Pathophysiology and treatment of hoarding disorder

"Falling between the cracks": Investigating the competing challenges experienced by professionals working with people who hoard

Hoarding disorder is characterised by both the distress associated with discarding and the resulting accumulation of possessions that clutter the home environment, and represents a substantial public health and social problem, requiring an effective multi-agency response. Although a recognised psychiatric condition since 2013, hoarding disorder is under-recognised within mental health treatment provision, and evidence-based treatment pathways are lacking. This study aimed to explore multi-agency working in practice and similarities and differences in how hoarding support is perceived across a broad range of front-line professionals. 35 semi-structured interviews representing a wide range of services from health, social care, housing, and the voluntary sector were conducted and analysed thematically. Three overarching themes are reported: Unique challenges of supporting people who hoard, Conflicting needs of client vs. needs of the organisation, Managing role boundaries and psychological tensions. Findings consistently highlight the challenges specific to these cases. However, they also point to a lack of consensus between professional groups in terms of perceived problems and risks to be addressed. Collaborating effectively with others to meet the psychological needs of clients while ensuring risk mitigation and addressing broader organisational, environmental, and community concerns was found to be a key challenge and associated with often going beyond designated role boundaries to support the person. Our findings point to a need for greater support and training of a diverse set of professionals in psychological models of people who hoard to enhance knowledge, awareness, and confidence of the psychological dimensions of hoarding disorder, and to support them in feeling more emotionally and practically prepared. The results indicate a need for greater integration of mental health measures in the assessment of hoarding cases, and to ensure adequate care pathways with dedicated psychological support along with assignment of case workers/coordination.

Spontaneous activity and functional connectivity in patients with hoarding disorder comorbid with attention-deficit/hyperactive disorder

Despite recent studies suggesting an important association of hoarder disorder (HD) and attention-deficit/hyperactive disorder (ADHD), no neuroimaging study has investigated the differences between patients with HD comorbid with ADHD and those without ADHD. This study investigated the regional spontaneous activity and functional connectivity in HD, focusing on the comorbidity with ADHD. Resting-state functional magnetic resonance imaging (MRI) data were obtained from 24 patients with HD and 31 healthy individuals. We investigated the group differences using the fractional amplitude of low-frequency fluctuation (fALFF). The altered regions in the fALFF were used as seeds in a functional connectivity analysis where we conducted group comparisons among the three groups: healthy controls (HCs), HD with ADHD (HD +ADHD), and HD without ADHD (HD -ADHD). Compared to HCs, patients with HD had a reduced fALFF in the right inferior frontal gyrus (IFG). Functional connectivity analysis revealed that patients with HD + ADHD had reduced functional connectivity between the IFG and dorsolateral prefrontal cortex (DLPFC) compared to HCs, while the HD -ADHD group was intermediate level between HD +ADHD and HCs groups. In conclusion, patients with HD have altered spontaneous activity of the IFG. Additionally, patients with HD + ADHD had significantly reduced functional connectivity between the IFG and the DLPFC. Our findings suggest the potential need to distinguish between subgroups of HD+ADHD to identify novel neurobiological models of HD that could guide future therapeutic strategies.

Environmental enrichment attenuates maternal separation-induced excessive hoarding behavior in adult female mice

BACKGROUND

Previous studies have demonstrated that early life stress (ELS) impacts hoarding behavior in adult humans. This study aimed to assess the potential mitigation by environmental enrichment on hoarding behavior in rodents caused by maternal separation, thereby providing insights into therapeutic strategies for hoarding disorder.

METHODS

Newborn mice were randomly divided into four groups. The control group was allowed to grow naturally. The maternal separation group underwent two weeks of maternal separation. The short-term environmental enrichment group received two weeks of environmental enrichment intervention after the two weeks of maternal separation. The long-term environmental enrichment group received five weeks of environmental enrichment intervention after the two weeks of maternal separation. Hoarding behavior was assessed during adolescence and adulthood. Hippocampal tissue from adult female mice was analyzed using LC-MS/MS-based metabolomics. Spearman correlation analysis was then performed to assess the relationship between differentially expressed metabolites and hoarding behavior.

RESULTS

Environmental enrichment attenuates maternal separation-induced excessive hoarding behavior in adult female mice. The untargeted metabolomics of the hippocampal region in female mice showed that long-term environmental enrichment reversed multiple differential metabolites, including Substance P, which were mainly concentrated in metabolic pathways such as cancer choline metabolism, glycolipid metabolism, and linoleic acid metabolism.

CONCLUSIONS

Our findings indicate that ELS and long-term environmental enrichment have sex-dependent effects on adult hoarding behavior, potentially related to altered hippocampal metabolism. This study highlights the importance of environmental enrichment in mitigating the long-term effects of early maternal separation on hoarding behavior.

Reduced resting-state functional connectivity between insula and inferior frontal gyrus and superior temporal gyrus in hoarding disorder

Background

Hoarding disorder (HD) is characterized by cognitive control impairments and abnormal brain activity in the insula and anterior cingulate cortex (ACC) during disposal of personal items or certain executive function tasks. However, whether there are any changes in resting-state functional connectivity of the insula and ACC remains unclear.

Methods

A total of 55 subjects, including 24 patients with HD and 31 healthy controls (HCs), participated in the study. We acquired resting-state functional magnetic resonance imaging data and examined group differences in functional connectivity from the insula and ACC in whole-brain voxels.

Results

In patients with HD, functional connectivity was significantly lower between the right insula and right inferior frontal gyrus (IFG) and left superior temporal gyrus (STG) compared to HCs. There was no correlation between these connectivities and HD symptoms.

Conclusions

Although the clinical implication is uncertain, our results suggest that patients with HD have resting-state functional alterations between the insula and IFG and STG, corresponding with the results of previous fMRI studies. These findings provide new insight into the neurobiological basis of HD.

The Impact of Hoarding Disorder on Family Members, Especially the Significant Other

Hoarding disorder, also known as compulsive hoarding, comes under the umbrella term of obsessive-compulsive disorder and related disorders. The constant building of clutter in the house of hoarders makes it impossible for family members to live a healthy life. It can have appalling effects on their mental health and can lead to severe depression and suicidal ideation. The shame and humiliation attached to hoarding does not allow the hoarders to seek help, causing them distress and hence continuing the vicious cycle of hoarding. By presenting the case of a patient with a spouse with a hoarding disorder, we want to bring to light the severity of the impact hoarding disorder can have on the partner and the grave need to spread awareness about it so that the patient or the family members can seek timely help.

Patients with Invisible Pain: How Might We See This Pain and Help These Patients More?

AbstractIn this piece I discuss two ways in which providers may become able to treat patients better. The first is for them to encourage all medical parties, including medical students, to always speak up. The second is to take initiatives to learn of pain that patients feel but neither show nor spontaneously report. They may refer to this pain as invisible pain, often bitterly, in that others not seeing their pain judge them wrongly and harshly. Providers, once seeing this pain, are encouraged to then take additional measures to try to alleviate it. Clinical examples provided to illustrate the range of treatments providers may add are post-traumatic stress disorders, problems involving substance use, and hoarding disorders. Similar concerns regarding people who are deaf and hard of hearing are also addressed.

Abnormal white matter structure in hoarding disorder

Although preliminary neuroimaging research suggests that patients with hoarding disorder (HD) show widespread abnormal task-related activity in the brain, there has been no research on alterations in the white matter tracts in these patients. The aim of this study was to investigate the characteristics of the major white matter tracts in patients with HD. Tract-based spatial statistics were used to search for white matter tract abnormalities throughout the brain in 25 patients with HD and 36 healthy controls. Post hoc analysis of regions of interest was performed to detect correlations with clinical features. Compared with the controls, patients with HD showed decreased fractional anisotropy and increased radial diffusivity in anatomically widespread white matter tracts. Post hoc analysis of regions of interest revealed a significant negative correlation between the severity of hoarding symptoms and fractional anisotropy in the left anterior limb of the internal capsule and a positive correlation between the severity of these symptoms and radial diffusivity in the right anterior thalamic radiation. Patients with HD showed a broad range of alterations in the frontal white matter tracts, including the frontothalamic circuit, frontoparietal network, and frontolimbic pathway. The findings of this study indicate associations between frontal white matter abnormalities related to the severity of hoarding symptoms in HD and the cortical regions involved in cognitive dysfunction. The insights provided would be useful for understanding the neurobiological basis of HD.

A Biopsychosocial Approach to Understanding Panic Buying: Integrating Neurobiological, Attachment-Based, and Social-Anthropological Perspectives

The global COVID-19 pandemic has focused the attention of researchers, civil authority and the general public on the phenomenon of "panic buying," characterized by the excessive purchase of specific materials-particularly food and hygiene-related products-in anticipation of an expected shortage. This phenomenon has been well-documented in response to several natural and man-made disasters, but its global scope and severity in the context of COVID-19 are unprecedented. This response can negatively impact health, food security, and disease prevention efforts. Attempts to modify such behaviors are more likely to succeed if they are based on insights from both the biomedical and the social sciences. From a biological perspective, the phenomenological overlap between panic buying and psychological disorders such as hoarding disorder and compulsive buying raises the possibility of a shared neurobiological underpinning. Evolutionary models suggest that these behaviors represent an attempt to enhance individual and group survival in the face of a threatened scarcity of resources. These phenomena may be influenced by specific genetic variants which are also implicated in hoarding-related psychological disorders. From a psychological perspective, attachment theory provides a conceptual framework that serves as a bridge between prior life adversity, current deprivation, and an increased attachment to material objects. Such a framework is of relevance when considering panic buying during the COVID-19 pandemic, which has been associated with significant disruptions in attachment bonds. From a social-anthropological perspective, hoarding and related behaviors have been associated with social exclusion and rejection, as well a lack of social support. These risk factors have affected large sections of the general population in the context of the COVID-19 pandemic and the governmental responses to it. This perspective also emphasizes the symbolic significance of the hoarded objects themselves. In this paper, an attempt is made to integrate these three perspectives and thereby formulate a biopsychosocial model of panic buying in response to this global health crisis. The existing scientific literature on panic buying is examined in the light of this model. Finally, suggestions are proposed as to how this model might inform social strategies aimed at preventing or reducing panic buying.

Clinical characteristics of hoarding disorder in Japanese patients

Previous studies have reported clinical characteristics of hoarding disorder (HD), such as early onset, a chronic course, familiality, high unmarried rate, and high rates of comorbidities. However, clinical research targeting Japanese HD patients has been very limited. As a result, there is a low recognition of HD in Japan, leading to insufficient evaluation and treatment of Japanese HD patients.

The aim of the current study was to delineate the clinical characteristics of Japanese HD patients. Thirty HD patients, 20 obsessive-compulsive disorder (OCD) patients, and 21 normal controls (NC) were targeted in this study.

The HD group had a tendency toward higher familiality, earlier onset, and longer disease duration compared to the OCD group. In addition, the HD group showed a significantly higher unmarried rate than the NC group. The top two comorbidities in the HD group were major depressive disorder (56.7%) and attention-deficit/hyperactivity disorder (26.7%). The HD group had significantly higher scores on hoarding rating scales and lower scores on the Global Assessment of Functioning Scale than the other two groups.

The current study showed a clinical trend in Japanese HD patients similar to previous studies in various countries, suggesting that HD may be a universal disease with consistent clinical symptoms.