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Cognitive behavior therapy for hoarding disorder: Follow-up findings and predictors of outcome
Depression and Anxiety
Abstract
A cognitive-behavioral model of hoarding posits deficits in information processing, maladaptive beliefs about and attachments to possessions that provoke distress and avoidance, and positive emotional responses to saving and acquiring that reinforce these behaviors. A 26-session individual cognitive-behavioral therapy (CBT) based on this model showed significant reductions in hoarding symptoms and large effect sizes (Steketee et al.([1]) ).
The present study presents findings at follow-up (up to 12 months), as well as predictors of outcome at posttreatment (n = 37) and follow-up (n = 31).
Significant improvements at post-treatment were sustained at follow-up with large effects, and Clinical Global Impression-Improvement (CGI-I) ratings by clinicians and patients at follow-up indicated that 62 and 79% of patients were rated "much improved" or "very much improved," respectively. The most prevalent patterns of outcome were improvement followed by stable gains or little improvement across all time points. Pretreatment severity of hoarding, overall clinical status, gender, perfectionism, and social anxiety were all associated with worse outcome. Only perfectionism and gender emerged as significant predictors after controlling for initial hoarding severity.
The present findings suggest general stability of individual CBT outcomes for hoarding and indicated that gender, perfectionism, and social anxiety may affect outcomes. More research on larger samples is needed to direct efforts to improve treatment for hoarding.
... In 4 studies, only the effectiveness of CBGT and in 3 studies, only the effectiveness of individual CBT was investigated and comparison could not be made because there was no control group. In addition, there was a study investigating the effectiveness of internet support system in combination with CBGT (Ivanov et al. 2018), a study comparing individual CBT to CBGT (Levy et al. 2017) and two studies comparing individual CBT to waiting list group (Steketee et al. 2010, Muroff et al. 2014. There was also a study comparing three different treatment groups. ...
... Follow-up evaluations were performed in a time range extending from 3 months to 1 years after the end of the treatment. The follow-up evaluation was given at 3 months in a study (Ivanov et al. 2018), 6 months in 2 studies , Kellett et al. 2015 and between 3 months and 1 year in Psikiyatride Güncel Yaklaşımlar -Current Approaches in Psychiatry another study (Muroff et al. 2014). In another study, there was no information about time of the follow-up evaluation (Pollock et al. 2014). ...
... In addition, the study comparing individual CBT and CBGT showed that both of the treatments had significant results similarly (Levy et al. 2017). While individual CBT was found more effective than waiting list groups in 2 studies (Steketee et al. 2010, Muroff et al. 2014), a study comparing CBGT with home assistant, CBGT and bibliotherapy showed that CBGT with home assistants and CBGT were superior than bibliotherapy (Muroff et al. 2012). ...
Although hoarding has been considered as a type of obsessive-compulsive disorder before, some differences that were found lead to reclassify hoarding as a separate disorder under obsessive-compulsive disorder and related disorders in DSM-5. Patients with hoarding disorder have negative feelings like strong fear when considering getting rid of items and exaggerate the importance of possessions. Different cognitive behavioral therapy protocols including individual, group and self-help treatments are used for treating hoarding disorder. The aim of this study is to review empirical studies that were carried out to evaluate the effectiveness of cognitive behavioral therapy for the treatment of hoarding disorder. The 12 studies fitting the search criteria were included in this review and were summarized in terms of their methods used and their therapy characteristic. The studies included in this review suggested that cognitive behavioral therapy for hoarding disorder is effective in decreasing the symptoms of the disorder and/or the accompanying problems like depression and anxiety.
... A follow up study found the typical hoard was relatively stable and unlikely to reduce further after treatment discontinuation up to 12-months after completion of CBT for HD therapy (Muroff, Steketee, Frost, & Tolin, 2013). This evidence intimates that the 26-week HD treatment protocol may not promote the permanent behavioural change required for symptom remission, and more specifically difficulty discarding, for some types of hoarding sufferers. ...
... Although limited information is available on treatment follow-up what has been found is that the reduction in clutter is likely to stall post treatment and no further discarding occurs without intervention (Muroff et al., 2013). ...
... While the CBT protocol calls for skills training in problem solving and organisational skills prior to exposure exercises, the proposed iHACT protocol suggests general ACT skills should be developed (both in the office and in the home) before approaching the actual organising of the home environment. The benefit of early organising and discarding action taken in the CBT protocol may appear to offer swift results for concerned parties; however, the results indicate the CBT for HD treatment does not lead to a further decrease in the volume of the hoard after the treatment programme has been completed (Muroff et al., 2013). This stagnation in the hoard volume suggests the skills being taught in CBT for HD may be ineffective in the long term and are unable to create lasting change in discarding for the majority of hoarding sufferers . ...
A novel acceptance-based emotion regulation theoretical model.
... To qualify participant response to the intervention and at followup, participants were categorized according to the categories used by Muroff, Steketee, Frost, and Tolin (2014). When participants showed no reliable improvement during treatment and follow-up, they were included in the "brick" category. ...
... When participants showed reliable improvement during treatment and reliable deterioration during follow-up, they were included in the "Vs" category (representing relapse during follow-up). When participants showed no reliable improvement during treatment, but reliable improvement during follow-up, they were included in the "late responder" category (called "sleepers" in Muroff et al., 2014). Finally, when participants showed reliable improvement during both treatment and follow-up, they were included in the "downward arrow" category. ...
... At the end of follow-up, 38% of participants could be considered to no long suffer from HD. The only follow-up data available for HD comes from studies on I-CBT (Muroff et al., 2014). In comparing the treatment trajectory of our participants with those of Muroff et al. ...
Background
Group cognitive–behavioural therapy (G‐CBT) for hoarding disorder (HD) may be an intervention of choice, considering its efficacy, low costs, and impact on comorbid anxiety and depression. But although G‐CBT and modifications of G‐CBT have been applied, none has assessed G‐CBT efficacy at follow‐up. In the current open‐label pilot study, we tested the efficacy of G‐CBT at posttreatment and 6‐month follow‐up and whether the inclusion of targeted reasoning and self‐identity components added to G‐CBT efficacy.
Methods
Participants (n = 16) with the HD according to the DSM‐5 criteria without major comorbid conditions and not requiring immediate medical intervention were retained. The intervention included a 20‐week G‐CBT with the inclusion of modules on reasoning and self‐identity.
Results
Very large/large effect sizes, depending on the outcome measure, were observed at posttreatment. Also, HD severity decreased from posttreatment to 6‐month follow‐up. All participants showed reliable change from pretreatment to follow‐up.
Conclusions
The results emphasize the efficacy of G‐CBT with additional targeted reasoning and self‐components.
... A total of 20 papers were identified for review, comprising 20 distinct samples. One paper (Frost et al., 2011b) included two separate studies (study 1 and study 2) and Muroff et al. (2014a) was a one-year follow-up of Steketee et al. (2010). ...
... Four out of the five controlled trials randomized participants to conditions, and the other was quasi-experimental as it used an existing wait-list control. Six studies followed up patients beyond the active phase of the study, with 1-month (Frost et al., 2011b, studies 1 & 2; Thompson et al., 2016), 6-month (Ayers et al., 2011Kellett et al., 2015), and one-year (Muroff et al., 2014a) follow-ups. ...
... All studies which trialed individual CBT based their intervention on Steketee and Frost's (2007) manual of CBT for compulsive hoarding (Ayers et al., 2011;Kellett et al., 2015;Muroff et al., 2014a;Steketee et al., 2010;Tolin et al., 2007b;Turner et al., 2010). Ayers et al. (2011) increased the intensity of the intervention to twice weekly for the first 20 sessions and Turner et al. (2010) delivered additional treatment sessions to the proposed number reported in the original protocol (mean = 35.3, ...
Introduction
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.
Method
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).
Results
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.
Conclusions
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.
... High rates of OCPD have also been reported in HD (e.g., 45% in Samuels et al., 2002;56.8% in Landau et al., 2011). Importantly, perfectionism has been found to be a complicating factor in CBT for HD (Muroff, Steketee, Frost, & Tolin, 2013). ...
... Much less is known about the effect of perfectionism in the treatment of OCD-related disorders. Muroff et al. (2013) examined predictors of response in a sample of 37 patients with HD who received 26 sessions of individual CBT. Adjusting for baseline hoarding symptoms, perfectionism (as measured by the perfectionism subscale of the Obsessive Beliefs Questionnaire) was a significant predictor of posttreatment symptoms, suggesting that more perfectionistic patients had less benefit from CBT for HD. ...
... Adjusting for baseline hoarding symptoms, perfectionism (as measured by the perfectionism subscale of the Obsessive Beliefs Questionnaire) was a significant predictor of posttreatment symptoms, suggesting that more perfectionistic patients had less benefit from CBT for HD. Moreover, the authors speculated that future therapy protocols for HD be adapted to more directly target perfectionism (Muroff et al., 2013). Other research has been less clear on the relationship between perfectionism and treatment outcome for OCD-related disorders. ...
Perfectionism is known to be highly prevalent in obsessive-compulsive disorder (OCD). This review seeks to explore perfectionism in OCD and related disorders, particularly in relation to treatment, in order to inform treating clinicians. We also evaluate the potential role of perfectionism in the maintenance of OCD. Evidence supports perfectionism as a transdiagnostic process central to the psychopathology of OCD and other mental illnesses. Treatment outcomes in EX/RP for OCD are diminished in the presence of perfectionism, which is thought to be due to inherent treatment interfering features of perfectionism. Successful OCD treatment has been shown to decrease perfectionistic thinking, though data are mixed on whether reducing perfectionism mediates subsequent reductions in OCD symptoms. Short-term cognitive behavioral protocols for perfectionism are reviewed here and recommendations are made for the treatment of perfectionism in the context of OCD and related disorders.
... Indeed, the association between clutter reduction and more sessions (both in the office and in the home) would suggest that clutter reduction is a timeconsuming and laborious process. Follow-up data do not indicate that clutter continues to decrease after treatment discontinuation, [48] although it could be argued that additional improvement would have occurred with ongoing external support. Additional research is needed to determine whether longer-term practical supports, such as help with sorting and organizing, or physical help with cleaning, would improve the efficacy of treatment on reducing clutter in patients who have received CBT. ...
... The existing research, however, suggests that treatment gains are largely maintained after treatment discontinuation. [48] We also did not include studies in which CBT was combined with alternative treatments. Two studies suggest that various forms of cognitive remediation, when added to CBT, might have a beneficial impact on cognitive function [73] or on HD severity. ...
(Appeared originally in Depression and Anxiety 2015; 32:158-166).
... Indeed, ongoing improvements in clutter levels have been one of the concerns with CBT for HD. Although limited information is available on treatment follow-up, what has been found is that the reduction in clutter is likely to stall post-treatment and no further discarding occurs without further intervention (Muroff, Steketee, Frost, & Tolin, 2013). ...
... While the CBT protocol calls for skills training in problem solving and organisational skills prior to exposure exercises, the proposed iHACT protocol suggests general ACT skills should be developed (both in the office and in the home) before approaching the actual organising of the home environment. The benefit of early organising and discarding action taken in the CBT protocol may appear to offer swift results for concerned parties; however, the results indicate the CBT for HD treatment does not lead to a further decrease in the volume of the hoard after the treatment program has been completed (Muroff et al., 2013). This stagnation in the hoard volume suggests the skills being taught in CBT for HD may be ineffective in the long term and unable to create lasting change in discarding for some hoarding sufferers . ...
This article offers a practical guide for an acceptance‐based hoarding disorder (HD) treatment protocol for clinicians, which is an augmentation of the cognitive behavioural therapy (CBT) for HD originally developed by Steketee and Frost. Although efficacy research is yet to be conducted on this new protocol, this proposed acceptance and commitment therapy (ACT) protocol for hoarding individuals is presented as a framework for current researchers and clinicians to pioneer evidence‐based efficacy studies. Ongoing improvements in clutter levels have been one of the concerns with CBT for HD. Although limited information is available on treatment follow‐up, what has been found is that the reduction in clutter is likely to stall post‐treatment and no further discarding occurs without further intervention. Thus the urgent need for the inclusion or augmentation of ACT into existing treatment protocols is warranted.
... P159-P166). Furthermore, no study of CBT for HD has lowered symptom severity below the clinical range threshold for HD symptoms on self-report and clinician administered measures (Ayers, Wetherell, Golshan, & Saxena, 2011;Frost et al., 2011;Gilliam et al., 2011;Muroff et al., 2009;Muroff, Steketee, Frost, & Tolin, 2014;Steketee et al., 2010;Steketee, Frost, Wincze, Greene, & Douglass, 2000;Tolin et al., 2007;Turner, Steketee, & Nauth, 2010). To better understand the shortcomings of current behavioral interventions for HD and to improve response to treatment, it is important to understand factors that influence treatment attrition and treatment response. ...
... To date, only a few studies have examined predictors of treatment attrition and response. Initial evidence suggests that homework noncompliance, perfectionism, and gender are predictive of poor treatment outcomes (Muroff et al., 2014;Tolin et al., 2007). In their meta-analysis, Tolin et al. (2015) found that a higher percentage of women enrolled in a trial significantly predicted larger reductions in overall hoarding severity, acquiring and clutter, and reduced difficulties with discarding. ...
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.
... Da mesma forma, pesquisas recentes de Timpano, Shaw, Cougle e Fitch (2014) e Shaw, Timpano, Steketee, Tolin e Frost (2015) demonstraram que a falta de habilidade em tolerar emoções desagradavelmente intensas pode induzir o paciente a manifestar condutas evitativas em diversas situações. Não raro, o curso do TA pode ocorrer concomitantemente a outros transtornos mentais comórbidos, como depressão (Ayers et al., 2014;Muroff, Steketee, Frost, & Tolin, 2014), ansiedade (Brakoulias & Milicevic, 2015), transtorno de déficit de atenção com hiperatividade, transtornos da personalidade e esquizofrenia, entre outros . ...
... No que se refere às principais intervenções terapêuticas estudadas para o tratamento do quadro, pesquisas realizadas por Brakoulias, Eslick e Starcevic (2015), Kress, Stargell, Zoldan, e Paylo (2016) e Muroff e Underwood (2016) destacam a psicofarmacologia e a terapia cognitivo--comportamental (TCC), que aborda os aspectos comportamentais, cognitivos e emocionais do indivíduo para o abatimento dos sintomas. Segundo o modelo cognitivo do TA, são as crenças do paciente que mantêm a sua sintomatologia (Schmidt et al., 2014), de modo que a psicoterapia cognitivo-comportamental consista em reduzir o recolhimento descontrolado dos itens (Wheaton, 2016), bem como promover a organização e a desobstrução do ambiente de convívio (Muroff et al., 2014). Juntamente com a exposição gradual ao descarte dos objetos coletados, realiza-se o processo de reestruturação cognitiva (Tolin, Frost, Steketee, & Muroff, 2015) no intuito de identificar os padrões de pensamento disfuncionais que propiciam a acumulação excessiva e impedem o descarte (Albert et al., 2015;. ...
Accumulation disorder (AD) is characterized by the acquisition of unnecessary items, difficulty in disposing objects, and disorganization of the convivial environment. The case study analyzes personality characteristics and comorbid psychological symptoms in a patient diagnosed with AD. For data collection, a semi-structured interview was used, the Young Schema Questionnaire (YSQ-S2), the Young Parenting Styles Inventory (PSI), the Beck Depression Inventory and the Beck Anxiety Inventory (BDI-II and BAI, respectively), the Lipp Stress Symptoms Inventory (LSSI), and the Rorschach Method. In the results, we observed the presence of Early Maladaptive Schemas (EMS) belonging to the disconnection and rejection domain, suggesting a connection between AD symptoms and negative emotional experiences experienced by the patient during childhood. In the future, new studies with a cross-sectional design are recommended in order to substantiate the results obtained by the present research. © 2017 Instituto Brasileiro de Avaliacao Psicologica. All rights reserved.
... Frost andGross (1993) found strong correl ati ons bet ween all subscales of the Frost Multidimensional Perfectionism Scale, including both evaluative concerns and striving components and hoarding symptoms. Not only is perfectionism associated with hoarding pathology, but Muroff et al. (2014) found that high levels of perfectionism interfere with treatment outcome for individuals with HD. In most of these studies, it was the evaluative concern dimension of perfectionism that showed the closest association with hoarding, characterized by overly critical self-evaluation and fears of making mistakes (Frost et al. 1990). ...
... Reducing evaluative concerns may reduce these avoidance behaviors that contribute to the disorder. Recent evidence strengthens these conclusions suggesting that perfectionism in people with HD may interfere with treatment outcome (Muroff et al. 2014). With respect to the second component of the bidimensional model of perfectionism, achievement striving, the analyses indicated that, consistent with prior literature (Frost et al. 1990), striving for high goals and concerns about performance evaluation are not similarly related to psychopathology. ...
Hoarding disorder is a new DSM-5 disorder that causes functional impairment and affects 2 to 6% of the population (Frost and Steketee 2014). The current study evaluated a multiple mediation model with 243 undergraduate women in which indecisiveness (VOCI; Thordarson et al. Behaviour Research and Therapy, 42(11), 1289-1314, 2004) and decisional procrastination (DPS; Mann 1982) mediated the relationship between dimensions of perfectionism (F-MPS-B; Burgess et al. 2016a) and hoarding behavior (SI-R; Frost et al. Behaviour Research And Therapy, 42(10), 1163–1182, 2004) and excessive acquiring (CAS; Frost et al. Annual Review of Clinical Psychology, 8, 219–242, 2012). Multiple mediational analyses indicated a significant indirect effect for decisional procrastination, but not indecisiveness, in mediating evaluative concerns (but not striving) to SI-R Total, SI-R Clutter, SIR Excessive Acquisition, and both CAS subscales. Both mediators were significant pathways between evaluative concerns and SI-R Difficulty Discarding. These findings support a cognitive behavioral model of hoarding, suggesting that evaluative concerns produces problems in decision-making that influence acquisition, discarding, and clutter.
... Interventions will necessarily vary according to the typology of the hoarder, with some types more amenable to treatment than others. Below are some potential issues relevant to most animal hoarders and guidelines for intervention (Nathanson 2009;Muroff et al. 2014): ...
... 7. Comorbid disorders must be addressed: It is likely that animal hoarders are suffering from one or several other psychological disorders. Several conditions show elevated rates of comorbidity with HD: depression (50.7 %), social anxiety (23.5 %), OCD (18 %), attention-deficit disorder (28 %) (Frost et al. 11), and perfectionism (Muroff et al. 2014). These disorders may well have a negative impact upon treatment delivery, patient adherence, and outcomes. ...
Depending on theoretical bent, target populations treated, and personal style, therapists develop their own ways of joining, connecting, or establishing a working alliance with their clients. Common tactics involve adopting the clients’ language, using candid language or straight talk, acknowledging a personal interest of the client (vocational or avocational), empathizing with the clients’ feelings, and exploring the clients’ views of the therapy and therapist. See Shapiro et al. (2014, pp. 26–30) for discussion of this initial phase of therapy in working with children. Clients’ views of the therapy are particularly important when working with adult clients who abuse animals as they often are court ordered to be in counseling. In addition to exploring the clients’ feelings (“I didn’t do anything wrong,” “I really don’t have time for this,” “I am just here ‘cause the judge told me to come”), the therapist at the outset needs to clarify his or her own relation to the court. Understandably, the client is concerned that the therapist is at best wearing two hats, one as agent of the court and another as human service provider—“Who are you working for, anyway?” To begin to gain the trust of the client, the therapist needs to acknowledge the issue that the therapy is court ordered as he or she and the client negotiate goals of the therapy (see discussion in “True Intentions” exercise below). The issue also colors and complicates the problem of client accountability which presents another block to establishing a working relation—discussed immediately below.
... To our knowledge, only one study (Muroff, Steketee, Frost & Tolin, 2014) ...
... has examined CONTINGENCY MANAGEMENT FOR HOARDING DISORDER 25 maintenance of gains after any treatment for hoarding disorder. TheMuroff et al. (2014) study suggested that while there was heterogeneity in outcome after treatment, most participants who had completed group CBT for hoarding maintained gains but did not continue to improve noticeably after treatment end. Therefore, creating maximal change while participants are still in treatment may be key. ...
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 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.
... Within populations with hoarding disorder, individuals who excessively acquire unneeded items as part of their hoarding symptomatology have been found to have higher levels of perfectionism than individuals who do not currently excessively acquire (Frost et al., 2013). Unfortunately, perfectionism has also been linked to poorer treatment outcomes in one study of cognitive-behavioral therapy for hoarding behaviors (Muroff et al., 2014). As such, examination of the relationship between perfectionism and hoarding behaviors is necessary to illuminate the role that perfectionism may play in hoarding behaviors and how it may be best targeted in treatment. ...
... Individuals with HD report a very poor quality of life, equivalent to those with schizophrenia (Ong et al., 2015;Saxena et al., 2011;Tolin et al., 2019). Tolin, Frost, and Steketee (Muroff et al., 2014;Tolin et al., 2007) developed a specific cognitive-behavioral therapy (CBT) for HD, with treatment strategies derived from the cognitive-behavioral model. In this model, hoarding is conceptualised as a multi-faceted problem that results from information processing deficits, problems with emotional attachment, rigid beliefs about saving possessions, and behavioral avoidance (Frost and Hartl, 1996). ...
Background
Cognitive-behavioral group therapy for hoarding disorder (HD) is efficacious, but outcomes are modest and dropout rates are generally high. Clinical challenges in this population include high rates of comorbidity and difficulty regulating and tolerating negative emotions, which may reduce engagement with discarding exposures and lead to increased dropout.
Methods
In the current naturalistic study, we evaluated standard group cognitive-behavioral therapy enhanced with a three-session emotion regulation module in a large sample of individuals (N = 115) seeking treatment for HD at a community mental health clinic. We evaluated outcomes for distress tolerance, as well as hoarding symptoms and comorbid depression and anxiety symptoms.
Results
Distress tolerance was significantly improved at post-treatment, Hoarding symptoms, anxiety, and depression were also significantly decreased. Distress tolerance predicted more severe hoarding symptoms at baseline, but improvement in distress tolerance was not significantly associated with improvement in hoarding symptoms.
Limitations
The primary limitation was the absence of a control treatment condition, but HD is known to be a chronic condition which tends not to improve in waitlist control conditions.
Conclusions
Integrating emotion regulation strategies may provide an important pathway to improving treatment outcomes for hoarding disorder.
... Within the OCD domains, perfectionism has been defined as the belief that "There is only one right way to do things and includes one's own and other performance and that the achievement of such perfection is not only desirable but highly necessary" (OCCWG, Obsessive Compulsive Cognitions Working Group, 1997;2003). Perfectionism, as a maladaptive trait dimension, has been shown to impede OCD treatment, suggesting that future therapy protocols for OCD should be adapted to more directly target perfectionism (Muroff et al., 2014). ...
One of the most used instruments to assess perfectionism is Hewitt and Flett's Multidimensional Perfectionism Scale (HFMPS). This article reports result of two studies aimed at evaluating and comparing two short HFMPS versions provided by literature in Italian samples. In Study 1, two previously proposed short forms–Cox and colleagues' and Hewitt and colleagues'–were compared in terms of factor structure and concurrent validity in a community sample of 324 participants. In Study 2, validity and reliability of the two short scales in 102 university students and 58 patients with a primary diagnosis of Obsessive-Compulsive Disorder were examined. Results revealed mixed findings concerning which of the two short form should be preferred.
... However, despite these promising results, there is still significant room for improvement, as most patients who complete a course of CBT for HD do not achieve clinical remission . There is some preliminary evidence to suggest that more severe HD symptoms, comorbid social anxiety symptoms, higher levels of perfectionism, and male gender predict worse outcomes in HD treatment (Muroff et al., 2014), however, further research is needed. Another contributing factor to the poor outcomes for those with HD may be that many patients with HD show poor or variable compliance with treatment (Tolin et al., 2019), and this is likely to affect treatment outcomes. ...
Hoarding disorder (HD) is a new psychiatric diagnosis in Diagnostic and Statistical Manual of Mental Disorders–Fifth edition and preliminary evidence suggests that cognitive-behavioral treatments are effective in treating this condition. However, it has been demonstrated that individuals with HD generally display poor compliance during treatment, which may lead to poor outcomes. Treatment compliance can be conceptualized as either within-session or between-session compliance, but currently there are no validated measures of within-session or between-session compliance specifically for HD. The aim of this study was to provide an initial validation of the CBT Compliance Measure and the Patient Exposure/Response Prevention Adherence Scale for Hoarding in a sample of participants with HD who were undergoing group cognitive behavioral therapy (CBT) for HD (N = 70). Both measures, which were administered at each relevant treatment session, demonstrated a unidimensional structure, good reliability, as well as predictive validity, and are thus promising in the measurement of within-session and between-session compliance with CBT for HD.
... In contrast, the World Health Organization's International Classification of Diseases new edition considers excessive acquisition as a core symptom of hoarding disorder. Furthermore, core hoarding symptoms display differential responses to treatment, with difficulty discarding and acquiring being more sensitive to intervention than clutter (Muroff, Steketee, Frost, & Tolin, 2014;. ...
Hoarding disorder is marked by strong attachments to everyday objects, extreme difficulties discarding, and impairing levels of clutter. We examined the associations between hoarding symptoms and associated clinical features using network analysis in a large sample of individuals with established hoarding disorder (n = 217) and matched healthy controls (n = 130). Network nodes included the three core features of hoarding (difficulties discarding, clutter, and acquiring), along with comorbid symptoms, impairment, and saving and acquiring motives. Models showed hoarding and comorbid symptoms as separate syndromes. Healthy and patient networks differed significantly in both global network strength and structure. For the hoarding patient network, the comorbidity and hoarding clusters were connected by acquiring and anxiety, which served as bridge symptoms. Clutter was the only hoarding node associated with impairment. Hoarding beliefs were not central to the model, and only difficulties discarding was associated with saving and acquiring motives, including emotional attachment and wastefulness beliefs. Our findings indicate that the network approach to mental disorders provides a new and complementary way to improve our understanding of the etiological model of hoarding, and may present novel hypotheses to examine in treatment development research.
... Studies have supported the efficacy of CBT, with or without exposure, for the treatment of anxiety disorders in general (Barlow et al., 2015;Kaczkurkin & Foa, 2015;Kishita & Laidlaw, 2017); for social anxiety (Mayo-Wilson et al., 2014;Norton et al., 2015); for hoarding (Muroff et al., 2014;Tolin, Frost et al., 2015); for obsessive-compulsive disorders (Öst et al., 2015;Franklin & Foa, 2011); for posttraumatic stress disorder (Botella et al., 2015;Chen et al., 2015;Cusack et al., 2016); for specific phobia (Galvao-de Almeida et al., 2013;Öst & Reuterskiöld, 2013); and for panic disorders (Pompoli et a., 2018;Westphal et al., 2015). ...
The chapter presents an overview of the application of cognitive-behavioral therapy in clinical social work practice with adults.
... In addition to investigating the effectiveness of CBT protocols for hoarding symptoms, research has also begun to examine other variables that may change across treatment or help moderate or predict treatment outcome. For example, research suggests that male gender, higher pretreatment severity and higher perfectionism are associated with poorer treatment outcome (Muroff, Steketee, Frost, & Tolin, 2014). A recent study found that changes in hoarding cognitions mediated change in symptom severity (Levy et al., 2017). ...
Cognitive behavioural therapy (CBT) for problematic hoarding is an effective treatment, but further research in diverse, naturalistic settings is needed to see whether this treatment is effective across settings and in smaller doses. The current study investigated the outcome of a 12-session group CBT for hoarding offered in an outpatient hospital setting. Sixty-four participants completed therapy, and 38 participants completed posttreatment assessments. Results demonstrated statistically significant improvements in hoarding symptom severity, saving cognitions, and self-reported distress tolerance. Effect sizes for changes in saving cognitions were generally large. However, effect sizes were modest for most other outcome variables, and only 4 of 38 participants achieved clinically significant change in hoarding symptom severity. These results suggest that 12 sessions of group CBT for hoarding is associated with significant change in saving cognitions, but less meaningful change in other indicators of symptom severity.
... Second, there was no follow-up assessment after treatment; therefore, it is unclear whether treatment gains were maintained after treatment discontinuation. This concern is attenuated somewhat by the findings of Muroff, Steketee, Frost, and Tolin (2014), who found generally strong maintenance of treatment gains 1 year after individual CBT for HD. Nevertheless, it is important to examine the long-term efficacy of Group CBT for HD. ...
Objective:
Hoarding disorder (HD) is a common and potentially debilitating psychiatric disorder. Thus far, psychological treatments have yielded modest effects and/or were time-consuming and costly to deliver. The aim of the present study was to test the efficacy of a brief group cognitive-behavioral therapy (CBT) for adults with HD and to test hypothesized mediators of treatment outcome.
Method:
Eighty-seven adults with a primary diagnosis of HD were randomized to either immediate CBT or wait list. CBT consisted of 16 weekly, 90-min group sessions that emphasized in-session practice of discarding and refraining from acquiring, decision-making and problem-solving training, emotional distress tolerance, motivational interviewing strategies, and contingency management. Participants were assessed at pretreatment, midtreatment, and posttreatment by an independent evaluator unaware of treatment condition.
Results:
CBT was efficacious for the symptoms of HD compared with wait list. Saving-related cognitions, but not subjective cognitive impairment, partially mediated treatment outcomes.
Conclusion:
Brief Group CBT is an efficacious and feasible treatment for adults with HD, and is partially mediated by reductions in maladaptive beliefs about possessions. Superiority trials comparing CBT to active treatments, and additional research into mechanisms of treatment outcome, are warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... • CBT for HD typically requires more sessions than CBT for other mental health conditions and most clients will need many more sessions than allotted through the Australian Government's Better Access to Mental Health Care Initiative. • Treatment outcomes are generally maintained up to 12 months post-treatment (Muroff, Steketee, Frost, & Tolin, 2014). • Even after current best-practice treatment, most individuals with HD will remain symptomatic (Tolin, Frost, Steketee, & Muroff, 2015) with significant clutter and functional impairment. ...
... Future research may establish which hoarding-related variables may predict treatment outcomes. So far, worse outcomes have been linked to male gender, sever hoarding to lack of insight, social anxiety, and pathological personality aspects such as perfectionism [89]. ...
This brief review deals with the various issues that contributed to the creation of the new Diagnostic and Statistical Manual condition of hoarding disorder (HD) and attempts at reviewing its pharmacotherapy. It appears that after the newly founded diagnosis appeared in the literature as an autonomous entity, distinct from obsessive-compulsive disorder, drug trials are not being conducted and the disorder is left in the hands of psychotherapists, who on their part, report fair results in some core dimensions of HD. The few trials on HD specifically regard the serotonin-noradrenaline reuptake inhibitor venlafaxine, and, possibly due to the suggestion of a common biological background of HD with attention-deficit/hyperactivity disorder, the psychostimulant methylphenidate and the noradrenaline reuptake inhibitor atomoxetine. For all these drugs, positive results have been reported, but the evidence level of these studies is low, due to small samples and non-blind designs. Regretfully, there are currently no future studies aiming at seriously testing drugs in HD.
... There is a growing body of research on various treatment programs to aid recovery from object hoarding (Muroff, Steketee, Frost, & Tolin, 2014). However, treatment of compulsive hoarding is characterized by high dropout rates and poor treatment outcomes when compared with non-hoarding OCD patients (Frost, Tolin, & Maltby, 2010). ...
Animal hoarding has been considered a significant problem by animal welfare and law enforcement professionals for over a century. However, it has only been recognized as an indication of a mental disorder in the last decade. I review the different forms that animal hoarding can take and the current understanding of the prevalence, demographics and possible etiology of this disorder. Conventional animal cruelty laws have often been inadequate to respond to animal hoarding cases until they reach levels that may involve serious harm to animals and people. I document how prosecution of such cases can be difficult and often does not adequately consider the mental health issues underlying the problem or the high likelihood of recidivism. Attempts to solve these problems by enacting new laws specifically addressing animal hoarding have been controversial and ineffective. I explore new approaches that coordinate a variety of community resources in response to hoarding cases that offer the best opportunity to respond to both the human and animal problems associated with animal hoarding.
... gender, less severe pre-treatment hoarding severity, co-occurring anxiety or depressive symptoms and in one study, treatment adherence). 11,13,16 None of the variables examined in previous studies were consistently found to predict treatment outcome. Given its chronic nature and high degree of functional impairment, 2 there continues to be a pressing need to identify predictors of treatment response for hoarding disorder. ...
Background
Treatment for hoarding disorder is typically performed by mental health professionals, potentially limiting access to care in underserved areas.
Aims
We aimed to conduct a non-inferiority trial of group peer-facilitated therapy (G-PFT) and group psychologist-led cognitive–behavioural therapy (G-CBT).
Method
We randomised 323 adults with hording disorder 15 weeks of G-PFT or 16 weeks of G-CBT and assessed at baseline, post-treatment and longitudinally (≥3 months post-treatment: mean 14.4 months, range 3–25). Predictors of treatment response were examined.
Results
G-PFT (effect size 1.20) was as effective as G-CBT (effect size 1.21; between-group difference 1.82 points, t = −1.71, d.f. = 245, P = 0.04). More homework completion and ongoing help from family and friends resulted in lower severity scores at longitudinal follow-up ( t = 2.79, d.f. = 175, P = 0.006; t = 2.89, d.f. = 175, P = 0.004).
Conclusions
Peer-led groups were as effective as psychologist-led groups, providing a novel treatment avenue for individuals without access to mental health professionals.
Declaration of interest
C.A.M. has received grant funding from the National Institutes of Health (NIH) and travel reimbursement and speakers’ honoraria from the Tourette Association of America (TAA), as well as honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. K.D. receives research support from the NIH and honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. R.S.M. receives research support from the National Institute of Mental Health, National Institute of Aging, the Hillblom Foundation, Janssen Pharmaceuticals (research grant) and the Alzheimer's Association. R.S.M. has also received travel support from the National Institute of Mental Health for Workshop participation. J.Y.T. receives research support from the NIH, Patient-Centered Outcomes Research Institute and the California Tobacco Related Research Program, and honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. All other authors report no conflicts of interest.
... The social, economic and personal costs of hoarding have spurred efforts to develop and disseminate efficacious treatments. Although HD was traditionally considered treatment resistant (Frost, 2010;Abramowitz et al., 2003), cognitive behavioral therapy (CBT) protocols adapted for HD have demonstrated promising outcomes in the reduction of hoarding symptom severity (Gilliam et al., 2011;Muroff et al., 2014;Tolin et al., 2007;Steketee et al., 2010; also see review by Tolin et al., 2015). ...
... Additionally, hoarding problems are related to greater anthropomorphic tendencies (Neave et al., 2015). Given that poor treatment outcomes are common for individuals with hoarding disorder (Ayers, Wetherell, Golshan, & Saxena, 2011;Muroff, Steketee, Frost, & Tolin, 2014), understanding the relationship between anxious attachment and anthropomorphism may be helpful in enhancing cognitive-behavioral treatment. If hoarding disorder is in part the result of anxious attachment style that facilitates the use of anthropomorphism to derive comfort from objects rather than human relationships, clinicians may be able to enhance treatment outcomes by addressing the cause and consequences of an anxious attachment style. ...
A systematic review of the literature was conducted to evaluate whether an insecure attachment style is associated with greater anthropomorphic tendencies. We searched eight electronic databases and checked reference lists for eligible studies. After removing duplicates, 1022 titles and abstracts were appraised for eligibility. Eligible studies were those that assessed insecure attachment and anthropomorphism of non-living entities, presented original data, contained sufficient data for computing effect sizes, and were written in English. We deemed 30 articles potentially eligible and read their full texts. Six studies were eligible, with a total of 1341 participants. A quality assessment tool was used to assess the quality of the included studies. Two independent raters achieved 85% agreement on the quality appraisal of the studies. The quality of the included studies was poor, with 10.7% of items coded zero (did not meet criterion at all), and an overall average quality rating of 60%. A narrative review of the eligible studies highlighted that anxious attachment and anthropomorphic tendencies are positively and moderately related, but that attachment avoidance is not related to anthropomorphism. Given the poor quality of the research to date, better quality research is needed to more conclusively establish whether and how insecure attachment styles are related to anthropomorphic tendencies.
... Although we chose to add online clinician support to group CBT throughout the whole treatment, other combinations are also worth taking into consideration. Given that further treatment gains after completed CBT are rare (Muroff, Steketee, Frost, & Tolin, 2013), future studies may wish to examine whether the addition of therapist support through COMMIT after treatment termination could lead to long-term improvements and come at a low cost. Alternatively, Internet support could be offered prior to CBT as a stepped care approach for individuals at risk for developing HD or instead of face-to-face CBT for highly motivated individuals with HD. ...
Objective:
Hoarding disorder (HD) is difficult to treat. In an effort to increase efficacy and engagement in cognitive-behavioral therapy (CBT), we developed and evaluated a novel intervention comprising group CBT combined with between-session Internet-based clinician support for people with HD.
Method:
Twenty participants with HD received group CBT combined with an Internet-support system enabling therapist-participant communication between group sessions.
Results:
The treatment was associated with a significant reduction on the Saving Inventory-Revised (SI-R) and a large effect size (Cohen's d = 1.57) was found at posttreatment. Treatment gains were maintained at the 3-month follow-up. Group attendance was high and no participants dropped out from treatment prematurely. Between-session motivational support from the therapist was most frequently mentioned as the main strength of the system.
Conclusion:
The results of this study support adding Internet-based clinician support to group CBT for HD to increase treatment adherence and, potentially, improve the overall efficacy of CBT.
... A variety of treatment trials have supported the validity of cognitive-behavioral therapy (CBT) in reducing symptom severity in HD (Frost, Pekareva-Kochergina, & Maxner, 2011;Moulding, Nedeljkovic, Kyrios, Osborne, & Mogan, 2016;Muroff, Steketee, Frost,-& Tolin, 2014;Steketee, Frost, Tolin, Rasmussen, & Brown, 2010). However, clinically significant change in total HD severity is only observed in approximately 35% of cases, highlighting the room for further improvement in treatment (Tolin, Frost, Steketee, & Muroff, 2015). ...
Hoarding disorder is a disabling psychiatric disorder, characterized by the acquisition and retention of possessions to the point where it negatively impacts the individual's life, regardless of the value of the items. While treatments for hoarding disorder are promising, the chronic and egosyntonic nature of the disorder means that further development of the underlying theoretical model of hoarding is important in order to improve treatments. In particular, one aspect of hoarding disorder that has not received specific theoretical emphasis is the link between possessions and the self-concept, reflecting notions dating back to William James that what we own can come to define who we are. The purpose of the current review is to specifically examine literature pertinent to the link between possessions and the self-concept in hoarding disorder. The paper includes an examination of the various definitions of self, a review of literature relevant to self in hoarding, an integration of consumer psychology perspectives, and a discussion of treatment implications. The review highlights the need for more dedicated research, the development of an appropriate quantitative measure relevant to the link between possessions and the self-concept, and investigation into possible underlying factors for this link. Potential implications for treatment are highlighted.
... These results are supported by consistent findings of an association between high levels of perfectionism and hoarding symptoms (Frost & Gross, 1993;Frost, Rosenfield, Steketee, & Tolin, 2013;Martinelli, Chasson, Wetterneck, Hart, & Björgvinsson, 2014;Timpano, Exner, et al., 2011). Though initially this process may appear helpful, it can reflect an inability to prioritise appropriately, paradoxically increasing the difficulty of the plan (Ayers et al., 2012), and is therefore likely to affect treatment outcomes (Muroff, Steketee, Frost, & Tolin, 2013). It also highlights the tendency to focus on specific details, with a difficulty in attending to the more global picture, which is also demonstrated in the studies examining completion of the RCFT (Hartl et al., 2004). ...
Individuals with ADHD and comorbid hoarding disorder are vulnerable to severe consequences from hoarding symptoms. Despite this, and the early onset of hoarding disorder, the nature of hoarding symptoms in children with comorbid ADHD is unknown. We therefore explored the phenomenology of hoarding symptoms among ten 8–12 year olds with ADHD and clinically significant hoarding symptoms through parental perceptions. Parents completed in-depth semi-structured interviews. The data was analysed using Interpretative Phenomenological Analysis. Six superordinate themes were identified: emotional distress; parental avoidance and accommodating behaviours; family impacts of hoarding; excessive acquisition and saving; executive functioning; parental insight and intervention. In contrast to previous suggestions that emotional distress was not associated with hoarding in ADHD, these findings highlight that emotional distress appeared to be core to the hoarding disorder profile of the present sample of children with ADHD. This has important implications for health practitioners who may consider conceptualising, assessing, and treating hoarding symptoms in children with comorbid ADHD using a cognitive behavioural model of hoarding disorder.
... The study by Frost, Pekareva-Kochergina, and Maxner [67] included two separate samples: study 1 and study 2. Study 2 was excluded as inclusion criteria did not limit the participants to those meeting criteria for clinical hoarding (defined as a score of ≥ 41 in the SI-R in study 1 of the same manuscript). Another study [68] was excluded as it was the one-year follow-up of the treatment trial by Steketee, Frost, Tolin, Rasmussen, and Brown [69], and therefore used the same sample. ...
Hoarding Disorder (HD) is characterized by difficulty discarding and parting with possessions, resulting in the accumulation of belongings that congest and clutter active living areas and compromises their use. While HD is thought to be a universal phenomenon, the phenomenological, epidemiological, and clinical research studies published to date have mainly been conducted in Western, industrialized countries, precluding conclusions about the prevalence and phenomenological differences that may exist across cultures in the expression of HD. A systematic review of treatment studies in HD, revealed that all have been carried out in the US and have included a large majority (about 90%) of White/Caucasian individuals, making it difficult to ascertain whether existing treatments are equally effective for minority groups. There is a need to consider HD from a transcultural perspective in order to understand the expression of this disorder across different cultures and ethnic groups. We highlight areas of priority for future studies to ensure that the conception of hoarding and its study is inclusive, sensitive, and informative.
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.
The application of cognitive behavioral therapy (CBT) for hoarding disorder (HD) is described. We describe the components of CBT for HD and provide examples of how this treatment was implemented with two individuals at our clinic, one in group treatment and the other in individual therapy. These case examples are used to highlight a process of troubleshooting common barriers to treatment, enhancing motivation, creating structure, and assessing treatment progress. We compare the group and individual treatment for HD and discuss the pros and cons of each approach. Furthermore, we emphasize the importance of in-session practice, accountability and clear expectations, and realistic goal-setting across individual and group treatment. Finally, based on the cases included here, we highlight the need for additional research to extend CBT for HD (e.g., additional modules to help family members support a loved one in treatment for HD).
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.
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.
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
Hoarding disorder is characterized by difficulty parting with possessions because of strong urges to save the items. Difficulty discarding often includes items others consider to be of little value and results in accumulation of a large number of possessions that clutter the home. Cognitive-behavioral therapy (CBT) with exposure and response prevention and selective serotonin reuptake inhibitor medications traditionally used to treat obsessive-compulsive disorder are generally not efficacious for people with hoarding problems. A specialized CBT approach for hoarding has shown progress in reaching treatment goals and has been modified to be delivered in group, peer-facilitated, and virtual models. Research on hoarding remains in the early phases of development. Animal, attachment, and genetic models are expanding. Special populations, such as children, older adults, and people who do not voluntarily seek treatment need special consideration for intervention. Community-based efforts aimed at reducing public health and safety consequences of severe hoarding are needed.
Hoarding disorder is a common and debilitating mental illness with a high public health burden. Current cognitive behavioral therapy (CBT) improves hoarding disorder symptoms, yet many patients refuse treatment, drop out prematurely, or remain symptomatic at treatment end. Additional approaches are needed to improve CBT engagement and enhance treatment outcomes. One possible strategy is imaginal exposure—or envisioning one’s worst case scenario (e.g., throwing something out that is then needed)—to facilitate learning to tolerate the associated distress and uncertainty. Imaginal exposure has been shown to be efficacious for disorders with similar underlying processes as hoarding disorder, including obsessive-compulsive disorder and generalized anxiety disorder; yet it has not been adapted for or investigated in hoarding disorder. To test the effects of imaginal exposure, eight adults with hoarding disorder participated in a written imaginal exposure for 20 minutes daily for three consecutive days. Participants were asked to write about their worst-case scenario related to discarding a possession. Results indicate that this intervention was tolerable, acceptable, and may reduce hoarding disorder-related symptoms, suggesting that it merits further investigation in a larger pilot trial. To our knowledge, this is the first study testing the effects of imaginal exposure in individuals with hoarding disorder.
Hoarding can be a challenging psychological and social problem. It involves both excessive acquisition and difficulty discarding old used possessions. Approximately 5% of the population shows some degree of hoarding behavior and 20% of the population encounters difficulty discarding possessions. Strong emotion is often experienced when attempting to discard possessions. Using CBT, information processing deficits, dysfunctional beliefs about possessions, behavioral avoidance, and emotional attachment to possessions are addressed.
While the hoarding of physical objects has been extensively explored, there is little research relating to the hoarding of digital materials. The research that has been conducted suggests that digital hoarding (DH) behaviours appear to have some similarities with physical hoarding (PH) behaviours, and can be just as psychologically distressing. This study uses the framework of the cognitive behavioural model of PH to explore DH behaviours, including possible similarities regarding emotional attachment to digital possessions, and possible links with Obsessive Compulsive Disorder (OCD) and indecisiveness. For the study, 282 participants completed an online survey which measured levels of digital and physical hoarding, compulsive acquisition, OCD, indecisiveness and mood. Strong emotional attachments to particular types of digital possessions were evident: this was especially true for photographs and videos. Significant positive relationships were found between all the variables measured. However, a regression analysis revealed that only OCD and PH scores were significant predictors of DH. DH thus appears to share some of the features of PH. Implications, limitations and future research possibilities are discussed.
In a number of scientific fields, researchers need to assess whether a variable has changed between two time points. Average-based change statistics (ABC) such as Cohen's d or Hays' ω 2 evaluate the change in the distributions' center, whereas Individual-based change statistics (IBC) such as the Standardized Individual Difference or the Reliable Change Index evaluate whether each case in the sample experienced a reliable change. Through an extensive simulation study we show that, contrary to what previous studies have speculated, ABC and IBC statistics are closely related. The relation can be assumed to be linear, and was found regardless of sample size, pre-post correlation, and shape of the scores' distribution, both in single group designs and in experimental designs with a control group. We encourage other researchers to use IBC statistics to evaluate their effect sizes because: (a) they allow the identification of cases that changed reliably; (b) they facilitate the interpretation and communication of results; and (c) they provide a straightforward evaluation of the magnitude of empirical effects while avoiding the problems of arbitrary general cutoffs.
A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena - edited by Leonardo F. Fontenelle January 2019
A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena - edited by Leonardo F. Fontenelle January 2019
This chapter reviews the state of the existing literature to assist with case conceptualization rather than a treatment guide, as interventions for hoarding disorder (HD) are still in the formation phase. Early studies linked hoarding behaviors with obsessive-compulsive disorder (OCD), schizophrenia, organic mental disorders, depression, and anorexia nervosa. Distorted thoughts about saving possessions are a hallmark feature of HD and part of the conceptualization of HD. The conceptual model posits that both positive and negative emotions play an important role in HD. The most common intervention for HD is cognitive-behavioral therapy (CBT). Motivational interviewing (MI) is a technique used for a variety of disorders to increase readiness for change prior to embarking on CBT. Most of the treatment manuals for HD and published articles regarding interventions for HD suggest that MI is an important technique to incorporate into treatment, particularly in the beginning and throughout the duration of treatment.
Hoarding symptoms frequently emerge in early adulthood and can result in considerable impairments. Hoarding is related to many other psychological symptoms; however, greater study of hoarding within its context as an obsessive compulsive spectrum disorder, as well the role of attention-deficit/hyperactivity symptoms amongst these disorders, warrants investigation. As such, this study explored the extent and nature of hoarding symptoms, as well as their relationship with other psychopathology, in a college sample. Participants were 578 undergraduate students who completed a series of measures assessing the presence and severity of hoarding, anxiety, depression, stress, obsessive-compulsive, body dysmorphic, trichotillomania, skin picking, and attention-deficit hyperactivity symptoms. Independent samples t-tests did not detect significant differences in frequency of hoarding symptoms among men versus women, or those living alone versus with others; however, hoarding symptoms were significantly more common in individuals with a self-reported family history of hoarding. Correlational analyses found positive relationships between hoarding and all other symptom areas. Results from path analyses suggest that contrary to prior investigations, ADHD symptoms were not uniquely related to hoarding relative to anxiety and other obsessive-compulsive-spectrum pathology. This research may aid in developing a more thorough clinical profile of hoarding symptoms, potentially leading to more effective treatment strategies.
Hoarding disorder (HD) is a severe psychiatric and public health problem characterized by extreme challenges with discarding possessions and severe acquisition resulting in excessive clutter that impairs daily functioning and may cause substantial health and safety risks. Over the past 20 years, research on HD has grown substantially and lead to its recent designation in the DSM-5 as a discrete disorder. The key features of the cognitive behavioral etiological model of hoarding include core vulnerabilities, information processing deficits, cognitions and meaning of possessions, and emotionally driven reinforcement patterns. This model has served as the theoretical foundation for efficacious, specialized cognitive behavioral treatment (CBT) for hoarding and validated hoarding assessment measures. The individual manualized CBT treatment has been adapted for delivery through various modalities (e.g., group, web-based, self-help), populations (e.g., geriatric), and providers (e.g., clinicians, peer support, case managers). While CBT is associated with significant reductions in hoarding severity, clinical levels of hoarding symptoms persist for greater than half of treatment completers; thus, more efficacious treatments need to be developed. Further research is necessary to elucidate components of the CBT model and their interaction, in order to inform treatment targets. Although research on pharmacological treatments for HD is in the nascent stages and extant results are somewhat mixed, future studies may assess medication as a standalone treatment or combined with CBT. Family-focused hoarding interventions may also be important given that persons with hoarding behaviors may have limited insight and motivation and its negative effects on the family. Current data indicate a cost-effective and coordinated response that combines community-based and individualized interventions for hoarding may be optimal in order to (1) reach the broadest group of clients with hoarding (e.g., beyond those who voluntarily seek treatment), (2) maximize incentives and motivation through housing, health services, and safety laws, (3) enhance communication and coordination between diverse teams of providers, (4) provide sustainable comprehensive services in a stepped care approach, and (5) reduce stigma.
The Obsessive Belief Questionnaire (OBQ) and the Interpretation of Intrusions Inventory (III) were designed to assess beliefs and appraisals considered critical to the pathogenesis of obsessions. In previous reports we have described the construction and psychometric properties of these measures. In this study a battery of questionnaires assessing anxiety, depression, and obsessive compulsive symptoms was completed by 410 outpatients diagnosed with obsessive compulsive disorder, 105 non-obsessional anxious patients, 87 non-clinical adults from the community, and 291 undergraduate students. Items from 6 theoretically derived subscales of the OBQ were submitted to factor analysis. Three factors emerged reflecting (1) Responsibility and threat estimation, (2) Perfectionism and intolerance for uncertainty, and (3) Importance and control of thoughts. A 44-item version (OBQ-44) composed of high-loading items from the 3 factors showed good internal consistency and criterion-related validity in clinical and non-clinical samples. Subscales showed less overlap than original scales. Factor analysis of the III yielded a single factor, suggesting the total score be used in lieu of the 3 rationally derived subscales. The scales performed well on tests of convergent validity. Discriminant validity was promising; hierarchical regression analyses indicated that the OBQ subscales and III generally predicted OC symptoms after controlling for general distress. A revision of the OBQ, the OBQ-44, is included in the appendix (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study examined the relationship between perfectionism, as measured by the Multidimensional Perfectionism Scale (MPS;
[R. O. Frost etal. (1990) Cognitive Therapy and Research, 14, 449–468], and treatment outcome in obsessive compulsive disorder (OCD). Patients (n=118) participated in group [McLean etal. (2001) Journal of Consulting and Clinical Psychology, 69, 205–214] or individual [Whittal etal. (2005) Behaviour Research and Therapy, 43, 1559–1576] cognitive therapy (CT) or exposure and response prevention (ERP) for OCD. Doubts about Actions (DA), a subscale
of the MPS, uniquely predicted worse treatment outcome in the Yale-Brown Obsessive-compulsive Scale (YBOCS; [Goodman etal.
(1989) Archives of General Psychiatry, 40, 1006–1011]) total score and compulsions subscale. Interactions between Concern over Mistakes (CM; another MPS subscale)
and DA, as well as DA alone, predicted poorer treatment outcome in patients who received ERP. Contrary to expectations, MPS
total score was not related to treatment response. Moreover, levels of perfectionism did not change over the course of treatment,
regardless of the type of treatment received. Implications for treatment in OCD are discussed.
The present study sought to identify predictors of outcome for a comprehensive cognitive therapy (CT) developed for patients with obsessive-compulsive disorder (OCD).
Treatment was delivered over 22 sessions and included standard CT methods, as well as specific strategies designed for subtypes of OCD including religious, sexual, and other obsessions. This study of 39 participants assigned to CT examined predictors of outcomes assessed on the Yale-Brown Obsessive Compulsive Scale. A variety of baseline symptom variables were examined as well as treatment expectancy and motivation.
Findings indicated that participants who perceived themselves as having more severe OCD at baseline remained in treatment but more severe symptoms were marginally associated with worse outcome for those who completed therapy. Depressed and anxious mood did not predict post-test outcome, but more Axis I comorbid diagnoses (mainly major depression and anxiety disorders), predicted more improvement, as did the presence of sexual (but not religious) OCD symptoms, and stronger motivation (but not expectancy). A small rebound in OCD symptoms at 1-year follow-up was significantly predicted by higher scores on personality traits, especially for schizotypal (but not obsessive-compulsive personality) traits.
Longer treatment may be needed for those with more severe symptoms at the outset. CT may have positive effects not only on OCD symptoms but also on comorbid depressive and anxious disorders and associated underlying core beliefs. Findings are discussed in light of study limitations and research on other predictors.
Compulsive hoarding is a serious health problem for the sufferers, their families, and the community at large. It appears to be highly prevalent and to run in families. However, this familiality could be due to genetic or environmental factors. This study examined the prevalence and heritability of compulsive hoarding in a large sample of twins.
A total of 5,022 twins completed a validated measure of compulsive hoarding. The prevalence of severe hoarding was determined using empirically derived cutoffs. Genetic and environmental influences on compulsive hoarding were estimated using liability threshold models, and maximum-likelihood univariate model-fitting analyses were employed to decompose the variance in the liability to compulsive hoarding into additive genetic and shared and nonshared environmental factors (female twins only; N=4,355).
A total of 2.3% of twins met criteria for caseness, with significantly higher rates observed for male (4.1%) than for female (2.1%) twins. Model-fitting analyses in female twins showed that genetic factors accounted for approximately 50% of the variance in compulsive hoarding, with nonshared environmental factors and measurement error accounting for the other half.
Compulsive hoarding is highly prevalent and heritable, at least in women, with nonshared environmental factors also likely to play an important role.
This article reports on the development of a revised version of the Obsessive-Compulsive Inventory (OCI; E. B. Foa, M. J. Kozak, P. Salkovskis, M. E. Coles, & N. Amir, 1998), a psychometrically sound, theoretically driven, self-report measure. The revised OCI (OCI-R) improves on the parent version in 3 ways: It eliminates the redundant frequency scale, simplifies the scoring of the subscales, and reduces overlap across subscales. The reliability and validity of the OCI-R were examined in 215 patients with obsessive-compulsive disorder (OCD), 243 patients with other anxiety disorders, and 677 nonanxious individuals. The OCI-R, which contains 18 items and 6 subscales, has retained excellent psychometric properties. The OCI-R and its subscales differentiated well between individuals with and without OCD. Receiver operating characteristic (ROC) analyses demonstrated the usefulness of the OCI-R as a diagnostic tool for screening patients with OCD, utilizing empirically derived cutscores.
Obsessive-compulsive disorder (OCD) is clinically heterogeneous. The authors examined how specific OCD symptom dimensions were related to neuropsychological functions using multiple regression analyses. A total of 39 OCD patients and 40 controls completed the Iowa Gambling Task (IGT; A. Bechara, A. R. Damasio, H. Damasio, & S. W. Anderson, 1994), which is a test of decision making, and the Wisconsin Card Sorting Test (R. K. Heaton, 1981), which is a test of set shifting. OCD patients and controls showed comparable decision making. However, patients with prominent hoarding symptoms showed impaired decision making on the IGT as well as reduced skin conductance responses. OCD patients had poorer set shifting abilities than controls, and symmetry/ordering symptoms were negatively associated with set shifting. These results help explain previous inconsistent findings in neuropsychological research in OCD and support recent neuroimaging data showing dissociable neural mechanisms involved in mediating the different OCD symptom dimensions.
Compulsive hoarding is a debilitating problem that is often associated with obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder. However, the precise nosology of compulsive hoarding has yet to be determined.
Participants were 25 patients with severe compulsive hoarding with OCD and 27 patients with severe compulsive hoarding without OCD. Both groups were carefully characterized and compared on the following sociodemographic and clinical variables: precise phenomenology of hoarding behavior, severity of other OCD symptoms, axis I and axis II psychopathology, and adaptive functioning. For comparison purposes, the following individuals were also recruited: 71 patients with OCD without hoarding, 19 patients with anxiety disorder, and 21 community participants.
Overall, the phenomenology of hoarding behavior was similar in the two hoarding groups. The majority of participants in both groups reported hoarding common items as a result of their emotional and/or intrinsic value. However, approximately one-fourth of participants in the compulsive hoarding with OCD group showed a different psychopathological profile, which was characterized by the hoarding of bizarre items and the presence of other obsessions and compulsions related to their hoarding, such as fear of catastrophic consequences, the need to perform checking rituals, and the need to perform mental compulsions before discarding any item. These patients had a more severe and disabling form of the disorder. The strong relationship between compulsive hoarding and obsessive-compulsive personality disorder was explained entirely by the overlapping item content.
In most individuals, compulsive hoarding appears to be a syndrome separate from OCD, which is associated with substantial levels of disability and social isolation. However, in other individuals, compulsive hoarding may be considered a symptom of OCD and has unique clinical features. These findings have implications for the classification of OCD and compulsive hoarding in the next edition of DSM.
The cornerstone of cognitive treatment (CT) for OCD is based upon the knowledge that unwanted intrusions are essentially a universal experience. As such, it is not the presence of the intrusion that is problematic but rather the associated meaning or interpretation. Treatment is flexible, depending upon the nature of the appraisals and beliefs, but can include strategies focused on inflated responsibility and overestimation of threat, importance and control of thoughts, and the need for perfectionism and certainty. The role of concealment and the relationship to personal values are important maintaining and etiological factors. The short-term and long-term treatment outcome is reviewed, along with predictors of treatment response and mechanisms of action, and the chapter concludes with future directions regarding CT for OCD.
Exposure and response prevention (ERP) is one of the oldest and most effective treatments for obsessive compulsive disorder. The present chapter describes the empirical foundations, development, delivery, and latest research on ERP. Commonly used methods and procedural variants of ERP are described, along with findings concerning the underlying mechanisms of action. The efficacy of ERP in relation to other treatments is discussed, in addition to research on the long-term effects of ERP and its effects in non-research settings. Pretreatment predictors of the outcome of treatments using ERP are also considered. Efforts to improve treatment outcome are discussed, including research into the benefits of combining ERP with other psychosocial interventions such as cognitive therapy, or with particular medications. The chapter concludes by considering important future research directions for improving the outcome of treatment packages that include ERP.
Children and adults with obsessive compulsive disorder (OCD) have impairments in social and family functioning, and relatives of those with OCD endorse elevated levels of relationship and psychological distress. The levels of impairments appear equal to or greater than those associated with other disorders. Furthermore, OCD is specifically associated with higher levels of accommodation, or behaviors that facilitate the completion of compulsive rituals, in relatives. Although levels of general social and family impairments do not demonstrate a clear association with treatment response in OCD, higher levels of pretreatment accommodation and hostility in relatives is associated with poorer response to exposure and response prevention (ERP). In contrast, higher levels of nonhostile criticism in relatives may be associated with enhanced response to ERP in patients. Findings are mixed as to whether family-based treatments for OCD, most of which include psychoeducation and attempts to reduce accommodating behaviors in relatives, are associated with enhanced response to ERP.
This chapter provides an overview of the nature of attention deficit/hyperactivity disorder (ADHD); briefly considers its history; and describes its diagnostic criteria, its developmental course and outcomes, and its causes. Critical issues related to these matters are raised along the way. The author's own theoretical model of ADHD is also presented, providing a more parsimonious accounting for the disorder; this model points to numerous promising directions for future research, while rendering a deeper appreciation for the developmental significance and seriousness of ADHD. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(chapter)
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.
The development and validation of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) two companion measures for assessing social phobia fears is described. The SPS assesses fears of being scrutinised during routine activities (eating, drinking, writing, etc.), while the SIAS assesses fears of more general social interaction, the scales corresponding to the DSM-III-R descriptions of Social Phobia—Circumscribed and Generalised types, respectively. Both scales were shown to possess high levels of internal consistency and test–retest reliability. They discriminated between social phobia, agoraphobia and simple phobia samples, and between social phobia and normal samples. The scales correlated well with established measures of social anxiety, but were found to have low or non-significant (partial) correlations with established measures of depression, state and trait anxiety, locus of control, and social desirability. The scales were found to change with treatment and to remain stable in the face of no-treatment. It appears that these scales are valid, useful, and easily scored measures for clinical and research applications, and that they represent an improvement over existing measures of social phobia.
Hoarding is a serious form of psychopathology that has been associated with significant health and safety concerns, as well as the source of social and economic burden (Tolin, Frost, Steketee, & Fitch, 2008; Tolin, Frost, Steketee, Gray, & Fitch, 2008). Recent developments in the treatment of hoarding have met with some success for both individual and group treatments. Nevertheless, the cost and limited accessibility of these treatments leave many hoarding sufferers without options for help. One alternative is support groups that require relatively few resources. Frost, Pekareva-Kochergina, and Maxner (2011) reported significant declines in hoarding symptoms following a non-professionally run 13-week support group (The Buried in Treasures [BIT] Workshop). The BIT Workshop is a highly structured and short term support group. The present study extended these findings by reporting on the results of a waitlist control trial of the BIT Workshop. Significant declines in all hoarding symptom measures were observed compared to a waitlist control. The treatment response rate for the BIT Workshop was similar to that obtained by previous individual and group treatment studies, despite its shorter length and lack of a trained therapist. The BIT Workshop may be an effective adjunct to cognitive behavior therapy for hoarding disorder, or an alternative when cognitive behavior therapy is inaccessible.
Background:
Time-limited group cognitive behavioral treatments (GCBT) for obsessive-compulsive disorder have demonstrated improvement in target symptoms. One small sample study of GCBT specifically for hoarding problems also showed benefit. This study examines the efficacy of a specialized GCBT for compulsive hoarding on a larger sample.
Methods:
Thirty-two clients diagnosed with hoarding participated in five groups. Four groups met once weekly for 2 hour over 16 weeks (n=27) and one group met for 20 weeks (n=5). All participants had two individual 90-min home sessions. Self-report assessments were completed at baseline, mid-treatment, and post-treatment about hoarding behavior and related symptoms (e.g., depression). The sample was predominantly female, White, highly educated, unemployed, and not partnered/married; mean age was 53. A majority was diagnosed with major depressive disorder and obsessive-compulsive personality disorder.
Results:
Participants showed significant improvement from pre- to post-treatment on the Saving Inventory Revised, Saving Cognitions Inventory, Clutter Image Rating, and Clinical Global Severity. The most recent group (n=8) that used a more formalized treatment and research protocol improved significantly more than did earlier members.
Conclusion:
This study demonstrates the feasibility and modest success of GCBT methods in improving hoarding symptoms. Group treatment may be especially valuable because of its cost-effectiveness, greater client access to trained clinicians, and reduction in social isolation and stigma linked to this problem. Further research is needed to improve the efficacy of GCBT methods for hoarding and to examine durability of change, predictors of outcomes, and processes that influence change.
This article reviews the empirical literature on treating clients with hoarding behaviors, including psychosocial treatments,
mainly cognitive behavioral, and pharmacotherapy. Standard treatments used for obsessive compulsive disorder (OCD) such as
medication and/or behavior therapy have been associated with poor treatment response for those with hoarding. Recent prospective
pharmacotherapy research suggests that serotonergic medication may be helpful to OCD patients with or without hoarding. A
multi-component cognitive behavioral treatment (CBT) designed specifically for hoarding has shown promising results especially
in trials of individual therapy with periodic home visits. Social work researchers have played a prominent role in the development
and testing of this CBT intervention and development of instruments to assess hoarding treatment outcomes. This CBT intervention
has demonstrated modest success when delivered individually in an open trial and a waitlist-controlled trial, and in quasi-experimental
studies of group treatment modalities, including in-person and web-based groups as well as bibliotherapy-based support groups.
Overall, evidence supports the use of specialized CBT methods to improve hoarding symptoms. Future testing may include controlled
trials with more diverse samples.
KeywordsHoarding–Cognitive-behavioral treatment–Pharmacotherapy–Review–Evidence based practice
This paper reviews findings of retrospective studies of factors predictive of behavior therapy outcome immediately after treatment or at follow-up for panic disorder with and without agoraphobia and obsessive compulsive disorder. Despite disagreement on some variables, most predictor variables (most demographic variables, severity of symptoms, depression, general anxiety, assertiveness, expectancy and motivation, and treatment context) were not consistently associated with outcome. Severe avoidance behavior and avoidant personality disorder were problematic for agoraphobic clients. Findings for depressed mood were contradictory, and comorbid major depression and other Axis I and II conditions are understudied. Research on marital quality for PDA is also conflicting. Spouse or family involvement in therapy appears more advantageous for PDA than OCD clients. For OCD, insight into the rationality of obsessions has not proven predictive. Therapist qualities associated with outcome varied somewhat with the disorder. Possible reasons for discrepant findings are discussed and implications for treatment regimens and additional research are proposed.
Compulsive hoarding is a little studied phenomenon within the research literature. The information available on compulsive hoarding is diverse and not well integrated. In the present article we propose a tentative cognitive-behavioral model of compulsive hoarding. The purpose of such a model is to provide a framework for the development and testing of hypotheses about compulsive hoarding. In this model hoarding is conceptualized as a multifaceted problem stemming from: (1) information processing deficits; (2) problems in forming emotional attachments; (3) behavioral avoidance; and (4) erroneous beliefs about the nature of possessions. Specific hypotheses about each of these are discussed.
Group cognitive behavioral treatments (GCBTs) for hoarding have produced modest benefits. The current study examined whether the outcomes of a specialized GCBT improve upon bibliotherapy (BIB) for hoarding, as part of a stepped care model. We also explored whether additional home assistance enhanced GCBT outcomes.
Hoarding patients (n = 38) were randomized and completed one of three conditions: (1) GCBT with nonclinician home assistants (GCBT+HA; N = 11), (2) GCBT without HA (CGBT; N = 14), and (3) BIB (N = 13). All GCBT participants received 20 weekly group sessions and four home visits by a group co-therapist. GCBT+HA groups received four additional visits by a nonclinician coach. BIB participants were assigned a self-help book describing specific skills to reduce hoarding over the 20-week period. All participants were assessed by self-report at baseline, mid-treatment, and posttreatment. The sample averaged 57 years old and was mainly female, White, highly educated, employed, and living alone.
GCBT+HA and GCBT participants showed significant reductions on hoarding and depression symptoms, whereas BIB did not. GCBT+HA and GCBT benefited substantially and similarly on the saving inventory-revised (reductions of 29.9 and 23.3%, respectively) and SI-R (Saving Inventory-Revised) (reductions of 26.5 and 25.4%), whereas BIB participants showed very limited improvement (9% reduction) on both measures.
This study provides support for the efficacy of GCBT for hoarding. The effect of adding nonclinician home assistance was not significant in this small sample. BIB was not sufficient to improve hoarding symptoms. The findings have implications for a stepped care model for treating hoarding (e.g., the benefits of psycho-education via BIB, added benefits of extra in-home visits) and suggest the need to further examine the role of in-home hoarding coaches.
Cognitive accounts of obsessive compulsive disorder (OCD) assert that core beliefs are crucial to the development, maintenance, and treatment of the disorder. There are a number of obsessive beliefs that are considered fundamental to OCD, including personal responsibility, threat estimation, perfectionism, need for certainty, importance of thoughts, and thought control. The present study investigated if pretreatment severity of obsessive beliefs, as well as the change in obsessive beliefs following treatment, predicted intensive, residential cognitive behavioral therapy (CBT) treatment outcome. A series of hierarchical regression analyses were carried out to investigate the relations between obsessive beliefs and treatment outcome. Results indicated that inflated pretreatment responsibility/threat estimation beliefs were significantly related to less overall obsessive compulsive (OC) symptom reduction at discharge, explaining 2% of the overall variance. Changes in obsessive beliefs broadly, and importance/control of thoughts specifically, were positively related to overall OC symptom reduction at discharge, respectively explaining 18% and 3.6% variance. Results are modestly consistent with a number of theoretical models, which argue that inflated responsibility, threat estimation, and thought control are important to the maintenance and treatment of OCD.
Current models of hoarding disorder (HD) emphasize problems of decision-making. Evidence for neuropsychological impairment in HD, however, has been mixed. The present study examined whether HD patients show problems of economic reasoning that could be associated with decision-making problems. Forty-two HD patients, 29 obsessive-compulsive disorder (OCD) patients, and 36 healthy control participants completed the Iowa gambling task (IGT), a computerized card playing game that assesses participants' ability to learn and utilize a rule of sacrificing short-term gain for long-term gain, and a cognitive dissonance reduction task that measured changes in preference for items (art prints) after selecting or rejecting them. Results showed no deficits on the IGT for HD participants, and no difference in dissonance reduction results after selecting or rejecting items on the dissonance reduction task. Furthermore, performance on these two tasks was unrelated to hoarding symptom severity or self-reported indecisiveness. It is suggested that the problems of cognitive processing in HD patients may be largely related to as-yet understudied processes, including idiosyncratic categorization problems for personally-owned items as well as other aspects of economic reasoning.
Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment.
Compulsive hoarding is characterized by the acquisition of, and failure to discard, a large number of possessions and clutter that prevents the use of living spaces as intended. Current successful treatments such as individual and group cognitive-behavioral therapy are lengthy and costly, requiring a time commitment ranging from four to twelve months, trained clinicians to administer treatment, and multiple home visits. Nonprofessional interventions may provide a cost-effective pre-treatment, adjunct, or alternative for individuals who want to work on hoarding problems but are unable or unwilling to engage in treatment. The purpose of the present study was to investigate the effectiveness of an innovative program consisting of a 13-session non-professionally facilitated biblio-based, action-oriented support group using Tolin, Frost, and Steketee's (2007b) self-help book. In study 1, seventeen self-identified hoarding participants experienced significant decreases in clutter, difficulty discarding, and excessive acquisition from pre-treatment to post-treatment, with reductions evident at mid-treatment. Study 2 replicated the findings of study 1 using interview and observational measures taken in participants' homes. These findings suggest that a facilitated biblio-based group may be a promising intervention for hoarding disorder.
This investigation examined response to a manualized cognitive-behavioral therapy (CBT) protocol for compulsive hoarding (Steketee & Frost, 2007) in a sample of 12 adults over age 65. All participants were cognitively intact, not engaging in any other psychotherapy, and had compulsive hoarding as their primary problem. All received 26 sessions of individual CBT over the course of 17 weeks. The primary outcome measures were the Savings Inventory-Revised and UCLA Hoarding Severity Scale, which were administered at baseline, mid-treatment, post-treatment, and 6-month follow-up. Other outcomes included Clinical Global Impression (CGI) scores, depression, anxiety, disability, and clutter image ratings. Results demonstrated statistically significant changes on hoarding severity and depression. However, only three of the twelve participants were classified as treatment responders at post-treatment, and their gains were not maintained at 6-month follow-up. CGI, anxiety, disability, and clutter ratings were unchanged at post-treatment and follow-up. No participants dropped out, but homework compliance was variable and correlated with decreases in hoarding severity. Findings suggest that older adults with compulsive hoarding may require an enhanced or alternative treatment.
Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM-5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large-scale study of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures.
We compared psychiatric comorbidity in a large HD sample (n = 217) to 96 participants meeting criteria for OCD without HD.
High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition-related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition-related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%).
These findings form important base rates for developing research and treatments for hoarding disorder.
Compulsive hoarding, characterized by the acquisition of and failure to discard a large number of possessions, is increasingly recognized as a significant public health burden. Many facets of the phenomenology, including an understanding of the population prevalence and associated features, are not yet fully understood. There is growing evidence that hoarding may warrant its own diagnosis in DSM-5, and it is therefore imperative to investigate the proposed cardinal symptoms along with correlated features that may be diagnostically relevant.
The present investigation examined the point prevalence of hoarding disorder in a nationally representative sample from the German population (N = 2,512). The hoarding definition considered in this study was derived from the Hoarding Rating Scale (HRS) and informed by 3 of the proposed DSM-5 criteria. Several hypothesized core components of hoarding disorder were also assessed using questions from the HRS and the UCLA Hoarding Severity Scale, including types of acquisition, perfectionism, indecision, procrastination, distress, and impairment. Data were collected from May 16, 2009, to June 19, 2009.
Analyses revealed a current population estimate of 5.8%. Hoarding prevalence did not differ between men and women. Hoarders were significantly more likely to buy items, acquire free things, and steal items they did not need, compared to nonhoarders (P < .001). Perfectionism, indecision, and procrastination were all uniquely and significantly associated with hoarding status (P < .001). Relationships between the proposed core features and distress/impairment are also detailed.
The current investigation identified the proposed hoarding disorder as a highly prevalent syndrome; however, it should be noted that we were not able to fully ascertain the DSM-5 criteria and that the current estimate may be higher than the actual population rate. Future research on the diagnostic criteria and associated features will be necessary to help clarify etiologic underpinnings, treatment efforts, and diagnostic nosology.
Despite elevated rates of obsessive compulsive personality disorder (OCPD) in patients with obsessive compulsive disorder (OCD), no study has specifically examined comorbid OCPD as a predictor of exposure and ritual prevention (EX/RP) outcome. Participants were adult outpatients (n = 49) with primary OCD and a Yale-Brown Obsessive Compulsive Scale (YBOCS) total score ≥ 16 despite a therapeutic serotonin reuptake inhibitor dose for at least 12 weeks prior to entry. Participants received 17 sessions of EX/RP over 8 weeks. OCD severity was assessed with the YBOCS pre- and post-treatment by independent evaluators. At baseline, 34.7% of the OCD sample met criteria for comorbid DSM-IV OCPD, assessed by structured interview. OCPD was tested as a predictor of outcome both as a diagnostic category and as a dimensional score (severity) based on the total number of OCPD symptoms coded as present and clinically significant at baseline. Both OCPD diagnosis and greater OCPD severity predicted worse EX/RP outcome, controlling for baseline OCD severity, Axis I and II comorbidity, prior treatment, quality of life, and gender. When the individual OCPD criteria were tested separately, only perfectionism predicted worse treatment outcome, over and above the previously mentioned covariates. These findings highlight the importance of assessing OCPD and suggest a need to directly address OCPD-related traits, especially perfectionism, in the context of EX/RP to minimize their interference in outcome.
This article describes the development and validation of the Hoarding Rating Scale-Interview (HRS-I), a brief (5-10 min) five-item semi-structured interview that assesses the features of compulsive hoarding (clutter, difficulty discarding, acquisition, distress and impairment). Trained interviewers administered the HRS-I to 136 adults (73 compulsive hoarding, 19 OCD, 44 non-clinical controls) along with a battery of self-report measures. An initial assessment was conducted in the clinic, and a second assessment was conducted in participants' homes. The HRS-I showed high internal consistency and reliability across time and context. The HRS-I clearly differentiated hoarding and non-hoarding participants, and was strongly associated with other measures of hoarding. It is concluded that the HRS-I is a promising measure for determining the presence and severity of compulsive hoarding.
This study investigated a multicomponent cognitive behavioral treatment (CBT) for hoarding based on a model proposed by Frost and colleagues and manualized in Steketee and Frost (2007).
Participants with clinically significant hoarding were recruited from the community and a university-based anxiety clinic. Of the 46 patients randomly assigned to CBT or waitlist (WL), 40 completed the 12-week assessment and 36 completed 26 sessions. Treatment included education and case formulation, motivational interviewing, skills training for organizing and problem solving, direct exposure to nonacquiring and discarding, and cognitive therapy. Measures included the Saving Inventory-Revised (self-report), Hoarding Rating Scale-Interview, and measures of clinical global improvement. Between group repeated measures analyses using general linear modeling examined the effect of CBT versus WL on hoarding symptoms and moodstate after 12 weeks. Within group analyses examined pre-post effects for all CBT participants combined after 26 sessions.
After 12 weeks, CBT participants benefited significantly more than WL patients on hoarding severity and mood with moderate effect sizes. After 26 sessions of CBT, participants showed significant reductions in hoarding symptoms with large effect sizes for most measures. At session 26, 71% of patients were considered improved on therapist clinical global improvement ratings and 81% of patients rated themselves improved; 41% of completers were clinically significantly improved.
Multicomponent CBT was effective in treating hoarding. However, treatment refusal and compliance remain a concern, and further research with independent assessors is needed to establish treatment benefits and durability of gains.
To identify the presence of factors associated with treatment outcome in patients under group cognitive-behavioral therapy (GCBT) for obsessive-compulsive disorder (OCD).
This study evaluated 181 patients with OCD that attended a 12-session weekly GCBT program. Response criteria were: >/=35% reduction in Y-BOCS scores and global improvement score of the Clinical Global Impression (CGI)</=2 at post-treatment evaluation. Sociodemographic data, OCD characteristics, and treatment data were studied.
In the bivariate analysis, the following variables showed statistical significance (p<0.20) to enter the regression model: being woman (p=0.074), greater insight (p=0.017) and better quality of life (QOL) in all domains before treatment (p=0.053), overall severity of disease according to the CGI (p=0.007), number of associated comorbidities (p=0.063), social phobia (p=0.044), and dysthymia (p=0.072). In the final regression model, these variables were associated with response to GCBT: female gender (p=0.021); WHOQOL-BREF psychological domain (p=0.011); insight (p=0.042); and global improvement score of the CGI severity-scale before therapy (p=0.045).
Special attention should be paid to patients with poor insight, increasing the cognitive aspects of the therapy in an attempt to modify the rigidity and fixity of their beliefs. In addition, male patients should be more observed, since they showed lower chance of response to GCBT when compared to women. Patients with more severe global symptoms (CGI) are poorer responders to GCBT, which indicates that not only obsessive-compulsive symptoms (OCS) should be evaluated, since other symptoms, such as depression and anxiety, may affect the treatment; therefore, an attempt to reduce these symptoms, prior to the treatment of OCD, should be considered as an option in some cases.
Three studies of nonfood hoarding are reported. Findings support the reliability and validity of a Hoarding Scale. Furthermore, the findings indicate a number of features of hoarding behavior. Hoarding was associated with indecisiveness, perfectionism (especially maladaptive evaluative concern) and obsessive compulsive symptoms among college students and community volunteers. Hoarders tended to buy extra things in order not to be caught without a needed item, and they carried more 'just-in-case' items in purses, pockets and cars. Onset of hoarding was childhood and adolescence. Hoarders had more first degree relatives who engaged in excessive saving than nonhoarders, and hoarders were less likely to be married. There was no evidence to suggest that hoarding was related to material deprivation. A model was suggested which conceptualizes hoarding as an avoidance behavior tied to indecisiveness and perfectionism. Saving allows the hoarder to avoid the decision required to throw something away, and the worry which accompanies that decision (worry that a mistake has been made). Also, it allows hoarders to avoid emotional reactions which accompany parting with cherished possessions, and results in increased perception of control.
The development and validation of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) two companion measures for assessing social phobia fears is described. The SPS assesses fear of being scrutinised during routine activities (eating, drinking, writing, etc.), while the SIAS assesses fear of more general social interaction, the scales corresponding to the DSM-III-R descriptions of Social Phobia--Circumscribed and Generalised types, respectively. Both scales were shown to possess high levels of internal consistency and test-retest reliability. They discriminated between social phobia, agoraphobia and simple phobia samples, and between social phobia and normal samples. The scales correlated well with established measures of social anxiety, but were found to have low or non-significant (partial) correlations with established measures of depression, state and trait anxiety, locus of control, and social desirability. The scales were found to change with treatment and to remain stable in the face of no-treatment. It appears that these scales are valid, useful, and easily scored measures for clinical and research applications, and that they represent an improvement over existing measures of social phobia.
In the study of social anxiety, it is common to differentiate between social interaction versus performance anxiety. The Social Interaction Anxiety Scale was designed to assess social interaction anxiety, and the Social Phobia Scale to assess fear of scrutiny by others (Mattick and Clarke, 1989). In common use, these scales are typically administered together and treated as subscales of a larger measure. However, the joint factor structure of these instruments has never been examined; therefore, it is unclear whether or not the items on these scales actually represent distinct aspects of social anxiety. In the present study, a confirmatory factor analysis of the pooled items from the SIAS and SPS failed to adequately fit the data. An exploratory factor analysis yielded three factors: (1) interaction anxiety, (2) anxiety about being observed by others, and (3) fear that others will notice anxiety symptoms. However, hierarchical factor analysis suggested that these factors all load on a single higher-order factor, social anxiety. Relationships of the first-order factors to other measures of social and performance fear and avoidance are examined, and implications of our findings for the assessment of social phobia are discussed.
presents a new theory concerning attention deficit hyperactivity disorder (ADHD) that takes off from the work of Jacob Bronowski rather than that of Jeffrey Gray / hypothesizes that the fundamental deficit in ADHD is an inability to delay responding / later in development, this deficit is considered to result in difficulty separating affect from the information accompanying it / subsequent effects include a lack of foresight or hindsight, poor internalization of language, and poor analysis and synthesis / reviews a very large literature in relation to this conceptual framework (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Systematic studies of course of illness in obsessive-compulsive disorder (OCD) using standardized diagnostic criteria are relatively rare. In the present study, 100 patients diagnosed with OCD were prospectively followed for up to 5 years. Other comorbid conditions included anxiety disorders (76%), major depressive disorder (33%), and at least one personality disorder (33%), mainly in the anxious cluster. Approximately 20% of patients had full remission and 50% had partial remission during follow-up. Significant predictors of partial remission included being married and having lower global severity scores at intake; the presence of major depression was marginally predictive of poorer course. Adequate serotonergic medication was associated with worse course, but findings are likely spurious. Only marital status and global severity were retained as predictors in a final regression model. Findings are discussed with regard to sample characteristics and similarity to other reports on predictors of course and of treatment outcome.
The impact of concurrent axis I diagnoses and axis II traits on the efficacy of a 22-session exposure-based treatment program for 43 outpatients with panic disorder and agoraphobia (PDA) and 63 with obsessive-compulsive disorder (OCD) was examined. Trained interviewers used the Structured Clinical Interview for DSM-III-R (SCID) to assess axis I diagnoses and the SCID-II to identify the number of axis II criteria met for anxious, dramatic, and odd clusters. Among axis I diagnoses, secondary major depressive disorder (MDD), dysthymia, social phobia, and generalized anxiety disorder (GAD) were present in sufficient numbers to study their effects on treatment outcome. Outcomes were assessed on self-rated target fears and functioning and on a behavioral avoidance test at post-treatment and at 6 months follow-up. Only GAD comorbidity predicted dropout, whereas MDD and all three personality cluster traits predicted post-treatment outcomes. Follow-up analyses showed significant effects of MDD and GAD, but axis II cluster criteria were not predictive.
This article reviews the literature on compulsive hoarding, including the definition and manifestations of the problem and a conceptual model for understanding hoarding behavior. This model addresses information processing deficits (e.g., attention, organization, memory, decision-making), beliefs about and emotional attachments to possessions, and distress and avoidance. Research regarding the diagnostic categorization of hoarding, its course and phenomenology, and evidence to support the model is presented. The limited research on treatment provides evidence that current serotonergic medications for OCD are largely ineffective for treating hoarding, but cognitive and behavioral treatments, especially those focused on deficits identified in the model, have some utility. Recommendations for further research on the psychopathology and treatment of hoarding are provided.
Four studies examined a new measure of compulsive hoarding (Saving Inventory-Revised; SI-R). Factor analysis using 139 hoarding participants identified 3 factors: difficulty discarding, excessive clutter, and excessive acquisition. Additional studies were conducted with hoarding participants, OCD participants without hoarding, community controls and an elderly sample exhibiting a range of hoarding behavior. Internal consistencies and test-retest reliabilities were good. The SI-R distinguished hoarding participants from all other non-hoarding comparison groups. The SI-R showed strong correlations with other indices and methods of measuring hoarding (beliefs, activity dysfunction from clutter, observer ratings of clutter in the home) and relatively weaker correlations with non-hoarding measures (positive and negative affect and OCD symptoms). The SI-R appears to be an appropriate instrument for assessing symptoms of compulsive hoarding in clinical and non-clinical samples.
A number of qualitative and meta-analytic reviews point to the efficacy of psychotherapeutic and pharmacological interventions for obsessive-compulsive disorder (OCD). In this article, we report a multidimensional meta-analysis of psychological and pharmacological treatment studies for OCD published between 1980 and 2001, examining a range of variables not previously meta-analyzed, including exclusion rates and exclusion criteria, percent of patients improved or recovered post-treatment, mean post-treatment symptomatology, and long-term outcome. These additional metrics provide a more nuanced view of the strengths and limitations of the existing data and their implications for clinical practice. Behavioral and cognitive-behavioral therapy, and a range of pharmacological interventions, lead to substantial improvement for the average patient, with individual psychotherapies and clomipramine and other Serotonin reuptake inhibitors faring best across multiple metrics. However, OCD symptoms persist at moderate levels even following adequate treatment course, and no replicable data are available on maintenance of gains for either form of treatment at 1 year or beyond. Future research should track recruitment and exclusion of study participants, include more comorbid patients, and focus on longer-term follow-up using multiple indices of outcome. More research on combined pharmacological and psychotherapeutic interventions is also indicated.
The current study investigated aspects of post-traumatic stress disorder and attention deficit/ hyperactivity disorder (ADHD) among hoarders. Compared to a sample of 36 controls, hoarders (n=26) reported a significantly greater number of different types of trauma, more frequent traumatic experiences, more symptoms of inattention, hyperactivity, and greater comfort derived from possessions. These findings are consistent with previous reports of extensive comorbidity associated with hoarding behaviors, and may reflect the potential usefulness of assessing PTSD and ADHD symptoms at the outset of hoarding treatments, as well as considering alternative pharmacological interventions.
The aim of the present study was to provide preliminary data on the efficacy of a new cognitive-behavioral treatment (CBT) for compulsive hoarding. Fourteen adults with compulsive hoarding (10 treatment completers) were seen in two specialty CBT clinics. Participants were included if they met research criteria for compulsive hoarding according to a semistructured interview, were age 18 or above, considered hoarding their main psychiatric problem, and were not receiving mental health treatment. Patients received 26 individual sessions of CBT, including frequent home visits, over a 7-12 month period between December 2003-February 2005. Primary outcome measures were the Saving Inventory-Revised (SI-R), Clutter Image Rating (CIR), and Clinician's Global Impression (CGI). Significant decreases from pre- to post-treatment were noted on the SI-R and CIR, but not the CGI-severity rating. CGI-Improvement ratings indicated that at mid-treatment, 40% (n=4) of treatment completers were rated "much improved" or "very much improved;" at post-treatment, 50% (n=5) received this rating. Adherence to homework assignments was strongly related to symptom improvement. CBT with specialized components to address problems with motivation, organizing, acquiring and removing clutter appears to be a promising intervention for compulsive hoarding, a condition traditionally thought to be resistant to treatment.
Little is known about the prevalence and correlates of hoarding behavior in the community. We estimated the prevalence and evaluated correlates of hoarding in 742 participants in the Hopkins Epidemiology of Personality Disorder Study. The prevalence of hoarding was nearly 4% (5.3%, weighted) and was greater in older than younger age groups, greater in men than women, and inversely related to household income. Hoarding was associated with alcohol dependence; paranoid, schizotypal, avoidant, and obsessive-compulsive personality disorder traits; insecurity from home break-ins and excessive physical discipline before 16 years of age; and parental psychopathology. These findings suggest that hoarding may be relatively prevalent and that alcohol dependence, personality disorder traits, and specific childhood adversities are associated with hoarding in the community.
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