Functioning and quality of life in hoarding: A systematic review

Randomized waitlist-controlled trial of buried in treasures facilitated support groups and in-home uncluttering (BIT+) for hoarding disorder

OBJECTIVE

The Buried in Treasures (BIT) workshop is a promising treatment for hoarding disorder (HD), though many participants struggle with home uncluttering. This randomized waitlist-controlled trial investigated the efficacy of a version of BIT, augmented with in-home uncluttering practice (BIT+).

METHOD

Adults (N = 41) with hoarding disorder were recruited from the community and randomly assigned to BIT+ or waitlist. BIT+ consisted of 16 sessions of the BIT workshop and 10 uncluttering home visits over 18 weeks. Outcome measures included the Saving Inventory-Revised (self-report) and the Clutter Image Rating Scale (self and independent evaluator rated). Between group repeated measures analyses using general linear modeling examined the effect of BIT+ vs waitlist control on hoarding symptoms after 18 weeks. Within group analyses examined pre-post effects for all BIT+ participants combined after 18 weeks.

RESULTS

After 18 weeks, BIT+ participants benefited significantly more than waitlist controls on hoarding severity with large effect size (Cohen's d = 1.5, p < .001). BIT+ was also associated with improvement reductions in hoarding symptoms, clutter, and functional impairment.

CONCLUSIONS

The BIT+ intervention offers promise as a treatment option for hoarding. Adding in-home uncluttering practice may incrementally improve discarding practices. Future controlled trials are warranted.

Relationship of Hoarding and Depression Symptoms in Older Adults

Hoarding disorder (HD) is a debilitating neuropsychiatric condition that affects 2%-6% of the population and increases in incidence with age. Major depressive disorder (MDD) co-occurs with HD in approximately 50% of cases and leads to increased functional impairment and disability. However, only one study to date has examined the rate and trajectory of hoarding symptoms in older individuals with a lifetime history of MDD, including those with current active depression (late-life depression; LLD). We therefore sought to characterize this potentially distinct phenotype. We determined the incidence of HD in two separate cohorts of participants with LLD (n = 73) or lifetime history of MDD (n = 580) and examined the reliability and stability of hoarding symptoms using the Saving Inventory-Revised (SI-R) and Hoarding Rating Scale-Self Report (HRS), as well as the co-variance of hoarding and depression scores over time. HD was present in 12% to 33% of participants with MDD, with higher rates found in those with active depressive symptoms. Hoarding severity was stable across timepoints in both samples (all correlations >0.75), and fewer than 30% of participants in each sample experienced significant changes in severity between any two timepoints. Change in depression symptoms over time did not co-vary with change in hoarding symptoms. These findings indicate that hoarding is a more common comorbidity in LLD than previously suggested, and should be considered in screening and management of LLD. Future studies should further characterize the interaction of these conditions and their impact on outcomes, particularly functional impairment in this vulnerable population.

Prevalence and correlates of hoarding behavior and hoarding disorder in children and adolescents

Although hoarding symptoms are reported to begin in childhood and adolescence, the true prevalence of the disorder in this age group is unknown. This study aims to estimate the prevalence of hoarding disorder (HD) in children and adolescents. The present study was planned as a two-stage epidemiological research. In the first stage, the Children's Saving Inventory (CSI) and informed consent forms were delivered to a group of students' parents. In the second stage, one-on-one psychiatric interviews with a physician were planned with the families and children who had hoarding behavior (HB), as described by their parents. The DSM-5-based HD interview and the Development and Well-Being Assessment (DAWBA) diagnostic tool were used to detect prevalence of HD and comorbid psychiatric disorders. A total of 3249 children were included in the study, and 318 children and their parents were evaluated in the second stage. As a result of the second assessment, 32 out of 318 children met the HD diagnostic criteria. The estimated prevalence of HD was 0.98% (95% CI 0.7-1.4). Hoarding disorder was found more frequently in females (F/M = 3/1). After a logistic regression analysis, variables such as female sex and the presence of any psychopathology were identified as independent correlates of HD. More than half (56.2%) of the children diagnosed as having HD also had a comorbid psychiatric disorder. In the present study, the two-stage evaluation method was used in a large pediatric sample to determine the estimated prevalence of HD, as well as the factors associated with the disorder and comorbid psychiatric disorders.

Impact of Hoarding and Obsessive–Compulsive Disorder Symptomatology on Quality of Life and Their Interaction With Depression Symptomatology

Hoarding disorder (HD) is a psychiatric condition characterized by difficulty discarding items and accumulation of clutter. Although studies have established the negative impact of HD and compulsive hoarding behavior, fewer have examined the impact on quality of life (QoL) of hoarding behavior independent of obsessive–compulsive disorder (OCD). Moreover, specific aspects of QoL such as success in work/academics or satisfaction with interpersonal relationships have not been well-investigated. In this study, we examined, in a sample of 2100 adult participants obtained from Amazon Mechanical Turk, the relationships between hoarding, OCD, and depression symptomatology and four QoL domains (success, enrichment, environment, and family) derived from a factor analysis of the Quality of Life Inventory (QoLI). We performed linear regressions to examine associations between psychiatric symptomatology and QoL domains and then conducted mediation analyses to investigate the role of depressive symptomatology in the identified relationships. We found that while hoarding and obsessive–compulsive symptoms were both negatively associated with QoL, they were associated with different domains [hoarding was significantly associated (p < 0.05) with total QoL and all domains and uniquely associated with environment and family QoL compared to obsessive–compulsive symptoms], whereas obsessive–compulsive symptoms were only significantly associated with total, success, and enrichment QoL. However, when depressive symptoms were included in the model, hoarding no longer accounted for significant variance in the total, environment, or family QoL domains (p > 0.05), and was less strongly associated with success or enrichment. Mediation analyses confirmed the role of depression as a complete mediator of hoarding’s effect on total, environment, and family QoL, and as a partial mediator of hoarding’s effect on success and enrichment QoL. Further examination of the relationship between hoarding symptoms and QoL in those with mild, moderate, and severe depression indicated that in those with more severe depression, hoarding was associated with improved QoL, indicating a possible buffering or compensatory effect. The findings suggest a differential impact of hoarding and obsessive–compulsive symptoms on QoL and emphasize the importance of considering co-morbid depressive symptoms in designing more targeted interventions. Future studies should continue to investigate these complex relationships, given the high co-morbidity of hoarding and depression.

Exploring the Relationship between Physical Activities and Health-Related Factors in the Health-Related Quality of Life among People with Disability in Korea

The purpose of this study is to explore the relationship between modes (e.g., frequency and total time) of physical activity and health-related conditions of disabled people on their health-related quality of life (HRQoL) in Korea. This study is a cross-sectional research funded by the Ministry of Health and Welfare. Data was obtained from the 2017 disability survey. A total of 6549 people with disabilities (Mage = 61.92, SD = 17.36; Male = 55.98%) were analyzed in this study. The higher the frequency of physical activity for the disabled in Korea, the more positive the HRQoL (p < 0.001). Among the elderly disabled, the higher the severity of disability and educational degree, the lower the HRQoL (all p < 0.05). Disabled people who had fewer diseases and lived an independent socio-economic and cultural life had a higher HRQoL (all p < 0.001). This study revealed different dimensions of how health-related factors influence the quality of life of people with disabilities. More attention should be paid to supporting people in being independent and active, in order to help them maintain a healthy life. Especially, the barriers to physical activity faced by disabled people are multi-layered and multifaceted. Increasing the frequency of physical activity for disabled people is not only beneficial for their physical function, but also for their HRQoL. This study enables welfare promotion for disabled people through various policies and incentives. Further, this will be an opportunity to reduce the socio-economic burden on medical and health-related services related to the disabled population.

Profiling Hoarding Within the Five-Factor Model of Personality and Self-Determination Theory

This study investigated the dispositional profile associated with hoarding symptoms by applying a personality and motivational trait perspective. A community sample oversampling high hoarding symptoms (N = 649, ages 18-74 years) completed an online questionnaire assessing hoarding, the five-factor model of personality, and general causality orientations drawn from self-determination theory. Personality aspects (10 traits), a level of measurement intermediate to factors (5 traits) and facets (30 traits), were assessed to provide greater specificity than a factor-level approach. Hoarding was correlated with neuroticism and conscientiousness. Aspects predicting hoarding were industriousness (C), orderliness (C), withdrawal (N), and assertiveness (E). Hoarding was significantly related to impersonal and control orientations, albeit with only slight (1.4%) incremental validity for general causality orientations above personality aspects in predicting hoarding. These findings may not generalize to a clinical treatment sample, and possible configurative interactions between traits were not assessed. This study extended the existing literature by reporting aspect-level personality and general causality orientation correlates of hoarding. These data may inform preventative monitoring and intervention programs, as well as predicting meaningful personality characteristics of hoarding clients.

Health-related quality of life in hoarding: A comparison to chronic conditions with high disease burden

Hoarding disorder often results in debilitating functional impairment and may also compromise health-related quality of life (QoL). This study investigated the association between hoarding behavior and QoL relative to six highly impairing medical and psychiatric disorders in a sample of 20,722 participants enrolled in the internet-based Brain Health Registry. Nearly 1 in 8 participants (12.2%) endorsed clinically relevant hoarding symptoms (CHS). In separate multivariable linear regression models, hoarding was more strongly associated with mental QoL than diabetes (Standardizedβ = -0.21, 95% CI: [-0.22, -0.20] vs. -0.01 [-0.02, 0.0]), heart disease (-0.22 [-0.23, -0.20] vs. 0.00 [-0.02, 0.01]), chronic pain (-0.18 [-0.19, -0.16] vs. -0.12 [-0.13, -0.10]), post-traumatic stress disorder (PTSD; -0.20 [-0.22, -0.19] vs. -0.07 [-0.09, -0.06]), and substance use disorder (SUD; -0.21 [-0.23, -0.20] vs. -0.04 [-0.05, -0.03]). Similarly, CHS was more strongly negatively associated with physical QoL than diabetes (-0.11 [-0.10, -0.12] vs. -0.08 [-0.06, -0.09]), major depressive disorder (-0.09 [-0.10, -0.08] vs. -0.05 [-0.06, 0.03]), PTSD (-0.11 [-0.12, -0.10] vs. -0.08 [-0.09, -0.07]), and SUD (-0.12 [-0.13, -0.09] vs. -0.01 [-0.02, 0.00]). Higher hoarding severity was associated with reductions in both mental (Standardizedβ = -0.28, ΔR² = 0.08, p < 0.0001) and physical (β = -0.12, ΔR² = 0.02, p < 0.0001) QoL, though the strength of the relationship between hoarding symptoms and QoL varied with depression severity. Efforts to improve the overall QoL and well-being of those with CHS are needed.

Cognitive impairment in hoarding disorder: a systematic review

OBJECTIVE

In the present study, we aimed to perform a systematic review evaluating the cognitive performance of patients with hoarding disorder (HD) compared with controls. We hypothesized that HD patients would present greater cognitive impairment than controls.

METHODS

A systematic search of the literature using the electronic databases MEDLINE, SCOPUS, and LILACS was conducted on May 2020, with no date limit. The search terms were "hoarding disorder," "cognition," "neuropsychology," "cognitive impairment," and "cognitive deficit." We included original studies assessing cognitive functioning in patients with HD.

RESULTS

We retrieved 197 studies initially. Of those, 22 studies were included in the present study. We evaluated 1757 patients who were 41 to 72 years old. All selected studies comprised case-control studies and presented fair quality. Contrary to our hypothesis, HD patients showed impairment only in categorization skills in comparison with controls, particularly at confidence to complete categorization tasks. Regarding attention, episodic memory, working memory, information-processing speed, planning, decision-making, inhibitory control, mental flexibility, language, and visuospatial ability, HD patients did not show impairment when compared with controls. There is a paucity of studies on social cognition in HD patients, although they may show deficits. The impact of emotion in cognition is also understudied in HD patients.

CONCLUSION

Except for categorization skills, the cognitive performance in HD patients does not seem to be impaired when compared with that in controls. Further work is needed to explore social cognition and the impact of emotion in cognitive performance in HD patients.

Interpersonal attachment, early family environment, and trauma in hoarding: A systematic review

The formation of intense emotional attachments to objects, difficulty parting with possessions, and the extreme accumulation of clutter are key features of Hoarding Disorder (HD). Although substantial literature implicates processes such as dysfunctional beliefs and maladaptive emotional cycles in HD, little is known about the vulnerability factors that lead to their development and hoarding symptomatology. The current review sought to systematically collate and integrate findings from studies investigating the relationship between hoarding symptoms and three proposed vulnerability factors: i) interpersonal attachment, ii) early family environment, and iii) traumatic or adverse life events. A comprehensive search of the databases PsycInfo, PubMed, and Scopus identified a total of 39 studies for inclusion. The results presented a complex pattern that supported the presence of relationships between insecure attachment, cold and controlling family experiences, and exposure to adverse life events with increased hoarding severity. However, the specificity of these factors to HD over other clinical groups remains unclear and findings are limited by the heterogenous and small number of studies. We conclude by discussing the clinical implications and limitations of these findings and propose new directions for future research.

Recent Advances in Research on Hoarding

PURPOSE OF REVIEW

The purpose of the following paper is to review recent literature trends and findings in hoarding disorder (HD). Our goal is to highlight recent research on etiology, associated features, and empirically based treatments.

RECENT FINDINGS

Recent literature has added support for cognitive differences as a risk factor for HD; however, there is evidence that individuals with HD may overestimate their level of cognitive impairment. Several associated features have been highlighted in recent studies, including emotion regulation, intolerance of uncertainty and distress intolerance, and attachment. Finally, several psychotherapeutic treatments for hoarding have been recently validated, including group-based therapy and treatments using the cognitive-behavioral model. Although recent research demonstrates that hoarding can be effectively treated with available psychotherapeutic modalities, the effectiveness of current treatments is not as robust as that for other psychiatric disorders and more work is needed in treatment precision.

Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be (provisionally) maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified.

Hoarding Symptoms in Children and Adolescents With Obsessive-Compulsive Disorder: Clinical Features and Response to Cognitive-Behavioral Therapy

OBJECTIVE

Although adult hoarding disorder is relatively common and often debilitating, few studies have examined the phenomenology of pediatric hoarding. We examined the clinical phenomenology and response to cognitive-behavioral therapy (CBT) treatment in youths with a diagnosis of obsessive-compulsive disorder (OCD) with and without hoarding symptoms. Age was tested as a moderator across analyses, given prior findings that the impact of hoarding symptoms may not become apparent until adolescence.

METHOD

Youths (N = 215; aged 7-17 years) with OCD pursuing evaluation and/or treatment at a university-based specialty clinic participated in the current study. Presence of hoarding symptoms was assessed as part of a larger battery. Data from a subset of youths (n = 134) who received CBT were included in treatment response analyses.

RESULTS

Youths with hoarding symptoms did not differ from those without hoarding symptoms with respect to overall OCD symptom severity and impairment. Youths with hoarding met criteria for more concurrent diagnoses, including greater rates of internalizing and both internalizing/externalizing, but not externalizing-only, disorders. Youths with and without hoarding symptoms did not significantly differ in rate of response to CBT. Age did not moderate any of these relationships, suggesting that the presence of hoarding symptoms was not associated with greater impairments across the clinical presentation of OCD or its response to treatment by age.

CONCLUSION

We found no evidence that hoarding is associated with greater OCD severity or poorer treatment response in affected youth. Theoretical and clinical implications of these findings, including future directions for research on testing developmental models of hoarding across the lifespan, are discussed.

Quality of Life in Patients with Hoarding Disorder

The aim of this study was to investigate health-related quality of life (QoL) in patients with hoarding disorder (HD). Fifty-four patients with a primary diagnosis of HD, and 24 age- and sex-matched healthy control (HC) participants, completed a battery of questionnaires including the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), Saving Inventory-Revised, and Depression, Anxiety, Stress Scales. Compared to HC participants, those with HD reported poorer health-related QoL across all domains of the SF-36. When controlling for comorbid affective symptoms, HD participants scored lower than did HC participants in the QoL domains of social functioning, emotional well-being, role limitations due to emotional problems, vitality, and general health. HD symptom severity predicted, beyond the effects of affective symptoms, lower QoL in social functioning, emotional well-being, role limitations due to emotional problems, vitality, and general health.

Can Occupational Therapy Address the Occupational Implications of Hoarding?

Hoarding is often described as a medical disorder, defined by a persistent difficulty in discarding possessions and associated high levels of emotional distress when forced to part with these. This article will discuss how having a different view of hoarding, seeing hoarding as a daily occupation which provides value, purpose, and meaning and with a relationship to self-identity and life purpose, could offer alternate interventions to support an individual who hoards. The article will consider the components of hoarding activity and how these relate to health and wellbeing and doing, being, belonging, and becoming as understood by occupational therapists. The article will consider what occupational therapy, a profession which considers a person's daily occupations, the things that occupy their time and which give meaning to their existence, could offer as an alternative to current hoarding interventions. Proposals for occupational therapy interventions will be suggested which would support occupational choice, support engagement in activities which have more positive outcomes on a person's health, and seek to address barriers which limit engagement and occupational performance in activities within the person's home environment.

An investigation of delay and probability discounting in hoarding disorder

Behavioral impulsivity may be a mechanism of hoarding disorder (HD). A commonly used and well-validated measure of impulsivity is the delay and probability discounting task, which consists of making decisions about receiving monetary rewards after varying delay intervals and delivery probabilities. We compared delay and probability discounting and self-reported behavioral impulsivity in 81 patients with a primary diagnosis of HD and 45 nonclinical controls. HD participants completed the impulsivity measures before and after 16 weekly sessions of cognitive-behavioral therapy (CBT), whereas control group participants completed the measures before and after a 16-week waiting period. Despite the fact that self-reported impulsivity was greater in the HD group than the control group, delay and probability discounting did not differ between groups. Additionally, while self-reported behavioral impulsivity improved over the course of CBT in HD participants, delay and probability discounting did not change during treatment. Furthermore, higher delay discounting scores (i.e., greater preference for immediate rewards, indicating greater impulsivity) were associated with lower hoarding symptom severity. The findings suggest that self-reported impulsivity, but not objective performance on a behavioral impulsivity task, may be impaired in HD, and are discussed in terms of cognitive and affective factors in decision-making.

"Blended" therapy: The development and pilot evaluation of an internet-facilitated cognitive behavioral intervention to supplement face-to-face therapy for hoarding disorder

Mixed findings regarding the long-term efficacy of cognitive behavior therapy (CBT) for the treatment of hoarding has led to the investigation of novel treatment approaches. "Blended" therapy, a combination of face-to-face (f2f) and online therapy, is a form of therapy that enables longer exposure to therapy in a cost-effective and accessible format. Blended therapy holds many benefits, including increased access to content, lower time commitment for clinicians, and lower costs. The aim of the present study was to develop and evaluate a "blended" treatment program for hoarding disorder (HoPE), involving 12-weeks of face-to-face group therapy, and an 8 week online therapist assisted program. A sample of 12 participants with hoarding symptomology were recruited from the Melbourne Metropolitan area, and were involved in one of two conditions; 12 weeks group therapy +8 weeks online therapy (bCBT) or 12 weeks group therapy +8 weeks waitlist +8 weeks online therapy. Questionnaires were completed at all time points. The 8-week online component consists of 8 CBT-based modules, addressing psychoeducation, goal setting, motivation, relapse prevention and other key components. No significant differences were found over time between the bCBT group and waitlist control group, however trends suggested continued improvement in overall hoarding scores for the bCBT group, when compared to the waitlist control group. There were significant differences in scores from pre-treatment to 28 weeks, suggesting that all participants who were involved in the online intervention showed continued improvement from pre-treatment to post-treatment. This study highlights the potential benefit of novel formats of treatment. Future research into the efficacy of blended therapy would prove beneficial.

Hoarding Disorder and Difficulties in Emotion Regulation

The present study aimed to examine self-reported deficits in emotion regulation (ER) among individuals with hoarding disorder (HD). Seventy-seven adult outpatients with HD and 45 age- and gender-matched healthy control (HC) participants received a diagnostic assessment and completed self-report measures of hoarding severity, depression, and anxiety. In addition, participants completed the Difficulties in Emotion Regulation Scale (DERS), which measures lack of emotional clarity (Clarity), difficulty regulating behavior when distressed (Impulse), difficulty engaging in goal-directed cognition and behavior when distressed (Goals), unwillingness to accept emotional responses (Accept), and lack of access to strategies for feeling better when distressed (Strategies). The HD group scored higher on all DERS subscales than did the HC group; self-reported ER deficits remained evident when controlling for baseline depression, anxiety, and stress. The DERS correlated significantly with hoarding severity in the HD group: acquiring was significantly correlated with DERS Impulse, Strategies, and Accept; saving was significantly correlated with DERS Accept. Correlations remained significant when controlling for depression, anxiety, and stress. Results suggest that HD is characterized by self-reported deficits in ER, and that this relationship is not solely attributable to high levels of depression and anxiety.

The relationship between age and neurocognitive and daily functioning in adults with hoarding disorder

OBJECTIVE

Given the increase in hoarding symptoms with age, there is a pressing need for understanding the clinical features as they relate to potential interventions for older adults with hoarding disorder (HD). The aim of the current investigation was to explore age-related differences in the level of functional and cognitive impairment in individuals with HD.

METHODS

The current study utilized the baseline assessments of 122 adults with HD. Age-related differences in the raw scores of psychiatric, cognitive, and daily functioning were analyzed using a series of multiple regression models controlling for the possible age-related differences in premorbid IQ.

RESULTS

Our results suggested that older adults with HD may experience increased levels of impairment in skills related to executive functioning and everyday functioning when compared with younger adults with HD.

CONCLUSIONS

Given these difficulties with neurocognitive functioning, older HD patients may require interventions that focus more on behavioral and functional skills, rather than focusing on changing thought processes. Copyright © 2016 John Wiley & Sons, Ltd.

Hoarding symptoms among psychiatric outpatients: confirmatory factor analysis and psychometric properties of the Saving Inventory - Revised (SI-R)

BACKGROUND

The growing interest in problematic hoarding as an independent clinical condition has led to the development of the Saving Inventory-Revised (SI-R) to assess hoarding phenomenology. The SI-R is one of the most widely used instruments to measure hoarding symptoms; however, it lacks validation in non-Western samples.

METHODS

The current study examined the construct, convergent, and discriminant validity of the SI-R among 500 outpatients at a psychiatric hospital in Singapore. The three-factor structure solution of the SI-R was fitted in a confirmatory factor analysis.

RESULTS

The final model achieved mediocre fit (χ2 = 1026.02, df = 186; RMSEA = 0.095, SRMR = 0.06; CFI = 0.86; NNFI = 0.85). Two reverse-coded items (items 2 and 4) were removed due to insufficient factor loadings, resulting in the modified 21-item SI-R (SIR-21). Our findings indicate the need to further examine the construct validity of the SI-R, particularly in non-Western samples. Nonetheless, correlations with other hoarding-related constructs, such as anxiety (Beck Anxiety Inventory) and depression (Beck Depression Inventory-II), supported the convergent and discriminant validity of the SIR-21 in our sample.

CONCLUSIONS

Findings in our current majority Chinese sample were consistent with previous observations from other Chinese samples. Implications were discussed from a cross-cultural perspective, such as cultural emphasis on saving for future use and overlap between the concepts of discarding and acquiring in Chinese samples. Future studies should also examine differences among other ethnic groups (e.g., Malay, Indian).