Cognitive-behavioral therapy for geriatric compulsive hoarding

Home-based motivational interviewing for late-life rural hoarding disorder: a pilot study

OBJECTIVES

The primary purpose of this pilot study was to determine the feasibility and acceptability of a novel brief (six-session) motivational interviewing home-based intervention for hoarding disorder designed for rural older adults. The secondary aims were to examine the engagement of proposed mechanisms of change and the preliminary efficacy of symptom reduction.

METHOD

Fifteen rural-dwelling older adults were enrolled in the pilot trial for Project RECLAIM (Reduce Clutter and Increase Meaning). Engagement of proposed mechanisms of change was assessed weekly for reported engagement in sorting/discarding behaviors and from baseline to post-treatment on readiness for change and motivation. Symptom reduction was assessed from baseline to post-treatment on hoarding symptoms and general psychological functioning.

RESULTS

Sixty percent of participants completed all six sessions of RECLAIM. Over the course of treatment, participants reported significant decreases in household clutter (d = -0.85) and object attachment (d = -1.01) and increases in positive affect (d = 0.71), readiness for change (d = 0.40) and motivation (d = 0.52), and sorting between sessions (ß = 3.82).

CONCLUSION

The significant reductions in hoarding symptoms after only six sessions of treatment suggest that a brief, in-home, intervention may be a viable option for symptom reduction, particularly for rural-dwelling older adults.

Hoarding behaviour: special features and complications in real-world clinical practice

OBJECTIVE

Hoarding behaviour is a common but poorly characterised problem in real-world clinical practice. Although hoarding behaviour is the key component of Hoarding Disorder (HD), there are people who exhibit hoarding behaviour but do not suffer from HD. The aim of the present study was to characterise a clinical sample of patients with clinically relevant hoarding behaviour and evaluate the differential characteristics between patients with and without HD.

METHODS

This study included patients who received treatment at the home visitation program in Barcelona (Spain) from January 2013 through December 2020, and scored ≥ 4 on the Clutter Image Rating scale. Sociodemographic, DSM-5 diagnosis, clinical data and differences between patients with and without an HD diagnosis were assessed.

RESULTS

A total of 243 subjects were included. Hoarding behaviour had been unnoticed in its early stages and the median length in the sample was 10 years (IQR 15). 100% of the cases had hoarding-related complications. HD was the most common diagnosis in 117 patients (48.1%).

CONCLUSIONS

The study found several differential characteristics between patients with and without HD diagnosis. Alcohol use disorder could play an important role among those without HD diagnosis. Home visitation programs could improve earlier detection, preventing hoarding-related complications.

The Impact of Hoarding Disorder on Family Members, Especially the Significant Other

Hoarding disorder, also known as compulsive hoarding, comes under the umbrella term of obsessive-compulsive disorder and related disorders. The constant building of clutter in the house of hoarders makes it impossible for family members to live a healthy life. It can have appalling effects on their mental health and can lead to severe depression and suicidal ideation. The shame and humiliation attached to hoarding does not allow the hoarders to seek help, causing them distress and hence continuing the vicious cycle of hoarding. By presenting the case of a patient with a spouse with a hoarding disorder, we want to bring to light the severity of the impact hoarding disorder can have on the partner and the grave need to spread awareness about it so that the patient or the family members can seek timely help.

Hoarding symptoms are associated with higher rates of disability than other medical and psychiatric disorders across multiple domains of functioning

BACKGROUND

Hoarding symptoms are associated with functional impairment, though investigation of disability among individuals with hoarding disorder has largely focused on clutter-related impairment to home management activities and difficulties using space because of clutter. This analysis assesses disability among individuals with hoarding symptoms in multiple domains of everyday functioning, including cognition, mobility, self-care, interpersonal and community-level interactions, and home management. The magnitude of the association between hoarding and disability was compared to that of medical and psychiatric disorders with documented high disability burden, including major depressive disorder (MDD), diabetes, and chronic pain.

METHODS

Data were cross-sectionally collected from 16,312 adult participants enrolled in an internet-based research registry, the Brain Health Registry. Pearson's chi-square tests and multivariable logistic regression models were used to quantify the relationship between hoarding and functional ability relative to MDD, diabetes, and chronic pain.

RESULTS

More than one in ten participants endorsed clinical (5.7%) or subclinical (5.7%) hoarding symptoms (CHS and SCHS, respectively). After adjusting for participant demographic characteristics and psychiatric and medical comorbidity, CHS and SCHS were associated with increased odds of impairment in all domains of functioning. Moderate to extreme impairment was endorsed more frequently by those with CHS or SCHS compared to those with self-reported MDD, diabetes, and/or chronic pain in nearly all domains (e.g., difficulty with day-to-day work or school: CHS: 18.7% vs. MDD: 11.8%, p < 0.0001) except mobility and self-care. While those with current depressive symptoms endorsed higher rates of impairment than those with hoarding symptoms, disability was most prevalent among those endorsing both hoarding and comorbid depressive symptoms.

CONCLUSIONS

Hoarding symptoms are associated with profound disability in all domains of functioning. The burden of hoarding is comparable to that of other medical and psychiatric illnesses with known high rates of functional impairment. Future studies should examine the directionality and underlying causality of the observed associations, and possibly identify target interventions to minimize impairment associated with hoarding symptomatology.

Evidence to guide ethical decision-making in the management of older people living in squalor: a narrative review

Older people living in squalor present healthcare providers with a set of complex issues because squalor occurs alongside a variety of medical and psychiatric conditions, and older people living in squalor frequently decline intervention. To synthesise empirical evidence on squalor to inform ethical decision‐making in the management of squalor using the bioethical framework of principlism. A systematic literature search was conducted using Medline, Embase, PsycINFO and CINAHL databases for empirical research on squalor in older people. Given the limited evidence base to date, an interpretive approach to synthesis was used. Sixty‐seven articles that met the inclusion criteria were included in the review. Our synthesis of the research evidence indicates that: (i) older people living in squalor have a high prevalence of frontal executive dysfunction, medical comorbidities and premature deaths; (ii) interventions are complex and require interagency involvement, with further evaluations needed to determine the effectiveness and potential harm of interventions; and (iii) older people living in squalor utilise more medical and social resources, and may negatively impact others around them. These results suggest that autonomous decision‐making capacity should be determined rather than assumed. The harm associated with squalid living for the older person, and for others around them, means a non‐interventional approach is likely to contravene the principles of non‐maleficence, beneficence and justice. Adequate assessment of decision‐making capacity is of particular importance. To be ethical, any intervention undertaken must balance benefits, harms, resource utilisation and impact on others.

A remote cognitive behavioural therapy approach to treating hoarding disorder in an older adult

Hoarding disorder (HD) is characterised by excessive acquisition and distress associated with discarding objects, resulting in significant clutter. At present, cognitive behavioural therapy (CBT) represents the strongest evidence base for treating HD, although some limitations exist. Little research has examined the effectiveness of remote-CBT interventions for HD in older adults. This case study focuses on Mary, an older female adult presenting with clinically significant hoarding behaviours which severely impact her daily functioning and quality of life. Assessment and intervention followed a structured CBT approach. Despite the complicating factor of COVID-19, Mary responded well to a remote-CBT intervention, with progress indicators suggesting modest improvements in personal, social and occupational functioning. These findings support the use of remote-CBT for HD in both reducing frequency and intensity of hoarding behaviours and improving wellbeing.

Key learning aims

(1)

Can a virtual environment enhance understanding of hoarding deficits? A pilot investigation

This pilot study tested the utility of a virtual environment for assessing cognitive deficits characteristic of hoarding. A sample representing a broad spectrum of hoarding traits (N = 20) was assessed using self-report measures of information processing skills and emotional experience, and placed in a virtually simulated house that contained cluttered spaces and clean spaces. Information-processing significantly differed between high-hoarding and low-hoarding groups, with the high-hoarding group showing increased proneness to emotional attachment and information processing difficulties in the cluttered environment. The high-hoarding group also showed differences in behaviour and appraisal of the simulated environment. The findings suggested that virtual reality is accessible to participants and elicits real-time emotions and behavioural parameters which can assist our understanding of hoarding behaviour. Virtual reality may contribute to hoarding therapy in future, as it allows participants to visualise a different perspective of their condition and could contribute to their knowledge about the severity of their behaviour.

Cognitive Behavioral Therapy For Hoarding Disorder: A Meta-Analysis

(Appeared originally in Depression and Anxiety 2015; 32:158-166).

Implementation and evaluation of a community-based treatment for late-life hoarding

OBJECTIVES

The objective of this paper was to examine the implementation and effectiveness of a community-based intervention for hoarding disorder (HD) using Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST).

DESIGN

This was a mixed-method, pre-post quasi-experimental study informed by the Practical, Robust Implementation and Sustainability Model for implementation science.

SETTING

Program activities took place in San Diego County, mainly within clients' homes or community, with some activities in-office.

PARTICIPANTS

Participants were aged 60 years or older, met eligibility for Medi-Cal or were uninsured, and met criteria for HD.

INTERVENTION

A manualized, mobile protocol that incorporated CREST was utilized.

MEASUREMENTS

The Clutter Image Rating and Hoarding Rating Scale were used as effectiveness outcomes. An investigator-created staff questionnaire was used to evaluate implementation.

RESULTS

Thirty-seven clients were reached and enrolled in treatment and 15 completed treatment during the initial 2 years of the program. There were significant changes in hoarding severity and clutter volume. Based on the initial 2 years of the program, funding was provided for expansion to cover additional San Diego County regions and hire more staff clinicians in year three.

CONCLUSION

Preliminary data suggest that the CREST intervention can be successfully implemented in a community setting with positive results for older adults with HD.

A critical review of cognitive behavioural therapy for hoarding disorder: How can we improve outcomes?

Psychological treatment for hoarding problems has historically been associated with poor outcomes. When treated as a subgroup of obsessive-compulsive disorder, individuals with hoarding beliefs were less likely to respond to treatment than individuals exhibiting other obsessive-compulsive beliefs and behaviours. When treated as its own disorder using cognitive behavioural therapy, individuals report approximately 25% improvement in symptoms on average. However, less than a third of people experience clinically meaningful change. Further, changes in functioning and quality of life are not routinely assessed. In this paper, we review the current conceptualization and treatment of hoarding problems to shed light on how treatment for hoarding disorder may be improved. Utilizing a harm reduction approach before administering treatment may be important to ensure the safety of individuals. Research should test whether treatment outcomes improve by including strategies that enhance a client's interpersonal functioning and ability to regulate emotions (i.e., based on dialectal behaviour therapy and mentalization-based treatments), especially while discarding and organizing belongings. We should also use modern learning theory to improve the delivery of exposure activities.

A systematic review and psychometric evaluation of self-report measures for hoarding disorder

BACKGROUND

Hoarding disorder (HD) affects approximately 2.5% of the general population, leads to significant distress and impairment, and is notoriously difficult to treat. The crux of developing effective treatments for HD is our ability to reliably and validly measure relevant constructs in HD to better understand its presentation and, subsequently, formulate appropriate interventions.

METHODS

We identified measures specific to HD and evaluated their psychometric properties using rating criteria formulated by the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) group.

RESULTS

The 17 included measures were developed to assess adult and pediatric hoarding severity, functional impairment, and maladaptive processes (e.g., material scrupulosity). The Saving Inventory-Revised, the most widely used measure of HD severity showed the strongest psychometric properties. However, psychometric investigations were generally of poor quality across all measures and results indicated unsatisfactory performance of measures.

LIMITATIONS

The current review excluded non-English measures and ratings inherently contain some element of subjectivity despite use of predetermined criteria and two independent reviewers.

CONCLUSIONS

We suggest that clinical researchers continue to develop and modify measures used to conceptualize and, ultimately, improve treatment for HD.

Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis

BACKGROUND

Hoarding disorder (HD) is a new disorder in DSM-5. While cognitive-behavioral therapy (CBT) is seen as the gold standard approach to treatment, the literature in this field is still emerging.

METHODS

The aim of the present study is to synthesize the current treatment outcome literature on CBT for HD, as well as secondary depressive symptoms, using a meta-analytic approach. Due to a lack of controlled trials only within-group effect sizes were calculated.

RESULTS

Sixteen studies were included in the meta-analysis (n = 505; mean age = 56 years; mean percentage female participants = 72%). Large effect sizes were found from pre-treatment to post-treatment (g = 1.11; 95% CI: 0.92-1.29) and from pre-treatment to follow-up (g = 1.25; 95% CI: 0.94-1.56) on HD symptoms. The gender distribution of the sample moderated treatment outcome, with larger effects seen in studies that included a larger proportion of female patients. Treatment modality (individual vs group), therapist training, use of home visits, trial type (efficacy vs effectiveness), number of treatment weeks, participant age, and study quality did not moderate treatment outcome. Small effect sizes were found from pre-treatment to post-treatment (g = 0.45; 95% CI: 0.28-0.61) for depressive symptoms and baseline depression severity, treatment modality, use of home visits, and assessment tool used did not moderate outcome.

LIMITATIONS

The study is limited by the small number of studies available in this field.

CONCLUSIONS

This study demonstrates that CBT for HD is an effective treatment, however, controlled trials are needed, as are trials examining the long-term efficacy of CBT for HD.

A Standardized Approach to Calculating Clinically Significant Change in Hoarding Disorder Using the Saving Inventory-Revised

This shorter communication explores the concept of clinically significant change in treatment outcome studies for hoarding disorder. We argue that cross-study comparisons have been hindered due to researchers using different formulations to assess individual change. As a result, we propose that researchers adopt a standardized approach to calculating rates of clinically significant change for the Saving Inventory-Revised (SI-R) based on Jacobson and Truax's (1991) two-step method. Specifically, we recommend that individuals whose SI-R total scores have reduced by at least 20 points and whose post-treatment score is 38 or less be classified as recovered. Individuals whose total score decreases by 20 points or more, but whose post-treatment score remains above 38, should be classified as improved but not recovered. Individuals whose total score increases by 20 or more points should be classified as deteriorated. Any individual whose total score has changed by less than 20 points should be classified as not changed. By adopting these criteria, researchers will facilitate cross-study treatment outcome comparisons and aid in our understanding of the impact that hoarding treatment has on its recipients.

Treatment outcomes in older adults with hoarding disorder: The impact of self-control, boredom and social support

OBJECTIVES

Hoarding disorder in older adults often develops in the context of co-occurring psychosocial maladies, and treatment response tends to be suboptimal. This preliminary investigation explored several ageing-related factors and their relationship to hoarding symptom severity (HSS), and examined treatment response to 15 sessions of cognitive behavioural therapy (CBT) with in-home support.

METHODS

Twenty-nine participants (Mage = 67) completed self-report questionnaires measuring HSS, self-control, indecisiveness, depression, loneliness, social support and boredom, before (T1) and after (T2) treatment.

RESULTS

At T1, HSS was associated marginally with loneliness and significantly with all other variables, except social support. At T2, HSS and depression decreased significantly and only boredom and self-control remained associated with HSS. Attrition rates were high, and those with low social support were more likely to discontinue treatment prematurely.

CONCLUSIONS

Increasing social support may improve treatment retention, and pre-emptively reducing sources of boredom and increasing self-control during treatment might improve outcomes for older adults with hoarding disorder.

Pilot Study Evaluating Critical Time Intervention for Individuals With Hoarding Disorder at Risk for Eviction

Hoarding disorder has significant health consequences, including the devastating threat of eviction. In this pilot study, critical time intervention (CTI), an evidence-based model of case management shown to be effective for vulnerable populations, was adapted for individuals with severe symptoms of hoarding disorder at risk for eviction (CTI-HD). Of the 14 adults who enrolled, 11 participants completed the 9-month intervention. Completers reported a modest decrease in hoarding severity, suggesting that, while helpful, CTI-HD alone is unlikely to eliminate the risk of eviction for individuals with severe symptoms of hoarding disorder.

Cognitive Behavioral Therapy for Hoarding Disorder in an Older Female

Relationships toward objects can be part of healthy development; however, problems develop when collecting becomes excessive or when the individual has difficulty getting rid of the accumulated items. Hoarding disorder (HD) is defined as an enduring difficulty in discarding possessions as result of a need to save these items, and significant distress linked to disposing of them. Hoarding difficulties are still covered by the clinical guidelines for obsessive-compulsive disorder (OCD) (National Institute for Health and Clinical Excellence), which recommend utilizing psychological therapy at the client’s home. The psychological intervention with the strongest evidence-base is cognitive-behavioral therapy (CBT), but dropout rates are high and difficulties still persist for more than 50% of clients, suggesting that further research is required. Although HD has a higher prevalence in older adults, there is a lack of research into the use of CBT in this population. Preliminary research suggests that adjustments should be made around the difficulties commonly faced by these individuals. This case report outlines the use of CBT to treat “Lucy,” a 67-year-old female with HD complicated by other mental health and physical health difficulties. The case reflects on adaptations that could be made to the existing CBT model.

Perceived emotion regulation and emotional distress tolerance in patients with hoarding disorder

Emotional distress tolerance (EDT) and emotion regulation (ER) appear to be highly relevant to hoarding pathology, as excessive saving and/or acquiring may be motivated by emotional avoidance or other attempts to regulate negative affect. While findings with nonclinical samples have suggested and EDT/ER predicts hoarding symptoms, there is little data on clinical samples. The aim of the current study was to examine several self-report measures of EDT and ER in individuals with HD (n = 87) and age-matched nonclinical controls (n = 46), and to explore whether this was predictive of treatment compliance and/or outcome in group CBT for HD. Results suggested that, the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) total score, DERS goals and awareness subscales, and Intolerance of Uncertainty Scale (IUS; Buhr & Dugas, 2002) were predictive of hoarding severity. However, EDT/ER did not change with treatment, did not mediate treatment outcome, and did not predicted treatment retention, compliance, or outcome. Results suggest that some EDT/ER constructs, such as uncertainty intolerance, difficulty persisting in goal behaviors when upset, and low emotional awareness, may explain significant variance in HD symptoms, although they did not appear to be mechanisms of change in CBT for HD.

Saving inventory - Revised: Psychometric performance across the lifespan

BACKGROUND

The Saving Inventory - Revised (SI-R) is the most widely used self-report measure of hoarding symptom severity. The goal of this study is to establish a firm empirical basis for a cutoff score on the SI-R and to examine the functioning of the SI-R as a screening tool and indicator of hoarding symptom severity across the lifespan.

METHODS

This study used archival data from 1,116 participants diagnosed with a clinical interview in 14 studies conducted by research groups who focus on hoarding. We used receiver operating characteristic (ROC) analysis and the Youden's J statistic to determine optimal cutoff scores for classifying participants who would be likely to receive a hoarding diagnosis.

RESULTS

Overall, the discriminant performance of the SI-R Total score and each of the three subscales was high, confirming the status of the SI-R is an excellent screening tool for differentiating hoarding from non-hoarding cases. The optimal SI-R Total cutoff score is 39, although analyses suggested that older adults require a significantly lower cutoff and adults younger than 40 years require a significantly higher cutoff score.

LIMITATIONS

The confidence interval around the optimal cutoff for the SI-R Total score for oldest age group was wide in comparison to those reported for the younger groups, creating more uncertainty around the optimal cutoff score for this group.

CONCLUSIONS

This paper provides investigators and clinicians with the data necessary to select evidence-based cutoff scores on the SI-R that optimally suit their relative need for sensitivity and specificity in different age groups.

Older adult hoarders' experiences of being helped by volunteers and volunteers' experiences of helping

BACKGROUND

There is limited research into the experiences of receiving and providing help in the context of hoarding disorder.

AIMS

The present study aimed to explore the experiences of older people with hoarding difficulties receiving help and volunteers providing support to people with hoarding problems.

METHOD

Qualitative methods were adopted to investigate the lived experience of participants. A total of seven volunteer helpers and four people with hoarding disorder were recruited and interviewed using a semi-structured interview, designed to explore experiences of providing and receiving help. Qualitative analysis of the interview data was performed using interpretive phenomenological analysis.

RESULTS

Four superordinate themes were identified: relationship between client and volunteer; 'live life again'; challenges; and supporting volunteers. The relationship was crucial in providing a trusting foundation from which clients felt able to move forward. Volunteers provided a space for clients to talk and appropriate self-disclosure helped to build a relationship. The informal and 'non-professional' status of volunteers enabled clients to take the lead and feel more in control of the therapeutic process. Volunteer flexibility and lack of time constraints contributed to clients 'making space' for themselves, both in their home and their lives. The support from volunteers enabled clients to 'live life again' and created a domino effect, bringing about improvements in other areas of their lives.

CONCLUSIONS

The findings are discussed in relation to the training of health professionals to work with people with hoarding difficulties and the implications of the findings for treatment approaches and service provision.

Pharmacotherapy for Hoarding Disorder: How did the Picture Change since its Excision from OCD?

This brief review deals with the various issues that contributed to the creation of the new Diagnostic and Statistical Manual condition of hoarding disorder (HD) and attempts at reviewing its pharmacotherapy. It appears that after the newly founded diagnosis appeared in the literature as an autonomous entity, distinct from obsessive-compulsive disorder, drug trials are not being conducted and the disorder is left in the hands of psychotherapists, who on their part, report fair results in some core dimensions of HD. The few trials on HD specifically regard the serotonin-noradrenaline reuptake inhibitor venlafaxine, and, possibly due to the suggestion of a common biological background of HD with attention-deficit/hyperactivity disorder, the psychostimulant methylphenidate and the noradrenaline reuptake inhibitor atomoxetine. For all these drugs, positive results have been reported, but the evidence level of these studies is low, due to small samples and non-blind designs. Regretfully, there are currently no future studies aiming at seriously testing drugs in HD.

Hoarding revisited: there is light at the end of the living room

Since 2013, hoarding disorder has been recognised as a standalone diagnosis in the DSM, affecting an estimated 2–6% of the general population. This article outlines the arguments for and against this separate classification and considers the differentiation of hoarding disorder from normative collecting. It then discusses aetiology, assessment, course and treatment (both psychological and pharmacological interventions). It concludes with a discussion of ethical and legal considerations, in particular the fact that the inclusion of hoarding disorder as a distinct diagnosis in DSM-5 confers specific protections for people with the disorder under the Equality Act 2010.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Predictors of treatment outcome and attrition in adults with hoarding disorder

While a number of hoarding disorder-specific therapeutic interventions have been developed over recent years, hoarding disorder (HD) remains difficult to treat. The purpose of this investigation is to inform HD treatment efforts by examining factors that influence treatment attrition and treatment response. Secondary data analysis of baseline and post-treatment data from two previously published psychotherapy treatment studies for hoarding were performed to identify predictors of hoarding symptom improvement and treatment attrition in 106 adults with HD. No demographic variables were associated with symptom improvement or treatment attrition. However, higher levels of avoidant coping (i.e., self-distraction combined with behavioral disengagement) significantly predicted symptom improvement. The maintenance stage of change along with high readiness for change also significantly predicted symptom improvement. Participants who dropped from treatment had significantly higher baseline levels of denial and clutter, both of which independently predicted treatment attrition. The findings from this study suggest that emotion-related constructs, such as managing stress and motivation for change, may play an important role in patients' response to and participation in HD treatment.

Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) for Hoarding Disorder in Older Adults: A Randomized Clinical Trial

OBJECTIVE

To compare the efficacy of Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) with geriatric case management (CM) in a sample of older adults meeting DSM-5 diagnostic criteria for hoarding disorder (HD).

METHODS

Fifty-eight older adults with HD were enrolled in a randomized controlled trial between December 2011 and March 2014. Thirty-one participants received CREST, and 27 participants received CM. Both interventions consisted of 26 individual sessions over a period of 6 months and included several home visits by the study therapists (CREST) or nurses (CM). The Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were the main outcome measures.

RESULTS

Participants in the CREST condition had significantly greater improvement on the SI-R than participants in the CM group (group × time interaction: β = 3.95, SE = 1.81, P = .029), with participants who completed the CREST condition averaging a 38% decrease in symptoms and participants who completed the CM condition averaging a 25% decrease in symptoms. In contrast, there was not a significant group × time interaction effect on the UHSS (β = 1.23, SE = 0.84, P = .144), although participants did report greater improvement in symptoms in the CREST condition (35%) than in the CM condition (24%). Treatment gains were maintained at 6-month follow-up.

CONCLUSIONS

CREST appears to be an efficacious treatment compared to CM for older adults, but CM also showed meaningful benefits.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01227057​.

A systematic review and quality assessment of psychological, pharmacological, and family-based interventions for hoarding disorder

INTRODUCTION

Hoarding disorder (HD) affects at least 1.5% of the population and is considered to be hard to treat. The current study aimed to systematically review the treatments designed to improve HD symptoms and family impact.

METHOD

Searches of PsycINFO, MEDLINE, EMBASE, and Web of Science were undertaken. Studies were included if: (i) the study evaluated an intervention for hoarding problems; (ii) outcome measures were reported; and (iii) study results were published in an indexed journal or were a published abstract from a professional/research conference. The quality of the studies was assessed using the Clinical Trials Assessment Measure (CTAM).

RESULTS

Twenty studies, comprising 492 participants with clinically significant hoarding symptoms or HD and 21 relatives of individuals with HD, met inclusion criteria. Treatments reviewed included cognitive-behavior therapy, medication, cognitive remediation, and multi-component interventions for relatives. Most studies yielded statistically significant improvements in hoarding symptoms, although reductions were generally modest and many participants remained in the clinical range after treatment. According to the CTAM, most studies were judged to be of low methodological quality.

CONCLUSIONS

HD is a chronic and highly burdensome condition for which efficacious treatments are needed. The current evidence base is somewhat limited and of low quality. Further research is needed to improve treatments, identify mechanisms of change, and increase the availability of evidence-based interventions for this group.

Systematic Review of the Clinical Application of Exposure Techniques to Community-Dwelling Older Adults with Anxiety

OBJECTIVES

Although exposure techniques are a first-line intervention for anxiety, clear evidence is lacking for their efficacy in treating the prevalent and debilitating condition of late life anxiety. This study sought to review the current literature on use of exposure with community-dwelling older patients.

METHODS

Searches of electronic databases were conducted to identify articles published through December 7, 2016. Inclusion criteria were: 1) sample age > 55, 2) therapy that included exposure, 3) anxiety as a target of the treatment. Exclusion criteria were: 1) not available in English, 2) no quantitative data, 3) inpatient setting. Methodological data and findings were extracted from the articles chosen for review.

RESULTS

The 54 eligible articles presented a total of 16 case studies, 9 uncontrolled trials, 24 controlled trials, and 6 secondary studies. A majority of the studies were conducted in the U.S.A with participants who received individual treatment. In vivo and imaginal exposure were the most frequently delivered techniques, and most treatments were multicomponent. Most studies found a reduction in anxiety symptoms.

CONCLUSIONS

Important research gaps need to be addressed.

CLINICAL IMPLICATIONS

The surveyed research provides a modest foundation of evidence for mental health practitioners who wish to incorporate exposure into treatment plans.

Psychometric Evaluation of the Saving Inventory-Revised in Older Adults

OBJECTIVES

Hoarding disorder (HD) is a chronic condition characterized by severe impairment in health and functioning for older adults. Researchers and clinicians commonly use the Saving Inventory-Revised (SI-R), a self-report measure validated for the assessment of HD, to establish symptom severity. This study represents the first evaluation of the psychometric properties of the SI-R in a sample of older adults with HD.

METHODS

Participants were 156 older adults with HD and 23 older adults with no psychiatric diagnoses. Demographic and HD symptom severity measures were compared between the two samples. Convergent and discriminant validity was examined in the HD sample. A confirmatory factor analysis was used to test the replicability of the three-factor structure observed in the original sample.

RESULTS

Participants in the HD sample scored significantly higher on the SI-R than did the non-psychiatric sample. The SI-R was significantly correlated with clutter level and symptoms of anxiety and depression. A three-factor model demonstrated poor fit in the HD sample.

CONCLUSIONS

The SI-R can be used to validly assess hoarding severity in geriatric populations.

CLINICAL IMPLICATIONS

Clinicians working with geriatric patients should consider refraining from use of the SI-R subscales as they may be less theoretically distinct in older adults.

Hoarding among older people: an evaluative review

While there is considerable evidence that the factors involved in hoarding typically begin to manifest early in life (mostly in adolescence), the majority of those sampled in research studies are in their later years. As so much of our understanding of the psychological factors involved in hoarding is derived from those who are older and more chronically affected, the core hoarding psychopathology may have been masked, overlaid or even disregarded in previous research and in our approaches to clinical intervention. That is, factors relating primarily to chronicity of the problem and feelings of demoralization, hopelessness, loss and the extent of the damage caused to the person's life may swamp the processes which led to and maintain the problem. The present review examines the extent to which this is so and considers theoretical and clinical implications. The literature relevant to hoarding in later life was reviewed evaluatively in relation to a number of questions placing hoarding in a lifespan developmental context. Many studies relied on purely descriptive methodologies, meaning that typical case presentations and case histories are well documented, with less attention paid to underlying causal and maintaining mechanisms. Efforts to identify and control for factors relating to age or problem chronicity were minimal. A key future direction is the identification of younger samples of people who hoard in order to identify more clearly the processes which drive acquisition and retention of excessive amounts of material.

Acceptability of Treatments and Services for Individuals with Hoarding Behaviors

OBJECTIVE

To explore the acceptability of currently available treatments and services for individuals who self-report hoarding behaviors.

METHOD

Between 10/2013 and 8/2014, participants were invited to complete an online survey that provided them descriptions of eleven treatments and services for hoarding behaviors and asked them to evaluate their acceptability using quantitative (0 [not at all acceptable] -10 [completely acceptable]) Likert scale ratings. The a priori definition of acceptability for a given resource was an average Likert scale score of six or greater. Two well-validated self-report measures assessed hoarding symptom severity: the Saving Inventory-Revised and the Clutter Image Rating Scale.

RESULTS

Two hundred and seventy two participants who self-reported having hoarding behaviors completed the questionnaire. Analyses focused on the 73% of responders (n=203) who reported clinically significant hoarding behaviors (i.e., Saving Inventory-Revised scores of ≥40). The three most acceptable treatments were individual cognitive behavioral therapy (6.2 ±3.1 on the Likert scale), professional organizing service (6.1 ±3.2), and use of a self-help book (6.0 ±3.0).

CONCLUSION

In this sample of individuals with self-reported clinically significant hoarding behaviors (n=203), only 3 out of 11 treatments and services for hoarding were deemed acceptable using an a priori score. While needing replication, these findings indicate the need to design more acceptable treatments and services to engage clients and maximize treatment outcomes for hoarding disorder.

Behavioral and emotional consequences of thought listing versus cognitive restructuring during discarding decisions in hoarding disorder

An essential criterion for hoarding disorder (HD) is difficulty discarding or parting with possessions, yet few studies have examined reactions to actual discarding behaviors. The present study examined whether individuals with HD differed from non-hoarding community controls (CC) in discarding behavior and emotional reactions to discarding. A second purpose was to examine the course of experienced distress following discarding. A third purpose was to determine whether HD participants responded differently to a simple thought listing (TL) instruction or to a cognitive restructuring (CR) protocol. Participants were asked to decide whether to keep or discard (a) a personal possession and (b) a newly acquired object (magazine). HD participants anticipated more and longer distress and reported stronger attachment motives than community controls, but they did not differ significantly from community controls in actual discarding behavior. TL was somewhat more effective than CR in improving discarding behavior and reducing negative emotions and attachments to discarded objects among HD participants. Reductions in distress were observed for both HD-TL and HD-CR groups. Thought listing may have reduced avoidance of decision-making about discarding or perhaps CR, but not TL, provoked therapeutic reactance. Discarding was not related to reductions in distress or hoarding-related beliefs.

Executive Functioning in Participants Over Age of 50 with Hoarding Disorder

OBJECTIVES

The current investigation utilized mid-life and late-life participants diagnosed with hoarding disorder (HD) to explore the relationship between executive functioning and hoarding severity.

DESIGN

Correlational analyses were used to investigate the associations between executive functioning and hoarding severity in nondemented participants. Multiple regression was used to determine if executive functioning had a unique association with HD severity when accounting for depressive symptoms.

SETTING

Participants were recruited from the San Diego area for HD intervention studies.

PARTICIPANTS

Participants were 113 nondemented adults aged 50-86 years who met DSM-5 criteria for HD. The mean age of the sample utilized in the analyses was 63.76 years (SD, 7.2; range, 51-85 years). The sample was mostly female (72%), Caucasian (81.4%), and unmarried (78%).

MEASUREMENTS

Hoarding severity was assessed using the Saving Inventory-Revised and the Clutter Image Rating and depression was assessed using the Hospital Anxiety and Depression Scale. Executive functioning was assessed using the Wisconsin Card Sorting Test (WCST-128) and the Trail Making and Verbal Fluency subtests of the Delis-Kaplan Executive Function System.

RESULTS

Executive function (operationalized as perseveration on the WCST-128) was significantly associated with Clutter Image Ratings. In a multivariate context, executive function and depressive symptom severity were both significant predictors of variance in Clutter Image Rating.

CONCLUSIONS

Our results suggest that executive function is related to severity of HD symptoms and should be considered as part of the conceptualization of HD.

Treating Hoarding Disorder in a real-world setting: Results from the Mental Health Association of San Francisco

Hoarding Disorder (HD) is associated with substantial distress, impairment, and individual and societal costs. Cognitive-behavioral therapy (CBT) tailored to HD is the best-studied form of treatment and can be led by mental health professionals or by non-professionals (peers) with specific training. No previous study has directly compared outcomes for therapist-led and peer-led groups, and none have examined the effectiveness of these groups in a real-world setting. We used retrospective data to compare psychologist-led CBT groups (G-CBT) to groups led by peer facilitators using the Buried in Treasures workbooks (G-BiT) in individuals who sought treatment for HD from the Mental Health Association of San Francisco. The primary outcome was change in Hoarding Severity Scale scores. Approximate costs per participant were also examined. Both G-CBT and G-BiT showed improvement consistent with previous reports (22% improvement overall). After controlling for baseline group characteristics, there were no significant differences in outcomes between G-CBT and G-BiT. For G-CBT, where additional outcome data were available, functional impairment and severity of hoarding symptoms improved to a similar degree as compared to previous G-CBT studies, while hoarding-related cognition improved to a lesser degree (also consistent with previous studies). G-BiT cost approximately $100 less per participant than did G-CBT.

An interrogation of cognitive findings in pediatric obsessive-compulsive and related disorders

Current findings in the field of psychology have led to increased interest and a new conceptualization of disorders characterized by repetitive behaviors, namely the obsessive compulsive and related disorders (OCRDs). Scant research, however, has sought to collect and categorize the extant research on pediatric OCRDs. Particularly, no adequate review of the pediatric cognitive literature existed until now, despite the clear implication of abnormalities in neuroanatomical structures and cognitive functioning in adult samples. While evidence for cognitive dysfunction in pediatric samples is presented, this paper also suggests that differences in cognitive dysfunction may indeed exist between adults and youth with OCRDs. Specifically, those irregularities present in said youth at varying developmental stages may impact the origination and maintenance of OCRDs across time. Finally, this paper seeks to formulate potential future goals for the research field, particularly through transdiagnostic approaches to processes linked with symptom presentations. This is of particular importance as an improved understanding of the interaction of cognitive function and growth is key to further comprehension of the OCRDs.

Functioning and quality of life in hoarding: A systematic review

Hoarding, the acquisition and inability to let go of a large number of possessions, has been found to be associated with high levels of impairment that can compromise functioning and quality of life (QoL). Yet few studies have specifically investigated the relationship between hoarding and functioning/QoL. The present review aimed to summarize the current status of research on functioning and QoL in hoarding as well as identify knowledge gaps in the extant literature. We conducted systematic searches in ProQuest, PsycINFO, PubMed and ScienceDirect, and identified 37 relevant articles for inclusion. There was much evidence to indicate that hoarding has a significant impact on various aspects of functioning and that functioning can improve with treatment, though findings on the relationship between hoarding and QoL were more tenuous. The limitations of previous studies and implications of our findings are discussed.

The UCLA Hoarding Severity Scale: development and validation

BACKGROUND

Effective management of Hoarding Disorder (HD) must begin with assessment of the severity of hoarding symptoms and functional impairment. We sought to validate the UCLA Hoarding Severity Scale (UHSS), a semi-structured, clinician-administered rating scale that measures the severity of both the core symptoms of HD and the associated features of indecisiveness, perfectionism, task prolongation, and procrastination, which are significantly associated with the diagnosis and impairment of HD.

METHODS

Hoarding symptom severity was measured in 62 patients who met DSM-5 diagnostic criteria for HD and 65 normal controls, using the UHSS and the Saving Inventory-Revised (SI-R), a well validated self-report measure of hoarding symptoms.

RESULTS

The UHSS showed significant internal consistency (Cronbach׳s α=.70). Principal components analysis revealed three factors that accounted for 58% of the variance: 1) associated features and functional impairment, 2) clutter volume and social impairment, and 3) difficulty discarding, urges to save, and excessive acquisition. UHSS and SI-R scores were significantly correlated. UHSS and SI-R total and factor scores of HD patients were all significantly different from those of controls.

LIMITATIONS

Inter-rater and test-retest reliability were not assessed. The initial version of the UHSS did not contain rater instructions, so it lacked quantifiable anchor points for ratings.

CONCLUSIONS

The UHSS showed internal consistency, construct validity, convergent validity, and known groups discriminant validity. The UHSS validly measures the core symptoms, associated features, and functional impairment of patients with HD. Utilizing a valid clinician-administered scale will provide a more comprehensive and accurate clinical assessment of patients with HD.

Hoarding disorder in older adulthood

OBJECTIVE

Hoarding disorder (HD) is a chronic condition associated with moderate to severe impairment in health and functioning. HD has been primarily studied in midlife adults, and there is limited research on HD in late life.

METHODS

In this review, we summarize research on the presentation and characteristics of HD and hoarding symptoms in older adults, including evidence for associated impairment in daily functioning, physical health, and cognitive function. Finally, we review the evidence available for intervention outcomes for treating HD in older adults.

RESULTS

Geriatric HD is characterized by severe functional impairment, medical and psychiatric comorbidities, and cognitive dysfunction.

CONCLUSION

There is a lack of randomized controlled trials investigating evidence-based treatments for geriatric HD.

Cognitive behavioral therapy for hoarding disorder: a meta-analysis

BACKGROUND

Hoarding disorder (HD) is a new diagnosis in DSM-5 (American Psychiatric Association, 2013). Cognitive-behavioral therapy (CBT) appears promising for the treatment of HD, and has been tested in both individual and group settings.

METHODS

The present study used meta-analytic techniques to examine the overall strength of effect of CBT on HD, as well as on its component symptoms (clutter, difficulty discarding, and acquiring) and associated functional impairment. Potential demographic and treatment-related moderators of CBT response, as well as the presence of clinically significant change were also examined. From 114 published articles, 10 articles comprising 12 distinct HD samples (N = 232) met inclusion criteria and were retained for analysis.

RESULTS

HD symptom severity decreased significantly across studies with a large effect size. The strongest effects were seen for difficulty discarding, followed by clutter and acquiring. Functional impairment showed the smallest effect in the moderate range. Female gender, younger age, a greater number of CBT sessions, and a greater number of home visits were associated with better clinical outcomes. Reliable change was found in the majority of samples for each outcome domain. Rates of clinically significant change, however, were lower (percentage ranged from 24 to 43). Thus, in most cases, study patients' post-treatment scores remained closer to the HD range than to the normal range.

CONCLUSIONS

CBT is a promising treatment for HD, although there is significant room for improvement. Results are discussed in terms of treatment refinement for HD, and additional moderator variables are suggested for further study.

Treatment Recruitment and Retention of Geriatric Participants With Hoarding Disorder

This study describes the initial contact of 255 potential participants, recruitment of 63 participants, and retention of 57 participants from three geriatric Hoarding Disorder (HD) studies. Patients with HD were easily recruited from the community, primarily through the use of clinician referrals and posted flyers, as evidenced by steady patient flow despite lack of compensation for participation. Contrary to treatment outcomes of late life mood and anxiety disorders, geriatric HD patients are largely retained in clinical research treatment studies. Results demonstrate that older adults with HD can be engaged in treatment. Participants often needed the study staff to provide substantial support, including informal motivational interviewing and problem solving, in scheduling and attending the initial visit.

Neuropsychological and neurophysiological insights into hoarding disorder

Hoarding disorder (HD) is associated with significant personal impairment in function and constitutes a severe public health burden. Individuals who hoard experience intense distress in discarding a large number of objects, which results in extreme clutter. Research and theory suggest that hoarding may be associated with specific deficits in information processing, particularly in the areas of attention, memory, and executive functioning. There is also growing interest in the neural underpinnings of hoarding behavior. Thus, the primary aim of this review is to summarize the current state of evidence regarding neuropsychological deficits associated with hoarding and review research on its neurophysiological underpinnings. We also outline the prominent theoretical model of hoarding and provide an up-to-date description of empirically based psychological and medical treatment approaches for HD. Finally, we discuss important future avenues for elaborating our model of HD and improving treatment access and outcomes for this disabling disorder.

Cognitive behavior therapy for hoarding disorder: follow-up findings and predictors of outcome

BACKGROUND

A cognitive-behavioral model of hoarding posits deficits in information processing, maladaptive beliefs about and attachments to possessions that provoke distress and avoidance, and positive emotional responses to saving and acquiring that reinforce these behaviors. A 26-session individual cognitive-behavioral therapy (CBT) based on this model showed significant reductions in hoarding symptoms and large effect sizes (Steketee et al.([1])).

METHODS

The present study presents findings at follow-up (up to 12 months), as well as predictors of outcome at posttreatment (n = 37) and follow-up (n = 31).

RESULTS

Significant improvements at post-treatment were sustained at follow-up with large effects, and Clinical Global Impression-Improvement (CGI-I) ratings by clinicians and patients at follow-up indicated that 62 and 79% of patients were rated "much improved" or "very much improved," respectively. The most prevalent patterns of outcome were improvement followed by stable gains or little improvement across all time points. Pretreatment severity of hoarding, overall clinical status, gender, perfectionism, and social anxiety were all associated with worse outcome. Only perfectionism and gender emerged as significant predictors after controlling for initial hoarding severity.

CONCLUSIONS

The present findings suggest general stability of individual CBT outcomes for hoarding and indicated that gender, perfectionism, and social anxiety may affect outcomes. More research on larger samples is needed to direct efforts to improve treatment for hoarding.

Meta-analysis: hoarding symptoms associated with poor treatment outcome in obsessive-compulsive disorder

DSM-5 recognizes hoarding disorder as distinct from obsessive-compulsive disorder (OCD), codifying a new consensus. Hoarding disorder was previously classified as a symptom of OCD and patients received treatments designed for OCD. We conducted a meta-analysis to determine whether OCD patients with hoarding symptoms responded differently to traditional OCD treatments compared with OCD patients without hoarding symptoms. An electronic search was conducted for eligible studies in PubMed. A trial was eligible for inclusion if it (1) was a randomized controlled trial, cohort or case-control study; (2) compared treatment response between OCD patients with and those without hoarding symptoms, or examined response to treatment between OCD symptom dimensions (which typically include hoarding) and (3) examined treatment response to pharmacotherapy, behavioral therapy or their combination. Our primary outcome was differential treatment response between OCD patients with and those without hoarding symptoms, expressed as an odds ratio (OR). Twenty-one studies involving 3039 total participants including 304 with hoarding symptoms were included. Patients with OCD and hoarding symptoms were significantly less likely to respond to traditional OCD treatments than OCD patients without hoarding symptoms (OR=0.50 (95% confidence interval 0.42-0.60), z=-7.5, P<0.0001). This finding was consistent across treatment modalities. OCD patients with hoarding symptoms represent a population in need of further treatment research. OCD patients with hoarding symptoms may benefit more from interventions specifically targeting their hoarding symptoms.

Venlafaxine extended-release treatment of hoarding disorder

Hoarding disorder, classified as a separate disorder in Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), is a common, chronic, and potentially disabling syndrome that can be difficult to treat. Only one previous study prospectively measured response to pharmacotherapy in compulsive hoarders, finding that hoarders responded as well to paroxetine as did nonhoarding obsessive-compulsive disorder patients. However, paroxetine was not tolerated well in that study, and the overall response was moderate. Therefore, we conducted an open-label trial of venlafaxine extended-release for hoarding disorder. Twenty-four patients fulfilling the DSM-5 criteria for hoarding disorder were treated with venlafaxine extended-release for 12 weeks. All patients were free of psychotropic medications for at least 6 weeks before the study. No other psychotropic medications, cognitive-behavioral therapy, organizers, or cleaning crews were permitted during the study. To measure the severity of hoarding, the Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were administered before and after treatment. Twenty-three of the 24 patients completed treatment. Hoarding symptoms improved significantly, with a mean 36% decrease in UHSS scores and a mean 32% decrease in SI-R scores. Sixteen of the 23 completers (70%) were classified as responders to venlafaxine extended-release. These results suggest that venlafaxine extended-release may be effective for the treatment of hoarding disorder.

Behavioral and experiential avoidance in patients with hoarding disorder

BACKGROUND AND OBJECTIVES

This study examined the relationship between experiential and behavioral avoidance and hoarding symptom severity, controlling for anxiety and depression symptoms, in 66 adult individuals (M age = 61.41; SD = 9.03) with HD.

METHODS

Hierarchical regression was used to test the associations between hoarding severity, as defined by the Savings Inventory-Revised (SI-R) total and its three subscales, and avoidance, as defined by the Acceptance and Action Questionnaire II (AAQ-II) and two scales from the Brief COPE (Self-Distraction and Behavioral Disengagement) when controlling for anxiety and depression symptoms.

RESULTS

Experiential avoidance (AAQ-II) and behavioral avoidance (Brief COPE subscales Self-Distraction and Behavioral Disengagement) uniquely accounted for aspects of hoarding severity (SI-R) in regression models. Behavioral avoidance contributed significant additional variance to the SI-R Clutter subscale, whereas experiential avoidance was uniquely predictive of additional variance in the SI-R Difficulty Discarding and the SI-R Acquisition subscales.

LIMITATIONS

Future research should examine the effect of experiential avoidance on hoarding behaviors experimentally.

CONCLUSIONS

Given that the AAQ-II and Self-Distraction and Behavioral Disengagement subscales were not correlated, these findings suggest that experiential and behavioral avoidance are two distinct processes contributing to the severity of specific HD. Results support the utility of avoidance in the cognitive-behavioral model for HD.

Novel treatment for geriatric hoarding disorder: an open trial of cognitive rehabilitation paired with behavior therapy

OBJECTIVES

To investigate the feasibility of an age-adapted, manualized behavioral treatment for geriatric hoarding.

METHODS

Participants were 11 older adults (mean age: 66 years) with hoarding disorder. Treatment encompassed 24 individual sessions of psychotherapy that included both cognitive rehabilitation targeting executive functioning and exposure to discarding/not acquiring. Hoarding severity was assessed at baseline, mid-treatment, and posttreatment.

RESULTS

Results demonstrated clinically and statistically significant changes in hoarding severity at posttreatment. No participants dropped out of treatment. Eight participants were classified as treatment responders, and three as partial responders. Partial responders reported severe/extreme hoarding and psychiatric comorbidities at baseline.

CONCLUSIONS

The combination of cognitive rehabilitation and exposure therapy is a promising approach in the treatment of geriatric hoarding. Targeting neurocognitive deficits in behavioral therapy for these geriatric patients with hoarding disorder doubled response rates relative to our previous trial of cognitive behavior therapy alone.