therapy « Peter H Brown Clinical Psychologist

Compulsive Collecting: Finding Hope In The Misunderstood Mess of Hoarding

Compulsive collecting or Hoarding is a misunderstood and debilitating mental health issue. Many psychologists and counsellors never see someone with this condition as they very rarely present for help. This article from an Australian newspaper provides an excellent overview of the condition and issues underlying hoarding, and I have included links to two brilliant books co-authored by the researchers discussed in the article, who have developed a wholistic and novel approach to it’s treatment.

Credit: Kate Benson, Sydney Morning Herald April 8 2010

They may dress well or hold down a good job. But hoarders are unhappy people who suffer from a debilitating condition.

Every suburb has one. The elderly woman weaving through an overgrown backyard full of cardboard boxes, old tyres and discarded furniture. Cats perch on every surface; kittens roll about among the rusted drums and long grass.

Inside, behind closed curtains, the rooms are piled high with papers, cups, plates and bottles. Broken toys, old clothes and shopping bags spill across kitchen benches and floor, smothering the stove and filling the sink, neither of which has been used in years.

The stench of cat faeces, urine and food scraps fill the house.

To her neighbours, she is an oddity. Or a pest, bringing down house values and encouraging vermin.

But to therapists she is one of a growing band across Australia suffering from a debilitating condition known as compulsive hoarding, where people feel a need to collect and store items that seem useless to others.

Their homes become havens of insurmountable clutter and junk, often leaving them unable to sleep in their beds or use appliances. Many end up with electricity or gas supplies disconnected or their fridge and washing machines unusable because they fear their lifestyle will be revealed if they contact a tradesmen to make repairs.

This secrecy and shame make it difficult to know exactly how many people have the disorder.

Some experts think between 200,000 and 500,000 Australians compulsively hoard, but others put the figure closer to 800,000.

“It’s a sleeping giant,” Chris Mogan, a clinical psychologist and expert on hoarding, says. “There is no systematic estimate of how many hoarders there are in any Australian setting. I suspect there are many, many more out there than we are aware of.”

Louise Newman, the president of the Royal Australian and New Zealand College of Psychiatrists, agrees.

Click image to read reviews

“I’ve only seen one case in my career [because] these people usually only come to light when the council steps in and orders a clean-up. Hoarders desperately want to keep hoarding. They don’t want to be stopped.”

There is little research on the condition in Australia and not much in the way of funding or treatment programs, but experts are hopeful hoarding will be included in the next (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders, the bible used by mental health experts to diagnose psychiatric conditions.

Many sufferers fall between the cracks because hoarding is not a clinical diagnosis in its own right, but is seen more as an offshoot of obsessive compulsive disorder, muddled with depression, anxiety, panic disorder and low self-esteem.

“But it is different to OCD and once we get it in the DSM-V, therapists, psychiatrists, psychologists and social workers can then be trained in the management of it [and] we can attract funding for research,” Mogan says.

Jessica Grisham, a clinical psychologist who specialises in obsessive compulsive disorder, also believes compulsive hoarding should be included in the next edition as it requires specialised treatment.

She cites recent neural imaging studies in the US that showed that different parts of the brain were activated in hoarders than in obsessive compulsive disorder patients.

Mogan and Grisham agree that cognitive behaviour therapy, where sufferers are slowly taught to change their thought patterns, is more effective than medication alone.

But hoarders responded better to a specially adapted version of the therapy, developed by the American hoarding experts Gail Steketee and Randy Frost. It had been achieving success with about 60 per cent of hoarders – far more than standard cognitive behaviour therapy.

“But it has to be a long-term project. You don’t go in to someone’s place and do a sudden excavation against their will,” Grisham says.

“That’s a violation and it’s very traumatic for them. It might make great TV, but it’s not good clinically.”

Mogan agrees. A pay TV show, Hoarders, was damaging to the public’s understanding of the illness, because it focused on forcefully cleaning houses in three days.

“Within six to 12 months that house will be recluttered because it is a compulsion … they suffer a lot of grief after things are taken away.”

Mogan makes weekly home visits to hoarders, and focuses on getting them to reduce the associated dangers by ensuring their home has two exits for safety, and working appliances and smoke alarms.

“Just as we do with drugs and alcohol, we’re into harm minimisation. Once the house is safe, we gradually set more goals. If they are comfortable with that, they will continue to stay in touch and not reject us.”

Sometimes the problem extends beyond mounds of paperwork and clothes. Mogan and Grisham know patients who hoarded urine or fingernail clippings. Some stored their own faeces or collected one particular item, such as bicycles. One sufferer was hoarding so much junk, the only access to the house was a 30-centimetre gap at the top of the front door.

But for Allie Jalbert, of the RSPCA, the most distressing hoarders are those who keep scores of cats and dogs, all battling for attention and food on a crowded suburban block.

She has been calling for years to have hoarding classified as an illness in its own right to allow more people to receive treatment and put an end to the 100 per cent recidivism rate.

“Often, we find that hoarders might be treated for peripheral symptoms such as anxiety or depression, but their core problem, the hoarding, is not addressed. So once we have cleaned out the house, they reoffend, which is very, very frustrating for everyone involved,” Jalbert says.

Some people threatened suicide and had to be removed by police when faced with the prospect of giving up their animals or clutter.

“There’s a mixed bag of emotion when you deal with hoarders. Firstly, there is the concern for your personal safety but there is also a degree of empathy because often these people are quite emotional and attached to the animals. But it’s quite frustrating to see animals living in such horrific situations,” she says.

“I’ve seen bathtubs full of faeces and rubbish, sinks that no longer work, homes with no heating or cooling. Sometimes it’s quite an overwhelming experience.”

Click image to view reviews

Who develops the condition and why?

Some studies have shown that many hoarders have been brought up in households where chaos reigned. Some were neglected as children and witnessed pets being treated poorly.

Mogan accepts the aetiology is mostly unknown, but cites an Australian study that found sufferers reported failing to connect with their parents or growing up in households lacking emotional warmth.

“The lack of attachment causes them to become ambivalent about their identity and about other people. As a compensatory mechanism, they link with things, which they find more compelling, more predictable and dependable and less rejecting.”

But Grisham believes there is no real trigger, apart from children of hoarders being rewarded for saving things and getting punished for discarding. “Sometimes there is a traumatic head injury but those cases are very rare.”

The condition affects slightly more women than men but is found across all occupations, age groups and ethnicities. “And they are in relationships,” Mogan says. “Albeit strained ones.

“Some are going out to work, but they make sure no one comes to their house. They’re not agoraphobic. On the contrary, many hoarders go out a lot to escape. But their children’s lives can’t be normalised because they can never sit down for a meal or find space to do homework. It’s a real impost on the family experience.”

Mogan runs group therapy sessions in Melbourne and says that many patients do want to be cured.

“This condition is a disability and the source of quite a lot of human suffering and neglect. A lot of these people are quite relieved to get help.”

//

Are You Developing Hoarding Behaviors? (blisstree.com)
How to handle the hoarding habit (nationalpost.com)

April 10, 2010 Posted by peterhbrown | anxiety, Books, Cognitive Behavior Therapy, diagnosis, Identity, research, Resources, therapy | anxiety, Australia, buried in treaures, Compulsive hoarding, Disorders, Health, hoarding, Mental disorder, Mental health, Obsessive–compulsive disorder, OCD, therapy, United States | 9 Comments

ADHD Treatment: Behavior Therapy & Medication Seem To Positively Affect The Brain In The Same Way

(Information provided by The Wellcome Trust 1 April 2010)

Read the original research paper HERE (PDF)

Medication and behavioural interventions help children with attention deficit hyperactivity disorder (ADHD) better maintain attention and self-control by normalising activity in the same brain systems, according to research funded by the Wellcome Trust.

In a study published today in the journal ‘Biological Psychiatry’, researchers from the University of Nottingham show that medication has the most significant effect on brain function in children with ADHD, but this effect can be boosted by complementary use of rewards and incentives, which appear to mimic the effects of medication on brain systems.

ADHD is the most common mental health disorder in childhood, affecting around one in 20 children in the UK. Children with ADHD are excessively restless, impulsive and distractible, and experience difficulties at home and in school. Although no cure exists for the condition, symptoms can be reduced by a combination of medication and behaviour therapy.

Methylphenidate, a drug commonly used to treat ADHD, is believed to increase levels of dopamine in the brain. Dopamine is a chemical messenger associated with attention, learning and the brain’s reward and pleasure systems. This increase amplifies certain brain signals and can be measured using an electroencephalogram (EEG). Until now it has been unclear how rewards and incentives affect the brain, either with or without the additional use of medication.

To answer these questions, researchers at Nottingham’s Motivation, Inhibition and Development in ADHD Study (MIDAS) used EEG to measure brain activity while children played a simple game. They compared two particular markers of brain activity that relate to attention and impulsivity, and looked at how these were affected by medication and motivational incentives.

Click Image to view reviews

The team worked with two groups of children aged nine to 15: one group of 28 children with ADHD and a control group of 28. The children played a computer game in which green aliens were randomly interspersed with less frequent black aliens, each appearing for a short interval. Their task was to ‘catch’ as many green aliens as possible, while avoiding catching black aliens. For each slow or missed response, they would lose one point; they would gain one point for each timely response.

In a test designed to study the effect of incentives, the reward for avoiding catching the black alien was increased to five points; a follow-up test replaced this reward with a five-point penalty for catching the wrong alien.

The researchers found that when given their usual dose of methylphenidate, children with ADHD performed significantly better at the tasks than when given no medication, with better attention and reduced impulsivity. Their brain activity appeared to normalise, becoming similar to that of the control group.

Similarly, motivational incentives also helped to normalise brain activity on the two EEG markers and improved attention and reduced impulsivity, though its effect was much smaller than that of medication.

“When the children were given rewards or penalties, their attention and self-control was much improved,” says Dr Maddie Groom, first author of the study. “We suspect that both medication and motivational incentives work by making a task more appealing, capturing the child’s attention and engaging his or her brain response control systems.”

Professor Chris Hollis, who led the study, believes the findings may help to reconcile the often-polarised debate between those who advocate either medication on the one hand, or psychological/behavioural therapy on the other.

“Although medication and behaviour therapy appear to be two very different approaches of treating ADHD, our study suggests that both types of intervention may have much in common in terms of their affect on the brain,” he says. “Both help normalise similar components of brain function and improve performance. What’s more, their effect

Click Image to view reviews

is additive, meaning they can be more effective when used together.”

The researchers believe that the results lend support from neuroscience to current treatment guidelines

for ADHD as set out by the National Institute for Health and Clinical Excellence (NICE). These recommend that behavioural interventions, which have a smaller effect size, are appropriate for moderate ADHD, while medication, with its larger effect size, is added for severe ADHD.

Although the findings suggest that a combination of incentives and medication might work most effectively, and potentially enable children to take lower doses of medication, Professor Hollis believes more work is needed before the results can be applied to everyday clinical practice or classroom situations.

“The incentives and rewards in our study were immediate and consistent, but we know that children with ADHD respond disproportionately less well to delayed rewards,” he says. “This could mean that in the ‘real world’ of the classroom or home, the neural effects of behavioural approaches using reinforcement and rewards may be less effective.”

Read the original research paper HERE (PDF)

Mount Sinai finds meta-cognitive therapy more effective for adult ADHD patients (scienceblog.com)
What Do Girls with ADHD Look Like As Adults? (psychcentral.com)

April 7, 2010 Posted by peterhbrown | ADHD /ADD, Books, brain, Cognitive Behavior Therapy, diagnosis, research | ADD.ADHD, Attention-deficit hyperactivity disorder, behavior, behaviour, CBT, child, dexamphetamine, Electroencephalography, Mental health, research, ritalin, Scientific control, therapy, University of Nottingham, Wellcome Trust | 3 Comments

Martin Seligman: Author Of “Learned Optimism” Speaks About Positive Psychology And Authentic Happiness

Martin Seligman was originally best known for his classic psychology studies and theory of “Learned Helplessness” (1967) and it’s relationship to depression.

These days he is considered to be a founder of positive psychology, a field of study that examines healthy states, such as authentic happiness, strength of character and optimism, and is the author of “Learned Optimism”.

This is a terrific talk on Positive Psychology and what it means to be happy. It’s about 20 mins. long but definitely worth a watch!

April 1, 2010 Posted by peterhbrown | anxiety, Cognitive Behavior Therapy, depression, Health Psychology, Mindfulness, Resilience, Resources, Technology, therapy, video | anxiety, depression, good, happiness, Health Psychology, Internet, martin-seligman, Positive Psychology, Resources, Technology, therapy | 2 Comments

Self Help For Anxiety & Depression: A List Of FREE Interactive Self Help Websites

Today I wanted to get around to doing what I have been meaning to do for a while and post a list of free access interactive and/or educational websites which I have come across. These sites are fantastic resources and each one offers a different way to get involved with your recovery. Please note I am not affiliated with any of these sites and they are not affiliate sites. I hope you find one or more useful as I know many of my clients have.

Click Image to Read Reviews

Self Help / Educational Websites

Updated 27th March 2010

There you have it! Check them out and let me know what you think. Know of any others? (No affiliate sites please).

March 24, 2010 Posted by peterhbrown | Acceptance and Commitment Therapy, anxiety, Cognitive Behavior Therapy, depression, Dialectical Behavior Therapy, Education, Internet, Mindfulness, Positive Psychology, Resilience, Resources, Technology, therapy | anxiety, depression, Education, Health Psychology, interactive, Internet, Resilience, Resources, self help, therapy | 8 Comments

Borderline Personality Disorder: What’s with the Name & Just What Is It?

I have continued to receive a number of requests by email and on Twitter about Borderline Personality Disorder, its name, its presentation, its treatment and its psycho-genesis. Below is a brief post which I think covers most of these questions in outline form. I am open to suggestions as to which, if any areas readers would like to discuss in more detail. A small collection of books on BPD which I recommend to patients, carers, significant others and counsellors can be found here, most with reader reviews. I would be happy to hear of others.

What’s with the name?

The term “borderline” was first used by early psychiatrists to describe people who were thought to be on the “border” between diagnoses. At the time, the system for diagnosing mental illness was far less sophisticated than it is today, and “borderline” referred to individuals who did not fit neatly into the two broad categories of mental disorder: psychosis or neurosis.

Today, far more is known about BPD, and it is no longer thought of as being related to psychotic disorders (and the term “neurosis” is no longer used in our diagnostic system). Instead, BPD is recognized as a disorder characterized by intense emotional experiences and instability in relationships and behavior.

Many experts are now calling for BPD to be renamed, because the term “borderline” is outdated and because, unfortunately, the name has been used in a stigmatizing way in the past. Suggestions for the new name have included: “Emotion Dysregulation Disorder,” Unstable Personality Disorder,” and “Complex Posttraumatic Stress Disorder.”

Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual’s sense of self-identity. Originally thought to be at the “borderline” of psychosis, people with BPD suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women.¹ There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.²^,3 Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.⁴ Yet, with help, many improve over time and are eventually able to lead productive lives.

Symptoms

While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day.⁵ These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.

People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

Treatment

Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies.⁶ Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.⁷

Recent Research Findings

Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children.⁸ Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.⁹ Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.

NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion.¹⁰ The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.¹¹

Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.⁷

Future Progress

Studies that translate basic findings about the neural basis of temperament, mood regulation, and cognition into clinically relevant insights which bear directly on BPD represent a growing area of NIMH-supported research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.

References

¹Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 1990; 4(3): 257-72.

²Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67.

³Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.

⁴Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press.

⁵Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry, 1998; 6(4): 201-7.

⁶Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67.

⁷Siever LJ, Koenigsberg HW. The frustrating no-mans-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).

⁸Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.

⁹Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.

¹⁰Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89.

¹¹Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation – a possible prelude to violence. Science, 2000; 289(5479): 591-4.

Bernstein, PhD, David P., Iscan, MD, Cuneyt, Maser, PhD, Jack, Board of Directors, Association for Research in Personality Disorder, & Board of Directors, International Society for the Study of Personality Disorders. “Opinions of personality disorder experts regarding the DSM-IV Personality Disorders classification system.” Journal of Personality Disorders, 21: 536-551, October 2007.

Sources: about.com and nimh.gov.org

March 15, 2010 Posted by peterhbrown | Cognitive Behavior Therapy, diagnosis, Dialectical Behavior Therapy, Education, Personality Disorder, Resources, self harm, therapy | borderline personality, bpd, diagnosis, dsm iv, Personality Disorder, therapy | 1 Comment

The Book Depository: Very Cheap Prices, FREE SHIPPING WORLDWIDE

I have just come across this site. The book prices are as good or better than Amazon and they ship free to any address worldwide no matter the size of the order. The Book Depository

www.thebookdepository.co.uk

I will be using this site for my blog links for highly recommended books from now on as I believe it provides the best value for most of my readers. I will continue to provide Amazon links in my Highly Recommended Books Library accessible from the menu on the right.

March 10, 2010 Posted by peterhbrown | Education, General, Resources, Technology | Books, Education, Resources, therapy | 2 Comments

Borderline Personality Disorder: What’s with the Name & Just What Is It?

I have had a number of requests by email and on Twitter about Borderline Personality Disorder, its name, its presentation, its treatment and its psycho-genesis. Below is a brief post which I think covers most of these questions in outline form. I am open to suggestions as to which, if any areas readers would like to discuss in more detail. A small collection of books on BPD which I recommend to patients, carers, significant others and counsellors can be found here, most with reader reviews. I would be happy to hear of others, and I will also add a few more over the next few days.