Hoarding by elderly people

Household factors and prevalence of squalor: meta-analysis and meta-regression

BACKGROUND

Severe domestic squalor occurs when a person lives in a dwelling that is significantly unclean, disorganised and unhygienic. The limited previous research has primarily focused on the characteristics of those who live in squalor and the associated risk factors. Robust and reliable studies of squalor prevalence have not been conducted. This study sought to produce a reliable estimate of the point prevalence of squalor.

METHODS

Using data from 13-years of the English Housing Survey, N = 85,681 households were included in a prevalence meta-analysis. Squalor prevalence over time, subgroup analysis and logistic regression investigated the role played by household and community characteristics.

RESULTS

The point prevalence of squalor was estimated to be 0.85% and squalor was seen to decrease significantly over time. More significant community deprivation, a rented dwelling, lower income and high numbers of people in the home was associated with a greater risk of squalor.

CONCLUSIONS

Squalor prevalence was higher than previous estimates and supports community care services in associated service planning. The results regarding household characteristics help to inform which households and individuals may be at a higher risk of living in squalid conditions.

[Problématiques d'accumulation chez les aînés : l'expérience de proches aidants québécois au sein des services communautaires et publics]

Cette recherche qualitative traite de la situation des proches aidants des aînés composant avec une problématique d'accumulation (trouble d'accumulation compulsive, autonégligence, syndrome de Diogène). Il s'agit d'un contexte de la proche aidance qui a été jusqu'à maintenant peu étudié, où les réalités du vieillissement et de la santé mentale sont en interaction. Onze proches aidants et huit intervenants sociaux des régions de la Capitale-Nationale et de Chaudière-Appalaches ont participé à des entretiens semi-dirigés, lesquels ont été soumis à une analyse thématique de contenu. Nos résultats indiquent que malgré l'interaction du vieillissement et de problématiques de santé mentale, ce sont les enjeux liés au vieillissement qui déclenchent le début de la proche aidance, puis le maintien de cet engagement dans la durée. Ils nous montrent aussi que des efforts de concertation et de coordination devraient être déployés afin que les différents acteurs interpellés prévoient des trajectoires de services pour la personne âgée et les proches avant que le problème d'accumulation engendre des enjeux de sécurité importants. Dans ces trajectoires, les organisations sociosanitaires gagneraient à davantage reconnaître les savoirs des proches et à mettre à leur disposition les services requis pour répondre à leurs besoins spécifiques.

Do they really care? Specificity of social support issues in hoarding disorder and obsessive-compulsive disorder

OBJECTIVES

Unmet interpersonal needs may play a role in excessive emotional attachments to objects for people with hoarding disorder (HD). Previous research indicates that social support (but not attachment difficulties) may be specific to HD. The study aimed to evaluate social networks and support in HD relative to clinical controls with obsessive-compulsive disorder (OCD) and healthy controls (HC). The secondary aim was to explore the extent of loneliness and thwarted belongingness. Potential mechanisms for deficits in social support were also considered.

DESIGN

A cross-sectional between-groups design was used to compare scores on measures in those with HD (n = 37); OCD (n = 31); and HCs (n = 45).

METHODS

Participants completed a structured clinical interview by telephone (to assign diagnostic categories) followed by online questionnaires.

RESULTS

Whilst individuals with HD and OCD both report smaller social networks than HC, lower levels of perceived social support appear to be specific to HD. The HD group also showed higher levels of loneliness and thwarted belonging compared to OCD and HC. No differences were found between groups for perceived criticism or trauma.

CONCLUSIONS

The results support previous findings of lower levels of self-reported social support within HD. Loneliness and thwarted belongingness also appear significantly elevated within HD compared with OCD and HC. Further research is required to explore the nature of felt support and belonging, direction of effect and to identify potential mechanisms. Clinical implications include advocating and promoting support systems (both personal supporters and professionals) for individuals with HD.

The generational impact of household clutter

OBJECTIVES

Hoarding disorder can create long-term problems for adult children of individuals with hoarding symptoms; however, the extent of the psychosocial consequences of growing up in a cluttered household are not yet fully understood. This study investigated the extent to which generational clutter (i.e., parent/caregiver and grandparent) influenced individuals' self-reported hoarding severity and psychiatric and psychosocial functioning.

METHODS

A total of 1306 adults completed an online survey that included measures of hoarding, anxiety, depression, companionship and emotional support. A subsample (n = 198) reported on parent and grandparent household clutter, as well as family impact from hoarding. We used correlations, t-tests, linear and hierarchical regressions and mediation analyses to investigate whether hoarding symptoms were predicted by parent or grandparent hoarding.

RESULTS

Parent clutter level significantly predicted participant hoarding symptoms. For participants who reported having caregivers with elevated clutter, self-reported psychosocial functioning was lower overall. Self-reported behaviour modification due to family hoarding symptoms (accommodation) was a significant predictor of participant hoarding symptoms.

CONCLUSIONS

Parent clutter and family accommodation behaviours may be a risk factor for future clutter in adult children. Further comparisons between parents and children are needed to determine whether this association increases children's risk for future hoarding symptoms.

Anosognosia in hoarding disorder is predicted by alterations in cognitive and inhibitory control

Insight impairment contributes significantly to morbidity in psychiatric disorders. The neurologic concept of anosognosia, reflecting deficits in metacognitive awareness of illness, is increasingly understood as relevant to psychopathology, but has been little explored in psychiatric disorders other than schizophrenia. We explored anosognosia as an aspect of insight impairment in n = 71 individuals with DSM-5 hoarding disorder. We used a standardized clutter severity measure to assess whether individuals with hoarding disorder underreport home clutter levels relative to independent examiners. We then explored whether underreporting, as a proxy for anosognosia, is predicted by clinical or neurocognitive behavioral measures. We found that individuals with hoarding disorder underreport their clutter, and that underreporting is predicted by objective severity of clutter. In an n = 53 subset of participants, we found that underreporting is predicted by altered performance on tests of cognitive control and inhibition, specifically Go/No-Go and Stroop tests. The relation of underreporting to objective clutter, the cardinal symptom of hoarding disorder, suggests that anosognosia may reflect core pathophysiology of the disorder. The neurocognitive predictors of clutter underreporting suggest that anosognosia in hoarding disorder shares a neural basis with metacognitive awareness deficits in other neuropsychiatric disorders and that executive anosognosia may be a transdiagnostic manifestation of psychopathology.

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.

What is underneath all that stuff? A Q-methodological exploration of profiles of beliefs and vulnerabilities in hoarding disorder

BACKGROUND

Hoarding disorder (HD) can be understood through the cognitive behavioural model in the context of vulnerability factors (for example, personality traits, co-morbidities, traumatic life events) and beliefs about possessions (for example, identity, emotional attachment, memory, utility). Less is known about the strength of these hypothesised beliefs, or how they interact within the hoarding population, with researchers suggesting that specifying beliefs would improve treatment outcomes.

AIM

The current study explored beliefs in HD, utilising Q-methodology to explore both categories of beliefs and the interactions between these. Moreover, Q-methodology allowed for comparison of the individuals endorsing specific categories of beliefs.

METHOD

A comprehensive list of beliefs about possessions was developed. Thirty-two adults with clinically significant levels of HD completed a Q-sort task, alongside measures of proposed vulnerabilities, including co-morbidity, trauma and attachment style.

RESULTS

Q-factor analysis produced four profiles consisting of groups of participants who endorsed the same beliefs and had shared characteristics: (1) 'Expression of identity', (2) 'Responsibility and morality', (3) 'Stability and predictability', and (4) 'Objects as emotional and meaningful beings'.

DISCUSSION

The profiles were distinguished by different categories of beliefs and co-morbid symptoms, suggesting that more targeted assessment tools and interventions would be beneficial to account for this heterogeneity within the clinical population. In particular, beliefs about identity and self-concept formed the largest profile, and beliefs about stability and predictability introduce a novel category of beliefs.

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)

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.

Working together when the problem is multi-faceted: understanding inter-agency working for the benefit of people with hoarding problems

Hoarding disorder is a surprisingly common problem which impacts on most areas of life. People who hoard typically have multiple agencies involved in their care due to the complex health and safety impact and risks associated with hoarding. ‘Treatment’ involves finding ways of supporting discarding large amounts, typically underpinned by CBT principles. We evaluated the impact and outcomes of a conference designed to boost professionals’ confidence and understanding in working with hoarding problems, both individually and with other agencies with a view to improving inter-agency service provision. Changes in professionals’ confidence and understanding were evaluated immediately before and after the conference. Conference participants’ qualitative responses related to service improvements were analysed using content analysis. People with personal experience of hoarding issues subsequently participated in a focus group where the results of the conference were presented. These data were analysed using thematic analysis. Confidence and understanding in working with hoarding problems substantially increased from pre- to post-conference. Professionals identified a range of possible improvements, most commonly working more closely and improving communication with other agencies. People with personal experience suggested improvements across three over-arching themes: developing an improved understanding of hoarding, the need for improved resources, and improved multi-agency working. A multi-agency conference increased confidence and understanding in professionals working with hoarding problems, and improvements specified by both people with personal experience and professionals provide a useful guide to service improvement. Results provide a framework in which CBT approaches should be embedded.

Key learning aims

(1)

Investigating associations between hoarding symptoms and affective and cognitive empathy

OBJECTIVES

Hoarding is associated with poor interpersonal functioning, such as social isolation and difficulties in forming relationships, but the reasons for these social problems are not well understood. Previous studies have identified empathy as an important precursor to social functioning, particularly for clinical disorders characterized by social deficits. The aim of the current study was therefore to investigate associations between measures of cognitive and emotional empathy and hoarding symptoms.

METHOD

A total of 278 participants recruited via MTurk completed online self-report questionnaires on hoarding, empathy (including cognitive and affective components), and depression. All participants subsequently completed The Awareness of Social Inference Test-Short version (TASIT-S), a behavioural measure of theory of mind, a concept used interchangeably with cognitive empathy.

RESULTS

Hoarding symptoms were associated with greater self-reported emotional empathy, specifically emotional contagion, and less self-reported cognitive empathy. Emotional empathy predicted hoarding even after controlling for depression symptoms. Hoarding symptoms were also associated with poorer performance on the TASIT-S with respect to both emotion recognition and theory of mind, with theory of mind remaining a unique predictor of hoarding symptoms after controlling for depression. Participants who reported clinically significant hoarding symptoms were impaired in emotion recognition and theory of mind according to TASIT-S norms.

CONCLUSIONS

Hoarding symptoms are associated with increased emotional contagion and decreased cognitive empathy. Empathy may be an avenue for understanding and treating interpersonal difficulties in hoarding disorder.

PRACTITIONER POINTS

As hoarding increased, self-reported emotional contagion increased As hoarding increased, self-reported and behavioural cognitive empathy decreased Self-reported emotional empathy and behavioural cognitive empathy predicted hoarding even after controlling for depression Empathy may be an avenue for understanding social difficulties in hoarding disorder.

Comparing the Efficacy of Defusion, Self-as-Context, and Distraction Strategies for Getting Rid of Possessions

Interventions for hoarding disorder need to target difficulty letting go of items to reduce clutter and improve functioning. The present studies were designed to test the efficacy of brief cognitive interventions for letting go of possessions and self-report outcomes. Participants (N = 67 in Study 1; N = 110 in Study 2) received training on defusion or distraction in Study 1 and defusion, self-as-context, or distraction in Study 2 and completed measures at pre- and postintervention. Study 1 found no differences between defusion and distraction on saving, self-rated discomfort with discarding, or perceived importance of the target belonging. In Study 2, participants provided most favorable feedback for self-as-context compared to defusion and distraction, indicating promise of this strategy. Nonetheless, findings from both studies overall provide minimal support for use of present procedures to reduce saving. Limitations include use of nonclinical samples and single-item variables to obtain participant feedback.

How can cities tackle hoarding? Examining an intervention program bringing together fire and health authorities in Vancouver

Hoarded homes can pose a threat to public safety, with heightened risks of fire hazards, pest infestations and noxious odours in both the home and neighbouring dwellings. Communities across North America are responding to these public safety concerns through a harm reduction approach. This descriptive study explores the implementation and outcomes of the City of Vancouver's approach involving a partnership between fire prevention and public health. Data were collected from the team's 2016-2018 case tracking systems, consisting of health records and team intervention record, as well as notes taken from case briefing meetings. Study objectives included describing the intervention model, providing descriptive statistics on clients and their clutter volume, the interventions undertaken, and exploring predictors of clutter volume and case outcome through exploratory analyses. The sample included 82 cases involving severely hoarded conditions or more moderate hoarding conditions paired with additional client vulnerabilities (e.g. health conditions, frailty). Results from paired samples t-tests and regression analysis, suggest the Hoarding Action Response Team's (HART) model of a community-based intervention for hoarding was associated with clutter reduction and tenancy preservation. HART successfully maintained engagement with most clients, and most cases were closed within six home visits. Despite these successes, the team dealt with several barriers including client avoidance and limited resources. This paper provides guidance for communities who are working to develop a coordinated response to problems associated with hoarding and begins to establish expectations for what can be achieved through a community-based hoarding intervention model.

Exploring emotions and cognitions in hoarding: a Q-methodology analysis

BACKGROUND

The cognitions and emotions of people prone to hoarding are key components of the dominant cognitive behavioural model of hoarding disorder.

AIMS

This study sought to use Q-methodology to explore the thoughts and feelings of people that are prone to hoarding, to identify whether distinct clusters of participants could be found.

METHOD

A 49-statement Q-set was generated following thematic analysis of initial interviews (n = 2) and a review of relevant measures and literature. Forty-one participants with problematic hoarding met various study inclusion criteria and completed the Q-sort (either online or offline). A by-person factor analysis was conducted and subsequent participant clusters compared on psychometric measures of mood, anxiety, hoarding and time taken on the online task as proxy for impulsivity.

RESULTS

Four distinct participant clusters were found constituting 34/41 (82.92%) of the participants, as the Q-sorts of n = 7 participants failed to cluster. The four clusters found were 'overwhelmed' (n = 11 participants); 'aware of consequences' (n = 13 participants); 'object complexity' (n = 6 participants) and 'object-affect fusion' (n = 4 participants). The clusters did not markedly differ with regard to hoarding severity, anxiety, depression or impulsivity.

CONCLUSIONS

Whilst the participant clusters reflect extant research evidence, they also reveal significant heterogeneity and so prompt the need for further research investigating emotional and cognitive differences between people prone to hoarding.

Determinants of object choice and object attachment: Compensatory consumption in compulsive buying-shopping disorder and hoarding disorder

BACKGROUND AND AIMS

Individuals who meet criteria for compulsive buying-shopping disorder (i.e., acquiring problems only) or hoarding disorder (i.e., acquiring and discarding problems) may acquire possessions to compensate for unmet belonging needs, but may do so in different ways. Those with compulsive buying-shopping disorder may acquire objects that they believe will relieve the distress associated with unmet belonging needs (e.g., objects that distract or comfort), whereas those with hoarding disorder may acquire objects that they believe achieve belonging needs (e.g., objects that have interpersonal connotations). Accordingly, this study examined whether a belongingness threat would drive individuals who excessively acquire possessions to choose a human-like object (person-shaped tea holder) or a comfort item (box of chamomile tea).

METHODS

One hundred seventy-five participants (57 self-reported excessive acquiring only; 118 self-reported excessive acquiring and difficulty discarding) recalled a time when they either felt supported or unsupported by a significant other before choosing an object to take home with them. Participants rated how anthropomorphic and comforting the objects were as well as how attached they became to their chosen object.

RESULTS

Unsupported individuals were more likely to acquire the comfort item than supported individuals; however, individuals with both acquiring and discarding problems were more likely to acquire the human-like item than those with an acquiring problem only. Comfort and anthropomorphism ratings predicted object choice and attachment.

DISCUSSIONS AND CONCLUSION

The current findings extend the Compensatory Consumer Behavior Model to include what factors determine strategy choice and object attachment.

Clinical characteristics of hoarding disorder in Japanese patients

Previous studies have reported clinical characteristics of hoarding disorder (HD), such as early onset, a chronic course, familiality, high unmarried rate, and high rates of comorbidities. However, clinical research targeting Japanese HD patients has been very limited. As a result, there is a low recognition of HD in Japan, leading to insufficient evaluation and treatment of Japanese HD patients.

The aim of the current study was to delineate the clinical characteristics of Japanese HD patients. Thirty HD patients, 20 obsessive-compulsive disorder (OCD) patients, and 21 normal controls (NC) were targeted in this study.

The HD group had a tendency toward higher familiality, earlier onset, and longer disease duration compared to the OCD group. In addition, the HD group showed a significantly higher unmarried rate than the NC group. The top two comorbidities in the HD group were major depressive disorder (56.7%) and attention-deficit/hyperactivity disorder (26.7%). The HD group had significantly higher scores on hoarding rating scales and lower scores on the Global Assessment of Functioning Scale than the other two groups.

The current study showed a clinical trend in Japanese HD patients similar to previous studies in various countries, suggesting that HD may be a universal disease with consistent clinical symptoms.

How well do hoarding research samples represent cases that rise to community attention?

This study used archival data from three different research groups and case file data from three independent community organizations to explore how well research samples reflect cases of hoarding that come to community attention. Using data from 824 individuals with hoarding, we found that research volunteers differ from community clients in several ways: community clients are older, more likely to be male and less likely to be partnered; they have lower socio-economic status and are less likely to demonstrate good or fair insight regarding hoarding severity and consequences. The homes of community clients had greater clutter volume and were more likely to have problematic conditions in the home, including squalor and fire hazards or fire safety concerns. Clutter volume was a strong predictor of these conditions in the home, but demographic variables were not. Even after accounting for the influence of clutter volume, the homes of community-based clients were more likely to have squalor. These findings suggest limitations on the generalizability of research samples to hoarding as it is encountered by community agencies.

Visually mediated functioning improves following treatment of hoarding disorder

BACKGROUND

Hoarding disorder (HD) is a highly debilitating psychiatric disorder that affects 2-6% of adults. Neuropsychological deficits in visual memory, detection, and categorization have been reported in HD. To date, no study has examined the relationship between neurocognitive functioning and treatment for HD. We aim to determine the association between neurocognitive functioning and treatment outcomes, as well as the impact of HD-specific treatment on cognitive functioning.

METHODS

323 individuals with HD were randomized to 20 weeks of peer- or clinician-led group behavioral treatment. 242 participants completed pre- and post-treatment neuropsychological testing covering eight neurocognitive domains. Rates of cognitive impairment (CI) were assessed for each neurocognitive domain. The association of baseline neurocognitive function on treatment response was examined using multiple regression. MANOVA and post-hoc tests were used to determine neurocognitive performance change pre- to post treatment.

RESULTS

Sixty-seven percent of participants had CI on ≥1 cognitive domain. There was no significant effect of pre-treatment neurocognitive functioning on treatment outcome. Post-treatment improvements were observed in visual memory, visual detection, decision making, information processing speed, visuospatial processing, attention/working memory (p≤.001). Declines in performance were found in visual reaction time and categorization.

LIMITATIONS

This was a non-inferiority trial to examine two treatment types with no normative comparison group. Treatment seeking individuals are more likely to be insightful, motivated, and have other features which limit generalizability.

CONCLUSIONS

Patterns of cognitive impairment in HD are similar to previous reports. Pre-treatment neurocognitive functioning did not impact treatment response. Neuropsychological functioning improved across multiple domains following targeted treatment.

Prevalence of Hoarding Disorder: A systematic review and meta-analysis

Currently there is uncertainty concerning the prevalence of Hoarding Disorder (HD) due to methodological issues in the evidence base. Estimates have widely ranged from between 1.5% and 6% of the general population. This systematic review and meta-analysis therefore aimed to summarise and reliably estimate the prevalence of HD by employing strict inclusion criteria and using studies with sufficiently large samples. A systematic literature search was conducted to identify all relevant prevalence studies. Inclusion criteria were studies that reported working age adult HD prevalence rates and had sample sizes of at least 1009 participants. Eleven studies met criteria (n = 53,378), had low risk of bias and were originally based in developed countries. A random effects meta-analysis was then conducted, with subgroup moderator analysis and meta-regression. The pooled estimated prevalence for HD was 2.5% (CI 1.7-3.6%) and subgroup analyses revealed that prevalence rates were similar for both males and females. Guidance on the manner in which HD is assessed in future prevalence studies is provided and the clinical implications of the results discussed.

Treating hoarding disorder with compassion-focused therapy: A pilot study examining treatment feasibility, acceptability, and exploring treatment effects

OBJECTIVES

Hoarding disorder (HD) was recognized as a psychiatric disorder in 2013. Existing literature suggests room for improvement in its treatment. The current pilot study aimed to provide an initial evaluation on the potential of compassion-focused therapy (CFT) as an intervention for HD, with the primary aim being assessing its feasibility and acceptability, and the secondary being evaluating its effects.

DESIGN

Both CFT and a second round of the current standard of treatment and cognitive behavioural therapy (CBT) were investigated in the current study as follow-up treatment options for individuals who had completed CBT but were still significantly symptomatic.

METHODS

Forty eligible individuals were enrolled (20 in each treatment). Treatment feasibility and acceptability were assessed by quantitative and qualitative measures. To explore treatment effects, HD symptom severity, HD-related dysfunctions, and their underlying mechanisms were assessed pre-treatment and post-treatment.

RESULTS

Retention rates were 72% for CFT and 37% for CBT. All participants and 79% of the participants rated CFT and CBT, respectively, as good or excellent. After receiving CFT as a follow-up treatment, HD symptom severity dropped below the cut-off point for clinically significant HD for 77% of the treatment completers, and 62% achieved clinically significant reduction in symptom severity. In contrast, after completing a second course of CBT, 23% had HD symptom severity dropped below the cut-off threshold, and 29% achieved clinically significant symptom reduction.

CONCLUSIONS

The current study showed satisfactory feasibility and acceptability of CFT. Moreover, it also found promising effects of CFT in addressing hoarding-related mechanisms that may not have been sufficiently addressed by CBT. The results suggest promising potential of CFT as a treatment for HD. Further investigation on this intervention is needed.

PRACTITIONER POINTS

CFT may be a promising treatment option, particularly for those who do not respond well to CBT. Improving emotion regulation and negative self-perception by applying CFT interventions may help relieve hoarding symptoms. Generalization of the findings should be applied with caution given the small convenience sample of the current study. Statistical comparison on treatment effect measures between CFT and CBT as follow-up treatments was not available due to small sample size. Therefore, the comparative conclusions based on this pilot study should be made with caution.

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.

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.

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.

Discarding personal possessions increases psychophysiological activation in patients with hoarding disorder

Difficulty discarding is the core behavioral symptom of hoarding disorder (HD). Patients with HD report greater subjective distress when discarding their own possessions as compared to others' possessions. To date, no prior studies have examined psychophysiological activation, an objective measure of anxious arousal, during discarding among individuals with HD. The current study assessed psychophysiological responses during a baseline resting period and two discarding tasks, one involving personal possessions and the other involving matched control ("experimenter-owned") items in 52 patients with a primary diagnosis of HD. Results showed that, compared to discarding control items, discarding personal possessions increased skin conductance and heart rate and decreased end tidal carbon dioxide. There were no differences in heart rate variability, respiratory sinus arrhythmia, and respiration rate between the two discarding tasks. Despite the fact that discarding increased psychophysiological arousal, self-reported HD symptoms (including difficulty discarding) failed to predict psychophysiological responses during the discarding tasks. The findings suggest that there may be discordance between objective and subjective measures of hoarding-related distress, and are discussed in terms of incorporating psychophysiological measures into the assessment and treatment of HD.

A qualitative analysis of emotion and emotion regulation in hoarding disorder

OBJECTIVE

The role of emotion regulation (ER) has been receiving increased attention in relation to various forms of psychopathology including hoarding disorder (HD). However, questionnaire designs are limited to finding associations of ER with symptoms or symptom groups, without finding out how such constructs might be involved in the disorder.

METHODS

This study was a qualitative investigation of ER in a clinical HD sample (N = 11).

RESULTS

Prominent themes provided support for ER difficulties in hoarding. In particular, difficulties with identifying and describing feelings, unhelpful attitudes toward the emotional experience, the use of avoidance-based strategies, and a perceived lack of effective ER strategies were prominent themes. Furthermore, emotional factors were identified as being associated with the onset and/or exacerbation of hoarding behavior, and possessions and acquiring behavior appeared to serve an ER function.

CONCLUSION

The current paper provides a nuanced account of the role of ER in hoarding difficulties.

Identifying hoarding disorder in the elderly using the interRAI

OBJECTIVES

Hoarding disorder (HD) is prevalent in older adults and contributes to morbidity and mortality. We attempted to estimate rates of hoarding amongst the elderly using the international Residential Assessment Instrument - Home Care (interRAI-HC).

SETTING

The interRAI is a mandatory prerequisite in New Zealand (NZ) for government-funded community support or for entry into aged residential care.

PARTICIPANTS

All 50 years and older people who were assessed using the interRAI in the southern district health board of NZ.

MEASUREMENTS

The age, gender, socially inappropriate or disruptive behaviour and squalor interRAI-HC items were analysed.

RESULTS

During the 3 years study period (Jan., 2015 to Dec., 2017) 6655 people, mean age 81.4 + 7.6 years, 56% female, were assessed. The interRAI socially inappropriate behaviour (includes hoarding as one of its descriptors) was present in 233 people (3.5%), herein defined as suspected HD. Squalid conditions were present in 98 additional people (1.5%). Mean age for suspected HD group was significantly younger [76.1 + 6.3 years (p < 0.001)] and there were more males [57% (p < 0.05)] compared with the general interRAI group.

CONCLUSIONS

Rates of HD estimated by using the interRAI are in line with published international data. As identification of HD with the interRAI is not straightforward it's use as a screening tool for identifying HD should be validated in future studies.

Presidential Address: Team Science Across Disciplines: Advancing CBT Research and Practice on Hoarding

This presidential address focuses on the recent history of research and practice on hoarding disorder (HD) as a potential model for coordinating interdisciplinary teams of professionals within and outside mental health fields to advance scientific efforts to understand and resolve mental health problems. To identify, assess, and intervene with clients who have HD, psychologists, social workers, psychiatrists, and other service professionals are needed, including those in public health, housing, medicine, aging and protective services, fire, safety, and animal protection. Research findings and practice methods developed by many of my colleagues highlight the various skills of these diverse disciplines and fields. Of particular interest are multimethod assessments and CBT interventions that span individual, group, and family treatments, delivered in the office, at home and via the web by mental health and other professionals, as well as peers. Outcomes are positive, but there remains much work to do to improve understanding and intervention outcomes.

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.

Scared and surrounded by clutter: The influence of emotional reactivity

BACKGROUND

Home visits can improve treatment outcomes for hoarding disorder, but factors influencing the success of home visits remain unknown. As home visits expose individuals to clutter and fear, the present study examined the effect that fear and emotional reactivity have on the relationship between clutter and discarding behaviour.

METHODS

Participants with at least subclinical discarding problems (n = 143) were asked to save or discard personal possessions of varying value following an emotional induction that took place in either a tidy or cluttered context. Participants also completed questionnaires assessing hoarding severity, emotional state, and emotional reactivity, as defined by one's sensitivity, persistence, and intensity of reactions to emotional stimuli.

RESULTS

As expected, participants discarded more items in the presence of clutter and when feeling fearful. However, emotional reactivity moderated the relations between environmental context, acute emotional state, and discarding. Low sensitivity, low persistence, and high emotional intensity negatively influenced discarding in the cluttered context. When feeling fearful, low dispositional emotional intensity negatively influenced discarding in the tidy context.

LIMITATIONS

Individuals in the tidy environment reported higher levels of fear and anxiety than individuals in the cluttered environment after the fear induction. These differences could have contributed to the difference noted between the two contexts when examining the effect of emotional intensity tendencies.

CONCLUSIONS

Providing treatment in an environment more representative of the cluttered home can improve discarding or at the very least give therapists a more accurate picture of what clients do in the context that matters most.

Factors Affecting the Referral Rate of the Hoarding Disorder at Primary Mental Health Care in Quebec

Hoarding disorder (HD) places an important burden on people with HD, on their family members and society. In this paper we evaluate help-seeking in HD at primary mental health, measured in referral rate, together with its individual, environmental and structural correlates. We conducted an aggregate study by combining existing official data with our own survey data at the catchment area level. We found a mean annual referral rate of 1.58 (SD = 1.79) cases of HD in primary mental health facilities per 10,000 of adult population. The referrals rate correlated with socio-demographic characteristics of the catchment area, the availability of tools for clinical management of HD, and affiliation to a University Medical school. We also found that: (1) family members, neighbours, municipal workers and health professionals are the primary source of complaints for HD; (2) 72% of primary mental health facilities worked with HD in crisis situations, 52% expressed difficulties in obtaining the consent of people with HD for an intervention (3) health/social services professionals lack HD clinical management tools, training and formal collaboration with municipal (housing, building security, fire prevention) specialists. Improvement of the readiness of the health-system to deal with HD will improve help-seeking for formal medical counselling on the part of people with HD. We can improve this readiness by providing primary mental-health facilities with training, clinical management tools and by helping them to establish formal collaboration with municipalities and community organisations. University medical schools can take a leadership role and become centers catalysing the change in HD clinical management.

Anxious attachment and excessive acquisition: The mediating roles of anthropomorphism and distress intolerance

Background and aims Most individuals with hoarding disorder (HD) are prone to excessively acquiring new possessions. Understanding the factors that contribute to this collecting behavior will allow us to develop better treatment approaches for HD. The aim of this study was to test our assumption that an anxious attachment style is associated with a tendency to anthropomorphize comforting objects and an inability to tolerate distress, which in turn leads to excessive acquisition. Methods A total of 361 participants with subclinical to clinical acquisition problems (77.8% female) completed a series of self-report measures. Results As expected, greater anxious attachment was related to greater distress intolerance and stronger tendencies to anthropomorphize inanimate objects. In turn, greater distress intolerance and anthropomorphism were related to more excessive buying and greater acquisition of free items. Examination of the pathways and indirect effects showed support for double mediation rather than serial mediation, as distress intolerance did not predict anthropomorphism. Discussion and conclusion These novel findings, if replicated, suggest that adding treatment modules that target improving distress tolerance and reducing anthropomorphism to standard treatment for HD may lead to further reductions in excessive acquiring.

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​.

The cognitive-behavioural model of hoarding disorder: Evidence from clinical and non-clinical cohorts

The cognitive-behavioural model of hoarding disorder incorporates information processing difficulties, maladaptive attachment to possessions, erroneous beliefs about the nature of possessions, and mood problems as etiologically significant factors, although developmental experiences such as a compromised early family environment have also been proposed in an augmented model. This study examined the specificity and relevance of variables highlighted in the augmented cognitive-behavioural model. Various clinical participants (n = 89) and community controls (n = 20) were assessed with structured clinical interviews to verify diagnosis. Participants completed self-report measures of hoarding severity, cognitions, meta-memory, and early developmental experiences (e.g., memories of warmth and security in one's family). Hoarding cohorts (with and without obsessive-compulsive disorder) reported poor confidence in memory, but relative to other groups (obsessive-compulsive disorder without hoarding disorder, anxiety disorders, and healthy controls), hoarding-relevant cognitions, need to keep possessions in view, and concerns about the consequences of forgetting were significantly higher. Hoarding groups reported the lowest recollections of warmth in their family, although no differences were found between hoarding and non hoarding clinical cohorts for uncertainty about self and others. Nonetheless, clinical cohorts reported generally higher scores of uncertainty than healthy controls. When predicting hoarding severity, after controlling for age and mood, recollections of lack of warmth in one's family was a significant predictor of hoarding severity, with hoarding-related cognitions and fears about decision-making being additional unique predictors. The study supports the augmented cognitive-behavioural model of hoarding, inclusive of the importance of early developmental influences in hoarding.

Elder Self-neglect and Suicidal Ideation in an U.S. Chinese Aging Population: Findings From the PINE Study

Background

Self-neglect and suicidal ideations are important public health issues among the aging population. This study aims to examine the association between self-neglect, its phenotypes, and suicidal ideation among U.S. Chinese older adults.

Methods

Guided by a community-based participatory research approach, the Population Study of Chinese Elderly in Chicago (PINE) study is a population-based epidemiological study conducted from 2011 to 2013 among 3,159 Chinese older adults aged 60 years and older in the Greater Chicago area. Self-neglect was assessed by a 27-item instrument, describing five phenotypes with hoarding, poor personal hygiene, unsanitary condition, lack of utilities, and need of home repair. Suicidal ideation was assessed by the ninth item of the Patient Health Questionnaire-9 (PHQ-9) and the Geriatric Mental State Examination-Version A (GMS-A). Logistic regression is utilized to analyze the association.

Results

Higher level of self-neglect was found significantly associated with increased risk of self-reported suicidal ideation within 2 weeks (odds ratio 2.97 [1.54-5.72]); 12 months (odds ratio 2.82 [1.77-4.51]); and lifetime (odds ratio 2.74 [1.89-3.95]). For phenotypes, the study found that poorer personal hygiene and severer level of unsanitary conditions were associated with increased risk of suicidal ideation at all three time periods.

Conclusion

This study suggests that self-neglect and its phenotypes are significantly associated with suicidal ideation among Chinese older adults. Longitudinal studies are needed to explore the mechanisms through which self-neglect links with suicidal ideation.

Age-Specific Prevalence of Hoarding and Obsessive Compulsive Disorder: A Population-Based Study

OBJECTIVE

Little is known about the age-specific prevalence of hoarding and obsessive compulsive symptoms (OCS), particularly in older age groups. The objectives of this study were to estimate the age-specific prevalence, severity, and relationships between hoarding and OCS in males and females using a large population-based sample.

METHODS

We assessed the age-specific prevalence rates of hoarding disorder (HD) and OC disorder (OCD) in males and females (at various age ranges between 15 and 97 years) from the Netherlands Twins Register (N = 15,194). Provisional HD and OCD diagnoses were made according to Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, criteria using self-report measures. We also assessed hoarding and OCS severity in the various age groups and explored specific hoarding and OCS patterns (e.g., difficulty discarding, excessive acquisition, clutter, checking, washing, perfectionism, and obsessions) with age.

RESULTS

Prevalence of provisional HD diagnoses (2.12%) increased linearly by 20% with every 5 years of age (z = 13.8, p < 0.0001) and did not differ between males and females. Provisional OCD diagnoses were most common in younger individuals and in individuals over age 65. Co-occurring OCD increased hoarding symptom severity (coefficient: 4.5; SE: 0.2; 95% CI: 4.1-4.9; t = 22.0, p < 0.0001). Difficulty discarding for HD and checking behaviors for OCD appeared to drive most increases in these diagnoses in older ages.

CONCLUSION

Increased prevalence and severity of HD with age appears to be primarily driven by difficulties with discarding. Increases in OCD prevalence with older age were unexpected and of potential clinical relevance.

Symptom subtype and quality of life in obsessive-compulsive disorder

Quality of life (QoL) is significantly impaired in OCD across several facets of life, such as social, occupational, and family functioning, subjective sense of well-being, and enjoyment of leisure activities. The present study examined the relationship between 5 symptom subtypes of OCD (contamination, symmetry, hoarding, overresponsibility for harm, and taboo) and QoL. Participants were 325 adults with OCD enrolled in the Brown Longitudinal Obsessive Compulsive Study. Hierarchical linear regression analyses indicated hoarding, contamination, symmetry, and overresponsibility for harm were associated with impairment in household functioning, enjoyment of leisure activities, social relationships, and physical health. The implications of these findings are discussed.

An examination of the role of intolerance of distress and uncertainty in hoarding symptoms

BACKGROUND

Hoarding disorder (HD) is a common and debilitating disorder characterized by an accumulation of and failure to discard one's possessions. The identification and examination of underlying factors that may contribute to hoarding symptoms are needed to elucidate the nature of the disorder and refine existing treatments. Two transdiagnostic vulnerability factors that have been associated with hoarding symptoms are distress intolerance (DI) and intolerance of uncertainty (IU).

OBJECTIVES

This study examined the relationships between DI, IU, and symptoms of hoarding in two samples consisting of outpatients and individuals recruited from Amazon's Mechanical Turk. We hypothesized that DI and IU would show unique and interactive associations with hoarding symptoms.

RESULTS

Across both samples, DI and IU were significantly associated with hoarding symptoms. However, DI and IU did not interact in their prediction of symptoms, and only IU remained a significant predictor, when accounting for relevant covariates.

CONCLUSIONS

Results suggest that IU is a robust predictor of hoarding symptoms and may be a promising and novel treatment target for HD.

Hoarding and depression: The mediating role of perceived burdensomeness

Despite clear indications that hoarding behaviors contribute to social isolation and strained family relationships, no research to date has examined the associations between hoarding and several important interpersonal constructs (i.e., perceived burdensomeness and thwarted belongingness). Moreover, no research has examined how these various interpersonal needs may account for the associations between symptoms of hoarding and depression. Community participants (N = 125) with elevated hoarding symptoms were assessed on the interpersonal constructs of interest. Hoarding severity was significantly associated with perceived burdensomeness even after controlling for overall levels of negative affect. Moreover, perceived burdensomeness significantly mediated the relationship between hoarding severity and depressive symptoms. To our knowledge this is the first study to examine potential mechanisms that may account for the robust associations between hoarding and depression. Future investigations should attempt to replicate these findings using clinical samples.

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.

Comparison of a peer facilitated support group to cognitive behavior therapy: Study protocol for a randomized controlled trial for hoarding disorder

Although individual and group cognitive-behavioral therapy (CBT) is the standard treatment approach for hoarding disorder (HD), it requires trained mental health professionals with specialization in HD. There is a need to offer additional options and services due to the limited number of professionals with advanced training, combined with the high prevalence rate of individuals with HD. A structured support group led by trained facilitators or lay professionals using a facilitator's manual and participant workbook (Buried in Treasures or BiT), addresses this need and increases accessibility. Prior studies of BiT groups have shown decreased hoarding symptoms. Only one retrospective study compared BiT and CBT outcomes in a naturalistic setting and showed no difference. Thus, a well-powered randomized controlled trial is needed to directly compare these forms of treatment. This paper presents a non-inferiority controlled trial protocol that compares group CBT to group BiT. Three hundred participants with HD, 18years or older, are being recruited for a 16-week treatment study. Participants are randomly assigned to either the CBT or BiT group. The primary outcome is reduction in hoarding symptom severity. Secondary outcomes include reduction in other indices of hoarding symptomology, including functional impairment, physical clutter, cognition, and changes in neuropsychological functioning.

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.

[Diogenes syndrome and Hoarding disorder: Same or different?]

INTRODUCTION

In 2013, the American Psychiatric Association published the DSM-5. In this new version, new diagnoses were proposed including the Hoarding disorder. In the French semeiology, the Diogenes syndrome is described, among other symptoms, by a pathological tendency to accumulate objects called syllogomania which is very close to hoarding. This paper explores the similarities and differences between the two syndromes.

DESCRIPTION

The Diogenes syndrome was first described in 1966 but was officially named for the ancient Greek philosopher in 1975 by Clark. Its frequency is around five for 100,000 persons. Many aetiologies have been known to be associated with the Diogenes syndrome: schizophrenia, dementia - especially frontotemporal type, anxiety disorders, mood disorders, and substance abuse - especially alcohol abuse. The diagnostic requires one major criterion, the inability to ask for medical or social help, and one of three minor criteria: a pathological relationship to the body, which leads to somatic illness; a pathological relationship to the society, which leads to a progressive exclusion from it; and finally, a pathological link with objects. This last criterion is very interesting because it is closely related to the Hoarding syndrome: indeed, patients with syllogamania, as also named, have a tendency to hoard every object they find. At the end, their homes are full of useless objects, and some living places can be unusable because they are cluttered and congested. This last point is similar to the definition given in the DSM-5 for the Hoarding disorder which describes a persistent difficulty parting with possessions; distress associated with discarding possessions; and accumulations that congest and clutter active living areas. The Hoarding disorder was first part of the Obsessive and compulsive disorders, but it has progressively appeared that it could be individualized with its own prevalence of 2.3% to 14% lifetime. Genetical studies have shown that at least 50% of patients suffering from excessive hoarding had a relative with a dimension of hoarding. Finally, Mattaix-Cols et al. decided to create a new syndrome in the DSM-5, and the Hoarding disorder was born.

DISCUSSION

The discussion begins with relationships between the Hoarding disorder and the Diogenes syndrome. A patient with hoarding, and a poor insight, could be very isolated, and could persist in a lack of calling for help, because of not being aware of his pathology. Thus, it could be diagnosed as a Hoarding syndrome with a poor insight, or as a Diogenes syndrome, with the first major criterion (lack of calling for help) and one of the three minor criteria, the syllogomania, or hoarding. Moreover, some authors have described old people living for many years with a tendency to hoard. Progressively, some of them had a congested and cluttered home, and a few were living in squalor, a description very close to the Diogenes syndrome. Finally, we discuss the comorbidity of Hoarding disorder and Diogenes syndrome. In particular, the first one is associated with Attention deficit and hyperactivity disorders; and some authors also described the links between ADHD, bipolar disorder and frontotemporal dementia which is one of the aetiologies of the Diogenes syndrome. A psychodynamic model in which ADHD, Hoarding disorder and Diogenes syndrome are linked can be imagined, and the last one could be an overlooked evolution of the two first syndromes.

CONCLUSION

In conclusion, we can imagine a dimensional model, based on two dimensions: hoarding and squalor. Hoarding disorder is the major expression of the first dimension, and Diogenes syndrome the major expression of the second. Both of them could be a different expression of one central aetiology. More studies are needed to complete this vision.

Clinical Correlates of Hoarding With and Without Comorbid Obsessive-Compulsive Symptoms in a Community Pediatric Sample

OBJECTIVE

We assessed the prevalence and clinical correlates of hoarding, with and without obsessive-compulsive (OC) symptoms, in a community-based pediatric sample.

METHOD

We measured hoarding and OC symptoms using the Toronto Obsessive-Compulsive Scale (TOCS) in 16,718 youth aged 6 to 17 years in the community. We classified participants with high and low symptom counts for hoarding and OC into 4 groups: hoarding+OC; hoarding-only; OC-only; and control (no OC or hoarding symptoms). We compared these 4 groups on parent- or self-reported medical and psychiatric conditions, anxiety symptoms measured with the Child Behavior Checklist (CBCL), and attention-deficit/hyperactivity disorder (ADHD) symptoms measured with the Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN).

RESULTS

Almost 10% of participants were in the high hoarding group. Of these participants, 40% did not fall into the high OC group. The prevalence of reported psychiatric disorders (e.g., ADHD, autism spectrum disorder, obsessive-compulsive disorder) was greater in the hoarding (hoarding+OC and hoarding-only) and OC groups (hoarding+OC and OC-only) than in the nonhoarding (OC-only and control) and non-OC groups (hoarding-only and control), respectively. ADHD, specifically inattentive, symptoms were more common in the hoarding-only than in the OC-only group while anxiety symptoms were more common in the OC-only than in the hoarding-only group.

CONCLUSION

In a community pediatric sample, hoarding symptoms occurred in both the presence and absence of obsessive-compulsive symptoms. Hoarding symptoms alone had some unique clinical correlates, in particular, more inattentive ADHD symptoms and fewer anxiety symptoms. These findings suggest that hoarding is distinct from OC traits in youth.

Error-related brain activity dissociates hoarding disorder from obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is associated with an abnormally large error-related negativity (ERN), an electrophysiological measure of error monitoring in response to performance errors, but it is unclear if hoarding disorder (HD) also shows this abnormality. This study aimed to determine whether the neurophysiological mechanisms underlying error monitoring are similarly compromised in HD and OCD.

METHOD

We used a visual flanker task to assess ERN in response to performance errors in 14 individuals with HD, 27 with OCD, 10 with HD+OCD, and 45 healthy controls (HC). Age-corrected performance and ERN amplitudes were examined using analyses of variance and planned pairwise group comparisons.

RESULTS

A main effect of hoarding on ERN (p = 0.031) was observed, indicating ERN amplitudes were attenuated in HD relative to non-HD subjects. A group × age interaction effect on ERN was also evident. In HD-positive subjects, ERN amplitude deficits were significantly greater in younger individuals (r = -0.479, p = 0.018), whereas there were no significant ERN changes with increasing age in OCD and HC participants.

CONCLUSIONS

The reduced ERN in HD relative to OCD and HC provides evidence that HD is neurobiologically distinct from OCD, and suggests that deficient error monitoring may be a core pathophysiological feature of HD. This effect was particularly prominent in younger HD participants, further suggesting that deficient error monitoring manifests most strongly early in the illness course and/or in individuals with a relatively early illness onset.