Cognitive Rehabilitation and Exposure Therapy for Veterans with Hoarding Disorder

描述(由申请人提供)： 作为《诊断和统计手册-5》(DSM-5)的新成员，囤积障碍(HD)的定义是由于与丢弃相关的痛苦、保存的冲动和/或难以决定保留或处置什么而持续难以摆脱财产。杂物堆积并填满了生活区，阻碍了空间的正常使用，导致了痛苦和/或残疾。囤积症状会导致退伍军人，特别是年长的退伍军人严重受损，增加医疗问题，并降低生活质量。提供者为退伍军人治疗其他医疗或精神疾病，但经常错过一个重要的残疾来源和我们系统的负担。这种隐匿的情况对VA系统来说代价高昂，因为患者继续失代偿，需要在整个生命周期内进行更多的护理。鉴于超过6%的人口患有HD，这一比例高于被诊断为精神分裂症或双相情感障碍的比例，因此迫切需要对适当治疗的机制和疗效进行进一步研究。目前对HD的行为干预方法从无效到相对较小的收益。病例管理通常用于治疗HD，这会产生不适当的结果，患者在护理系统中重新浮出水面。HD的认知行为疗法(CBT)包括多个组成部分(评估：2-3个疗程，病例形成：2个疗程，技能培训：2-3个疗程，暴露和认知疗法结合：15-20个疗程，以及动机访谈：贯穿始终)，在老年人中产生不良反应率(即症状减轻20%)。中年HD患者的结果也好不到哪里去，在长期(4-9个月)的CBT治疗HD后，HD症状的症状缓解率从14-29%不等。执行功能障碍(ED)与HD症状的严重程度和CBT治疗HD的不良结局有关。决策、分类、解决问题、抑制、计划、组织和认知灵活性困难在HD患者的一生中都很明显，尤其是在老年患者中。退伍军人事务部资助开发了一种综合行为疗法(认知康复和暴露/分类疗法；CREST)，针对神经认知功能和HD的核心症状(退伍军人管理局职业发展奖；Ayers Pi)。这种治疗包括补偿性认知训练(CCT)以改善执行功能，并与旨在避免丢弃/不获得的暴露疗法(ET)相结合。初步结果表明，CREST是一种高度可行和可接受的治疗方法，与CBT相比，CREST治疗HD的结果发生率翻了一番。我们拟议的研究将进一步开发这种创新的干预措施，同时测试它是否通过其目标机制发挥作用，并检查可能确定哪些患者更有可能受益的结果调节因素。我们建议在136名HD患者中进行一项随机对照试验，比较6个月(26个疗程)的CREST和6个月的ET。评估将在基线、治疗期间(第7、13、21节)、治疗后以及3个月和6个月的随访中进行。主要目标是评估与单独暴露治疗相比，CREST是否显著减少囤积症状，改善功能能力和生活质量。我们还将检查治疗介体、治疗依从性、执行功能的变化、回避和症状严重程度对结果的影响。年龄和执行功能也将作为潜在的主持人进行探讨。最后，通过反复测量治疗指标，考察达到最大治疗效果的时间。通过为许多患有HD的退伍军人提供治疗，我们可以改变他们的症状轨迹和负面后果的过程，从而减轻医疗系统的负担，提高退伍军人的生活质量。

DESCRIPTION (provided by applicant): As a new addition to the Diagnostic and Statistical Manual-5 (DSM-5), Hoarding Disorder (HD) is defined by persistent difficulty parting with possessions due to distress associated with discarding, urges to save, and/or difficulty making decisions about what to keep or dispose of. Clutter accumulates and fills living areas to prevent normal use of space, resulting in distress and/or disability. Hoarding symptoms cause significant impairment, increased medical problems, and poor quality of life for our Veterans, particularly our older Veterans. Providers treat Veterans for other medical or psychiatric complaints yet frequently miss an important source of disability and burden on our system. This insidious condition is costly to the VA system as patients continue to decompensate and need greater amounts of care over the lifespan. Given that over 6% of the population has HD, a higher proportion than are diagnosed with schizophrenia or bipolar disorder, further research on the mechanism and efficacy of an appropriate treatment is desperately needed. Current behavioral intervention methods for HD range from ineffective to relatively small gains. Case management is typically used to treat HD, which produces inadequate outcomes and clients resurface in systems of care. Cognitive-behavioral therapy (CBT) for HD includes multiple components (assessment: 2-3 sessions, case formulation: 2 sessions, skills training: 2-3 sessions, combined exposure and cognitive therapy: 15-20 sessions, and motivational interviewing: throughout) and yields poor responses rates (i.e. <20% symptom reduction) in older adults. Outcomes in midlife HD patients are not much better, with symptom reduction rates ranging from 14-29% in HD symptoms following a lengthy course (4-9 months) of CBT for HD. Executive dysfunction (ED) is linked to both HD symptom severity and poor outcomes of CBT for HD. Decision making, categorization, problem solving, inhibition, planning, organization, and cognitive flexibility difficulties are evident in HD patients across th lifespan, particularly in older patients. The VA has funded the development of an integrated behavioral treatment (Cognitive Rehabilitation and Exposure/Sorting Therapy; CREST) that targets both neurocognitive functioning and the core symptoms of HD (VA Career Development Award; Ayers PI). This treatment includes Compensatory Cognitive Training (CCT) to improve executive functioning and is combined with exposure therapy (ET) that targets avoidance of discarding/not acquiring. Preliminary results suggest that CREST is a highly feasible and acceptable treatment that doubles outcome rates compared to CBT for HD. Our proposed study will further develop this innovative intervention while testing whether it works through the mechanisms it targets and examining outcome moderators that may identify which patients are more likely to benefit. We propose to conduct a randomized controlled trial comparing six months (26 sessions) of CREST to six months of ET alone, in 136 participants with HD. Assessments will be administered at baseline, during treatment (sessions 7, 13, 21), post-treatment, and 3 and 6-month follow-up. The primary objective is to evaluate whether CREST significantly reduces hoarding symptoms and improves functional capacity and quality of life when compared to exposure therapy alone. We will also examine the impact of treatment mediators; treatment adherence, changes in executive functioning, avoidance, and symptom severity on outcomes. Age and executive functioning will also be explored as potential moderators. Finally, by repeatedly measuring treatment targets, we will examine time to maximum treatment effect. By providing a treatment for many Veterans with HD, we can alter the course of their symptom trajectory and negative consequences, resulting in both reduced burden on the healthcare system and improved quality of life for Veterans.