A randomized trial of 115 Veterans found that exposure therapy alone reduced hoarding disorder symptoms by 42% posttreatment, matching the improvement seen when cognitive rehabilitation was added to exposure therapy. The added cognitive work yielded one specific advantage: better interpersonal functioning.
Hoarding disorder is a serious psychiatric condition characterized by persistent difficulty discarding possessions, resulting in cluttered living spaces that impair daily functioning. It affects roughly 2-6% of the population and is particularly common in older adults, making it one of the most frequent and disabling neuropsychiatric conditions in late life. Despite its prevalence, evidence-based treatment options remain limited, and researchers have worked to identify which therapeutic approaches work best.
This randomized controlled trial tested whether adding cognitive rehabilitation to exposure therapy would offer superior outcomes compared to exposure therapy alone. Researchers enrolled 115 Veterans (average age 62, mostly male) and assigned them to receive 26 weekly one-hour sessions of either CREST (Cognitive Rehabilitation and Exposure/Sorting Therapy, n=59) or exposure therapy (ET) alone (n=56). Both groups received the same 19 sessions of manualized exposure therapy, but the CREST group received an additional seven sessions of cognitive rehabilitation focused on decision-making, organization, and cognitive flexibility early in treatment. The ET control group received seven psychoeducation sessions instead.
The core finding was striking in its clarity: both groups improved substantially and equally on hoarding symptoms. Participants averaged a 42% reduction in Savings Inventory-Revised (SI-R) scores from baseline to posttreatment, representing clinically meaningful improvement. There were no significant differences between groups on the primary outcome (hoarding symptom severity), functional capacity, self-reported disability, or quality of life. This indicates that exposure therapy, structured properly and delivered consistently over 26 sessions, is highly effective for hoarding disorder, even without added cognitive rehabilitation.
However, the CREST group did show a meaningful advantage in one domain: self-reported interpersonal functioning (Cohen's d = 0.48, p = 0.012). This suggests that the cognitive work on decision-making and organizational skills may translate to better social engagement and relationship quality, even if it doesn't accelerate symptom reduction. The practical meaning of this finding remains to be tested in larger or longer-term studies, but it indicates cognitive rehabilitation is not wasted effort; it may offer benefits that extend beyond the clutter itself.
If you or someone you know struggles with hoarding behaviors, this study offers concrete hope. Exposure therapy for hoarding disorder works, and it works reliably when delivered by trained therapists over sufficient duration (26 weekly sessions in this trial). The specific manuals and protocols used here demonstrate that structured, manualized treatment is feasible and produces real reductions in symptoms.
The choice between ET alone and CREST is less clear-cut. If the goal is rapid symptom reduction and functional improvement, the evidence suggests either approach will work equally well. If relationship quality and social functioning are priorities, or if cognitive deficits (executive dysfunction, decision-making paralysis) are prominent features of the person's hoarding, adding cognitive rehabilitation may provide additional value. However, this would require discussion with a mental health provider who can assess whether the added cost and time commitment justify the targeted interpersonal benefit.
It's worth noting that this study was conducted in Veterans, a population with high rates of trauma and comorbid psychiatric conditions. Results may differ in other populations. Additionally, the follow-up period ended at posttreatment, so durability of gains beyond treatment remains unknown. Both exposure therapy and cognitive rehabilitation require active engagement and practice; these are not passive treatments.
| Detail | Value |
|---|---|
| Study type | Randomized controlled trial (RCT) |
| Participants | 115 Veterans with hoarding disorder |
| CREST group | n = 59 |
| ET group | n = 56 |
| Treatment duration | 26 once-weekly 1-hour sessions |
| CREST structure | 7 cognitive rehabilitation + 19 exposure/sorting sessions |
| ET structure | 7 psychoeducation + 19 exposure/sorting sessions |
| Primary outcome | Hoarding symptom severity (SI-R score) |
| Primary finding | Both groups: 42% symptom improvement; no between-group difference (p > 0.05) |
| Secondary finding | CREST > ET on interpersonal functioning (d = 0.48, p = 0.012) |
| Demographics | 64% male, 72% White/non-Hispanic, mean age 62 years |
| Registry | NCT02402647 |
| Journal | Journal of Consulting and Clinical Psychology |
Ayers CR, Castriotta N, Dozier ME, et al. Cognitive rehabilitation and exposure/sorting therapy for hoarding disorder: A randomized controlled trial. J Consult Clin Psychol. 2024. PubMed ID: 42658588
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