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Raila H, Avanesyan T, Valentine KE, Koo B, Huang C, Tsutsumi Y, Andreeff E, Qiu T, Muñoz Rodríguez PA, Varias A, Filippou-Frye M, van Roessel P, Bullock K, Periyakoil VS, Rodríguez CI. Augmenting group hoarding disorder treatment with virtual reality discarding: A pilot study in older adults. J Psychiatr Res 2023; 166:25-31. [PMID: 37716272 PMCID: PMC10803069 DOI: 10.1016/j.jpsychires.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 09/18/2023]
Abstract
Hoarding disorder is common and debilitating, especially in older adults, and novel treatment approaches are needed. Many current treatments emphasize skills related to discarding and decision-making about possessions, which can be practiced in the patient's home. However in many cases, in-home visits are unfeasible, or real-life discarding is too difficult. Virtual reality (VR) offers the ability to create a virtual "home" including 3D scans of the patient's actual possessions that can be moved or discarded. VR discarding is an alternative to in-home visits and an approach that provides a stepping stone to real-life discarding. VR has been successfully utilized to treat many disorders but tested minimally in hoarding disorder. In nine older adults with hoarding disorder, we tested an 8-week VR intervention administered to augment a 16-week Buried in Treasures group treatment. Individualized VR rooms were uniquely modeled after each patient's home. During clinician-administered VR sessions, patients practiced sorting and discarding their virtual possessions. The intervention was feasible to administer. Open-ended participant responses, examined by two independent evaluators, indicated that VR sessions were well-tolerated and that participants found them useful, with nearly all participants noting that VR helped them increase real-life discarding. Self-reported hoarding symptoms decreased from baseline to close, with seven of the nine participants showing reliable improvement in this timeframe and none showing deterioration. Results from this exploratory pilot study suggest that VR is a feasible way to simulate an at-home sorting and discarding experience in a manner that may augment skills acquisition. It remains an open question whether VR discarding practice yields greater improvement than existing treatments. VR for this population merits further clinical investigation.
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Affiliation(s)
- Hannah Raila
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Department of Psychology, University of California Santa Cruz, Santa Cruz, CA, USA.
| | - Tatevik Avanesyan
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Keara E Valentine
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Brenden Koo
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Chloe Huang
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Yuri Tsutsumi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Elisabeth Andreeff
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Tori Qiu
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Paula Andrea Muñoz Rodríguez
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Andrea Varias
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Maria Filippou-Frye
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Peter van Roessel
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Kim Bullock
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Vyjeyanthi S Periyakoil
- Department of Medicine, Stanford University, Palo Alto, CA, USA; Extended Care and Palliative Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Carolyn I Rodríguez
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
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Jägholm S, Lindstedt S, Andersson E, Mataix-Cols D, Fernández de la Cruz L, Rück C, Ivanov VZ. Study protocol for a randomized controlled trial of in-home decluttering augmentation of group cognitive-behavioral therapy for hoarding disorder: the Joining Forces Trial. Trials 2023; 24:483. [PMID: 37507772 PMCID: PMC10386309 DOI: 10.1186/s13063-023-07509-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Cognitive behavioral therapy (CBT) is a moderately efficacious treatment for hoarding disorder (HD), with most individuals remaining symptomatic after treatment. The Joining Forces Trial will evaluate whether 10 weeks of in-home decluttering can significantly augment the outcomes of group CBT. METHODS A randomized controlled trial of in-home decluttering augmentation of group CBT for HD. Adult participants with HD (N = 90) will receive 12 weeks of protocol-based group CBT for HD. After group CBT, participants will be randomized to either 10 weeks of in-home decluttering led by a social services team or a waitlist. The primary endpoint is 10 weeks post-randomization. The primary outcome measures are the self-reported Saving Inventory-Revised and the blind assessor-rated Clutter Image Rating. Participants on the waitlist will cross over to receive the in-home decluttering intervention after the primary endpoint. Data will be analyzed according to intention-to-treat principles. We will also evaluate the cost-effectiveness of this intervention from both healthcare and societal perspectives. DISCUSSION HD is challenging to treat with conventional psychological treatments. We hypothesize that in-home decluttering sessions carried out by personnel in social services will be an efficacious and cost-effective augmentation strategy of group CBT for HD. Recruitment started in January 2021, and the final participant is expected to reach the primary endpoint in December 2024. TRAIL REGISTRATION ClinicalTrials.gov NCT04712474. Registered on 15 January 2021.
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Affiliation(s)
- Sofia Jägholm
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, M48, Karolinska Universitetssjukhuset Huddinge, 14186, Stockholm, Sweden.
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Sara Lindstedt
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, M48, Karolinska Universitetssjukhuset Huddinge, 14186, Stockholm, Sweden
| | - Erik Andersson
- Division of Psychology, Karolinska Institutet, Nobelsväg 9, 17195, Solna, Sweden
| | - David Mataix-Cols
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Gävlegatan 22, 113 30, Stockholm, Sweden
| | - Lorena Fernández de la Cruz
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Gävlegatan 22, 113 30, Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, M48, Karolinska Universitetssjukhuset Huddinge, 14186, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Volen Z Ivanov
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, M48, Karolinska Universitetssjukhuset Huddinge, 14186, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Linkovski O, Eitan R. When radical uncertainty is too much: Clinical aspects of Conviction Narrative Theory. Behav Brain Sci 2023; 46:e101. [PMID: 37154123 DOI: 10.1017/s0140525x2200259x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
We propose extrapolating Conviction Narrative Theory (CNT) to clinical psychology and psychiatry. We demonstrate how CNT principles may benefit assessment, therapy, and possibly even modify public health views of neuropsychiatric disorders. Our commentary focuses on hoarding disorder as a model, elaborates on discrepancies in the scientific literature and suggests how the CNT may resolve them.
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Affiliation(s)
- Omer Linkovski
- Department of Psychology and The Gonda Interdisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan 5290002, Israel https://linkovskilab.com
| | - Renana Eitan
- Department of Psychiatry, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel https://www.tasmc.org.il/sites/en/Personnel/pages/eitan-renana.aspx
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Lin N, Bacala L, Martin S, Bratiotis C, Muroff J. Hoarding Disorder: The Current Evidence in Conceptualization, Intervention, and Evaluation. Psychiatr Clin North Am 2023; 46:181-196. [PMID: 36740352 DOI: 10.1016/j.psc.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Nancy Lin
- University of British Columbia, School of Social Work, Jack Bell Building, 2080 West Mall, Vancouver, British Columbia V6T 1Z2, Canada
| | - Lindsay Bacala
- University of Manitoba, Faculty of Social Work, 521 Tier Building, 173 Dafoe Road West, Winnipeg, Manitoba R3J 2N2, Canada
| | - Spenser Martin
- Canadian Mental Health Association, 930 Portage Avenue, Winnipeg, Manitoba R3G 0P8, Canada
| | - Christiana Bratiotis
- University of British Columbia, School of Social Work, Jack Bell Building, 2080 West Mall, Vancouver, British Columbia V6T 1Z2, Canada
| | - Jordana Muroff
- Boston University, School of Social Work, 264 Bay State Road, Boston, MA 02215, USA.
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Bratiotis C, Muroff J, Lin NXY. Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:392-404. [PMID: 35747296 PMCID: PMC9063579 DOI: 10.1176/appi.focus.20210016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Christiana Bratiotis
- School of Social Work, University of British Columbia, Vancouver, British Columbia, Canada (Bratiotis, Lin);School of Social Work, Boston University, Boston (Muroff)
| | - Jordana Muroff
- School of Social Work, University of British Columbia, Vancouver, British Columbia, Canada (Bratiotis, Lin);School of Social Work, Boston University, Boston (Muroff)
| | - Nancy X Y Lin
- School of Social Work, University of British Columbia, Vancouver, British Columbia, Canada (Bratiotis, Lin);School of Social Work, Boston University, Boston (Muroff)
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David J, Crone C, Norberg MM. A critical review of cognitive behavioural therapy for hoarding disorder: How can we improve outcomes? Clin Psychol Psychother 2021; 29:469-488. [PMID: 34409679 DOI: 10.1002/cpp.2660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/08/2021] [Accepted: 08/13/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Jonathan David
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, New South Wales, Australia
| | - Cassandra Crone
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, New South Wales, Australia
| | - Melissa M Norberg
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, New South Wales, Australia
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Examining subjective sleep quality in adults with hoarding disorder. J Psychiatr Res 2021; 137:597-602. [PMID: 33309063 PMCID: PMC8091966 DOI: 10.1016/j.jpsychires.2020.10.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/24/2020] [Accepted: 10/28/2020] [Indexed: 02/07/2023]
Abstract
Hoarding disorder (HD), characterized by difficulty parting with possessions and functionally impairing clutter, affects 2-6% of the population. Originally considered part of Obsessive-Compulsive Disorder (OCD), HD became a distinct diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. While sleep impacts OCD, little is known about sleep in HD. As HD patients often report poor sleep in clinical settings, understanding global subjective sleep quality and disturbances may lead to novel therapeutic targets. To address this gap, the authors used a sample of convenience: an existing data set designed to screen research study eligibility and explore the psychopathology and phenomenology of OCD and HD. The data set included information collected from individuals with HD (n = 38), OCD (n = 26), and healthy participants (n = 22) about insomnia, sleep quality, and mood using interviews and structured instruments including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Depression Anxiety Stress Scales (DASS). In this data set, HD and OCD groups reported significantly greater insomnia symptoms and poorer sleep quality compared with healthy controls while controlling for depression, age, and gender. A sizable minority of HD and OCD individuals met criteria for comorbid sleep disorders. OCD and HD groups differed in delayed sleep phase prevalence. To our knowledge, this is the first study examining subjective sleep quality and insomnia in HD as compared to healthy individuals and those with OCD, while controlling for relevant clinical characteristics. Given that there are evidence-based treatments for insomnia and other sleep disorders, our study raises the possibility that treatment interventions targeting sleep may improve HD outcomes.
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Abstract
Deficient inhibitory control and difficulty resolving uncertainty are central in psychopathology. How these factors interact remains unclear. Initial evidence suggests that inducing inhibitory control improves resolution of uncertainty. This may occur only when participants overcome action tendencies, which are dominant tendencies to perform certain behaviors. Our study explored the links between inhibitory control and behavioral responses to uncertainty while manipulating action-tendencies’ strength. In three experiments, 132 undergraduates completed a task that combined induction of momentary changes in inhibitory control level (Stroop task), with responses to uncertainty (visual-search task). We manipulated action-tendencies’ strength by varying uncertainty proportions across experiments. Results indicated that momentary induction of inhibitory control improved resolution of high-uncertainty during mostly low-uncertainty trials but hampered resolution of low-uncertainty during mostly high-uncertainty trials. Identical inhibitory control induction did not affect resolution of uncertainty when uncertainty conditions were equalized. Participants’ subjective uncertainty measures were similar across experiments. Our results suggest that momentary inhibitory control induction modifies behavioral responses to uncertainty and selectively affects trials that require overcoming dominant action tendencies. These findings indicate a potentially unique and multifaceted relationship between inhibitory control and behavioral responses to uncertainty. Clinical implications for models of Obsessive-Compulsive Disorder and experimental implications to post-conflict processes are discussed.
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Norberg MM, Chasson GS, Tolin DF. A Standardized Approach to Calculating Clinically Significant Change in Hoarding Disorder Using the Saving Inventory-Revised. J Obsessive Compuls Relat Disord 2021; 28:100609. [PMID: 35079564 PMCID: PMC8786213 DOI: 10.1016/j.jocrd.2020.100609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This shorter communication explores the concept of clinically significant change in treatment outcome studies for hoarding disorder. We argue that cross-study comparisons have been hindered due to researchers using different formulations to assess individual change. As a result, we propose that researchers adopt a standardized approach to calculating rates of clinically significant change for the Saving Inventory-Revised (SI-R) based on Jacobson and Truax's (1991) two-step method. Specifically, we recommend that individuals whose SI-R total scores have reduced by at least 20 points and whose post-treatment score is 38 or less be classified as recovered. Individuals whose total score decreases by 20 points or more, but whose post-treatment score remains above 38, should be classified as improved but not recovered. Individuals whose total score increases by 20 or more points should be classified as deteriorated. Any individual whose total score has changed by less than 20 points should be classified as not changed. By adopting these criteria, researchers will facilitate cross-study treatment outcome comparisons and aid in our understanding of the impact that hoarding treatment has on its recipients.
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Affiliation(s)
- Melissa M. Norberg
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, AUSTRALIA
| | | | - David F. Tolin
- Anxiety Disorders Center, The Institute of Living, Hartford, CT, USA
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Timpano KR, Bainter SA, Goodman ZT, Tolin DF, Steketee G, Frost RO. A Network Analysis of Hoarding Symptoms, Saving and Acquiring Motives, and Comorbidity. J Obsessive Compuls Relat Disord 2020; 25:100520. [PMID: 36212770 PMCID: PMC9544394 DOI: 10.1016/j.jocrd.2020.100520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - David F. Tolin
- Institute of Living and Yale University School of Medicine
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Spence C, Kellett S, Totterdell P, Parry G. Can cognitive analytic therapy treat hoarding disorder? An adjudicated hermeneutic single-case efficacy design evaluation. Clin Psychol Psychother 2019; 26:673-683. [PMID: 31343093 DOI: 10.1002/cpp.2390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 11/07/2022]
Abstract
This paper sought to assess whether cognitive analytic therapy (CAT) was effective with a male patient meeting diagnostic criteria for hoarding disorder (HD) who had been nonresponsive to two previous courses of cognitive behaviour therapy. An adjudicated hermeneutic single-case efficacy design (HSCED) evaluation was undertaken. A rich case record (i.e., a summary document containing the case details, formulations, and detailed qualitative and quantitative outcomes) was created. The rich case record was then debated by affirmative (N = 3) and sceptic (N = 3) research teams. Expert judges (N = 3) reviewed the debate and then delivered a final verdict as to whether treatment had worked. Judges unanimously returned a verdict in favour of the sceptic position, concluding that CAT had not enabled change. Lack of change on the primary nomothetic hoarding outcome measure was particularly influential in the final judgement. In this case of HD, CAT was therefore not effective as an intervention. More research is needed before any definitive conclusions can be drawn however as to the wider utility of CAT with HD. Methodological limitations are outlined, alongside considerations for future research.
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Affiliation(s)
| | - Stephen Kellett
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, UK.,Specialist Psychotherapy Service, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
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