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.

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.

Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial.

Background: Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD. Methods: In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions. Results: The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue. Conclusions: Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.

The Relationship Between Loneliness and Positive Affect in Older Adults.

OBJECTIVE: To establish whether positive affect (PA) is uniquely associated with loneliness and other social functioning variables beyond negative affect (NA) among older adults. METHODS: Four hundred and twenty-eight participants (aged 60+ years old, 82% White, and 48% female) were recruited using random digit-dialing and completed scales for loneliness (UCLA Loneliness Scale), companionship (PROMIS scale), satisfaction with discretionary social activities (PROMIS scale), PA (Center for Epidemiologic Studies [CES] Happiness Scale), and NA (CES-Depression scale and Brief Symptom Inventory-Anxiety Subscale). RESULTS: Multiple linear regression models found PA to be a significant predictor of lower loneliness where the effect of PA on loneliness is dependent on the level of NA; a large effect size at the mean level of NA, which becomes attenuated when NA increases. Although the direction of effect of PA on loneliness will change for NA > 5.10, which is 5 standard deviations away from 0, based on the model estimates, the percent of subjects with this large NA levels is practically 0. Thus, higher PA is associated with lower loneliness, however this effect is attenuated for larger NA. Similarly, multiple linear regression models found that companionship was associated with PA and NA where the effect of PA is dependent on the level of NA; a medium effect size at the mean level of NA, which becomes attenuated when NA increases. As in the case of loneliness, the direction of effect of PA on companionship will change for NA > 3.52, which is 3.5 standard deviation away from 0, based on the model estimates, but the percent of subjects with this large NA levels is practically 0. Thus, higher PA is associated with increased companionship, aand this effect is attenuated with greater NA. Satisfaction with social activities was associated with PA only (medium effect size). CONCLUSION: Results suggest PA appears to be uniquely associated with social functioning among older adults. These findings support the potential for treatments that target PA to decrease loneliness among older adults, or vice versa.

Implementation and evaluation of a community-based treatment for late-life hoarding.

OBJECTIVES: The objective of this paper was to examine the implementation and effectiveness of a community-based intervention for hoarding disorder (HD) using Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST). DESIGN: This was a mixed-method, pre-post quasi-experimental study informed by the Practical, Robust Implementation and Sustainability Model for implementation science. SETTING: Program activities took place in San Diego County, mainly within clients' homes or community, with some activities in-office. PARTICIPANTS: Participants were aged 60 years or older, met eligibility for Medi-Cal or were uninsured, and met criteria for HD. INTERVENTION: A manualized, mobile protocol that incorporated CREST was utilized. MEASUREMENTS: The Clutter Image Rating and Hoarding Rating Scale were used as effectiveness outcomes. An investigator-created staff questionnaire was used to evaluate implementation. RESULTS: Thirty-seven clients were reached and enrolled in treatment and 15 completed treatment during the initial 2 years of the program. There were significant changes in hoarding severity and clutter volume. Based on the initial 2 years of the program, funding was provided for expansion to cover additional San Diego County regions and hire more staff clinicians in year three. CONCLUSION: Preliminary data suggest that the CREST intervention can be successfully implemented in a community setting with positive results for older adults with HD.

Object attachment as we grow older.

Extreme object attachment in adults can form as a way to compensate for a lack of interpersonal attachment or as a symptom of hoarding disorder; however, normative levels of object attachment also exist across the lifespan. Although the importance of secure interpersonal attachment as a protective factor for older adults has been well established, research into object attachment in older adults is still a nascent field. As individuals age, they inevitably experience a series of cognitive, emotional, and physical changes that may influence their attachment to objects. Life events may impact the way that we view our possessions, particularly over time. Given individual differences, multiple pathways may affect normative object attachment as we age.

The Association between Age and Experienced Emotions in Hoarding Disorder.

Objectives: Hoarding disorder (HD) is conceptualized as a fear-based disorder and exposure to sorting/discarding possessions is a core part of treatment. However, there has been no investigation of age-related differences in emotional reaction to sorting. The objective of this study was to explore the association between age and affective response during a sorting task.Methods: Forty-nine adults with HD completed a standardized sorting task. Participants reported their current emotion before and after the sorting task and reported their subjective distress throughout the task.Results: Older participants reported significantly lower distress ratings. Only 43% of participants reported fear prior to the task and 22% reported fear after the task. The probability of reporting fear before and after the task decreased significantly with age.Conclusions: Fear may not be the emotion experienced when discarding items, particularly for older adults with HD. Future work should focus on mechanisms of action in HD treatment.Clinical Implications: Clinicians should not assume fear or anxiety to be the primary emotional response in older adults with HD when engaged in an exposure to sorting/discarding. Older hoarding patients with a more fear-oriented aversion to sorting possessions may require a treatment emphasis on increasing the percentage of items discarded.

The Association Between Sleep and Late Life Hoarding.

Sleep problems are associated with many different forms of psychopathology in late life; however, there is currently a gap in the literature on the association between sleep quality and hoarding in older adults. This secondary data analysis of 40 older adults with hoarding disorder examined the association between sleep and hoarding, change in sleep disturbance following treatment, and the impact of sleep on treatment response. Sleep disturbance was correlated with hoarding severity, and this association remained significant when controlling for inability to sleep in a bed due to clutter in a multiple regression analysis. Following treatment, there was no change in sleep disturbance using a paired t-test, and baseline sleep disturbance was not correlated with change in hoarding severity. Future studies on the potential impact of sleep disturbance on hoarding treatment in older adults should examine if targeting sleep issues adjunctively could lead to improved sleep and improved treatment adherence/efficacy.

Personality traits in adults with hoarding disorder.

BACKGROUND: Prior research has demonstrated a link between compulsive hoarding symptoms and personality traits; however, no studies have investigated the link between hoarding and personality traits utilizing a sample of individuals diagnosed with hoarding disorder (HD) using formal diagnostic criteria. The aim of the current study was to evaluate the frequency and type of personality traits in adults diagnosed with HD and to explore the associations among hoarding severity and personality disorder traits within this sample. METHODS: Seventy-two veterans enrolled in an ongoing treatment trial for HD completed a battery of self-report measures during their initial assessment. Linear regression analyses were used to determine the unique variance accounted for by hoarding severity in predicting scores on the personality disorder scales from the Millon Clinical Multiaxial Inventory-III (MCMI-III). RESULTS: The majority of participants had an elevated score on at least one of the MCMI-III Personality scales. The most frequently elevated scores were for the Avoidant, Dependent, Depressive, and Schizoid scales. Hoarding severity was a significant predictor of personality traits in 10 out of 14 MCMI-III scales. LIMITATIONS: Given the exploratory nature of the investigation, we did not control for multiple comparisons or the presence of mood or anxiety disorders. CONCLUSIONS: The elevated prevalence of co-occurring personality pathology in adults with HD indicates the importance of considering underlying personality structure when developing individualized treatment plans.

Cognitive Rehabilitation and Exposure/Sorting Therapy for Late-Life Hoarding: Effects on Neuropsychological Performance.

OBJECTIVES: Hoarding disorder (HD) is characterized by urges to save items, difficulty discarding possessions, and excessive clutter and has been associated with executive functioning deficits. A randomized controlled trial comparing Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) with a care management control condition demonstrated the efficacy of CREST in reducing hoarding symptoms in older adults. The purpose of the current study was to assess whether CREST may also lead to improved executive functioning. METHOD: All participants were administered a neurocognitive battery at baseline and posttreatment. Linear mixed models with random intercepts were used to evaluate change in global neuropsychological functioning as well as change in individual executive functioning variables. RESULTS: There was no significant group by time interaction for the Global Deficit score; however, there were significant group by time interactions on two of the executive functioning variables examined, such that participants in the CREST condition demonstrated significant improvement in cognitive flexibility and inhibition over time compared with the participants in the care management condition. DISCUSSION: Our initial findings support the notion that CREST may be able to improve task switching, an important component of executive functioning, in older adults with HD.

Efficacy and safety of pharmacotherapies for smoking cessation in anxiety disorders: Subgroup analysis of the randomized, active- and placebo-controlled EAGLES trial.

BACKGROUND: Smoking rates are high in adults with anxiety disorders (ADs), yet little is known about the safety and efficacy of smoking-cessation pharmacotherapies in this group. METHODS: Post hoc analyses in 712 smokers with AD (posttraumatic stress disorder [PTSD], n = 192; generalized anxiety disorder [GAD], n = 243; panic disorder [PD], n = 277) and in a nonpsychiatric cohort (NPC; n = 4,028). Participants were randomly assigned to varenicline, bupropion, nicotine-replacement therapy (NRT), or placebo plus weekly smoking-cessation counseling for 12 weeks, with 12 weeks follow-up. General linear models were used to test the effects of treatment group, cohort, and their interaction on neuropsychiatric adverse events (NPSAEs), and continuous abstinence weeks 9-12 (treatment) and 9-24 (follow-up). RESULTS: NPSAE incidence for PTSD (6.9%), GAD (5.4%), and PD (6.2%) was higher versus NPC (2.1%), regardless of treatment. Across all treatments, smokers with PTSD (odds ratio [OR] = 0.58), GAD (OR = 0.72), and PD (OR = 0.53) had lower continuous abstinence rates weeks 9-12 (CAR9-12) versus NPC. Varenicline demonstrated superior efficacy to placebo in smokers with GAD and PD, respectively (OR = 4.53; 95% confidence interval [CI] = 1.20-17.10; and OR = 8.49; 95% CI = 1.57-45.78); NRT was superior to placebo in smokers with PD (OR = 7.42; 95% CI = 1.37-40.35). While there was no statistically significant effect of any treatment on CAR9-12 for smokers with PTSD, varenicline improved 7-day point prevalence abstinence at end of treatment in this subcohort. CONCLUSION: Individuals with ADs were more likely than those without psychiatric illness to experience moderate to severe NPSAEs during smoking-cessation attempts, regardless of treatment. While the study was not powered to evaluate abstinence outcomes with these subgroups of smokers with ADs, varenicline provided significant benefit for cessation in those with GAD and PD, while NRT provided significant benefit for those with PD.

Recent Advances in Research on Hoarding.

PURPOSE OF REVIEW: The purpose of the following paper is to review recent literature trends and findings in hoarding disorder (HD). Our goal is to highlight recent research on etiology, associated features, and empirically based treatments. RECENT FINDINGS: Recent literature has added support for cognitive differences as a risk factor for HD; however, there is evidence that individuals with HD may overestimate their level of cognitive impairment. Several associated features have been highlighted in recent studies, including emotion regulation, intolerance of uncertainty and distress intolerance, and attachment. Finally, several psychotherapeutic treatments for hoarding have been recently validated, including group-based therapy and treatments using the cognitive-behavioral model. Although recent research demonstrates that hoarding can be effectively treated with available psychotherapeutic modalities, the effectiveness of current treatments is not as robust as that for other psychiatric disorders and more work is needed in treatment precision.

Safety and efficacy of first-line smoking cessation pharmacotherapies in bipolar disorders: Subgroup analysis of a randomized clinical trial.

OBJECTIVES: Post hoc analyses of EAGLES data to examine safety and efficacy of first-line smoking cessation pharmacotherapies in smokers with bipolar disorders (BD). METHODS: Smokers with BD I/II (n = 285; 81.4% with BD I) and a comparison nonpsychiatric cohort (NPC; n = 2794) were randomly assigned to varenicline, bupropion, nicotine replacement therapy (NRT), or placebo for 12 weeks, plus weekly counseling. Primary outcomes were occurrence of moderate to severe neuropsychiatric adverse events (NPSAEs) and Weeks 9-12 biochemically-confirmed continuous abstinence (CA) rates. RESULTS: For BD smokers, NPSAE risk differences versus placebo were: varenicline, 6.17 (95% CI: -7.84 to 20.18); bupropion, 4.09 (-8.82 to 16.99); NRT, -0.56 (-12.34 to 11.22). ORs for Weeks 9-12 CA, comparing active medication to placebo among BD smokers were: varenicline, 2.61 (0.68-9.95); bupropion, 1.29 (0.31-5.37), NRT, 0.71 (0.14-3.74). Pooling across treatments, NPSAE occurrence was higher (10.7% versus 2.3%; P < 0.001) and CA rates were lower (22.8% versus 13.3%; P = 0.008) in BD than NPC. LIMITATIONS: Study not powered to detect differences in safety and efficacy in the BD subcohort; generalizability limited to stably treated BD without current substance use disorders. CONCLUSIONS: Smokers with BD had higher risk of NPSAEs and were less likely to quit overall than NPC smokers. Among smokers with BD, NPSAE risk difference estimates for active treatments versus placebo ranged from 1% lower to 6% higher. Efficacy of varenicline in smokers with BD was similar to EAGLES main outcomes; bupropion and NRT effect sizes were descriptively lower. Varenicline may be a tolerable and effective cessation treatment for smokers with BD. TRIAL REGISTRATION: ClinicalTrials.gov identifier (https://clinicaltrials.gov/): NCT01456936.

A description of 17 animal hoarding case files from animal control and a humane society.

This study describes 17 publicly available cases of animal hoarding, a special manifestation of hoarding disorder. The cases, which included court documents, animal service documents, photographs, and newspaper clippings, were reviewed by Masters-level clinicians and a veterinarian in private practice. The veterinarian rated the animals in the case files for possible neglect. Over half of the homes had signs of object hoarding. The most commonly hoarded animals were cats, dogs, and rabbits. The majority of animals in the cases reviewed required veterinary care. Individuals with animal hoarding often lack insight about the condition of their animals and require community intervention.

Intolerance of uncertainty in hoarding disorder.

BACKGROUND: Intolerance of uncertainty (IU) has been proposed as a transdiagnostic risk and maintenance factor underlying various forms of psychopathology. Few studies, however, have examined IU in hoarding disorder (HD)-a condition characterized by excessive urges to acquire and difficulties discarding possessions-core symptoms that may be fueled by inflated IU. We examined cross-sectional relationships between IU and different symptom facets of HD, controlling for anxiety and depression severity, and explored whether pre-treatment levels of IU predicted response to exposure-based treatment for HD. METHOD: Fifty-seven individuals seeking treatment for HD completed baseline measures of hoarding symptoms, IU, anxiety and depression. Participants then completed 26 sessions of group exposure-based treatment for HD with or without compensatory cognitive training. Hoarding symptoms were assessed following the final treatment session to index treatment response. RESULTS: IU was positively and significantly associated with greater urges to acquire and greater difficulties discarding possessions, beyond shared variance accounted for by anxiety and depression. IU was not significantly related to clutter symptom severity. Higher pre-treatment IU predicted increased odds of treatment non-response. CONCLUSIONS: Elevated IU is associated with specific hoarding symptom clusters and may be an important target for HD treatment.

Comparing clinical characteristics and treatment outcomes between Veterans and non-Veterans with hoarding disorder.

BACKGROUND: Because Veterans have higher rates of mental health conditions and both physical and mental health comorbidities are known to affect treatment outcomes, the purpose of this investigation was to compare the rates of risk factors for poor hoarding treatment outcomes between Veterans and non-Veterans with hoarding disorder (HD). This is the first study to investigate differences between Veterans and non-Veterans with HD. MATERIAL AND METHODS: Baseline data were used from three different treatment studies of adults with hoarding disorder (n = 159). Demographic characteristics, baseline hoarding symptom severity, baseline medical and psychiatric comorbidities, and treatment attrition and response were compared between Veterans and non-Veterans. RESULTS: Veterans were significantly less likely to be employed than non-Veterans. Veterans did not report significantly more severe hoarding symptoms at baseline when compared to non-Veterans. Veterans reported having a greater mean number of overall medical and psychiatric comorbidities. Veterans were more likely than non-Veterans to meet criteria for major depressive disorder and post-traumatic stress disorder. There was no significant difference in the rate of attrition between Veterans and non-Veterans and Veterans were not significantly more likely to be classified as treatment responders. CONCLUSION: Many similarities were observed between the two groups, including demographic characteristics, hoarding symptom severity, and rates of treatment response. Given that Veterans with HD may suffer from greater medical and psychiatric comorbidities, clinicians should ensure that their clients are receiving adequate medical care and that any other psychiatric comorbidities should be addressed in conjunction for treatment with HD.

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: ß = 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 (ß = 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​.

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.

The Etiology of Hoarding Disorder: A Review.

This article will review the evidence of various proposed factors that contribute to the onset and maintenance of hoarding disorder (HD). Data suggests that hoarding is a chronic condition that starts early in life and does not remit if left untreated. There is emerging evidence that a number of factors contribute to the expression of HD symptoms, including genetics, neurocognitive functioning, attachments to possessions, beliefs, avoidance, personality factors, and life events. The extent to which each etiological factor uniquely contributes to hoarding is still unknown. Other demographic factors, such as socioeconomic status, age, and gender, may impact hoarding severity. Research on the causes and characteristics of hoarding has recently started making progress into understanding this newly recognized disorder, yet we still have a ways to go in understanding the biological and environmental causes. This paper will synthesize available literature on the etiology of HD.

Psychometric Evaluation of the Saving Inventory-Revised in Older Adults.

OBJECTIVES: Hoarding disorder (HD) is a chronic condition characterized by severe impairment in health and functioning for older adults. Researchers and clinicians commonly use the Saving Inventory-Revised (SI-R), a self-report measure validated for the assessment of HD, to establish symptom severity. This study represents the first evaluation of the psychometric properties of the SI-R in a sample of older adults with HD. METHODS: Participants were 156 older adults with HD and 23 older adults with no psychiatric diagnoses. Demographic and HD symptom severity measures were compared between the two samples. Convergent and discriminant validity was examined in the HD sample. A confirmatory factor analysis was used to test the replicability of the three-factor structure observed in the original sample. RESULTS: Participants in the HD sample scored significantly higher on the SI-R than did the non-psychiatric sample. The SI-R was significantly correlated with clutter level and symptoms of anxiety and depression. A three-factor model demonstrated poor fit in the HD sample. CONCLUSIONS: The SI-R can be used to validly assess hoarding severity in geriatric populations. CLINICAL IMPLICATIONS: Clinicians working with geriatric patients should consider refraining from use of the SI-R subscales as they may be less theoretically distinct in older adults.