Neighborhood experience and hoarding disorder.

Is Compulsive Hoarding a Genetically and Neurobiologically Discrete Syndrome? Implications for Diagnostic Classification

Although standard diagnostic classifications consider obsessive-compulsive disorder (OCD) to be a single diagnostic entity, it has become clear that it is a heterogeneous disorder, with great variability in clinical presentation. This heterogeneity has complicated the interpretation of clinical, neurobiological, and genetic studies in OCD. Therefore, researchers have sought to identify clinically meaningful phenotypes that might be more homogeneous and heritable to facilitate our understanding of the etiology and pathophysiology of OCD and ultimately lead to improved treatments (1). Factor analytic studies have consistently identified four principal OCD symptom dimensions: 1) harm-related, aggressive, sexual, and religious obsessions with checking compulsions; 2) symmetry obsessions with arranging and repeating compulsions; 3) contamination obsessions with cleaning compulsions; and 4) hoarding and saving symptoms (1, 2). These symptom factors are relatively stable over time and show different patterns of genetic inheritance, age at onset, comorbidity, and treatment response (see 1 for review). Cluster analyses, which seek to identify mutually exclusive, categorical subgroups, indicate that some of these symptom factors, such as hoarding, may constitute discrete subtypes of OCD (3, 4). Hoarding is defined as the acquisition of and inability to discard items, even though they appear (to others) to have no value (5). Hoarding behavior has been observed in several neuropsychiatric disorders, including schizophrenia, dementia, eating disorders, autism, and mental retardation, as well as in non-clinical populations, but it is most commonly found in OCD (6). 30% to 40% of OCD patients report hoarding and saving symptoms (6–8), and about 10% to 15% have hoarding as their most prominent symptom factor (3, 6). Compulsive hoarding is most commonly driven by obsessional fears of losing important items that the patient believes will be needed later, distorted beliefs about the importance of possessions, excessive acquisition, and exaggerated emotional attachments to possessions (5). Compulsive hoarding and saving leads to clutter that can cover living and work spaces, rendering them unusable. Hoarding frequently causes significant impairment in social and occupational functioning. In severe cases, it can produce health risks from infestations, falls, fires, and inability to cook or eat in the home (6). In this issue of the Journal, Jack Samuels, Ph.D., et al. report results from the OCD Collaborative Genetics Study, finding “suggestive” linkage of compulsive hoarding to a marker on chromosome 14 in families with OCD. The linkage became stronger when only families with two or more family members with compulsive hoarding were tested. Compulsive hoarding is well known to run in families. Hoarding behaviors are significantly more prevalent in the relatives of hoarding OCD patients than nonhoarding OCD patients (9). In the OCD Collaborative Genetics Study, hoarding was the most strongly familial of the OCD symptom factors, with robust correlations among sibling pairs (10). Only two previous genetic studies have examined the hoarding phenotype. Lochner et al. (8) found that the met/met (L/L) genotype of the catechol O-methyltransferase val158met polymorphism on chromosome 22q11 was significantly more prevalent in Afrikaner OCD patients with

Although standard diagnostic classifications consider obsessive-compulsive disorder (OCD) to be a single diagnostic entity, it has become clear that it is a heterogeneous disorder, with great variability in clinical presentation. This heterogeneity has complicated the interpretation of clinical, neurobiological, and genetic studies in OCD. Therefore, researchers have sought to identify clinically meaningful phenotypes that might be more homogeneous and heritable to facilitate our understanding of the etiology and pathophysiology of OCD and ultimately lead to improved treatments (1). Factor analytic studies have consistently identified four principal OCD symptom dimensions: 1) harm-related, aggressive, sexual, and religious obsessions with checking compulsions; 2) symmetry obsessions with arranging and repeating compulsions; 3) contamination obsessions with cleaning compulsions; and 4) hoarding and saving symptoms (1, 2). These symptom factors are relatively stable over time and show different patterns of genetic inheritance, age at onset, comorbidity, and treatment response (see 1 for review). Cluster analyses, which seek to identify mutually exclusive, categorical subgroups, indicate that some of these symptom factors, such as hoarding, may constitute discrete subtypes of OCD (3, 4). Hoarding is defined as the acquisition of and inability to discard items, even though they appear (to others) to have no value (5). Hoarding behavior has been observed in several neuropsychiatric disorders, including schizophrenia, dementia, eating disorders, autism, and mental retardation, as well as in non-clinical populations, but it is most commonly found in OCD (6). 30% to 40% of OCD patients report hoarding and saving symptoms (6–8), and about 10% to 15% have hoarding as their most prominent symptom factor (3, 6). Compulsive hoarding is most commonly driven by obsessional fears of losing important items that the patient believes will be needed later, distorted beliefs about the importance of possessions, excessive acquisition, and exaggerated emotional attachments to possessions (5). Compulsive hoarding and saving leads to clutter that can cover living and work spaces, rendering them unusable. Hoarding frequently causes significant impairment in social and occupational functioning. In severe cases, it can produce health risks from infestations, falls, fires, and inability to cook or eat in the home (6). In this issue of the Journal, Jack Samuels, Ph.D., et al. report results from the OCD Collaborative Genetics Study, finding “suggestive” linkage of compulsive hoarding to a marker on chromosome 14 in families with OCD. The linkage became stronger when only families with two or more family members with compulsive hoarding were tested. Compulsive hoarding is well known to run in families. Hoarding behaviors are significantly more prevalent in the relatives of hoarding OCD patients than nonhoarding OCD patients (9). In the OCD Collaborative Genetics Study, hoarding was the most strongly familial of the OCD symptom factors, with robust correlations among sibling pairs (10). Only two previous genetic studies have examined the hoarding phenotype. Lochner et al. (8) found that the met/met (L/L) genotype of the catechol O-methyltransferase val158met polymorphism on chromosome 22q11 was significantly more prevalent in Afrikaner OCD patients with

Compulsive hoarding is a debilitating problem that is often associated with obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder. However, the precise nosology of compulsive hoarding has yet to be determined. Participants were 25 patients with severe compulsive hoarding with OCD and 27 patients with severe compulsive hoarding without OCD. Both groups were carefully characterized and compared on the following sociodemographic and clinical variables: precise phenomenology of hoarding behavior, severity of other OCD symptoms, axis I and axis II psychopathology, and adaptive functioning. For comparison purposes, the following individuals were also recruited: 71 patients with OCD without hoarding, 19 patients with anxiety disorder, and 21 community participants. Overall, the phenomenology of hoarding behavior was similar in the two hoarding groups. The majority of participants in both groups reported hoarding common items as a result of their emotional and/or intrinsic value. However, approximately one-fourth of participants in the compulsive hoarding with OCD group showed a different psychopathological profile, which was characterized by the hoarding of bizarre items and the presence of other obsessions and compulsions related to their hoarding, such as fear of catastrophic consequences, the need to perform checking rituals, and the need to perform mental compulsions before discarding any item. These patients had a more severe and disabling form of the disorder. The strong relationship between compulsive hoarding and obsessive-compulsive personality disorder was explained entirely by the overlapping item content. In most individuals, compulsive hoarding appears to be a syndrome separate from OCD, which is associated with substantial levels of disability and social isolation. However, in other individuals, compulsive hoarding may be considered a symptom of OCD and has unique clinical features. These findings have implications for the classification of OCD and compulsive hoarding in the next edition of DSM.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessHoarding Disorder Data Suggest It's Not OCD SubtypeLeslie SinclairLeslie SinclairSearch for more papers by this authorPublished Online:21 Oct 2011https://doi.org/10.1176/pn.46.20.psychnews_46_20_18_2AbstractIs compulsive hoarding a component of obsessive-compulsive disorder (OCD) or something else entirely? That's one of the questions being considered by DSM-5 Task Force members as they move toward publication of the manual's next edition in May 2013. The DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group conducted a focused review of the literature on compulsive hoarding (published in the June 2010 Depression and Anxiety) and recommended the classification of hoarding disorder (HD) as a separate entity, although the group is still examining the evidence as to whether inclusion is merited in the main manual or in the "Appendix for Further Research." Their publication includes working diagnostic criteria for compulsive hoarding and mentions several clinician and self-administered measures that have been developed to reflect these criteria and are widely used in the field. They include the Saving Inventory-Revised, the Hoarding Rating Scale, and the UCLA Hoarding Severity Scale. Randy Frost, Ph.D., a professor of psychology at Smith College in Northampton, Mass., and colleagues have recently characterized HD by examining comorbidities associated with the disorder, making HD appear even less as simply a subtype of OCD or even of obsessive-compulsive personality disorder. Researchers at Smith College in Northampton, Mass., said they are "experimenting with highly structured support groups for hoarding disorder, facilitated by peers, and having some success."Credit: Shadwwulf at en.wikipediaFrost and colleagues recruited participants with "a large amount of clutter, trouble using rooms in the home, or difficulty throwing things away" from health and mental health clinic settings, newspaper and information Web sites, and investigator media appearances. They then evaluated psychiatric comorbidity in a sample of 217 people who met the diagnostic criteria for HD outlined by the work group and compared that cohort with data for 96 participants meeting criteria for OCD without HD. Relatively few HD-diagnosed participants were diagnosed with OCD. Other disorders, including major depressive disorder (MDD), generalized anxiety disorder, and social phobia were more frequent among HD subjects than were OCD cases. MDD was the most frequent comorbid condition among HD patients, with more than half the sample receiving that diagnosis. Inattentive attention-deficit/hyperactivity disorder was significantly more frequent in HD than in OCD, evident in nearly 30 percent of HD participants. Doesn't Appear to Be OCD Subtype"This finding accords with recent research suggesting that hoarding is not a subtype of OCD, but instead a distinct condition related to a variety of disorders," Frost and colleagues wrote. Frost told Psychiatric News that these findings open the way for further research of HD: "We are working on a host of new studies, some having to do with the phenomenology of HD, and some having to do with interventions. For example, we are doing some basic research on the process of acquiring. How are decisions about acquiring being made, and what features are associated with those decisions? Exactly how does the process of discarding things go awry? Many people with hoarding disorder try to discard, but are unsuccessful. What gets in their way?" Animal Hoarding Also StudiedIn a separate report in the June 2010 Depression and Anxiety, Frost and Gary Patronek, V.M.D., Ph.D., a clinical assistant professor at the Cummings School of Veterinary Medicine at Tufts University, presented a comparison of object and animal hoarding. They examined the ways in which people who hoard animals differ from people who hoard objects. "Because of the dissimilarities, inclusion of a description of animal hoarding in the text accompanying the diagnostic criteria in DSM-5 may be needed to clarify whether it should be considered as a separate subtype or hoarding disorder," they noted. "Basic studies of animal hoarding, comorbidity, neural substrates, information-processing deficits, and family features are all sorely needed." Frost explained that a problem with studying animal hoarding is that few sufferers voluntarily seek treatment, and few volunteer to be study participants. "This is slowly changing as researchers learn how to find and successfully recruit these individuals for study," said Frost, who believes there will be many more researchers studying HD and animal hoarding once the DSM-5 is published. The research was funded by grants from the National Institute of Mental Health and research funding from Organon/Merck, Endo Pharmaceuticals, and Eli Lilly. An abstract of "Hoarding Disorder: A New Diagnosis forDSM-V?" is posted at <www.ncbi.nlm.nih.gov/pubmed/20336805>. An abstract of "Comorbidity in Hoarding Disorder" is posted at <www.ncbi.nlm.nih.gov/pubmed/21770000>. An abstract of "Comparison of Object and Animal Hoarding" is posted at <www.ncbi.nlm.nih.gov/pubmed/21608085>. ISSUES NewArchived

Treatment of obsessive compulsive disorder: Steketee, Gail New York: Guilford Press (1993), 224 pp

Hoarding disorder (HD), characterized by difficulty parting with possessions and functionally impairing clutter, affects 2–6% of the population. Originally considered part of Obsessive-Compulsive Disorder (OCD), HD became a distinct diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. While sleep impacts OCD, little is known about sleep in HD. As HD patients often report poor sleep in clinical settings, understanding global subjective sleep quality and disturbances may lead to novel therapeutic targets. To address this gap, the authors used a sample of convenience: an existing data set designed to screen research study eligibility and explore the psychopathology and phenomenology of OCD and HD. The data set included information collected from individuals with HD (n = 38), OCD (n = 26), and healthy participants (n = 22) about insomnia, sleep quality, and mood using interviews and structured instruments including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Depression Anxiety Stress Scales (DASS). In this data set, HD and OCD groups reported significantly greater insomnia symptoms and poorer sleep quality compared with healthy controls while controlling for depression, age, and gender. A sizable minority of HD and OCD individuals met criteria for comorbid sleep disorders. OCD and HD groups differed in delayed sleep phase prevalence. To our knowledge, this is the first study examining subjective sleep quality and insomnia in HD as compared to healthy individuals and those with OCD, while controlling for relevant clinical characteristics. Given that there are evidence-based treatments for insomnia and other sleep disorders, our study raises the possibility that treatment interventions targeting sleep may improve HD outcomes.

Hoarding Disorder (HD) is a new category of Obsessive-Compulsive Spectrum Disorder (OCSD). Developing research has provided assessment, phenomenological, and cognitive-behavioral evidence for the independent diagnosis of HD from Obsessive-Compulsive Disorder (OCD). Meanwhile, HD was also found to be comorbid with various other mental disorders with significant impairments for its externality. The paper has reviewed several comorbidity research about HD, aiming to generalize the prevalence and duration of comorbidity disorders in HD conditions. In addition, this paper has also tentatively introduced the concept of compensatory mechanism to interpret the reasons for comorbid conditions in HD, especially the acquisition of specific beliefs or emotional attachments where some Personality Disorders could also form. In conclusion, Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD) are most likely comorbid with HD, whereas posttraumatic stress disorder (PTSD) and Obsessive-Compulsive Personality Disorder (OCPD) might be absent after arguing. Impulse Control Disorder (ICD) could supersede a certain stage of HD with the absence of psychological compensation. Attention Deficit Hyperactive Disorder (ADHD) could also be comorbid with HD on a neurological basis, it could however not conclude that the compensation functions and require further investigation. Based on summarizing and assessing comorbidity disorders in HD, the present paper has provided recommendations for future research development and optimization of therapies.

Back to table of contents previous chapternext chapter No AccessChapter 12.Anxiety, Obsessive-Compulsive, and Trauma-Related DisordersEdited by:https://doi.org/10.1176/appi.books.9781615375196.ds12AboutSectionsView chapterExcerptView Full Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View chapterSectionsEpidemiology | Fear, Phobias, and Panic | Obsessive-Compulsive Disorder | Hoarding Disorder | PTSD and Acute Stress Disorder | Anxiety in Comorbid Medical Illness | Anxiety and Late-Life Depression | Neurobiological and Neuropsychological Findings | Anxiety and Related Disorders in the Context of Neurocognitive Impairment | Assessment Instruments for Anxiety in Older Adults | Treatment of Late-Life Anxiety Disorders | Conclusion | ReferencesExcerptDevelopments in clinical neuroscience have resulted in a rapid expansion in how brain disorders are understood. Included in this seemingly exponential growth in knowledge is a deepening insight into the biology and clinical phenotypes inherent to late-life neuropsychiatric syndromes. This chapter explores a subset of these syndromes: anxiety, obsessive-compulsive, and trauma-related disorders in older adults. Important to highlight in the beginning is a shift in how these three entities are now conceptualized, which is in part due to advances in basic and translational neuroscience. With the publication of DSM-5 (American Psychiatric Association 2013), trauma-related and obsessive-compulsive disorders were given their own respective sections, acknowledging that, although all three most assuredly contain some facet of anxious symptomatology, several key features warrant their being separated. Doing so allows for more valid diagnostic constructs, lessens heterogeneity in clinical research, and is more in line with neuronal network dysfunction corresponding to illness presentations. By characterizing the relevant epidemiology, biological underpinnings, clinical phenomenology, and evidence-based treatments, this chapter summarizes the current state of the field. Access content To read the fulltext, please use one of the options below to sign in or purchase access. Institutional Login Sign in via OpenAthens Please login/register if you wish to pair your device and check access availability. Not a subscriber? Subscribe Now / Learn More PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development. Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.). FiguresReferencesCited byDetailsCited byNone The American Psychiatric Association Publishing Textbook of Geriatric Psychiatry Information©American Psychiatric Association Publishing History Published online 8 January 2023 Published in print 9 August 2022

Cognitive functioning in compulsive hoarding

IntroductionThere is suggestive evidence linking hoarding with several problems in emotional regulation, and though this is shared with OCD patients, it may not correlate to the presence of obsessive symptoms.ObjectivesThe present study aimed to examine self-reported deficits in emotion regulation (ER) and obsessiveness among individuals with hoarding disorder (HD) in comparison with others with obsessive compulsive disorder (OCD) and healthy controlsMethodsTwenty-two adult outpatients with HD, twenty-two with OCD and twenty-two age and gender matched healthy control (HC) participants completed the Emotion Regulation Questionnaire (ERQ) which measures respondents tendency to regulate their emotions in two ways: Cognitive Reappraisal and Expressive Suppression. They fulfilled as well the OCI-R which evaluates six groups of OCD symptoms: Washing, Checking, Ordering, Obsessing, Hoarding, and Neutralizing.ResultsThe HD and OCD groups scored higher, (p 0.04), on Cognitive Reappraisal than did the HC group. There was no significant difference between groups in Expressive Suppression. HD and HC groups scored significantly lower, (p &lt; 0.001), in OCI-R than OCD patients.ConclusionsResults suggest that OCD and HD are characterized by self-reported deficits in ER, but this relationship in HD patients is not solely attributable to obsessive symptoms.

Summary: Hoarding disorder, newly included as a separate diagnostic entity in the Obsessive-Compulsive and Related Disorders section of DSM-5, has been reported to have significantly different symptoms and etiology than obsessive-compulsive disorder (OCD). However, the validity of this new diagnosis in China - where the storing of possessions is sanctioned and normalized - remains to be proven. We considered available data about pathological hoarding in East Asia and found the condition to be relatively common and symptomatically similar to that reported in western countries. We conclude that the 'Hoarding Disorder' diagnosis defined in DSM-5 is a valid clinical entity in China, though when making the diagnosis clinicians must take care to differentiate pathological hoarding that is distressing to the individual and significantly interferes with social and occupational functioning from culturally sanctioned thriftiness that is not associated with either distress or social dysfunction.

Hoarding disorder (HD), previously considered a subtype of obsessive-compulsive disorder (OCD), has been proposed as a unique diagnostic entity in DSM-5. Current models of HD emphasize problems of decision-making, attachment to possessions, and poor insight, whereas previous neuroimaging studies have suggested abnormalities in frontal brain regions. To examine the neural mechanisms of impaired decision making in HD in patients with well-defined primary HD compared with patients with OCD and healthy control subjects (HCs). We compared neural activity among patients with HD, patients with OCD, and HCs during decisions to keep or discard personal possessions and control possessions from November 9, 2006, to August 13, 2010. Private, not-for-profit hospital. A total of 107 adults (43 with HD, 31 with OCD, and 33 HCs). Neural activity as measured by functional magnetic resonance imaging in which actual real-time and binding decisions had to be made about whether to keep or discard possessions. Compared with participants with OCD and HC, participants with HD exhibited abnormal activity in the anterior cingulate cortex and insula that was stimulus dependent. Specifically, when deciding about items that did not belong to them, patients with HD showed relatively lower activity in these brain regions. However, when deciding about items that belonged to them, these regions showed excessive functional magnetic resonance imaging signals compared with the other 2 groups. These differences in neural function correlated significantly with hoarding severity and self-ratings of indecisiveness and "not just right" feelings among patients with HD and were unattributable to OCD or depressive symptoms. Findings suggest a biphasic abnormality in anterior cingulate cortex and insula function in patients with HD related to problems in identifying the emotional significance of a stimulus, generating appropriate emotional response, or regulating affective state during decision making.

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.

Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM-5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large-scale study of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures. We compared psychiatric comorbidity in a large HD sample (n = 217) to 96 participants meeting criteria for OCD without HD. High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition-related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition-related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%). These findings form important base rates for developing research and treatments for hoarding disorder.