Posttraumatic stress disorder, Veterans Health Administration use, and care-seeking among recent-era U.S. veterans.

The current study investigated the associations among probable posttraumatic stress disorder (PTSD), recent Veterans Health Administration (VHA) health care use, and care-seeking for PTSD in U.S. military veterans. Analyses were conducted among 19,691 active duty military personnel enrolled in the Millennium Cohort Study who separated from the military between 2000 and 2012 and were weighted to the 1,130,103 active duty personnel who separated across this time period. VHA utilization was identified from electronic medical records in the year before survey completion, and PTSD care-seeking and PTSD symptoms were assessed through self-report on the 2014-2016 survey; thus, the observation period regarding care-seeking and VHA use encompassed 2013-2016. Veterans with probable PTSD were more likely to use VHA services than those without probable PTSD, aOR = 1.12, 95% CI [1.01, 1.24], although the strongest association with recent VHA use was a depression diagnosis, aOR = 2.47, 95% CI [2.26, 2.70]. Among veterans with probable PTSD, the strongest predictor of care-seeking was recent VHA use compared to community care, aOR = 4.01, 95% CI [3.40, 4.74); reporting a diagnosis of depression was the second strongest predictor of PTSD care-seeking, OR = 2.99, 95% CI [2.53, 3.54]. However, the absolute number of veterans with probable PTSD who were not seeking care was approximately equivalent between veterans using VHA services and those not using VHA services. Additionally, certain groups were identified as being at risk of not seeking care, namely Air Force veterans and veterans with high physical and mental functioning despite substantial PTSD symptoms.

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.

Increased animal ownership in the home is correlated with worse health outcomes based on health-care indicators investigated in canines and felines in rural Mississippi.

OBJECTIVE: Although research on animal hoarding, both in urban and rural settings, is growing, a gap remains in the literature about community patterns of animal ownership. Our objective was to determine patterns of companion animal ownership in a rural setting and the association between number of animals in a household and indicators of animal health. SAMPLE: Retrospective review of veterinary medical records from 2009 to 2019 from a university-based community clinic in Mississippi. PROCEDURES: Review of all owners who reported having animals from a household with 8 or more other animals on average, excluding animals from shelters, rescues, or veterinary practices. Across the study period, 28,446 unique encounters occurred among 8,331 unique animals and 6,440 unique owners. Indicators of care for canine and feline animals were taken from values indicated on the physical examination. RESULTS: Animals were largely from single-animal households (46.9%) or households with 2 to 3 animals (35.9%). However, 2.1% of all animal cases reviewed lived in a household reported to have 8 or more animals, and 2.4% of canines and 4.3% of felines lived in a household with 8 or more animals. Increased animal ownership in the home correlated with worse health outcomes based on the health-care indicators investigated in canines and felines. CLINICAL RELEVANCE: Veterinarians working in community settings are likely to encounter cases of animal hoarding and should consider collaborating with mental health practitioners if repeated incidences of negative health-care indicators occur for animals from the same household.

The generational impact of household clutter.

OBJECTIVES: Hoarding disorder can create long-term problems for adult children of individuals with hoarding symptoms; however, the extent of the psychosocial consequences of growing up in a cluttered household are not yet fully understood. This study investigated the extent to which generational clutter (i.e., parent/caregiver and grandparent) influenced individuals' self-reported hoarding severity and psychiatric and psychosocial functioning. METHODS: A total of 1306 adults completed an online survey that included measures of hoarding, anxiety, depression, companionship and emotional support. A subsample (n = 198) reported on parent and grandparent household clutter, as well as family impact from hoarding. We used correlations, t-tests, linear and hierarchical regressions and mediation analyses to investigate whether hoarding symptoms were predicted by parent or grandparent hoarding. RESULTS: Parent clutter level significantly predicted participant hoarding symptoms. For participants who reported having caregivers with elevated clutter, self-reported psychosocial functioning was lower overall. Self-reported behaviour modification due to family hoarding symptoms (accommodation) was a significant predictor of participant hoarding symptoms. CONCLUSIONS: Parent clutter and family accommodation behaviours may be a risk factor for future clutter in adult children. Further comparisons between parents and children are needed to determine whether this association increases children's risk for future hoarding symptoms.

The association between personality traits and hoarding behaviors.

PURPOSE OF REVIEW: Hoarding is a behavior that occurs across a variety of disorders, including hoarding disorder, obsessive-compulsive disorder (OCD), and schizophrenia. Hoarding is also a normative human behavior within certain contexts, including the recent coronavirus disease 2019 pandemic, when individuals became panicked about the availability of products such as toilet paper and antibacterial wipes. Previous research suggests that personality traits and personality disorder symptoms may be linked with hoarding behaviors. The purpose of this review is to provide a snapshot of recent research on hoarding and personality. RECENT FINDINGS: Most recent research on this topic has focused on hoarding behaviors as the action of stockpiling goods during a pandemic. Research on this area was mixed with regard to extraversion and openness but was strongly suggestive of a link between stockpiling behaviors and increased neuroticism. Hoarding in the context of OCD was linked with lower levels of both extraversion and conscientiousness. Patients with hoarding disorder almost universally have clinically elevated levels of personality disorder traits. SUMMARY: The directions of observed associations between five-factor model personality traits and hoarding behaviors differ across diagnostic and geographic contexts. Additional research is needed with participants who meet diagnostic criteria for hoarding disorder.

Perceived locus of control for clutter: Reported reasons for clutter in adults with and without hoarding symptoms.

OBJECTIVES: The goal of the current investigation was to expand on previous work on reasons for saving/discarding in the context of hoarding by examining individuals' perceived locus of control for household clutter. METHODS: Participants were asked to list their perceived reasons for clutter and assign each reason a percentage rating reflecting the extent to which they judged the reason to be responsible for their household clutter. RESULTS: Lack of time was an almost universally endorsed reason for clutter. Clinically severe hoarding levels were associated with lower responsibility ratings for time-related reasons and increased endorsement of distress-related reasons. CONCLUSIONS: Future research should examine whether insight level affects how individuals with clinically severe hoarding perceive the locus of control for household clutter. PRACTITIONER PONITS: Perception of lack of time may influence individuals' sense of locus of control for their household clutter levels. Hoarding severity is associated with being more likely to attribute distress around discarding or decision making as the reason for clutter.

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.

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.

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.