Cognitive Therapy and Research

, Volume 42, Issue 3, pp 315–327 | Cite as

Group Cognitive Rehabilitation and Exposure/Sorting Therapy: A Pilot Program

  • Catherine R. AyersEmail author
  • Mary E. Dozier
  • Charles T. Taylor
  • Tina L. Mayes
  • James O. E. Pittman
  • Elizabeth W. Twamley
Original Article


While cognitive-behavioral therapy for hoarding disorder (HD) has resulted in significant reductions in symptoms, most individuals continue to have significant hoarding symptoms following treatment. This investigation sought to extend the literature on the behavioral treatments for hoarding by examining (1) group cognitive rehabilitation and exposure/sorting therapy (CREST) and (2) group exposure therapy (ET) for hoarding. Participants in both studies reported significant decreases in hoarding symptom severity from baseline to post-treatment on all primary outcome measures using mixed-effects linear regression models with the intent to treat sample. Participants who received group CREST reported statistically significant reductions in anxiety, depression, and overall severity at post-treatment, while participants who received group ET did not. Results provide preliminary evidence for both group CREST and group ET as effective treatments for hoarding disorder.


Hoarding Behavior therapy Treatment 



This study was funded by a Career Development Award (CSRD-068-10S) and a Merit Award (CLNA-005-14S) from the Clinical Science R and D Program of the Veterans Health Administration awarded to Catherine Ayers, Ph.D., ABPP. The contents do not reflect the views of the Department of Veterans Affairs or the United States Government.

Compliance with Ethical Standards

Conflict of Interest

Catherine R. Ayers, Mary E. Dozier, Charles T. Taylor, Tina L. Mayes, James O. E. Pittman, Elizabeth W. Twamley declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Animal Rights Statement

No animal studies were carried out by the authors for this article.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders: DSM-5. Washington, DC: American Psychiatric Publishing.Google Scholar
  2. Ayers, C. R., Bratiotis, C., Saxena, S., & Wetherell, J. L. (2012). Therapist and patient perspectives on cognitive-behavioral therapy for older adults with hoarding disorder: A collective case study. Aging & Mental Health, 16, 915–921.CrossRefGoogle Scholar
  3. Ayers, C. R., Dozier, M. E., Mayes, T. L., Espejo, E. P., Wilson, A., Iqbal, Y., & Strickland, K. (2015). Treatment recruitment and retention of geriatric participants with hoarding disorder. Clinical Gerontologist, 38, 235–250.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Ayers, C. R., Dozier, M. E., Twamley, E. T., Granholm, E., Saxena, S., Mayes, T. L., & Wetherell, J. L. (2017). Cognitive rehabilitation and exposure/sorting therapy for hoarding disorder among older adults: A randomized controlled trial. The Journal of Clinical Psychiatry.
  5. Ayers, C. R., Dozier, M. E., Wetherell, J. L., Twamley, E. W., & Schiehser, D. M. (2016). Executive functioning in participants over age of 50 with hoarding disorder. The American Journal of Geriatric Psychiatry, 24, 342–349.CrossRefPubMedGoogle Scholar
  6. Ayers, C. R., Najmi, S., Mayes, T., & Dozier, M. E. (2015). Hoarding disorder in older adults. American Journal of Geriatric Psychiatry, 23, 416–422.CrossRefPubMedGoogle Scholar
  7. Ayers, C. R., Saxena, S., Espejo, E., Twamley, E. W., Granholm, E., & Wetherell, J. L. (2014). Novel treatment for geriatric hoarding disorder: An open trial of cognitive rehabilitation paired with behavior therapy. The American Journal of Geriatric Psychiatry, 22, 248–252.Google Scholar
  8. 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, 142–149.CrossRefPubMedPubMedCentralGoogle Scholar
  9. Ayers, C. R., Schiehser, D., Liu, L., & Wetherell, J. L. (2012). Functional impairment in geriatric hoarding participants. Journal of Obsessive-Compulsive and Related Disorders, 1, 263–266.CrossRefGoogle Scholar
  10. Bulli, F., Melli, G., Carraresi, C., Stopani, E., Pertusa, A., & Frost, R. O. (2014). Hoarding behaviour in an Italian non-clinical sample. Behavioural and Cognitive Psychotherapy, 42, 297–311.CrossRefPubMedGoogle Scholar
  11. Cougle, J. R. (2012). What makes a quality therapy? A consideration of parsimony, ease, and efficiency. Behavior Therapy, 43, 468–481.CrossRefPubMedGoogle Scholar
  12. Diefenbach, G. J., DiMauro, J., Frost, R., Steketee, G., & Tolin, D. F. (2013). Characteristics of hoarding in older adults. The American Journal of Geriatric Psychiatry, 21, 1043–1047.CrossRefPubMedGoogle Scholar
  13. Dozier, M. E., Wetherell, J. L., Twamley, E. W., Schiehser, D. M., & Ayers, C. R. (2016). The relationship between age and neurocognitive and daily functioning in adults with hoarding disorder. International Journal of Geriatric Psychiatry, 31, 1329–1336.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34, 341–350.CrossRefPubMedGoogle Scholar
  15. Frost, R. O., Hristova, V., Steketee, G., & Tolin, D. F. (2013). Activities of daily living scale in hoarding disorder. Journal of Obsessive-Compulsive and Related Disorders, 2, 85–90.CrossRefPubMedGoogle Scholar
  16. Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: Saving inventory-revised. Behaviour Research and Therapy, 42, 1163–1182.CrossRefPubMedGoogle Scholar
  17. Frost, R. O., Steketee, G., Tolin, D. F., & Renaud, S. (2008). Development and validation of the clutter image rating. Journal of Psychopathology and Behavioral Assessment, 30, 193–203.CrossRefGoogle Scholar
  18. Guy, W. (1976). Clinical global impression scale. The ECDEU assessment manual for psychopharmacology-revised Vol. DHEW Publ No ADM, 76, 218–222.Google Scholar
  19. Iervolino, A. C., Perroud, N., Fullana, M. A., Guipponi, M., Cherkas, L., Collier, D. A., & Mataix-Cols, D. (2009). Prevalence and heritability of compulsive hoarding: A twin study. American Journal of Psychiatry, 166, 1156–1161.CrossRefPubMedGoogle Scholar
  20. Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., … Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 695–699.CrossRefPubMedGoogle Scholar
  21. Saxena, S., Ayers, C. R., Dozier, M. E., & Maidment, K. M. (2015). The UCLA hoarding severity scale: Development and validation. Journal of Affective Disorders, 175, 488–493.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Saxena, S., Ayers, C. R., Maidment, K. M., Vapnik, T., Wetherell, J. L., & Bystritsky, A. (2011). Quality of life and functional impairment in compulsive hoarding. Journal of Psychiatric Research, 45, 475–480.CrossRefPubMedGoogle Scholar
  23. Sheehan, D., Lecrubier, Y., Sheehan, K. H., Sheehan, K., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. (1998). Diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33.PubMedGoogle Scholar
  24. StataCorp. (2013). Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.Google Scholar
  25. Steketee, G., & Frost, R. O. (2014). Compulsive Hoarding and Acquiring: Therapist Guide (2nd ed.). New York: Oxford University Press.Google Scholar
  26. Thompson, C., de la Cruz, L. F., Mataix-Cols, D., & Onwumere, J. (2017). A systematic review and quality assessment of psychological, pharmacological, and family-based interventions for hoarding disorder. Asian Journal of Psychiatry, 27, 53–66.CrossRefPubMedGoogle Scholar
  27. Timpano, K. R., Exner, C., Glaesmer, H., Rief, W., Keshaviah, A., Brähler, E., & Wilhelm, S. (2011). The epidemiology of the proposed DSM-5 hoarding disorder: Exploration of the acquisition specifier, associated features, and distress. The Journal of Clinical Psychiatry, 72, 780–786.CrossRefPubMedGoogle Scholar
  28. 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, 200–211.CrossRefPubMedPubMedCentralGoogle Scholar
  29. Tolin, D. F., Frost, R. O., Steketee, G., & Muroff, J. (2015). Cognitive behavioral therapy for hoarding disorder: A meta-analysis. Depression and Anxiety, 32, 158–166.CrossRefPubMedGoogle Scholar
  30. 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, 829–838.CrossRefPubMedGoogle Scholar
  31. Turner, K., Steketee, G., & Nauth, L. (2010). Treating elders with compulsive hoarding: A pilot program. Cognitive and Behavioral Practice, 17, 449–457.CrossRefGoogle Scholar
  32. Twamley, E. W., Savla, G. N., Zurhellen, C. H., Heaton, R. K., & Jeste, D. V. (2008). Development and pilot testing of a novel compensatory cognitive training intervention for people with psychosis. American Journal of Psychiatric Rehabilitation, 11, 144–163.CrossRefPubMedPubMedCentralGoogle Scholar
  33. Twamley, E. W., Thomas, K. R., Burton, C. Z., Vella, L., Jeste, D. V., Heaton, R. K., & McGurk, S. R. (2017). Compensatory cognitive training for people with severe mental illnesses in supported employment: A randomized controlled trial. Schizophrenia Research.
  34. Twamley, E. W., Thomas, K. R., Gregory, A. M., Jak, A. J., Bondi, M. W., Delis, D. C., & Lohr, J. B. (2015). CogSMART compensatory cognitive training for traumatic brain injury: Effects over 1 year. The Journal of Head Trauma Rehabilitation, 30, 391–401.CrossRefPubMedGoogle Scholar
  35. Twamley, E. W., Vella, L., Burton, C. Z., Heaton, R. K., & Jeste, D. V. (2012). Compensatory cognitive training for psychosis: Effects in a randomized controlled trial. The Journal of Clinical Psychiatry, 73, 1212–1219.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Woody, S. R., Kellman-McFarlane, K., & Welsted, A. (2014). Review of cognitive performance in hoarding disorder. Clinical Psychology Review, 34, 324–336.CrossRefPubMedGoogle Scholar
  37. Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature (outside the USA) 2017

Authors and Affiliations

  • Catherine R. Ayers
    • 1
    • 3
    • 4
    Email author
  • Mary E. Dozier
    • 1
    • 3
  • Charles T. Taylor
    • 3
  • Tina L. Mayes
    • 4
  • James O. E. Pittman
    • 1
    • 2
    • 5
  • Elizabeth W. Twamley
    • 2
    • 3
    • 4
    • 5
  1. 1.VA San Diego Healthcare SystemSan DiegoUSA
  2. 2.Department of PsychiatryUniversity of California, San Diego School of MedicineSan DiegoUSA
  3. 3.San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical PsychologySan DiegoUSA
  4. 4.Research ServiceVA San Diego Healthcare SystemSan DiegoUSA
  5. 5.Center of Excellence for Stress and Mental HealthVA San Diego Healthcare SystemSan DiegoUSA

Personalised recommendations