Behavioral and emotional consequences of thought listing versus cognitive restructuring during discarding decisions in hoarding disorder

Childhood environmental unpredictability and hoarding: Mediating roles of attachment and security

Life history theory provides a unified perspective for understanding human behaviors as adaptive strategies to specific environmental conditions. Within this theoretical framework, hoarding emerges as a behavior reflecting an evolved strategy in response to unpredictable environmental challenges, serving as a buffer against resource scarcity and enhancing survival prospects. This study aimed to explore the key roles of childhood environmental unpredictability, attachment, and sense of security in the development of hoarding. 662 participants completed scales on childhood environmental unpredictability, Revised Experiences in Close Relationships (ECR-R), sense of insecurity, and Savings Inventory-Revised (SI-R). The results showed that childhood environmental unpredictability was significantly positively correlated with hoarding. Attachment anxiety and sense of security individually mediate the effect of childhood environmental unpredictability on hoarding. Additionally, 'attachment anxiety--sense of security' and 'attachment avoidance--sense of security' serve as chain mediators in this relationship separately. This study offers insights into the cognitive-behavioral model of hoarding, highlighting the importance of life history theory in examining childhood environmental unpredictability's relationship with hoarding. It also integrates insights from the psychosocial acceleration theory into our comprehension of hoarding's development. Future research directions are also discussed.

The experience of leaving a valuable object: An investigation of emotional processes related to Hoarding disorder features

One of the core features of hoarding is a significant resistance to discarding objects, which is fueled by dysfunctional beliefs and unwarranted negative emotions that hoarders tend to feel when disposing of their possessions. To our knowledge, longitudinal studies investigating the psychological effects that people who hoard experience after separating from their valuable possessions have yet to be conducted. Our study's principal aim was to explore psychological processes that individuals with high hoarding features (n = 53; 49.1%) and individuals with low hoarding features (n = 55; 50.9%) experienced when they had to separate from a valuable possession. To do this, we evaluated participants' thoughts and feelings at several time points after they had to leave a valuable object at the University laboratory (evaluations were specifically conducted at baseline, during the week, and at the end of the week). To investigate hoarding and anxiety, as well as depressive, obsessive-compulsive, and emotional processes-related features, a mixed-method approach was employed involving self-report questionnaires, ad hoc surveys, and a daily self-monitoring schedule. Our findings showed that compared to participants with low hoarding features, participants with high hoarding traits: 1) scored higher for anxiety sensitivity, distress tolerance, and emotional dysregulation; 2) reported having more negative emotions when leaving their object; 3) had more intrusive object-related beliefs; and 4) experienced a higher frequency of negative emotions as well as a higher level of distress during the week. Both groups experienced more negative emotions in the first part of the week, which decreased as the time at which participants could receive their object back drew closer. Finally, dysfunctional beliefs about leaving a personal object (Saving Cognitions Inventory), sensitivity to anxiety (Anxiety Sensitivity Index-3), and distress tolerance (Distress Tolerance Scale) contributed to the level of discomfort that participants with higher hoarding scores reported when they had to leave their possession. These results highlight the relevance of emotional processes in the hoarding disorder framework as well as underscore the importance of assessing and treating them in clinical settings.

The Association between Age and Experienced Emotions in Hoarding Disorder

Objectives: Hoarding disorder (HD) is conceptualized as a fear-based disorder and exposure to sorting/discarding possessions is a core part of treatment. However, there has been no investigation of age-related differences in emotional reaction to sorting. The objective of this study was to explore the association between age and affective response during a sorting task.Methods: Forty-nine adults with HD completed a standardized sorting task. Participants reported their current emotion before and after the sorting task and reported their subjective distress throughout the task.Results: Older participants reported significantly lower distress ratings. Only 43% of participants reported fear prior to the task and 22% reported fear after the task. The probability of reporting fear before and after the task decreased significantly with age.Conclusions: Fear may not be the emotion experienced when discarding items, particularly for older adults with HD. Future work should focus on mechanisms of action in HD treatment.Clinical Implications: Clinicians should not assume fear or anxiety to be the primary emotional response in older adults with HD when engaged in an exposure to sorting/discarding. Older hoarding patients with a more fear-oriented aversion to sorting possessions may require a treatment emphasis on increasing the percentage of items discarded.

A critical review of cognitive behavioural therapy for hoarding disorder: How can we improve outcomes?

Psychological treatment for hoarding problems has historically been associated with poor outcomes. When treated as a subgroup of obsessive-compulsive disorder, individuals with hoarding beliefs were less likely to respond to treatment than individuals exhibiting other obsessive-compulsive beliefs and behaviours. When treated as its own disorder using cognitive behavioural therapy, individuals report approximately 25% improvement in symptoms on average. However, less than a third of people experience clinically meaningful change. Further, changes in functioning and quality of life are not routinely assessed. In this paper, we review the current conceptualization and treatment of hoarding problems to shed light on how treatment for hoarding disorder may be improved. Utilizing a harm reduction approach before administering treatment may be important to ensure the safety of individuals. Research should test whether treatment outcomes improve by including strategies that enhance a client's interpersonal functioning and ability to regulate emotions (i.e., based on dialectal behaviour therapy and mentalization-based treatments), especially while discarding and organizing belongings. We should also use modern learning theory to improve the delivery of exposure activities.

An Examination of the Association Between Subjective Distress and Functional Connectivity During Discarding Decisions in Hoarding Disorder

BACKGROUND

Individuals with hoarding disorder (HD) demonstrate exaggerated subjective distress and hyperactivation of cingulate and insular cortex regions when discarding personal possessions. No prior study has sought to determine whether this subjective distress is associated with specific profiles of abnormal brain function in individuals with HD.

METHODS

We used multimodal canonical correlation analysis plus joint independent component analysis to test whether five hoarding-relevant domains of subjective distress when deciding to discard possessions (anxiety, sadness, monetary value, importance, and sentimental attachment) are associated with functional magnetic resonance imaging-measured whole-brain functional connectivity in 72 participants with HD and 44 healthy controls.

RESULTS

Three extracted components differed between HD participants and healthy control subjects. Each of these components depicted an abnormal profile of functional connectivity in HD participants relative to control subjects during discarding decisions, and a specific distress response profile. One component pair showed a relationship between anxiety ratings during discarding decisions and connectivity among the pallidum, perirhinal ectorhinal cortex, and dorsolateral prefrontal cortex. Another component comprised sadness ratings during discarding decisions and connectivity in the pallidum, nucleus accumbens, amygdala, and dorsolateral prefrontal cortex. The third component linked HD brain connectivity in several dorsolateral prefrontal cortex regions with perceived importance ratings during discarding decisions.

CONCLUSIONS

The findings indicate that in patients with HD, the subjective intensity of anxiety, sadness, and perceived possession importance is related to abnormal functional connectivity in key frontal and emotional processing brain regions. The findings are discussed in terms of emerging neurobiological models of HD.

An Ecological Momentary Assessment Study Investigating the Function of Hoarding

This study examined the function of hoarding behaviors and the relations between hoarding and a series of cognitive and affective processes in the moment using ecological momentary assessment. A matched-groups design was used to compare college students with higher hoarding symptoms (n = 31) and matched controls (n = 29). The two groups did not differ in what function they reported acquiring served, and positive automatic reinforcement was the most commonly reported function in both groups. Engaging in hoarding-relevant behaviors did not predict change in positive or negative affect when controlling for previous affect. Emotional reactivity and experiential avoidance in the moment were both elevated in the higher hoarding group compared to controls, while momentary mindfulness and negative affect differentiation were lower. Overall, these findings support the importance of emotion regulation processes in hoarding. They also suggest individuals may not be successfully regulating affect in the moment with hoarding behaviors, despite efforts to do so. It may be useful to evaluate processes such as striving for positive affect in hoarding disorder in the future.

Comparing the Efficacy of Defusion, Self-as-Context, and Distraction Strategies for Getting Rid of Possessions

Interventions for hoarding disorder need to target difficulty letting go of items to reduce clutter and improve functioning. The present studies were designed to test the efficacy of brief cognitive interventions for letting go of possessions and self-report outcomes. Participants (N = 67 in Study 1; N = 110 in Study 2) received training on defusion or distraction in Study 1 and defusion, self-as-context, or distraction in Study 2 and completed measures at pre- and postintervention. Study 1 found no differences between defusion and distraction on saving, self-rated discomfort with discarding, or perceived importance of the target belonging. In Study 2, participants provided most favorable feedback for self-as-context compared to defusion and distraction, indicating promise of this strategy. Nonetheless, findings from both studies overall provide minimal support for use of present procedures to reduce saving. Limitations include use of nonclinical samples and single-item variables to obtain participant feedback.

A Comparison of Cognitive Restructuring and Thought Listing for Excessive Acquiring in Hoarding Disorder

Excessive acquiring is a common symptom of hoarding disorder (HD). Little is known about subjective distress associated with acquiring in HD. The present study examined acquiring- related distress and reactions to cognitive restructuring (CR) in 92 individuals with HD and 66 community control (CC) participants. All participants identified an item of interest at a high-risk acquiring location and then decided whether or not to acquire the item. HD participants completed the acquiring task while receiving a CR-based intervention or a thought-listing (TL) control condition. Results showed that HD participants reported more severe distress and greater urges to acquire the item of interest than did CC participants. Nevertheless, subjective distress decreased in both groups following the acquiring task. There were no differences in acquiring- related distress between the CR and TL conditions. The findings indicate that subjective distress may decrease after relatively short periods of time in individuals with HD, but that a single session of CR may not alleviate acquiring-related distress in HD participants.

Discarding personal possessions increases psychophysiological activation in patients with hoarding disorder

Difficulty discarding is the core behavioral symptom of hoarding disorder (HD). Patients with HD report greater subjective distress when discarding their own possessions as compared to others' possessions. To date, no prior studies have examined psychophysiological activation, an objective measure of anxious arousal, during discarding among individuals with HD. The current study assessed psychophysiological responses during a baseline resting period and two discarding tasks, one involving personal possessions and the other involving matched control ("experimenter-owned") items in 52 patients with a primary diagnosis of HD. Results showed that, compared to discarding control items, discarding personal possessions increased skin conductance and heart rate and decreased end tidal carbon dioxide. There were no differences in heart rate variability, respiratory sinus arrhythmia, and respiration rate between the two discarding tasks. Despite the fact that discarding increased psychophysiological arousal, self-reported HD symptoms (including difficulty discarding) failed to predict psychophysiological responses during the discarding tasks. The findings suggest that there may be discordance between objective and subjective measures of hoarding-related distress, and are discussed in terms of incorporating psychophysiological measures into the assessment and treatment of HD.

An Examination of the Role of Psychological Inflexibility in Hoarding Using Multiple Mediator Models

Hoarding is associated with functional impairment and impacts quality of life. One process that has been theorized to explain how hoarding develops and leads to impairment is psychological inflexibility, in which behavior is rigidly controlled by a perceived need to regulate internal experiences, at the expense of more effective, valued actions. The present study aimed to test the mediational role of psychological inflexibility in the development of hoarding and its impact on life satisfaction with a sample of 489 college students completing an online survey. Results indicated that multiple measures of psychological inflexibility (overall inflexibility, inattention, and values obstruction) mediated the relationship between distress and hoarding. Other measures of psychological inflexibility (overall inflexibility, cognitive fusion, and lack of values progress) mediated the link between hoarding severity and life satisfaction. These findings suggest that how one responds to distress and hoarding symptoms can influence symptom severity and life satisfaction, and that psychological flexibility may promote more adaptive outcomes. Thus, current interventions for problematic hoarding may be strengthened by targeting psychological inflexibility and related processes.

Hoarding Disorder and Difficulties in Emotion Regulation

The present study aimed to examine self-reported deficits in emotion regulation (ER) among individuals with hoarding disorder (HD). Seventy-seven adult outpatients with HD and 45 age- and gender-matched healthy control (HC) participants received a diagnostic assessment and completed self-report measures of hoarding severity, depression, and anxiety. In addition, participants completed the Difficulties in Emotion Regulation Scale (DERS), which measures lack of emotional clarity (Clarity), difficulty regulating behavior when distressed (Impulse), difficulty engaging in goal-directed cognition and behavior when distressed (Goals), unwillingness to accept emotional responses (Accept), and lack of access to strategies for feeling better when distressed (Strategies). The HD group scored higher on all DERS subscales than did the HC group; self-reported ER deficits remained evident when controlling for baseline depression, anxiety, and stress. The DERS correlated significantly with hoarding severity in the HD group: acquiring was significantly correlated with DERS Impulse, Strategies, and Accept; saving was significantly correlated with DERS Accept. Correlations remained significant when controlling for depression, anxiety, and stress. Results suggest that HD is characterized by self-reported deficits in ER, and that this relationship is not solely attributable to high levels of depression and anxiety.

Changes in Saving Cognitions Mediate Hoarding Symptom Change in Cognitive-Behavioral Therapy for Hoarding Disorder

Cognitive-behavioral therapy (CBT) is an empirically-supported treatment for hoarding disorder (HD). However, meta-analytic studies suggest that CBT is only modestly effective, and a significant number of individuals with HD remain symptomatic following treatment. To inform the development of more effective and targeted treatments, it will be important to clarify the mechanisms of treatment response in CBT for HD. To this end, the current study examined whether change in maladaptive saving beliefs mediated symptom change in CBT for HD. Sixty-two patients with primary HD completed measures of maladaptive saving cognitions and hoarding severity at pre-, mid-, and post-CBT. Results showed that change in saving cognitions mediated change in all three domains of HD symptoms (i.e., acquiring, difficulty discarding, and excessive clutter), suggesting that cognitive change may be a mechanism of treatment response in CBT. The findings indicate that cognitive change may have an impact on treatment outcomes, and are discussed in terms of cognitive-behavioral theory of HD and potential ways in which to enhance belief change in treatment.