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Received: 28 October 2019 
|
  Revised: 1 April 2020 
|  Accepted: 9 May 2020

DOI: 10.1111/ajag.12817

BRIEF REPORT

Treatment outcomes in older adults with hoarding disorder: The

impact of self-control, boredom and social support

Emily R. Weiss1   | Alyssa Landers2  | McWelling Todman1  | David M. Roane2

1
Department of Psychology, The New
School for Social Research, New York, NY,
USA
2
Department of Psychiatry, Lenox Hill,
Northwell Health, New York, NY, USA
Correspondence
Emily R. Weiss, Department of Psychology,
New School for Social Research, 80 5th
Avenue, 6th Floor, New York, NY 10011,
USA.
Email: Weise935@newschool.edu
Funding information
Harriet & Robert H. Heilbrunn Fund
through UJA-Federation of New York.
Abstract
Objectives: Hoarding disorder in older adults often develops in the context of co-oc-
curring psychosocial maladies, and treatment response tends to be suboptimal. This
preliminary investigation explored several ageing-related factors and their relation-
ship to hoarding symptom severity (HSS), and examined treatment response to 15
sessions of cognitive behavioural therapy (CBT) with in-home support.
Methods: Twenty-nine participants (Mage  =  67) completed self-report question-
naires measuring HSS, self-control, indecisiveness, depression, loneliness, social
support and boredom, before (T1) and after (T2) treatment.
Results: At T1, HSS was associated marginally with loneliness and significantly
with all other variables, except social support. At T2, HSS and depression decreased
significantly and only boredom and self-control remained associated with HSS.
Attrition rates were high, and those with low social support were more likely to dis-
continue treatment prematurely.
Conclusions: Increasing social support may improve treatment retention, and pre-
emptively reducing sources of boredom and increasing self-control during treatment
might improve outcomes for older adults with hoarding disorder.

KEYWORDS
boredom, hoarding, hoarding disorder, self-control, social support

1  |   IN T RO D U C T ION with standard CBT approaches, thus limiting recovery. These

Hoarding disorder (HD) is characterised by excessive clut-
ter which compromises the use and functionality of living
spaces and leads to impairment in the afflicted individual.1 It
is estimated to be almost three times more prevalent and sig-
nificantly more severe in adults aged 55-94 than in younger
individuals.1,2 However, the cognitive behavioural therapy
(CBT) protocol typically used with younger HD patients ap-
pears to be less effective with older patients.3
One possible explanation for this divergence may be that in
the case of older HD individuals, the deficits that commonly
co-occur with HD symptoms are not adequately addressed
deficits include the symptoms and impairments that tend to
characterise HD individuals more generally, such as depres-
sion,4 indecisiveness5 and diminished self-control,6 as well
as contextual and psychosocial deficits that are particularly
relevant to older HD individuals. Included in this latter cat-
egory are factors such as social impairments, living alone,7
feelings of social isolation,8 a diminished sense of agency and
heightened feelings of boredom.9
Surprisingly, little is known about the extent to which
these putatively ageing-related contributing factors are as-
sociated with hoarding severity among older HD patients,
and even less about their impact on treatment response. We

[Correction added on 6th August 2020, after first online publication: David M. Roane’s affiliation has been amended accordingly.]

Australas J Ageing. 2020;39:375–380. wileyonlinelibrary.com/journal/ajag |

© 2020 AJA Inc.     375
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376       WEISS et al.
attempted to begin addressing these questions in a prelimi-
nary study involving a small sample of older individuals who
were receiving 15 weeks of CBT coupled with in-home sup-
port (IHS) during the actual process of de-cluttering. First,
we aimed to determine the efficacy of this treatment pro-
gram. Second, we aimed to examine the associations between
hoarding symptoms and well-established attributes of HD, as
well as understudied psychosocial factors, before and after
the intervention.
2  | METHODS
2.1  | Participants
Twenty-nine (20 female and 9 male) community-dwelling
individuals aged 52-85 (Mage = 67, SD = 8) were recruited
with the assistance of a Jewish community-based social ser-
vice agency in New York. The agency serves older adults
experiencing a range of psychosocial issues and provides
clinical support for older adults with HD. A team of men-
tal health professionals associated with the agency identified
individuals displaying significant hoarding behaviours, who
were then referred for clinical assessment and possible study
inclusion. Preliminary diagnoses were based on clinical eval-
uation by a licensed psychiatrist using criteria outlined in the
Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM 5).1
Those who exhibited clinically significant hoarding be-
haviours and consented to clinical assessment were included
in the study. Individuals were screened for cognitive impair-
ment using the Montreal Cognitive Assessment (MoCA),10
and those deemed to be too cognitively impaired to provide
informed consent were excluded from the study. The study
was approved by the Institutional Review Board (IRB) of the
Mount Sinai Beth Israel in NYC (Reference number: 115-13).
2.2  | Measures
Self-report measures were used to assess the variables of in-
terest. Specifically, hoarding symptomology was assessed
using the Savings Inventory-Revised (SI-R), a 23-item scale
measuring severity of clutter, acquisition and difficulty dis-
carding.11 Items are rated on a Likert-type scale, and sum-
mary scores are calculated for overall symptomology and for
each symptom cluster. Participants also completed the Clutter
Image Rating (CIR), a pictorial scale designed to measure
clutter severity in multiple rooms of the home.12 Participants
are presented with a series of photographs showing increas-
ingly cluttered bedrooms, kitchens and living rooms, and se-
lect the photographs that best represent their homes. A mean
score is calculated for the 3 rooms.
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Policy Impact Statement
Given that low levels of self-control, perceived lack
of social support and frequent experiences of bore-
dom are associated with worse outcomes for older
adults with hoarding disorder, treatment programs
designed to address these factors may contribute to
improved treatment response and retention for older
adults with this debilitating disorder.
Practice Impact Statement
In older adults with hoarding disorder, lack of social
support appears to be associated with decreased like-
lihood of treatment completion, whereas high levels
of boredom and low levels of self-control may be
associated with significantly poorer treatment out-
comes. These findings warrant closer scrutiny of the
role these psychosocial and contextual factors play in
treatment retention and symptom severity in ageing
hoarding patients.
Depression, indecisiveness, self-control, loneliness, so-
cial support and boredom were assessed using the 30-item
Geriatric Depression Scale (GDS),13 the Indecisiveness Scale
(IS),5 the Self-Control Scale (SCS),14 the UCLA Loneliness
Scale (UCLA-LS),15 the 6-item Lubben Social Network
Scale (LSNS)16 and the State Boredom Measure (SBM),17
respectively. These measures are rated on Likert-type scales,
and summary scores are calculated. All of the measures have
been reported to be psychometrically sound.5,11-17
2.3  | Procedure
Participants completed all study measures prior to receiv-
ing 15 sessions of individual CBT for HD,18 coupled with
IHS from one of the agency's social workers to facilitate de-
cluttering (T1). Follow-up contact with the agency's staff in-
volved the usual case management services available to all
individuals served by the agency. Treatment was provided by
one of several psychiatric residents or geropsychiatry fellows.
The study therapists were supervised by a PhD-level clinical
psychologist with extensive experience in CBT. Each partici-
pant was seen by the same therapist for the duration of the
study. The CIR and SI-R were completed again at the mid-
point of treatment. All measures were completed again at the
conclusion of treatment or in a follow-up measurement (T2).
Due to scheduling inconsistencies among study participants,
the time between the final session of CBT and T2 assessment
varied. While the majority (80%; n = 10) of the participants
were assessed at a date close to the termination of treatment,

WEISS et al.
F I G U R E 1   The mean per cent increase
or decrease from T1 to T2 across all
variables, and the number of participants
who completed the measure at each
time point. SI-R = Savings Inventory-
Revised; CIR = Clutter Image Rating;
GDS = depression; IS = indecisiveness;
SBM = state boredom; SCS = self-
control, LSNS = social support; UCLA-
LS = loneliness. * = P ≤ .05
a minority were unable to be assessed until 3 months after the
endpoint of treatment (20%; n = 2).
2.4  |  Statistical analysis
All analyses were conducted using SPSS Statistics version
25 (IBM, Armonk, NY). Several steps were taken to ac-
count for the small sample size. Midpoint hoarding scores
were used for participants with missing hoarding symptom
data at T1. For treatment completers who were missing
data at T2, we entered T1 values for T2 (last observation
carried forward method). Missing items were replaced
with list-wise means in order to compute summary scores.
Finally, we utilised non-parametric statistical tests for all
analyses.19 P-values of < 0.05 were considered statistically
significant.
3  |   R E S U LTS
3.1  |  T1 correlations
A sample of 29 participants (20 female and 9 male)
community-dwelling individuals aged 52-85 (Mage  =  67,
SD  =  8) completed at least one of the study measures at
T1 and/or at midpoint. A total of 12 participants completed
treatment. Ten participants completed the CIR at both T1
and T2, whereas 11 completed the SI-R at T1 and T2. Due
to the small sample size, it was not feasible to examine
the potential confounding effects of most demographic
differences. However, T1 SI-R scores were not associated
with gender, Mann-Whitney's U = 64.5, P> .05. Kendall's
Tau-b inter-correlations revealed that T1 SI-R scores were
|
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   377
not correlated with age, τb  =  −0.14, P> .05 or MoCA
scores, τb = −0.25, P> .05.
The number of participants included in all T1 correla-
tions ranged from 17 to 27. Kendall's Tau-b inter-correlations
among the variables at T1 revealed that CIR scores were pos-
itively associated with recent/current boredom, τb  =  0.33,
P < .05. Overall hoarding symptom severity on the SI-R was
positively correlated with depression, τb = 0.41, P < . 05, and
indecisiveness, τb = 0.55, P < .001.
Interestingly, the three SI-R subscales displayed unique
relationships with the variables of interest. Clutter was posi-
tively correlated with state boredom, τb = 0.34, P < .05, de-
pression, τb = 0.38, P < .05, and indecisiveness, τb = 0.44,
P < .05, and marginally with loneliness, τb = 0.28, P = .054.
Acquisition was associated positively with depression,
τb = 0.40, P < .05, and indecisiveness, τb = 0.57, P < .001,
and negatively with self-control, τb = −0.33, P < .05. Finally,
difficulties discarding were positively associated with de-
pression, τb = 0.36, P < .05, and indecisiveness, τb = 0.50,
P < .05.
3.2  |  Treatment compliance and response
Despite a high level of attrition (59%), HD symptoms signifi-
cantly improved following the CBT/ IHS intervention (see
Figure  1). Specifically, related-samples Wilcoxon signed
ranks tests confirmed that both SI-R and CIR median pre-
test ranks were significantly higher (Mdn-SI-R  =  50; Mdn-
CIR  =  4) than median post-test ranks (Mdn-SI-R  =  43;
Mdn-CIR  =  3), T  =  8.00, P  <  .05, r  =  −.60 and T  =  6.0,
P  =  .05, r  =  −.45, respectively. GDS (depression) median
pretest ranks were significantly higher (Mdn = 9) than me-
dian post-test ranks (Mdn = 6), T = 3.00, P < .05, r = −.62.
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378       WEISS et al.

Overall, out of the 10 participants who completed the CIR 4  |  DISCUSSION

at both time points, 80% evidenced improvement, with scores
decreasing by 19% on average. Out of the 11 participants
who completed the SI-R at both time points, 64% evidenced
improvement, with scores decreasing by 22% on average.
Thirty-six per cent of the sample showed decreases consis-
tent with clinically significant change (≥14 points) in their
SI-R scores.
Additionally, Mann-Whitney U tests revealed that par-
ticipants who completed treatment reported significantly
more social support on the LSNS (Mdn = 15) than non-com-
pleters (those who failed to complete either the 15 weeks of
CBT and/or T2 hoarding measures; Mdn = 10), U = 132.50,
z = 2.10, P < .05, r = .41. No other variables differed sig-
nificantly between treatment completers and non-completers,
or changed significantly from T1 to T2. However, most of
the study variables increased or decreased in the expected di-
rections. Notably, SBM scores decreased by 19% and LSNS
scores increased by 9% (see Figure 1).
3.3  |  T2 correlations
Interestingly, in contrast to the abundance of inter-correla-
tions at T1, the only variables found to be associated with
hoarding severity at end of treatment (T2) were state bore-
dom (SBM) and self-control (SCS) (see Table  1). SBM
scores were positively associated with greater amounts of
clutter on both the SI-R, τb  =  0.50, P  <  .05, and the CIR,
τb  =  0.54, P  <  .05, and with more acquisition, τb  =  0.51,
P < .05. SCS scores were associated negatively with both ac-
quisition, τb = −0.55, P < .05, and CIR scores, τb = −0.61,
P < .05.
The results, albeit preliminary, confirm that depression,
loneliness, boredom, self-control and indecisiveness are as-
sociated with hoarding severity in older adults. Importantly,
changes in many of these variables were not correlated
with changes in hoarding symptom severity, as many of
the observed relationships at T1 became non-significant at
T2. This finding may be explained by an attenuation of the
range in both hoarding symptom severity, and the severity
of depression, indecisiveness and loneliness, at the end of
treatment.
At T2, hoarding symptom severity was significantly
correlated only with boredom and self-control: individ-
uals who continued to exhibit high levels of boredom
and low levels of self-control following the intervention
demonstrated less improvement in terms of hoarding
symptoms. Although the observed relationship between
self-control and hoarding symptom severity is consistent
with previous research,6 the apparent role of boredom is
a novel finding.
The results also indicated that HD symptoms of older
adults tend to decrease significantly with a CBT/IHS inter-
vention, as do depressive symptoms. The level of improve-
ment in the current study is comparable to what has been
observed with CBT in other studies with older patients.20
However, it is important to note that less than half of the
sample demonstrated clinically significant change, and the
median post-treatment SI-R score remained above the rec-
ommended clinical cut-off for older adults.21 This suggests
that many participants continued to experience considerable
levels of distress and impairment and indicates a need for fur-
ther treatment.

T A B L E 1   Correlational relationships among All study variables at T2

SI-R
Acquiring Clutter Discarding Sum CIR GDS UCLA-LS LSNS IS SCS SBM
Acquiring 1
Clutter 0.59* 1
*
Discarding 0.44 0.73* 1
*
SI-R Sum 0.68 0.81* 0.76* 1
* *
CIR 0.43 0.65 0.58 0.60* 1
GDS 0.22 0.17 0.10 0.06 0.11 1
UCLA-LS 0.38 0.32 0.13 0.18 0.20 0.37 1
LSNS -0.29 -0.08 0.16 -0.19 0.14 -0.19 -0.25 1
IS 0.09 0.25 0.18 0.00 0.45 0.55* 0.27 0.05 1
* *
SCS -0.55 0.38 -0.40 -0.43 -0.61 -0.44 -0.21 0.02 -0.42 1
SBM 0.51* 0.50* 0.30 0.33 0.54* 0.41 0.48* 0.15 0.30 -0.54* 1
Note: CIR, Clutter Image Rating; SI-R, Savings Inventory-Revised; Clutter, Acquiring and Discarding, SI-R Subscales; GDS, depression; IS, indecisiveness; LSNS,
social network; SCS, self-control, SBM, boredom; UCLA-LS, loneliness.
*=P <.05; **=P < .01. N’s range from 10 to 13.

WEISS et al.
Moreover, several limitations must be taken into account
when interpreting the results, most notably, the unusually high
attrition rate. Although the reasons for such a high level of drop-
out remain unclear, several factors may have contributed to
this outcome. Possible contributing factors include the fact that
participants were not compensated for participation, and some
lacked significant supports that may have encouraged therapy
compliance. Indeed, our findings revealed that individuals with
lower levels of social support at T1 were more likely to discon-
tinue treatment prematurely. It is possible that an increased focus
on social support may have attenuated the high dropout rate.
The small sample size and missing data for some partici-
pants at T1 or T2 are also notable limitations. It was not feasi-
ble to analyse the possible confounding effects of the majority
of the demographic variables. It was also not viable to deter-
mine whether having multiple treatment providers and vary-
ing amounts of time between the termination of treatment and
T2 assessments impacted treatment outcomes. Additionally,
while indecisiveness, boredom, self-control, loneliness and
social support did not change significantly from T1 to T2,
many of these variables increased or decreased in the expected
directions, some showing changes close to 20% (Figure  1).
Consequently, it is possible that with a larger sample size, some
of these changes would have reached statistical significance.
In addition to the small sample size, the unique cultural
characteristics of the sample limit the generalisability of
the findings. It is unknown whether the patterns observed
in the present study would generalise to older adults liv-
ing within a different cultural context. However, recent
research has demonstrated that the core features of HD ap-
pear to be phenomenologically similar across cultures.22
While this suggests that the relationships observed in
the current study may be invariant across cultures, future
cross-cultural research is needed to address this question.
5  |   CO NC LU SION S
Overall, the findings are consistent with previous studies ex-
amining the efficacy of CBT for older adults with HD; how-
ever, even with the IHS intervention more than half of the
participants did not complete treatment. Although the high
rate of attrition warrants further investigation, the findings
indicate that the retention of older HD patients in treatment
is likely to improve with enhanced perceived social support.
Moreover, the findings suggest that treatment response might
improve with pre-emptive or concurrent interventions de-
signed to target boredom and feelings of self-control. Future
research should attempt to replicate these preliminary find-
ings in a sample large enough to permit the partitioning of
the unique contributions of each of the predictor variables
employed in the current study.
|
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   379
CONFLICTS OF INTEREST
No conflicts of interest declared.
ORCID
Emily R. Weiss  https://orcid.org/0000-0003-2194-2091
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