Despite Addition to DSM, Few Treatments Emerge for Hoarding Disorder

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Hoarding disorder, defined as a persistent difficulty and distress over discarding personal possessions, typically results in an avalanche of papers, clothing, plastic containers, or even trash, overwhelming individuals’ living spaces so they can longer be used as intended.

A meta-analysis by Adam Postlethwaite and colleagues in June 2018 suggests that hoarding disorder occurs in about 2.5% of the worldwide population in developed countries, making it more prevalent than obsessive-compulsive disorder. Although it was approved as a distinct diagnosis in DSM-5 in 2013, new treatments have not been forthcoming. Few studies have since investigated evidence-based treatments—either drug or behavioral therapy—for people with hoarding disorder, particularly in the geriatric population, Catherine R. Ayers, Ph.D., section chief of the Outpatient Mental Health Clinics at the La Jolla VA San Diego and a professor of psychiatry at the University of California, San Diego, told Psychiatric News.

Complex Disorder Difficult to Treat

Ayers said the reason for the lack of treatment options is that hoarding is a complex, difficult-to-treat disorder that is associated with severe impairment, and patients are slow to show improvement. Ayers first realized the prevalence of hoarding disorder while conducting home visits with elderly patients during her training and has devoted her career to better understanding and treating patients with the disorder.

Randy O. Frost, Ph.D., an expert on hoarding disorder, professor emeritus of psychology at Smith College, and co-author of soon-to-be published Hoarding Disorder: A Comprehensive Clinical Guide, said many patients are reluctant to come forward. Frost told Psychiatric News that he urges clinicians to use simple screening tools such as the Hoarding Rating Scale, particularly for patients with anxiety, depression, or attention-deficit disorder or those who present with hygiene problems. One of Frost’s research studies examined hoarding in patients entering treatment at a center for anxiety disorders. “Many of them never mentioned hoarding as problem, yet they had significant problems with it. This is something that carries with it stigma and a lack of understanding that this is a mental health disorder.”

Frost said hoarding comes down to three problems: excessive levels of acquisition; intense attachments to objects and a desire to save things, despite rarely using them; and a neurocognitive deficit in the ability to organize or categorize objects. One patient’s home he visited had clothes and other objects stacked in separate piles up to the ceiling, but her dresser drawers were empty. She told him that if she put the clothes in the drawers, she feared she would forget about them. Frost said one theory—but unproven—is that individuals with the disorder may have a higher level of intelligence, which results in a richness of association with objects that can be overwhelming to patients and is not present in individuals without the disorder.

The greatest risk factor for hoarding disorder is genetic, and most people with the disorder have a first-degree relative who also has the disorder. At least two-thirds of cases develop before age 20, and with each decade of life, hoarding symptom severity increases, Ayers added.

Having a psychiatric comorbidity amplifies the condition, with major depression seen in 33% to 50% of people with hoarding disorder and obsessive-compulsive disorders seen in 15% of patients, she said at a recent conference held by the Psychiatry Education Network. Ayers advises clinicians to treat patients for the disorder that’s most prominent and severe, which is often the hoarding disorder. “Oftentimes when we successfully treat hoarding, the depression goes away, so the depression is secondary.”

Novel Treatments

What is the best way to manage these patients? The solution that many family members attempt—simply cleaning out the patient’s home either partially or completely—can damage relationships with trusted providers and family members and may increase hoarding symptoms, Ayers said.

Frost explained that understanding the root of patients’ intense attachment to objects may be one key to helping them. The hoarded objects may be seen as providing an opportunity to experience something or become someone new; for example, one patient said her massive cookbook and recipe collection might allow her to be a good hostess to potential guests. However, the patient’s home was too cluttered to allow her to invite guests or cook anything. Objects saved may harken memories of events past in a more visceral way. For others, saving objects may fulfill an exaggerated sense of responsibility to avoid waste: One patient flattened and saved a lifetime of cereal boxes because they could potentially be used as stationery.

Cognitive-behavioral therapy (CBT), typically delivered in the patients’ home, has been shown to be the most effective treatment. Yet studies by Ayers have found that most patients didn’t make remarkable gains, even after 26 sessions of in-home treatment. “The neurocognitive deficits typical of patients with hoarding disorder make CBT not a good fit for this group. The cognitive restructuring strategies in CBT are largely dependent on intact executive functioning abilities, and these individuals tend to have deficits in these areas.”

Ayers has developed a novel manualized treatment protocol for hoarding disorder called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST). Each module aims to improve a different facet of patients’ executive functioning, particularly planning, preparation, problem solving, and ability to think flexibly, or change plans when something isn’t working. Appointments occur in patients’ homes or virtually so therapists can encourage patients to repeatedly select and discard their belongings and learn that this gets easier over time. For her next research project, Ayers plans to study how much the cognitive rehabilitation helps and whether the desensitization alone is sufficient.

Frost has also found that systematic exposure exercises help patients become comfortable with resisting their intense urge to acquire. First patients drive by a compelling shop without stopping in; next they walk by the shop without entering; next patients enter the shop and leave without purchasing anything; and finally, they enter the store, pick up a desired item, and put it back without buying it. Patients also write out and carry a card with questions to ask themselves before acquiring items: Do I really need it? Do I have a place for it? Can I afford it? and Do I already have one similar?

Frost said another novel treatment that shows promise for the treatment of hoarding disorder is compassion-focused therapy. “It’s important to keep in mind that patients with this disorder have typically come through decades worth of criticism about their behavior, and their behavior has been portrayed to them as a moral fault. For many of these patients, their families have abandoned them.” Compassion-focused therapy aims to help individuals cultivate self-compassion, which can help regulate mood and lead to feelings of safety, self-acceptance, and comfort, which in turn can lead to reduced hoarding. ■