The Influence of Aging on the Process of Accumulation: A Qualitative Study of Older Adults with Hoarding and Cluttering Behaviors

Individuals with hoarding and cluttering behaviors have difficulty discarding items, acquiring such a large number of items that their home environments become severely cluttered. Severe clutter interferes with activities of daily living and often causes distress to those living in the environment. Once viewed as personal lifestyle preferences, these behaviors are currently recognized as a mental health disorder associated with anxiety disorders and cognitive dysfunction. While hoarding and cluttering behaviors affect individuals of all ages, older adults are at increased risk of isolation, injury and other poor outcomes as a result of these behaviors. However, very little is currently known about the influence of age-related factors on hoarding and cluttering behaviors. To address this gap in our understanding, a qualitative study using Grounded Theory Methodology was conducted. Twenty-two adults age 65-91 with hoarding and cluttering behaviors were interviewed in their homes. Interviews were transcribed verbatim and analyzed using Atlas Ti software. All participants noted long-standing problems with hoarding and cluttering but narratives suggested how aging contributed to their current situation. Participants described a three-part process of accumulation that included acquiring, maintaining and discarding items. Patterns of behaviors emerged from data, describing two distinct "types" of individuals with hoarding behaviors. These two types, called Impulsive Acquirers and Anxious Keepers, differed in the ways in which they acquired, maintained, and discarded their belongings. In addition, participants described a dynamic interaction between the process of accumulation and aging. Changes in health status, social context, and home environment associated with aging generally contributed to worsening of the behaviors or outcomes, although some participants indicated that growing older increased their motivation to make changes in their home environments. By identifying these age-related factors and distinguishing the "type" of behaviors exhibited by older adults, clinicians will be able to develop more targeted interventions to reduce the risk of harm to older adults living in severely cluttered homes

The Influence of Aging on the Process of Accumulation: A Qualitative Study of Older Adults with Hoarding and Cluttering Behaviors

Individuals with hoarding and cluttering behaviors have difficulty discarding items, acquiring such a large number of items that their home environments become severely cluttered. Severe clutter interferes with activities of daily living and often causes distress to those living in the environment. Once viewed as personal lifestyle preferences, these behaviors are currently recognized as a mental health disorder associated with anxiety disorders and cognitive dysfunction. While hoarding and cluttering behaviors affect individuals of all ages, older adults are at increased risk of isolation, injury and other poor outcomes as a result of these behaviors. However, very little is currently known about the influence of age-related factors on hoarding and cluttering behaviors. To address this gap in our understanding, a qualitative study using Grounded Theory Methodology was conducted. Twenty-two adults age 65–91 with hoarding and cluttering behaviors were interviewed in their homes. Interviews were transcribed verbatim and analyzed using Atlas Ti software. All participants noted long-standing problems with hoarding and cluttering but narratives suggested how aging contributed to their current situation. Participants described a three-part process of accumulation that included acquiring, maintaining and discarding items. Patterns of behaviors emerged from data, describing two distinct "types" of individuals with hoarding behaviors. These two types, called Impulsive Acquirers and Anxious Keepers, differed in the ways in which they acquired, maintained, and discarded their belongings. In addition, participants described a dynamic interaction between the process of accumulation and aging. Changes in health status, social context, and home environment associated with aging generally contributed to worsening of the behaviors or outcomes, although some participants indicated that growing older increased their motivation to make changes in their home environments. By identifying these age-related factors and distinguishing the "type" of behaviors exhibited by older adults, clinicians will be able to develop more targeted interventions to reduce the risk of harm to older adults living in severely cluttered homes

Comparison of a peer facilitated support group to cognitive behavior therapy: Study protocol for a randomized controlled trial for hoarding disorder.

Although individual and group cognitive-behavioral therapy (CBT) is the standard treatment approach for hoarding disorder (HD), it requires trained mental health professionals with specialization in HD. There is a need to offer additional options and services due to the limited number of professionals with advanced training, combined with the high prevalence rate of individuals with HD. A structured support group led by trained facilitators or lay professionals using a facilitator's manual and participant workbook (Buried in Treasures or BiT), addresses this need and increases accessibility. Prior studies of BiT groups have shown decreased hoarding symptoms. Only one retrospective study compared BiT and CBT outcomes in a naturalistic setting and showed no difference. Thus, a well-powered randomized controlled trial is needed to directly compare these forms of treatment. This paper presents a non-inferiority controlled trial protocol that compares group CBT to group BiT. Three hundred participants with HD, 18years or older, are being recruited for a 16-week treatment study. Participants are randomly assigned to either the CBT or BiT group. The primary outcome is reduction in hoarding symptom severity. Secondary outcomes include reduction in other indices of hoarding symptomology, including functional impairment, physical clutter, cognition, and changes in neuropsychological functioning

Contributions of self-criticism and shame to hoarding.

Pathological hoarding-related beliefs, such as need to control possessions, and inflated sense of responsibility over possessions, have been used to explain the development of symptoms of hoarding disorder (HD). While these beliefs have been the focus of the current standard treatment for HD, it is of significant clinical interest to further examine other constructs that may be linked to, or may underliethese beliefs, as well as the pathology of HD. To this end, the current study aimed to build on existing findings regarding the relationship of compromised self-identity with HD. Specifically, we investigated the relationship between self-criticism, shame, hoarding beliefs, and severity of HD symptoms among 104 treatment-seeking individuals with HD. We found that self-criticism and shame are positively associated with HD symptoms and hoarding related beliefs. Moreover, our data shed light on how these factors are connected by elucidating the indirect effects of self-criticism and shame on HD symptoms, mediated through beliefs about inflated sense of responsibility over possessions. The findings have implications for future research to examine interventions targeting compromised self-identity, including self-criticism and shame, among individuals with HD

Recruiting under-represented populations into psychiatric research: Results from the help for hoarding study

This study compares the effectiveness of approaches used to recruit a diverse sample for a randomized clinical trial for Hoarding Disorder (HD) in the San Francisco Bay Area. Of the 632 individuals who inquired about the study, 313 were randomized and 231 completed treatment. Most participants heard about the study via flyering (N = 161), followed by advocacy groups (N = 113), word of mouth (N = 84), health care professionals (N = 78), online (N = 68), and media (N = 11). However, those that heard about the study via advertising methods, such as flyers, were less likely to complete the study, p = .01, while those recruited via advocacy groups were most likely to be randomized, p = .03. No source proved more effective in recruiting underrepresented groups such as men, p = .60; non-whites, p = .49; or Hispanics, p = .97. Advertising recruited the youngest individuals, p < 0.001, and word of mouth was most likely to recruit unemployed, disabled, or retired individuals, p = .01. Thus, results suggest an ongoing multimodal approach is likely to be most effective in both soliciting and retaining a diverse sample. Future studies should compare recruitment methods across greater geographical regions too, as well as in terms of financial and human costs. Keywords: Hoarding disorder, Recruitment, Psychiatry, Advertising, Samplin

Randomised clinical trial of community-based peer-led and psychologist-led group treatment for hoarding disorder.

BackgroundTreatment for hoarding disorder is typically performed by mental health professionals, potentially limiting access to care in underserved areas.AimsWe aimed to conduct a non-inferiority trial of group peer-facilitated therapy (G-PFT) and group psychologist-led cognitive-behavioural therapy (G-CBT).MethodWe 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.ResultsG-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).ConclusionsPeer-led groups were as effective as psychologist-led groups, providing a novel treatment avenue for individuals without access to mental health professionals.Declaration of interestC.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

Visually mediated functioning improves following treatment of hoarding disorder.

BackgroundHoarding disorder (HD) is a highly debilitating psychiatric disorder that affects 2-6% of adults. Neuropsychological deficits in visual memory, detection, and categorization have been reported in HD. To date, no study has examined the relationship between neurocognitive functioning and treatment for HD. We aim to determine the association between neurocognitive functioning and treatment outcomes, as well as the impact of HD-specific treatment on cognitive functioning.Methods323 individuals with HD were randomized to 20 weeks of peer- or clinician-led group behavioral treatment. 242 participants completed pre- and post-treatment neuropsychological testing covering eight neurocognitive domains. Rates of cognitive impairment (CI) were assessed for each neurocognitive domain. The association of baseline neurocognitive function on treatment response was examined using multiple regression. MANOVA and post-hoc tests were used to determine neurocognitive performance change pre- to post treatment.ResultsSixty-seven percent of participants had CI on ≥1 cognitive domain. There was no significant effect of pre-treatment neurocognitive functioning on treatment outcome. Post-treatment improvements were observed in visual memory, visual detection, decision making, information processing speed, visuospatial processing, attention/working memory (p≤.001). Declines in performance were found in visual reaction time and categorization.LimitationsThis was a non-inferiority trial to examine two treatment types with no normative comparison group. Treatment seeking individuals are more likely to be insightful, motivated, and have other features which limit generalizability.ConclusionsPatterns of cognitive impairment in HD are similar to previous reports. Pre-treatment neurocognitive functioning did not impact treatment response. Neuropsychological functioning improved across multiple domains following targeted treatment