Hoarding in obsessive compulsive disorder: results from a case-control study

Recent advances in compulsive hoarding

Compulsive hoarding is a common and often disabling neuropsychiatric disorder. This article reviews the conceptualization, phenomenology, diagnosis, etiology, neurobiology, and treatment of compulsive hoarding. Compulsive hoarding is part of a discrete clinical syndrome that includes difficulty discarding, urges to save, excessive acquisition, indecisiveness, perfectionism, procrastination, disorganization, and avoidance. It was thought to be part of obsessive-compulsive disorder or obsessive-compulsive personality disorder, but recent evidence indicates that it should be classified as a separate disorder with its own diagnostic criteria. Compulsive hoarding is a genetically discrete, strongly heritable phenotype. Neuroimaging and neuropsychological studies are elucidating its neurobiology, implicating dysfunction of ventral and medial prefrontal cortical areas that mediate decision-making, attention, and emotional regulation. Effective treatments include pharmacotherapy and cognitive-behavioral therapy. More research will be required to determine the prevalence, etiology, and pathophysiology of compulsive hoarding and to develop better treatments.

Juvenile-onset OCD: clinical features in children, adolescents and adults

OBJECTIVE

To examine clinical correlates of juvenile-onset OCD across the lifespan.

METHOD

Data collected at the intake interview from 257 consecutive participants with juvenile-onset OCD (20 children, 44 adolescents and 193 adults) in a naturalistic study of the clinical course of OCD were examined. Participants and parents of juvenile participants completed a structured diagnostic interview, rater-administered severity measures and self-report questionnaires.

RESULTS

Children and adolescents (i.e. juveniles) shared similar features with the exception of age at onset and OCD symptom expression. Clinically meaningful differences between juvenile and adult participants were also found. Compared with adults, juveniles were more likely to be male, recall an earlier age at OCD onset and have different lifetime comorbidity patterns.

CONCLUSION

Juvenile-onset OCD symptom expression is remarkably similar across the lifespan. However, findings also suggest clinically meaningful differences between juveniles and adults. Future work using a prospective design will improve our understanding of course patterns of juvenile-onset OCD.

Genetic susceptibility to obsessive-compulsive hoarding: the contribution of neurotrophic tyrosine kinase receptor type 3 gene

Recent work suggests that neurotrophic factors may contribute to the genetic susceptibility to obsessive-compulsive disorder (OCD). Among other clinical dimensions, the presence of hoarding obsessions and compulsions has been shown to be correlated with a number of clinical and neuroimaging findings, as well as with a different pattern of genetic inheritance. We used a linkage disequilibrium (LD)-mapping approach to investigate whether neurotrophic tyrosine kinase receptor type 3 (NTRK3), the high-affinity receptor of neurotrophin 3 (NT-3), plays a role in increasing susceptibility to hoarding in OCD. We performed an association study of 52 tag single nucleotide polymorphisms (tagSNPs) covering the whole NTRK3 gene in a sample comprising 120 OCD patients and 342 controls. Single nucleotide polymorphism association and haplotype analysis were performed. Thirty-six of our patients (30%) exhibited significant hoarding obsessions and compulsions. A significant association of two SNPs in the 3' downstream region of NTRK3 gene and obsessive-compulsive hoarding was identified: rs1017412 [odds ratio (OR) = 2.16; P = 0.001] and rs7176429 (OR = 2.78; P = 0.0001), although only the latter remained significant after Bonferroni correction. Although the haplotype analysis did not show significant results, a more extended block of LD in the OCD hoarders with respect to the control group was observed, suggesting a lower haplotype diversity in these individuals. Our findings suggest that NTRK3 may contribute to the genetic susceptibility to hoarding in OCD and may constitute an interesting gene to focus on in studies of the genetic basis of obsessive-compulsive hoarding.

Further development of YBOCS dimensions in the OCD Collaborative Genetics study: symptoms vs. categories

Despite progress in identifying homogeneous subphenotypes of obsessive-compulsive disorder (OCD) through factor analysis of the Yale Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC), prior solutions have been limited by a reliance on presupposed symptom categories rather than discrete symptoms. Furthermore, there have been few attempts to evaluate the familiality of OCD symptom dimensions. The purpose of this study was to extend prior work by this collaborative group in category-based dimensions by conducting the first-ever exploratory dichotomous factor analysis using individual OCD symptoms, comparing these results to a refined category-level solution, and testing the familiality of derived factors. Participants were 485 adults in the six-site OCD Collaborative Genetics Study, diagnosed with lifetime OCD using semi-structured interviews. YBOCS-SC data were factor analyzed at both the individual item and symptom category levels. Factor score intraclass correlations were calculated using a subsample of 145 independent affected sib pairs. The item- and category-level factor analyses yielded nearly identical 5-factor solutions. While significant sib-sib associations were found for four of the five factors, Hoarding and Taboo Thoughts were the most robustly familial (r ICC>or=0.2). This report presents considerable converging evidence for a five-factor structural model of OCD symptoms, including separate factor analyses employing individual symptoms and symptom categories, as well as sibling concordance. The results support investigation of this multidimensional model in OCD genetic linkage studies.

Sex-specific clinical correlates of hoarding in obsessive-compulsive disorder

Little is known about whether the clinical correlates of hoarding behavior are different in men and women with obsessive-compulsive disorder (OCD). In the current study, we evaluated the association of hoarding with categories of obsessions and compulsions, psychiatric disorders, personality dimensions, and other clinical characteristics separately in 151 men and 358 women with OCD who were examined during the OCD Collaborative Genetics Study. We found that, among men but not women, hoarding was associated with aggressive, sexual, and religious obsessions and checking compulsions. In men, hoarding was associated with generalized anxiety disorder and tics whereas, among women, hoarding was associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, nail biting, and skin picking. In women but not men, hoarding was associated with schizotypal and dependent personality disorder dimensions, and with low conscientiousness. These findings indicate that specific clinical correlates of hoarding in OCD are different in men and women and may reflect sex-specific differences in the course, expression, and/or etiology of hoarding behavior in OCD.

The status of hoarding as a symptom of obsessive-compulsive disorder

Hoarding is considered by many to be a symptom of obsessive-compulsive disorder (OCD). Yet although it is observed in people with OCD, hoarding symptoms also appear in a number of other psychological and psychiatric conditions. The present studies were conducted using samples of OCD patients, patients with other anxiety disorders, and a non-clinical sample to further elucidate the relationship between hoarding and OCD. Across two investigations, we found that (a) whereas OCD patients had higher scores than the other groups on non-hoarding symptoms, this was not the case for hoarding symptoms; (b) hoarding tended to correlate more weakly with other OCD symptoms (e.g., washing, checking) than these other symptoms intercorrelated; (c) items measuring hoarding had the weakest factor loadings when a measure of OCD symptoms was submitted to factor analysis; (d) hoarding symptoms were not correlated with global OCD or anxiety severity, whereas other OCD symptoms were; and (e) hoarding did not show consistent relationships with OCD-related cognitive variables. These results do not support a specific relationship between hoarding and OCD; and they call into question hoarding's status as a specific symptom of OCD. Results are also discussed in terms of the importance of functional assessment of hoarding and OCD symptoms.

Demographic and clinical characteristics associated with treatment status in family members with obsessive-compulsive disorder

This study investigated the demographic and clinical factors that influence treatment status in family members with obsessive compulsive disorder (OCD). Six hundred and two subjects from the OCD Collaborative Genetics Study were interviewed using the Structured Clinical Interview for DSM-IV (SCID) to diagnose Axis I disorders, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for assessment of OCD symptoms. The demographic and clinical data were compared between subjects who had received treatment and those who had not. A precipitous onset of symptoms, severe illness, multiple obsessions and compulsions, and co-morbid affective disorders were all positively associated with receiving treatment. Older age and the presence of obsessive compulsive personality disorder (OCPD) or OCPD traits were negatively associated with treatment. Gender and age at onset of symptoms did not predict treatment history. The mean duration from onset of symptoms to receiving treatment was 13.8+/-SD 11.9 years, but there was a direct relationship between current age and time to treatment, with younger subjects receiving treatment sooner. Clinical factors are predominant in predicting treatment status in family members with OCD. Although the mean duration from onset of symptoms to treatment was long, younger family members appear to receive treatment sooner.

Escitalopram in the treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a chronic, distressing illness that is associated with a specific and unique response to selective serotonin reuptake inhibitors. Escitalopram was granted marketing authorization for the treatment of OCD from the European authorities in 2007 based on results from two Phase-III clinical trials in patients with moderate-to-severe OCD. One, a relapse prevention study, demonstrated substantial efficacy of escitalopram 10-20 mg/day in both acute and maintenance treatment, and the other demonstrated superior efficacy and favorable tolerability of escitalopram compared with placebo during 24-week, double-blind treatment. These data, and other studies reviewed here, suggest that escitalopram is an important additional tool for the treatment of OCD.

Prevalence and correlates of hoarding behavior in a community-based sample

Little is known about the prevalence and correlates of hoarding behavior in the community. We estimated the prevalence and evaluated correlates of hoarding in 742 participants in the Hopkins Epidemiology of Personality Disorder Study. The prevalence of hoarding was nearly 4% (5.3%, weighted) and was greater in older than younger age groups, greater in men than women, and inversely related to household income. Hoarding was associated with alcohol dependence; paranoid, schizotypal, avoidant, and obsessive-compulsive personality disorder traits; insecurity from home break-ins and excessive physical discipline before 16 years of age; and parental psychopathology. These findings suggest that hoarding may be relatively prevalent and that alcohol dependence, personality disorder traits, and specific childhood adversities are associated with hoarding in the community.

Do all obsessive-compulsive disorder subtypes respond to medication?

Obsessive-compulsive disorder (OCD) in children is strikingly similar in clinical presentation and treatment responsiveness to OCD in adults. While treatment is commonly effective for OCD not all subtypes of OCD are similarly responsive to treatment. Numerous studies describe the differential responsiveness of OCD subtypes to pharmacological treatment in adults, yet few such studies exist in pediatric OCD. This manuscript reviews the extant literature that addresses differential response of OCD subtypes to medication intervention. Specific OCD subtypes can be derived utilizing the following strategies: symptom factor analysis, comorbidity latent class analysis, concurrent internalizing disorders, concurrent externalizing disorders, tic-related subtype and early-onset subtype are reviewed in relation to data on differential pharmacotherapy response. Only externalizing disorders moderate treatment response in pediatric OCD. Specifically, attention-deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder are associated with poorer response to medication treatment. Hoarding appears to be associated with a poor response to medication in adults, but data are sparse in children. The presence of tic disorders may also predict poorer response to pharmacotherapy in pediatric OCD. Strategies for treatment of the tic-related subtype of OCD, while strongly supporting the use of antipsychotic-augmentation for enhanced response in adults, are lacking controlled data in pediatric OCD.

Family burden of compulsive hoarding: results of an internet survey

Compulsive hoarding, the acquisition of and failure to discard large numbers of possessions, is associated with substantial health risk, impairment in functioning, and economic burden. Despite clear indications that hoarding has a detrimental effect on people living with or near someone with a hoarding problem, no empirical research has examined these harmful effects. The aim of the present study was to examine the burden of hoarding on family members. Six hundred sixty-five family informants who reported having a family member or friend with hoarding behaviors completed an internet-based survey. Living with an individual who hoards during childhood was associated with elevated reports of childhood distress and family strain. Family members reported high levels of patient rejection attitudes, suggesting high levels of family frustration and hostility. Rejecting attitudes were predicted by severity of hoarding symptoms, the individual's perceived lack of insight into the behavior, and having lived in a cluttered environment during childhood. These results suggest that compulsive hoarding adversely impacts not only the hoarding individual, but also those living with them.

Characterizing the hoarding phenotype in individuals with OCD: associations with comorbidity, severity and gender

Hoarding frequently occurs in obsessive-compulsive disorder (OCD), and some evidence suggests that it constitutes a distinct OCD subtype, with genetic contributions. This study investigated differences between OCD patients with and without hoarding symptoms. Of the 473 OCD patients studied, 24% were classified as hoarders according to combined interviewer and self-ratings, which were validated with the Savings Inventory-Revised in a subsample. Hoarders suffered from significantly more severe OCD symptoms, (especially compulsions) and had greater impairment and dysphoria. Hoarders also had more comorbid psychiatric disorders. Further study revealed that many of these differences were attributable to the female subjects: Compared to female non-hoarders, female hoarders were more likely to suffer from bipolar I, substance abuse, panic disorder, binge-eating disorder, and had greater OCD severity. Male hoarders had an increased prevalence of social phobia compared to non-hoarding males. These results suggest that there are gender-specific differences in the hoarding sub-phenotype of OCD.

Memory and executive functioning in obsessive-compulsive disorder: a selective review

BACKGROUND

The neurocognitive deficits that underlie the unique features of obsessive-compulsive disorder (OCD) are not yet completely understood. This paper reviews the main neuropsychological findings in memory and executive functioning in this disorder, and examines a number of challenges facing this area of research.

METHOD

A selective review of the neuropsychological literature on OCD was conducted using MEDLINE and drawing on literature known to the authors.

RESULTS

The neuropsychological profile of OCD appears to be one of primary executive dysfunction. Although memory functioning may be affected, these deficits appear secondary to an executive failure of organizational strategies during encoding. On tasks of executive functioning patients with OCD demonstrate increased response latencies, perseveration of responses, and difficulties utilizing feedback to adapt to change.

LIMITATIONS

A statistical meta-analysis was not performed and only the cognitive domains of memory and executive functioning were examined.

CONCLUSIONS

Given the prominence of chronic doubt and indecision in clinical settings, it is surprising that decision making as a cognitive construct as related to OCD has not received greater attention in the neuropsychological literature. On the basis of emerging literature we suggest that it is a potential area of dysfunction and one that warrants further investigation as it may assist in enhancing our understanding of the pathophysiology of OCD.

Paroxetine treatment of compulsive hoarding

OBJECTIVE

Compulsive hoarding, found in many patients with obsessive-compulsive disorder (OCD), has been associated with poor response to serotonin reuptake inhibitor (SRI) medications in some reports. However, no prior study has quantitatively measured response to standardized pharmacotherapy in compulsive hoarders. We sought to determine whether compulsive hoarders would respond as well as non-hoarding OCD patients to the SRI, paroxetine.

METHODS

Seventy-nine patients with OCD (32 patients with the compulsive hoarding syndrome and 47 patients without prominent hoarding symptoms) were treated openly with paroxetine (mean dose 41.6+/-12.8 mg/day; mean duration 80.4+/-23.5 days) according to a standardized protocol, from 3/1993 to 7/2005. All subjects were free of psychotropic medication for at least four weeks prior to study entry. No psychotherapy or psychotropic medications except paroxetine were allowed during the study period. Subjects were assessed before and after treatment with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Scale (Ham-A), Global Assessment Scale (GAS), and Clinical Global Impression/Improvement (CGI) scale.

RESULTS

Both compulsive hoarders and non-hoarding OCD patients improved significantly with treatment (p<0.001), with nearly identical changes in Y-BOCS, HDRS, Ham-A, and GAS scores. There were no significant differences between groups in the proportions of patients who completed or responded to treatment. Hoarding symptoms improved as much as other OCD symptoms.

CONCLUSIONS

Compulsive hoarders responded as well to paroxetine treatment as non-hoarding OCD patients, suggesting that SRI medications are effective for compulsive hoarding. Controlled trials of SRI medications for compulsive hoarding are now warranted.

Bipolar co-morbidity in pediatric obsessive-compulsive disorder: clinical and treatment implications

This paper reports on implications of bipolar disorder (BD) co-morbidity in 120 children and adolescents with obsessive-compulsive disorder (OCD) (84 males, 36 females, age 13.7 +/- 2.8 years), diagnosed using a clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, and naturalistically followed-up for 12 +/- 6 months. The aim of this naturalistic, retrospective study was to explore the effect of BD co-morbidity, disentangling it from other co-occurring variables, namely the co-morbidity with disruptive behavior disorders. Forty three patients (35.8%) had a bipolar co-morbidity. Compared with OCD patients without BD, they had an earlier onset of OCD, a greater severity and functional impairment, more frequent hoarding obsessions and compulsions, and a poorer response to treatments. They had a higher co-morbidity with attention-deficit/hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD), and a lower co-morbidity with generalized anxiety disorder (GAD). Finally, they received more mood stabilizers, and 30.2% of them did not receive serotonin-selective reuptake inhibitors (SSRIs) because of pharmacological (hypo)mania. When all the OCD responders and nonresponders were compared, nonresponders (n = 42, 35%) were more severe at baseline and at end of the follow-up, had more frequently hoarding obsessions and compulsions, and had more frequent BD, ODD, and conduct disorder (CD) and less GAD and panic disorder. In the final regression model, hoarding obsessions and compulsions, co-morbidity with ODD, and CD were negative predictors of treatment outcome. This study suggests that even though bipolar co-morbidity is frequent and affects phenomenology and co-morbidity in pediatric OCD, its effect on treatment response seems prevalently accounted for by co-morbidity with disruptive behavior disorders. The significance of the hoarding subtype deserves further research on larger samples of pediatric patients.

Clinical features of children and adolescents with obsessive-compulsive disorder and hoarding symptoms

OBJECTIVE

This study was conducted to examine whether pediatric patients with obsessive-compulsive disorder (OCD) and hoarding symptoms differed in terms of clinical characteristics from pediatric OCD patients without hoarding symptoms.

METHOD

Eighty children and adolescents with OCD (range, 7-17 years) completed clinician-administered and parent- and child-report measures of OCD symptom severity, impairment, and emotional and behavioral symptoms.

RESULTS

Twenty-one youth endorsed significant hoarding symptoms. Relative to nonhoarders, youth with hoarding symptoms had worse insight, more magical thinking obsessions, and ordering/arranging compulsions than nonhoarders, higher levels of anxiety, aggression, somatic complaints, and overall externalizing and internalizing symptoms. Higher rates of panic disorder were found in youth with hoarding symptoms although other comorbidity rates did not differ.

CONCLUSIONS

These findings in children are partially consistent with studies in adults, and suggest that pediatric patients with hoarding symptoms may exhibit a unique clinical presentation.

Do traumatic events influence the clinical expression of compulsive hoarding?

Traumatic experiences have been posited as one potential catalyst for the abrupt onset of obsessive-compulsive symptoms including compulsive hoarding. To determine whether traumatic life events (TLEs) might influence the expression of compulsive hoarding in obsessive-compulsive disorder (OCD), interview responses to the Posttraumatic Stress Disorder module of the Structured Clinical Interview for DSM-IV (SCID) were examined in 180 individuals with OCD. Compared to individuals with OCD who did not meet criteria for hoarding, participants classified as hoarders (24% of the sample) were significantly more likely to have reported at least one TLE in their lifetime. Patients who met criteria for hoarding and who had also experienced TLEs had significantly greater hoarding symptom severity than those hoarders not exposed to trauma. This association was found to be robust. That is, the relationship between TLEs and hoarding symptom severity was not better accounted for by age, age of OCD onset, depressive symptoms, general OCD symptomatology, or mood and anxiety comorbidity. Closer examination revealed that the clutter factor of compulsive hoarding (and not difficulty discarding or acquisitioning) was most strongly associated with having experienced a traumatic event.

Factor analysis of the Yale-Brown Obsessive Compulsive Scale in a family study of obsessive-compulsive disorder

Our objective in this study was to determine whether symptoms of obsessive-compulsive disorder (OCD) cluster into groups that can usefully subclassify OCD. Psychiatrists or psychologists interviewed 221 subjects using the Lifetime Anxiety Version of the Schedule for Affective Disorders and Schizophrenia (SADS-LA) for the diagnosis of DSM-IV disorders, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for OCD symptoms. We analyzed 16 symptom categories from the Y-BOCS using exploratory factor analysis to identify latent symptom dimensions. The relationship between these symptom dimensions and clinical characteristics and familiality was investigated. A four-factor model emerged as the best classification of OCD symptoms in the Y-BOCS. These factors were labeled Pure Obsessions, Contamination, Symmetry/Order, and Hoarding. The contamination factor was least likely to be associated with other Axis I disorders. Whereas no significant relationship was found between the factor scores of probands and the presence of OCD in their first-degree relatives, the Symmetry/Order and Hoarding factors did breed true. Hoarding was found to predict poorer treatment response. A four-factor classification of OCD features best describes the symptom patterns of a sample of patients with OCD. There were specific clinical correlates for these factors, and significant intrafamilial sib-sib correlations were found for the Symmetry/Order and Hoarding factors.

Obsessive-compulsive symptoms in sibling pairs concordant for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a heterogeneous disorder of unknown etiology. Phenotypic studies of affected sib-pairs (SPs) may help to characterize familial components of the phenotype. To determine whether SPs affected with OCD are similar in age at onset of obsessive-compulsive symptoms (OCS), symptom dimensions and presence of tic disorders (TDs). Forty OCD siblings ranging from 13 to 59 years old were evaluated by expert psychiatrists or psychologists. Families with two or more siblings affected with OCD were recruited from several OCD clinics in Brazil. The Yale Brown Obsessive-Compulsive Scale Checklist was used to assess OCS and the severity of OCD. The OCD diagnoses were made according to the DSM-IV. The chi-square test was used to assess concordance of TD presence within SPs based on the TD frequency reported in the literature (30%). There were significantly more siblings with early-onset OCS than with late-onset OCS (P = 0.002). Age at onset of OCS correlated positively and significantly between the two members of each SP (P = 0.005). Fourteen patients (35%) were diagnosed with TDs. There was no concordance of the TD presence within the SPs. When both were male, there was a significant sibling correlation in the contamination obsessions/cleaning compulsions dimension (ICC = 0.74; P = 0.002). Similarly, when both siblings were female, they were comparable in the hoarding obsessions/compulsions dimension (ICC = 0.76; P = 0.01). Familial factors seem to contribute to specific OCD phenotypic components such as age at onset of OCS and specific dimensions. The obvious influence of gender is as yet unexplained.

Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation. The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with "normal" worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's "tic-related" status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.

Obsessive-compulsive disorder: boundary issues

The boundaries between obsessive-compulsive disorder (OCD) and other neuropsychiatric disorders remain unresolved and may well differ from one disorder to another. Endophenotypes are heritable, quantitative traits hypothesized to more closely represent genetic risk for complex polygenic mental disorders than overt symptoms and behaviors. They may have a role in identifying how closely these disorders are associated with another and with other mental disorders with which they share major comorbidity. This review maps the nosological relationships of OCD to other neuropsychiatric disorders, using OCD as the prototype disorder and endophenotype markers, such as cognitive, imaging, and molecular data as well as results from demographic, comorbidity, family, and treatment studies. Despite high comorbidity rates, emerging evidence suggests substantial endophenotypic differences between OCD and anxiety disorders, depression, schizophrenia, and addictions, though comparative data is lacking and the picture is far from clear. On the other hand, strong relationships between OCD, Tourette syndrome, body dysmorphic disorder, hypochondriasis, grooming disorders, obsessive-compulsive personality disorder, and pediatric autoimmune neuropsychiatric disorders associated with streptococcus are likely. Studies designed to delineate the cause, consequences, and common factors are a challenging but essential goal for future research in this area.

Hoarding in obsessive–compulsive disorder: Results from the OCD Collaborative Genetics Study

Hoarding behavior occurs frequently in obsessive-compulsive disorder (OCD). Results from previous studies suggest that individuals with OCD who have hoarding symptoms are clinically different than non-hoarders and may represent a distinct clinical group. In the present study, we compared 235 hoarding to 389 non-hoarding participants, all of whom had OCD, collected in the course of the OCD Collaborative Genetics Study. We found that, compared to non-hoarding individuals, hoarders were more likely to have symmetry obsessions and repeating, counting, and ordering compulsions; poorer insight; more severe illness; difficulty initiating or completing tasks; and indecision. Hoarders had a greater prevalence of social phobia and generalized anxiety disorder. Hoarders also had a greater prevalence of obsessive-compulsive and dependent personality disorders. Five personality traits were independently associated with hoarding: miserliness, preoccupation with details, difficulty making decisions, odd behavior or appearance, and magical thinking. Hoarding and indecision were more prevalent in the relatives of hoarding than of non-hoarding probands. Hoarding in relatives was associated with indecision in probands, independently of proband hoarding status. The findings suggest that hoarding behavior may help differentiate a distinct clinical subgroup of people with OCD and may aggregate in some OCD families. Indecision may be a risk factor for hoarding in these families.

Heritability and clinical features of multigenerational families with obsessive-compulsive disorder and hoarding

To date, only one complete genome screen for obsessive-compulsive disorder (OCD) has been published. That study identified a region of suggestive linkage (maximum lod score of 2.25) with a relatively small sample size (N = 56; 27 with OCD). Additional complete genome screens are needed to confirm this finding and identify other regions of linkage. We present the clinical characteristics and power to detect linkage of 11 multigenerational families with OCD and hoarding (N = 92; 44 with OCD), as well as heritability estimates for several quantitative traits. Families with at least two individuals with OCD were identified through probands with childhood-onset OCD. Expected lod scores were calculated for simulated genetic marker data under an additive and two dominant models assuming a dense SNP marker map. All affected individuals had an early age of onset (18 or younger). Hoarding was present in 46% of subjects. Obsessive-compulsive symptoms and hoarding were highly heritable. The maximum mean expected lod score was 3.31 for OCD and 1.39 for hoarding. We found reasonable power to detect regions of interest (lod = 2) for OCD in these families, but will need to expand our family collection to have adequate power to detect regions of interest for hoarding.

An open trial of cognitive-behavioral therapy for compulsive hoarding

The aim of the present study was to provide preliminary data on the efficacy of a new cognitive-behavioral treatment (CBT) for compulsive hoarding. Fourteen adults with compulsive hoarding (10 treatment completers) were seen in two specialty CBT clinics. Participants were included if they met research criteria for compulsive hoarding according to a semistructured interview, were age 18 or above, considered hoarding their main psychiatric problem, and were not receiving mental health treatment. Patients received 26 individual sessions of CBT, including frequent home visits, over a 7-12 month period between December 2003-February 2005. Primary outcome measures were the Saving Inventory-Revised (SI-R), Clutter Image Rating (CIR), and Clinician's Global Impression (CGI). Significant decreases from pre- to post-treatment were noted on the SI-R and CIR, but not the CGI-severity rating. CGI-Improvement ratings indicated that at mid-treatment, 40% (n=4) of treatment completers were rated "much improved" or "very much improved;" at post-treatment, 50% (n=5) received this rating. Adherence to homework assignments was strongly related to symptom improvement. CBT with specialized components to address problems with motivation, organizing, acquiring and removing clutter appears to be a promising intervention for compulsive hoarding, a condition traditionally thought to be resistant to treatment.

Neuropsychological impairment associated with compulsive hoarding

A group of patients with compulsive hoarding (n=30) was compared to a mixed clinical group (n=30) and a nonclinical community group (n=30) on laboratory tests of information-processing features hypothesized to be central to hoarding (memory, attention, and decision-making). Hoarding patients demonstrated slower and more variable reaction time, increased impulsivity, greater difficulty distinguishing targets and nontargets, and worse spatial attention relative to comparison groups. Multiple regression analyses demonstrated that slower reaction time and increased impulsivity were significantly related to hoarding symptoms over and above the effect of depression, schizotypy, and other obsessive-compulsive disorder (OCD) symptoms. There were no group differences on a test of emotion-based decision-making. Results are discussed in terms of previous findings and theoretical models of compulsive hoarding.

Age of onset of compulsive hoarding

Although compulsive hoarding appears to be a chronic, progressive disorder, little is known about its onset and course. The current study employed retrospective assessment of 51 individuals with compulsive hoarding difficulties to determine onset of various hoarding symptoms (clutter, acquisition, difficulty discarding), as well as the individual's degree of recognition of the problem at various times throughout his or her life. Participants were asked to describe life events from each decade that occurred at the time hoarding symptoms were developing. Symptoms of clutter and difficulty discarding appeared to begin at approximately the same age, whereas acquiring problems began slightly later. Recognition of the problem developed significantly later than any of the symptoms themselves. A portion of participants reported that their hoarding symptoms were reduced at some point in their lives, but few reported full remission of hoarding at any point. Survival analysis of age of onset of hoarding symptoms indicated that individuals who reported a stressful event when saving behavior started had a significantly later age of onset than those who reported no events at the age of onset. Perhaps for some individuals compulsive hoarding is a lifelong characterological phenomenon, whereas for others hoarding behavior develops later as a reaction to stress or loss.

The hoarding dimension of OCD: Psychological comorbidity and the five-factor personality model

Although hoarding has been associated with several psychological disorders, it is most frequently linked to obsessive-compulsive disorder (OCD). The present study assessed hoarding obsessions and compulsions in 204 individuals with OCD, and evaluated how hoarding was related to obsessive-compulsive symptom severity, psychological comorbidity, and personality as measured by the five-factor model. Results indicated that hoarding in OCD is a dimensional variable that is positively associated with dysphoria, total number of lifetime Axis I disorders, and lifetime histories of bipolar I, PTSD, and body dysmorphic disorder. Hoarding was negatively correlated with the NEO-Personality Inventory-Revised (NEO-PI-R) factor of Conscientiousness and positively associated with the NEO-PI-R factor of Neuroticism. When all personality and psychopathology variables were entered into a regression equation, dysphoria, bipolar II disorder, Conscientiousness, age, and Extraversion emerged as significant predictors of hoarding severity. Recommendations are made for clinicians and for future research.

Genomewide linkage scan for obsessive-compulsive disorder: evidence for susceptibility loci on chromosomes 3q, 7p, 1q, 15q, and 6q

Obsessive-compulsive disorder (OCD) is the tenth most disabling medical condition worldwide. Twin and family studies implicate a genetic etiology for this disorder, although specific genes have yet to be identified. Here, we present the first large-scale model-free linkage analysis of both extended and nuclear families using both 'broad' (definite and probable diagnoses) and 'narrow' (definite only) definitions of OCD. We conducted a genome-scan analysis of 219 families collected as part of the OCD Collaborative Genetics Study. Suggestive linkage signals were revealed by multipoint analysis on chromosomes 3q27-28 (P=0.0003), 6q (P=0.003), 7p (P=0.001), 1q (P=0.003), and 15q (P=0.006). Using the 'broad' OCD definition, we observed the strongest evidence for linkage on chromosome 3q27-28. The maximum overall Kong and Cox LODall score (2.67) occurred at D3S1262 and D3S2398, and simulation based P-values for these two signals were 0.0003 and 0.0004, respectively, although for both signals, the simulation-based genome-wide significance levels were 0.055. Covariate-linkage analyses implicated a possible role of gene(s) on chromosome 1 in increasing the risk for an earlier onset form of OCD. We are currently pursuing fine mapping in the five regions giving suggestive signals, with a particular focus on 3q27-28. Given probable etiologic heterogeneity in OCD, mapping gene(s) involved in the disorder may be enhanced by replication studies, large-scale family-based linkage studies, and the application of novel statistical methods.

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.

Common and distinct neural correlates of obsessive-compulsive and related disorders

Obsessive-compulsive disorder (OCD) often co-occurs with other anxiety disorders and a number of other disorders of similar phenomenology known as the "OCD spectrum" disorders. Neurobiologically, it is unclear how all these disorders relate to each other. The picture is further complicated by the clinical heterogeneity of OCD itself. This article reviews the literature on the common and distinct neural correlates of OCD, its symptom dimensions, and other anxiety and OCD spectrum disorders with the hope of providing a conceptual and heuristic framework to help understand the relationship between these phenomena.

Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome

OBJECTIVE

A significant number of patients with obsessive-compulsive disorder (OCD) fail to benefit sufficiently from treatments. This study aimed to evaluate whether certain OCD symptom dimensions were associated with cognitive-behavioral therapy (CBT) outcome.

METHOD

Symptoms of 104 CBT-treated in-patients with OCD were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale symptom checklist. Logistic regression analyses examined outcome predictors.

RESULTS

The most frequent OCD symptoms were aggressive and contamination obsessions, and compulsive checking and cleaning. Patients with hoarding symptoms at baseline (n = 19) were significantly less likely to become treatment responders as compared to patients without these symptoms. Patients with sexual and religious obsessions tended to respond less frequently, although this failed to reach statistical significance (P = 0.07). Regression analyses revealed that higher scores on the hoarding dimension were predictive of non-response, even after controlling for possible confounding variables.

CONCLUSION

Our results strongly indicate that in-patients with obsessive-compulsive hoarding respond poorly to CBT.

Categorization in compulsive hoarding

Based on hypothesizing about the role of information processing, and in particular, underinclusive categorization in compulsive hoarding, this study examined categorization processes in people with clinically significant compulsive hoarding problems. Twenty-one participants with primary compulsive hoarding, 21 with OCD without hoarding, and 21 non-psychiatric controls completed three categorization tasks. Hoarding and OCD participants reported significantly more distress prior to each of the three tasks than did controls. On tasks sorting common household items, the groups did not differ on the number of piles created nor on the amount of time taken to sort. However, on a task sorting personally relevant items, hoarding participants took more time, created more piles, and reported more anxiety than non-psychiatric controls. Hoarders also took more time than the OCD group, and tended to create more piles. Hoarding severity was correlated with the number of piles created, but only when the objects were personally relevant. Results support under-inclusive categorizing for people with compulsive hoarding, but the effect was largely confined to objects of personal relevance.

Psychometric properties of the Spanish version of the Obsessive-Compulsive Inventory--revised in a non-clinical sample

The psychometric properties of a Spanish version of the Obsessive-Compulsive Inventory-Revised (OCI-R) were examined in a non-clinical student sample (n=381). A confirmatory factor analysis replicated the original six-factor structure. The total and each of the subscales of the Spanish OCI-R demonstrated moderate to good internal consistency and test-retest reliability, moderate convergent validity and good divergent validity. The Spanish version of the OCI-R retains the sound psychometric properties of the original version.

Latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder criteria

AIMS

This study investigated the internal construct validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorders and explored alternative models to characterize the personality disorder traits. The relationship between the obtained personality disorder dimensions and measures of functioning and disability was examined.

METHODS

The subjects in the study were 742 community-residing individuals who participated in the Hopkins Epidemiology of Personality Disorders Study. The presence of DSM-IV personality disorder traits was assessed by psychologists using the International Personality Disorder Examination (IPDE). Confirmatory factor analysis was performed on all the IPDE criteria for each of the 10 personality disorders using the Mplus program. Exploratory factor analysis of all personality disorder traits was completed using the same program. Factor scores were correlated with subjects' GAF ratings and number of missed days from work for physical and psychological reasons.

RESULTS

A single underlying factor was found for the IPDE item criteria of avoidant and dependent personality disorder, with less evidence for the other 8 personality disorders. Five factors were retained as the dimensional accounting for the personality disorder criteria. These factors were named compulsive, neurotic avoidant, aloof, impulsive callous, and egocentric. Of the five factors, 4 were associated with evidence of diminished functioning.

CONCLUSIONS

The IPDE pathological personality traits did not empirically cluster according to the current DSM-IV axis II diagnostic system but instead defined 5 relatively independent PD symptom dimensions that were related to functional impairments.

The distinctiveness of compulsive hoarding from obsessive-compulsive disorder

The present study investigated the relation of compulsive hoarding to other obsessive-compulsive disorder (OCD) symptoms in a sample of 162 patients with OCD. Obsessions and compulsions reported on the Anxiety Disorders Interview Schedule for DSM-IV were submitted to an exploratory factor analysis. Results suggested a four-factor model: "Certainty," "Contamination," "Obsessions," and "Numbers/Ordering." Hoarding did not load on any factor. The sample was divided into three groups: pure hoarding, nonhoarding OCD, and mixed OCD and hoarding. The hoarding group endorsed significantly less anxiety, worry, stress, and negative affect on self-report measures than the mixed and nonhoarding groups. Although hoarding sometimes functions as a compulsion among individuals with OCD, hoarding in the absence of other OCD symptoms may be a clinically distinct syndrome.

Hoarding and its relation to obsessive-compulsive disorder

Although hoarding is observed in some patients with obsessive-compulsive disorder (OCD), it has not been shown to share a specific relation with OCD. Across two studies, we found that (a) whereas the classic OCD symptoms of checking, rituals, and contamination intercorrelated consistently strongly with one another, hoarding related only moderately to both these OCD symptoms and to depression; (b) OCD patients were distinguished from both other patients and non-patients by classic OCD symptoms, but not by hoarding; and (c) whereas OCD symptoms showed consistent relations with Negative Affect, hoarding largely was uncorrelated with this dimension. These results do not support a specific OCD-hoarding relation but rather call into question the trend of considering it a specific symptom of OCD.

Insight and alexithymia in adult outpatients with obsessive-compulsive disorder

OBJECTIVE

To elucidate the relationships between insight and alexithymia in a sample of adult outpatients with obsessive-compulsive disorder (OCD).

METHODS

112 adult outpatients with OCD were tested. Severity of OCD was assessed with the first 10-items of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and score for item # 11 on the Y-BOCS was considered as a measure of insight. Alexithymia was measured with 20-item Toronto Alexithymia Scale (TAS-20). Additional measures were Maudsley Hospital Obsessive Compulsive Inventory (MOCI) and Montgomery Asberg Depression Rating Scale (MADRS).

RESULTS

Of the patients, 29.5% showed poor or no insight. Patients with poor or no insight were more alexithymic than patients with excellent, good and moderate insight. TAS-20 total score and subfactors positively correlated with score for item # 11 on the Y-BOCS, severity of OCD and MADRS scores. In stepwise regression model, MADRS scores, factor 3 of TAS-20 (Externally Oriented Thinking), somatic and hoarding-saving obsessions were significantly associated with lower insight.

CONCLUSIONS

Results show a relationship between poor or absent insight and high alexithymia levels in OCD patients.

On phenomenology and classification of hoarding: a review

OBJECTIVE

Hoarding is a behavioural abnormity characterized by the excessive collection of poorly usable objects. It is described mainly in association with obsessive-compulsive disorders (OCDs) and in geriatric populations. Yet the literature on the phenomenon is heterogeneous and the notion obviously lacks a consistent definition. This review attempts to describe the psychopathological and clinical spectrum of hoarding and may contribute to clarify its classification.

METHOD

Systematic review and discussion of the literature on hoarding.

RESULTS

Hoarding is a complex behavioural phenomenon associated with different mental disorders. The psychopathological structure is variously composed of elements of OCDs, impulse-control disorders, and ritualistic behaviour. Severe self-neglect is a possible consequence of hoarding.

CONCLUSION

Without further specifications the term hoarding is of limited heuristic value and cannot guide therapeutic interventions satisfactorily. The condition needs to be evaluated carefully in every particular case in relation to the aforementioned psychopathological concepts.

Patients with obsessive-compulsive disorder and hoarding symptoms: a distinctive clinical subtype?

We investigated whether patients with obsessive-compulsive disorder (OCD) and hoarding symptoms can be differentiated from their counterparts with other types of obsessions and compulsions in terms of sociodemographic and clinical features. Ninety-seven patients with OCD were assessed with a sociodemographic and clinical questionnaire, the Structured Clinical Interview for DSM-IV (SCID-I), the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HDRS), and the Global Assessment of Functioning (GAF). Fifteen patients who reported hoarding symptoms in the Y-BOCS checklist (15.6% of the total sample) were compared and contrasted with 82 patients without those symptoms using the Mann-Whitney U test for continuous variables and the Pearson's goodness-of-fit chi-square test for categorical ones; Fisher's exact test was employed when indicated. Hoarders were characterized by (1) higher educational levels (chi(2) = 7.49; df = 2; P =.02); (2) earlier age at onset (Z = -2.99; P =.003); (3) higher rates of symmetry obsessions (chi(2) = 7.03; df = 1; P =.01); (4) greater frequency of ordering (chi(2) = 10.08; df = 1; P =.004); (5) rituals repetition (chi(2) = 4.42; df = 1; P =.03); (6) counting compulsions (chi(2) = 5.92; df = 1; P =.02); and (7) significantly higher rates of comorbidity with bipolar II disorder (chi(2) = 10.62; df = 1; P =.02) and (8) with eating disorders (chi(2) = 7.42; df = 1; P =.02). In conclusion, patients with OCD exhibiting hoarding feature a distinctive sociodemographic and clinical profile. It remains to be investigated whether these phenotypical characteristics are underlined by specific neurobiological mechanisms.

Compulsive hoarding: current status of the research

This article reviews the literature on compulsive hoarding, including the definition and manifestations of the problem and a conceptual model for understanding hoarding behavior. This model addresses information processing deficits (e.g., attention, organization, memory, decision-making), beliefs about and emotional attachments to possessions, and distress and avoidance. Research regarding the diagnostic categorization of hoarding, its course and phenomenology, and evidence to support the model is presented. The limited research on treatment provides evidence that current serotonergic medications for OCD are largely ineffective for treating hoarding, but cognitive and behavioral treatments, especially those focused on deficits identified in the model, have some utility. Recommendations for further research on the psychopathology and treatment of hoarding are provided.