An exploration of neural predictors of treatment compliance in cognitive-behavioral group therapy for hoarding disorder.

A persistent and influential barrier to effective cognitive-behavioral therapy (CBT) for patients with hoarding disorder (HD) is treatment retention and compliance. Recent research has suggested that HD patients have abnormal brain activity identified by functional magnetic resonance (fMRI) in regions often engaged for executive functioning (e.g., right superior frontal gyrus, anterior insula, and anterior cingulate), which raises questions about whether these abnormalities could relate to patients' ability to attend, understand, and engage in HD treatment. We examined data from 74 HD-diagnosed adults who completed fMRI-measured brain activity during a discarding task designed to elicit symptom-related brain dysfunction, exploring which regions' activity might predict treatment compliance variables, including treatment engagement (within-session compliance), homework completion (between-session compliance), and treatment attendance. Brain activity that was significantly related to within- and between-session compliance was found largely in insula, parietal, and premotor areas. No brain regions were associated with treatment attendance. The results add to findings from prior research that have found prefrontal, cingulate, and insula activity abnormalities in HD by suggesting that some aspects of HD brain dysfunction might play a role in preventing the engagement needed for therapeutic benefit.

Written Imaginal Exposure for Hoarding Disorder: A Preliminary Pilot Study.

ABSTRACT: Hoarding disorder (HD) is marked by difficulty discarding possessions. Many refuse treatment or drop out, which may be due to treatment's incorporation of in-home decluttering, which is feared and avoided. Thus, strategies to prepare patients for decluttering/discarding are needed. Imaginal exposure (IE), or imagining one's worst fears about discarding, could be one such strategy. This pilot preliminarily tested a short-duration IE intervention compared with a control intervention. Over 3 days, adults diagnosed with HD (n = 32) were randomly assigned to either write about and imagine their worst fears about discarding (IE condition) or a neutral topic (control writing [CW] condition). The IE condition showed significant improvements in HD symptoms from preintervention to 1-week follow-up, with medium to large effects; however, the CW condition did as well. Comparing change scores between conditions, the IE condition's improvements were not significantly different than the CW condition's. Overall, IE was helpful in improving HD symptoms, but this pilot did not indicate that it was more helpful than CW. This raises important questions about possible demand characteristics, placebo effects, or regression to the mean, and it has implications for the design and methodology of other studies assessing IE's utility.

Rates of diagnosis and service utilization in veterans with hoarding disorder.

Hoarding Disorder (HD) is a prominent and disabling neuropsychiatric condition defined by the inability to discard objects resulting in impairing levels of clutter. The prevalence rate is 2-6 % and increases with age. The aging Veteran population is a high risk group for impairment associated with HD. Medical and psychiatric comorbidities as well as associated rates of disability and poor quality of life are very common in both HD and the related disorder of OCD. We examined rates of HD and OCD diagnoses at the VA San Diego Healthcare System. Data were obtained from medical records for all Veterans with these diagnoses over 8-years and included information on medical and psychiatric care, homelessness services, and Care Assessment Needs (CAN) scores. Rates of diagnosis for both HD and OCD were well below epidemiological estimates. Veterans with HD were older, had higher rates of medical hospital admissions with longer stays; had more cardiac, neurological, and acquired medical conditions; had more psychiatric comorbidities; had more interactions with the suicide prevent team and homelessness services; and had higher CAN scores than Veterans with OCD. The low rate of diagnosis and high services utilization of Veterans with HD demonstrates an area of unmet need.

One Health approach for Brucella canis: Serological and molecular detection in animal-hoarding individuals and their dogs.

Animal hoarding disorder (AHD) is classified as a psychiatric obsessive-compulsive condition characterized by animal accumulation and often accompanied by unsanitary conditions and animal cruelty. Although AHD may increase pathogen transmission and spread, particularly for zoonotic diseases, human and dog exposure in such cases has yet to be fully established. Accordingly, this study aimed to assess Brucella canis in 19 individuals with AHD (11 households) and their 264 dogs (21 households) in Curitiba, the eighth largest city in Brazil, with approximately 1.8 million habitants. Anti-B. canis antibodies were detected by the 2-mercaptoethanol microplate agglutination test (2ME-MAT) and by a commercial lateral flow immunoassay (LFIA), while molecular detection of previously positive seropositive samples was performed by conventional PCR. Although all the human samples were 2ME-MAT negative, 12/264 (4.5%, 95% Confidence Interval: 2.0-7.0%) dog samples were 2ME-MAT and LFIA positive, with 2ME-MAT titers ranging from 20 to 640. At least one dog in 4/21 (19.0%, 95% CI: 2.0-46.0%) households was seropositive. Despite the absence of seropositivity in individuals with AHD and the comparatively low seroprevalence in dogs, B. canis circulation and outbreaks should be considered in such human populations due to the high burden and recurrent character of B. canis exposure in high-density dog populations and the constant introduction of susceptible animals.

Preliminary investigation of objective and subjective experiences of relatives of individuals with hoarding behaviors.

OBJECTIVE: Families of individuals with hoarding symptoms report substantial burden; however, there has been no investigation of potential positive experiences. The objective of this study was to examine the experiences reported by individuals with a relative with elevated hoarding symptoms using a cross-sectional design. The current investigation expands on the literature in this area by incorporating a detailed interview of experiences in conjunction with validated measures of hoarding symptomology. METHODS: Twenty-nine adults with relatives with elevated hoarding symptoms completed self-report measures of hoarding severity for themselves and their relative and a clinician-administered assessment of their experiences with their family member with hoarding symptoms. RESULTS: Participants endorsed significant burden across a range of areas, including permanent changes in their daily routine. The majority (93%) of participants reported at least one positive experience, with 69% endorsing companionship as a benefit of the relationship. Greater symptom severity of the relative with hoarding symptoms was associated with greater subjective burden and decreased positive experiences. CONCLUSION: Our results add further evidence to the potential for interpersonal psychotherapy to lead to a reduction in hoarding symptomology.

Hoarding Symptoms in Late Life Depression are Associated With Greater Executive Dysfunction and Disability and Poorer Response to Depression Treatment.

OBJECTIVES: Late life depression (LLD) and hoarding disorder (HD) are common in older adults and characterized by executive dysfunction and disability. We aimed to determine the frequency of co-occurring HD in LLD and examine hoarding severity as an additional contributor to executive dysfunction, disability, and response to psychotherapy for LLD. DESIGN: Cross-sectional. SETTING: Outpatient psychiatry program. PARTICIPANTS: Eighty-three community-dwelling adults ages 65-90 with LLD. INTERVENTION: Problem-solving therapy. MEASUREMENTS: Measures of executive function, disability, depression, and hoarding severity were completed at post-treatment. Pearson's chi-squared tests evaluated group differences in rates of cognitive impairment, disability, and depression treatment response between participants with HD (LLD+HD) and LLD only. Separate linear regressions assessed associations between hoarding severity and executive function, disability, and psychotherapy response. Covariates included age, education, gender, and depression severity. RESULTS: 30.1% (25/83) of LLD participants met HD criteria. Relative to LLD, LLD+HD participants demonstrated greater impairment rates on measures of executive function (Letter-Number-Sequencing, X2(1)=4.0, p = 0.045; Stroop-Interference, X2(1) = 4.8, p = 0.028). Greater hoarding severity was associated with poorer executive functioning performance (Letter-Number-Sequencing (t[70] = -2.1, ß = -0.05, p = 0.044), Digit-Span (t[71] = -2.4, ß = -0.07, p = 0.019), Letter-Fluency (t[ 71] = -2.8, ß = -0.24, p = 0.006)). Rates of disability were significantly higher for LLD+HD (88.0%) than LLD (62.3%), (X2[1] = 5.41, p = 0.020) and higher hoarding severity was related to greater disability (t[72] = 2.97, ß = 0.13, p = 0.004). Depression treatment response rates were significantly lower for LLD+HD (24.0%) compared to LLD (48.3%), X2(1) = 4.26, p = 0.039, and HD status predicted psychotherapy response, t(67) = -2.15, ß = -15.6, p = 0.035. CONCLUSIONS: We found 30.1% co-occurrence of HD in LLD, which was accompanied by greater executive dysfunction, disability, and poorer response to depression treatment. Results underscore the need for increased screening of hoarding behaviors in LLD and tailored interventions for this LLD+HD group.

Relationship of Hoarding and Depression Symptoms in Older Adults.

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

Hard to let it go: repetitive negative thinking and hoarding in later life in Japan.

Objectives: Hoarding in older adults can have a detrimental effect on daily life. Repetitive negative thinking (RNT) could result in a greater avoidance of discarding and increased saving behaviors; yet, the unique role of RNT on hoarding in older adults remains understudied. This study aimed to investigate whether the intensity of RNT contributes to hoarding in older adults. Methods: Two hundred and sixty-four older adults in Japan (ages 65-86 years, 132 males and 132 females) participated in an online survey. Hierarchical regression analyses were conducted to examine whether RNT could significantly explain the variance of hoarding after controlling for age, sex, years of education, self-reported cognitive impairment, and depression. Results: As we expected, RNT was significantly associated with greater hoarding behaviors, such as excessive acquisition (ß = .27, p = .005) and difficulty in discarding (ß = .27, p = .003). On the other hand, reflection, repetitive thinking without negative emotional valence, was significantly associated with higher scores on clutter (ß = .36 p < .001). Conclusion: Our findings highlight the importance of addressing RNT in the prevention and treatment of hoarding symptoms among older adults, potentially leading to more effective interventions and improved outcomes in managing hoarding behaviors in this population.

Augmenting group hoarding disorder treatment with virtual reality discarding: A pilot study in older adults.

Hoarding disorder is common and debilitating, especially in older adults, and novel treatment approaches are needed. Many current treatments emphasize skills related to discarding and decision-making about possessions, which can be practiced in the patient's home. However in many cases, in-home visits are unfeasible, or real-life discarding is too difficult. Virtual reality (VR) offers the ability to create a virtual "home" including 3D scans of the patient's actual possessions that can be moved or discarded. VR discarding is an alternative to in-home visits and an approach that provides a stepping stone to real-life discarding. VR has been successfully utilized to treat many disorders but tested minimally in hoarding disorder. In nine older adults with hoarding disorder, we tested an 8-week VR intervention administered to augment a 16-week Buried in Treasures group treatment. Individualized VR rooms were uniquely modeled after each patient's home. During clinician-administered VR sessions, patients practiced sorting and discarding their virtual possessions. The intervention was feasible to administer. Open-ended participant responses, examined by two independent evaluators, indicated that VR sessions were well-tolerated and that participants found them useful, with nearly all participants noting that VR helped them increase real-life discarding. Self-reported hoarding symptoms decreased from baseline to close, with seven of the nine participants showing reliable improvement in this timeframe and none showing deterioration. Results from this exploratory pilot study suggest that VR is a feasible way to simulate an at-home sorting and discarding experience in a manner that may augment skills acquisition. It remains an open question whether VR discarding practice yields greater improvement than existing treatments. VR for this population merits further clinical investigation.

Study protocol for a randomized controlled trial of in-home decluttering augmentation of group cognitive-behavioral therapy for hoarding disorder: the Joining Forces Trial.

BACKGROUND: Cognitive behavioral therapy (CBT) is a moderately efficacious treatment for hoarding disorder (HD), with most individuals remaining symptomatic after treatment. The Joining Forces Trial will evaluate whether 10 weeks of in-home decluttering can significantly augment the outcomes of group CBT. METHODS: A randomized controlled trial of in-home decluttering augmentation of group CBT for HD. Adult participants with HD (N = 90) will receive 12 weeks of protocol-based group CBT for HD. After group CBT, participants will be randomized to either 10 weeks of in-home decluttering led by a social services team or a waitlist. The primary endpoint is 10 weeks post-randomization. The primary outcome measures are the self-reported Saving Inventory-Revised and the blind assessor-rated Clutter Image Rating. Participants on the waitlist will cross over to receive the in-home decluttering intervention after the primary endpoint. Data will be analyzed according to intention-to-treat principles. We will also evaluate the cost-effectiveness of this intervention from both healthcare and societal perspectives. DISCUSSION: HD is challenging to treat with conventional psychological treatments. We hypothesize that in-home decluttering sessions carried out by personnel in social services will be an efficacious and cost-effective augmentation strategy of group CBT for HD. Recruitment started in January 2021, and the final participant is expected to reach the primary endpoint in December 2024. TRAIL REGISTRATION: ClinicalTrials.gov NCT04712474. Registered on 15 January 2021.

Hair pulling disorder and skin picking disorder have relatively limited associations with negative emotionality: A meta-analytic comparison across obsessive-compulsive and related disorders.

The obsessive-compulsive and related disorders (OCRD) chapter in DSM-5 includes two relatively distinct groups of disorders: (1) Compulsive disorders [i.e., obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder (HD)] and (2) grooming disorders [i.e., skin picking disorder (SPD) and hair pulling disorder (HPD)]. The two groups may relate differently with negative emotionality; however, the literature has produced mixed findings. The current study sought to quantify the concurrent association between negative emotionality and each of the five OCRDs. We conducted systematic reviews of research reporting correlations between (1) negative emotionality (i.e., depression, anxiety, stress, negative affect, and neuroticism) and (2) severity of OCRD symptoms in both clinical and non-clinical adult samples. We used three-level meta-analytic models to estimate the size of the correlations. Negative emotionality had robust positive correlation with symptoms of OCD [k = 156, r = 0.44, 95% CI= 0.43-0.46], BDD [k = 58, r = 0.45, 95% CI= 0.43-48], and HD [k = 67, r = 0.39, 95% CI= 0.36-0.42] but significantly smaller correlation with SPD [k = 31, r = 0.31, 95% CI= 0.27-0.34] and HPD [k = 24, r = 0.28, 95% CI= 0.25-0.32]. Overall, the results indicate that grooming disorders have relatively limited associations with negative emotionality. Implications for classification of OCRDs within the broader taxonomy of psychopathology are discussed.

When radical uncertainty is too much: Clinical aspects of Conviction Narrative Theory.

We propose extrapolating Conviction Narrative Theory (CNT) to clinical psychology and psychiatry. We demonstrate how CNT principles may benefit assessment, therapy, and possibly even modify public health views of neuropsychiatric disorders. Our commentary focuses on hoarding disorder as a model, elaborates on discrepancies in the scientific literature and suggests how the CNT may resolve them.

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.

Changes in neural activity following a randomized trial of cognitive behavioral therapy for hoarding disorder.

OBJECTIVE: Cognitive behavioral therapy (CBT) is efficacious for hoarding disorder (HD), though results are modest. HD patients show an increase in activity in the dorsal anterior cingulate cortex (dACC) when making decisions. The aim of this study is to determine whether CBT's benefits follow improvements in dACC dysfunction or abnormalities previously identified in other brain regions. METHOD: In this randomized clinical trial of 64 treatment-seeking HD patients, patients received group CBT, delivered weekly for 16 weeks, versus wait list. Functional magnetic resonance imaging was used to examine neural activity during simulated decisions about whether to acquire and discard objects. RESULTS: During acquiring decisions, activity decreased in several regions, including right dorsolateral prefrontal, right anterior intraparietal area, both right and left medial intraparietal areas, left and right amygdala, and left accumbens. During discarding decisions, activity decreased in right and left dorsolateral prefrontal, right and left rostral cingulate, left anterior ventral insular cortex, and right medial intraparietal areas. None of the a priori brain parcels of interest significantly mediated symptom reduction. Moderation effects were found for left rostral cingulate, right and left caudal cingulate, and left medial intraparietal parcels. CONCLUSIONS: Therapeutic benefits of CBT for HD do not appear to be mediated by changes in dACC activation. However, pretreatment dACC activation predicts outcome. Findings suggest the need to re-evaluate emerging neurobiological models of HD and our understanding of how CBT affects the brain in HD, and perhaps shift focuses to new neural target discovery and target engagement trials. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Situational, emotional, and individual dispositions to weight gain in people with hoarding problems.

OBJECTIVES: Individuals with hoarding disorder are more likely to be overweight or obese than the general population for unknown reasons. METHODS: One hundred and twenty-nine individuals (Hoarding Group: n = 63; Control Group: n = 66) completed self-report measures and were offered snacks in a tidy and a cluttered environment in a counterbalanced order. Groups were based on the self-reporting of high or low hoarding symptoms. RESULTS: The hoarding group reported being less able to use their kitchen and prepare food at home and experiencing more impulsivity, distress intolerance and problematic eating beliefs than did the control group. The hoarding group consumed more cookies in the tidy room, whereas the control group consumed more cookies in the cluttered room. Greater impulsivity, distress intolerance and problematic body and eating beliefs were related to greater cookie consumption for the hoarding group. CONCLUSIONS: Early interventions that help individuals to tolerate distress and to engage in goal-directed behaviour regardless of their emotional state may have benefits for both hoarding and eating behaviour. We encourage future researchers to examine this hypothesis.

"In an ideal world that would be a multiagency service because you need everybody's expertise." Managing hoarding disorder: A qualitative investigation of existing procedures and practices.

Hoarding disorder is characterised by the acquisition of, and failure to discard large numbers of items regardless of their actual value, a perceived need to save the items and distress associated with discarding them, significant clutter in living spaces that render the activities associated with those spaces very difficult causing significant distress or impairment in functioning. To aid development of an intervention for hoarding disorder we aimed to identify current practice by investigating key stakeholders existing practice regarding identification, assessment and intervention associated with people with hoarding disorder. Two focus groups with a purposive sample of 17 (eight male, nine female) stakeholders representing a range of services from housing, health, and social care were audio recorded, transcribed verbatim and analysed thematically. There was a lack of consensus regarding how hoarding disorder was understood and of the number of cases of hoarding disorder however all stakeholders agreed hoarding disorder appeared to be increasing. The clutter image rating scale was most used to identify people who needed help for hoarding disorder, in addition to other assessments relevant to the stakeholder. People with hoarding disorder were commonly identified in social housing where regular access to property was required. Stakeholders reported that symptoms of hoarding disorder were often tackled by enforced cleaning, eviction, or other legal action however these approaches were extremely traumatic for the person with hoarding disorder and failed to address the root cause of the disorder. While stakeholders reported there was no established services or treatment pathways specifically for people with hoarding disorder, stakeholders were unanimous in their support for a multi-agency approach. The absence of an established multiagency service that would offer an appropriate and effective pathway when working with a hoarding disorder presentation led stakeholders to work together to suggest a psychology led multiagency model for people who present with hoarding disorder. There is currently a need to examine the acceptability of such a model.

The experience of leaving a valuable object: An investigation of emotional processes related to Hoarding disorder features.

One of the core features of hoarding is a significant resistance to discarding objects, which is fueled by dysfunctional beliefs and unwarranted negative emotions that hoarders tend to feel when disposing of their possessions. To our knowledge, longitudinal studies investigating the psychological effects that people who hoard experience after separating from their valuable possessions have yet to be conducted. Our study's principal aim was to explore psychological processes that individuals with high hoarding features (n = 53; 49.1%) and individuals with low hoarding features (n = 55; 50.9%) experienced when they had to separate from a valuable possession. To do this, we evaluated participants' thoughts and feelings at several time points after they had to leave a valuable object at the University laboratory (evaluations were specifically conducted at baseline, during the week, and at the end of the week). To investigate hoarding and anxiety, as well as depressive, obsessive-compulsive, and emotional processes-related features, a mixed-method approach was employed involving self-report questionnaires, ad hoc surveys, and a daily self-monitoring schedule. Our findings showed that compared to participants with low hoarding features, participants with high hoarding traits: 1) scored higher for anxiety sensitivity, distress tolerance, and emotional dysregulation; 2) reported having more negative emotions when leaving their object; 3) had more intrusive object-related beliefs; and 4) experienced a higher frequency of negative emotions as well as a higher level of distress during the week. Both groups experienced more negative emotions in the first part of the week, which decreased as the time at which participants could receive their object back drew closer. Finally, dysfunctional beliefs about leaving a personal object (Saving Cognitions Inventory), sensitivity to anxiety (Anxiety Sensitivity Index-3), and distress tolerance (Distress Tolerance Scale) contributed to the level of discomfort that participants with higher hoarding scores reported when they had to leave their possession. These results highlight the relevance of emotional processes in the hoarding disorder framework as well as underscore the importance of assessing and treating them in clinical settings.

Psychological mechanism of acceptance and commitment therapy and rational emotive behavior therapy for treating hoarding: Evidence from randomized controlled trials.

Hoarding is a common problem behavior worldwide and is detrimental to the physical and mental health of individuals and groups. Currently, effective interventions for hoarding are cognitive-behavioral therapies, but their post-intervention efficacy is questionable, and the available research does not examine the mediating variables of the effects of interventions on clinical outcomes. Moreover, current research on hoarding has focused on Western countries. Therefore, there is a need to investigate the efficacy of other forms of cognitive behavioral therapy on hoarding as well as other psychological outcomes related to hoarding and mediating variables that contribute to its effectiveness in different cultural contexts. One hundred thirty-nine college students with higher hoarding behaviors were randomly divided into three groups: 45 in the Acceptance and Commitment Therapy (ACT) group, 47 in the Rational Emotive Behavior Therapy (REBT) group, and 47 in the control group. They completed the Saving Inventory-Revised (SI-R), Obsessive-Compulsive Symptom Scale (OCSS), Difficulties in Emotion Regulation Scale (DERS), Experiences in Close Relationships Inventory-Attachment Anxiety Subscale (ECR), Depression Anxiety Stress Scales (DASS-21), Acceptance and Action Questionnaire II (AAQ-II), and Cognitive Fusion Questionnaire (CFQ) before and immediately after the intervention. The results showed that ACT and REBT improved individuals' psychological flexibility, cognitive fusion, acquisition-difficulty discarding, clutter, negative affect (anxiety, depression, stress), attachment anxiety, obsessive-compulsive disorder, and difficulty in emotion regulation compared to the control group. In addition, ACT was more effective than REBT in improving psychological flexibility and reducing hoarding, cognitive fusion, depression, stress, and obsessive-compulsive disorder; there were no significant differences between the two in anxiety and emotion regulation difficulties. Furthermore, psychological flexibility is a mediator of the effect of ACT and REBT on some behavioral and psychological outcomes (hoarding, negative affect, attachment anxiety). Limitations were discussed.