Treating hoarding disorder with imagery rescripting following insufficient response to cognitive behavioural therapy:...

Childhood trauma, cold and controlling parenting experiences, and attachment difficulties are common in individuals with hoarding disorder (HD). One theory suggests that strong attachment to objects may arise as a compensatory response for early thwarted relatedness needs. However, first-line cognitive behavioural therapies (CBT) for HD rarely address these early adverse experiences during treatment. This study evaluated the feasibility, acceptability, and preliminary efficacy of an imagery rescripting intervention targeting early aversive memories in 10 individuals diagnosed with HD (Mage = 65.80 years; 80% female) who failed to sufficiently benefit from CBT. Participants attended an assessment appointment, followed by 12 bi-weekly sessions of imagery rescripting. Primary outcomes included hoarding symptoms, hoarding beliefs, and negative intrusive imagery, whereas secondary outcomes included anxiety, depression, obsessive-compulsive symptoms, and attachment difficulties. Measures were taken before a randomised baseline monitoring period, at pre-, mid-, and post-treatment, and at 1-month follow-up. Treatment credibility and acceptability were also assessed. We found that patients rated rescripting as moderately credible, and most participants (9 of 10) completed treatment with high satisfaction ratings. Significant and large reductions in hoarding symptoms (hedge's g = 0.90, p = .04), hoarding beliefs (hedge's g = 1.13, p = .01), depression (hedge's g = 1.18, p < .01), and avoidant attachment (hedge's g = 1.12, p < .01) were observed post-treatment and largely maintained at follow-up. Anxiety (hedge's g = 0.92, p =.04) and obsessive-compulsive symptoms (hedge's g = 1.28, p <. 01) also decreased by follow-up, whereas negative intrusive imagery and anxious attachment showed minimal change. Clinically significant improvements in hoarding symptoms occurred for half the sample, with three participants classifiable as 'recovered'. These findings suggest imagery rescripting may be a feasible, acceptable and promising adjuvant intervention for HD treatment non-responders. Future research should evaluate its efficacy in randomised controlled trials.