Could written imaginal exposure be helpful for hoarding disorder? A case series

Abstract

Hoarding disorder is a common and debilitating mental illness with a high public health burden. Current cognitive behavioral therapy (CBT) improves hoarding disorder symptoms, yet many patients refuse treatment, drop out prematurely, or remain symptomatic at treatment end. Additional approaches are needed to improve CBT engagement and enhance treatment outcomes. One possible strategy is imaginal exposure—or envisioning one's worst-case scenario (e.g., throwing something out that is then needed)—to facilitate learning to tolerate the associated distress and uncertainty. Imaginal exposure has been shown to be efficacious for disorders with similar underlying processes as hoarding disorder, including obsessive-compulsive disorder and generalized anxiety disorder; yet it has not been adapted for or investigated in hoarding disorder. To test the effects of imaginal exposure, eight adults with hoarding disorder participated in a written imaginal exposure for 20 min daily for three consecutive days. Participants were asked to write about their worst-case scenario related to discarding a possession. Results indicate that this intervention was tolerable, acceptable, and may reduce hoarding disorder-related symptoms, suggesting that it merits further investigation in a larger pilot trial. To our knowledge, this is the first study testing the effects of imaginal exposure in individuals with hoarding disorder.