The study provides insight of cognitive-behavioral therapy (CBT) on hoarding disorder by examining its impact on brain activity.
Findings indicate that group CBT for adults led to heightened activity in brain regions linked to decision-making and emotional regulation during the process of discarding possessions. This neurological shift corresponded with a reduction in maladaptive beliefs about the importance of retaining possessions.
Hoarding disorder is characterized by severe difficulty in letting go of possessions, resulting in significant clutter, disruption of daily activities, and emotional distress. Although CBT has been established as an effective intervention, treatment outcomes vary widely. Many participants experience improvement, though complete symptom resolution remains uncommon. Greater insights into the mechanisms by which therapy induces change are considered essential for enhancing its effectiveness.
Previous studies have emphasized the influence of maladaptive beliefs—such as intense emotional attachments to objects or fears of losing control over possessions—in perpetuating hoarding behaviors. Symptom improvement has been linked to a reduction in these beliefs during CBT. However, limited knowledge exists regarding the connection between changes in these beliefs and brain activity, particularly in neural regions activated during decisions about discarding possessions.
“There remains much to uncover about hoarding disorder, which is estimated to affect 2–6% of the population and occurs more frequently in older adults. Cognitive-behavioral therapy for hoarding disorder has been shown to improve symptoms for most individuals, which is promising, but not all experience clinically significant progress, leaving room for further research.”
– Kelly Knowles, a clinical psychologist at the Institute of Living at Hartford Hospital
Notably, those engaged in hoarding treatment often exhibit distinct thought patterns compared to the average older adult, such as endorsing beliefs like, ‘Responsibility for the well-being of possessions lies with the owner,’ or, ‘Throwing this item away would be intolerable.’ This study offered an opportunity to closely examine specific brain changes from pre-treatment to post-treatment and assess links between these changes and such beliefs.”
The research involved 58 adults diagnosed with hoarding disorder who participated in group CBT. Functional magnetic resonance imaging (fMRI) scans were conducted before and after therapy to observe brain activity during a simulated discarding task. During the task, participants viewed images of items and decided whether to “keep” or “discard” them, imagining the process as part of a “spring cleaning” scenario.
The Study
The study concentrated on brain regions previously linked to hoarding disorder, including the insula and anterior cingulate cortex, known for their roles in processing emotional significance and facilitating decision-making. Changes in beliefs regarding possessions were evaluated using a validated questionnaire. These beliefs were categorized into areas such as emotional attachment, memory concerns, control over possessions, and feelings of responsibility for objects.
Prior to therapy, stronger maladaptive beliefs about possessions were associated with heightened activity in brain regions, including the left middle insula and the left anterior cingulate cortex, during decisions to discard items. These findings are consistent with earlier research indicating hyperactivity in these regions among individuals with hoarding disorder, reflecting the significant emotional and cognitive challenges involved in discarding possessions.
Following therapy, substantial reductions in maladaptive beliefs were reported, such as diminished feelings of excessive responsibility for belongings or fears of experiencing unbearable distress when discarding items. These changes were connected to increased activity in brain regions involved in decision-making and emotional processing, including the right anterior ventral insula, left middle frontal gyrus, and bilateral inferior temporal lobe.
Increased brain activity in visuospatial regions was observed, suggesting an enhanced ability to visually assess items during the discarding process. This shift may reflect a more balanced approach to decision-making, with reduced emotional interference influencing choices.
The findings indicate that therapy not only diminishes maladaptive beliefs but also alters the brain’s response to emotionally charged decisions involving possessions. For individuals experiencing hoarding disorder, the act of discarding items often feels “risky.” Therapy appears to support a reinterpretation of these decisions, making them feel less threatening, as evidenced by changes in brain activity.
“It is common for an average person to know a relative or friend exhibiting hoarding symptoms. Awareness is important, as cognitive-behavioral therapy for hoarding disorder is available and effective, though ongoing efforts are needed in the scientific community to refine treatments.
The encouraging aspect is that beliefs sustaining hoarding disorder, such as intense emotional attachment to objects, do show significant changes over the course of CBT. These belief changes are linked to shifts in brain activity during the process of discarding possessions.”
Kelly Knowles
Researchers accounted for factors such as overall emotional distress and psychiatric medication use to ensure that the observed effects were specific to therapy’s impact on hoarding-related beliefs and brain activity. As with any study, limitations were acknowledged.
Although significant changes in neural activity were identified, further studies with larger and more diverse samples are necessary to confirm the connections between belief changes and brain activity. Future research may also investigate how these neural changes influence long-term treatment outcomes and whether they can help predict the individuals most likely to benefit from therapy.
“While neuroimaging (fMRI) research is fascinating, many unknowns remain. Changes in brain activity observed during a laboratory task do not necessarily indicate that these changes are stable, enduring, or directly responsible for clinical improvement.”
Kelly Knowles
As often stated, ‘correlation is not causation.’ Changes in brain activity during a specific task are associated with cognitive changes, but it remains unclear whether cognitive changes drive brain changes or if brain changes result in symptom improvement.
Much remains to be discovered about how beliefs are represented in the brain.
“The narrative is rarely as straightforward as ‘this brain region controls this function, and this treatment corrects brain functioning.’ This complexity makes the field an exciting area for future exploration.”
Kelly Knowles
https://doi.org/10.1016/j.jpsychires.2024.11.017
Abstract
Hoarding disorder (HD) is maintained by maladaptive beliefs about possessions, and recent research has demonstrated that changes in these beliefs partially mediate improvement in cognitive-behavioral therapy (CBT) for hoarding. It is not yet known whether changes in neural activity, particularly when discarding possessions, are associated with cognitive change during CBT for HD. Adults who completed group CBT for HD (N = 58) participated in a simulated discarding task before and after CBT. Neural activity was measured using functional magnetic resonance imaging (fMRI) as participants made simulated discarding decisions. At baseline, activity in the left middle insula and left anterior cingulate cortex was significantly associated with hoarding-related beliefs. After receiving CBT for HD, decreases in maladaptive hoarding-related beliefs were significantly associated with increased activity compared to baseline in the right anterior ventral insula, along the left middle frontal gyrus and bilateral inferior temporal lobe, and in visuospatial areas. These results demonstrate that maladaptive beliefs in HD are associated with activation of specific neural regions during discarding decisions and that reduction in beliefs over a course of CBT for HD is associated with specific changes in neural activity.