Imaginal Exposure for Hoarding Disorder

Efficacy and Feasibility of Intensive Imaginal Exposure for Hoarding Disorder

The present study will test a potential new treatment strategy, imaginal exposure, for hoarding disorder. Although cognitive behavioral therapy often reduces hoarding, some people do not want to start, or cannot handle, that option. To help such individuals, the present study will provide imaginal exposure therapy to people with hoarding disorder, wherein they imagine discarding possessions as a way of becoming acclimated to the idea. We predict that imaginal exposure will improve hoarding symptoms as well as two psychological experiences linked to the condition: intolerance of uncertainty and emotional avoidance.

Study Overview

• Status: Completed
• Conditions: Hoarding Disorder
• Intervention / Treatment: Behavioral: Imaginal Exposure Writing; Other: Neutral Writing

Detailed Description

Hoarding disorder is a common mental illness characterized by difficulty parting with possessions and by clutter that makes living spaces unusable. Cognitive behavioral therapy (CBT) is an effective treatment for hoarding disorder, but new approaches are needed to engage those who are reluctant to start or cannot tolerate CBT. Both intolerance of uncertainty and emotional avoidance are linked to hoarding disorder and may interfere with treatment engagement. Imaginal exposure, a therapeutic technique which involves repeatedly imagining feared scenarios and experiencing the evoked emotions, effectively targets both intolerance of uncertainty and emotional avoidance. The present study is the first to test whether imagining discarding possessions can improve hoarding symptoms more than does a control exercise. We hypothesize that compared to a control exercise, imaginal exposure will improve hoarding symptoms, intolerance of uncertainty and emotional avoidance.

• Study Type: Interventional
• Enrollment (Actual): 32
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Palo Alto, California, United States, 94304
      • Stanford University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Age 18 and older
2. Any gender and all ethno-racial categories
3. Hoarding Disorder primary condition
4. Willing and able to understand and complete consent and study procedures
5. English speaking

Exclusion Criteria:

1. Severe depression
2. Clinically at risk of suicide with Columbia Suicide Severity Rating Scale (C-SSRS) Suicidal Ideation Subscale of 4 or higher (i.e. suicidal intent without specific plan)
3. Currently receiving Cognitive Behavioral Therapy (CBT)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Imaginal Exposure Writing; People with hoarding disorder will write for 20 minutes on each of 3 consecutive days about their worst-case scenario regarding discarding a possession (i.e., imaginal exposure).	Behavioral: Imaginal Exposure Writing; Imaginal exposure is a psychotherapy strategy that has been studied and shown to be helpful in the improvement of symptoms (e.g., anxiety, worry) for other psychiatric conditions, including excessive worry and obsessive-compulsive disorder symptoms.
Sham Comparator: Neutral Writing; People with hoarding disorder will write for 20 minutes on each of 3 consecutive days about what they would do if they had a day off work or school.	Other: Neutral Writing; Used in prior research as a control condition for imaginal exposure. Neutral writing will involve writing about what one would do on a day off work or school.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Savings Inventory Revised (Frost, Steketee & Grisham, 2004; Tolin, Meunier, Frost & Steketee, 2011)	Gold-standard 23-item self-report measure of hoarding disorder symptoms. Scale scores range from 0 to 92, with higher scores indicating more severe hoarding symptoms. More severe hoarding symptoms are considered a worse outcome.	Baseline (Pre Writing) and Follow Up (week 1)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Compulsive Acquisitions Scale (Frost et al. 2002)	Self-report 18-item measure of behaviors associated with hoarding disorder (i.e., acquiring).Scale scores range from 18 to 126, with higher scores indicating more severe hoarding behaviors. More severe hoarding behaviors are considered a worse outcome.	Baseline (Pre Writing) and Follow Up (week 1)
Intolerance of Uncertainty Scale (Buhr & Dugas, 2002)	Self-report 27-item measure of a cognitive process related to hoarding called intolerance of uncertainty. Scale scores range from 27 to 135 (some items are reverse scored), with higher scores indicating more severe intolerance of uncertainty. More severe intolerance of uncertainty is considered a worse outcome.	Baseline (Pre Writing) and Follow Up (week 1)
Acceptance and Action Questionnaire - II (Hayes, Luoma, Bond, Masuda and Lillis, 2006)	Self-report 7-item measure of a cognitive process related to hoarding called experiential avoidance. Scale scores range from 7 to 49, with higher scores indicating more severe experiential avoidance. More severe hoarding behaviors are considered a worse outcome.	Baseline (Pre Writing) and Follow Up (week 1)

Collaborators and Investigators

• Sponsor: Stanford University
• Collaborators: Brain & Behavior Research Foundation
• Investigators: Principal Investigator: Katie Fracalanza, PhD, Stanford University

Publications and helpful links

General Publications

• Fracalanza K, Raila H, Avanesyan T, Rodriguez CI. Written Imaginal Exposure for Hoarding Disorder: A Preliminary Pilot Study. J Nerv Ment Dis. 2024 May 1;212(5):289-294. doi: 10.1097/NMD.0000000000001719.

Study record dates

Study Major Dates

• Study Start (Actual): January 13, 2020
• Primary Completion (Actual): January 27, 2021
• Study Completion (Actual): January 27, 2021

Study Registration Dates

• First Submitted: November 5, 2018
• First Submitted That Met QC Criteria: November 6, 2018
• First Posted (Actual): November 8, 2018

Study Record Updates

• Last Update Posted (Actual): May 29, 2025
• Last Update Submitted That Met QC Criteria: May 27, 2025
• Last Verified: May 1, 2025

More Information

Terms related to this study

• Keywords: attachment; hoarding disorder; clutter; experiential avoidance; intolerance of uncertainty; imaginal exposure
• Additional Relevant MeSH Terms: Mental Disorders; Anxiety Disorders; Obsessive-Compulsive Disorder; Hoarding Disorder
• Other Study ID Numbers: 48109

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No