A new study published in the Journal of Affective Disorders explores the neural underpinnings of treatment compliance in cognitive behavioural therapy (CBT) for hoarding disorder (HD). Conducted by researchers at the Institute of Living and Yale University, the study aims to uncover specific brain regions that may predict a patient’s engagement and adherence to treatment, providing a deeper understanding of the neurobiological barriers to effective therapy.
Regardless of their actual value, hoarding disorder is characterized by a persistent inability to discard possessions, which results in cluttered living spaces and serious distress or impairment. CBT has been shown to be an effective treatment for HD; however, maintaining patient compliance remains a significant challenge. Treatment compliance is crucial, as it is generally predictive of positive outcomes in psychological therapies.
Blaise Worden, PhD, a licensed psychologist in Connecticut and one of the study’s authors, said: “We wanted to look at neural indicators of treatment compliance in cognitive-behavioural treatment. Specifically, we examined homework completion, attendance, and indicators of treatment compliance within treatment sessions, such as clinician ratings of patient understanding, participation, and agreement with the treatment model.
“While many studies have looked at neural predictors of treatment outcome, next to no studies have examined whether fMRI activation is related to behavioural indicators of treatment compliance, which is highly predictive of outcome. Individuals with hoarding disorder, in particular, have relatively poorer treatment compliance and attendance than related disorders, and may have neurobiological abnormalities in neural areas that may impact their ability to attend to and comply with treatment.”
The goal of the study is to identify brain activity patterns that might affect a patient’s capacity to adhere to CBT. Prior research has indicated that HD patients exhibit abnormal brain activity in regions associated with executive functions, such as decision-making, attention, and memory. This study delves deeper into these findings to link specific brain activity with treatment compliance.
The study involved 74 adults diagnosed with HD who underwent functional magnetic resonance imaging (fMRI) while performing a discarding task designed to trigger HD-related brain dysfunction. The participants then engaged in a 16-week CBT group therapy programme, where their treatment compliance was meticulously recorded.
The researchers employed two primary measures of compliance: the CBT Compliance Measure (CCM) for within-session compliance and the Patient Adherence Scale for Exposure and Response Prevention for Hoarding Disorder (PEAS-H) for homework compliance. The participants’ brain activity during the discarding task was analysed to identify correlations with these compliance measures.
“In our exploratory analyses,” Worden explains, “we found that treatment compliance was linked to specific areas of brain activity (during a discarding task in people with hoarding disorder) in the insular, parietal, and premotor cortex.” To our knowledge, this is the first study to examine how fMRI activation in specific HD patients’ brain regions might be related to treatment compliance variables, including within-session compliance (observed understanding of treatment and participation), between-session homework completion, and treatment attendance. It seems plausible that there is a relationship between the specific neural correlates found in this study and impaired attentional symptoms in HD.”
The study found significant correlations between brain activity and treatment compliance in several cortical regions. It was found that compliance during a session was linked to activity in several areas of the brain, including the right dorsal area 24d, the left medial intraparietal area, the dorsal area 6, and the seventh visual area. These regions are involved in social information processing, visuomotor integration, visual perception, and complex movement planning.
The post-central area 7 and the frontal opercular area 4 showed positive correlations between between-session compliance and brain activity. Interestingly, no brain regions were significantly associated with overall treatment attendance, suggesting that different neural mechanisms might underpin various aspects of compliance.
These findings suggest that specific neural deficits in HD patients may impact their ability to fully engage in and benefit from CBT. For instance, impairments in visuospatial processing and memory, which are critical for sorting and discarding tasks, might hinder within-session compliance. Similarly, deficits in executive functions necessary for planning and adhering to homework tasks might explain variations in between-session compliance.
The study underscores the importance of considering neurobiological factors when designing and implementing therapeutic interventions for HD. Understanding these neural predictors can help clinicians develop targeted strategies to improve treatment adherence, such as incorporating exercises that enhance visuospatial skills or memory functions as part of CBT.
Worden highlights the future directions for this research: “Taken together, the results raise the possibility that visuospatial and memory impairments may impact HD patients’ ability to attend and comply with CBT. However, it remains unclear how these neural abnormalities might contribute to reduced compliance with treatment. In the future, we may begin to examine further mechanisms behind this relationship, particularly using methods of examining brain networks rather than individual parcels. Ideally, this will help us identify malleable factors that can be targeted in more effective therapies for hoarding disorder.”
While this study provides valuable insights, further research is needed to explore the causal relationships between brain activity and treatment compliance. Longitudinal studies could help determine whether these neural patterns are pre-existing conditions that predispose individuals to HD or consequences of prolonged hoarding behaviour.
Expanding this research to include other psychological disorders with known compliance issues could provide a broader understanding of the neurobiological barriers to effective therapy. Integrating neuroimaging data with behavioural and cognitive assessments may pave the way for more personalised and effective treatment plans.
