weeks, and those people who had been waiting entered the CBT, and then were continued to 26 sessions. As you can see, with 26 sessions of CBT, there was a very large effect size for reduction in symptoms, and around almost 30% symptom reduction, 29%. This same trial, and then followed up at a 12-month follow-up, evaluating treatment response. So here, people were using the CGI to have either the therapist rate the person or the person rate themselves. The response was defined as much or very much improved. Shows that immediately after treatment, more than 70% of people perceived themselves to have improved with CBT. And that number was still above 60% a year later. The numbers from the therapist are a little bit lower, but still, more than half of people were rated as significantly improved, substantially improved. I think what's really great about what Randy did next, along with Dave Tolan and Gail Steketee, was to recognize this particular form of CBT, not enough clinicians have been trained in it. They took the principles and exercises from this form of CBT and developed into a self-help book that is called Buried in Treasures. That book is published and disseminable, but there's also a program called the Buried in Treasures Workshop. People can join a group of peer-led, co-facilitated self-help, where for 15 to 20 sessions, meeting weekly, six to nine members per group will meet and go through the self-help exercises together. You can read about it at this website, MutualSupport.com, to see the guide for the facilitator. Sometimes the person facilitating these groups, the BIT, what are called BIT groups, is actually someone who also has suffered from hoarding problems in their life, but not always. In terms of the data, so this was a trial that Randy did a while back. So this trial entered 43 people who had hoarding problems and were referred from hoarding task forces across Western Massachusetts. And they received 13 weeks of these peer-led support groups. And what they show is that, compared to a waiting list, there was a significant reduction in hoarding symptoms, both self-rated by the patient on the saving inventory and as assessed by an independent rater using the hoarding rating scale. Okay, and a recent trial by Carol Matthews and her group at University of San Francisco wanted to see, well, these peer-led groups, how does that compare to doing group therapy that's led by a professional, a clinical psychologist? So in their study, they had a very large group of patients, over 300 patients with hoarding disorder who were randomized to get treatment in a group format that was either facilitated by a peer, a non-professional person, or facilitated by a clinical psychologist leading the group. What the data show was that both treatment options, both interventions were associated with a significant reduction in hoarding, and there really wasn't a differentiation so that the group that was getting peer-led treatment was getting basically equivalent outcomes to that of group therapy led by a clinical psychologist. So this would suggest that the BIT groups are a really nice way to be able to disseminate the treatment and make it more available because you wouldn't necessarily need a professional, and it could be more affordable because sometimes if the BIT group is offered by an agency, there might be no cost to patients. And then in work that I've had the great opportunity to work with Carolyn on was her trial of BIT, a buried-in-treasures work group, with the addition of in-home at-cluttering. So these results are still under review. Hopefully, they'll get accepted for publication soon. But in Carolyn's study, there were 41 patients who were randomized to get either this BIT group or waiting list, but the BIT group here included in the second half, the second half of the 16 weeks, people would actually go to the person's home to help with in-home uncluttering practices. They did 10 sessions of two hours each, so 20 hours of in-home uncluttering. What we're showing is that there's a significant reduction in hoarding symptoms with this intervention with a large effect size. More than half of people were experiencing a treatment response. And in terms of percent reduction in clutter, although there isn't a comparison to the treatment without the in-home uncluttering, it does seem like the in-home uncluttering was associated with greater reduction in clutter than certain past trials. Oh, okay. Just to mention some of the factors that seem important in successful treatment, even though CBT for hoarding is effective, it's not universally so. And we want to look at what factors foster success and maybe what's a barrier. So one factor that seems really important is the extent to which patients are doing homework that has been assigned to them, both in terms of the number of homework assignments they're completing and their rating of quality. So in one study, they found that people were, on average, completing less than half of their assigned homework. And in terms of homework quality, doing a median split where you just say, the average homework quality rating, people who are above the median did a better-than-average job completing their homework. They had an 80% chance of a treatment response. People who are below average on their homework had less than a 20% chance of having a treatment response. So homework completion seems to really matter. Another factor that seems to really matter is whether there are home visits. Just as we talked about with Carolyn's trial, having people go to the home can really be helpful and enhance the potency of the treatment. As Randy had mentioned, some research from Jordana Mura found that a pretreatment level of perfectionism predicts less treatment response. Clinically perfectionistic patients who are afraid of making a mistake or, I need to find the perfect person to give this possession to, can really bog down treatment and make it less likely to happen. And then another factor that seems to matter is the extent to which there's cognitive change happening in terms of beliefs about possessions and emotional attachments to possessions. So Hannah Levy, in one of her studies, used the Saving Cognitions Inventory to measure attachment to possessions and found that change in your attachment to your possessions actually preceded and predicted subsequent improvement in hoarding. And then lastly, although hoarding populations tend to be in adults, hoarding behaviors can be observed in children and adolescents. In those specialty populations, you need to adapt the treatment to make it developmentally appropriate for the child, but also hopefully to incorporate family members in the treatment. And then we'd probably also want to adapt treatment for older adults experiencing hoarding problems if they might be experiencing issues such as health problems or cognitive decline. And I think that's the point that I will transition over to Carolyn. All right, we're at the American Psychiatric Association. You might be wondering, what FDA-approved medications are there for hoarding disorder? None. We've got one slide. We need more work. Start thinking about your Q&As now because we're at the end of the talk here. There's only small and open-label trials, no controlled trials, and some of the potential agents that have open-label data are the following listed here. So you see there's some SSRI, SNRI, and stimulants. So that's what we have. We need more. And I see Michael van Ameringen there. We need more. We need more. Okay. So just to peek at what we're thinking about in terms of future research directions is how can we incorporate technology into helping with hoarding disorder? There are some homes that we can't get to, right, because they are dangerous, hazardous. There's people in remote areas with these problems. And some people, they're too attached to their objects in order to get treatment. So we pilot-tested virtual reality for individuals where we combined the buried and treasures, and then we scanned in items. We recreated their home in virtual reality. So their same rug, their same couch, and these items. And so now they can actually start to pick up these objects and practice discarding them, not once, but as many times as needed, right, like kind of a weightlifting program. And what we found that is motivating us to continue in this space is that there was improved hoarding symptoms and decreases in clutter, and it was feasible and well-tolerated. And most important, the majority of individuals actually went on to uncluttering in real life after doing this practice. Okay, two more slides. So for friends and family, what can you do? If you have a loved one, get information and get professional help. The International OCD Foundation has a whole hoarding research center, so you can get a lot of information there. Express empathy and praise progress, even if it's slow. Try and roll with the resistance, so avoid arguments and negative comments, and really put the oxygen mask on yourself. This is a challenging problem, and it takes a village, so really taking care of your own well-being. So in sum, hoarding is an accepted psychiatric diagnosis. It develops from various vulnerabilities, information processes, and attachments. There is treatment. Cognitive behavioral therapy is effective for adults. There is no FDA-approved medication for hoarding disorder, and we need to improve treatments. Here are some resources, and Ron Winchell, just to give him a shout, has done an incredible job in terms of this clinical toolkit. You can go online, you can download our slides, and you can look at these resources. And downstairs in the APA bookstore, I had the great pleasure to work with Randy on this book. It's really a career highlight for me to be able to work with him, and it's a comprehensive clinical guide that we wrote for folks here, right? Trainees, people who are coming to the American Psychiatric Association to give them a guide. And with that, we'll close. So thank you very much for your attention. Hi, okay, so we're gonna be alternating questions between the remote audience and the audience here. Please try to keep your questions crisp, and within 30 seconds, generalizable, as opposed to, I have a patient who. Okay, please. Hi, good afternoon, thank you very much for this very interesting talk. I have a telehealth practice, and one of the things I love about that is you really get to see much more about the patient's environment. And I have two questions, hopefully you can answer both of them. The first one is, is there a screening question or some sensitive way that you might suggest kind of bringing up the topic of their messy house when you see it in the background when they're presenting problem as something else? And then the second question is, I guess from a diagnostic standpoint, can you say anything about those people who simply have kind of a messy house, they don't have hoarding disorder, but they just don't do their dishes, they don't fold their laundry, they don't have any of the issues that you've talked about, but clearly they're living in filthy environment and it's creating problems. Thank you. Maybe I'll just feel the first one and I'll pass it on to Randy for the second one. Thanks. So Randy developed a scale called the clutter image rating scale that will also be available in the toolkit, but you can just Google clutter image rating scale. And it's one of these scales where a picture is worth a thousand words. And it has a visual picture of like three different rooms in the home with progressively more things. You can just say, hey, this is a scale to assess your environment. And then if you see them mark a four or higher, then that is a signal that potentially you can go into more of a screening and more formal assessment for hoarding disorder. With respect to the second part of the question about people who are messy but don't have hoarding, I think the issue appears to be more motivational than having any of these other features that we find in this model, like information processing deficits. There may be some of that, but the attachment, the nature of the attachment to the object isn't there. So the kinds of strategies should focus more on motivational things and maybe even using some of the motivational interviewing strategies we see. Motivational interviewing is, as you probably know, developed with drug and alcohol problems. And they're much the same way. People have a difficult time being motivated enough to stop drinking or to stop using drugs. And so it's the program, motivational interviewing, is designed for that sort of problem and it might be helpful there. Question from the remote audience. Yeah, all right, thank you. So I'm gonna combine a couple of questions because they're kind of similar, but regarding psychopharmacology, is there any evidence for use of NAC, naltrexone, or antipsychotics in hoarding use? No, there's no data. That was a quick one. Next question, please. Also a couple questions on the CBT data. I saw that patients, taken as a group, started at around 60, got down to around 40, which leaves 40, and I wanna know if that's enough to make the family happy and make the patient happy? And also, some of my patients who don't like CBT for other things, like ACT, and I'm very curious to know if there have been any studies on acceptance and commitment therapy, because I saw experiential avoidance, good values, and so forth. Yeah, good question. Frank, you wanna take it? Maybe I would just say that the slide that showed that there's like a 15 to 20 point drop in hoarding severity, it's enough to be considered a significant improvement in improvement. The idea, like remission with no clutter at all would be very rare, but often what we're going for is sort of like a harm reduction approach of trying to make sure there's no fire hazards, safety hazards, that it's more under control, and then I think people are still benefiting, even if it may not be the case that clutter gets to zero. Are the families happy? I mean, are they satisfied with a reduction from 60 to 40? Yeah, the families are certainly happier. Now, and partly it's a matter of managing the family member's expectations. If they're expecting this to be house beautiful at the end or to look like it does on the horror TV shows, sometimes then you got a problem, because that's typically not how it works. And ACT, acceptance and commitment? Oh, yes, there is some research on ACT and hoarding, and there aren't any control trials yet, but the open trials make it look promising. So there's probably more of that research to come. And I think we briefly touched on this, but there was a question about what variations in treatment you would anticipate for either children or adolescents if that's been developed? Let me start with that, see if you guys want to contribute. When you see hoarding in kids, it looks a little bit different, because kids don't have control, complete control over their environment. And what you see typically are exaggerated emotional reactions to parents getting rid of things. We also see with kids and hoarding is a great deal more comorbidity, and comorbidity with other anxiety and sensory problems often. So there's a lot going on with a kid with hoarding problems. There's a lot more going on than just the hoarding problem, and so it makes it a little more difficult. And I think I would just add, usually with kids, it's not just about identifying a problem you don't want and trying to punish it out of them. It's more identifying an adaptive, skillful behavior to try to reward. So whether that means incorporating reward into discarding practices or earning points or something like that, that's a general principle. Next. First, I want to thank you all for a very informative and well-presented discussion, whatever. This is to anyone, but maybe a little more to you, Dr. Frost, sort of with a psychodynamic-ish perspective, a word that comes up a lot is their attachment to these things. And Marnie, I believe, said, throwing out that stroller, it's like she's losing the connection with her daughter, who I later found out was adolescent, a teenager, I assume, living at home. It's like, well, she's there, but it's maybe longing for the connection as a child who's... And the flip side is she clearly had a very strong attachment to you, and my guess is you were very, a lot of positive reinforcement. And the way she was talking in the videos was like, see, I'm doing a good job here. So just wondering how, if there's any, the studies or your own thoughts about if there's some inabilities to maybe embrace positive reinforcement from other people so they get it from almost like a transitional object, your teddy bear, and this is really mom because she's off doing laundry. Yeah, that's a good question. I clearly think a lot of what Marnie experienced with these things was a communication with me, and whether she needed my approval or not, I don't know, because my conversations with her really had to do with the fact that, well, you're making a decision about an object. You can keep it if you want. It's not any better to throw something away. That's your approval. But yeah, but if she decides to keep something, she would have the same thing. So the emphasis here is on her life and so forth. But going back to the sort of psychoanalytic notions, there is some stuff coming out now about the nature of the self in hoarding and the nature of attachments to family and friends. We don't know much about it yet, but it looks like there are some attachment issues associated with hoarding and with family members. We know that the homes of people with this problem, as they were growing up, seemed to lack some warmth, some degree of warmth, and so there's something there. It's unexplored at this point. We're done, okay. Next question from the audience. Again, thank you so much for the presentation. So my question is, I work on a community treatment team, so an ACT team with SMI, and I also have a private practice, so I'm seeing the hoarding kind of show up like in a neurotic expression and then a psychotic kind of level of organization, but then when you go over to the SMI, which is what I primarily work with, I have a hard time understanding when the delusional system is wrapped around the objects and the items, like do I treat the psychosis, and then we have the hoarding that's left, and how do we kind of complement treatments at the same time? And what comes first, the chicken or the egg? I would say, yes, you wanna definitely treat the psychosis first, and that's the case for somebody who may have psychosis and OCD or psychosis and hoarding disorder. And what you may see is that when you treat the psychosis, then maybe they don't meet criteria for hoarding disorder anymore, because clutter is kind of like fever. It's a sign and symptom of a lot of things, but in order to meet the hoarding disorder diagnosis, it can't be due to another psychiatric condition. So sometimes it will improve with just treatment, and if the current antipsychotic regimen isn't working, maybe Clauseril is the next step. I can add something more to that with respect to what we treat when there's comorbidity. Mike made a reference to something as he was talking. We had a patient who had a severe hoarding problem that we were treating, and she also had a history of abuse. What happened was that she was in bed one night, someone climbed up the gutter and raped her in her bedroom, and her home was full. And as we helped her unload it, when she got close to that room, that's when the PTSD symptoms started. Before that, she had a lot of hoarding-related problems, but not PTSD, until we had to interrupt the treatment and treat the PTSD and then come back to hoarding behavior. Thank you. Hi. I wanna, like the other speaker, I wanna thank you for a phenomenal presentation. This has been really, I've learned so much. This is a personal subject to me, because on October the 1st, my husband found his mother dead in her apartment in the Bronx, and we had no idea that she was a hoarder. She'd been shutting us out since just before the pandemic, and we got sort of lulled into that lack of access. We kind of suspected something, but we rationalized, and it's been hard for, I'm a psychiatrist. I work in suicide bereavement. I see parallels, actually. My husband's a social worker, and it's heartbreaking. It really is. You just have this sort of sense, like how did we miss this? Anyway, thank you so much. I don't know if you've had some post-vention experience with family members who have lost someone to this. Thank you so much for sharing that story, and I just wanna say that you're not alone. The inspiration for writing this book with Randy was my mother-in-law, who slipped and fell, and it was discovered later that it was due to all the items, and magazines are very slippery, and I just felt the same way, which is there's gotta be something out there, and we really wrote this book with Randy as a tribute to her, so. Well, it's 3 p.m., and sorry to cut off this discussion. Thank you all so much. It's been an under-discussed.

hoarding disorder

DSM-5 criteria

cognitive behavioral therapy

emotional dysregulation

perfectionism

virtual reality therapy

motivational interviewing

major depression

generalized anxiety disorder

post-traumatic stress disorder

fire hazards

organizational skills

screening techniques