Compulsive Hoarding Due to Childhood

Compulsive Hoarding Due to Childhood Sexual Abuse

The objective of this work is to research and examine childhood sexual abuse and compulsive hoarding. This work will identify the social impediments to the treatment interventions of this population with traumagenic compulsions and will further analyze how cognitive behavioral therapy would overcome these impediments and provide treatment for this disorder.

OCD Obsessive Compulsive Disorder

SLE Stressful Life Events

CSA Childhood Sexual Abuse

PTSD Post Traumatic Stress Disorder

CRF Corticotropin Releasing Factor

HPA Hypothalamic Pituitary Adrenal

ACTH Adrenocorticotropic Hormone

NIMH National Institute of Mental Health

LITERATURE REVIEW

The work of Saxena, et al. (2004) entitled: "Cerebral Glucose Metabolism in Obsessive-Compulsive Hoarding" states the fact that "Compulsive hoarding and saving symptoms, found in many patients with obsessive-compulsive disorder (OCD) are part of a discrete clinical syndrome that includes indecisiveness, disorganization, perfectionism, procrastination, and avoidance and has been associated with poor response to medications and cognitive behavior therapy." (p.1) it is related that the standards in diagnostic classifications view obsessive-compulsive disorder (OCD) "...to be a single entity" however research has related findings that show clearly that there are several different "symptoms dimensions" of OCD that exist. According to Saxena et al. (2004): "Large-scale factor and cluster analysis studies of OCD have identified four principal symptoms factors" including: (1') aggressive, sexual and religious obsessions with checking compulsions; (2) symmetry obsessions with ordering, arranging and repeating compulsions; (3) contamination obsessions with washing and cleaning compulsions; and (4) hoarding, saving, and collecting symptoms." (Saxena, 2004; p.1) Saxena (2004) defines 'hoarding' as: "...the acquisition of, and inability to discard, worthless items even though they appears to others to have no value." (p.1) This behavior of hoarding has been observed in "several neuropsychiatric disorders including schizophrenia, dementia, eating disorders, autism, and mental retardation, as well as nonclincial populations, but it is mostly found in patients with OCD." (Saxena, 2004; p.1) of those with OCD approximately 18 to 42% are characterized as having hoarding compulsions with 10 to 20% of all OCD patients believed to have compulsive hoarding are the "most prominent and distressing type of OCD." (Saxena, et al. 2004); p.1) the compulsive and hoarding symptoms are believed by Frost et al. (Saxena, et al., 2004) to be "part of a discrete clinical syndrome that also includes indecisiveness, perfectionism, procrastination, difficulty organizing tasks, and avoidance." (Saxena, et al., 2004) This disorder is "most commonly driven by obsessional fears of losing important items that the patient believes will be needed later, distorted beliefs about the importance of possessions, and excessive emotional attachments to possessions." (Saxena, et al.; p.1) the individual with this disorder has great fear concerning 'wrong decisions' about what to throw away and what to keep "so they acquire and save items to prepare for every imaginable contingency." (Saxena, 2004; p.1) the most commonly items which are saved or hoarded include "newspapers, magazines, old clothing, bags, books, mail, notes, and lists." (Saxena, 2004) the place where the individual functions, or their 'living spaces' become so cluttered that the individual is not able to correctly function resulting in "significant impairment in social and/or occupational functioning." (Saxena, et al., 2004) of those with OCD the individuals with the specific hoarding OCD have more "severe family and social disability, anxiety, depression, and personality disorder symptoms; lower global functioning and higher rates of hoarding tics in their first-degree relatives." (Saxena, et al. 2004) the patterns of genetic inheritance for compulsive hoarding is different that those of other OCD symptom factors and where the hoarding factors has a recessive inheritance patterns, the aggressive checking and symmetry factors reveal a dominant pattern. In a study conducted through a "genome-wide scan...in sibling pairs with Gilles de la Tourette's syndrome" states findings that "the hoarding phenotype was significantly associated with genetic markers on chromosomes 4q34-35, 5q35.2-35.3 and 17q25." (Saxena, et al. 2004) Related is that when these studies are "taken together..." It is indicated that compulsive hoarding syndrome is a genetically distinct subgroup or variant of OCD with a characteristic patterns associated symptoms and functional disability." (Saxena, et al. 2004) it has been shown that treatment of OCD hoarding compulsions are poorly responsive to selective reuptake inhibitors and cognitive behavior therapy. Therefore, the hoarding phenotype is held to be a "reliable predictor of poor treatment response in OCD...in order to develop more effective treatments for this syndrome, it is crucial to elucidate its pathophysiology." (Saxena, et al. 2004)

The work of Turner (2002) relates that child sexual abuse has been found to be linked to obsessive compulsive disorders later in the individuals life and specifically that compulsive shopping and spending as well as hoarding disorders are related to child sexual abuse because these types of disorders "provides something else to focus on, instead of facing what is going on" emotionally in the life of the individual. Turner additional states that Young (1999) in the work entitled: "The Role of Incest Issues in Relapse" relates that relapse of addictions and cross-addictions are often related to "uncovering painful early childhood incest experiences that have been defended through self-destructive behaviors. Comprehensive studies have established that relapse has been the most common outcome of recovery programs that treat addictive behaviors. However, the possible existence of childhood sexual abuse issues as predisposing factor of relapse, and the connection between cross-addiction and relapse, needs to be more fully explored." (Turner, 2002)

The work of Cromer (2005) entitled: "A Pathoplastic Vulnerability Model: An Association Between Traumatic Stressful life Events & OCD" relates that obsessive compulsive disorder (OCD) is an anxiety disorder that manifests by causing distress and "recurrent obsessions and compulsions" and is one of the ten leading causes of disability throughout the world according to Lopez & Murray. Cromer states that "While research in the last few decades has expanded our understanding of the classification and treatment of OCD, many of the mechanisms and vulnerability factors involved in the etiology and maintenance of this disorder remain unknown. One putative vulnerability factor for psychiatric disorders is stressful life events (SLEs)." (p. 8) Cromer reports a study conducted for the purpose of reviewing the literature regarding the role of 'stressful life events' (SLE) in the etiology and maintenance of obsessive-compulsive disorders (OCDs). Cromer relates that "Aversive life experiences have been associated with specific anxiety disorders..." And that stressful life events "often precede the onset" of the obsessive-compulsive disorders. The work of Zvolensky et al. (2001) is reported by Cromer (2005) to have found that: "...an individual's perception of stress predicted fear responses to a biological challenges. Similar results were found in an investigation with panic disordered patients." Studies have demonstrated that the individual's "perception of control ultimately influenced panic reaction to the biological challenges. Those individuals who did not have perceived control were therefore in the more stressful conditions, reported a greater number of anxiety symptoms and increased subjective anxiety." (Cromer, 2005; p. 9) Therefore, the individual's perception of stress is a primary factor in the anxiety related response processes. The affect of the stressful life event on the "development and maintenance of psychiatric disorders have been extensively examined..." however the "direct association between SLEs and OCD has received relatively less empirical attention." (Cromer, 2005; p. 10) the work of Pierre Janet in 1903 in the area of anxiety disorder held that obsessive-compulsive disorder was caused "by extreme emotional shock." (Cromer, 2005; p. 10) Janet related the case of a woman who after seeing her daughter's dead body who had died in a house fire, developed OCD and as well "numerous modern case studies highlight the potential role that extreme stress and trauma play" (Cromer, 2005; p. 10) in inducing obsessive-compulsive symptoms. Experimental studies have supported findings that a general association exists between life-stress and obsessive compulsive disorders and as well that a "unique relationship between traumatic negative life events and OCD may also exist." (Cromer, 2005) Cromer relates that the link between "trauma and OCD is also evidence in samples of individuals with co-morbid post-traumatic stress disorder (PTSD)" (p. 11) Further, the work of Pitman (1993) and de Silva & Marks (1999) as cited in Cromer (2005) relate that case studies have shown that the onset of OCD is clearly tied to "an extremely upsetting event such as high-combat exposure, industrial accidents or sexual assault." (Cromer, 2005; p.11) in fact, these case studies "appear to provide support for a traumatic origin model of OCD." (p.11) Cromer states that: "Gothelf and colleagues (2004) found that pediatric OCD patients reported significantly more total life events and increased negative life events in the year preceding OCD onset when compared to healthy controls. Finally, Hartl et al. (2005) found that compulsive hoarders (N=26; 32% with a reported diagnosis of OCD) related a significantly greater number of different types of trauma and more frequent traumatic experiences when compared to controls. Measurements were obtained via the Traumatic Events Scale-lifetime, which assesses 16 different traumatic events according to frequency and severity (Gershuny, Baer, Jenike, Minichiello, & Wilhelm, 2002). Interestingly, hoarding and non-hoarding groups did not differ in reported severity of disturbing events, nor in the degree of fear, helplessness, or horror they experienced." (p. 12) According to Cromer (2005) the literature that addresses the relationship between stressful life events and obsessive compulsive disorders does provide some degree of support implicating traumatic life-stress as being a factor in the onset and maintenance of the obsessive compulsive disorders however the exact relationship between the SLE and OCD "remains an empirical questions" specifically relating to "traumatic negative life events" (2005; p.13) Most of studies in this area investigation the association between SLEs and OCD have held limitations of: (1) small sample sizes; and (2) difficulty of establishing retrospectively the temporal relationship between onset and SLEs; and (3) a limited scope with regard to the effect of SLEs on OCD. (2005; p.13) Cromer relates that "mounting evidence suggests that early life-stress, in particular may preferentially incline individuals to develop adult psychiatric disorders." (2005; p.13) McCauley et al. (1997) states evidence from a large epidemiological investigation that childhood abuse "was related to a large range of physical and psychosocial difficulties." (Cromer, 2005; p. 14) the work of Nemeroff et al. (2004)states findings that there is an association between experiences in childhood and "increased adult psychopathology" which can be explained by the "profound effect early-life experiences have on the developing brain...research indicates that changes in the brain can lead to life-long psychiatric sequelae." (Nemeroff, 2004; as cited in Cromer, 2005; p.14) Nemeroff et al. along with other researchers state implications from both preclinical and clinical investigations that "neurobiological systems, relating the corticotropic releasing factor (CRF) system in the etiology of mood and anxiety disorders." (Cromer, 2005; p. 14) Related is: "In conjunction with the hypothalamic-pituitary-adrenal (HPA) axis, this system represents the major mammalian neuroendocrine stress response system Hypothalamic CRF is released by an organism in response to stress that leads to the stimulation of the HPA axis, which in turn results in the secretion of the adrenocorticotropic hormone (ACTH). ACTH stimulates the secretion of other neuropeptides, which ultimately releases cortisol (Dallman et al., 1994). Through a number of well-executed analogue Nemeroff and colleagues have proposed a neurochemical hypothesis that would explain how early life-stress antecedes psychological disorders, such as anxiety disorders. It is hypothesized that particularly early life-stress leads to neuronal changes that result in the induction of persistently-elevated neuronal releases of CRF. The net effect is an increased responsiveness to stress Several investigations have shown that this increased responsiveness then renders individuals more susceptible to psychopathology in adulthood (Heim & Nemeroff, 2002; as cited in Cromer, 2005; p. 14).Cromer relates the 'biopsychosocial model of psychopathology which is illustrated in the following figure.

Biopsychosocial Model of Psychopathology

Source: Cromer (2005)

The findings of Cromer (2005) include those relating that the experience of SLEs "would be more strongly associated with specific OC symptom dimensions (hoarding and obsessions/checking) as SLEs were "significantly correlated with the obsessions/checking and symmetry/ordering symptoms dimensions, as well as the SI-R hoarding dimensions." (p. 27) Cromer relates that the total number of "comorbid disorders was not significantly associated with SLEs" which indicates that the SLEs are closer related to mood and anxiety disorder comorbidty as compared with other comorbid disorders.(p. 28; paraphrased) Cromer states that "alternatively, it may be that SLEs act through a common vulnerability pathway that leads to a comorbidity phenotype of OCD." (2005 p. 28) the third stated possibility is that OCD in combination with SLE "acts as a trigger for the expression of comorbid disorders." (2005; p.29) Cromer relates that the work conducted by Hasler et al. (2005) relates that "neither hoarding, nor the contamination/cleaning symptom dimensions were strongly associated with mood and/or anxiety disorders." (as cited in Cromer, 2005; p.29) Cromer additionally relates that when comparing individuals experiencing SLE in childhood or adulthood that these individuals "differed significantly from those who reported no SLEs in mood and anxiety disorder comorbidity." (p. 29) These findings partially corroborate evidence from neurobiological investigations relating to hyperactivation of the CRF system nd the HPA axis" (Cromer, 2005; p. 30) in the work of Memeroff (2004).

The work of Bechtel and Ts'erts'man entitled: "The Handbook of Environmental Psychology" states the fact that hoarding behavior is not related to material deprivation with researchers making suggestion of a model that conceptualizes hoarding as an "avoidance behavior tied to indecision and perfectionism." (Bechtel and Ts'erts'man, 2002) Furthermore, sexual abuse "whether it occurs in childhood or adulthood has been a major source of post-traumatic stress disorder and has the focus of an extensive body of research..." which relate that "disassociation occurs both peritraumatically - at the time of the event - and posttraumatically - as a long-term consequence of traumatic exposure." (Bechtel and Ts'erts'man, 2002) Symptoms of disassociation that arises from childhood abuse include: "...depersonalization, derealization, dissociative amnesia, fragmentation of identity and posttraumatic re-experiencing phenomena such as flashbacks of traumatic stress, people begin to dissociate what is happening through an altered sense of time, either much slower or accelerated than it actually is; profound feelings of unreality, that the event is not actually happening to them, confusion and disorientation, feelings of being disconnected from their bodies." (Bechtel and Ts'erts'man, 2002) the work of Holman and Stokols (1994) made an analysis of child sexual abuse and from "drawing upon theoretical construction from clinical, social, developmental and environmental psychology examined contextual influences on the etiology and psychosocial outcomes of child sexual abuse and suggest clinical and environmental design strategies to reduce the prevalence and disruptive impacts of this pressing social problem." (Bechtel and Ts'erts'man, 2002) it is speculated by researcher that "microlevel sociospatial factors may increase opportunities or motivations for perpetrators to molest children." (Bechtel and Ts'erts'man, 2002)

Boston University's Danielsen Institute has developed a training for cognitive behavioral treatment protocol, specifically developed by Stekee and Frost for intervention with compulsive hoarding. The treatment modules are focused on: (1) assessment, (2) model building, (3) treatment planning, (4) skill building, (5) cognitive therapy, and (6) motivational interviewing. (Boston University School of Social Work, 2007)

The work of Beamish and Hill (2007) entitled: "Treatment Outcomes for Obsessive-Compulsive Disorder: A Critical Review" states that "Behavioral therapy is considered the most effective modality for treating OCD. Behavioral approaches to OCD arrests on the assumptions that compulsions are perpetrated through negative reinforcement. The goals of behavior therapy are to interrupt the association between obsession and subsequent anxiety and to eliminate the connection between completing the compulsion and the reduction of anxiety." (p.1) There are numerous interventions of a behavioral nature used for treatment of OCD. The 'combined treatment of choice is stated to be "exposure and response prevention." (Beamish and Hill, 2007) Other techniques "have not demonstrated such consistent positive outcomes." (Beamish and Hill, 2007) the component of exposure treatment involves clients confronting themselves "with the action, thought, or entity that contributes to their anxiety." (Beamish and Hill, 2007) the component of 'response prevention' involves a delay or minimization of "the compulsion associated with the encountered event, thought, or impulse. Habituation is the process underlying the efficacy of response prevention in that exposure and nonresponding across time result in decreased feelings of anxiety and fear and in habituation to the stimulus. The compulsions will become extinguished as the high level of emotions associated with the obsession disappear and as the reinforcement for engaging in the compulsion is removed." (Beamish and Hill, 2007) Research findings indicate that: "50% to 100% of clients respond positively to exposure and response prevention treatment immediately after treatment and retain the positive response at follow-up assessment at a certain time after treatment." (Beamish and Hill, 2007) There are correlations noted between exposure and response prevention with changes in neurophysiology." (Beamish and Hill, 2007) Behavioral treatments for OCD are stated to be between 72% and 90% effective however making the adjustment of the success rate with considerations of drop-out rates the actual percentage is more likely in the range of 40% to 50%." (Beamish and Hill, 2007)

Group therapy has also been shown to be an intervention that is effective in treating individuals diagnosed with OCD. Beamish and Hill state: "The substantiation of the effectiveness of this approach tends to be theoretical and anecdotal because few empirical studies have explored the impact of group interventions. The general therapeutic benefits of group experiences are well documented in the literature on group dynamics and forces." (2007)

Cognitive Treatment therapy for OCD "rests on the assumption that compulsions are a product of a persistent thought pattern of putting self or others at risk through an action or a failure to act. The thought patterns for clients with OCD tend to include an irrational sense of personal responsibility and irrational perception of threat. Cognitive interventions include challenging excessive responsibility and perfectionist tendencies. Cognitive restructuring also focuses on the specific fear connected with the obsession and the compulsion. Thought-stopping is another cognitive technique during which counselors or clients yell "stop" when the intrusive obsession surfaces in their thinking." (Beamish and Hill, 2007) Little research exists on cognitive therapy's efficacy with clients diagnosed with OCD although some research does indicate a positive change in the thought patterns of an irrational nature however indications are that little difference between behavioral therapy and cognitive therapy exists in outcomes of clients. Beamish and Hill state: "Small sample sizes, lack of control groups, and inconsistent research findings hinder professional recognition of the efficacy of cognitive therapy with clients who have OCD. The influence of behavioral therapy is well articulated in the literature, so the limited support for cognitive interventions means that it is not perceived as a significant treatment modality in obsessive-compulsive literature." (2007) Psychopharmacological treatment research indicates that a genetic correlate for obsessive-compulsive disorder exists in that: "...neurological diseases and brain chemistry have been associated with OCD symptomatology. Psychopharmacological treatment has received support in the literature as a method for enhancing the influence of behavioral. What follows is a review of the primary medications used for the treatment of OCD and a discussion of combined therapy. The medications most frequently used to treat OCD are clomipramine (Anafranil), tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRI) such as fluoxetine (Prozac) and fluvoxamine Hendrix noted that all three medications function by increasing the brain's ability to use serotonin. Clomipramine was the first drug to show an indication of having an impact on OCD symptomatology (Dattilio, 1993; Eddy & Walbroehl, 1998). Tricyclic antidepressants have traditionally been used to treat OCD because of their anxiolytic and antidepressant effects; however, they can have significant negative side effects. The SSRIs have emerged as a more client-friendly option for treating OCD." (Beamish and Hill, 2007) in a meta-analysis of placebo-controlled studies of clominpramine, fluvoxamine, and fluxotine it was indicated that: "...clomipramine was more effective than the other drug interventions. The impact of adverse side effects was also not substantiated, as evidenced by low drop-out rates for clients using clomipramine. Another mete-analysis documented similar results after reviewing 47 double-blind studies. Combined Treatment.