Between-Session Compliance

Within-Session and Between-Session Compliance in Hoarding Disorder: The Relationship with Treatment Outcome

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Laura B. Bragdon, M.S. Binghamton University

Bethany M. Wootton, Ph.D. University of New England

Gretchen J. Diefenbach, Ph.D. Anxiety Disorders Center, Institute of Living; Yale University School of Medicine

David F. Tolin, Ph.D., ABPP Anxiety Disorders Center, Institute of Living; Yale University School of Medicine

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Overview

• Hoarding disorder (HD) and treatment

• Treatment Compliance • Development and validation of two new measures • Relationship between compliance and outcome • Future Directions

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Hoarding Disorder DSM-5 classified as an OCRD

A.Persistent difficulty discarding possessions B. Difficulty is due to the perceived need to save the items and the distress associated with discarding them C. Accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use 4

Hoarding Disorder Chronic, costly and disabling • Prevalence: 2-5% • Early onset • 7.0 work impairment days in the past month • Mental health service utilization • 8-12% evicted/threat of eviction • 3% child or elder removed from home

Tolin, Frost, Steketee, Gray, & Fitch, (2008)

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Hoarding Disorder Treatment • Cognitive Behavioral Group Therapy (gCBT) • 4 Modules 1) executive functioning deficits 2) emotion regulation deficits 3) problematic thoughts and beliefs that are specific to HD 4) motivational deficits

• Homework: continue sorting and discarding at home

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Hoarding Disorder Treatment CBT for HD vs. Waitlist 1.2 1.1 1 0.9 Large effect

Cohen’s d

0.8 0.7 0.6 0.5

Medium effect

0.4 0.3 Small effect

0.2 0.1 0 SI-R Total

SI-R Clutter

SI-R Discarding

SI-R Acquiring

HRS Steketee, Frost, Tolin, Rasmussen & Brown, (2010)

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Hoarding Disorder Treatment 1

Pre to Post-treatment Effect Sizes of CBT for HD

0.9 Large effect

0.8

Hedges g

0.7 0.6 Medium effect

0.5 0.4 0.3

Small effect

0.2 0.1 0

Total HD Severity Difficulty Discarding

Acquiring

Clutter

Impairment Tolin, Frost, Steketee & Muroff (2015)

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Hoarding Disorder Treatment • Many patients with HD are non-compliant with treatment • Steketee, Frost, Tolin, Rasmussen & Brown, (2010) • 27 (37%) declined • 5 (total of 44%) dropped prior to starting CBT

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Compliance The extent to which the patient is practicing homework and adhering to cognitive behavioral therapy

• Between session compliance • Within session compliance

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Between-Session Compliance Extent that the client engages in homework and adheres to cognitive-behavioral therapy (CBT) principles outside of the session Relates to treatment outcome in a range of disorders • OCD (Simpson et al., 2011, 2012) • MDD (Burns & Spanger, 2000)

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Between-Session Compliance • Tolin, Frost, and Steketee (2007) • 80% of participants with ‘good’ homework adherence reached criteria for ‘much improved’ or ‘very much improved’ on the CGI-I at post-treatment • Only 20% of the individuals in the ‘poor’ homework adherence reached ‘much’ or ‘very much improved

• Ayers, Wetherell, Golshan, and Saxena (2011) • Large correlation (r = .74) between homework compliance and post-treatment SI-R score

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Within-Session Compliance Adherence to CBT techniques during the session and overall commitment to the CBT approach

• Currently no studies investigating within-session compliance in a HD • Clinical experience suggests that individuals with HD may have adherence difficulties

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Between-Session Compliance The Patient Adherence Scale for Exposure and Response Prevention for HD (PEAS-H) • Modified from PEAS (Simpson et al., 2010)

1. Quantity of the patient’s sorting and discarding 2. Quality of the patient’s sorting and discarding 3. Degree to which the patient resisted urges to acquire new items.

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Within-Session Compliance CBT Adherence Measure (CAM) 1. To what extent did the patient espouse and understand the goals of treatment during the session? 2. To what extent did the patient provide a report of progress? 3. To what extent did the patient's words and actions in session adhere to the session agenda?

4. To what extent were the patient's comments and statements appropriate to the topic? 5. To what extent did the patient cooperate with attempts to challenge thoughts or beliefs? 6. To what extent did the patient cooperate with attempts to change behaviors?

7. To what extent did the patient make appropriate reports of thoughts and feelings in session? 8. To what extent did the patient adhere to the time requirements of the session (arrive on time, remain in the room throughout the session, leave on time)? 9. To what extent did the patient bring requested materials to the session? 15

Method Participants • • • •

N = 20 70% female Primary diagnosis of HD Participating in 16-week gCBT for HD

Data Analysis • • • •

Factor structure: Principal component analysis (PCA) with varimax rotation Internal consistency: Cronbach’s alpha Convergent validity: correlations with SI-R, HRS-I change scores Discriminant validity: correlations with DASS change scores

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Results: PEAS-H Factor Loadings Item

M

SD

Factor loading

1.Sorting/Discarding Assignments: what % of sorting/discarding assignments did the patient attempt since the last visit?

4.91

1.51

.94

2. Sorting/Discarding Assignments: how well did the patient do the assigned sorting/discarding tasks that were attempted?

4.38

1.08

.92

3. Acquiring: what % of urges to acquire did patient successfully resist since the last visit?

5.29

1.28

.55

Cronbach’s α = 0.73 Correlations between PEAS-H mean score • HRS-I Δ score (r = .49, p = .03 ) • SI-R Δ score (r = .36, ns) • DASS Δ score (r = .05, ns) 17

Results: CAM Factor Loadings M

SD

Factor loading

1.To what extent did the patient espouse and understand the goals of treatment during the session?

3.05

0.56

.89

2. To what extent did the patient provide a report of progress?

3.21

1.00

.68

3. To what extent did the patient's words and actions in session adhere to the session agenda?

3.03

0.58

.87

4. To what extent were the patient's comments and statements appropriate to the topic?

3.05

0.46

.72

5. To what extent did the patient cooperate with attempts to challenge thoughts or beliefs?

3.13

0.73

.85

6. To what extent did the patient cooperate with attempts to change behaviors?

3.05

1.00

.48

7. To what extent did the patient make appropriate reports of thoughts and feelings in session?

2.95

0.61

.91

8. To what extent did the patient adhere to the time requirements of the session?

3.72

0.51

.28

9. To what extent did the patient bring requested materials to the session?

3.82

0.51

.34

CAM Item

Cronbach’s α = 0.83 Correlations between CAM mean score • HRS-I Δ score (r = .55, p = .02 ) • SI-R Δ score (r = .50, p = .03) • DASS Δ score (r = -.23, ns) 18

Conclusions CAM and PEAS-H demonstrated adequate reliability and validity • Single factor • Correlate with convergent measures of symptom change

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Limitations • Sample • Small • Generalizability

• PEAS-H relies on some self-report • Preliminary analyses

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Future Directions • Examine CAM in other diagnostic groups • Does compliance predict outcome? • When does compliance matter the most? • Who has poor compliance?

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Conclusion • The PEAS-H and CAM are two measures that can be used to investigate compliance in the treatment of HD • Studying predictors of treatment outcome may help enhance existing therapies

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Within-Session and Between-Session Compliance in Hoarding Disorder: The Relationship with Treatment Outcome

Thank you. [email protected]

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References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. L. (2010). Age at onset and clinical features of late life compulsive hoarding. International Journal of Geriatric Psychiatry, 25(2), 142-149. Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34(4), 341-350. Grisham, J. R., Frost, R. O., Steketee, G., Kim, H. J., & Hood, S. (2006). Age of onset of compulsive hoarding. Journal of Anxiety Disorders, 20(5), 675-686.

Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle, M. A., Liang, K. Y., ... & Nestadt, G. (2008). Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour Research and Therapy, 46(7), 836-844. Simpson, H. B., Maher, M., Page, J. R., Gibbons, C. J., Franklin, M. E., & Foa, E. B. (2010). Development of a patient adherence scale for exposure and response prevention therapy. Behavior Therapy, 41(1), 30-37. Steketee, G. S., & Frost, R. (2007). Treatment of compulsive hoarding. New York: Oxford University Press Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlist‐controlled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27(5), 476-484.

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References Tolin, D. F., Frost, R. O., Steketee, G., Gray, K. D., & Fitch, K. E. (2008). The economic and social burden of compulsive hoarding. Psychiatry Research, 160(2), 200-211. Tolin, D. F., Frost, R. O., Steketee, G., & Muroff, J. (2015). Cognitive behavioral therapy for hoarding disorder: A metaanalysis. Depression and Anxiety, 32(3), 158-166.

Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2010). Course of compulsive hoarding and its relationship to life events. Depression and Anxiety, 27(9), 829-838. Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2011). Hoarding among patients seeking treatment for anxiety disorders. Journal of Anxiety Disorders, 25(1), 43-48. Tolin, D. F., & Villavicencio, A. (2011). Inattention, but not OCD, predicts the core features of hoarding disorder. Behaviour Research and Therapy, 49(2), 120-125. Tolin, Worden, Wootton, & Gilliam, Submitted

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