Hoarding and clozapine-risperidone combination

Hoarding and Animal Hoarding: Psychodynamic and Transitional Aspects

Hoarding is a disorder that has only recently begun to be understood by researchers and clinicians. This disorder has been examined from a biopsychosocial perspective and has features that overlap with obsessive-compulsive disorder as well as some unique characteristics. Hoarding disorder is widespread and maybe related to the evolution of collecting and storing resources among humans and other animals. While there have been a number of non-analytic theories related to hoarding and its treatment, psychoanalytic thinkers have rarely described the disorder or explored its underlying psychodynamics. Beginning with Freud, it is possible to understand hoarding in relationship to the vicissitudes of the anal stage of development. However, loss of a loved object, especially loss of the mother, can play an important role in the development of hoarding behavior in adults. The hoarding of inanimate items, examined from a developmental object-relations perspective, appears to involve transitional phenomena. Animal hoarding also involves transitional phenomena, but animals, which can serve as animated transitional objects, also have a repetition compulsion function. These psychodynamic characteristics are relevant for establishing a working transference with the analyst or therapist, in order to promote positive therapeutic outcomes.

Critical Review of the Use of Second-Generation Antipsychotics in Obsessive-Compulsive and Related Disorders

Currently, all second-generation antipsychotics are approved for schizophrenia. Many are also approved for bipolar disorder, with some also approved as adjunctive treatment for depression and autism-related irritability. Second-generation antipsychotics are increasingly being prescribed for indications other than those approved by the Food and Drug Administration, such as in dementia, anxiety, and post-traumatic stress disorder to name a few. Obsessive-compulsive and related disorders are a group of disorders characterized by preoccupation and repetitive behaviors. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, obsessive-compulsive disorder, body dysmorphic disorder, trichotillomania, hoarding disorder, and excoriation, the latter two being newly designated disorders, fall under obsessive-compulsive and related disorders. Due to a lack of well designed clinical studies specifically addressing the use of second-generation antipsychotics in obsessive-compulsive and related disorders, it is unknown whether these agents are clinically beneficial. Current research describing the pathophysiology of these disorders shows the involvement of similar brain regions and neurotransmitters across the five obsessive-compulsive and related disorders. Despite differences in the receptor binding profiles, second-generation antipsychotics share many common pharmacodynamics properties. This review sought to examine all the published reports of second-generation antipsychotics being used in the management of symptoms of the aforementioned diseases and compile evidence for clinicians who encounter patients who are unresponsive to standard treatment.

Prevalence, comorbidity and heritability of hoarding symptoms in adolescence: a population based twin study in 15-year olds

BACKGROUND

Hoarding Disorder (HD) is often assumed to be an 'old age' problem, but many individuals diagnosed with HD retrospectively report first experiencing symptoms in childhood or adolescence. We examined the prevalence, comorbidity and etiology of hoarding symptoms in adolescence.

METHODS

To determine the presence of clinically significant hoarding symptoms, a population-based sample of 15-year old twins (N = 3,974) completed the Hoarding Rating Scale-Self Report. Co-occurring Obsessive Compulsive Disorder (OCD), Autism Spectrum Disorders (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) were estimated from parental report. Model-fitting analyses divided hoarding symptom scores into additive genetic, shared, and non-shared environmental effects.

RESULTS

The prevalence of clinically significant hoarding symptoms was 2% (95% CI 1.6-2.5%), with a significantly higher prevalence in girls than boys. Exclusion of the clutter criterion (as adolescents do not have control over their environment) increased the prevalence rate to 3.7% (95% CI 3.1-4.3%). Excessive acquisition was reported by 30-40% among those with clinically significant hoarding symptoms. The prevalence of co-occurring OCD (2.9%), ASD (2.9%) and ADHD (10.0%) was comparable in hoarding and non-hoarding teenagers. Model-fitting analyses suggested that, in boys, additive genetic (32%; 95% CI 13-44%) and non-shared environmental effects accounted for most of the variance. In contrast, among girls, shared and non-shared environmental effects explained most of the variance, while additive genetic factors played a negligible role.

CONCLUSIONS

Hoarding symptoms are relatively prevalent in adolescents, particularly in girls, and cause distress and/or impairment. Hoarding was rarely associated with other common neurodevelopmental disorders, supporting its DSM-5 status as an independent diagnosis. The relative importance of genetic and shared environmental factors for hoarding differed across sexes. The findings are suggestive of dynamic developmental genetic and environmental effects operating from adolescence onto adulthood.

Role of CYP pharmacogenetics and drug-drug interactions in the efficacy and safety of atypical and other antipsychotic agents

Cytochrome P450 (CYP) drug oxidases play a pivotal role in the elimination of antipsychotic agents, and therefore influence the toxicity and efficacy of these drugs. Factors that affect CYP function and expression have a major impact on treatment outcomes with antipsychotic agents. In particular, aspects of CYP pharmacogenetics, and the processes of CYP induction and inhibition all influence in-vivo rates of drug elimination. Certain CYPs that mediate the oxidation of antipsychotic drugs exhibit genetic variants that may influence in-vivo activity. Thus, single nucleotide polymorphisms (SNPs) in CYP genes have been shown to encode enzymes that have decreased drug oxidation capacity. Additionally, psychopharmacotherapy has the potential for drug-drug inhibitory interactions involving CYPs, as well as drug-mediated CYP induction. Literature evidence supports a role for CYP1A2 in the clearance of the atypical antipsychotics clozapine and olanzapine; CYP1A2 is inducible by certain drugs and environmental chemicals. Recent studies have suggested that specific CYP1A2 variants possessing individual SNPs, and possibly also SNP combinations (haplotypes), in the 5′-regulatory regions may respond differently to inducing chemicals. CYP2D6 is an important catalyst of the oxidation of chlorpromazine, thioridazine, risperidone and haloperidol. Certain CYP2D6 allelic variants that encode enzymes with decreased drug oxidation capacity are more common in particular ethnic groups, which may lead to adverse effects with standard doses of psychoactive drugs. Thus, genotyping may be useful for dose optimization with certain psychoactive drugs that are substrates for CYP2D6. However, genotyping for inducible CYPs is unlikely to be sufficient to direct therapy with all antipsychotic agents. In-vivo CYP phenotyping with cocktails of drug substrates may assist at the commencement of therapy, but this approach could be complicated by pharmacokinetic interactions if applied when an antipsychotic drug regimen is ongoing.

Antipsychotic polypharmacy in patients with schizophrenia in a brief hospitalization unit

INTRODUCTION

Antipsychotic monotherapy is considered the gold standard in pharmacological treatment of schizophrenia and other psychotic disorders. Only 2 of the main clinical guides recommend the use of antipsychotic polypharmacy (AP) for those patients refractory to monotherapy. Nonetheless, there is a large rate of studies, conducted in many different settings, showing that AP is more frequent as would be expected attending experts' recommendations.

METHODS

In this retrospective study, we review all the psychotropic drugs dispensed to inpatients of a brief hospitalization psychiatric unit diagnosed as having schizophrenia or schizoaffective disorder (International Statistical Classification of Diseases, 10th Revision) at time of discharge in the year 2005. These included a total of 209 patients older than 18 years.

RESULTS

Of the 209 studied patients, 55.5% were discharged under AP treatment. Inpatients were given a mean of 3.06 psychotropic drugs and a mean of 1.61 antipsychotics at the time of hospital discharge. A total of 33.2% of the studied patients got anticholinergic drugs, and 66.2% were given benzodiazepines. The most prevalent combination of drugs was intramuscular long-acting risperidone plus an atypical antipsychotic. Amisulpride was the most used antipsychotic as adjuvant treatment.

CONCLUSIONS

Despite different clinical guidelines, AP is a common pharmacological strategy as it is shown in our study and in the reviewed literature. Data in our study indicate that the observed rates of AP cannot exclusively be attributed to the treatment of patients with clozapine-resistant schizophrenia.

Polypharmacy with second-generation antipsychotics: a review of evidence

OBJECTIVE

The objective of this study was to review the prevalence of polypharmacy with second-generation antipsychotics (SGAs) in clinical practice, pharmacological reasons for such practice, and the evidence for and against such polypharmacy.

METHODS

Clinical trial reports, case reports, and reviews were identified by a PubMed literature search from 1966 through October 2006, with retrieved publications queried for additional references. We excluded reports on augmentation with non-antipsychotic medications and polypharmacy involving combinations of SGAs and first-generation (conventional) antipsychotics (FGAs) or combinations of two FGAs. We identified 75 reports concerning SGA polypharmacy, from which we extracted data on study design, sample size, medications, rating scales, outcome, and conclusions. Data from randomized controlled trials and larger case series are presented in detail and case reports are briefly discussed.

CONCLUSIONS

Polypharmacy with SGAs is not uncommon, with prevalence varying widely (3.9% to 50%) depending on setting and patient population, despite limited support from blinded, randomized, controlled trials or case reports that employed an A-B-A (monotherapy-combination therapy-monotherapy) design and adequate dosing and duration of treatment. Rather than prohibiting or discouraging co-prescription of SGAs, needs of patients and clinicians should be addressed through evidence-based algorithms. Based on unmet clinical needs and modest evidence from case reports, combinations of two SGAs may merit future investigation in efficacy trials involving patients with schizophrenia who have treatment-resistant illness (including partial response) or who are responsive to treatment but develop intolerable adverse effects. Other areas that may merit future research are efficacy of SGA polypharmacy for schizophrenia accompanied by comorbid conditions (eg, anxiety, suicidal or self-injurious behavior, aggression) and for reducing length of stay in acute care settings.

Benefits and risks of antipsychotic polypharmacy: an evidence-based review of the literature

Combination antipsychotic prescription is an increasingly common practice in clinical psychiatry. This clinical practice is at odds with clinical guidelines promoting antipsychotic monotherapy. Moreover, there has been increased concern over the safety profile of atypical antipsychotics in the last 10-15 years. We reviewed the literature on antipsychotic combinations with a focus on safety and efficacy. Multiple electronic database searches were complemented by relevant bibliography cross-checking and expert discussions. The review showed a literature that is dominated by case reports and uncontrolled studies. Polypharmacy was unequally studied, with some recent combinations (i.e. clozapine and risperidone) being extensively, albeit inconclusively, studied and other more commonly used combinations (first- with second-generation agents) receiving little attention. From an evidence-based perspective, further trials of antipsychotic association of sufficient power to address safety issues are needed before recommending any antipsychotic combination. Particular weaknesses of the present literature are low number of participants, lack of adequate control of confounding variables, short duration of experimental follow-up and inadequate monitoring of potential adverse effects.

Adjunctive Treatment With Risperidone in Clozapine-Resistant Schizophrenia

OBJECTIVES

Long-term studies show that 47% to 63% of schizophrenic patients treated with clozapine fail to respond after 12 years of treatment. Such high rates of resistance justify the growing interest in therapeutic strategies based on enhancing the effect of clozapine with other antipsychotics. The combination of clozapine and risperidone in the treatment of partial responders to clozapine has been one of those receiving most interest from research.

METHODS AND RESULTS

The present work reports the case of a 26-year-old man, diagnosed with schizophrenia who, after treatment with clozapine at appropriate doses over 12 weeks without observable response, showed a marked and sustained improvement after the addition of risperidone to the clozapine treatment. We also present a detailed review of publications related to the therapeutic combination of clozapine and risperidone in clozapine-resistant schizophrenia.

CONCLUSIONS

Despite the contradictory nature of the published data, our results are in support of other work reporting that treatment with a combination of clozapine and risperidone, apart from being well tolerated, may constitute an effective alternative in this type of patient. Nevertheless, there is a need for further, controlled studies, with larger samples, with a view to drawing definitive conclusions and making specific recommendations.

Risperidone augmentation of clozapine: a critical review

OBJECTIVE

Atypical antipsychotics are frequently used as augmentation agents in clozapine-resistant schizophrenic patients. Risperidone (RIS) is the one most studied as a clozapine (CLZ) adjunct. The aim of this study is to critically review all published studies regarding the efficacy and safety of RIS as an adjunctive agent in CLZ-resistant schizophrenic or schizoaffective patients.

METHODS

A MEDLINE search from January 1988 to June 2005 was conducted. Identified papers were examined against several clinical, pharmacological and methodological parameters.

RESULTS

A total of 15 studies were found (2 randomized controlled trials, 3 open-label trials (OTs) and 8 case-studies (CSs)) comprising 86 schizophrenic or schizoaffective patients (mean age 38.4 years). Mean CLZ dosage during the combined treatment was 474.2 mg/day. Plasma CLZ levels were assessed in 62 patients (72.1%). RIS was added at a mean dosage of 4.6 mg/day for a mean of 7.9 weeks. Significant improvement in psychopathology was reported for 37 patients (43%). A lower RIS dosage and a longer duration of the trial seemed to be associated with a better outcome. Main side effects reported were: extrapyramidal symptoms or akathisia (9.3%), sedation (7%) and hypersalivation (5.8%).

CONCLUSIONS

Existing evidence encourages the use of RIS as an adjunctive agent in CLZ-resistant schizophrenic or schizoaffective patients.

Augmentation strategies of clozapine with antipsychotics in the treatment of ultraresistant schizophrenia

BACKGROUND

Approximately 40% to 70% of neuroleptic-resistant schizophrenic patients are nonresponders to clozapine. Several clozapine augmentation strategies have come into clinical practice although often without evidence-based support. Among these strategies, the combined use of clozapine with another antipsychotic has been reported for up to 35% of patients receiving clozapine.

OBJECTIVE

The purposes of the present work were to (1) review the available literature on the efficacy and safety of the clozapine augmentation with another antipsychotic using a MEDLINE search of the literature from 1978 to December 2005 and (2) to propose an operational definition of schizophrenia refractory to clozapine ("ultraresistant schizophrenia") for the implementation and homogenization of future therapeutic trials.

CONCLUSION

Case controls and open clinical trials largely dominate the literature, and there are only 4 double-blind studies of clozapine augmentation with antipsychotics. The results of these studies are somewhat discrepant. Moreover, the heterogeneity of definitions of resistance to clozapine, of outcome measures and of dose and duration of pharmacological trials is a major limitation for drawing conclusions.

Categorization in compulsive hoarding

Based on hypothesizing about the role of information processing, and in particular, underinclusive categorization in compulsive hoarding, this study examined categorization processes in people with clinically significant compulsive hoarding problems. Twenty-one participants with primary compulsive hoarding, 21 with OCD without hoarding, and 21 non-psychiatric controls completed three categorization tasks. Hoarding and OCD participants reported significantly more distress prior to each of the three tasks than did controls. On tasks sorting common household items, the groups did not differ on the number of piles created nor on the amount of time taken to sort. However, on a task sorting personally relevant items, hoarding participants took more time, created more piles, and reported more anxiety than non-psychiatric controls. Hoarders also took more time than the OCD group, and tended to create more piles. Hoarding severity was correlated with the number of piles created, but only when the objects were personally relevant. Results support under-inclusive categorizing for people with compulsive hoarding, but the effect was largely confined to objects of personal relevance.

Augmentation strategies in clozapine-resistant schizophrenia

The introduction of antipsychotics in the 1950s revolutionised the treatment of schizophrenia, but it soon became apparent that a substantial number of patients demonstrated a suboptimal response to these antipsychotics. Clozapine proved to be beneficial in patients whose symptoms were treatment resistant, but it too had limitations, with as many as 40-70% of those treated with clozapine demonstrating inadequate response to this drug as well. The availability of other 'atypical' antipsychotics offers options, but clozapine appears to remain the most effective option in treatment-resistant schizophrenia. This, of course, raises the question of what to do when clozapine is only partially effective. To address the issue of treatment in patients who have demonstrated a suboptimal response to clozapine, efforts have focused on a variety of augmentation strategies, including numerous medications and electroconvulsive therapy. The current body of evidence consists largely of data from smaller open trials and case series/reports, although data from a limited number of controlled studies are now available. Not surprisingly, the evidence drawn from the former is more supportive of augmentation strategies, although the controlled trials are not without positive findings. The available information is certainly not so overwhelming as to endorse any single augmentation approach. Indeed, it argues for more controlled data and cautions us regarding the cost-benefit ratio in adopting this strategy. Over and above the added adverse effects of another treatment, there is evidence to indicate that actual clinical worsening can occur. Without compelling evidence, clinicians must resort to guiding principles. The potential benefits of augmentation cannot be ruled out, but it should be approached with caution and in a systematic fashion. Factors compromising clozapine response should first be ruled out, and any augmentation trials should be guided by existing evidence and a treatment plan that incorporates a clear understanding of target symptoms. A means of evaluating outcome effectively needs to be in place, and the trial should be circumscribed to prevent needless polypharmacy. A priori, an endpoint needs to be established and the trial discontinued unless results firmly support added benefits.

Antipsychotic polypharmacy: is there evidence for its use?

Antipsychotic polypharmacy occurs frequently in clinical practice; however, there is a lack of controlled clinical studies testing the efficacy of the combinations used. The purpose of this literature review was to examine studies and other reports that have assessed the incremental benefits and deficits of combination antipsychotic therapy versus monotherapy. A PUBMED search covering a 26-year period from 1976 to 2002 was conducted. The search was limited to clinical trials, case series, and reports. Fifty-two reports were identified that systematically assessed the efficacy of combination therapy as opposed to monotherapy: 4 double-blind studies, 13 open-label clinical trials, and 35 case reports. Only one open-label trial and 2 case reports met the design criteria of having trials of each medication and the combination in the same patients and using some type of standardized assessment to evaluate outcome. The most frequent combination was clozapine-risperidone. Of the clinical trials, 75% (3/4) of the double-blind studies and 69% (9/13) of the open-label trials found that combination therapy was effective in reducing symptoms, while 37% (13/35) of case reports documented an overall positive outcome. Currently, the clinical practice of antipsychotic polypharmacy is not evidence-based; however, there is also no evidence against its use. Expanded systematic research to assess this clinical practice is needed.

The paradox of quetiapine in obsessive-compulsive disorder

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.

Case Studies of Adjunctive Agents in Clozapine-Resistant Schizophrenic Patients

Approximately 40%-70% of neuroleptic-resistant schizophrenic patients are nonresponders even to clozapine. Several clozapine augmentation strategies have come into clinical practice, although often without evidence-based support. This study aims to critically review all the reported case studies regarding the efficacy and safety of adjunctive agents in clozapine-resistant schizophrenic or schizoaffective patients. All published case studies examining the efficacy and safety of adjunctive agents in clozapine-resistant schizophrenic patients were searched for in the MEDLINE database from January 1980 to February 2004. Case studies regarding ECT as a clozapine augmentation strategy were not included in our study. All the included papers were critically reviewed and examined against a set of clinical and pharmacological parameters, outcome measures, and reported side effects. Fifteen case studies regarding the efficacy and safety of sulpiride, risperidone, olanzapine, lithium, lamotrigine, fluvoxamine, and bromocriptine as clozapine adjuncts were found. A total of 33 schizophrenic or schizoaffective patients were included. Of the 15 studies, 8 were associated with risperidone. The duration and dosage of previous clozapine monotherapy was adequate for 16 patients. Plasma clozapine level was assessed for only 7 patients. Outcome measures were used for only 11 patients. The outcome was positive in 13 studies. Combined treatments were generally well tolerated, and side effects never resulted in discontinuation of treatment. Most case studies favor the use of risperidone as an adjunctive agent in clozapine-resistant schizophrenic or schizoaffective patients. However, small numbers of patients and other methodological shortcomings limit the impact of evidence provided.

Combination of "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder

BACKGROUND

This article reviews the published clinical data on treatment-resistant schizophrenic and schizoaffective patients managed with combinations of "atypical" antipsychotic medication.

METHOD

A computerized MEDLINE literature search covering an 18-year period (1985-2003) was conducted. All pertinent papers on the subject of the use of combination "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder were obtained with subsequent analysis and discussion of the retrieved data.

RESULTS

The search identified 29 case reports and case series reports (172 patients) and one double-blind placebo-controlled trial (28 patients) describing the use of combination "atypical" antipsychotic medication (clozapine-risperidone; clozapine-sulpiride; clozapine-olanzapine; clozapine-quetiapine; olanzapine-sulpiride; olanzapine-quetiapine; risperidone-olanzapine; risperidone-quetiapine) in the treatment of resistant schizophrenic and schizoaffective patients. An overview of results suggests that the combinations were beneficial in the described patients with reduction of positive symptoms and occasionally negative symptoms. Significant adverse effects, while rare, were reported in a few cases and did not appear to different in nature from those managed on monotherapeutic regimens.

CONCLUSION

Combinations of "atypical" antipsychotic medications are well tolerated and may be effective in the management of treatment refractory schizophrenia and schizoaffective disorder. However, further double-blind placebo-controlled trials are required in order to test and confirm these observations.

Antipsychotic combination therapy in schizophrenia. A review of efficacy and risks of current combinations

OBJECTIVE

To review the literature on efficacy and risks of combining antipsychotics (atypical with atypical or conventional) and suggest a rationale and strategies for future clinical trials.

METHOD

A computerized Medline search supplemented by an examination of cross-references and reviews was performed.

RESULTS

Empirical evidence for the efficacy of combining antipsychotics is too limited to draw firm conclusions. The practice of augmenting clozapine with more 'tightly bound' D2 receptor antagonists as exemplified by risperidone augmentation of clozapine has some empirical and theoretical support. The risks of augmentation strategies have not been studied systematically. No study has examined the economic impact of combination treatment.

CONCLUSION

Further trials of antipsychotic combination therapies are needed before this currently unsupported practice can be recommended. Rationales for combination treatment include a broadening of the range of receptor activity or an increase in D2 receptor occupancy with certain atypical agents. Trial methodology needs to take into account subject characteristics, duration of treatment, optimization of monotherapy comparators, and appropriate outcome measures.

Intervention in compulsive hoarding. A case study

Historically, the compulsive hoarding of possessions has been examined in the context of other obsessive-compulsive disorders. More recently, researchers have begun to explore compulsive hoarding as a separate and distinct syndrome. The cognitive behavioral model proposed by Frost and Hartl suggests that deficits in information processing, emotional attachment problems, behavioral avoidance, and beliefs about the nature of possessions are important components in understanding compulsive hoarding. This article presents a case study of a successful intervention with a compulsive hoarder that addresses each of the components proposed in the model. Implications for future interventions are discussed.

Combined use of risperidone and olanzapine in the treatment of patients with resistant schizophrenia: a preliminary case series report

Polypharmacy, or the use of multiple drugs in the therapy of psychiatric disorders, is not recommended. However, appropriate combinations of pharmacologic mechanisms may enhance the efficacy of antipsychotic drugs and alter the course of schizophrenia. In recent years, some articles have been published about the successful use of clozapine and risperidone in combination for the treatment of patients with resistant schizophrenic and schizoaffective disorders. However, safety of this drug combination is open to discussion. This report presents the results of a preliminary study of five patients with resistant schizophrenia successfully treated with risperidone-olanzapine combination. The results suggest that this combination may be useful. In the future, the efficacy of risperidone-olanzapine combination should be confirmed in larger study populations before its clinical application is considered.

Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study

The present case study describes a cognitive-behavioral intervention directed at helping a 53 year old female suffering from compulsive hoarding decrease clutter and improve decision-making and sorting techniques. The intervention focused on decision-making training, exposure and response prevention, and cognitive restructuring. Ratios of cluttered space to overall space were calculated for floor and furniture tops for each of five rooms over a period of 17 months. Clutter decreased substantially in each of the rooms targeted for intervention, while clutter ratios remained stable for a room used as a baseline control (no intervention). In addition, D.'s scores on self-report measures of obsessive-compulsive symptomatology decreased after 9 months of intervention suggesting that the treatment protocol affected symptoms of hoarding distress, as well as clutter. Despite previously reported difficulties in the treatment of compulsive hoarding, our results provide preliminary evidence that a cognitive-behavioral intervention can be successful in reducing hoarding symptoms. Suggestions for future research include streamlining the treatment program and testing its efficacy on large clinical samples.