Treating Elders With Compulsive Hoarding: A Pilot Program

doi:10.1016/j.cbpra.2010.04.001

Cognitive and Behavioral Practice

Volume 17, Issue 4, November 2010, Pages 449-457

https://doi.org/10.1016/j.cbpra.2010.04.001 Get rights and content

Abstract

Hoarding among elderly clients can have serious health and safety consequences, including death. Because medications and standard behavioral treatments have yielded limited benefits for people with serious hoarding problems, we employed a specialized cognitive behavioral treatment (CBT) based on Frost and colleagues' model of hoarding problems. Of 11 elderly clients who met screening criteria for hoarding at a community mental health center, 6 completed an average of 35 sessions of therapy administered by a B.A.-level therapist trained and supervised in CBT methods. Treatment consisted of weekly home visits that included motivational interviewing, organizing and decision-making skills, cognitive therapy regarding hoarding and related beliefs, and practice sorting, discarding, and not acquiring. Modest improvement was evident in ratings of clutter, risky situations in the home, and functioning. Clients were generally satisfied with treatment. Challenges in treating hoarding in elderly clients include health and safety risks as well as reduced physical capacity that required problem-solving strategies.

Section snippets

Design

The treatment team consisted of three licensed master's-level social workers (including the first author, KT), three bachelor's-level counselors (one, LN, hired specifically for this project), an agency psychiatrist, and a doctoral-level social worker experienced in CBT for hoarding (GS). Treating clinicians attended three 2-hour training sessions and received monthly group supervision with phone consultation as needed. The inclusion of several clinicians was intended to reduce potential staff

Pretreatment Comparisons

We first examined pretest scores for the 6 treatment completers and the 5 clients who discontinued. CIR data were not available for this comparison. No significant differences were found on measures of hoarding symptoms (HRS items) or functioning (ADL) according to t tests (all ps > .16).

Hoarding Outcomes for 6 Treatment Completers

Individual severity scores for the 6 completers on the CIR and ADL at pre- and posttreatment are provided in Table 1. Mean scores were calculated across all completers to provide an index of overall response. A

Discussion

The present study presents outcomes for 6 of 11 clients with hoarding problems from a community-based agency that provides services to elders. We included 1 client with a past history of severe mental illness, but this client required hospitalization for a recurrence of psychosis and had to be dropped from the protocol. Four other clients refused or dropped out of the therapy protocol for a variety of reasons, a relatively high rate of attrition in this community sample. In a wait-list

Acknowledgement

This project was funded by a grant from Springwell Elder Services in Watertown, MA, awarded to the first author.

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Cited by (47)

Developing Psychosocial Interventions for Late-Life Depression and Comorbid Hoarding Disorder
2024, American Journal of Geriatric Psychiatry
Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis
2021, Journal of Affective Disorders
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.
Predictors of treatment outcome and attrition in adults with hoarding disorder
2019, Journal of Obsessive-Compulsive and Related Disorders
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.
Saving inventory – Revised: Psychometric performance across the lifespan
2019, Journal of Affective Disorders
Citation Excerpt :
The average age of treatment-seeking samples is consistently in the 50 s (e.g., Frost et al., 2012; Muroff et al., 2012; Saxena and Sumner, 2014; Steketee et al., 2010). Older adults also frequently come to clinical attention, many because they are community-referred, although some actively seek treatment (Ayers et al., 2014, 2011; Luu et al., 2018; Turner et al., 2010). Furthermore, although clinical hoarding is associated with older age, researchers often study hoarding using much younger student analogue samples (e.g., Burgess et al., 2018; Oglesby et al., 2013).
The Saving Inventory – Revised (SI-R) is the most widely used self-report measure of hoarding symptom severity. The goal of this study is to establish a firm empirical basis for a cutoff score on the SI-R and to examine the functioning of the SI-R as a screening tool and indicator of hoarding symptom severity across the lifespan.
This study used archival data from 1,116 participants diagnosed with a clinical interview in 14 studies conducted by research groups who focus on hoarding. We used receiver operating characteristic (ROC) analysis and the Youden's J statistic to determine optimal cutoff scores for classifying participants who would be likely to receive a hoarding diagnosis.
Overall, the discriminant performance of the SI-R Total score and each of the three subscales was high, confirming the status of the SI-R is an excellent screening tool for differentiating hoarding from non-hoarding cases. The optimal SI-R Total cutoff score is 39, although analyses suggested that older adults require a significantly lower cutoff and adults younger than 40 years require a significantly higher cutoff score.
The confidence interval around the optimal cutoff for the SI-R Total score for oldest age group was wide in comparison to those reported for the younger groups, creating more uncertainty around the optimal cutoff score for this group.
This paper provides investigators and clinicians with the data necessary to select evidence-based cutoff scores on the SI-R that optimally suit their relative need for sensitivity and specificity in different age groups.
A systematic review and quality assessment of psychological, pharmacological, and family-based interventions for hoarding disorder
2017, Asian Journal of Psychiatry
Citation Excerpt :
A number of different cognitive-behavioral therapy (CBT) protocols for individual (Steketee and Frost, 2013, 2007), group (Muroff et al., 2014b), and self-help treatments have now been developed for HD (Bubrick et al., 2004; Tolin et al., 2007a). More recently, approaches other than CBT have been tested, such as ‘harm reduction’ for clients not motivated to change their hoarding behavior (Tompkins, 2015), pharmacological treatments using serotonin reuptake inhibitors (Saxena et al., 2007; Saxena and Sumner, 2014), interventions utilizing cognitive remediation to address neurocognitive deficits (Ayers et al., 2014; Dimauro et al., 2014), and family-based interventions to enhance motivation of the person with HD and/or support the needs of family members (Chasson et al., 2014; Sampson et al., 2012; Thompson et al., 2016; Tompkins, 2011). To date, three treatment reviews have been conducted examining the outcomes of psychological and pharmacological treatments for hoarding difficulties (Muroff et al., 2011; Tolin et al., 2015; Williams and Viscusi, 2016).
Hoarding disorder (HD) affects at least 1.5% of the population and is considered to be hard to treat. The current study aimed to systematically review the treatments designed to improve HD symptoms and family impact.
Searches of PsycINFO, MEDLINE, EMBASE, and Web of Science were undertaken. Studies were included if: (i) the study evaluated an intervention for hoarding problems; (ii) outcome measures were reported; and (iii) study results were published in an indexed journal or were a published abstract from a professional/research conference. The quality of the studies was assessed using the Clinical Trials Assessment Measure (CTAM).
Twenty studies, comprising 492 participants with clinically significant hoarding symptoms or HD and 21 relatives of individuals with HD, met inclusion criteria. Treatments reviewed included cognitive-behavior therapy, medication, cognitive remediation, and multi-component interventions for relatives. Most studies yielded statistically significant improvements in hoarding symptoms, although reductions were generally modest and many participants remained in the clinical range after treatment. According to the CTAM, most studies were judged to be of low methodological quality.
HD is a chronic and highly burdensome condition for which efficacious treatments are needed. The current evidence base is somewhat limited and of low quality. Further research is needed to improve treatments, identify mechanisms of change, and increase the availability of evidence-based interventions for this group.
An open trial of cognitive behavioral therapy with contingency management for hoarding disorder
2017, Journal of Obsessive-Compulsive and Related Disorders
Citation Excerpt :
These protocols have included more of a focus on the development of practical skills, typically including modules surrounding methods of organization, applying problem solving models, and emotional distress tolerance skills and practice. Some of these treatments (e.g., Muroff, Steketee, Bratiotis, & Ross, 2012; Turner, Steketee, & Nauth, 2010) have utilized in-home and/or in-session de-cluttering sessions. Although most participants show reliable change over the course of CBT, the rate of clinically significant change (i.e., post-treatment scores that are more likely to come from the distribution of scores in the general population than from an HD population) is only 35%, with most patients continuing to show significant hoarding behaviors and related impairment at post-treatment (Frost, Muroff, Steketee & Tolin, 2014).
Cognitive behavioral therapy (CBT) for hoarding disorder (HD) has resulted in statistically significant improvements in hoarding symptoms, but gains have been modest and most participants continue to have clinically significant symptoms at post treatment. Contingency management, an empirically-supported intervention for substance use, may be effective in overcoming barriers to effective treatment of HD, such as fluctuating motivation and insight. The objective of the current open trial was to examine the potential effectiveness of contingency management for HD in the context of a cognitive-behavioral group therapy. Twenty-two patients completing 16-week CBT groups for HD were administered monthly contingency payments based on independent evaluator-rated reductions in overall in-home clutter. Mixed effects models suggested significant reductions in hoarding symptoms as measured by the Saving Inventory-Revised (SI-R; Frost, Steketee, & Grisham, 2004) and the Clutter Image Rating Scale (CIR; Frost, Steketee, Tolin, & Renaud, 2008), with SI-R reductions resulting in a large effect size (Cohen's d =2.59) that surpassed those obtained previously in trials of CBT for HD. Mean total earning per patient was $139, and ranged from $0 to $270. These preliminary results suggest that contingency management shows promise as a cost-efficient adjunctive intervention to boost gains in CBT for HD.

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Treating Elders With Compulsive Hoarding: A Pilot Program

Abstract

Section snippets

Design

Pretreatment Comparisons

Hoarding Outcomes for 6 Treatment Completers

Discussion

Acknowledgement

Journal of Anxiety Disorders

Clinical Psychology Review

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Psychiatry Research

Intervention in compulsive hoarding

Behavior Modification

Hoarding: A symptom, not a syndrome

Journal of Clinical Psychiatry

Patterns of comorbidity in compulsive hoarding

Development and validation of the Clutter Image Rating

Journal of Psychopathology and Behavioral Assessment

Hoarding: A community health problem

Health & Social Care in the Community

Prevalence and heritability of compulsive hoarding: A twin and genetic association study

American Journal of Psychiatry