– Cognitive-behavioral therapy for hoarding disorder leaves substantial room for improvement in efficacy, and additional therapeutic attention to maladaptive beliefs regarding perfectionism just might be the answer, Hannah C. Levy, PhD, said at the annual conference of the Anxiety and Depression Association of America.

She presented a secondary analysis of the relationship between cognitive-behavioral therapy (CBT) outcomes and baseline maladaptive beliefs in a wait list–controlled study of 36 patients with hoarding disorder (HD) who were not on psychiatric medication. Her purpose was to identify which cognitive domains predicted treatment outcome. This, in turn, could point the way to new treatment targets.

Dr. Hannah C. Levy of the anxiety disorders center at the Institute of Living in Hartford, Conn. Bruce Jancin/Frontline Medical News

Dr. Hannah C. Levy

The strongest predictor of a weak treatment response proved to be a high baseline score on the Obsessive Beliefs Questionnaire subscale for perfectionism/certainty. Patients with a high level of perfectionism and rigidity of thinking showed the least improvement in HD symptoms both mid- and post treatment as measured by the Saving Inventory–Revised (SI-R).

In contrast, the baseline strength of Saving Cognitions Inventory maladaptive beliefs about saving, such as emotional attachment to hoarded objects or a belief that keeping those objects is the only way to be able to remember an important event, proved unrelated to CBT outcomes. And this finding may help explain CBT’s limited effectiveness in HD.

“I think traditionally our CBT interventions are more focused on the maladaptive saving beliefs. We’re currently not doing a whole lot about the perfectionism ideas that people may be bringing in,” said Dr. Levy of the anxiety disorders center at the Institute of Living in Hartford, Conn.

A strong unmet need exists for novel targets for CBT in hoarding disorder to improve current less-than-stellar outcomes, she said. A recent meta-analysis demonstrated that while CBT did provide a statistically significant benefit for this common and often disabling disease, outcomes were far from optimal. Indeed, after completing their course of CBT, patients still scored an average of 3 standard deviations above mean normal for scores on the SI-R (Depress Anxiety. 2015 Mar;32[3]:158-66).

Other investigators have recognized the limitations of current CBT for HD and tried tweaking the therapy to boost efficacy. These efforts have included formal studies incorporating home visits, adding cognitive remediation to reduce the neuropsychological deficits often present in patients with HD, and/or extending the treatment duration to 26 weekly sessions from the current standard of 15 or 16.

Unfortunately, none of these innovations has really panned out when tested, Dr. Levy said. For example, in the 36-patient study analyzed by Dr. Levy, clinically significant improvement was seen in only 41% of subjects following 26 weeks of CBT (Depress Anxiety. 2010 May;27[5]:476-84). In contrast, published response rates for CBT in patients with obsessive-compulsive disorder – a related condition – are in the 85% range.

She described the perfectionism that often figures prominently in HD as a maladaptive belief that if something can’t be done perfectly, it’s not worth doing at all.

“People will say to me, ‘I can’t start discarding until I’ve got my organizational system down.’ They’re completely stymied. They can’t make any progress because their system isn’t fully coordinated yet,” the psychologist explained.

One way to potentially target this perfectionism more explicitly might be to incorporate cognitive restructuring or behavioral experiments that enable patients to test out and perhaps discard those beliefs, according to Dr. Levy.

She reported no financial conflicts regarding her analysis, which was based upon data collected in an earlier study sponsored by the National Institute of Mental Health.