Is Cognitive Remediation Therapy potentially helpful for Hoarding Disorder? The evidence

by Imogen Kilcoyne BA, former Cognitive Remediation Therapist at the South London and Maudsley (SLaM) NHS Trust Cognitive Clinic

The largest meta-analysis of Cognitive Remediation Therapy (CRT) to date demonstrates that CRT promotes durable cognitive and functional improvements for individuals experiencing schizophrenia (1). There is also evidence of benefits from CRT for those experiencing Anorexia Nervosa (2) and Bipolar Disorder (3), and it has been suggested that it has the potential to improve recovery in other mental health conditions such as Hoarding Disorder.

Hoarding Disorder is a complex mental health condition with a prevalence rate estimated to be around 2.5% in the general population (4) and over 6% in adults over 70 years of age (5). Cognitive impairments are related to functioning. Interestingly, people with Hoarding Disorder are aware of their difficulties but tend to overestimate them, resulting in a mismatch between self-reported and objectively measured cognitive impairment (6). Given that cognitive problems are prominent in Hoarding Disorder, CRT might be an intervention that can contribute to functional outcomes by reducing cognitive impairment and improving awareness of the level of cognitive difficulty. As adherence to treatment is also a problem, the effects of CRT might help to increase the use of other routinely available interventions for this disorder.

A pilot study by DiMauro and colleagues (7) evaluated the effectiveness of computer-assisted CRT in improving attention and cognitive function in those with Hoarding Disorder compared to a relaxation exercise/task. A total of 17 participants completed 24 sessions over eight weeks. The results showed CRT improved attention but did not significantly affect memory, executive functioning or hoarding severity. This study suggests limited benefits of CRT that might be helpful, but larger samples are needed to investigate this further.

Ayers and colleagues (8) evaluated whether Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST), a treatment developed for older adults with Hoarding Disorder, improved executive functioning. In this randomized controlled trial, 43 older adults with Hoarding Disorder received either CREST or geriatric care management (CM). CREST consisted of 6 sessions of compensatory cognitive training followed by 20 sessions of exposure therapy. Participants in the CM group received supportive care but no targeted cognitive or behavioural interventions.

Results from this study showed no significant differences between the groups in global executive functioning despite the CREST participants showing significant improvements in cognitive flexibility and inhibition/switching, reporting fewer executive dysfunction behaviours and finding the intervention helpful (9).

The emerging evidence for CRT for those experiencing Hoarding Disorder so far does not suggest much promise. This is despite a model suggesting a direct causal link to functioning. Future studies need to consider whether the type, mode of implementation or content of cognitive remediation needs some adaptation and investigate the link between potential cognitive improvement and functional outcome in people with Hoarding Disorder. This sort of analysis might increase the sophistication of the model and consider the types of maintenance behaviours that support hoarding behaviour. Future studies might also consider providing CRT together with other treatments as in psychosocial treatment, often more means better outcomes.

References

(1) Vita, A., Barlati, S., Ceraso, A., Nibbio, G., Deste, G., & Wykes, T. (2021). Effectiveness, core elements, and moderators of response of cognitive remediation for schizophrenia: A systematic review and meta-analysis of randomized clinical trials. JAMA Psychiatry, 78(8), 848–858. https://doi.org/10.1001/jamapsychiatry.2021.0620

(2) Meneguzzo, P., Tenconi, E., Todisco, P., & Favaro, A. (2021). Cognitive remediation therapy for anorexia nervosa as a rolling group intervention: Data from a longitudinal study in an eating disorders specialized inpatient unit. European Eating Disorders Review, 29(5), 770–782. https://doi.org/10.1002/erv.2848

(3) Strawbridge, R., Tsapekos, D., Hodsoll, J., Mantingh, T., Yalin, N., McCrone, P., Boadu, J., Macritchie, K., Cella, M., Reeder, C., Fish, J., Wykes, T., & Young, A. H. (2021). Cognitive remediation therapy for patients with bipolar disorder: A randomised proof-of-concept trial. Bipolar Disorders, 23(2), 196–208. https://doi.org/10.1111/bdi.12968

(4) Postlethwaite, A., Kellett, S., & Mataix-Cols, D. (2019). Prevalence of hoarding disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 256, 309–316. https://doi.org/10.1016/j.jad.2019.06.004

(5) Steketee, G., & Frost, R. (2003). Compulsive hoarding: Current status of the research. Clinical Psychology Review, 23(7), 905–927. https://doi.org/10.1016/j.cpr.2003.08.002

(6) Davidson, E. J., Broadnax, D. V., Dozier, M. E., Pittman, J. O. E., & Ayers, C. R. (2021). Self-reported helpfulness of cognitive rehabilitation and exposure/sorting therapy (CREST) for hoarding disorder. Journal of Obsessive-Compulsive and Related Disorders, 28, 100622. https://doi.org/10.1016/j.jocrd.2021.100622

(7) DiMauro, J., Genova, M., Tolin, D. F., & Kurtz, M. M. (2014). Cognitive remediation for neuropsychological impairment in hoarding disorder: A pilot study. Journal of Obsessive-Compulsive and Related Disorders, 3(2), 132–138. https://doi.org/10.1016/j.jocrd.2014.03.006

(8) Ayers, C. R., Davidson, E. J., Dozier, M. E., & Twamley, E. W. (2019). Cognitive rehabilitation and exposure/sorting therapy for late-life hoarding: Effects on neuropsychological performance. The Journals of Gerontology: Series B, 75(6), 1193–1198. https://doi.org/10.1093/geronb/gbz062

(9) Davidson, E. J., Dozier, M. E., Pittman, J. O. E., Mayes, T. L., Blanco, B. H., Gault, J. D., Schwarz, L. J., & Ayers, C. R. (2019). Recent advances in research on hoarding. Current Psychiatry Reports, 21(9), 91. https://doi.org/10.1007/s11920-019-1078-0

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