Features of hoarding include difficulty parting with personal possessions, even those of apparently useless or limited value, resulting in the accumulation of large amounts of clutter in the living areas of the home and often other personal and/or work environments (1
). Excessive acquiring through buying or collecting free items is also evident in most cases (2
). These symptoms impair functioning and/or pose significant health and safety risks, as well as distress to those who hoard and/or those living with or near them (3
Although hoarding has traditionally been considered a subtype of OCD, increasing evidence points to substantial differences in clinical and biological features (7
). Hoarding is also included in DSM-IV-TR
as a symptom of obsessive compulsive personality disorder, but does not appear strongly associated with other features of this condition (see review by Pertusa and colleagues, 11). Epidemiological findings indicate that clinically significant hoarding occurs in 2–5% of the population, making it a strikingly common problem (12
Retrospective treatment studies have recruited OCD patients with hoarding symptoms rather than people with hoarding as a primary problem. Most large scale pharmacological studies have found that hoarding symptoms predict poor outcomes following SRI treatment (15
), and another study reported non-significant trends for hoarding to predict worse outcome (e.g., 16
). A prospective study by Saxena et al. (17
) reported no difference in response to paroxetine among hoarding and non-hoarding OCD patients; however, both groups showed only modest improvement (approximately 25%) on standard measures of OCD symptoms.
Findings from retrospective studies of behavioral treatments for OCD patients with hoarding symptoms have followed the trend of hoarding predicting worse outcomes. This was evident for a computer-based behavioral therapy (18
) and for therapist administered exposure and response prevention (ERP), a CBT method developed for OCD that utilizes prolonged exposure to increasingly feared obsessive situations and gradual blocking of rituals associated with these obsessions to achieve habituation of fear and reduction or elimination of rituals. Abramowitz and colleagues (19
) reported that only 31% of hoarders exhibited a clinically significant response compared to 46–76% of patients with non-hoarding OCD, a relatively poor response for hoarding to this typically effective ERP method. Unfortunately, these studies suffer from sampling and measurement problems, with most recruiting hoarding patients from OCD clinics and utilizing the 2-item Symptom Checklist of the Yale-Brown Obsessive Compulsive Scale to identify hoarders. Retrospective studies that have combined serotonergic medication with behavior therapy for OCD also reported disappointing outcomes for hoarding compared to non-hoarding OCD patients (20
). Descriptive case reports of hoarding patients receiving behavior therapy have reported generally negative treatment outcomes accompanied by poor insight, treatment refusal, and lack of cooperation (23
Over the past decade, a cognitive-behavioral model of compulsive hoarding has emerged (1
) that posits that the excessive acquisition, difficulty discarding, and clutter that comprise hoarding stem from information processing deficits, problematic beliefs and behaviors, and emotional distress and avoidance. Research findings support many aspects of the model, including problems with focusing and sustaining attention (30
), categorizing possessions (32
), and decision making (33
), as well as problematic beliefs about possessions (34
). The model proposes that strong negative emotional reactions to possessions (e.g., anxiety, grief, guilt) lead to avoidance of discarding and organizing, while strong positive emotions (pleasure, joy) reinforce acquiring and saving possessions (Steketee & Frost, (7
In a recent open trial, Tolin, Frost and Steketee (37
) tested a multi-component cognitive-behavioral therapy (CBT) intervention for hoarding based on this model. Treatment included office and home visits with motivational interviewing to address low insight and limited motivation, decision-making training to improve cognitive processing, exposure to reduce negative emotions associated with discarding and resisting acquiring, and cognitive restructuring to alter beliefs. This treatment resulted in reductions of the major manifestations of hoarding (clutter, difficulty discarding, acquiring) in 14 adults, of whom 10 completed 26 sessions of treatment over 7 to12 months. Significant decreases from pre- to post-treatment were evident on standardized measures of hoarding symptoms, and at post-treatment, half of the sample (n
= 5) were rated much or very much improved on clinical global improvement ratings.
Following upon this pilot work and minor modifications to the treatment protocol, the present study tested these CBT methods in a waitlist controlled trial conducted at two sites. CBT was hypothesized to lead to greater improvement in hoarding symptoms than a wait period of 12 weeks for patients seeking treatment for hoarding. In addition, 26 sessions of this treatment was expected to produce significant and substantial benefits on hoarding symptoms.