Imaginal Exposure for Hoarding Disorder

The present study will test a potential new treatment strategy, imaginal exposure, for hoarding disorder. Although cognitive behavioral therapy often reduces hoarding, some people do not want to start, or cannot handle, that option. To help such individuals, the present study will provide imaginal exposure therapy to people with hoarding disorder, wherein they imagine discarding possessions as a way of becoming acclimated to the idea. We predict that imaginal exposure will improve hoarding symptoms as well as two psychological experiences linked to the condition: intolerance of uncertainty and emotional avoidance.

Hoarding disorder is a common mental illness characterized by difficulty parting with possessions and by clutter that makes living spaces unusable. Cognitive behavioral therapy (CBT) is an effective treatment for hoarding disorder, but new approaches are needed to engage those who are reluctant to start or cannot tolerate CBT. Both intolerance of uncertainty and emotional avoidance are linked to hoarding disorder and may interfere with treatment engagement. Imaginal exposure, a therapeutic technique which involves repeatedly imagining feared scenarios and experiencing the evoked emotions, effectively targets both intolerance of uncertainty and emotional avoidance. The present study is the first to test whether imagining discarding possessions can improve hoarding symptoms more than does a control exercise. We hypothesize that compared to a control exercise, imaginal exposure will improve hoarding symptoms, intolerance of uncertainty and emotional avoidance.

hoarding disorder, intolerance of uncertainty, experiential avoidance, imaginal exposure, clutter, attachment

Participants will be randomly assigned to imaginal exposure writing intervention or neutral control writing.

People with hoarding disorder will write for 20 minutes on each of 3 consecutive days about their worst-case scenario regarding discarding a possession (i.e., imaginal exposure).

People with hoarding disorder will write for 20 minutes on each of 3 consecutive days about what they would do if they had a day off work or school.

Imaginal exposure is a psychotherapy strategy that has been studied and shown to be helpful in the improvement of symptoms (e.g., anxiety, worry) for other psychiatric conditions, including excessive worry and obsessive-compulsive disorder symptoms.

Used in prior research as a control condition for imaginal exposure. Neutral writing will involve writing about what one would do on a day off work or school.

Gold-standard 23-item self-report measure of hoarding disorder symptoms. Scale scores range from 0 to 92, with higher scores indicating more severe hoarding symptoms. More severe hoarding symptoms are considered a worse outcome.

Self-report 18-item measure of behaviors associated with hoarding disorder (i.e., acquiring).Scale scores range from 18 to 126, with higher scores indicating more severe hoarding behaviors. More severe hoarding behaviors are considered a worse outcome.

Self-report 27-item measure of a cognitive process related to hoarding called intolerance of uncertainty. Scale scores range from 27 to 135 (some items are reverse scored), with higher scores indicating more severe intolerance of uncertainty. More severe intolerance of uncertainty is considered a worse outcome.

Self-report 7-item measure of a cognitive process related to hoarding called experiential avoidance. Scale scores range from 7 to 49, with higher scores indicating more severe experiential avoidance. More severe hoarding behaviors are considered a worse outcome.

A CPT administered by computer will be given to assess attention difficulties, a hallmark feature of hoarding disorder. The scoring of the task will include 1) reaction time, with slower reaction times indicating worse attention, and 2) omission errors, which is when a stimulus is presenting and the participant does not respond. Higher omission errors indicate worse attention.

Inclusion Criteria: Age 18 and older Any gender and all ethno-racial categories Hoarding Disorder primary condition Willing and able to understand and complete consent and study procedures English speaking Exclusion Criteria: Severe depression Clinically at risk of suicide with Columbia Suicide Severity Rating Scale (C-SSRS) Suicidal Ideation Subscale of 4 or higher (i.e. suicidal intent without specific plan) Currently receiving Cognitive Behavioral Therapy (CBT)