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.

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.

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.

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.

"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.

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).

Hoarding Disorder: The Current Evidence in Conceptualization, Intervention, and Evaluation.

Hoarding disorder is characterized by difficulty parting with possessions due to strong urges to save the items, leading to the excessive accumulation of items. High clutter levels result in varied personal, social, and legal consequences. Specialized treatments, including individual, virtual, and group cognitive and behavioral therapies, community-based interventions, and peer support approaches have shown preliminary effectiveness. Animal, attachment, and neurobiological models are expanding our understanding of the etiological bases of the disorder. Specialized populations such as children, older adults, and involuntary patients are highlighted as requiring special consideration for intervention and risk mitigation. Directions for future research are identified.

Percepções de profissionais sobre política pública municipal para pessoas em situação de acumulação / Professional's perceptions about municipal public policy for people living with hoarding disorder / Percepciones de profesionales sobre política pública municipal para personas en situación de acumulación

A política pública, enquanto exercício do poder público para resolver problemas da sociedade, é passível de aproximações para entendimento sobre seu funcionamento. Este trabalho faz esse exercício ao analisar as percepções dos profissionais atuantes em política municipal para atendimento a pessoas em situação de acumulação, de município da Região Metropolitana de Curitiba/PR. Para a construção da pesquisa qualitativa, de tipo exploratório-descritiva, utilizou-se entrevistas com profissionais do serviço municipal, após, o conteúdo foi analisado pela análise categorial temática. O transtorno de acumulação, caracterizado pela dificuldade em desfazer-se de objetos, tem como manifestação especial o acúmulo de animais e implica em sofrimentos para a própria pessoa e a coletividade. O Comitê Municipal para atendimento a essa situação é multiprofissional, viabilizando tratamento em saúde, assistência aos animais, orientações de cunho sanitário e demais intervenções pertinentes. A partir desse panorama geral, apreendeu-se que a multiprofissionalidade é imprescindível para o serviço, ao invés da concentração apenas na psicologia e psiquiatria. A evolução terapêutica do paciente é gradual e envolve reincidências, assim, as expectativas dos profissionais em relação aos casos atendidos, idealmente, precisa levar em conta a especificidade da condição de sofrimento do paciente, e prever alternativas àquelas que prescrevem a supressão dos sintomas apenas, como a perspectiva da redução de danos. (AU)

Public policy, as a means of the government's authority to solve society's problems, is passive of approaches for understanding how it functions. This dissertation intends to do as such, by analyzing the perceptions of professionals working with municipal policy to assist people living nearby Curitiba--PR city that struggles with Hoarding Disorder. To build the repertory for an exploratory-descriptive type of qualitative research, interviews with municipal service workers were collected, then, the content was analyzed using thematic analysis. Hoarding Disorder, distinguished by the difficulty in getting rid of acquired objects, has as special manifestation the acumulation of animals, and entails suffering for itself and the community. The Municipal Committee created to address this issue is multi-professional, enabling access to health care, animal care, sanitary guidelines, and other relevant interventions. From this survey, it was possible to understand that the multi-professional nature of the Committee is essential in this field, instead of concentrating only psychiatric and psychology professionals for the task. The patient's therapeutic evolution is gradual and involves recidivisms, therefore, the professionals' expectations regarding each case needs to, preferably, consider the specificity of the patient's suffering condition, and foresee alternatives that solely prescribe the suppression of symptoms, such as harm reduction. (AU)

La política pública, como ejercicio del poder público para resolver problemas de la sociedad, es posible de aproximaciones para entendimiento de su funcionamiento. Este trabajo haz ese ejercicio al analizar las percepciones de los profesionales actuantes en la política municipal de atendimiento a personas en situación de acumulación, del municipio de la Región Metropoli-tana de Curitiba/PR. Para la construcción de la pesquisa cualitativa, de tipo exploratorio-descriptiva, usamos entrevistas con profesionales del servicio municipal, después, el contenido fue analizado por el análisis temática. El trastorno de acumulación, caracterizado por la dificultad en deshacerse de objetos, tiene como manifestación especial la acumulación de animales, e implica en sufrimientos para la persona y la colectividad. El Comité Municipal para atendimiento a esa situación es multiprofesional, posibilitando trata-miento en salud, asistencia a los animales, orientaciones sanitarias y demás intervenciones pertinentes. A partir de ese panorama general, comprenderse que la multiprofesionalidad es imprescindible para el servicio, en lugar de apenas contratación de psicología y psiquiatría. La evolución terapéutica del paciente es gradual y muchas veces con recurrencias, así, las expectativas de los profesionales en relación con los casos atendidos, idealmente, necesita llevar en cuenta la especificidad de la condición del sufrimiento del paciente, y promover alternativas a aquellas que prescriban el desaparecimiento de los síntomas solamente, tal como la perspectiva reducción de los danos. (AU)

What is underneath all that stuff? A Q-methodological exploration of profiles of beliefs and vulnerabilities in hoarding disorder.

BACKGROUND: Hoarding disorder (HD) can be understood through the cognitive behavioural model in the context of vulnerability factors (for example, personality traits, co-morbidities, traumatic life events) and beliefs about possessions (for example, identity, emotional attachment, memory, utility). Less is known about the strength of these hypothesised beliefs, or how they interact within the hoarding population, with researchers suggesting that specifying beliefs would improve treatment outcomes. AIM: The current study explored beliefs in HD, utilising Q-methodology to explore both categories of beliefs and the interactions between these. Moreover, Q-methodology allowed for comparison of the individuals endorsing specific categories of beliefs. METHOD: A comprehensive list of beliefs about possessions was developed. Thirty-two adults with clinically significant levels of HD completed a Q-sort task, alongside measures of proposed vulnerabilities, including co-morbidity, trauma and attachment style. RESULTS: Q-factor analysis produced four profiles consisting of groups of participants who endorsed the same beliefs and had shared characteristics: (1) 'Expression of identity', (2) 'Responsibility and morality', (3) 'Stability and predictability', and (4) 'Objects as emotional and meaningful beings'. DISCUSSION: The profiles were distinguished by different categories of beliefs and co-morbid symptoms, suggesting that more targeted assessment tools and interventions would be beneficial to account for this heterogeneity within the clinical population. In particular, beliefs about identity and self-concept formed the largest profile, and beliefs about stability and predictability introduce a novel category of beliefs.

Is it as good as being in person? The effectiveness of a modified clinician facilitated buried in treasures group for hoarding disorder using video teleconferencing.

The COVID-19 pandemic has necessitated the use of video-teleconferencing (VTC) for psychological treatments but VTC effectiveness studies are sparse. We examined treatment outcomes for a modified Buried in Treasures (BIT) group program for hoarding disorder (HD) delivered via VTC. Participants were 10 individuals with HD. Hoarding severity was evaluated at pre, mid, post, and six-month follow-up. Results showed significant decrease in hoarding symptoms over time (with an average decrease of 32%). The dropout rate was low (9%) and 30% of participants were fully recovered at follow-up. These results support the adaptation of in-person BIT for HD into a VTC format.

Grit predicts less severe hoarding symptoms among patients seeking treatment at an anxiety disorders clinic.

Grit is associated with positive outcomes in nonclinical samples. However, no studies have examined grit in relation to psychopathology in patients with clinical mood or anxiety disorders. Research and clinical experience suggest that individuals who hoard struggle with characteristics associated with grit, such as task persistence, impulsivity, and self-control. The authors tested the hypothesis that hoarding symptoms are associated with less grit in a sample of individuals (N = 72) presenting for treatment to an anxiety disorders clinic. After covarying symptoms of the four mood and anxiety disorders most commonly comorbid with hoarding disorder (viz. depression, generalized anxiety, social anxiety, and obsessive-compulsive disorder), the authors found that hoarding symptoms were associated with less grit, and the effects were medium-to-large. These results indicate that grit is worthy of investigation in individuals with hoarding disorder using methodologies that permit inferences about causality, and with attention to clinical implications for prevention or treatment.

Council tenancies and hoarding behaviours: A study with a large social landlord in England.

Hoarding behaviours are highly stigmatised and often hidden. People with problematic hoarding behaviours have a higher rate of mental health and other healthcare and social services utilisation. Hoarding is a community health problem, one factor being housing insecurity. Hoarding behaviours represent significant burden to housing providers, impact the community and dealing with it involves multiple community agencies. This study with a city council in England with a large housing stock (over 14,000 properties) in summer 2021 sought to understand the nature, circumstances and extent that hoarding presents. We developed a reporting system and conducted 11 interviews with housing officers in which they described a case to explain their involvement. Our report details the nature of 38 people who hoard: 47% had a known disability or vulnerability, 34% presented a fire and environmental risk, 87% lived alone and 60% were resident in flats. Our qualitative themes are: Working with others, Balancing an enforcement approach, Feeling conflicted, Complex needs of people who hoard and Staff needs. The cases described by the housing officers are combined into six case studies and illustrate the complex, multi-agency circumstances around decision making and risk stratification. Our findings point to housing officers as frontline professionals dealing with a public health and social care issue which is often the manifestation of complex life histories and mental health conditions. We suggest a greater focus on risk stratification and a more holistic approach to hoarding cases to effectively deal with this most complex of community health and social care issues.

Co-occurring Obsessive-Compulsive Disorder and Hoarding Disorder: A Review of the Current Literature.

Current research suggests obsessive-compulsive disorder (OCD) co-occurs in around 20% of people with hoarding disorder (HD). The article discusses the theoretical conceptualization of co-occurring HD and OCD (HD+OCD), highlighting similarities between the disorders that may contribute to comorbidity, such as potentially overlapping etiological factors, comorbidity profiles, and phenomenological aspects; and differences that are important to consider in differential diagnosis and conceptualization, such as belief patterns, ego-syntonicty/dystonicity, and trajectory. The combination of HD+OCD versus either disorder alone appears to be associated with a profile characterized by higher nonhoarding OCD symptoms, anxiety symptoms, depression, and tic disorders, and which may be more treatment-refractory. The authors discuss some commonly used measures to assess hoarding that may be relevant in the context of OCD, as differential diagnosis of hoarding behaviors is often difficult, and hoarding may be difficult to detect in patients with OCD, especially in children. The article ends with a discussion on considerations for the treatment of HD+OCD with cognitive-behavioral therapy, as hoarding symptoms are less likely to respond to gold-standard exposure and response prevention, and there are no established treatment protocols that are designed to treat co-occurring HD and OCD.

Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis.

BACKGROUND: Hoarding disorder (HD) is a new disorder in DSM-5. While cognitive-behavioral therapy (CBT) is seen as the gold standard approach to treatment, the literature in this field is still emerging. METHODS: The aim of the present study is to synthesize the current treatment outcome literature on CBT for HD, as well as secondary depressive symptoms, using a meta-analytic approach. Due to a lack of controlled trials only within-group effect sizes were calculated. RESULTS: Sixteen studies were included in the meta-analysis (n = 505; mean age = 56 years; mean percentage female participants = 72%). Large effect sizes were found from pre-treatment to post-treatment (g = 1.11; 95% CI: 0.92-1.29) and from pre-treatment to follow-up (g = 1.25; 95% CI: 0.94-1.56) on HD symptoms. The gender distribution of the sample moderated treatment outcome, with larger effects seen in studies that included a larger proportion of female patients. Treatment modality (individual vs group), therapist training, use of home visits, trial type (efficacy vs effectiveness), number of treatment weeks, participant age, and study quality did not moderate treatment outcome. Small effect sizes were found from pre-treatment to post-treatment (g = 0.45; 95% CI: 0.28-0.61) for depressive symptoms and baseline depression severity, treatment modality, use of home visits, and assessment tool used did not moderate outcome. LIMITATIONS: The study is limited by the small number of studies available in this field. CONCLUSIONS: This study demonstrates that CBT for HD is an effective treatment, however, controlled trials are needed, as are trials examining the long-term efficacy of CBT for HD.

A systematic review and psychometric evaluation of self-report measures for hoarding disorder.

BACKGROUND: Hoarding disorder (HD) affects approximately 2.5% of the general population, leads to significant distress and impairment, and is notoriously difficult to treat. The crux of developing effective treatments for HD is our ability to reliably and validly measure relevant constructs in HD to better understand its presentation and, subsequently, formulate appropriate interventions. METHODS: We identified measures specific to HD and evaluated their psychometric properties using rating criteria formulated by the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) group. RESULTS: The 17 included measures were developed to assess adult and pediatric hoarding severity, functional impairment, and maladaptive processes (e.g., material scrupulosity). The Saving Inventory-Revised, the most widely used measure of HD severity showed the strongest psychometric properties. However, psychometric investigations were generally of poor quality across all measures and results indicated unsatisfactory performance of measures. LIMITATIONS: The current review excluded non-English measures and ratings inherently contain some element of subjectivity despite use of predetermined criteria and two independent reviewers. CONCLUSIONS: We suggest that clinical researchers continue to develop and modify measures used to conceptualize and, ultimately, improve treatment for HD.