Recent advances in compulsive hoarding

A prospective investigation of impacts of comorbid attention deficit hyperactivity disorder (ADHD) on clinical features and long-term treatment response in adult patients with obsessive-compulsive disorder (OCD)

BACKGROUND

A close association between obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents has been investigated in previous studies. However, few studies examined the relationship between lifetime comorbidity of ADHD and OCD in adults. Therefore, we sought to investigate the clinical and psychopathological features related to comorbid ADHD in Japanese adult patients with OCD.

METHODS

We assessed lifetime comorbidity of ADHD in 93 adult Japanese patients with OCD. Additionally, we used the Japanese version of Conners' Adult ADHD Rating Scales to assess the characteristics and severity of ADHD in each participant. According to the results, we excluded OCD patients that did not have ADHD but who exhibited elevated levels of ADHD traits. We compared OCD patients with ADHD (ADHD+ group) and those without ADHD or its trait (ADHD- group) in terms of background profiles and clinical features, such as OCD symptomatology and psychometric test results. Additionally, the 6-month treatment outcome was compared prospectively between groups.

RESULTS

Of the 93 OCD participants, the prevalence of lifetime comorbidity of ADHD was estimated as 16.1%. Compared with the ADHD- group, participants in the ADHD+ group had an earlier age of onset of OCD, higher frequencies of hoarding symptoms, higher levels of depressive and anxiety symptoms and lower quality of life, more elevated levels of impulsivity, and higher rates of substance or behavioral addiction and major depression. Finally, the mean improvement rate on the Yale-Brown Obsessive Compulsive Scale after 6 months of standardized OCD treatment in the ADHD+ group (16.1%) was significantly lower than that in the ADHD- group (44.6%).

CONCLUSION

The lifetime comorbidity of ADHD is likely to exert a significant effect on clinical features and treatment outcome in adult patients with OCD. It is important to consider that underlying ADHD pathology may function as a facilitator for increased severity of global clinical features and treatment refractory conditions in OCD patients. Further studies are required to examine treatment strategies for such patients.

Resting-State Functional Connectivity Differences Following Experimental Manipulation of the Orbitofrontal Cortex in Two Directions via Theta-Burst Stimulation

Compulsive behaviors (CBs) have been linked to orbitofrontal cortex (OFC) function in animal and human studies. However, brain regions function not in isolation but as components of widely distributed brain networks—such as those indexed via resting-state functional connectivity (RSFC). Sixty-nine individuals with CB disorders were randomized to receive a single session of neuromodulation targeting the left OFC—intermittent theta-burst stimulation (iTBS) or continuous TBS (cTBS)—followed immediately by computer-based behavioral “habit override” training. OFC seeds were used to quantify RSFC following iTBS and following cTBS. Relative to cTBS, iTBS showed increased RSFC between right OFC (Brodmann’s area 47) and other areas, including dorsomedial prefrontal cortex (dmPFC), occipital cortex, and a priori dorsal and ventral striatal regions. RSFC connectivity effects were correlated with OFC/frontopolar target engagement and with subjective difficulty during habit-override training. Findings help reveal neural network-level impacts of neuromodulation paired with a specific behavioral context, informing mechanistic intervention development.

The prefrontal cortex and OCD

Obsessive Compulsive Disorder (OCD) is a highly prevalent and severe neuropsychiatric disorder, with an incidence of 1.5-3% worldwide. However, despite the clear public health burden of OCD and relatively well-defined symptom criteria, effective treatments are still limited, spotlighting the need for investigation of the neural substrates of the disorder. Human neuroimaging studies have consistently highlighted abnormal activity patterns in prefrontal cortex (PFC) regions and connected circuits in OCD during both symptom provocation and performance of neurocognitive tasks. Because of recent technical advances, these findings can now be leveraged to develop novel targeted interventions. Here we will highlight current theories regarding the role of the prefrontal cortex in the generation of OCD symptoms, discuss ways in which this knowledge can be used to improve treatments for this often disabling illness, and lay out challenges in the field for future study.

Animal Models for OCD Research

OCD has lagged behind other psychiatric illnesses in the identification of molecular treatment targets, due in part to a lack of significant findings in genome-wide association studies. However, while progress in this area is being made, OCD's symptoms of obsessions, compulsions, and anxiety can be deconstructed into distinct neural functions that can be dissected in animal models. Studies in rodents and non-human primates have highlighted the importance of cortico-basal ganglia-thalamic circuits in OCD pathophysiology, and emerging studies in human post-mortem brain tissue point to glutamatergic synapse abnormalities as a potential cellular substrate for observed dysfunctional behaviors. In addition, accumulated evidence points to a potential role for neuromodulators including serotonin and dopamine in both OCD pathology and treatment. Here, we review current efforts to use animal models for the identification of molecules, cell types, and circuits relevant to OCD pathophysiology. We start by describing features of OCD that can be modeled in animals, including circuit abnormalities and genetic findings. We then review different strategies that have been used to study OCD using animal model systems, including transgenic models, circuit manipulations, and dissection of OCD-relevant neural constructs. Finally, we discuss how these findings may ultimately help to develop new treatment strategies for OCD and other related disorders.

Pharmacotherapy for Hoarding Disorder: How did the Picture Change since its Excision from OCD?

This brief review deals with the various issues that contributed to the creation of the new Diagnostic and Statistical Manual condition of hoarding disorder (HD) and attempts at reviewing its pharmacotherapy. It appears that after the newly founded diagnosis appeared in the literature as an autonomous entity, distinct from obsessive-compulsive disorder, drug trials are not being conducted and the disorder is left in the hands of psychotherapists, who on their part, report fair results in some core dimensions of HD. The few trials on HD specifically regard the serotonin-noradrenaline reuptake inhibitor venlafaxine, and, possibly due to the suggestion of a common biological background of HD with attention-deficit/hyperactivity disorder, the psychostimulant methylphenidate and the noradrenaline reuptake inhibitor atomoxetine. For all these drugs, positive results have been reported, but the evidence level of these studies is low, due to small samples and non-blind designs. Regretfully, there are currently no future studies aiming at seriously testing drugs in HD.

A comparison of the neuropsychological profiles of people living in squalor without hoarding to those living in squalor associated with hoarding

OBJECTIVE

Squalor affects 1 in 1000 older people and is regarded as a secondary condition to other primary disorders such as dementia, intellectual impairment and alcohol abuse. Squalor frequently is associated with hoarding behaviour. We compared the neuropsychological profile of people living in squalor associated with hoarding to those presenting with squalor only.

METHODS

This study is a retrospective case series of hospital inpatient and community healthcare services of 69 people living in squalor (49 from aged care, 16 from aged psychiatry, 3 from acute medical and 1 from a memory clinic). Forty per cent had co-morbid hoarding behaviours. The main outcomes were neuropsychologists' opinions of domain-specific cognitive impairment.

RESULTS

The squalor-hoarding group (M age 75.8, SD = 6.9,) was significantly older (p < 0.05) than the squalor-only group (M age 69.9 years, SD = 13.1), significantly more likely to have vascular or Alzheimer's type neurodegeneration (p < 0.05) and significantly less likely to have alcohol-related impairment (p < 0.05). Chi-square analyses revealed significantly greater rates of impairment for the squalor-only group (p < 0.05) in visuospatial reasoning, abstraction, planning, organisation, problem solving and mental flexibility, compared with the squalor-hoarding group. Logistic regression analysis indicated that impaired mental flexibility was a significant predictor and strongly indicated squalor only (odds ratio = 0.07; 95% confidence interval: 0.01-0.82).

CONCLUSIONS

Preliminary evidence suggests that squalor associated with hoarding may have distinct neuropsychological features compared against squalor only. Future work should be conducted using a larger sample and a common neuropsychological battery to better understand the deficits associated with hoarding-related squalor. Copyright © 2016 John Wiley & Sons, Ltd.

Acceptability of Treatments and Services for Individuals with Hoarding Behaviors

OBJECTIVE

To explore the acceptability of currently available treatments and services for individuals who self-report hoarding behaviors.

METHOD

Between 10/2013 and 8/2014, participants were invited to complete an online survey that provided them descriptions of eleven treatments and services for hoarding behaviors and asked them to evaluate their acceptability using quantitative (0 [not at all acceptable] -10 [completely acceptable]) Likert scale ratings. The a priori definition of acceptability for a given resource was an average Likert scale score of six or greater. Two well-validated self-report measures assessed hoarding symptom severity: the Saving Inventory-Revised and the Clutter Image Rating Scale.

RESULTS

Two hundred and seventy two participants who self-reported having hoarding behaviors completed the questionnaire. Analyses focused on the 73% of responders (n=203) who reported clinically significant hoarding behaviors (i.e., Saving Inventory-Revised scores of ≥40). The three most acceptable treatments were individual cognitive behavioral therapy (6.2 ±3.1 on the Likert scale), professional organizing service (6.1 ±3.2), and use of a self-help book (6.0 ±3.0).

CONCLUSION

In this sample of individuals with self-reported clinically significant hoarding behaviors (n=203), only 3 out of 11 treatments and services for hoarding were deemed acceptable using an a priori score. While needing replication, these findings indicate the need to design more acceptable treatments and services to engage clients and maximize treatment outcomes for hoarding disorder.

Prevalence and correlates of difficulty discarding: results from a national sample of the US population

This study presents nationally representative data on the prevalence and the correlates of difficulty discarding, a behavior described in many psychiatric disorders, including a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, called hoarding disorder. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions, a national sample of the US population (N=43,093). Difficulty discarding worn-out/worthless items (assessed by a single item) and diagnoses of psychiatric disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule. The prevalence of difficulty discarding worn-out/worthless items in the general population was 20.6%. Difficulty discarding strongly correlated with axis I and axis II disorders, level of impairment, and use of mental health services. Difficulty discarding worn-out/worthless items is a common behavior that can be associated with various forms of psychopathology. When reported in a clinical setting, it may signal that careful assessment is needed to clarify diagnosis and inform treatment strategies.

Hoarding and the multi-faceted construct of impulsivity: a cross-cultural investigation

The proposed hoarding disorder represents a serious psychiatric condition and considerable public health burden. Although tremendous strides have been made in understanding the phenomenology and treatment of this condition, many features regarding the etiology and nosology remain unclear. In particular, the association between impulsivity and hoarding, as well as the differential role of impulsivity versus compulsivity has yet to be fully considered. The current investigation sought to fill this gap in the literature by examining the relationship between hoarding and impulsivity across two independent, cross-cultural investigations. Two separate conceptualizations of the impulsivity construct were considered, including the Barratt Impulsivity Scale and the UPPS Impulsive Behavior Scale. Across Study 1 (US young adult sample; N = 372) and Study 2 (German young adult sample; N = 160) results revealed that hoarding was associated with greater rates of impulsivity, despite controlling for theoretically relevant covariates. More fined-grained analyses revealed a differential relationship with respect to the various facets of impulsivity, such that hoarding was most strongly linked with attentional and motor impulsivity, as well as urgency (i.e., impulsive behaviors in response to negative affect) and lack of perseverance. When considered simultaneously, both impulsivity and non-hoarding OCD symptoms explained unique variance in hoarding. The implications of impulsivity for hoarding are discussed from a classification perspective, as well as from a vulnerability standpoint.

Clinically significant hoarding in obsessive-compulsive disorder: results from an Indian study

BACKGROUND

Hoarding is frequently conceptualized as a symptom of obsessive-compulsive disorder (OCD), but recent evidence indicates that, in most cases, hoarding may be better conceptualized as a distinct disorder that can coexist with OCD. Most of the research on hoarding is from the Western countries. This study aimed to provide data on the prevalence and correlates of clinically significant hoarding in a large sample of patients with OCD from the Indian subcontinent.

METHODS

We examined 200 patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition OCD for clinically significant hoarding using the Saving Inventory-Revised, followed by a clinical interview.

RESULTS

Twenty patients (10%) had clinically significant hoarding. In all cases, hoarding did not appear to be related or secondary to other OCD symptoms. None of the cases consulted for their hoarding problems. Compared with nonhoarders, hoarders hailed exclusively from an urban background and had a significantly higher frequency of certain obsessions and compulsions, bipolar disorder, generalized anxiety disorder, cluster C personality disorders, and a higher number of lifetime suicidal attempts. They also had a more severe OCD along with poorer global functioning and somewhat poorer insight into obsessive-compulsive symptoms.

CONCLUSIONS

The results suggest that clinically significant hoarding is relatively prevalent in Indian patients with OCD and that it appears to be largely unrelated to the OCD phenotype. However, the presence of comorbid hoarding is associated with more severe OCD, high comorbidity, more suicidal attempts, and a lower level of functioning. The results contribute to the current nosologic debate around hoarding disorder and provide a unique transcultural perspective.

Clinical features of obsessive-compulsive disorder with hoarding symptoms: a multicenter study

BACKGROUND

Factor analyses indicate that hoarding symptoms constitute a distinctive dimension of obsessive-compulsive disorder (OCD), usually associated with higher severity and limited insight. The aim was to compare demographic and clinical features of OCD patients with and without hoarding symptoms.

METHOD

A cross sectional study was conducted with 1001 DSM-IV OCD patients from the Brazilian Research Consortium of Obsessive-Compulsive Spectrum Disorders (CTOC), using several instruments. The presence and severity of hoarding symptoms were determined using the Dimensional Yale-Brown Obsessive-Compulsive Scale. Statistical univariate analyses comparing factors possibly associated with hoarding symptoms were conducted, followed by logistic regression to adjust the results for possible confounders.

RESULTS

Approximately half of the sample (52.7%, n = 528) presented hoarding symptoms, but only four patients presented solely the hoarding dimension. Hoarding was the least severe dimension in the total sample (mean score: 3.89). The most common lifetime hoarding symptom was the obsessive thought of needing to collect and keep things for the future (44.0%, n = 440). After logistic regression, the following variables remained independently associated with hoarding symptoms: being older, living alone, earlier age of symptoms onset, insidious onset of obsessions, higher anxiety scores, poorer insight and higher frequency of the symmetry-ordering symptom dimension. Concerning comorbidities, major depressive, posttraumatic stress and attention deficit/hyperactivity disorders, compulsive buying and tic disorders remained associated with the hoarding dimension.

CONCLUSION

OCD hoarding patients are more likely to present certain clinical features, but further studies are needed to determine whether OCD patients with hoarding symptoms constitute an etiologically discrete subgroup.

Annual research review: hoarding disorder: potential benefits and pitfalls of a new mental disorder

BACKGROUND

The inclusion of a new mental disorder in the nomenclature is not a trivial matter. Many have highlighted the risks of an ever-increasing number of mental disorders and of overpathologizing human behaviour. Given the proposed inclusion of a new hoarding disorder (HD) in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), it is pertinent to discuss the potential benefits and pitfalls of such a development.

METHOD

In this article, we examine whether HD fits with the current DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) and proposed DSM-5 definitions of 'mental disorder'. We next discuss the potential benefits and risks of the creation of this diagnosis. Finally, we address some additional considerations that may arise when proposing a new disorder for the nomenclature and identify some of the gaps in the knowledge base.

CONCLUSION

  HD fits the current DSM-IV and proposed DSM-5 definitions for a mental disorder. On balance, the potential benefits of creating the new diagnosis (e.g. identification of the majority of cases who clearly suffer and need help but are currently missed out by the existing diagnostic categories) outweigh the potential harms (e.g. pathologizing normal behaviour). Whether the criteria will need modification for their use in children/adolescents is unclear and more research is needed to address this question.

Prevalence of hoarding disorder in individuals at potential risk of eviction in New York City: a pilot study

This study estimated the prevalence of hoarding disorder (HD) in individuals seeking help from Eviction Intervention Services Housing Research Center (EIS), a not-for-profit community organization in New York City (NYC) that aids clients with housing problems including eviction. One hundred fifteen EIS clients were screened for HD. The prevalence of HD among those seeking help from EIS was 22% (clinician-rated) and 23% (self-rated), which is nearly 5 to 10 times greater than the rate of hoarding (2% to 5%) in the general population. Of individuals seeking help from EIS who met the criteria for HD (n = 25), 32% were currently in legal eviction proceedings (i.e., threatened with imminent eviction), 44% had a history of previous legal eviction proceedings, and 20% had been evicted from their home one or more times, yet only 48% were currently seeking mental health treatment. Almost a quarter of individuals seeking help for housing problems from a community eviction prevention organization met the criteria for HD; only about half of these individuals were receiving mental health treatment. Future studies are needed to determine whether HD treatment can reduce the risk of eviction and homelessness in NYC.

An exploration of economic reasoning in hoarding disorder patients

Current models of hoarding disorder (HD) emphasize problems of decision-making. Evidence for neuropsychological impairment in HD, however, has been mixed. The present study examined whether HD patients show problems of economic reasoning that could be associated with decision-making problems. Forty-two HD patients, 29 obsessive-compulsive disorder (OCD) patients, and 36 healthy control participants completed the Iowa gambling task (IGT), a computerized card playing game that assesses participants' ability to learn and utilize a rule of sacrificing short-term gain for long-term gain, and a cognitive dissonance reduction task that measured changes in preference for items (art prints) after selecting or rejecting them. Results showed no deficits on the IGT for HD participants, and no difference in dissonance reduction results after selecting or rejecting items on the dissonance reduction task. Furthermore, performance on these two tasks was unrelated to hoarding symptom severity or self-reported indecisiveness. It is suggested that the problems of cognitive processing in HD patients may be largely related to as-yet understudied processes, including idiosyncratic categorization problems for personally-owned items as well as other aspects of economic reasoning.

Development and preliminary psychometric evaluation of the Children's Saving Inventory

This study reports on the development and initial psychometric properties of the Children's Saving Inventory (CSI), a parent-rated measure designed to assess child hoarding behaviors. Subjects included 123 children and adolescents diagnosed with primary Obsessive-Compulsive Disorder (OCD) and their parents. Trained clinicians administered the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), items assessing Family Accommodation and the Clinical Global Impressions--Severity index. Parents completed the CSI, Child Obsessive-Compulsive Impact Scale (COIS)--Parent Version and Child Behavior Checklist. Youth completed the COIS--Child Version, Obsessive-Compulsive Inventory Child Version (OCI-CV), Multidimensional Anxiety Scale for Children, and Children's Depression Inventory--Short Form. A four factor solution was identified; factors were named Discarding, Clutter, Acquisition, and Distress/Impairment. Internal consistency for the CSI Total and factor scores were good. One-week test-retest reliability (n = 31) from a random subsample was excellent. Known groups validity was supported vis-à-vis higher CSI scores for those endorsing hoarding on the CY-BOCS Symptom Checklist. Convergent and discriminant validity was evidenced by weak relationships with OCI-CV Checking and Contamination factors but strong relationships with the OCI-CV Hoarding factor and with hoarding obsession/compulsions on the CY-BOCS. These findings provide initial support for the reliability and validity of the CSI for the assessment of hoarding behaviors among youth with OCD. Future studies are needed to extend these findings to non-OCD samples of youth.

Stressful life events and material deprivation in hoarding disorder

Traumatic life events and early material deprivation have been identified as potential environmental risk factors for the development of pathological hoarding behavior, but the evidence so far is preliminary and confounded by the presence of comorbid obsessive-compulsive disorder (OCD). This study retrospectively examined the occurrence of traumatic/stressful life events and material deprivation in four well-characterized groups: hoarding disorder without comorbid OCD (HD; n=24), hoarding disorder with comorbid OCD (HD+OCD; n=20), OCD without hoarding symptoms (OCD; n=17), and non-clinical controls (Control; n=20). Participants completed clinician and self-administered measures of hoarding, OCD, depression, psychological adjustment, and traumatic experience. Semi-structured interviews were undertaken to assess the temporal relation between traumatic/stressful life events and the onset and worsening of hoarding symptoms, and to determine the level of material deprivation. Although rates of post-traumatic stress disorder were comparable across all three clinical groups, hoarders (regardless of the presence of comorbid OCD) reported greater exposure to a range of traumatic and stressful life events compared to the two non-hoarding groups. Results remained unchanged after controlling for age, gender, education level, depression, and obsessive-compulsive symptoms. The total number of traumatic life events correlated significantly with the severity of hoarding but not of obsessive-compulsive symptoms. About half (52%) of hoarding individuals linked the onset of hoarding difficulties to stressful life circumstances, although this was significantly less common among those reporting early childhood onset of hoarding behavior. There was no link between levels of material deprivation and hoarding. Results support a link between trauma, life stress and hoarding, which may help to inform the conceptualization and treatment of hoarding disorder, but await confirmation in a representative epidemiological sample and using a longitudinal design.

Autism and ADHD symptoms in patients with OCD: are they associated with specific OC symptom dimensions or OC symptom severity?

In obsessive-compulsive disorder (OCD), the relationship between autism spectrum disorders (ASD), attention-deficit/hyperactivity disorder (ADHD) symptom, and obsessive-compulsive (OC) symptom dimensions and severity has scarcely been studied. Therefore, 109 adult outpatients with primary OCD were compared to 87 healthy controls on OC, ADHD and ASD symptoms. OCD patients showed increased ADHD and autism symptom frequencies, OCD + ADHD patients reporting more autism symptoms (particularly attention switching and social skills problems) than OCD − ADHD patients. Attention switching problems were most significant predictors of OC symptom dimensions (except hoarding) and of symptom severity. Hoarding was not associated with elevated autism scale scores, but with inattention. In conclusion, attention switching problems may reflect both symptom overlap and a common etiological factor underlying ASD, ADHD and OCD.

Hoarding disorder: a new diagnosis for DSM-V?

This article provides a focused review of the literature on compulsive hoarding and presents a number of options and preliminary recommendations to be considered for DSM-V. In DSM-IV-TR, hoarding is listed as one of the diagnostic criteria for obsessive-compulsive personality disorder (OCPD). According to DSM-IV-TR, when hoarding is extreme, clinicians should consider a diagnosis of obsessive-compulsive disorder (OCD) and may diagnose both OCPD and OCD if the criteria for both are met. However, compulsive hoarding seems to frequently be independent from other neurological and psychiatric disorders, including OCD and OCPD. In this review, we first address whether hoarding should be considered a symptom of OCD and/or a criterion of OCPD. Second, we address whether compulsive hoarding should be classified as a separate disorder in DSM-V, weighing the advantages and disadvantages of doing so. Finally, we discuss where compulsive hoarding should be classified in DSM-V if included as a separate disorder. We conclude that there is sufficient evidence to recommend the creation of a new disorder, provisionally called hoarding disorder. Given the historical link between hoarding and OCD/OCPD, and the conservative approach adopted by DSM-V, it may make sense to provisionally list it as an obsessive-compulsive spectrum disorder. An alternative to our recommendation would be to include it in an Appendix of Criteria Sets Provided for Further Study. The creation of a new diagnosis in DSM-V would likely increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder.

Obsessive-compulsive disorder: diagnostic and treatment issues

This article reviews current issues in the diagnosis and treatment of obsessive-compulsive disorder (OCD). The introduction of the selective serotonin reuptake inhibitors and of cognitive-behavioral therapy were significant advances for treating OCD. Nevertheless, there is a need to improve awareness of OCD and its management, and to develop novel approaches to treatment-refractory patients. Although the diagnostic criteria for OCD have remained unchanged for some time, there are several areas where potential modification may be useful. There is a growing evidence base on OCD symptom dimensions and subtyping, and it is timely to consider incorporating some of these emerging data into diagnostic classification systems.

Recent advances in the genetics of obsessive-compulsive disorder

This article reviews recent developments in understanding the genetic etiology of obsessive-compulsive disorder (OCD). Family studies provide further support for the familial aggregation of OCD. Genome-wide linkage studies indicate that specific chromosomal regions are linked to OCD. Moreover, results from recent molecular genetic studies suggest that several candidate genes are associated with OCD. However, specific genes causing OCD have not been conclusively identified, and the molecular pathogenesis of the disorder has not been elucidated. The search for genes is complicated by the clinical and etiologic heterogeneity of OCD, as well as the possibility of gene-gene and gene-environment interactions. Despite this complexity, further refinement of the phenotype and developments in molecular and statistical genetics hold promise for further deepening our genetic understanding of OCD in the future.