- Email: [email protected]
Group cognitive-behavioral therapy for hoarding disorder: An open trial
Behaviour Research and Therapy 49 (2011) 802e807
Contents lists available at SciVerse ScienceDirect
Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat
Shorter communication
Group cognitive-behavioral therapy for hoarding disorder: An open trial Christina M. Gilliama, *, Melissa M. Norbergb, Anna Villavicencioa,1, Samantha Morrisona, Scott E. Hannana, David F. Tolina a b
Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA National Cannabis Prevention and Information Centre, University of New South Wales, Sydney, PO Box 684, Randwick, NSW 2031, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 June 2011 Received in revised form 26 August 2011 Accepted 30 August 2011
Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Hoarding Cognitive-behavioral therapy Group therapy
Despite the high prevalence rate (2e5%; Grisham & Norberg, 2010; Iervolino et al., 2009; Ruscio, Stein, Chiu, & Kessler, 2010; Samuels et al., 2008) and the significant impairment and burden associated with hoarding, research and treatment on hoarding has been limited. Earlier research that applied treatments for OCD to hoarding disorder, such as exposure and response prevention (Abramowitz, Franklin, Schwartz, & Furr, 2003; Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; Rufer, Fricke, Moritz, Kloss, & Hand, 2006) or serotonergic medications (Black et al., 1998; Mataix-Cols, Rauch, Manzo, Jenike, & Baer, 1999; Stein, Andersen, & Overo, 2007) generally showed a less favorable response among those with hoarding compared to those with OCD. In response to these disappointing outcomes, a cognitive-behavioral model of hoarding disorder was developed that emphasizes mechanisms of maintenance including information processing deficits and maladaptive beliefs about possessions, which in turn result in emotional distress and avoidance behaviors (Frost & Hartl, 1996; Frost & Tolin, 2008; Steketee & Frost, 2003, 2007). Cognitive-behavioral therapy (CBT)
* Corresponding author. Tel.: þ1 860 545 7685; fax: þ1 860 545 7156. E-mail addresses: [email protected], [email protected] (C.M. Gilliam), m. [email protected] (M.M. Norberg), [email protected] (A. Villavicencio), [email protected] (S. Morrison), [email protected] (S.E. Hannan), [email protected] (D.F. Tolin). 1 Present address: Bradley Hospital, 1110 Veterans Memorial Parkway, East Providence, RI 02915, USA. 0005-7967/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2011.08.008
for hoarding disorder has shown some promising results. Case studies (Cermele, Melendez-Pallitto, & Pandina, 2001; Hartl & Frost, 1999), uncontrolled clinical trials (Saxena et al., 2002; Tolin, Frost, & Steketee, 2007), and a randomized wait-list controlled trial (Steketee, Frost, Tolin, Rasmussen, & Brown, 2010) have demonstrated significant improvement in hoarding symptoms following treatment or compared to a wait-list control group. Although these CBT clinical trials for hoarding have been promising, the treatments delivered in these studies were labor intensive and costly. For example, both the open trial by Tolin et al. (2007) as well as the wait-list controlled trial by Steketee et al. (2010) consisted of twenty-six individual sessions, including monthly home and non-acquiring shopping sessions lasting two hours. Although such an intensive and comprehensive treatment approach may be ideal, it may not be feasible in a clinical setting outside of the context of a research study, as the additional time and cost of travel for home visits are generally not covered by most third party payers. Further, one challenge of specialized treatments, such as CBT for hoarding, is that few trained clinicians are available to offer such services. Group CBT for hoarding disorder may help increase access to and reduce the cost of this specialized treatment, as well as potentially enhance social support and learning by observing others. To date, two group treatment studies that have included clinician home visits have been published (Muroff et al., 2009; Steketee, Frost, Wincze, Greene, & Douglass, 2000). Although
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
these studies showed promising results, they appear to be inferior to that found in clinical trials of individual CBT for hoarding. For example, participants in Muroff et al.’s (2009) open trial of group CBT demonstrated a reduction of 14% on the Saving Inventory Revised (SIR; Frost, Steketee, & Grisham, 2004) from pre- to posttreatment compared to a 27e28% reduction in the clinical trials of individual CBT (Steketee et al., 2010; Tolin et al., 2007). Interestingly, Muroff et al. (2009) noted that their last treatment group, which followed a more formalized treatment protocol, showed the greatest improvements (22% reduction in the SIR compared to 14% for the entire sample). Thus, the goal of this study was to provide further data on the effectiveness of group CBT for hoarding. In particular, our aim was to determine whether treatment outcomes could be improved to be comparable to that of individual CBT by following a more formalized treatment protocol, as Muroff et al. (2009) suggested. Since one of the potential advantages of group treatment is to increase access to care, our secondary aim was to examine the effectiveness of treatment that may be feasible to provide in the community setting, not solely in the context of a research study. Therefore, we elected to exclude clinician home visits from our treatment. We also required participants to pay a small fee for treatment ($20 per session), as would be expected in a community setting. Our third aim was to examine changes in other important aspects related to hoarding, but not assessed directly through hoarding specific measures, such as anxiety, depression, and quality of life. Hoarding has been associated with a high level of comorbidity, particularly depression and anxiety (Fontenelle, Mendlowicz, Soares, & Viersiani, 2004; Frost, Steketee, & Tolin, in press; Lochner et al., 2005; Samuels et al., 2002, 2007), yet it remains unclear whether CBT for hoarding has an impact on these co-occurring symptoms. Finally, we wanted to examine potential changes in the quality of life from pre- to post-treatment, as effective treatments ideally impact not only the target symptoms of a disorder, but also one’s quality of life. Individuals with hoarding often report significant problems with their work, social life, and family life due to their hoarding (Frost, Steketee, Williams, & Warren, 2000; Tolin, Frost, Steketee, & Fitch, 2008). We predicted the following outcomes: (1) Participants would show improvements in hoarding symptoms from pre- to post-treatment; (2) Participants would show improvements in co-occurring symptoms of anxiety and depression from pre- to post-treatment; and (3) Participants would show improved psychosocial functioning from pre- to post-treatment. Method Participants Forty-five participants with primary hoarding disorder who presented at a specialty outpatient anxiety disorders clinic within a psychiatric hospital enrolled into treatment. Patients at this clinic are generally self-referred, referred by another medical provider, or completed a non-treatment study at the same clinic. Of these, 35 participants completed assessment measures at two time points or more (i.e. pre-treatment and mid-treatment, or pre-treatment and post-treatment) and were therefore included in the data analyses. Only 30 individuals completed treatment. Of the five nontreatment completers included in the data analyses, one participant withdrew due to time constraints, two withdrew due to personal problems, one withdrew due to financial difficulties and keeping up with the treatment, and one participant was lost to contact. Reasons for withdrawing from treatment for the remaining 10 participants who were not included in the data analyses due to having data from only one time point included: personal problems
803
(N ¼ 4), lost to contact (N ¼ 2), medical reason (N ¼ 1), depression (N ¼ 1), distance (N ¼ 1), and dissatisfaction with treatment (N ¼ 1). To be included in the treatment, individuals had to be 18 years of age or older and have a Clinician’s Global Impression (CGI; Guy, 1976) score of 4 (“moderately ill”) or greater for severity of hoarding disorder. Exclusionary criteria included any concurrent symptoms or diagnosis that required immediate attention and/or would interfere with the patient’s ability to engage in treatment, such as serious suicidal or homicidal ideation, substance abuse/ dependence, psychosis, or a pervasive developmental disorder. Measures The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, Di Nardo, Lehman, & Campbell, 2001) or the Mini-International Neuropsychiatric Interview Plus (MINI Plus; Sheehan et al., 1997, 1998) was used to determine Axis I diagnoses. As neither the ADIS-IV nor the MINI Plus includes questions necessary to determine a diagnosis of hoarding disorder, the interviewers supplemented several questions to the OCD sections. These questions assessed the impairment and distress associated with clutter, the presence of excessive acquisition, and the functional nature of the difficulty discarding to conduct a differential diagnosis. When a participant reported symptoms of disorders not included in the ADIS-IV (e.g. attention-deficit/hyperactivity disorder), diagnosis was made by referring to the diagnostic criteria in the DSM-IV (American Psychiatric Association, 2000). Twenty-seven participants (77%) completed the ADIS-IV and eight (23%) completed the MINI Plus. A self-report version of the Clinical Global Impression Scale (CGI; Guy, 1976; Hannan & Tolin, 2007) was used to obtain ratings of global symptom severity and symptom improvement. The Sheehan Disability Scale (SDS; Leon, Shear, Portera, & Klerman, 1992), a self-report measure was used to assess impairment in psychosocial functioning and quality of life. For this study, the mean score of the three items were examined in the analyses. Internal consistency (a) for this sample was .75. The Activities of Daily Living for Hoarding (ADL-H; Frost & Steketee, 2003; Hristova, 2011), a self-report measure, was used to assess the level of impact of clutter on one’s ability to complete basic daily activities. Recent research on the ADL-H suggests that the first 12 items of the original 29 item scale show superior psychometric properties, with strong internal consistency, testeretest reliability, and convergent and discriminant validity (Hristova, 2011). The 12-item version was therefore used in the analyses. Internal consistency (a) for this sample was .86. The Saving Inventory Revised (SIR; Frost et al., 2004), a 23-item self-report measure was used to assess the level of compulsive acquisition, difficulty discarding, and cluttered living spaces. Internal consistency (a) for this sample was .90. The Depression Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995), a self-report measure, was used to assess the negative emotional states of depression, anxiety and stress. Internal consistency (a) for this sample was .93 for the depression subscale and .78 for the anxiety subscale. The Client Satisfaction Questionnaire-8 (CSQ-8; Nguyen, Attkisson, & Stegner, 1983), an eight item self-report questionnaire was used to assesses satisfaction with a specific healthcare or counseling service. Internal consistency (a) for this sample was .87. Procedure All participants were initially evaluated by a trained clinician (an advanced level graduate student or postdoctoral fellow supervised by a licensed psychologist, or a licensed psychologist) who administered the ADIS-IV or MINI Plus to determine Axis I diagnoses. Clinicians who completed the evaluation were generally not
804
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
involved in the treatment. Participants completed self-report measures at pre, mid, and post-treatment. Treatment Treatment consisted of 16e20 (90 min) sessions of weekly group CBT for hoarding disorder. There were a total of five separate groups, with each group consisting of 4e12 participants (mean ¼ 9.00; SD ¼ 3.32). Three of the groups consisted of 16 sessions, and two groups consisted of 20 sessions to accommodate a slower pace. Four of the five groups were co-facilitated by two postdoctoral fellows and one group was co-facilitated by a postdoctoral fellow and an advanced level graduate student. The postdoctoral fellows were experienced cognitive-behavioral therapists with a Ph.D. in psychology and received training in CBT for hoarding disorder by an expert in the area. Treatment was based on a cognitive-behavioral model of hoarding disorder (Steketee & Frost, 2007) and was adapted from an individual CBT protocol of hoarding to be used in a group format. Data analyses QeQ plots for all the variables were inspected visually to examine normality and to check for outliers. The QeQ plots for the SDS at pre-treatment, the ADL at post-treatment, as well as the DASS subscales of anxiety at mid and post-treatment, and the depression subscale at post-treatment showed outliers that compromised the normality of the distribution. Therefore, these outliers were removed, leaving 32e34 participant’s data available for analysis. Chi-square and t-test analyses were performed to examine any differences in sociodemographic or diagnostic variables, or psychotropic medications taken at pre-treatment between included and excluded participants in the outcome analyses. Modified intent-to-treat (ITT) mixed-model analyses were used to account for missing data during hypothesis testing (modified in that not all persons who completed the baseline measures completed a second assessment). Mixed-effects models without any ad hoc imputation are more powerful than mixed-effects models with imputations for missing values (Chakraborty & Gu, 2009). Outcome variables were the SIR, ADL, the anxiety and depression subscales of the DASS, CGI self-report, SDS, and OBQ. In order to examine whether the number of sessions attended was related to treatment outcomes, degree of change from pre- to posttreatment was calculated for each outcome variable, which was then correlated with the number of sessions attended. In all cases, p was greater than .15, and thus number of sessions was not included as a covariate in the hypothesis testing. We also calculated the number of participants who met criteria for clinically significant change (CSC; Jacobson & Truax, 1991; McGlinchey, Atkins, & Jacobson, 2002). CSC is a reliable reduction in symptoms based on the known testeretest reliability of a measure along with a posttreatment score falling within a nonclinical range. For the SIR, CSC was defined as a 14 point or greater reduction from pre- to posttreatment, and a post-treatment score of 42 or less, which is the point half-way between the means of the clinical and nonclinical populations (Frost et al., 2004). Responder status using CSC as well as CGI-I self-report is reported as a percentage of both the completer and the modified ITT sample. Demographic and diagnostic information, as well as the CSQ and CGI-I are presented descriptively. Results Demographic and diagnostic information of both participants who were included (N ¼ 35) and excluded (N ¼ 10) from the study
analyses are presented in Table 1. t-Test and chi-square analyses revealed no significant differences in demographic or diagnostic variables, as well as psychotropic medications. Mean score on the CSQ was 29.19 (SD ¼ 2.75; N ¼ 21), demonstrating that participants found group treatment to be highly satisfying. The average participant included in the data analyses attended 88% of sessions [M ¼ 17.25 (86%), SD ¼ 3.98, range ¼ 8e20 for those in the 20 session group; M ¼ 14.27 (89%), SD ¼ 1.49, range ¼ 12e16 for those in the 16 session group]. To test hypothesis one, three mixed-model analyses were conducted with the SIR, CGI self-report, and ADL as the outcome variables and time (pre-treatment, mid-treatment, post-treatment) as the repeated measure. These analyses revealed a significant main effect of time for SIR total score (F2, 58.64 ¼ 25.07, p < .001) and all SIR subscales [Clutter (F2, 56.82 ¼ 21.87, p < .001); Acquiring (F2, 57.14 ¼ 17.75, p < .001); Difficulty Discarding (F2, 67.41 ¼13.94, p < .001)], CGI (F2, 57.49 ¼ 6.94, p ¼ .002), and ADL (F2, 56.00 ¼ 8.14, p ¼ .001)]. These analyses were followed by post-hoc pairwise comparisons to examine changes between each time point (pre to mid, mid to post, and pre to post). The results, including means and standard deviations of all outcome variables at each time point (pre, mid, and post), are displayed in Table 2. At mid-treatment, 11 participants (42% of completers and 31% of the modified ITT sample) rated themselves as much or very much improved on the
Table 1 Sample description (N ¼ 35). N (%) or M (SD) Completers (N ¼ 35)
p Value Drops (N ¼ 10)
Female
30 (85.7%)
9 (90%)
.73
Age
55.06 (10.63)
49.90 (11.83)
.24
Race/ethnicity Caucasian Other Missing data
30 (91%) 2 (6%) 2
10 (100%) 0 (0%) 0
.61
Employed full or part time Missing data
19 (56%) 1
5 (50%) 0
.74
Married or cohabitating Missing data
9 (26%) 1
5 (50%) 0
.16
Education level BA or higher Missing data
23 (68%) 1
7 (70%) 0
.89
Number of comorbid diagnoses Any One Two Three or more Missing data
27 (82%) 8 (24%) 8 (24%) 11 (33%) 2
7 2 2 3 1
(78%) (22%) (22%) (33%)
.78 .90 .90 1.00
Comorbid diagnoses Depressive disorders Social phobia Generalized anxiety disorder OCD ADHD Missing data
20 (61%) 10 (30%) 5 (15%) 5 (15%) 4 (12%) 2
7 2 1 0 0 1
(78%) (22%) (11%) (0%) (0%)
.34 .63 .76
Taking psychotropic medications SSRI Benzodiazepines Atypical antidepressants Stimulants Missing data
25 (74%) 17 (50%) 6 (18%) 12 (35%) 8 (24%) 1
5 4 2 4 2 0
(50%) (40%) (20%) (40%) (20%)
.26 .16 .58 .87 .79 .82
Note. BA ¼ bachelor’s degree, OCD ¼ obsessive compulsive disorder, ADHD ¼ attention-deficit/hyperactivity disorder, SSRI ¼ selective serotonin reuptake inhibitor.
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
805
Table 2 Means and standard deviations and mixed-model results, post-hoc pairwise comparisons (N ¼ 35). Measure
Mean (SD)
F (df), Cohen’s d
Pre
Mid
Post
Pre to post
Pre to mid
Mid to post
SIR total
64.23 (12.41) N ¼ 35
53.12 (12.68) N ¼ 32
47.15 (13.73) N ¼ 26
F ¼ 55.46 (1, 27.61)** d ¼ 1.31
F ¼ 23.51(1, 31.33)** d ¼ .86
F ¼ 16.54 (1, 24.44)** d ¼ .45
SIR clutter
27.63 (4.89) N ¼ 35
24.27 (4.76) N ¼ 32
21.42 (4.61) N ¼ 35
F ¼ 36.95 (1, 51.11)** d ¼ 1.31
F ¼ 20.36 (1, 51.70)** d ¼ .70
F ¼ 18.82 (1, 40.06)** d ¼ .61
SIR acquiring
16.86 (5.60) N ¼ 35
12.60 (5.46) N ¼ 32
11.07 (5.29) N ¼ 26
F ¼ 47.82 (1, 44.24)** d ¼ 1.06
F ¼ 18.93 (1, 49.24)** d ¼ .77
F ¼ 6.46 (1, 37.58)* d ¼ .29
SIR difficulty discarding
19.74 (4.77) N ¼ 35
16.25 (4.68) N ¼ 32
14.64 (4.60) N ¼ 35
F ¼ 31.54 (1, 47.45)** d ¼ 1.09
F ¼ 16.50 (1, 53.87)** d ¼ .74
F ¼ 4.03 (1, 44.13) d ¼ .35
CGI self-report
5.24 (.96) N ¼ 33
4.84 (.97) N ¼ 32
4.41 (1.05) N ¼ 26
F ¼ 12.76 (1, 27.14)** d ¼ .83
F ¼ 5.91 (1, 32.37)* d ¼ .41
F ¼ 5.18 (1, 26.77)* d ¼ .43
CGI-I self-report
e
2.23 (.65) N ¼ 26
2.58 (.90) N ¼ 26
e
e
e
ADL-H
23.63 (6.42) N ¼ 35
21.03 (6.26) N ¼ 32
18.59 (5.94) N ¼ 25
F ¼ 14.43 (1, 23.72)* d ¼ .82
F ¼ 8.63 (1, 31.58)* d ¼ .41
F ¼ 8.98 (1, 23.55)* d ¼ .40
DASS anxiety
7.12 (4.55) N ¼ 34
5.28 (4.33) N ¼ 28
3.19 (4.33) N ¼ 25
F ¼ 18.45 (1, 24.67)** d ¼ .88
F ¼ 5.28 (1, 28.52)* d ¼ .41
F ¼ 8.16 (1, 21.68)* d ¼ .48
DASS depression
12.99 (8.14) N ¼ 32
11.36 (8.10) N ¼ 32
6.87 (7.98) N ¼ 23
F ¼ 14.40 (1, 23.16)* d ¼ .76
F ¼ .91 (1, 31.94) d ¼ .20
F ¼ 6.09 (1, 24.01)* d ¼ .56
SDS
6.47 (1.89) N ¼ 32
5.92 (1.95) N ¼ 32
4.34 (1.92) N ¼ 26
F ¼ 22.43 (1, 20.15)** d ¼ 1.12
F ¼ 2.58 (1, 32.70)* d ¼ .29
F ¼ 14.42 (1, 31.63)* d ¼ .82
Note. *p < .05, **p < .001. SIR ¼ Saving Inventory Revised, CGI ¼ Clinical Global Impressions, CGI-I ¼ Clinical Global Impressions e Improvement, ADL ¼ Activities of Daily Living Scale for Hoarding e 12, DASS ¼ Depression Anxiety Stress Scale, SDS ¼ Sheehan Disability Scale.
CGI-I. At post-treatment, 19 participants (73% of completers and 54% of modified ITT sample) rated themselves as much or very much improved on the CGI-I. Eight participants (31% of completers and 23% of the modified ITT sample) met criteria for CSC on the SIR. To test hypothesis two, two mixed-model analyses were conducted on the anxiety and depression subscales of the DASS with time (pre-treatment, mid-treatment, post-treatment) as the repeated measure. These analyses revealed a significant main effect of time for both the anxiety (F2, 50.48 ¼ 8.64, p ¼ .001) and depression subscales (F2, 57.34 ¼ 4.58, p ¼ .014). Post-hoc pairwise comparisons for the DASS anxiety and depression are revealed in Table 2. To test hypothesis three, a mixed-model analysis was conducted with the SDS as the outcome variable, which revealed a significant main effect of time (F2, 59.29 ¼ 11.68, p < .001). Again, post-hoc pairwise comparisons are reported in Table 2. Discussion The results of this study show promise for the effectiveness of group CBT for hoarding disorder, and contribute to the small body of published literature on CBT for hoarding. Participants demonstrated significant improvements from pre- to post-treatment not only in hoarding symptoms, but also in symptoms of depression and anxiety, as well as quality of life, with all areas showing large effect sizes. A strength of this study is that it may closely resemble how CBT can be delivered in the community, outside the context of a research study. Group participants were not recruited to participate in a research study, and they paid a small fee to receive treatment, as one would in a community setting. The degree of clinician demand per each patient was significantly lower than that of other published individual CBT studies for hoarding (Steketee et al., 2010; Tolin et al., 2007) Muroff et al. (2009) provided 16e20 sessions of group CBT as we did in this study; however, they
also offered two individual home visits. Although home visits by a clinician likely contribute to effectiveness of treatment, it may not be a realistic component of treatment outside of a research context due to insurance constraints and additional travel time for the clinician. Despite the reduced clinician burden per patient in this study, treatment outcome appears comparable to other published studies of individual CBT (Steketee et al., 2010; Tolin et al., 2007), and superior to group CBT studies (Muroff et al., 2009; Steketee et al., 2000). Unfortunately, we are not able to adequately compare our study in terms of CSC to previous studies since Steketee et al. (2010) and Tolin, Fitch, Frost, and Steketee (2010) both used a significantly more liberal CSC definition (a change of 14 points or greater and a post-treatment score of 50, which is two SD above the nonclinical mean) compared to our significantly more conservative criterion (a change of 14 points or greater and a post-treatment score of 42 or less). Muroff et al. (2009) noted from their study on group CBT for hoarding that their last treatment group, which followed a more formalized treatment protocol, showed the greatest improvements. This may help explain the superior results obtained in this study of group CBT; all treatment groups were facilitated following a flexible, yet structured treatment protocol that included specific skills to be covered, along with a workbook that included readings and worksheets. Further, stringent rules were enforced regarding attendance, punctuality, and homework compliance. Homework and overall treatment compliance among this population has been cited repeatedly as a concern in the literature (Christensen & Greist, 2001; Hartl & Frost, 1999; Steketee et al., 2000; Tolin et al., 2007). Furthermore, homework adherence is correlated with treatment outcome (Tolin et al., 2007). Close monitoring of homework completion, along with consequences for poor adherence may have improved compliance, and thus treatment outcomes, among participants in this study. Despite some of it strengths, there are significant limitations to this study. As this study was not a randomized controlled trial, we
806
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
cannot draw definitive conclusions about the effectiveness of group CBT for hoarding, including how it compares to individual CBT, or CBT with clinician home visits. Any changes from pre- to posttreatment can be attributed to nonspecific factors, including group processes, demand characteristics, natural changes with the passage of time, and attention from therapists and other group members. One of the major limitations is the attrition; only 67% of the participants completed treatment, and we were only able to report results from 78% of participants who had at least two data points (pre and mid or pre and post). The attrition rate of this study (33%) was slightly higher than those reported in previous clinical trials of CBT for hoarding disorder (20% in Steketee et al., 2010 and 29% in Tolin et al., 2007). It is possible that group treatment may lead to greater attrition, as each person does not necessarily receive the same level of attention compared to individual treatment. The stringent requirements for continued participation of attendance, punctuality, and homework compliance may have also increased the likelihood of attrition for those individuals who could not comply with such demands. Another significant limitation is the reliance on self-report data, and presence of missing data. As data from this study was collected from a clinic sample, there was a significant amount of missing data even among participants who completed treatment, particularly the CSQ, which only included data from 21 participants. Results of this study, therefore, should be interpreted with caution, particularly ratings of client satisfaction. Given that this population has often been cited as having limited insight into the severity of one’s hoarding problems (Frost, Krause, & Steketee, 1996; Samuels et al., 2007; Tolin et al., 2010), we cannot definitely conclude that hoarding symptoms truly improved following treatment without an in-home assessment of the severity of clutter. We also did not collect follow-up data, and therefore cannot draw any conclusions about the long-term outcome of group CBT after treatment discontinuation. This may be particularly important to assess in hoarding disorder, which is considered to be a chronic condition, and one in which even those patients who are considered treatment responsive often continue to exhibit noticeable symptoms after successful treatment. Finally, like most other published studies on hoarding disorder, our sample was primarily female, Caucasian, and highly educated. Although this appears to be a common characteristic among those selected in treatment studies on hoarding disorder (Muroff et al., 2009; Steketee et al., 2010; Tolin et al., 2007), recent epidemiological studies suggest that hoarding is equally represented across different ethnic groups (Samuels et al., 2008). Group CBT for hoarding may be a viable treatment option that improves access to treatment and lowers clinician burden and financial cost to hoarding individuals or third party payers. Future research is needed directly comparing the effectiveness as well as cost-effectiveness of group and individual CBT. Acknowledgments We thank the participants in the treatment groups for contributing their data for this study. We thank Danielle Dufresne for co-facilitating one of the groups. We also thank Diana Alamo, Jennifer Dimauro, Claire Doucette, Diana Harrington, and Kolette Ring for their assistance on the study. References Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology, 71(6), 1049e1057.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th text revision ed.). Washington, DC: Author. Black, D. W., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessivecompulsive disorder. Journal of Clinical Psychiatry, 59(8), 420e425. Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110(1), 49e58. Cermele, J. A., Melendez-Pallitto, L., & Pandina, G. J. (2001). Intervention in compulsive hoarding. A case study. Behavior Modification, 25(2), 214e232. Chakraborty, H., & Gu, H. (2009). A mixed model approach for intent-to-treat analysis in longitudinal clinical trials with missing values. Research Triangle Park, NC: RTI International Press. Christensen, D. D., & Greist, J. H. (2001). The challenge of obsessive-compulsive disorder hoarding. Primary Psychiatry, 8, 79e86. Fontenelle, L. F., Mendlowicz, M. V., Soares, I. D., & Viersiani, M. (2004). Patients with obsessive-compulsive disorder and hoarding symptoms: a distinct clinical subtype? Comprehensive Psychiatry, 45, 375e383. Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34(4), 341e350. Frost, R. O., Krause, M. S., & Steketee, G. (1996). Hoarding and obsessive-compulsive symptoms. Behavior Modification, 20, 116e132. Frost, R. O., & Steketee, G. (2003). A measure of activities of daily living for hoarding (ADL-H). Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: saving inventory-revised. Behaviour Research and Therapy, 42(10), 1163e1182. Frost, R. O., Steketee, G., & Tolin, D. F. Comorbidity in hoarding disorder. Depression and Anxiety, in press. Frost, R. O., Steketee, G., Williams, L. F., & Warren, R. (2000). Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls. Behaviour Research and Therapy, 38, 1071e1081. Frost, R. O., & Tolin, D. F. (2008). Compulsive hoarding. In S. Taylor, J. S. Abramowitz, & D. McKay (Eds.), Clinical handbook of obsessive-compulsive disorder and related problems (pp. 76e94). Baltimore: Johns Hopkins University Press. Grisham, J. R., & Norberg, M. M. (2010). Compulsive hoarding: current controversies and new directions. Dialogues in Clinical Neuroscience, 12(2), 233e240. Guy, W. (1976). Assessment manual for psychopharmacology. Washington, DC: U.S. Government Printing Office. Hannan, S. E., & Tolin, D. F. (2007, November). Examination of the validity of therapist rated and patient rated clinical global impression scores. Paper presented at the annual meeting of the Association of Behavioral and Cognitive Therapies, Philadelphia. Hartl, T. L., & Frost, R. O. (1999). Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study. Behaviour Research and Therapy, 37(5), 451e461. Hristova, V. (2011). Activities of daily living scale in hoarding disorder. Unpublished manuscript, Smith College, Northampton, MA. Iervolino, A. C., Perroud, N., Fullana, M. A., Guipponi, M., Cherkas, L., Collier, D. A., et al. (2009). Prevalence and heritability of compulsive hoarding: a twin study. American Journal of Psychiatry, 166(10), 1156e1161. Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12e19. Leon, A. C., Shear, M. K., Portera, L., & Klerman, G. L. (1992). Assessing impairment in patients with panic disorder: the Sheehan disability scale. Social Psychiatry and Psychiatric Epidemiology, 27, 78e82. Lochner, C., Kinnear, C. J., Hemmings, S. M., Seller, C., Niehaus, D. J., Knowles, J. A., et al. (2005). Hoarding in obsessive-compulsive disorder: clinical and genetic correlates. Journal of Clinical Psychiatry, 66, 1155e1160. Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety stress scales. Sydney: The Psychology Foundation of Australia. Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K. A., & Baer, L. (2002). Obsessivecompulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychotherapy and Psychosomatics, 71(5), 255e262. Mataix-Cols, D., Rauch, S. L., Manzo, P. A., Jenike, M. A., & Baer, L. (1999). Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 156(9), 1409e1416. McGlinchey, J. B., Atkins, D. C., & Jacobson, N. S. (2002). Clinical significance methods: which one to use and how useful are they? Behavior Therapy, 33, 529e550. Muroff, J., Steketee, G., Rasmussen, J., Gibson, A., Bratiotis, C., & Sorrentino, C. (2009). Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial. Depression and Anxiety, 26(7), 634e640. doi:10.1002/ da.20591. Nguyen, T. D., Attkisson, C. C., & Stegner, B. L. (1983). Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire. Evaluation and Program Planning, 6(3e4), 299e313. Rufer, M., Fricke, S., Moritz, S., Kloss, M., & Hand, I. (2006). Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica, 113(5), 440e446.
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807 Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15(1), 53e63. doi:10.1038/mp.2008.94, mp200894 [pii]. Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle, M. A., Liang, K. Y., et al. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour Research and Therapy, 46(7), 836e844. Samuels, J. F., Bienvenu, O. J., Pinto, A., Fyer, A. J., McCracken, J. T., Rauch, S. L., et al. (2007). Hoarding in obsessive-compulsive disorder: results from the OCD collaborative genetics study. Behaviour Research and Therapy, 45, 673e686. Samuels, J. F., Bienvenu, O. J., Riddle, M. A., Cullen, B. A., Grados, M. A., Liang, K. Y., et al. (2002). Hoarding in obsessive compulsive disorder: results from a casee control study. Behaviour Research and Therapy, 40(5), 517e528. Saxena, S., Maidment, K. M., Vapnik, T., Golden, G., Rishwain, T., Rosen, R. M., et al. (2002). Obsessive-compulsive hoarding: symptom severity and response to multimodal treatment. Journal of Clinical Psychiatry, 63(1), 21e27. Sheehan, D. V., Lecrubier, Y., Harnett-Sheehan, K., Janavs, J., Weiller, E., Bonora, L. I., et al. (1997). Reliability and validity of the MINI international neuropsychiatric interview (M.I.N.I.): according to the SCID-P. European Psychiatry, 12, 232e241. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview
807
for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22e33, quiz 34e57. Stein, D. J., Andersen, E. W., & Overo, K. F. (2007). Response of symptom dimensions in obsessive-compulsive disorder to treatment with citalopram or placebo. Revista Brasileira de Psiquiatria, 29(4), 303e307. Steketee, G., & Frost, R. O. (2003). Compulsive hoarding: current status of the research. Clinical Psychology Review, 23, 905e927. Steketee, G., & Frost, R. O. (2007). Compulsive hoarding and acquiring: Therapist guide. New York: Oxford University Press. Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlistcontrolled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27(5), 476e484. doi:10.1002/da.20673. Steketee, G., Frost, R. O., Wincze, J., Greene, K., & Douglass, H. (2000). Group and individual treatment of compulsive hoarding: a pilot study. Behavioural and Cognitive Psychotherapy, 28, 259e268. Tolin, D. F., Fitch, K. E., Frost, R. O., & Steketee, G. (2010). Family informants’ perceptions of insight in compulsive hoarding. Cognitive Therapy and Research, 34, 69e81. Tolin, D. F., Frost, R. O., & Steketee, G. (2007). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461e1470. Tolin, D. F., Frost, R. O., Steketee, G., & Fitch, K. E. (2008). Family burden of compulsive hoarding: results of an internet survey. Behaviour Research and Therapy, 46(3), 334e344.
Contents lists available at SciVerse ScienceDirect
Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat
Shorter communication
Group cognitive-behavioral therapy for hoarding disorder: An open trial Christina M. Gilliama, *, Melissa M. Norbergb, Anna Villavicencioa,1, Samantha Morrisona, Scott E. Hannana, David F. Tolina a b
Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA National Cannabis Prevention and Information Centre, University of New South Wales, Sydney, PO Box 684, Randwick, NSW 2031, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 June 2011 Received in revised form 26 August 2011 Accepted 30 August 2011
Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Hoarding Cognitive-behavioral therapy Group therapy
Despite the high prevalence rate (2e5%; Grisham & Norberg, 2010; Iervolino et al., 2009; Ruscio, Stein, Chiu, & Kessler, 2010; Samuels et al., 2008) and the significant impairment and burden associated with hoarding, research and treatment on hoarding has been limited. Earlier research that applied treatments for OCD to hoarding disorder, such as exposure and response prevention (Abramowitz, Franklin, Schwartz, & Furr, 2003; Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; Rufer, Fricke, Moritz, Kloss, & Hand, 2006) or serotonergic medications (Black et al., 1998; Mataix-Cols, Rauch, Manzo, Jenike, & Baer, 1999; Stein, Andersen, & Overo, 2007) generally showed a less favorable response among those with hoarding compared to those with OCD. In response to these disappointing outcomes, a cognitive-behavioral model of hoarding disorder was developed that emphasizes mechanisms of maintenance including information processing deficits and maladaptive beliefs about possessions, which in turn result in emotional distress and avoidance behaviors (Frost & Hartl, 1996; Frost & Tolin, 2008; Steketee & Frost, 2003, 2007). Cognitive-behavioral therapy (CBT)
* Corresponding author. Tel.: þ1 860 545 7685; fax: þ1 860 545 7156. E-mail addresses: [email protected], [email protected] (C.M. Gilliam), m. [email protected] (M.M. Norberg), [email protected] (A. Villavicencio), [email protected] (S. Morrison), [email protected] (S.E. Hannan), [email protected] (D.F. Tolin). 1 Present address: Bradley Hospital, 1110 Veterans Memorial Parkway, East Providence, RI 02915, USA. 0005-7967/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2011.08.008
for hoarding disorder has shown some promising results. Case studies (Cermele, Melendez-Pallitto, & Pandina, 2001; Hartl & Frost, 1999), uncontrolled clinical trials (Saxena et al., 2002; Tolin, Frost, & Steketee, 2007), and a randomized wait-list controlled trial (Steketee, Frost, Tolin, Rasmussen, & Brown, 2010) have demonstrated significant improvement in hoarding symptoms following treatment or compared to a wait-list control group. Although these CBT clinical trials for hoarding have been promising, the treatments delivered in these studies were labor intensive and costly. For example, both the open trial by Tolin et al. (2007) as well as the wait-list controlled trial by Steketee et al. (2010) consisted of twenty-six individual sessions, including monthly home and non-acquiring shopping sessions lasting two hours. Although such an intensive and comprehensive treatment approach may be ideal, it may not be feasible in a clinical setting outside of the context of a research study, as the additional time and cost of travel for home visits are generally not covered by most third party payers. Further, one challenge of specialized treatments, such as CBT for hoarding, is that few trained clinicians are available to offer such services. Group CBT for hoarding disorder may help increase access to and reduce the cost of this specialized treatment, as well as potentially enhance social support and learning by observing others. To date, two group treatment studies that have included clinician home visits have been published (Muroff et al., 2009; Steketee, Frost, Wincze, Greene, & Douglass, 2000). Although
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
these studies showed promising results, they appear to be inferior to that found in clinical trials of individual CBT for hoarding. For example, participants in Muroff et al.’s (2009) open trial of group CBT demonstrated a reduction of 14% on the Saving Inventory Revised (SIR; Frost, Steketee, & Grisham, 2004) from pre- to posttreatment compared to a 27e28% reduction in the clinical trials of individual CBT (Steketee et al., 2010; Tolin et al., 2007). Interestingly, Muroff et al. (2009) noted that their last treatment group, which followed a more formalized treatment protocol, showed the greatest improvements (22% reduction in the SIR compared to 14% for the entire sample). Thus, the goal of this study was to provide further data on the effectiveness of group CBT for hoarding. In particular, our aim was to determine whether treatment outcomes could be improved to be comparable to that of individual CBT by following a more formalized treatment protocol, as Muroff et al. (2009) suggested. Since one of the potential advantages of group treatment is to increase access to care, our secondary aim was to examine the effectiveness of treatment that may be feasible to provide in the community setting, not solely in the context of a research study. Therefore, we elected to exclude clinician home visits from our treatment. We also required participants to pay a small fee for treatment ($20 per session), as would be expected in a community setting. Our third aim was to examine changes in other important aspects related to hoarding, but not assessed directly through hoarding specific measures, such as anxiety, depression, and quality of life. Hoarding has been associated with a high level of comorbidity, particularly depression and anxiety (Fontenelle, Mendlowicz, Soares, & Viersiani, 2004; Frost, Steketee, & Tolin, in press; Lochner et al., 2005; Samuels et al., 2002, 2007), yet it remains unclear whether CBT for hoarding has an impact on these co-occurring symptoms. Finally, we wanted to examine potential changes in the quality of life from pre- to post-treatment, as effective treatments ideally impact not only the target symptoms of a disorder, but also one’s quality of life. Individuals with hoarding often report significant problems with their work, social life, and family life due to their hoarding (Frost, Steketee, Williams, & Warren, 2000; Tolin, Frost, Steketee, & Fitch, 2008). We predicted the following outcomes: (1) Participants would show improvements in hoarding symptoms from pre- to post-treatment; (2) Participants would show improvements in co-occurring symptoms of anxiety and depression from pre- to post-treatment; and (3) Participants would show improved psychosocial functioning from pre- to post-treatment. Method Participants Forty-five participants with primary hoarding disorder who presented at a specialty outpatient anxiety disorders clinic within a psychiatric hospital enrolled into treatment. Patients at this clinic are generally self-referred, referred by another medical provider, or completed a non-treatment study at the same clinic. Of these, 35 participants completed assessment measures at two time points or more (i.e. pre-treatment and mid-treatment, or pre-treatment and post-treatment) and were therefore included in the data analyses. Only 30 individuals completed treatment. Of the five nontreatment completers included in the data analyses, one participant withdrew due to time constraints, two withdrew due to personal problems, one withdrew due to financial difficulties and keeping up with the treatment, and one participant was lost to contact. Reasons for withdrawing from treatment for the remaining 10 participants who were not included in the data analyses due to having data from only one time point included: personal problems
803
(N ¼ 4), lost to contact (N ¼ 2), medical reason (N ¼ 1), depression (N ¼ 1), distance (N ¼ 1), and dissatisfaction with treatment (N ¼ 1). To be included in the treatment, individuals had to be 18 years of age or older and have a Clinician’s Global Impression (CGI; Guy, 1976) score of 4 (“moderately ill”) or greater for severity of hoarding disorder. Exclusionary criteria included any concurrent symptoms or diagnosis that required immediate attention and/or would interfere with the patient’s ability to engage in treatment, such as serious suicidal or homicidal ideation, substance abuse/ dependence, psychosis, or a pervasive developmental disorder. Measures The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, Di Nardo, Lehman, & Campbell, 2001) or the Mini-International Neuropsychiatric Interview Plus (MINI Plus; Sheehan et al., 1997, 1998) was used to determine Axis I diagnoses. As neither the ADIS-IV nor the MINI Plus includes questions necessary to determine a diagnosis of hoarding disorder, the interviewers supplemented several questions to the OCD sections. These questions assessed the impairment and distress associated with clutter, the presence of excessive acquisition, and the functional nature of the difficulty discarding to conduct a differential diagnosis. When a participant reported symptoms of disorders not included in the ADIS-IV (e.g. attention-deficit/hyperactivity disorder), diagnosis was made by referring to the diagnostic criteria in the DSM-IV (American Psychiatric Association, 2000). Twenty-seven participants (77%) completed the ADIS-IV and eight (23%) completed the MINI Plus. A self-report version of the Clinical Global Impression Scale (CGI; Guy, 1976; Hannan & Tolin, 2007) was used to obtain ratings of global symptom severity and symptom improvement. The Sheehan Disability Scale (SDS; Leon, Shear, Portera, & Klerman, 1992), a self-report measure was used to assess impairment in psychosocial functioning and quality of life. For this study, the mean score of the three items were examined in the analyses. Internal consistency (a) for this sample was .75. The Activities of Daily Living for Hoarding (ADL-H; Frost & Steketee, 2003; Hristova, 2011), a self-report measure, was used to assess the level of impact of clutter on one’s ability to complete basic daily activities. Recent research on the ADL-H suggests that the first 12 items of the original 29 item scale show superior psychometric properties, with strong internal consistency, testeretest reliability, and convergent and discriminant validity (Hristova, 2011). The 12-item version was therefore used in the analyses. Internal consistency (a) for this sample was .86. The Saving Inventory Revised (SIR; Frost et al., 2004), a 23-item self-report measure was used to assess the level of compulsive acquisition, difficulty discarding, and cluttered living spaces. Internal consistency (a) for this sample was .90. The Depression Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995), a self-report measure, was used to assess the negative emotional states of depression, anxiety and stress. Internal consistency (a) for this sample was .93 for the depression subscale and .78 for the anxiety subscale. The Client Satisfaction Questionnaire-8 (CSQ-8; Nguyen, Attkisson, & Stegner, 1983), an eight item self-report questionnaire was used to assesses satisfaction with a specific healthcare or counseling service. Internal consistency (a) for this sample was .87. Procedure All participants were initially evaluated by a trained clinician (an advanced level graduate student or postdoctoral fellow supervised by a licensed psychologist, or a licensed psychologist) who administered the ADIS-IV or MINI Plus to determine Axis I diagnoses. Clinicians who completed the evaluation were generally not
804
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
involved in the treatment. Participants completed self-report measures at pre, mid, and post-treatment. Treatment Treatment consisted of 16e20 (90 min) sessions of weekly group CBT for hoarding disorder. There were a total of five separate groups, with each group consisting of 4e12 participants (mean ¼ 9.00; SD ¼ 3.32). Three of the groups consisted of 16 sessions, and two groups consisted of 20 sessions to accommodate a slower pace. Four of the five groups were co-facilitated by two postdoctoral fellows and one group was co-facilitated by a postdoctoral fellow and an advanced level graduate student. The postdoctoral fellows were experienced cognitive-behavioral therapists with a Ph.D. in psychology and received training in CBT for hoarding disorder by an expert in the area. Treatment was based on a cognitive-behavioral model of hoarding disorder (Steketee & Frost, 2007) and was adapted from an individual CBT protocol of hoarding to be used in a group format. Data analyses QeQ plots for all the variables were inspected visually to examine normality and to check for outliers. The QeQ plots for the SDS at pre-treatment, the ADL at post-treatment, as well as the DASS subscales of anxiety at mid and post-treatment, and the depression subscale at post-treatment showed outliers that compromised the normality of the distribution. Therefore, these outliers were removed, leaving 32e34 participant’s data available for analysis. Chi-square and t-test analyses were performed to examine any differences in sociodemographic or diagnostic variables, or psychotropic medications taken at pre-treatment between included and excluded participants in the outcome analyses. Modified intent-to-treat (ITT) mixed-model analyses were used to account for missing data during hypothesis testing (modified in that not all persons who completed the baseline measures completed a second assessment). Mixed-effects models without any ad hoc imputation are more powerful than mixed-effects models with imputations for missing values (Chakraborty & Gu, 2009). Outcome variables were the SIR, ADL, the anxiety and depression subscales of the DASS, CGI self-report, SDS, and OBQ. In order to examine whether the number of sessions attended was related to treatment outcomes, degree of change from pre- to posttreatment was calculated for each outcome variable, which was then correlated with the number of sessions attended. In all cases, p was greater than .15, and thus number of sessions was not included as a covariate in the hypothesis testing. We also calculated the number of participants who met criteria for clinically significant change (CSC; Jacobson & Truax, 1991; McGlinchey, Atkins, & Jacobson, 2002). CSC is a reliable reduction in symptoms based on the known testeretest reliability of a measure along with a posttreatment score falling within a nonclinical range. For the SIR, CSC was defined as a 14 point or greater reduction from pre- to posttreatment, and a post-treatment score of 42 or less, which is the point half-way between the means of the clinical and nonclinical populations (Frost et al., 2004). Responder status using CSC as well as CGI-I self-report is reported as a percentage of both the completer and the modified ITT sample. Demographic and diagnostic information, as well as the CSQ and CGI-I are presented descriptively. Results Demographic and diagnostic information of both participants who were included (N ¼ 35) and excluded (N ¼ 10) from the study
analyses are presented in Table 1. t-Test and chi-square analyses revealed no significant differences in demographic or diagnostic variables, as well as psychotropic medications. Mean score on the CSQ was 29.19 (SD ¼ 2.75; N ¼ 21), demonstrating that participants found group treatment to be highly satisfying. The average participant included in the data analyses attended 88% of sessions [M ¼ 17.25 (86%), SD ¼ 3.98, range ¼ 8e20 for those in the 20 session group; M ¼ 14.27 (89%), SD ¼ 1.49, range ¼ 12e16 for those in the 16 session group]. To test hypothesis one, three mixed-model analyses were conducted with the SIR, CGI self-report, and ADL as the outcome variables and time (pre-treatment, mid-treatment, post-treatment) as the repeated measure. These analyses revealed a significant main effect of time for SIR total score (F2, 58.64 ¼ 25.07, p < .001) and all SIR subscales [Clutter (F2, 56.82 ¼ 21.87, p < .001); Acquiring (F2, 57.14 ¼ 17.75, p < .001); Difficulty Discarding (F2, 67.41 ¼13.94, p < .001)], CGI (F2, 57.49 ¼ 6.94, p ¼ .002), and ADL (F2, 56.00 ¼ 8.14, p ¼ .001)]. These analyses were followed by post-hoc pairwise comparisons to examine changes between each time point (pre to mid, mid to post, and pre to post). The results, including means and standard deviations of all outcome variables at each time point (pre, mid, and post), are displayed in Table 2. At mid-treatment, 11 participants (42% of completers and 31% of the modified ITT sample) rated themselves as much or very much improved on the
Table 1 Sample description (N ¼ 35). N (%) or M (SD) Completers (N ¼ 35)
p Value Drops (N ¼ 10)
Female
30 (85.7%)
9 (90%)
.73
Age
55.06 (10.63)
49.90 (11.83)
.24
Race/ethnicity Caucasian Other Missing data
30 (91%) 2 (6%) 2
10 (100%) 0 (0%) 0
.61
Employed full or part time Missing data
19 (56%) 1
5 (50%) 0
.74
Married or cohabitating Missing data
9 (26%) 1
5 (50%) 0
.16
Education level BA or higher Missing data
23 (68%) 1
7 (70%) 0
.89
Number of comorbid diagnoses Any One Two Three or more Missing data
27 (82%) 8 (24%) 8 (24%) 11 (33%) 2
7 2 2 3 1
(78%) (22%) (22%) (33%)
.78 .90 .90 1.00
Comorbid diagnoses Depressive disorders Social phobia Generalized anxiety disorder OCD ADHD Missing data
20 (61%) 10 (30%) 5 (15%) 5 (15%) 4 (12%) 2
7 2 1 0 0 1
(78%) (22%) (11%) (0%) (0%)
.34 .63 .76
Taking psychotropic medications SSRI Benzodiazepines Atypical antidepressants Stimulants Missing data
25 (74%) 17 (50%) 6 (18%) 12 (35%) 8 (24%) 1
5 4 2 4 2 0
(50%) (40%) (20%) (40%) (20%)
.26 .16 .58 .87 .79 .82
Note. BA ¼ bachelor’s degree, OCD ¼ obsessive compulsive disorder, ADHD ¼ attention-deficit/hyperactivity disorder, SSRI ¼ selective serotonin reuptake inhibitor.
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
805
Table 2 Means and standard deviations and mixed-model results, post-hoc pairwise comparisons (N ¼ 35). Measure
Mean (SD)
F (df), Cohen’s d
Pre
Mid
Post
Pre to post
Pre to mid
Mid to post
SIR total
64.23 (12.41) N ¼ 35
53.12 (12.68) N ¼ 32
47.15 (13.73) N ¼ 26
F ¼ 55.46 (1, 27.61)** d ¼ 1.31
F ¼ 23.51(1, 31.33)** d ¼ .86
F ¼ 16.54 (1, 24.44)** d ¼ .45
SIR clutter
27.63 (4.89) N ¼ 35
24.27 (4.76) N ¼ 32
21.42 (4.61) N ¼ 35
F ¼ 36.95 (1, 51.11)** d ¼ 1.31
F ¼ 20.36 (1, 51.70)** d ¼ .70
F ¼ 18.82 (1, 40.06)** d ¼ .61
SIR acquiring
16.86 (5.60) N ¼ 35
12.60 (5.46) N ¼ 32
11.07 (5.29) N ¼ 26
F ¼ 47.82 (1, 44.24)** d ¼ 1.06
F ¼ 18.93 (1, 49.24)** d ¼ .77
F ¼ 6.46 (1, 37.58)* d ¼ .29
SIR difficulty discarding
19.74 (4.77) N ¼ 35
16.25 (4.68) N ¼ 32
14.64 (4.60) N ¼ 35
F ¼ 31.54 (1, 47.45)** d ¼ 1.09
F ¼ 16.50 (1, 53.87)** d ¼ .74
F ¼ 4.03 (1, 44.13) d ¼ .35
CGI self-report
5.24 (.96) N ¼ 33
4.84 (.97) N ¼ 32
4.41 (1.05) N ¼ 26
F ¼ 12.76 (1, 27.14)** d ¼ .83
F ¼ 5.91 (1, 32.37)* d ¼ .41
F ¼ 5.18 (1, 26.77)* d ¼ .43
CGI-I self-report
e
2.23 (.65) N ¼ 26
2.58 (.90) N ¼ 26
e
e
e
ADL-H
23.63 (6.42) N ¼ 35
21.03 (6.26) N ¼ 32
18.59 (5.94) N ¼ 25
F ¼ 14.43 (1, 23.72)* d ¼ .82
F ¼ 8.63 (1, 31.58)* d ¼ .41
F ¼ 8.98 (1, 23.55)* d ¼ .40
DASS anxiety
7.12 (4.55) N ¼ 34
5.28 (4.33) N ¼ 28
3.19 (4.33) N ¼ 25
F ¼ 18.45 (1, 24.67)** d ¼ .88
F ¼ 5.28 (1, 28.52)* d ¼ .41
F ¼ 8.16 (1, 21.68)* d ¼ .48
DASS depression
12.99 (8.14) N ¼ 32
11.36 (8.10) N ¼ 32
6.87 (7.98) N ¼ 23
F ¼ 14.40 (1, 23.16)* d ¼ .76
F ¼ .91 (1, 31.94) d ¼ .20
F ¼ 6.09 (1, 24.01)* d ¼ .56
SDS
6.47 (1.89) N ¼ 32
5.92 (1.95) N ¼ 32
4.34 (1.92) N ¼ 26
F ¼ 22.43 (1, 20.15)** d ¼ 1.12
F ¼ 2.58 (1, 32.70)* d ¼ .29
F ¼ 14.42 (1, 31.63)* d ¼ .82
Note. *p < .05, **p < .001. SIR ¼ Saving Inventory Revised, CGI ¼ Clinical Global Impressions, CGI-I ¼ Clinical Global Impressions e Improvement, ADL ¼ Activities of Daily Living Scale for Hoarding e 12, DASS ¼ Depression Anxiety Stress Scale, SDS ¼ Sheehan Disability Scale.
CGI-I. At post-treatment, 19 participants (73% of completers and 54% of modified ITT sample) rated themselves as much or very much improved on the CGI-I. Eight participants (31% of completers and 23% of the modified ITT sample) met criteria for CSC on the SIR. To test hypothesis two, two mixed-model analyses were conducted on the anxiety and depression subscales of the DASS with time (pre-treatment, mid-treatment, post-treatment) as the repeated measure. These analyses revealed a significant main effect of time for both the anxiety (F2, 50.48 ¼ 8.64, p ¼ .001) and depression subscales (F2, 57.34 ¼ 4.58, p ¼ .014). Post-hoc pairwise comparisons for the DASS anxiety and depression are revealed in Table 2. To test hypothesis three, a mixed-model analysis was conducted with the SDS as the outcome variable, which revealed a significant main effect of time (F2, 59.29 ¼ 11.68, p < .001). Again, post-hoc pairwise comparisons are reported in Table 2. Discussion The results of this study show promise for the effectiveness of group CBT for hoarding disorder, and contribute to the small body of published literature on CBT for hoarding. Participants demonstrated significant improvements from pre- to post-treatment not only in hoarding symptoms, but also in symptoms of depression and anxiety, as well as quality of life, with all areas showing large effect sizes. A strength of this study is that it may closely resemble how CBT can be delivered in the community, outside the context of a research study. Group participants were not recruited to participate in a research study, and they paid a small fee to receive treatment, as one would in a community setting. The degree of clinician demand per each patient was significantly lower than that of other published individual CBT studies for hoarding (Steketee et al., 2010; Tolin et al., 2007) Muroff et al. (2009) provided 16e20 sessions of group CBT as we did in this study; however, they
also offered two individual home visits. Although home visits by a clinician likely contribute to effectiveness of treatment, it may not be a realistic component of treatment outside of a research context due to insurance constraints and additional travel time for the clinician. Despite the reduced clinician burden per patient in this study, treatment outcome appears comparable to other published studies of individual CBT (Steketee et al., 2010; Tolin et al., 2007), and superior to group CBT studies (Muroff et al., 2009; Steketee et al., 2000). Unfortunately, we are not able to adequately compare our study in terms of CSC to previous studies since Steketee et al. (2010) and Tolin, Fitch, Frost, and Steketee (2010) both used a significantly more liberal CSC definition (a change of 14 points or greater and a post-treatment score of 50, which is two SD above the nonclinical mean) compared to our significantly more conservative criterion (a change of 14 points or greater and a post-treatment score of 42 or less). Muroff et al. (2009) noted from their study on group CBT for hoarding that their last treatment group, which followed a more formalized treatment protocol, showed the greatest improvements. This may help explain the superior results obtained in this study of group CBT; all treatment groups were facilitated following a flexible, yet structured treatment protocol that included specific skills to be covered, along with a workbook that included readings and worksheets. Further, stringent rules were enforced regarding attendance, punctuality, and homework compliance. Homework and overall treatment compliance among this population has been cited repeatedly as a concern in the literature (Christensen & Greist, 2001; Hartl & Frost, 1999; Steketee et al., 2000; Tolin et al., 2007). Furthermore, homework adherence is correlated with treatment outcome (Tolin et al., 2007). Close monitoring of homework completion, along with consequences for poor adherence may have improved compliance, and thus treatment outcomes, among participants in this study. Despite some of it strengths, there are significant limitations to this study. As this study was not a randomized controlled trial, we
806
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807
cannot draw definitive conclusions about the effectiveness of group CBT for hoarding, including how it compares to individual CBT, or CBT with clinician home visits. Any changes from pre- to posttreatment can be attributed to nonspecific factors, including group processes, demand characteristics, natural changes with the passage of time, and attention from therapists and other group members. One of the major limitations is the attrition; only 67% of the participants completed treatment, and we were only able to report results from 78% of participants who had at least two data points (pre and mid or pre and post). The attrition rate of this study (33%) was slightly higher than those reported in previous clinical trials of CBT for hoarding disorder (20% in Steketee et al., 2010 and 29% in Tolin et al., 2007). It is possible that group treatment may lead to greater attrition, as each person does not necessarily receive the same level of attention compared to individual treatment. The stringent requirements for continued participation of attendance, punctuality, and homework compliance may have also increased the likelihood of attrition for those individuals who could not comply with such demands. Another significant limitation is the reliance on self-report data, and presence of missing data. As data from this study was collected from a clinic sample, there was a significant amount of missing data even among participants who completed treatment, particularly the CSQ, which only included data from 21 participants. Results of this study, therefore, should be interpreted with caution, particularly ratings of client satisfaction. Given that this population has often been cited as having limited insight into the severity of one’s hoarding problems (Frost, Krause, & Steketee, 1996; Samuels et al., 2007; Tolin et al., 2010), we cannot definitely conclude that hoarding symptoms truly improved following treatment without an in-home assessment of the severity of clutter. We also did not collect follow-up data, and therefore cannot draw any conclusions about the long-term outcome of group CBT after treatment discontinuation. This may be particularly important to assess in hoarding disorder, which is considered to be a chronic condition, and one in which even those patients who are considered treatment responsive often continue to exhibit noticeable symptoms after successful treatment. Finally, like most other published studies on hoarding disorder, our sample was primarily female, Caucasian, and highly educated. Although this appears to be a common characteristic among those selected in treatment studies on hoarding disorder (Muroff et al., 2009; Steketee et al., 2010; Tolin et al., 2007), recent epidemiological studies suggest that hoarding is equally represented across different ethnic groups (Samuels et al., 2008). Group CBT for hoarding may be a viable treatment option that improves access to treatment and lowers clinician burden and financial cost to hoarding individuals or third party payers. Future research is needed directly comparing the effectiveness as well as cost-effectiveness of group and individual CBT. Acknowledgments We thank the participants in the treatment groups for contributing their data for this study. We thank Danielle Dufresne for co-facilitating one of the groups. We also thank Diana Alamo, Jennifer Dimauro, Claire Doucette, Diana Harrington, and Kolette Ring for their assistance on the study. References Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology, 71(6), 1049e1057.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th text revision ed.). Washington, DC: Author. Black, D. W., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessivecompulsive disorder. Journal of Clinical Psychiatry, 59(8), 420e425. Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110(1), 49e58. Cermele, J. A., Melendez-Pallitto, L., & Pandina, G. J. (2001). Intervention in compulsive hoarding. A case study. Behavior Modification, 25(2), 214e232. Chakraborty, H., & Gu, H. (2009). A mixed model approach for intent-to-treat analysis in longitudinal clinical trials with missing values. Research Triangle Park, NC: RTI International Press. Christensen, D. D., & Greist, J. H. (2001). The challenge of obsessive-compulsive disorder hoarding. Primary Psychiatry, 8, 79e86. Fontenelle, L. F., Mendlowicz, M. V., Soares, I. D., & Viersiani, M. (2004). Patients with obsessive-compulsive disorder and hoarding symptoms: a distinct clinical subtype? Comprehensive Psychiatry, 45, 375e383. Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34(4), 341e350. Frost, R. O., Krause, M. S., & Steketee, G. (1996). Hoarding and obsessive-compulsive symptoms. Behavior Modification, 20, 116e132. Frost, R. O., & Steketee, G. (2003). A measure of activities of daily living for hoarding (ADL-H). Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: saving inventory-revised. Behaviour Research and Therapy, 42(10), 1163e1182. Frost, R. O., Steketee, G., & Tolin, D. F. Comorbidity in hoarding disorder. Depression and Anxiety, in press. Frost, R. O., Steketee, G., Williams, L. F., & Warren, R. (2000). Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls. Behaviour Research and Therapy, 38, 1071e1081. Frost, R. O., & Tolin, D. F. (2008). Compulsive hoarding. In S. Taylor, J. S. Abramowitz, & D. McKay (Eds.), Clinical handbook of obsessive-compulsive disorder and related problems (pp. 76e94). Baltimore: Johns Hopkins University Press. Grisham, J. R., & Norberg, M. M. (2010). Compulsive hoarding: current controversies and new directions. Dialogues in Clinical Neuroscience, 12(2), 233e240. Guy, W. (1976). Assessment manual for psychopharmacology. Washington, DC: U.S. Government Printing Office. Hannan, S. E., & Tolin, D. F. (2007, November). Examination of the validity of therapist rated and patient rated clinical global impression scores. Paper presented at the annual meeting of the Association of Behavioral and Cognitive Therapies, Philadelphia. Hartl, T. L., & Frost, R. O. (1999). Cognitive-behavioral treatment of compulsive hoarding: a multiple baseline experimental case study. Behaviour Research and Therapy, 37(5), 451e461. Hristova, V. (2011). Activities of daily living scale in hoarding disorder. Unpublished manuscript, Smith College, Northampton, MA. Iervolino, A. C., Perroud, N., Fullana, M. A., Guipponi, M., Cherkas, L., Collier, D. A., et al. (2009). Prevalence and heritability of compulsive hoarding: a twin study. American Journal of Psychiatry, 166(10), 1156e1161. Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12e19. Leon, A. C., Shear, M. K., Portera, L., & Klerman, G. L. (1992). Assessing impairment in patients with panic disorder: the Sheehan disability scale. Social Psychiatry and Psychiatric Epidemiology, 27, 78e82. Lochner, C., Kinnear, C. J., Hemmings, S. M., Seller, C., Niehaus, D. J., Knowles, J. A., et al. (2005). Hoarding in obsessive-compulsive disorder: clinical and genetic correlates. Journal of Clinical Psychiatry, 66, 1155e1160. Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety stress scales. Sydney: The Psychology Foundation of Australia. Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K. A., & Baer, L. (2002). Obsessivecompulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychotherapy and Psychosomatics, 71(5), 255e262. Mataix-Cols, D., Rauch, S. L., Manzo, P. A., Jenike, M. A., & Baer, L. (1999). Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 156(9), 1409e1416. McGlinchey, J. B., Atkins, D. C., & Jacobson, N. S. (2002). Clinical significance methods: which one to use and how useful are they? Behavior Therapy, 33, 529e550. Muroff, J., Steketee, G., Rasmussen, J., Gibson, A., Bratiotis, C., & Sorrentino, C. (2009). Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial. Depression and Anxiety, 26(7), 634e640. doi:10.1002/ da.20591. Nguyen, T. D., Attkisson, C. C., & Stegner, B. L. (1983). Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire. Evaluation and Program Planning, 6(3e4), 299e313. Rufer, M., Fricke, S., Moritz, S., Kloss, M., & Hand, I. (2006). Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica, 113(5), 440e446.
C.M. Gilliam et al. / Behaviour Research and Therapy 49 (2011) 802e807 Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15(1), 53e63. doi:10.1038/mp.2008.94, mp200894 [pii]. Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle, M. A., Liang, K. Y., et al. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour Research and Therapy, 46(7), 836e844. Samuels, J. F., Bienvenu, O. J., Pinto, A., Fyer, A. J., McCracken, J. T., Rauch, S. L., et al. (2007). Hoarding in obsessive-compulsive disorder: results from the OCD collaborative genetics study. Behaviour Research and Therapy, 45, 673e686. Samuels, J. F., Bienvenu, O. J., Riddle, M. A., Cullen, B. A., Grados, M. A., Liang, K. Y., et al. (2002). Hoarding in obsessive compulsive disorder: results from a casee control study. Behaviour Research and Therapy, 40(5), 517e528. Saxena, S., Maidment, K. M., Vapnik, T., Golden, G., Rishwain, T., Rosen, R. M., et al. (2002). Obsessive-compulsive hoarding: symptom severity and response to multimodal treatment. Journal of Clinical Psychiatry, 63(1), 21e27. Sheehan, D. V., Lecrubier, Y., Harnett-Sheehan, K., Janavs, J., Weiller, E., Bonora, L. I., et al. (1997). Reliability and validity of the MINI international neuropsychiatric interview (M.I.N.I.): according to the SCID-P. European Psychiatry, 12, 232e241. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview
807
for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22e33, quiz 34e57. Stein, D. J., Andersen, E. W., & Overo, K. F. (2007). Response of symptom dimensions in obsessive-compulsive disorder to treatment with citalopram or placebo. Revista Brasileira de Psiquiatria, 29(4), 303e307. Steketee, G., & Frost, R. O. (2003). Compulsive hoarding: current status of the research. Clinical Psychology Review, 23, 905e927. Steketee, G., & Frost, R. O. (2007). Compulsive hoarding and acquiring: Therapist guide. New York: Oxford University Press. Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlistcontrolled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27(5), 476e484. doi:10.1002/da.20673. Steketee, G., Frost, R. O., Wincze, J., Greene, K., & Douglass, H. (2000). Group and individual treatment of compulsive hoarding: a pilot study. Behavioural and Cognitive Psychotherapy, 28, 259e268. Tolin, D. F., Fitch, K. E., Frost, R. O., & Steketee, G. (2010). Family informants’ perceptions of insight in compulsive hoarding. Cognitive Therapy and Research, 34, 69e81. Tolin, D. F., Frost, R. O., & Steketee, G. (2007). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461e1470. Tolin, D. F., Frost, R. O., Steketee, G., & Fitch, K. E. (2008). Family burden of compulsive hoarding: results of an internet survey. Behaviour Research and Therapy, 46(3), 334e344.