Abstract
Hoarding disorder, now pigeonholed in DSM-5 as one of the obsessive-compulsive and related disorders, presents particular challenges in therapy and deserves attention. The disorder is characterized by persisting difficulty parting with items because the individual feels a strong need to save them and intense distress when discarding them. This behavior leads to home clutter that either interferes with the ability to use living space appropriately or makes it impossible.
Particularly tricky is dealing with the patients’ lack of insight and their ambivalence about getting help. Poor insight may border on delusional thinking, and vacillation about getting help, unfortunately, interferes greatly with treatment.
Since hoarding disorder was made a new DSM-5 diagnosis, it has attracted increased attention. Since 2013, several groups have published systematically about the disease. In addition, pathological hoarding has increased. Some psychopathological syndromes seem to come in waves, and recent observations suggest a small epidemic of hoarding problems.
Larger cities, such as Toronto and Ottawa, now have specialized experts and special services both for people who suffer from hoarding and for cleaning the habitations that have been made unlivable. They have long waiting lists. Talking to these services offers an amazing, and at times bizarre, list of hoarding collections that have made some homes in need of professional decluttering.
As to how common these problems are, the estimates of these experts resonate with the numbers from recent epidemiological studies: 4% to 5% of inhabitants of major cities. Presumably, these numbers are also inflated by the widespread online shopping that makes hoarding too easy, even without leaving the dwelling.
Hoarding disorder is a difficult problem to manage. The concise and well-written text by Chassan and Siev summarizes the latest knowledge on the assessment and treatment of hoarding disorder and presents the current treatment approaches to those who suffer from debilitating problems of hoarding. The authors, 2 senior psychologists, provide information on the definition, diagnosis, differential diagnosis, clinical course, and prognosis of the condition. At some length, they focus on the diagnostic assessment.
So far, research on treatment for hoarding has been limited and is much less robust than investigations on obsessive-compulsive disorder. Compared with other patients with obsessive-compulsive disorder, pharmacotherapeutic trials with venlafaxine and paroxetine have been rather unsatisfactory. The authors recommend multimodal treatment, with an emphasis on modified cognitive behavior treatment.
The authors designed a treatment protocol that is based on a cognitive-behavioral conceptualization of hoarding. A specific focus of cognitive-behavioral therapy is conjoint with psychoeducational, motivational, and harm reduction approaches. The protocol allows for a range of total treatment sessions. Depending on the complexity of the case, the severity of comorbid conditions, and treatment compliance, the treatment can range from 15 to more than 30 sessions. A succinct protocol that outlines the most critical elements of cognitive-behavioral therapy includes suggestions as to how to deal with diminished insight and motivation and how to work with families.
Rich anecdotes and clinical observations elucidate the recommendations, and the book also includes information for particular client groups, such as older individuals and those who hoard animals. Clinical vignettes are included in the text. They describe some success of this approach in comparison with controls, subjects who were on the waiting list for services.
Particularly useful are practical tools and resources provided in the appendix, the example of exposure and response prevention hierarchy for hoarding; types of cognitive errors by hoarders, and a cognitive-behavioral therapy contract. Printable handouts may be particularly useful to busy practitioners.
The text includes a list of further reading and references. This book is useful reading for clinical psychiatrists, psychotherapists, psychologists, and mental health practitioners.