NU671 Unit 3 Hoarding Maintaining Cycle Analysis Example

The Dining Room She Has Not Used Since 2019: A Maintaining Cycle Analysis of Hoarding Disorder in a 56-Year-Old Dental Hygienist

[Student Name]

Purdue University Global

NU671: PMHNP Psychopathological Disorders and Psychotherapy

Unit 3 Maintaining Cycle Analysis

[Instructor Name]

[Date]

The patient is composite; details are bracketed.

The Problem as She Describes It

Ms. [L.] lives alone in a three-bedroom house. The dining room, the spare bedroom and half of the kitchen counters are covered with items: unopened mail, newspapers, clothes bought on sale with tags still attached, craft supplies for projects she has not started, and plastic containers she keeps "because they are perfectly good." She sleeps in her bed but cannot use her guest room or dining table, and she has not had a visitor inside for [three] years. At work she is organized and well regarded, which surprises people who learn about her home, and which she uses as evidence that the problem is not serious. She was referred after her sister found her kitchen stove partly blocked.

She meets criteria for hoarding disorder: persistent difficulty discarding possessions regardless of their value, a perceived need to save them and distress at discarding, clutter that prevents the use of living areas, and significant distress and impairment. She also shows excessive acquiring, most often of discounted clothing and craft materials.

Frost and Hartl proposed that hoarding is maintained by four interacting elements: difficulties in processing information, especially in deciding and categorizing; strong emotional attachment to possessions; beliefs about possessions, such as responsibility for them and the need to control them; and behavioral avoidance, in which not discarding and continuing to acquire relieve distress in the short term (Frost & Hartl, 1996). The analysis below draws Ms. [L.]'s version of those elements as two loops.

Loop One: Not Discarding

1. Trigger. She picks up a magazine from the dining table to throw it away.

2. Thought. "There might be an article in here I need. If I throw it out, I will lose that information and it will be my fault."

3. Emotion. Anxiety rises quickly, along with a sense of guilt about waste.

4. Behavior. She puts the magazine back on the pile, or moves it to another pile to sort later.

5. Short-term result. The anxiety drops at once.

6. Long-term result. The pile grows, the room remains unusable, and she never learns what would have happened if she had thrown the magazine away.

Each time she puts the magazine back, relief arrives within seconds, and that relief is the most reliable reward in her day. This is negative reinforcement: the behavior is strengthened because it removes an unpleasant feeling. It is also avoidance in the sense used for anxiety disorders, since it prevents her from discovering that she can tolerate discarding and that the consequences she fears rarely happen.

Her difficulty making decisions adds to the loop. Faced with a pile, she has trouble deciding which category each item belongs to, so she creates more categories and more "to sort" piles, which increases the clutter rather than reducing it (Frost & Hartl, 1996).

Loop Two: Acquiring

1. Trigger. She passes a store with a clearance sign on her way home from work, after a tiring day.

2. Thought. "That sweater is 70 percent off. I would be foolish not to buy it. It would make a nice gift."

3. Emotion. Excitement and pleasure, a lift in mood after a flat day.

4. Behavior. She buys the sweater, and often two more items.

5. Short-term result. She feels good on the drive home.

6. Long-term result. The item joins a pile, she feels guilty about the money, and the flat mood returns, making her more likely to seek the same lift the next day.

This loop runs on positive reinforcement, since the purchase produces a pleasant feeling. The two loops feed each other: acquiring adds items, and difficulty discarding means nothing leaves.

The Outer Loop: Shame and Isolation

Around both loops sits a larger cycle. The clutter causes shame, so she no longer invites people in. Without visitors, nobody sees the house or comments on it, which removes a source of motivation to change. Isolation also lowers her mood, and low mood makes the acquiring loop more rewarding. The stove incident shows the risk of this loop: safety problems can grow unseen when nobody else enters the home. The wider costs are substantial. In an internet survey of people with compulsive hoarding, hoarding was associated with an average of [7.0] days of work impairment in the past month, comparable to people with psychotic disorders, and [8 to 12] percent had been evicted or threatened with eviction because of it (Tolin et al., 2008). Ms. [L.] still works full time, but the survey is a reminder that the outer loop can reach her job and her housing if it continues.

Why the Forced Cleanout Failed

Two years ago her sister rented a dumpster and cleared the spare bedroom while Ms. [L.] was at work. She was furious, stopped speaking to her sister for [four] months, and within a year the room was full again. The maintaining cycle explains why. The cleanout removed the items but did nothing to the loops. She did not practice discarding, so she learned nothing new about her ability to tolerate it. Her beliefs about waste and responsibility were untouched. And the experience of losing control over her possessions probably strengthened her belief that she must guard them.

What the Cycle Suggests for Treatment

Each part of the cycle suggests a target. Discarding practice, done by her, starting with low-attachment items and gradually moving to harder ones, addresses the avoidance in loop one. Skills training in sorting and deciding addresses the information-processing difficulty. Cognitive work on her beliefs about waste and responsibility addresses the thoughts that start each loop. Exposure to passing sales without buying addresses loop two. And reconnecting with her sister and eventually inviting a friend in addresses the outer loop.

Pooling twelve treated samples, Tolin and colleagues found that cognitive behavioral treatment of hoarding produced large reductions in overall symptom severity, with the strongest effects on difficulty discarding, followed by clutter and acquiring. However, only a minority of patients, [24 to 43] percent depending on the measure, reached clinically significant change, and more home visits and more sessions were associated with better outcomes (Tolin et al., 2015). That evidence argues for including home sessions in her plan and for setting realistic goals: a usable dining table and a clear stove within [three] months, rather than an empty house.

References

Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34(4), 341-350. https://doi.org/10.1016/0005-7967(95)00071-2

Tolin, D. F., Frost, R. O., Steketee, G., Gray, K. D., & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160(2), 200-211. https://doi.org/10.1016/j.psychres.2007.08.008

Tolin, D. F., Frost, R. O., Steketee, G., & Muroff, J. (2015). Cognitive behavioral therapy for hoarding disorder: A meta-analysis. Depression and Anxiety, 32(3), 158-166. https://doi.org/10.1002/da.22327