Do People with Hoarding Disorder Under-Report Their Symptoms?

Changes in neural activity following a randomized trial of cognitive behavioral therapy for hoarding disorder

OBJECTIVE

Cognitive behavioral therapy (CBT) is efficacious for hoarding disorder (HD), though results are modest. HD patients show an increase in activity in the dorsal anterior cingulate cortex (dACC) when making decisions. The aim of this study is to determine whether CBT's benefits follow improvements in dACC dysfunction or abnormalities previously identified in other brain regions.

METHOD

In this randomized clinical trial of 64 treatment-seeking HD patients, patients received group CBT, delivered weekly for 16 weeks, versus wait list. Functional magnetic resonance imaging was used to examine neural activity during simulated decisions about whether to acquire and discard objects.

RESULTS

During acquiring decisions, activity decreased in several regions, including right dorsolateral prefrontal, right anterior intraparietal area, both right and left medial intraparietal areas, left and right amygdala, and left accumbens. During discarding decisions, activity decreased in right and left dorsolateral prefrontal, right and left rostral cingulate, left anterior ventral insular cortex, and right medial intraparietal areas. None of the a priori brain parcels of interest significantly mediated symptom reduction. Moderation effects were found for left rostral cingulate, right and left caudal cingulate, and left medial intraparietal parcels.

CONCLUSIONS

Therapeutic benefits of CBT for HD do not appear to be mediated by changes in dACC activation. However, pretreatment dACC activation predicts outcome. Findings suggest the need to re-evaluate emerging neurobiological models of HD and our understanding of how CBT affects the brain in HD, and perhaps shift focuses to new neural target discovery and target engagement trials. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Anosognosia in hoarding disorder is predicted by alterations in cognitive and inhibitory control

Insight impairment contributes significantly to morbidity in psychiatric disorders. The neurologic concept of anosognosia, reflecting deficits in metacognitive awareness of illness, is increasingly understood as relevant to psychopathology, but has been little explored in psychiatric disorders other than schizophrenia. We explored anosognosia as an aspect of insight impairment in n = 71 individuals with DSM-5 hoarding disorder. We used a standardized clutter severity measure to assess whether individuals with hoarding disorder underreport home clutter levels relative to independent examiners. We then explored whether underreporting, as a proxy for anosognosia, is predicted by clinical or neurocognitive behavioral measures. We found that individuals with hoarding disorder underreport their clutter, and that underreporting is predicted by objective severity of clutter. In an n = 53 subset of participants, we found that underreporting is predicted by altered performance on tests of cognitive control and inhibition, specifically Go/No-Go and Stroop tests. The relation of underreporting to objective clutter, the cardinal symptom of hoarding disorder, suggests that anosognosia may reflect core pathophysiology of the disorder. The neurocognitive predictors of clutter underreporting suggest that anosognosia in hoarding disorder shares a neural basis with metacognitive awareness deficits in other neuropsychiatric disorders and that executive anosognosia may be a transdiagnostic manifestation of psychopathology.

Perceived locus of control for clutter: Reported reasons for clutter in adults with and without hoarding symptoms

OBJECTIVES

The goal of the current investigation was to expand on previous work on reasons for saving/discarding in the context of hoarding by examining individuals' perceived locus of control for household clutter.

METHODS

Participants were asked to list their perceived reasons for clutter and assign each reason a percentage rating reflecting the extent to which they judged the reason to be responsible for their household clutter.

RESULTS

Lack of time was an almost universally endorsed reason for clutter. Clinically severe hoarding levels were associated with lower responsibility ratings for time-related reasons and increased endorsement of distress-related reasons.

CONCLUSIONS

Future research should examine whether insight level affects how individuals with clinically severe hoarding perceive the locus of control for household clutter.

PRACTITIONER PONITS

Perception of lack of time may influence individuals' sense of locus of control for their household clutter levels. Hoarding severity is associated with being more likely to attribute distress around discarding or decision making as the reason for clutter.

A systematic review and realist synthesis on toilet paper hoarding: COVID or not COVID, that is the question

OBJECTIVE

To explore whether the coronavirus disease 2019 (COVID-19) pandemic is associated with toilet paper hoarding and to assess which risk factors are associated with the risk of toilet paper hoarding.

DESIGN

A systematic review and realist review were conducted.

DATA SOURCES

PubMed, Web of Science, Scopus and PsycINFO were searched (systematic review). PubMed, pre-prints and grey literature were also searched (realist review). The databases were searched from inception until October 2020.

STUDY SELECTION

There were no restrictions on the study design.

OUTCOMES AND MEASURES

For the systematic review, toilet paper hoarding was the main outcome, and pathological use of toilet paper was the secondary outcome. For the realist review, the context-mechanisms-outcome (CMO) scheme included the COVID-19 pandemic (context), four proposed mechanisms, and one outcome (toilet paper hoarding). The four potential mechanisms were (1) gastrointestinal mechanisms of COVID-19 (e.g. diarrhoea), (2) social cognitive biases, (3) stress-related factors (mental illnesses, personality traits) and (4) cultural aspects (e.g. differences between countries).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

All studies of human populations were considered (including general population studies and clinical studies of patients suffering from mental health problems).

RESULTS

The systematic review identified 14 studies (eight studies for the main outcome, six studies for the secondary outcome). Three surveys identified the role of the COVID-19 threat in toilet paper hoarding in the general population. One study pointed to an association between a personality trait (conscientiousness) and toilet paper buying and stockpiling as well as an additional significant indirect effect of emotionality through the perceived threat of COVID-19 on toilet paper buying and stockpiling. Six case reports of pathological use of toilet paper were also identified, although none of them were associated with the COVID-19 pandemic. The realist review suggested that of all the mechanisms, social cognitive biases and a bandwagon effect were potential contributors to toilet paper hoarding in the general population. The stressful situation (COVID-19 pandemic) and some personality traits (conscientiousness) were found to be associated with toilet paper hoarding. Cultural differences were also identified, with relatively substantial effects of toilet paper hoarding in several Asian regions (Australia, Japan, Taiwan and Singapore).

CONCLUSIONS

The COVID-19 pandemic has been associated with a worldwide increase in toilet paper hoarding. Social media and social cognitive biases are major contributors and might explain some differences in toilet paper hoarding between countries. Other mental health-related factors, such as the stressful situation of the COVID-19 pandemic, fear of contagion, or particular personality traits (conscientiousness), are likely to be involved.

REGISTRATION

PROSPERO CRD42020182308.

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.

Validation of a Behavioral Measure of Acquiring and Discarding in Hoarding Disorder

Behavioral assessment is an important component of evidence-based assessment and treatment in anxiety and related disorders. The purpose of the current study was to validate a behavioral measure of difficulty discarding and acquiring, the core features of hoarding disorder (HD). Seventy-eight patients with a primary diagnosis of HD completed a computerized acquiring and discarding task; the task consisted of making simulated decisions about acquiring and discarding items of varying monetary value. A subset of patients (n = 42) went on to receive cognitive behavioral therapy (CBT) for HD and completed the computer tasks again after treatment. An additional 30 age- and sex-matched healthy control participants (HCs) also completed the acquiring and discarding tasks. Results showed that HD patients saved and acquired more items than the HC group, and had longer response times during the tasks. In support of the convergent validity of the tasks, item decisions and reaction times were positively correlated with established measures of HD symptoms. Among treatment completers, items saved and acquired and response times decreased from pre- to post-CBT, suggesting that the tasks were sensitive to detect treatment-related changes in difficulty discarding and acquiring behaviors. The findings support the validity of the discarding and acquiring tasks in measuring HD symptoms, and are discussed in terms of the potential advantages of behavioral measures in HD treatment and research.

The relationship between age and neurocognitive and daily functioning in adults with hoarding disorder

OBJECTIVE

Given the increase in hoarding symptoms with age, there is a pressing need for understanding the clinical features as they relate to potential interventions for older adults with hoarding disorder (HD). The aim of the current investigation was to explore age-related differences in the level of functional and cognitive impairment in individuals with HD.

METHODS

The current study utilized the baseline assessments of 122 adults with HD. Age-related differences in the raw scores of psychiatric, cognitive, and daily functioning were analyzed using a series of multiple regression models controlling for the possible age-related differences in premorbid IQ.

RESULTS

Our results suggested that older adults with HD may experience increased levels of impairment in skills related to executive functioning and everyday functioning when compared with younger adults with HD.

CONCLUSIONS

Given these difficulties with neurocognitive functioning, older HD patients may require interventions that focus more on behavioral and functional skills, rather than focusing on changing thought processes. Copyright © 2016 John Wiley & Sons, Ltd.

Executive Functioning in Participants Over Age of 50 with Hoarding Disorder

OBJECTIVES

The current investigation utilized mid-life and late-life participants diagnosed with hoarding disorder (HD) to explore the relationship between executive functioning and hoarding severity.

DESIGN

Correlational analyses were used to investigate the associations between executive functioning and hoarding severity in nondemented participants. Multiple regression was used to determine if executive functioning had a unique association with HD severity when accounting for depressive symptoms.

SETTING

Participants were recruited from the San Diego area for HD intervention studies.

PARTICIPANTS

Participants were 113 nondemented adults aged 50-86 years who met DSM-5 criteria for HD. The mean age of the sample utilized in the analyses was 63.76 years (SD, 7.2; range, 51-85 years). The sample was mostly female (72%), Caucasian (81.4%), and unmarried (78%).

MEASUREMENTS

Hoarding severity was assessed using the Saving Inventory-Revised and the Clutter Image Rating and depression was assessed using the Hospital Anxiety and Depression Scale. Executive functioning was assessed using the Wisconsin Card Sorting Test (WCST-128) and the Trail Making and Verbal Fluency subtests of the Delis-Kaplan Executive Function System.

RESULTS

Executive function (operationalized as perseveration on the WCST-128) was significantly associated with Clutter Image Ratings. In a multivariate context, executive function and depressive symptom severity were both significant predictors of variance in Clutter Image Rating.

CONCLUSIONS

Our results suggest that executive function is related to severity of HD symptoms and should be considered as part of the conceptualization of HD.

Neurocognitive performance in unmedicated patients with hoarding disorder

OBJECTIVE

Hoarding disorder (HD) is an often incapacitating psychiatric illness associated with a wide range of neurocognitive abnormalities. Some prior neuropsychological studies have found executive dysfunction in HD, but no clear pattern has emerged. One potential reason for discrepant results in previous studies might be the inclusion of patients on psychotropic and other medications that can affect neurocognitive performance. Therefore, we examined neurocognitive functioning in medication-free HD patients. We also added a novel investigation of implicit learning, which has been found to be abnormal in obsessive-compulsive disorder (OCD) and related disorders.

METHOD

Twenty-six participants meeting the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnostic criteria for HD and 23 normal controls were administered a battery of neuropsychological tests and symptom rating scales. All participants were free of psychotropic medications for at least 6 weeks prior to the study.

RESULTS

HD participants showed no significant differences from normal controls on measures of verbal memory, attention, or executive functioning, including response inhibition, planning, organization, and decision making. However, HD participants demonstrated a trend toward less implicit learning and greater use of explicit learning strategies during perceptual categorization compared to normal controls. HD participants who used an implicit strategy performed significantly worse than controls who used an implicit strategy. Hoarding symptom severity was not associated with neurocognitive performance.

CONCLUSIONS

HD patients may have a tendency to use explicit rather than implicit learning strategies for perceptual categorization but perform as well as normal controls on many other neurocognitive measures. Future studies should assess unmedicated participants and examine test strategies, not just outcomes.

Predictors of hoarding severity in older adults with hoarding disorder

BACKGROUND

The recent addition of hoarding disorder (HD) to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition, has highlighted the dearth of information about the demographic, sociologic, and medical predictors of HD severity, particularly in older adults. Although there have been several previous studies examining the characteristics of older adults with HD, and one investigation of psychiatric correlates of hoarding symptom severity in non-clinical older adults, there has been little investigation about which characteristics predict hoarding symptom severity in older adults with HD.

METHODS

Participants were 71 older adults who were enrolled for one of the two studies of HD at the VA San Diego Healthcare System between January 2010 and January 2014.

RESULTS

There were multiple differences in the predictive ability of patient characteristics between the more cognition-related symptoms of HD and the more concrete measure of clutter, including gender-based differences and anxiety severity. Further, married participants were more likely to report lower hoarding severity, and there was no significant relationship between hoarding severity and intervention attempts or hoarding and reported falls in the past three years.

CONCLUSIONS

Multiple predictive factors have been presented, which may result in further studies to investigate possible predictive differences in cognition and clutter symptoms of HD. Future studies should examine the possibility of the predictive factors also identified to be moderators of treatment outcomes.

Validation of the Clutter Image Rating in older adults with hoarding disorder

BACKGROUND

The Clutter Image Rating (CIR) was created to meet a gap in the research on compulsive hoarding: how to ascertain clutter level in an individual's home without a home visit, as not all clinicians have the ability to conduct a home visit. The CIR has proven itself to be both reliable and valid for use in adults with compulsive hoarding symptoms. However, there is currently a dearth of information on performance of the CIR in older adults diagnosed with hoarding disorder (HD). Because older adults have increased medical issues, including fall risks, evaluating the level of clutter in the house is especially critical in geriatric populations.

METHOD

The current study was an investigation of the reliability and validity of the CIR in assessing late life HD. The internal consistency, convergent and divergent validity, and norms of the CIR were investigated in a large geriatric HD sample and compared with a midlife sample of individuals with HD. Criterion validity of the CIR was investigated through the comparison of participant ratings conducted in the clinic and clinician ratings conducted in the home.

RESULTS

The current study found similar levels of reliability and validity in a late life sample as in previous studies conducted in mid-life adults.

CONCLUSIONS

Unlike previous studies, the current study did not find a significant relationship between the CIR and the non-clutter related subscales of the Savings Inventory-Revised. The CIR appears to be both reliable and valid for assessing clutter levels in older adults diagnosed with HD.

The UCLA Hoarding Severity Scale: development and validation

BACKGROUND

Effective management of Hoarding Disorder (HD) must begin with assessment of the severity of hoarding symptoms and functional impairment. We sought to validate the UCLA Hoarding Severity Scale (UHSS), a semi-structured, clinician-administered rating scale that measures the severity of both the core symptoms of HD and the associated features of indecisiveness, perfectionism, task prolongation, and procrastination, which are significantly associated with the diagnosis and impairment of HD.

METHODS

Hoarding symptom severity was measured in 62 patients who met DSM-5 diagnostic criteria for HD and 65 normal controls, using the UHSS and the Saving Inventory-Revised (SI-R), a well validated self-report measure of hoarding symptoms.

RESULTS

The UHSS showed significant internal consistency (Cronbach׳s α=.70). Principal components analysis revealed three factors that accounted for 58% of the variance: 1) associated features and functional impairment, 2) clutter volume and social impairment, and 3) difficulty discarding, urges to save, and excessive acquisition. UHSS and SI-R scores were significantly correlated. UHSS and SI-R total and factor scores of HD patients were all significantly different from those of controls.

LIMITATIONS

Inter-rater and test-retest reliability were not assessed. The initial version of the UHSS did not contain rater instructions, so it lacked quantifiable anchor points for ratings.

CONCLUSIONS

The UHSS showed internal consistency, construct validity, convergent validity, and known groups discriminant validity. The UHSS validly measures the core symptoms, associated features, and functional impairment of patients with HD. Utilizing a valid clinician-administered scale will provide a more comprehensive and accurate clinical assessment of patients with HD.

A study of poor insight in social anxiety disorder

We investigated levels of insight among patients with Social Anxiety Disorder (SAD) as compared to patients with Obsessive-Compulsive Disorder (OCD) and evaluated whether levels of insight in SAD were related to specific sociodemographic and/or clinical features. Thirty-seven SAD patients and 51 OCD patients attending a tertiary obsessive-compulsive and anxiety disorders clinic were assessed with a sociodemographic and clinical questionnaire, a structured diagnostic interview, the Brown Assessment of Beliefs Scale (BABS), the Social Phobia Inventory (SPIN), the Beck Depression Inventory (BDI), the Sheehan Disability Scale (SDS), and the Treatment Adherence Survey-patient version (TAS-P). According to the BABS, SAD patients exhibited insight levels that were as low as those exhibited by OCD patients, with up to 29.7% of them being described as "poor insight" SAD. Although poor insight SAD patients were more frequently married, less depressed and displayed a statistical trend towards greater rates of early drop-out from cognitive-behavioral therapy, their insight levels were not associated with other variables of interest, including sex, age, employment, age at onset, duration of illness, associated psychiatric disorders, SPIN and SDS scores. Patients with poor insight SAD might perceive their symptoms as being less distressful and thus report fewer depressive symptoms and high rates of treatment non-adherence.

Venlafaxine extended-release treatment of hoarding disorder

Hoarding disorder, classified as a separate disorder in Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), is a common, chronic, and potentially disabling syndrome that can be difficult to treat. Only one previous study prospectively measured response to pharmacotherapy in compulsive hoarders, finding that hoarders responded as well to paroxetine as did nonhoarding obsessive-compulsive disorder patients. However, paroxetine was not tolerated well in that study, and the overall response was moderate. Therefore, we conducted an open-label trial of venlafaxine extended-release for hoarding disorder. Twenty-four patients fulfilling the DSM-5 criteria for hoarding disorder were treated with venlafaxine extended-release for 12 weeks. All patients were free of psychotropic medications for at least 6 weeks before the study. No other psychotropic medications, cognitive-behavioral therapy, organizers, or cleaning crews were permitted during the study. To measure the severity of hoarding, the Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were administered before and after treatment. Twenty-three of the 24 patients completed treatment. Hoarding symptoms improved significantly, with a mean 36% decrease in UHSS scores and a mean 32% decrease in SI-R scores. Sixteen of the 23 completers (70%) were classified as responders to venlafaxine extended-release. These results suggest that venlafaxine extended-release may be effective for the treatment of hoarding disorder.

Empowering families to help a loved one with Hoarding Disorder: pilot study of Family-As-Motivators training

Individuals with Hoarding Disorder (HD)-a dangerous problem and public health concern-are often ambivalent about treatment. Furthermore, family members of those with HD report high levels of distress and often attempt to intervene unsuccessfully. The current study reports outcome data from a pilot study of a new training package-designed exclusively for empowering family members to address a loved one's treatment ambivalence-called Family-As-Motivators (FAM) training. Nine family members of a loved one with HD initiated 14 sessions of FAM Training and were measured at pre-, mid-, and post-training on a comprehensive outcome battery. Results over the course of training suggested that family members improved in the use of certain coping strategies and in the application of motivational interviewing techniques. They also exhibited increased hopefulness, reported a reduced negative impact of HD on the family, rated a reduction in family accommodation of HD behaviors, and displayed boosts in HD and motivational interviewing knowledge. According to participants who completed the program, FAM Training was rated as highly acceptable. Although only preliminary, the current pilot study suggests that FAM Training is palatable for participants and shows promise for improving the lives of family members of those with HD.

Caregiver burden, family accommodation, health, and well-being in relatives of individuals with hoarding disorder

BACKGROUND

Hoarding Disorder (HD), a new diagnostic entity in DSM-5, is associated with substantial functional impairment and family frustration but data from well-characterized samples is lacking.

METHOD

Participants were 37 individuals meeting DSM-5 criteria for HD, 55 relatives of individuals meeting criteria for HD, and comparison groups of 51 self-identified collectors and 25 relatives of collectors. All participants completed a clinician-administered diagnostic interview for HD and an online battery of standardized measures of health, well-being, and impairment.

RESULTS

Substantial functional impairment was found for both HD individuals and their relatives. HD relatives reported significantly greater carer burden and accommodation of hoarding behaviors than relatives of collectors. Perceived level of squalor, co-habiting with, and increasing age of the HD individual were significant predictors of carer burden and functional impairment in the relatives.

LIMITATIONS

The use of self-identified HD individuals may have produced a bias towards participants with relatively good insight. Subjective biases in self-reported symptoms cannot be ruled out, although the use of informant-report data provided some independent validation.

CONCLUSIONS

HD is associated with substantial functional impairment for both sufferers and their relatives. The level of carer burden experienced by HD relatives was comparable to or greater than that reported in the literature by relatives of individuals with dementia. The findings indicate that relatives of individuals with HD may benefit from increased support and suggest that it may be beneficial to involve family members in the treatment of HD.