Hoarding Disorder: Executive Functioning and Treatment Acceptability

Objectives. Hoarding disorder (HD) incurs significant disability and disease burden, but psychological interventions for HD have difficulty engaging and retaining adult patients in treatment. This systematic review and meta-analysis synthesized evidence around acceptability in HD intervention literature, extracted key themes and conducted a proportional meta-analysis of treatment refusal and dropout rates.
Methods. PubMed, PsycInfo, SCOPUS and ProQuest were searched in April 2025 for quantitative and qualitative research exploring psychological interventions for adult HD patients. Sekhon et al.’s (2017) acceptability framework was used to narratively synthesize study findings. Pooled treatment refusal and dropout rates were synthesised using proportional meta-analysis and benchmarked against other diagnoses.
Results. Fifty-four studies were included (n=2027 of 13 different psychological interventions). The treatment refusal rate (k=27) was 13.43% (95% CI[8.10-19.67]) and treatment dropout rate (k=48) was 14.93% (95% CI [10.73-19.58]). Participants reported high anxiety about interventions, but actual experiences were generally positive with few adverse effects. Interventions were less acceptable on domains of self-efficacy and perceived effectiveness (e.g. adherence, maintenance of gains). S, and significant flexibility and effort was required to reduce ongoing intervention burden. Treatment refusal and dropout for HD benchmarks as equivalent in the main to other disorders.
Conclusion. HD treatments have refusal and dropout rates similar to interventions for other conditions. Many barriers prevent HD populations from accessing interventions, with some groups underrepresented in both treatments and research. Universal definitions of treatment refusal and dropout and further research into lived experiences of treatment are required.

Objectives. Hoarding disorder (HD) is conceptualised to be associated with deficits in executive functioning, but little research has explored the specific role of clutter in this relationship. This study aimed to a) develop an ecologically valid hoarding environment in virtual reality (VR) and b) test the impact of exposure to excessive clutter compared to no clutter in this environment on participants completing tasks of attention.
Design. A within-subject counterbalanced repeated measures design was used to identify differences in attention performance in cluttered and uncluttered VR environments.
Methods. Healthy community participants (N=44) spent time in cluttered and uncluttered VR houses completing two continuous performance tasks (X-CPT and AX-CPT) within each home environment. Environment and task order were randomised. Participants rated experienced realism, sense of presence and subjective distress in both environments. Repeated-measures multivariate analysis of variance tested the effects for clutter and relevant covariates.
Results. VR environments were realistic and immersive and participants experienced significantly greater distress in the cluttered environment. There were slower mean reaction times and more omission errors in the cluttered home. Differences in commission errors and sustained attention were non-significant. Increased distress in the cluttered home predicted greater deterioration in X-CPT reaction time and omission errors.
Conclusions. Exposure to clutter is detrimental to attention (particularly selective attention and response initiation) and may contribute to HD information processing deficits. Responses to clutter appear heterogeneous and distress influences attentional ability in cluttered environments. VR offers a valid and immersive means of better understanding the mechanisms of HD.