A Pilot Study of Contingency Management for Hoarding Disorder Blaise Worden, Ph.D. & David F. Tolin, Ph.D. Anxiety Disorders Center/Center for Cognitive-Behavioral Therapy Hartford Hospital/Institute of Living, Hartford, CT

Background There are few empirically-supported treatments for hoarding disorder (HD). CBT has resulted in only moderate improvement High rates of ongoing functional impairment post-treatment Majority continue to meet the diagnosis at post-treatment Rates of clinically significant change around 24-43% (Tolin, Frost, Steketee, & Muroff, 2014) Problems Low treatment compliance Psychological reactivity Overvalued ideation

Why Try Contingency Management for HD? Contingency management is an empirically supported treatment for substance use disorders Has also been used with successfully with health maintenance behaviors, weight loss, etc. Likely capitalizes on a pre-existing high drive for material reward, and high loss aversion Provides additional incentive to complete “risky” behavioral experiments Does not rely on good insight

Myths about Contingency Management CM “bribes” the patient--it relies on external motivation and will thereby decrease internal motivation for change. CM doesn’t provide lasting skills. Once you remove the contingencies, you’re back to square one. The cost and resource burden of CM is too high to be worthwhile.

Study Aims Gauge preliminary efficacy of CM for HD Compare effect sizes to existing treatments for HD Gauge patient interest and satisfaction Retention and refusal rates Patient feedback Examine tolerability

Method CM was administered in the context of 16-session group CBT Contingency payments based on results of in-home assessments Two successive group cohorts; n = 14; 8 completers 2 dropped from both study and group 2 dropped from study only, citing that the intervention made them feel too anxious and pressured to change

Contingencies Group 1 Group 2 $30 per 1-point reduction in mean CIR rating Total amount earned: $660; mean per person = $132 Payment for each goal completed 8 goals per month collaboratively set with in-home evaluator; were discarding-focused Escalating payments; $3, 5, 7, 10 Also received $40 bonus payment for each 1-point CIR reduction Total amount earned: $730; mean per person = $123

Measures Clutter Image Rating (CIR) Saving Inventory Revised (SI-R) Hoarding Rating Scale (HRS) Clinical Global Improvement Ratings (CGI-S; CGI-I)

Results: Saving Inventory-R ITT results (n = 10); red = group 1; blue = group 2 C = 42.9 (60%) F(2, 8) = 4.74, p = .04; d = 1.18

Results: Clutter Image Rating-IE Mean IE-rated CIR score dropped from 4.3 to 3.2

Results: SIR Subscales

Results: CGI-I

Conclusions Size of mean percent SI-R reduction (32%) was larger than any prior psychosocial intervention for HD Briefer than existing treatments Large effect sizes High patient interest and retention Results are promising and suggest additional research on CM for HD is indicated

Conclusions Limitations Future Directions Difficult to decide what to reinforce; reinforcing decreases in clutter required home visits Two patients dropped, citing anxiety No follow-up Relatively higher functioning sample Future Directions Determine who is most likely to benefit from CM Determine ideal reinforcement system Obtain follow-up data