Improvement in Executive Functioning and Symptomatology Following Treatment for Hoarding Disorder in Veterans

Jessica Zakrzewski, UCSD, La Jolla, United States
Mary Dozier, Mississippi State University, Starkville, United States
Tina Mayes, San Diego VA, La Jolla, United States
Elizabeth Twamley, UCSD, La Jolla, United States
Catherine Ayers, UCSD, La Jolla, United States


Hoarding Disorder (HD) is one of the most common and impairing neuropsychiatric conditions in late life. Individuals with HD, especially those at older ages, often have executive functioning deficits. Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) for HD is effective in reducing HD symptoms and improving executive functioning (cognitive flexibility and inhibition) when compared with case management. In the current trial, we compared CREST to a robust control condition, exposure therapy (ET), to determine if CREST provides additional benefit to HD symptom reduction and neuropsychological functioning over ET in a group of treatment-seeking Veterans with HD.

Participants and Methods:

115 Veterans who met clinical criteria for HD were randomized to receive 26 once weekly, 1 hour manualized individual sessions of either CREST (n=59) or ET (n=56). CREST included 7 sessions targeting prospective memory, prioritizing, problem solving, planning, and cognitive flexibility, followed by 19 sessions of exposure therapy. ET included the same manualized exposure therapy for 26 sessions. Participants completed assessments at baseline, week 7 of treatment, post-treatment, 3 month follow-up, and 6 month follow-up. Outcome measures included self-report hoarding symptom ratings (Saving Inventory-Revised) and neuropsychological tests focused on executive functioning (D-KEFS Color Word, Trails, Tower, Design Fluency, Verbal Fluency; Wisconsin Card Sorting Test). Multi-level modeling was used to examine treatment-related change at post-treatment and follow-up timepoints.


Participants were mostly male (62%), White/Non-Hispanic (63%), and on average were 62 years old with 16 years of education. At baseline, mean HD symptoms were above clinical cut-offs for HD (mean SIR=57.7); 72% met criteria for comorbid major depression and 33% for post-traumatic stress disorder. Groups did not significantly differ at baseline on demographics, symptom severity, or neuropsychological performance. 60% of the sample demonstrated at least mild impairments on at least one task, with impairments on Verbal Fluency category switching and Color Word inhibition/switching being the most common. HD symptoms improved over time in both groups (estimate=-6.2, se=0.7, p<0.001); at post-treatment through 6-month follow up, both groups were, on average, below clinical cut-offs for HD. Similarly, neuropsychological test scores tended to improve over time in both groups (global deficit score across estimate=1.1, se=0.4, p=0.007; D-KEFS Design Fluency estimate=1.3, se=0.3, p<0.001; D-KEFS Tower estimate=0.3, se=0.1, p=0.002; Wisconsin Card Sorting Test estimate=1.1, se=0.4, p=0.007). Only the visual scanning condition of D-KEFS Trails improved differentially in the CREST group (estimate=0.5, se=0.2, p=0.011). There were no other CREST-associated effects on treatment outcomes.


Both CREST and ET groups demonstrated significant reductions in HD symptoms as well as improvements on several measures of executive functioning. CREST participants demonstrated an additional improvement in visual scanning, a key visual attention and processing speed function. Given the frequent attentional concerns with individuals with HD, more research is needed to determine if CREST provides additional benefit above that of ET alone.

Category: Psychiatric Disorders

Keyword 1: treatment outcome
Keyword 2: cognitive rehabilitation
Keyword 3: executive functions