Intervention in compulsive hoarding. A case study

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

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

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

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

Integrating Treatments for HD and PTSD: A Clinical Report

This report details the course of psychotherapy methods and outcomes for a 57-year-old White man who sought services for hoarding disorder (HD) and posttraumatic stress disorder (PTSD). Over 14 months, he completed 54 treatment sessions that spanned two distinct treatment approaches. Given his presentation and the conceptualized relations among his symptoms, therapy was sequenced to address PTSD symptoms prior to undergoing cognitive–behavioral therapy (CBT) for HD. The implications of this decision were key to his treatment progress and outcome, and they are reviewed in detail. Together, treatment consisted of psycho-education, cognitive restructuring, and a combination of in-clinic and home-based exposures. Results were positive, with the client experiencing a decrease in self-reported HD and PTSD symptoms, reduction in home clutter and decreased distress related to discarding, and increased feelings of self-efficacy. In light of limited data addressing treatment for individuals with HD who have a salient trauma history, the major aim of this report is to detail how each step of the client’s treatment was approached, what factors and data were considered for reaching specific decision points, and how the sequencing of treatment is believed to have contributed to the positive outcome achieved.

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.

Hoarding in Children and Adolescents: A Review

The diagnostic conceptualization of hoarding has recently changed, and yet the application of these changes to hoarding in youth remains to be clarified. In this review we examine the literature on hoarding in youth. We discuss issues related to the assessment of pediatric hoarding, and the nature of hoarding in youth. We consider evidence for hoarding disorder as a distinct diagnosis in youth, and review the relationship between pediatric hoarding and other psychiatric disorders. Finally, we describe preliminary models of treatment for pediatric hoarding. We conclude that there is support for hoarding disorder as a distinct diagnosis in youth. However, more precise and developmentally appropriate assessment tools are needed to provide stronger evidence for this claim and to further our knowledge of prevalence and associated clinical characteristics. Although there is no evidence-based treatment for pediatric hoarding, preliminary evidence from case studies suggests that cognitive and behavioral methods may have promise.

Specific and general facets of hoarding: A bifactor model

Whereas it has been suggested that hoarding is a multidimensional construct comprising distinct but interrelated factors (i.e., difficulty discarding, excessive clutter, and excessive acquisition), a high degree of overlap as well as a lack of discriminant validity among these factors and exogenous constructs suggests that a correlated factors approach may not adequately capture this phenomenon. The factor structure of the Saving Inventory Revised (SIR) was examined in a large non-selected clinic sample (N=490). A bifactor model of hoarding, comprising a general Hoarding factor and orthogonal Urge-Related Acquiring, Distress-Related Acquiring, Difficulty Discarding, and Clutter factors fit the data best. Further, whereas the general Hoarding factor was related to several depression facets, the specific hoarding factors demonstrated differential relations with depression. This study establishes that acquiring behaviors are motivated by both positive/urge-related and negative/distress-related emotions. Additionally, general and distinct factors should be considered to properly contextualize hoarding behavior.

Hoarding disorder in older adulthood

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment Recruitment and Retention of Geriatric Participants With Hoarding Disorder

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

Helping those with hoarding behaviors

Hoarding--the excessive acquisition of and failure to discard possessions, which preclude the appropriate use of living spaces--undermines safety and health by increasing risk for fire, falls, and infections. Hoarding does not result from deprivation early in life, nor are elders with hoarding behaviors merely "thrifty or frugal." Up to 64% of elders with hoarding behaviors have self-care deficits. Comorbid depression, anxiety, alcohol dependence, physical trauma, and damage to the prefrontal and orbitofrontal cortex are common. Hoarding was historically viewed as a variant of obsessive-compulsive disorder (OCD), but compulsive hoarding is a symptom in just 24% of all OCDs. Approximately half of elders with hoarding behaviors suffer from psychiatric conditions, mostly major depression and mood disorders. Treating elders with hoarding behavior in a medical-psychiatric model is a complex matter that may include prescription medication if an underlying condition contributes to the problem. Hoarding behavior results in placement in a nursing facility when squalor poses a health or safety issue.

An intensive time-series evaluation of the effectiveness of cognitive behaviour therapy for hoarding disorder: a 2-year prospective study

OBJECTIVE

To intensively evaluate the effectiveness of cognitive-behavioural therapy (CBT) for Hoarding Disorder.

METHOD

An ABC with extended follow-up N=1 single-case experimental design (SCED) measured discard incidence/frequency/volume and associated cognitions, behaviours and emotions in a 644-day time series. Following a 4-week baseline (A), CBT was initially delivered via out-patient sessions (B) and then out-patient sessions plus domiciliary visits (C). Total treatment duration was 45 sessions (65 weeks) and follow-up was 4 sessions over 23 weeks.

RESULTS

There was a significant increase in frequency and volume of discard, with a reliable and clinically significant reduction in hoarding. The addition of domiciliary visits did not significantly improve discard ability.

DISCUSSION

The clinical utility of domiciliary visits whilst treating of hoarding is discussed and study limitations noted.

The synergistic effect of growing older with hoarding behaviors

Clinically significant hoarding behaviors (HB) have been defined as acquisition of, and failure to discard, large numbers of items, which limits the use of one's home and causes functional impairment or distress. HB disproportionally affect adults aged 55 and older, and although research on HB has accelerated in the past decade, few studies focus on older adults. This qualitative study, based on grounded theory methodology, utilized interview data from 22 older adults with HB to understand the dynamic interaction between HB and the aging process. Participants described the specific ways that their chronic HB were complicated by changes in their health status, social context, and home setting, resulting in greater functional impairment and distress. By identifying these changes that commonly occur with age and their synergistic relationship with HB, nurses and other health professionals can develop targeted interventions to improve home safety and support the independence of these older adults.

Group cognitive and behavioral therapy and bibliotherapy for hoarding: a pilot trial

BACKGROUND

Group cognitive behavioral treatments (GCBTs) for hoarding have produced modest benefits. The current study examined whether the outcomes of a specialized GCBT improve upon bibliotherapy (BIB) for hoarding, as part of a stepped care model. We also explored whether additional home assistance enhanced GCBT outcomes.

METHODS

Hoarding patients (n = 38) were randomized and completed one of three conditions: (1) GCBT with nonclinician home assistants (GCBT+HA; N = 11), (2) GCBT without HA (CGBT; N = 14), and (3) BIB (N = 13). All GCBT participants received 20 weekly group sessions and four home visits by a group co-therapist. GCBT+HA groups received four additional visits by a nonclinician coach. BIB participants were assigned a self-help book describing specific skills to reduce hoarding over the 20-week period. All participants were assessed by self-report at baseline, mid-treatment, and posttreatment. The sample averaged 57 years old and was mainly female, White, highly educated, employed, and living alone.

RESULTS

GCBT+HA and GCBT participants showed significant reductions on hoarding and depression symptoms, whereas BIB did not. GCBT+HA and GCBT benefited substantially and similarly on the saving inventory-revised (reductions of 29.9 and 23.3%, respectively) and SI-R (Saving Inventory-Revised) (reductions of 26.5 and 25.4%), whereas BIB participants showed very limited improvement (9% reduction) on both measures.

CONCLUSION

This study provides support for the efficacy of GCBT for hoarding. The effect of adding nonclinician home assistance was not significant in this small sample. BIB was not sufficient to improve hoarding symptoms. The findings have implications for a stepped care model for treating hoarding (e.g., the benefits of psycho-education via BIB, added benefits of extra in-home visits) and suggest the need to further examine the role of in-home hoarding coaches.

Older adults with hoarding behaviour aging in place: looking to a collaborative community-based planning approach for solutions

This paper reports on and synthesizes new research that examines how a collaborative community response can promote successful aging in place for older adults with hoarding behaviour. Through interviews with older adults with hoarding behaviour, who used a particular community support and a focus group interview with members of the community collaborative that directed supports for this population, our findings suggest that there were valuable outcomes for both groups. These older adults with hoarding behaviour were able to remain in their own homes, their safety was enhanced, their sense of isolation was minimized, empowerment was fostered, and they gained valuable insight into their behaviour. The members of the community collaborative were able to access the expertise of other professionals, maximize their own expertise, and they generated an enhanced understanding of the experience of older adults living with hoarding behaviour in Edmonton. This study is a significant addition to the much too sparse literature about the community planning needs of older adults with hoarding behaviour. It offers knowledge that is integral to theories and principles of better aging in place but attempts to translate this into practice.

Group cognitive-behavioral therapy for hoarding disorder: an open trial

Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment.

The effectiveness of a biblio-based support group for hoarding disorder

Compulsive hoarding is characterized by the acquisition of, and failure to discard, a large number of possessions and clutter that prevents the use of living spaces as intended. Current successful treatments such as individual and group cognitive-behavioral therapy are lengthy and costly, requiring a time commitment ranging from four to twelve months, trained clinicians to administer treatment, and multiple home visits. Nonprofessional interventions may provide a cost-effective pre-treatment, adjunct, or alternative for individuals who want to work on hoarding problems but are unable or unwilling to engage in treatment. The purpose of the present study was to investigate the effectiveness of an innovative program consisting of a 13-session non-professionally facilitated biblio-based, action-oriented support group using Tolin, Frost, and Steketee's (2007b) self-help book. In study 1, seventeen self-identified hoarding participants experienced significant decreases in clutter, difficulty discarding, and excessive acquisition from pre-treatment to post-treatment, with reductions evident at mid-treatment. Study 2 replicated the findings of study 1 using interview and observational measures taken in participants' homes. These findings suggest that a facilitated biblio-based group may be a promising intervention for hoarding disorder.

Compulsive hoarding

Compulsive hoarding is a chronic and debilitating condition that represents a significant public health concern. Hoarding is characterized by four key elements: difficulty discarding, excessive acquiring, clutter, and distress and impairment due to hoarding. This article reviews the current literature on compulsive hoarding, including its course and features, comorbidity, nosology, clinical presentation, and treatment response. The authors describe the cognitive-behavioral therapy model and treatment of hoarding, including a case presentation of a cognitive behavioral group treatment of compulsive hoarding.

Hoarding cases involving older adults: the transition from a private matter to the public sector

Hoarding interventions with older adults require significant resources from multiple public agencies, yet recidivism occurs frequently. To improve services through better coordination, some communities have formed multiagency hoarding teams (MAHT), which include aging services. MAHTs requested this mixed methods study to understand the progression of cases through the public sector. Quantitative data collected on 52 cases involving adults ages 60+ identified steps in this process. Qualitative data collected from MAHT members were the basis for case studies illustrating the progression of cases through the public sector. Findings have implications for social workers involved in local service coordination, training, and policy.

Excessive acquisition in hoarding

Compulsive hoarding (the acquisition of and failure to discard large numbers of possessions) is associated with substantial health risk, impairment, and economic burden. However, little research has examined separate components of this definition, particularly excessive acquisition. The present study examined acquisition in hoarding. Participants, 878 self-identified with hoarding and 665 family informants (not matched to hoarding participants), completed an Internet survey. Among hoarding participants who met criteria for clinically significant hoarding, 61% met criteria for a diagnosis of compulsive buying and approximately 85% reported excessive acquisition. Family informants indicated that nearly 95% exhibited excessive acquisition. Those who acquired excessively had more severe hoarding; their hoarding had an earlier onset and resulted in more psychiatric work impairment days; and they experienced more symptoms of obsessive-compulsive disorder, depression, and anxiety. Two forms of excessive acquisition (buying and free things) each contributed independent variance in the prediction of hoarding severity and related symptoms.

An open trial of cognitive-behavioral therapy for compulsive hoarding

The aim of the present study was to provide preliminary data on the efficacy of a new cognitive-behavioral treatment (CBT) for compulsive hoarding. Fourteen adults with compulsive hoarding (10 treatment completers) were seen in two specialty CBT clinics. Participants were included if they met research criteria for compulsive hoarding according to a semistructured interview, were age 18 or above, considered hoarding their main psychiatric problem, and were not receiving mental health treatment. Patients received 26 individual sessions of CBT, including frequent home visits, over a 7-12 month period between December 2003-February 2005. Primary outcome measures were the Saving Inventory-Revised (SI-R), Clutter Image Rating (CIR), and Clinician's Global Impression (CGI). Significant decreases from pre- to post-treatment were noted on the SI-R and CIR, but not the CGI-severity rating. CGI-Improvement ratings indicated that at mid-treatment, 40% (n=4) of treatment completers were rated "much improved" or "very much improved;" at post-treatment, 50% (n=5) received this rating. Adherence to homework assignments was strongly related to symptom improvement. CBT with specialized components to address problems with motivation, organizing, acquiring and removing clutter appears to be a promising intervention for compulsive hoarding, a condition traditionally thought to be resistant to treatment.

On phenomenology and classification of hoarding: a review

OBJECTIVE

Hoarding is a behavioural abnormity characterized by the excessive collection of poorly usable objects. It is described mainly in association with obsessive-compulsive disorders (OCDs) and in geriatric populations. Yet the literature on the phenomenon is heterogeneous and the notion obviously lacks a consistent definition. This review attempts to describe the psychopathological and clinical spectrum of hoarding and may contribute to clarify its classification.

METHOD

Systematic review and discussion of the literature on hoarding.

RESULTS

Hoarding is a complex behavioural phenomenon associated with different mental disorders. The psychopathological structure is variously composed of elements of OCDs, impulse-control disorders, and ritualistic behaviour. Severe self-neglect is a possible consequence of hoarding.

CONCLUSION

Without further specifications the term hoarding is of limited heuristic value and cannot guide therapeutic interventions satisfactorily. The condition needs to be evaluated carefully in every particular case in relation to the aforementioned psychopathological concepts.

Compulsive hoarding: current status of the research

This article reviews the literature on compulsive hoarding, including the definition and manifestations of the problem and a conceptual model for understanding hoarding behavior. This model addresses information processing deficits (e.g., attention, organization, memory, decision-making), beliefs about and emotional attachments to possessions, and distress and avoidance. Research regarding the diagnostic categorization of hoarding, its course and phenomenology, and evidence to support the model is presented. The limited research on treatment provides evidence that current serotonergic medications for OCD are largely ineffective for treating hoarding, but cognitive and behavioral treatments, especially those focused on deficits identified in the model, have some utility. Recommendations for further research on the psychopathology and treatment of hoarding are provided.