Hoarding Disorder: Jenny's Case Study and CBT Treatment

Childhood Characteristics Associated with Hoarding Disorder

Hoarding disorder typically involves difficulty discarding items and maintaining control over belongings. These behaviors affect school and social functioning, and they first appeared in Jenny when she was eight years old (Sorensen, 2011). Jenny also experienced problems at school, as her teacher frequently sent notes home reporting that her desk was messy and that she appeared to be absent-minded in class. By the time she reached second grade, she had begun falling behind in several subjects.

The literature indicates that hoarding behaviors occur at higher rates among children with ADHD than among typically developing children (Sorensen, 2011). In Jenny's case, she was diagnosed with ADHD by a neuropsychologist, who determined that she had a neurodevelopmental disorder that made it difficult for her to sustain attention for extended periods.

Hoarding behaviors can also emerge as a way of strengthening a person's sense of control and safety following a traumatic experience or a chaotic childhood environment. Accumulating possessions becomes a means of regaining a sense of control. Jenny played with toys throughout most of her childhood and developed a strong sense of ownership over them. When her parents began receiving complaints from her teachers, they confiscated her toys as a form of punishment, which deepened her attachment to objects.

These experiences shaped her core beliefs and made her prone to the disorder. The most commonly reported core beliefs include feelings of being unloved, helpless, and unworthy. Environmental factors — including traumatic and stressful events, emotional deprivation, family attachments, and economic and cultural forces — all play a role in forming these core beliefs (Sorensen, 2011).

Jenny was a daddy's girl in early childhood, but she felt lonely and sad as she grew older because her father was frequently away on business. A particularly traumatic childhood event occurred when her cousin Andrew, aged 17, died in a motorcycle accident. Andrew and Jenny were close, and she was deeply affected by his death.

Difficulty categorizing items and making decisions is often reflected in the clutter found in the homes of compulsive hoarders. They take an unusually long time to organize possessions, and they experience significant anxiety when trying to sort items into categories (Sorensen, 2011). Jenny struggled to make even basic decisions, such as what to wear, what to have for dinner, or which toys to discard. As a young child, she rarely made most of her own decisions.

A particular challenge for her was deciding what to do with jewelry boxes and original toy packaging. She began by saving small jewelry boxes, paper towel rolls, and empty toilet paper rolls, believing they might be useful for future art projects such as papier-mâché animals. Although she never found time to use these items, Jenny believed for years that they might come in handy someday. She also felt it was important to keep her toys' original packaging because she had arranged with her parents that she would eventually sell the toys on Craigslist and keep the proceeds. She understood that items with their original packaging sold for more. While this was a reasonable idea in theory, Jenny managed to sell only a single game, because she found it too difficult to decide whether to list any item for sale.

Family Patterns and Triggering Episodes

Hoarding symptoms appear to be linked to family history, suggesting a degree of genetic vulnerability (Tolin, 2011). People with hoarding tendencies commonly have first-degree relatives who display similar behaviors (Sorensen, 2011). Jenny's aunt appeared to have similar tendencies: when Jenny visited Andrew's old bedroom, she noticed it was filled with items connected to him. On the way home, Jenny asked her mother about this, and her mother replied that Aunt Olivia was grieving and had been collecting anything associated with Andrew.

A key event that triggered a serious episode involved Jenny's mother purchasing designer clothing for her. Intending to surprise her daughter, Grace went to Jenny's room to place the clothes in the closet, only to find it packed with cardboard boxes, toys, and old clothes. She decided to move some items into Jenny's dresser to create space, but was appalled to discover that nearly every drawer was filled with empty toilet paper rolls and small boxes. Unsure why Jenny kept so many items there, and frustrated by how long it was taking to sort through everything, she filled a garbage bag with enough empty boxes to clear four drawers.

When Jenny came home, her mother proudly showed her the reorganized closet and explained that she had tidied it up and discarded the saved junk to make room for the new clothes. Instead of reacting with excitement, Jenny ran to the dresser and frantically opened every drawer. She screamed at her mother, demanding to know why her things had been thrown away. She cried that she had been saving them for future use and that they were now gone. She collapsed sobbing on the floor. Grace left the room, bewildered by what she perceived as her daughter's irrational reaction.

Lack of Insight in Hoarding Patients

Like nearly all patients with this disorder, Jenny was defensive about her habits and demonstrated poor insight into her condition. Poor insight is frequently cited as a reason why hoarding patients respond poorly to treatment. Clinicians generally rate hoarding patients as having lower levels of insight than patients with other disorders, which makes them less likely to seek help and more likely to drop out if they do begin treatment. Some individuals are not even aware of the extent of their hoarding problem. In one study of family members of people with hoarding problems, 55% of respondents reported that their loved ones had "poor insight" or were "delusional" about their behavior.

High levels of anxiety also contribute to this problem. People who hoard apparently experience unusually intense emotional reactions — and can become agitated — at the mere thought of anyone challenging their deeply held beliefs about waste, personal identity, and the emotional significance of their possessions. The intensity of these feelings is difficult to comprehend from the outside. Some female clients have independently told counselors that having others discard their belongings feels akin to a serious personal violation. Others describe the experience as so painful that they feel they cannot endure it. When even the most basic discarding attempts produce such levels of distress, patients will go to great lengths to avoid discarding at all. Many do not even use words like "discard," "garbage," or "trash" to refer to their belongings, because the images these words conjure are too painful (Frost, Tolin, & Maltby, 2010).

The Cognitive-Behavioral Model of Hoarding

The cognitive-behavioral model links compulsive hoarding to four main problem areas: information processing deficits, problems with emotional attachment, behavioral avoidance, and erroneous beliefs about the nature of possessions. Information processing deficits include difficulty making decisions about possessions, trouble categorizing and organizing items, low confidence in one's own memory, and faulty judgments about the importance of remembering information. These deficits lead individuals to acquire and save items for potential future use or perceived financial value.

Problems with emotional and sentimental attachment arise when individuals assign excessive value to objects because of their connection to the past. Behavioral avoidance refers to the tendency to avoid discarding items as a way of escaping the anxiety triggered by decision-making, sorting, and dealing with clutter. False or maladaptive beliefs are centered on the emotional significance of objects and the sense of safety they are perceived to provide (Pogosian, 2010).

Based on this model, clinicians have developed a multi-modal CBT approach targeting each of these problem areas — including information processing difficulties, erroneous beliefs about possessions, emotional distress linked to discarding, and avoidance behaviors that limit exposure to the distress associated with letting things go. Therapy emphasizes setting specific goals, establishing clear therapeutic rules, and improving daily functioning, such as ensuring that living spaces are used appropriately.

The therapeutic rules require patients to make all decisions about their possessions — whether to save or discard — themselves. Group therapy, including psychoeducational sessions, provides additional support (Pogosian, 2010). The cognitive-behavioral model also proposes that hoarders experience strong positive emotions — such as joy or pleasure — when acquiring or saving items, which makes it difficult to change these patterns without professional assistance.

References

American Psychiatric Association. (2014). Hoarding disorder. Retrieved 26 February 2015, from http://www.psychiatry.org/hoarding-disorder

Frost, R., Tolin, D., & Maltby, N. (2010). Insight-related challenges in the treatment of hoarding. Cognitive and Behavioral Practice, 17(4), 404–413. doi:10.1016/j.cbpra.2009.07.004

Pogosian, L. (2010). Treatment of compulsive hoarding: A case study. The Einstein Journal of Biology and Medicine, 8–11. Retrieved from http://www.einstein.yu.edu/uploadedfiles/ejbm/page8_page11.pdf

Sorensen, R. J. (2011). Hoarding disorder (compulsive hoarding): A comprehensive literature review and professional training to prepare clinicians to treat problematic hoarding. Retrieved from http://ir.stthomas.edu/cgi/viewcontent.cgi?article=1002&context=caps_gradpsych_docproj

Tolin, D. (2011). Understanding and treating hoarding: A biopsychosocial perspective. Journal of Clinical Psychology, 67(5), 517–526. doi:10.1002/jclp.20795