Sunday, October 16, 2011

Saving Children's Artwork

What is more precious then your children's artwork? They bring it home for you to admire, and admire you do. I've had many clients that have decision making problems and one problematic area is what to do with all of their children's artwork. What to keep, what to toss? Well, that decision is a pretty personal and difficult thing for some parents.

There has been many a time I suggest that my clients choose a number that they are comfortable with, and keep a certain amount of artwork per month. Let's say you like the number 5. You keep 5 items per month and at the end of the year, you and your children sit down and pick one or two from each month. If you have limited space, you limit the number of artwork keeps to suit your storage needs. Decide what will make the cut and what won't. Will you involve your child in the decision making or make the decisions yourself or on your own?

If you have a problem making a decision about what to keep, think about how helpful it will be if you limit what you choose to display and what you choose to archive. You'll be sending a message to your children that we make choices and don't keep everything. Not everything is worth keeping. When we make choices, we help ourselves and our children to understand that decision making is an important process. We also want to honor the artwork our children have created by making sure that these treasures are preserved and stored safely.

There are some really cute ways of displaying children's artwork. Pottery Barn kids has these cute butterfly clips that work as a way to display and string their artwork on a wall. (http://tinyurl.com/7k52a3h) Works of art can be rotated in and out with this idea. Another cute site is Land of Nod. They also offer these cute art clips in different styles. (http://tinyurl.com/3ucnd6o).

Improvements offers a "Dynamic Artwork Frame' that displays one work of art at a time, but holds 50 works of art. You'll always have a new masterpiece to look at with that frame. (http://www.dynamicframes.com)

One last important place for wonderful archive boxes is Container Store. They have them in all different sizes for your needs. Let's celebrate your budding Monet's with some creative displays and storage.


Wednesday, October 12, 2011

Psychiatric Issues in Hoarding

[I'd like to share this article which originally ran in Psychiatric Times, Volume 28, No. 8.  This is the full version of the original article with the website reference at the end. Randi Lyman]


Psychiatric Issues in Hoarding

Strategies for Diagnosing and Treating Symptoms of Hoarding

By Suzanne Otte, MBA, MSW and Gail Steketee, PhD | August 19, 2011
Ms Otte is Hoarding Research Project Affiliate at Boston University School of Social Work and Dr Steketee is Dean and Professor at Boston University School of Social Work. The authors report no conflicts of interest concerning the subject matter of this article.
In North America, an estimated 30% of the population maintains a collection of some sort.1 The practice of collecting, in which individuals maintain collections of objects that are generally considered interesting and valuable is distinctly different from that of hoarding.2 Compulsive hoarding is characterized by the following criteria3,4:
• The acquisition of, and failure to discard, a large number of possessions
• Excessive clutter that precludes activities for which the living space was designed
• Significant distress or impairment in functioning caused by the hoarding
Hoarding has broad-reaching implications, including a substantial public health burden linked to occupational impairment, poor physical health, and demand for social services.5 For example, it is not uncommon for community public health departments to become overburdened with property complaints regarding unsanitary conditions and fire hazard risks, and the cost to address a problem (eg, repetitive clean-outs, repeated visits by health inspectors, multiple-agency involvement) is high.6 These costs have led to the establishment of community-wide task forces in a number of cities.7 However, efforts to reconcile the problem are often diminished by the relative unavailability or ineffectiveness of mental health services.8
In addition to the effects of hoarding on the community, family dynamics are often strained.9 Substantial distress, frustration, hostility, and rejection of hoarders are not uncommon.3 In a recent online study of hoarding, more than half of the participants were described as having poor or no insight into the severity of their hoarding behaviors, and family members’ attitudes of rejection were correlated with less awareness of illness among those who hoard.10
For the individual who hoards, outcomes may include substantial work impairment, eviction or threat of eviction, or having a child or elder removed from the home.10 In general, persons with hoarding problems seek treatment after age 40 years, although hoarding symptoms commonly begin in the early teenage years.11 Those who hoard tend to live alone and may have a family member (parent, sibling, older relative) with the problem.12-14
The prevalence of clinically significant hoarding in the general population ranges from 2% to 5%, and between 6 million and 15 million persons in the United States are affected, according to recent epidemiological studies.15-17 Hoarding appears to affect more men than women, although women are more likely to participate in research and seek treatment.17
Hoarding is a significant psychiatric problem that occurs at twice the rate of obsessive-compulsive disorder (OCD) and at almost 4 times the rate of bipolar disorder and schizophrenia.13 It has been linked with impulse control disorders and appears to have high comorbid rates of major depressive disorder (MDD), social anxiety disorder, generalized anxiety disorder (GAD), attention-deficit/hyperactivity disorder (ADHD), and personality disorders.18-26

What is already known about hoarding?

Clinically significant hoarding affects between 6 million and 15 million persons in the United States, according to recent epidemiological studies, occurring at twice the rate of obsessive-compulsive disorder (OCD) and at 4 times the rate of bipolar disorder and schizophrenia. It appears that hoarding is accompanied by high rates of comorbidity. A number of self-report and clinician-administered hoarding-specific measures aid in the assessment of symptoms and severity. Treatment for hoarding is guided by a cognitive-behavioral therapy (CBT) approach.

What new information does this article provide?

Historically, hoarding has been deemed a subtype of OCD, although forthcoming evidence suggests there are more differences than similarities. Hoarding is under consideration for inclusion in DSM-5 as a stand-alone disorder. A set of provisional criteria for hoarding disorder has been proposed and will require further study in the future. A recent study conducted by Frost and colleagues that examined the largest sample of participants to date confirmed that major depressive disorder was the most frequently occurring comorbid condition (more than 50%) and that kleptomania was a factor in 10% of the sample. This article highlights treatment options for hoarding that are available to practitioners, including alternative approaches focusing on self-help, support group, and Web-based delivery models.

What are the implications for psychiatric practice?

Individually administered CBT, following the protocol developed by Steketee and Frost, appears to be the most effective treatment, with a 70% to 80% rate of clinical improvement for patients who complete treatment. Given the expense and limited availability of individual treatment, alternatives, including group CBT, Web-based treatment, in-person self-help groups, and in-home coaching assistance, may provide sustainable and affordable approaches to this significant societal problem. Further research to better understand hoarding and to provide additional cost and resource-sensitive solutions is ongoing.

Historically, hoarding has been considered a subtype of OCD, although recent evidence suggests that there are more differences than similarities.13 Studies of patients with OCD have shown an 18% to 40% frequency of hoarding in adults and children and adolescents, although, hoarding is identified as a major or primary symptom in fewer than 5% of cases.19,26-29 Early studies that support this finding were derived from measures that do not adequately assess the presence or severity of hoarding (ie, Yale-Brown Obsessive Compulsive Scale30).8 Recent studies have incorporated reliable and valid measures (eg, Saving Inventory-Revised [SI-R], Hoarding Rating Scale-Interview [HRS-I], Clutter Image Rating [CIR]) that assess specific symptoms of hoarding as well as changes in symptoms following treatment.8

Comorbidity and implications for diagnosis
The identification of hoarding as a subtype of OCD has influenced scientific understanding of its comorbidity. Progressive research efforts have advanced the definition and measurement of hoarding, providing a more reliable diagnosis and assessment of comorbidity.12,31,32 A recent study by Frost and colleagues (R. O. Frost, G. Steketee, D. F. Tolin, K. Glossner, unpublished data, 2011) examined 217 hoarding participants, the largest sample to date, who were recruited to meet diagnostic criteria for hoarding disorder (HD) currently under review for DSM-5.12 The study confirmed that a minority of participants with HD (fewer than 20%) also had OCD diagnoses and that MDD was the most frequent comorbid condition (more than 50%). This was followed by GAD and social phobia in approximately 25% of HD participants.


The rates for posttraumatic stress disorder were relatively low (7%), but the HD sample was more likely than OCD patients to have experienced a traumatic event as an adult or as a child. This finding is consistent with earlier research about the frequency of traumatic events among those who hoard.17,33,34 Inattentive ADHD was significantly more frequent in hoarding than in OCD (30% vs 3%), which supports the speculation that attention deficits are relatively common among those who hoard, but certainly this is not a universal characteristic.
It is not surprising that compulsive buying and excessive acquiring of free things were common among the hoarding sample (about 60%), and even the prevalence of kleptomania was surprisingly high at 10% of the sample. These findings confirm recent reports that more than 80% of people with self-reported hoarding acquire excessively.35 Obsessive-compulsive personality disorder (OCPD) was the most frequent personality disorder found among hoarding participants, even when hoarding was omitted from the criteria for OCPD.

Status of DSM-5 diagnostic criteria
Today, hoarding is cited in DSM-IV-TR as one of the diagnostic criteria for OCPD and, when hoarding is deemed severe, a symptom of OCD.12Hoarding has been a core diagnostic criterion for OCPD only since DSM-III-R and as a possible OCD symptom within the differential diagnosis section OCPD since DSM-IV.12,36 Given the presumption that hoarding was a symptom of OCD, many studies have evolved from this assumption and have influenced clinical understanding of the disorder.13 More recently, however, growing evidence supports the separation of hoarding from OCD.13,36-38
In the interest of clarifying the clinical phenomenon, increasing public awareness, improving identification of cases, and stimulating further research and development of effective treatments for hoarding, a set of provisional criteria has been proposed (Table).12 These will require further study in the coming years.

Theoretical model
The manifestations of hoarding (acquisition, difficulty with discarding, clutter), outlined in an emerging cognitive-behavioral model, are hypothesized to evolve from core vulnerabilities based on early life experiences, genetic predisposition, current mood state, and personality traits (Figure).4,39,40 On the basis of this model, cognitive information processing deficits (focusing attention, decision making, organizing, and possibly perception) are thought to be persistent factors in generating hoarding. A combination of early experiences and cognitive challenges result in mistaken beliefs about and attachments to possessions, with resulting negative emotions that lead to avoidance behaviors (saving unneeded items) and clutter. In addition, objects that evoke feelings of positive attachment and experiences of pleasure may result in excessive acquiring and clutter.8

CBT methods and outcomes
The elements of mental health treatment for hoarding are based on the theoretical model for this multidimensional problem. The protocol uses a manualized cognitive-behavioral therapy (CBT) approach that incorporates assessment and goal setting, organizing and problem-solving skills training, exposure practice methods to reduce acquiring and remove clutter, and motivational interviewing to address patient resistance when it arises during treatment.2,8,41
The tools to measure hoarding symptoms and severity include the SI-R, a 23-item self-report questionnaire that assesses difficulty with discarding, clutter, and excessive acquisition; a score of 41 or higher typically indicates a clinical hoarding problem.31 The HRS-I helps clinicians make a diagnostic assessment of the 5 main features of hoarding (clutter, acquisition, difficulty with discarding, distress, impairment), each rated on a 0 to 8 scale; the HRS-I can also be used as a self-report scale.32 The CIR is a pictorial measure of in-home clutter severity intended for use by patients, family members, clinicians, or independent assessors.42 The Saving Cognitions Inventory is a 24-item self-report measure of beliefs experienced by patients when they attempt to discard items; subscales of this measure include emotional attachment, concerns about memory, control over possessions, and responsibility toward possessions.40

The most effective approach to date appears to be individually administered CBT, following the model and methods of Steketee and Frost.2 A recent pilot study of 10 completers and a controlled trial with 37 completers yielded rates of 70% improved or much improved according to the therapists and 80% according to patients. Overall, 60% of patients showed clinically significant improvement following 26 sessions of individual CBT that included monthly in-home visits.10 Group interventions that included 20 sessions of CBT were only slightly less effective and appear to offer considerable potential for cost-saving solutions.22

Further research is necessary to examine methods to enhance cognitive function (eg, attention, executive functioning) to improve the effectiveness of CBT.43 Expanding study inclusion criteria to allow men and persons from other cultures, races, and socioeconomic status will help generate more information about outcomes and strategies appropriate for all persons who hoard.

Cost-saving, stepped-care strategies for delivering CBT
The delivery of in-person, individual or group therapy for hoarding depends on skilled clinicians trained to treat persons with this problem. Because individual and even group treatment can be expensive and unavailable to many individuals with this highly prevalent condition, alternative approaches have focused on the application of self-help bibliotherapy, online and in-person support groups, coaching, and Web-based CBT.
Muroff and colleagues8 describe a 2009 study undertaken by Pekareva-Kochergina and Frost. The researchers examined the benefits of a 13-week intervention during which 2 undergraduate students supervised by a senior clinician facilitated 2 self-help groups. Participants read Buried in Treasures: Help for Compulsive Hoarding,44 a book describing hoarding, and were encouraged to practice the strategies proposed. At the close of the group sessions, 41% of participants rated themselves “much improved.” This student-led group yielded a surprisingly positive outcome for group members in a relatively short period.

In 2010, a Web-based self-help group for hoarding, established in 1998, was studied by Muroff and colleagues.45 Members participated in online chats, accessed an archive of resources hosted on the Web site, and were required to post action steps and progress reports at least monthly. Both long-term and recent members showed reductions in clutter and hoarding symptoms over a 15-month period. More active participants on the Web site showed statistically lower levels of hoarding. This group represents an intervention model that holds the potential to economically extend treatment to a geographically dispersed group.

The benefit of in-home assistance by clinicians is time-consuming and costly. Muroff and colleagues8 introduced non-clinician, in-home assistants (trained undergraduate student coaches) into a hoarding treatment group to reinforce skills learned in group treatment and boost CBT-based outcomes for participants. Clinicians who led the group communicated with coaches through in-person and telephone group supervision and use of a system to track and docu-ment home visits throughout the 20-week treatment period. One group of participants received 4 home visits from one of the cotherapists, the second group received an additional 4 home visits from the undergraduate coaches. Although reductions in hoarding symptoms were not statistically significant, additional in-home assistance appeared to offer improved (albeit small) outcomes. Additional studies will help further define the effect of this enhancement to group treatment.
A pilot study is under way to test the feasibility, acceptability, and effectiveness of computer- and Webcam-delivered CBT for hoarding symptoms. Preliminary results show potential for a cost-effective, direct service solution to in-home locations where hoarding occurs.8 Initial outcomes of this 26-session, weekly home-based CBT treatment delivered via Webcam showed moderate improvement of participant’s hoarding symptoms and was administered over a 30- to 38-week period compared with an average 49 weeks of in-person treatment.
These stepped-care strategies demonstrate potential to assist a broader spectrum of patients using CBT hoarding interventions and offer a sustainable, economic approach to this societal problem. Given the large number of persons who hoard, the debilitating and potentially deadly consequences, and the sometimes limited insight into the severity of their symptoms, it seems essential to learn more about this complicated problem. Current CBT regimens are effective, but they are costly. Accordingly, more research is needed to better understand the disorder and to provide relief from this chronic problem.


References
1. Pearce S. On Collecting: An Investigation Into Collecting in the European Tradition. London: Routledge; 1995.
2. Steketee G, Frost RO. Compulsive Hoarding and Acquiring: A Therapist Guide. New York: Oxford University Press; 2007.
3. Frost RO, Gross RC. The hoarding of possessions. Behav Res Ther. 1993;31:367-381.
4. Frost, RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther. 1996;34:341-350.
5. Tolin DF, Frost RO, Steketee G, et al. The economic and social burden of compulsive hoarding. Psychiatry Res. 2008;160:200-211.
6. Frost RO, Steketee G, Williams L. Hoarding: a community health problem. Health Soc Care Community. 2000;8:229-234.
7. Steketee G, Frost R. Compulsive hoarding: current status of the research. Clin Psychol Rev. 2003;23:905-927.
8. Muroff J, Bratiotis C, Steketee G. Treatment for hoarding behaviors: a review of the evidence. Clin Soc Work J. 2010. doi:10.1007/s10615-010-0311-4. 2010.
9. Tolin DF, Frost RO, Steketee G, Fitch KE. Family burden of compulsive hoarding: results of an internet survey. Behav Res Ther. 2008;46:334-344.
10. Tolin DF, Frost RO, Steketee G. An open trial of cognitive-behavioral therapy for compulsive hoarding. Behav Res Ther. 2007;45:1461-1470.
11. Grisham JR, Frost RO, Steketee G, et al. Age of onset of compulsive hoarding. J Anxiety Disord. 2006;20:675-686.
12. Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010;27:556-572.
13. Pertusa A, Frost RO, Fullana MA, et al. Refining the diagnostic boundaries of compulsive hoarding: a critical review. Clin Psychol Rev.2010;30:371-386.
14. Saxena S. Recent advances in compulsive hoarding. Curr Psychiatry Rep. 2008;10:297-303.
15. Iervolino AC, Perroud N, Fullana MA, et al. Prevalence and heritability of compulsive hoarding: a twin study. Am J Psychiatry. 2009;166:1156-1161.
16. Mueller A, Mitchell JE, Crosby RD, et al. The prevalence of compulsive hoarding and its association with compulsive buying in a German population-based sample. Behav Res Ther. 2009;47:705-709.
17. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther.2008;46:836-844.
18. Frost RO, Steketee G, Williams L. Compulsive buying, compulsive hoarding, and obsessive-compulsive disorder. Behav Ther. 2002;33:201-214.
19. Samuels J, Bienvenu OJ 3rd, Riddle MA, et al. Hoarding in obsessive compulsive disorder: results from a case-control study. Behav Res Ther. 2002;40:517-528.
20. Frost RO, Steketee G, Tolin D, Brown T. Co-morbidity and diagnostic issues in compulsive hoarding. Paper presented at: Annual Meeting of the Anxiety Disorders Association of America 2006; Miami.
21. Frost RO, Steketee G, Williams LF, Warren R. Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls. Behav Res Ther. 2000;38:1071-1081.
22. Muroff J, Steketee G, Rasmussen J, et al. Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial. Depress Anxiety. 2009;26:634-640.
23. Steketee G, Frost RO, Wincze J, et al. Group and individual treatment for compulsive hoarding: a pilot study. Br Assoc Behav Cognit Psychother. 2000;23:259-268.
24. Hartl TL, Frost RO. Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study. Behav Res Ther.1999;37:451-461.
25. Meunier SA, Tolin DF, Frost RO, et al. Prevalence of hoarding symptoms across the anxiety disorders. Paper presented at: Annual Meeting of the Anxiety Disorders Association of America; 2006; Miami.
26. Mataix-Cols D, Rauch SL, Manzo PA, et al. Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 1999;156:1409-1416.
27. Frost RO, Krause MS, Steketee, G. Hoarding and obsessive-compulsive symptoms. Behav Modif. 1996;20:116-132.
28. Mataix-Cols D, Nakatani E, Micali N, Heyman I. Structure of obsessive-compulsive symptoms in pediatric OCD. J Am Acad Child Adolesc Psychiatry. 2008;47:773-778.
29. Rasmussen SA, Eisen J. Clinical features and phenomenology of obsessive-compulsive disorder. Psychiatr Ann. 1989;19:67-73.
30. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-1011.
31. Frost RO, Steketee G, Grisham J. Measurement of compulsive hoarding: saving inventory-revised. Behav Res Ther. 2004;42:1163-1182.
32. Tolin DF, Frost RO, Steketee G. A brief interview for assessing compulsive hoarding: the Hoarding Rating Scale-Interview. Psychiatry Res.2010;178:147-152.
33. Wheaton M, Timpano KR, Lasalle-Ricci VH, Murphy D. Characterizing the hoarding phenotype in individuals with OCD: associations with comorbidity, severity and gender. J Anxiety Disord. 2008;22:243-252.
34. Cromer KR, Schmidt NB, Murphy DL. Do traumatic events influence the clinical expression of compulsive hoarding? Behav Res Ther.2007;45:2581-2592.
35. Frost RO, Tolin DF, Steketee G, et al. Excessive acquisition in hoarding. J Anxiety Disord. 2009;23:632-639.
36. Wu KD, Watson D. Hoarding and its relation to obsessive-compulsive disorder. Behav Res Ther. 2005;43:897-921.
37. Abramowitz JD, Wheaton MG, Storch EA. The status of hoarding as a symptom of obsessive-compulsive disorder. Behav Res Ther.2008;46:1026-1033.
38. Pertusa A, Fullana MA, Singh S, et al. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both. Am J Psychiatry.2008;165:1289-1298.
39. Frost RO, Tolin DF. Compulsive hoarding. In: Taylor S, Abramowitz JS, McKay D, eds. Clinical Handbook of Obsessive-Compulsive Disorder and Related Problems. Baltimore: Johns Hopkins University Press; 2008:76-94.
40. Steketee G, Frost RO, Kyrios M. Cognitive aspects of compulsive hoarding. Cognit Ther Res. 2003;27:463-479.
41. Steketee G, Frost RO. Compulsive Hoarding and Acquiring: Workbook. New York: Oxford University Press; 2007.
42. Frost R, Steketee G, Tolin D, Renaud S. Development and validation of the clutter image rating. J Psychopathol Behav Assess. 2008;30:193-203.
43. Tolin DF, Villavicencio A. Inattention, but not OCD, predicts the core features of hoarding disorder. Behav Res Ther. 2011;49:120-125.
44. Tolin DF, Frost RO, Steketee G. Buried in Treasures: Help for Compulsive Hoarding. New York: Oxford University Press; 2007.
45. Muroff J, Steketee G, Himle J, Frost R. Delivery of internet treatment for compulsive hoarding (D.I.T.C.H.). Behav Res Ther. 2010;48:79-85.
46. American Psychiatric Association. DSM-5 development: F 02 hoarding disorder.http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=398. Accessed July 6, 2011.


This articles' original website:
http://www.psychiatrictimes.com/display/article/10168/1932177

Grown-Up Approach To Our Finances

Well I did it! I've been thinking about putting together a family budget. Along with talking about this subject a lot with clients, I propelled myself forward & set-up an account on https://www.mint.com/.

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