Neural mechanisms of decision making in hoarding disorder

Central and peripheral physiological responses to decision making in hoarding disorder

Individuals with hoarding disorder (HD) have difficulty parting with personal possessions, which leads to the accumulation of excessive clutter. According to a proposed biphasic neurobiological model, HD is characterized by blunted central and peripheral nervous system activity at rest and during neutral (non-discarding) decisions, and exaggerated activity during decision-making about discarding personal possessions. Here, we compared the error-related negativity (ERN) and psychophysiological responses (skin conductance, heart rate and heart rate variability, and end tidal CO2) during neutral and discarding-related decisions in 26 individuals with HD, 37 control participants with anxiety disorders, and 28 healthy control participants without psychiatric diagnoses. We also compared alpha asymmetry between the HD and control groups during a baseline resting phase. Participants completed a series of Go/No Go decision-making tasks, one involving choosing certain shapes (neutral task) and the other involving choosing images of newspapers to imaginally "discard" (discarding task). While all participants showed expected increased frontal negativity to commission of an error, contrary to hypotheses, there were no group differences in the ERN or any psychophysiological measures. Alpha asymmetry at rest also did not differ between groups. The findings suggest that the ERN and psychophysiological responses may not differ in individuals with HD during simulated discarding decisions relative to control participants, although the null results may be explained by methodological challenges in using Go/No Go tasks as discarding tasks. Future replication and extension of these results will be needed using ecologically valid discarding tasks.

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.

An exploration of neural predictors of treatment compliance in cognitive-behavioral group therapy for hoarding disorder

A persistent and influential barrier to effective cognitive-behavioral therapy (CBT) for patients with hoarding disorder (HD) is treatment retention and compliance. Recent research has suggested that HD patients have abnormal brain activity identified by functional magnetic resonance (fMRI) in regions often engaged for executive functioning (e.g., right superior frontal gyrus, anterior insula, and anterior cingulate), which raises questions about whether these abnormalities could relate to patients' ability to attend, understand, and engage in HD treatment. We examined data from 74 HD-diagnosed adults who completed fMRI-measured brain activity during a discarding task designed to elicit symptom-related brain dysfunction, exploring which regions' activity might predict treatment compliance variables, including treatment engagement (within-session compliance), homework completion (between-session compliance), and treatment attendance. Brain activity that was significantly related to within- and between-session compliance was found largely in insula, parietal, and premotor areas. No brain regions were associated with treatment attendance. The results add to findings from prior research that have found prefrontal, cingulate, and insula activity abnormalities in HD by suggesting that some aspects of HD brain dysfunction might play a role in preventing the engagement needed for therapeutic benefit.

When radical uncertainty is too much: Clinical aspects of Conviction Narrative Theory

We propose extrapolating Conviction Narrative Theory (CNT) to clinical psychology and psychiatry. We demonstrate how CNT principles may benefit assessment, therapy, and possibly even modify public health views of neuropsychiatric disorders. Our commentary focuses on hoarding disorder as a model, elaborates on discrepancies in the scientific literature and suggests how the CNT may resolve them.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The experience of leaving a valuable object: An investigation of emotional processes related to Hoarding disorder features

One of the core features of hoarding is a significant resistance to discarding objects, which is fueled by dysfunctional beliefs and unwarranted negative emotions that hoarders tend to feel when disposing of their possessions. To our knowledge, longitudinal studies investigating the psychological effects that people who hoard experience after separating from their valuable possessions have yet to be conducted. Our study's principal aim was to explore psychological processes that individuals with high hoarding features (n = 53; 49.1%) and individuals with low hoarding features (n = 55; 50.9%) experienced when they had to separate from a valuable possession. To do this, we evaluated participants' thoughts and feelings at several time points after they had to leave a valuable object at the University laboratory (evaluations were specifically conducted at baseline, during the week, and at the end of the week). To investigate hoarding and anxiety, as well as depressive, obsessive-compulsive, and emotional processes-related features, a mixed-method approach was employed involving self-report questionnaires, ad hoc surveys, and a daily self-monitoring schedule. Our findings showed that compared to participants with low hoarding features, participants with high hoarding traits: 1) scored higher for anxiety sensitivity, distress tolerance, and emotional dysregulation; 2) reported having more negative emotions when leaving their object; 3) had more intrusive object-related beliefs; and 4) experienced a higher frequency of negative emotions as well as a higher level of distress during the week. Both groups experienced more negative emotions in the first part of the week, which decreased as the time at which participants could receive their object back drew closer. Finally, dysfunctional beliefs about leaving a personal object (Saving Cognitions Inventory), sensitivity to anxiety (Anxiety Sensitivity Index-3), and distress tolerance (Distress Tolerance Scale) contributed to the level of discomfort that participants with higher hoarding scores reported when they had to leave their possession. These results highlight the relevance of emotional processes in the hoarding disorder framework as well as underscore the importance of assessing and treating them in clinical settings.

Neural correlates of overvaluation and the effort to save possessions in a novel decision task: An exploratory fMRI study

Introduction

People exhibit a strong attachment to possessions, observed in behavioral economics through loss aversion using new items in the Endowment or IKEA effects and in clinical psychology through pathological trouble discarding domestic items in Hoarding Disorder. These fields rarely intersect, but both document a reticence to relinquish a possessed item, even at a cost, which is associated with feelings of loss but can include enhanced positive states as well.

Methods

To demonstrate the shared properties of these loss-related ownership effects, we developed the Pretzel Decorating Task (PDT), which concurrently measures overvaluation of one's own over others' items and feelings of loss associated with losing a possession, alongside enhanced positive appraisals of one's items and an effort to save them. The PDT was piloted with 31 participants who decorated pretzels and responded to their own or others' items during functional neuroimaging (fMRI). Participants observed one item per trial (self or other) and could work to save it (high or low probability loss) before learning the fate of the item (trashed or saved). Finally, participants rated items and completed hoarding tendency scales.

Results

The hypotheses were supported, as even non-clinical participants overvalued, viewed as nicer, feared losing, and worked harder to save their items over others'-a response that correlated with hoarding tendencies and motor-motivational brain activation. Our region of interest in the nucleus accumbens (NAcc) was engaged when viewing one's own items to the extent that people worked harder to save them and was more active when their items were saved when they felt emotionally attached to possessions in real life. When their items were trashed, NAcc activity negatively correlated with trouble discarding and emotional attachments to possessions. Right anterior insula was more active when working to save one's own over others' items. Extensive motor-motivational areas were engaged when working to save one's own over others' items, including cerebellum, primary motor and somatosensory regions, and retrosplenial/parahippocampal regions-even after controlling for tapping.

Discussion

Our attachments to items are emotional, continuous across typical and pathological populations, and drive us to save possessions that we value.

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

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

A Case of Coexisting Depression and Hoarding Disorder

A hoarding disorder manifests as difficulty in discarding or letting go of items irrespective of their actual worth and persistent acquisition of items. Increasing numbers of possessions clutter active living spaces to the point where their intended use is no longer possible, leading to significant functional impairment. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), it is classified under the category obsessive-compulsive and related disorders. First considered to be a part of obsessive-compulsive disorder, compulsive hoarding was subsequently classified as an additional dimension of the obsessive-compulsive disorder spectrum. Hoarding disorder had been largely ignored clinically until recently, despite negative consequences on individuals, families, and communities. Comorbid conditions like anxiety, depression, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder are well known to accompany hoarding disorder. This study illustrates the case of a 35-year-old married man who was referred to a psychiatrist by his primary care physician for collecting many different objects of little or no importance. These objects were lying unorganized throughout his house and cluttering most of his living space. Some of these things were discarded by his wife, which, according to him, contributed to his emotional distress. The pattern of behavior began about 10 years earlier, and it became increasingly problematic with time. Although hoarding disorder is often underreported, it is vital to diagnose this condition as it significantly affects the individual and their family and friends. Severe hoarding can pose a number of health and safety risks, including fire hazards, tripping hazards, and health code violations.

Profiling Hoarding Within the Five-Factor Model of Personality and Self-Determination Theory

This study investigated the dispositional profile associated with hoarding symptoms by applying a personality and motivational trait perspective. A community sample oversampling high hoarding symptoms (N = 649, ages 18-74 years) completed an online questionnaire assessing hoarding, the five-factor model of personality, and general causality orientations drawn from self-determination theory. Personality aspects (10 traits), a level of measurement intermediate to factors (5 traits) and facets (30 traits), were assessed to provide greater specificity than a factor-level approach. Hoarding was correlated with neuroticism and conscientiousness. Aspects predicting hoarding were industriousness (C), orderliness (C), withdrawal (N), and assertiveness (E). Hoarding was significantly related to impersonal and control orientations, albeit with only slight (1.4%) incremental validity for general causality orientations above personality aspects in predicting hoarding. These findings may not generalize to a clinical treatment sample, and possible configurative interactions between traits were not assessed. This study extended the existing literature by reporting aspect-level personality and general causality orientation correlates of hoarding. These data may inform preventative monitoring and intervention programs, as well as predicting meaningful personality characteristics of hoarding clients.

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.

Neural correlates of product attachment to cosmetics

The neurobiological basis of brand and product attachment has received much attention in consumer neuroscience research, although it remains unclear. In this study, we conducted functional MRI experiments involving female users of famous luxury brand cosmetics as participants, based on the regions of interest involved in human attachment and object attachment. The results showed that the left ventral pallidum (VP), which is involved in positive reward, and the right posterior cingulate cortex (PCC), which is involved in self-concept, a key concept in object attachment, are the core regions in cosmetic attachment. Moreover, the performed psychophysiological interaction analyses showed that VP-temporoparietal junction connectivity positively correlated with activity in the dorsal raphe nucleus, and PCC-anterior hippocampus (aHC) connectivity positively correlated with subjective evaluation of attachment. The former suggests that object attachment is a human-like attachment and a stronger tendency of anthropomorphism is associated with stronger feelings of security. The latter suggests that the individual's concept of attachment as well as the relationships with the attached cosmetics are represented in the aHC, and the PCC-aHC associations produce subjective awareness of the attachment relationships. These associations between memory and reward systems have been shown to play critical roles in cosmetic attachment.

Can a virtual environment enhance understanding of hoarding deficits? A pilot investigation

This pilot study tested the utility of a virtual environment for assessing cognitive deficits characteristic of hoarding. A sample representing a broad spectrum of hoarding traits (N = 20) was assessed using self-report measures of information processing skills and emotional experience, and placed in a virtually simulated house that contained cluttered spaces and clean spaces. Information-processing significantly differed between high-hoarding and low-hoarding groups, with the high-hoarding group showing increased proneness to emotional attachment and information processing difficulties in the cluttered environment. The high-hoarding group also showed differences in behaviour and appraisal of the simulated environment. The findings suggested that virtual reality is accessible to participants and elicits real-time emotions and behavioural parameters which can assist our understanding of hoarding behaviour. Virtual reality may contribute to hoarding therapy in future, as it allows participants to visualise a different perspective of their condition and could contribute to their knowledge about the severity of their behaviour.

The Association between Age and Experienced Emotions in Hoarding Disorder

Objectives: Hoarding disorder (HD) is conceptualized as a fear-based disorder and exposure to sorting/discarding possessions is a core part of treatment. However, there has been no investigation of age-related differences in emotional reaction to sorting. The objective of this study was to explore the association between age and affective response during a sorting task.Methods: Forty-nine adults with HD completed a standardized sorting task. Participants reported their current emotion before and after the sorting task and reported their subjective distress throughout the task.Results: Older participants reported significantly lower distress ratings. Only 43% of participants reported fear prior to the task and 22% reported fear after the task. The probability of reporting fear before and after the task decreased significantly with age.Conclusions: Fear may not be the emotion experienced when discarding items, particularly for older adults with HD. Future work should focus on mechanisms of action in HD treatment.Clinical Implications: Clinicians should not assume fear or anxiety to be the primary emotional response in older adults with HD when engaged in an exposure to sorting/discarding. Older hoarding patients with a more fear-oriented aversion to sorting possessions may require a treatment emphasis on increasing the percentage of items discarded.

Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation

Hoarding disorder is characterized by difficulty parting with possessions because of strong urges to save the items. Difficulty discarding often includes items others consider to be of little value and results in accumulation of a large number of possessions that clutter the home. Cognitive-behavioral therapy (CBT) with exposure and response prevention and selective serotonin reuptake inhibitor medications traditionally used to treat obsessive-compulsive disorder are generally not efficacious for people with hoarding problems. A specialized CBT approach for hoarding has shown progress in reaching treatment goals and has been modified to be delivered in group, peer-facilitated, and virtual models. Research on hoarding remains in the early phases of development. Animal, attachment, and genetic models are expanding. Special populations, such as children, older adults, and people who do not voluntarily seek treatment need special consideration for intervention. Community-based efforts aimed at reducing public health and safety consequences of severe hoarding are needed.

A Case of Clutter and Chaos: Attention Deficit Hyperactivity Disorder Confounding Hoarding

ABSTRACT

Hoarding disorder is a chronic disorder defined as the persistent difficulty in parting with possessions and the need to save items, regardless of their actual value. Severe hoarding has largely been a hidden clinical problem, and awareness has mostly been limited to voyeuristic depictions of the plight of hoarders in popular media. Approximately 28% to 32% of individuals with attention deficit hyperactivity disorder (ADHD), especially the inattentive subtype, have been reported to have clinically significant hoarding. It has been hypothesized that patients with ADHD initially acquire objects impulsively and later develop emotional attachments or intrinsic meaning, resulting in a perpetuating cycle of reliance on hoarding as a coping mechanism. Treatment focused on impaired attention has shown improved prognosis, which further signifies the relationship between inattentive ADHD and hoarding. We discuss the case of a patient with ADHD (inattentive type), major depressive disorder, and hoarding traits.

An Examination of the Association Between Subjective Distress and Functional Connectivity During Discarding Decisions in Hoarding Disorder

BACKGROUND

Individuals with hoarding disorder (HD) demonstrate exaggerated subjective distress and hyperactivation of cingulate and insular cortex regions when discarding personal possessions. No prior study has sought to determine whether this subjective distress is associated with specific profiles of abnormal brain function in individuals with HD.

METHODS

We used multimodal canonical correlation analysis plus joint independent component analysis to test whether five hoarding-relevant domains of subjective distress when deciding to discard possessions (anxiety, sadness, monetary value, importance, and sentimental attachment) are associated with functional magnetic resonance imaging-measured whole-brain functional connectivity in 72 participants with HD and 44 healthy controls.

RESULTS

Three extracted components differed between HD participants and healthy control subjects. Each of these components depicted an abnormal profile of functional connectivity in HD participants relative to control subjects during discarding decisions, and a specific distress response profile. One component pair showed a relationship between anxiety ratings during discarding decisions and connectivity among the pallidum, perirhinal ectorhinal cortex, and dorsolateral prefrontal cortex. Another component comprised sadness ratings during discarding decisions and connectivity in the pallidum, nucleus accumbens, amygdala, and dorsolateral prefrontal cortex. The third component linked HD brain connectivity in several dorsolateral prefrontal cortex regions with perceived importance ratings during discarding decisions.

CONCLUSIONS

The findings indicate that in patients with HD, the subjective intensity of anxiety, sadness, and perceived possession importance is related to abnormal functional connectivity in key frontal and emotional processing brain regions. The findings are discussed in terms of emerging neurobiological models of HD.

Investigating executive functions in youth with OCD and hoarding symptoms

Executive functions (EF) deficits are hypothesized to be a core contributor to hoarding symptoms. EF have been studied in adult hoarding populations, but studies in youth are lacking. The current study compared multiple EF subdomains between youth with obsessive-compulsive disorder (OCD) and youth with OCD and hoarding symptoms. Forty youth (8-18 years old) with a primary diagnosis of OCD were recruited. Participants were divided by hoarding severity on the Child Saving Inventory (CSI) into either the "hoarding group" (upper 33.3%) or the "low-hoarding group" (lower 66.7%). Groups were compared on EF tasks of cognitive flexibility, decision-making, and inhibitory control. Youth in the hoarding group exhibited significantly higher cognitive flexibility and lowered perseveration than the low-hoarding group. Hoarding and low-hoarding groups did not differ in any other EF subdomain. Hoarding symptoms in youth with OCD were not associated with deficits in EF subdomains; instead, youth who hoard exhibited higher cognitive flexibility compared to youth with low hoarding symptoms.

Electrophysiological dynamics of visuocortical processing in hoarding disorder

Individuals with hoarding disorder (HD) typically perform worse than peers on neuropsychological tasks involving visual perception. Functional neuroimaging shows diffusely increased activity in the visual cortex, consistent with inefficient visual processing in HD. The temporal locus of these inefficiencies in HD is unknown. This study examined the temporal unfolding of visual event-related brain potentials (ERPs) to help better define the neurophysiological mechanisms underlying visual dysfunction in HD. Thirty-three individuals with HD and 35 healthy controls (HC) were assessed using a 64-channel EEG during a modified flanker task. Permutation-controlled analyses were conducted to detect group differences in visual evoked ERPs on a millisecond-to-millisecond basis. Bayesian ANCOVAs and linear regressions that included hoarding and age were conducted to identify the best-fit model for the identified VEPs, compared to a null model that included depression and anxiety severity. Three temporal regions (175 ms, 270 ms, and 440 ms), showed differences in amplitude between HD and HC and were consistent with ERP components N1, P1/N2, and a late negative slow wave (LNSW), respectively. After controlling for depression and anxiety, HD demonstrated an enhanced ERP amplitude at N1 and an attenuated amplitude in LNSW compared to HC but did not show differences at P1/N2. For the N1 and LNSW, there was also a primary effect of the interaction between hoarding and age. This study indicates that altered visuocortical reactivity in HD first occurs at the level of visuocortical processing after 170 ms, indicating alterations of middle and later, but not early, processing in occipitotemporal visual cortex.

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.

How well do hoarding research samples represent cases that rise to community attention?

This study used archival data from three different research groups and case file data from three independent community organizations to explore how well research samples reflect cases of hoarding that come to community attention. Using data from 824 individuals with hoarding, we found that research volunteers differ from community clients in several ways: community clients are older, more likely to be male and less likely to be partnered; they have lower socio-economic status and are less likely to demonstrate good or fair insight regarding hoarding severity and consequences. The homes of community clients had greater clutter volume and were more likely to have problematic conditions in the home, including squalor and fire hazards or fire safety concerns. Clutter volume was a strong predictor of these conditions in the home, but demographic variables were not. Even after accounting for the influence of clutter volume, the homes of community-based clients were more likely to have squalor. These findings suggest limitations on the generalizability of research samples to hoarding as it is encountered by community agencies.

Differential patterns of brain activation between hoarding disorder and obsessive-compulsive disorder during executive performance

BACKGROUND

Preliminary evidence suggests that hoarding disorder (HD) and obsessive-compulsive disorder (OCD) may show distinct patterns of brain activation during executive performance, although results have been inconclusive regarding the specific neural correlates of their differential executive dysfunction. In the current study, we aim to evaluate differences in brain activation between patients with HD, OCD and healthy controls (HCs) during response inhibition, response switching and error processing.

METHODS

We assessed 17 patients with HD, 18 patients with OCD and 19 HCs. Executive processing was assessed inside a magnetic resonance scanner by means of two variants of a cognitive control protocol (i.e. stop- and switch-signal tasks), which allowed for the assessment of the aforementioned executive domains.

RESULTS

OCD patients performed similar to the HCs, differing only in the number of successful go trials in the switch-signal task. However, they showed an anomalous hyperactivation of the right rostral anterior cingulate cortex during error processing in the switch-signal task. Conversely, HD patients performed worse than OCD and HC participants in both tasks, showing an impulsive-like pattern of response (i.e. shorter reaction time and more commission errors). They also exhibited hyperactivation of the right lateral orbitofrontal cortex during successful response switching and abnormal deactivation of frontal regions during error processing in both tasks.

CONCLUSIONS

Our results support that patients with HD and OCD present dissimilar cognitive profiles, supported by distinct neural mechanisms. Specifically, while alterations in HD resemble an impulsive pattern of response, patients with OCD present increased error processing during response conflict protocols.

Hoarding and obsessive-compulsive behaviours in frontotemporal dementia: Clinical and neuroanatomic associations

BACKGROUND

Hoarding and obsessive-compulsive behaviours (OCB) are well documented symptoms in frontotemporal dementia (FTD). While contemporary models consider hoarding and obsessive-compulsive disorder distinct, the related behaviours have not been separately examined in patients with FTD, and the neuroanatomical correlates of hoarding in patients with FTD have not been previously examined (American Psychiatric Association, 2013; Grisham and Baldwin, 2015; Mataix-Cols et al., 2010).

METHODS

Patients with FTD who were evaluated between 2004 and 2018 at our centre were included. Cortical thickness and subcortical volumetric analyses were completed on available T1 high resolution anatomic scans using FreeSurfer.

RESULTS

Eighty-seven patients met inclusion criteria, and 49 had scans available for quantitative MRI volumetric analysis. New hoarding behaviours were present in 29% of patients and were more common in the semantic variant subtype of FTD, while 49% of individuals had new or increased OCB. Hoarding behaviours were associated with decreased thickness in a factor comprised of left temporal, insular and anterior cingulate cortices. The presence of OCB was predicted by reduced cortical thickness and volumes in a factor comprised of the anterior cingulate and subcortical volumes in the bilateral amygdala and hippocampus. OCB were associated with greater right temporal cortical thickness in comparison to patients with hoarding.

DISCUSSION

The association of the semantic variant with hoarding, together with the observed associations between left temporal atrophy and hoarding indicate that degeneration of the left temporal lobe has a role in the emergence of hoarding in FTD. As in current models of Hoarding disorder and Obsessive-Compulsive disorder, our results suggest that in patients with FTD, hoarding and OCB are clinically and anatomically partially dissociable phenomenon. The results may also help to further elucidate the cognitive processes and neural networks contributing to Hoarding disorder and Obsessive-Compulsive disorder in persons without dementia.

Functional Neuroimaging Test of an Emerging Neurobiological Model of Hoarding Disorder

BACKGROUND

Over the past decade, functional neuroimaging studies have found abnormal brain function in several cortical systems when patients with compulsive hoarding behaviors make decisions about personal possessions. The purpose of this study was to use functional magnetic resonance imaging to test a neurobiological model of hoarding disorder (HD) that has begun to emerge from these small studies by confirming HD-related brain dysfunction in previously implicated brain regions in the largest sample of HD patients examined to date.

METHODS

We compared 79 adults diagnosed with DSM-5 HD with 44 non-HD control participants using a functional magnetic resonance imaging task of decision making to acquire or discard material possessions and on a control task involving semantic processing.

RESULTS

HD brain activation profiles prominently featured insular and anterior cingulate cortex overengagement during possession-related choices that were not seen in non-HD brain activation profiles and also correlated with hoarders' clutter and difficulty discarding. Although HD patients overengaged the insula when deciding to discard, relative to when performing the non-decision making task contrast, the HD insula also was generally blunted.

CONCLUSIONS

This study links the defining behavioral symptoms of HD to localized brain dysfunction within cingulo-opercular brain systems and firmly establishes the context-dependent importance of this network dysfunction in HD. The relevance of dysfunction in these brain regions is highlighted by a failure to replicate HD-related abnormalities in other brain regions implicated in prior HD functional magnetic resonance imaging studies. This study also raises the novel possibility that HD may involve abnormality in the inferior frontal cortex engaged for executive control over semantic processing.

Editorial: Hoarding and Obsessive-Compulsive Disorder

Hoarding disorder is more than surplus clothes and belongings that could be remedied by a visit from Marie Kondo (https://konmari.com). It is officially recognized as a distinct condition in DSM-5 and placed under obsessive-compulsive conditions.1 Before the designation in DSM-5, hoarding was regarded as a diagnostic element in obsessive-compulsive personality disorder or a symptom nested within obsessive-compulsive disorder (OCD).2 In DSM-5, hoarding disorder is defined by great reluctance or outright refusal to discard belongings-including articles of limited value. Individuals with hoarding disorder commonly describe indecision, distress, or both when faced with discarding superfluous items. They may claim that the item could be useful in the future or that it has sentimental value. A direct consequence of refusing to discard items of limited value is accumulation of clutter that, over time, interferes with daily activities and functional use of living space. For example, a sink piled high with dishes and food containers may not be available for practical use. The accumulation of poorly organized possessions may restrict movement in the home to narrow winding pathways through the mounds of debris. Excessive accrual of debris may also extend to vehicles. A car stuffed with rags, take-out containers, old mail, cardboard, and rolls of paper towels may not accommodate passengers.

Perceived emotion regulation and emotional distress tolerance in patients with hoarding disorder

Emotional distress tolerance (EDT) and emotion regulation (ER) appear to be highly relevant to hoarding pathology, as excessive saving and/or acquiring may be motivated by emotional avoidance or other attempts to regulate negative affect. While findings with nonclinical samples have suggested and EDT/ER predicts hoarding symptoms, there is little data on clinical samples. The aim of the current study was to examine several self-report measures of EDT and ER in individuals with HD (n = 87) and age-matched nonclinical controls (n = 46), and to explore whether this was predictive of treatment compliance and/or outcome in group CBT for HD. Results suggested that, the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) total score, DERS goals and awareness subscales, and Intolerance of Uncertainty Scale (IUS; Buhr & Dugas, 2002) were predictive of hoarding severity. However, EDT/ER did not change with treatment, did not mediate treatment outcome, and did not predicted treatment retention, compliance, or outcome. Results suggest that some EDT/ER constructs, such as uncertainty intolerance, difficulty persisting in goal behaviors when upset, and low emotional awareness, may explain significant variance in HD symptoms, although they did not appear to be mechanisms of change in CBT for HD.

Distinct resting state functional connectivity abnormalities in hoarding disorder and major depressive disorder

Emerging research suggests that hoarding disorder (HD) is associated with abnormal hemodynamic activity in frontal brain regions. Prior studies have not examined intrinsic network connectivity in HD during unstructured "resting state" fMRI. Furthermore, it remains unclear whether previously observed HD abnormalities might be better explained by the presence of other disorders frequently comorbid with HD, such as major depressive disorder (MDD). The current study compared resting state functional connectivity in HD-only patients (n = 17), MDD-only patients (n = 8), patients with co-occurring HD and MDD (n = 10), and healthy control participants (n = 18). Using independent component analysis, we found that HD-only patients exhibited lower functional connectivity in a "task positive" cognitive control network, compared to the other three groups. The HD group also had greater connectivity in regions of the "task negative" default mode network than did the other groups. Findings suggest that HD is associated with a unique neurobiological profile, and are discussed in terms of recent neurological and neuropsychological findings and models in HD and related disorders.

Saving inventory - Revised: Psychometric performance across the lifespan

BACKGROUND

The Saving Inventory - Revised (SI-R) is the most widely used self-report measure of hoarding symptom severity. The goal of this study is to establish a firm empirical basis for a cutoff score on the SI-R and to examine the functioning of the SI-R as a screening tool and indicator of hoarding symptom severity across the lifespan.

METHODS

This study used archival data from 1,116 participants diagnosed with a clinical interview in 14 studies conducted by research groups who focus on hoarding. We used receiver operating characteristic (ROC) analysis and the Youden's J statistic to determine optimal cutoff scores for classifying participants who would be likely to receive a hoarding diagnosis.

RESULTS

Overall, the discriminant performance of the SI-R Total score and each of the three subscales was high, confirming the status of the SI-R is an excellent screening tool for differentiating hoarding from non-hoarding cases. The optimal SI-R Total cutoff score is 39, although analyses suggested that older adults require a significantly lower cutoff and adults younger than 40 years require a significantly higher cutoff score.

LIMITATIONS

The confidence interval around the optimal cutoff for the SI-R Total score for oldest age group was wide in comparison to those reported for the younger groups, creating more uncertainty around the optimal cutoff score for this group.

CONCLUSIONS

This paper provides investigators and clinicians with the data necessary to select evidence-based cutoff scores on the SI-R that optimally suit their relative need for sensitivity and specificity in different age groups.

A narrative synthesis of possible causes and risk factors of hoarding behaviours

BACKGROUND

Hoarding is a disorder characterized by excessive acquisition and persistent difficulty in discarding possessions. The behaviour has adverse emotional, physical, social, financial, and legal outcomes for the person with the disorder and family members, and might pose a significant public health problem. Hoarding has been included as a distinct disorder in the Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5). The prevalence of hoarding disorder is approximately 2-6% globally. The current state of the evidence does not offer clear understanding of the causes of hoarding behaviours. A systematic review of the extant literature was carried out to determine the possible causal factors of hoarding behaviours.

METHODS

This review is conducted in line with PRISMA guidelines. The following electronic databases: Medline through Ovid, EMBASE and PsycINFO were searched for relevant articles published between January 2000 and November 2018. Only articles published in English language were included. Two reviewers independently scrutinized the studies and included them in this review.

RESULTS

Our search strategy returned a total of 396 references. Preliminary findings suggest that individuals with hoarding behaviours may have a genetic susceptibility; abnormal neural activity in the fronto-temporal, para-hippocampal gyrus and insular parts of the brain has also been identified. Traumatic life experiences have also been posited to predispose individuals to hoard.

CONCLUSION

Although the understanding of hoarding disorder hasgrown in recent years, greater efforts are still needed to clarify the etiology and mechanisms of hoarding disorder as these may help in planning of more holistic interventions to treat the problem.

Applying attachment theory to indecisiveness in hoarding disorder

Research shows that individuals who experience distress when discarding their possessions are more indecisive than individuals who do not experience such difficulty. These individuals report more intense emotional responses and greater intolerance to distress when faced with a discarding task. The aim of this study was to determine whether an insecure attachment style contributes to indecisiveness among individuals with discarding difficulties and whether this association is mediated by emotional reactivity and distress intolerance. This study used a within-group cross-sectional design. One hundred fifty-six participants with clinically significant discarding problems (82.7% female; Mean age = 21.96, SD = 7.38) from a population of university students and community members completed self-report questionnaires that assessed severity of hoarding behaviours, insecure attachment styles, emotional reactivity, distress intolerance, and indecisiveness. Analyses revealed that an anxious attachment style was associated with greater indecisiveness, and this relationship was mediated by emotional reactivity, but not distress intolerance. Furthermore, avoidant attachment was not related to indecisiveness. Clinical interventions should consider the role of attachment styles in hoarding disorder and address emotional reactivity difficulties in treatment through the use of discarding exposures, as emotion plays an important role in these decision-making processes.

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

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

Discarding personal possessions increases psychophysiological activation in patients with hoarding disorder

Difficulty discarding is the core behavioral symptom of hoarding disorder (HD). Patients with HD report greater subjective distress when discarding their own possessions as compared to others' possessions. To date, no prior studies have examined psychophysiological activation, an objective measure of anxious arousal, during discarding among individuals with HD. The current study assessed psychophysiological responses during a baseline resting period and two discarding tasks, one involving personal possessions and the other involving matched control ("experimenter-owned") items in 52 patients with a primary diagnosis of HD. Results showed that, compared to discarding control items, discarding personal possessions increased skin conductance and heart rate and decreased end tidal carbon dioxide. There were no differences in heart rate variability, respiratory sinus arrhythmia, and respiration rate between the two discarding tasks. Despite the fact that discarding increased psychophysiological arousal, self-reported HD symptoms (including difficulty discarding) failed to predict psychophysiological responses during the discarding tasks. The findings suggest that there may be discordance between objective and subjective measures of hoarding-related distress, and are discussed in terms of incorporating psychophysiological measures into the assessment and treatment of HD.

An investigation of delay and probability discounting in hoarding disorder

Behavioral impulsivity may be a mechanism of hoarding disorder (HD). A commonly used and well-validated measure of impulsivity is the delay and probability discounting task, which consists of making decisions about receiving monetary rewards after varying delay intervals and delivery probabilities. We compared delay and probability discounting and self-reported behavioral impulsivity in 81 patients with a primary diagnosis of HD and 45 nonclinical controls. HD participants completed the impulsivity measures before and after 16 weekly sessions of cognitive-behavioral therapy (CBT), whereas control group participants completed the measures before and after a 16-week waiting period. Despite the fact that self-reported impulsivity was greater in the HD group than the control group, delay and probability discounting did not differ between groups. Additionally, while self-reported behavioral impulsivity improved over the course of CBT in HD participants, delay and probability discounting did not change during treatment. Furthermore, higher delay discounting scores (i.e., greater preference for immediate rewards, indicating greater impulsivity) were associated with lower hoarding symptom severity. The findings suggest that self-reported impulsivity, but not objective performance on a behavioral impulsivity task, may be impaired in HD, and are discussed in terms of cognitive and affective factors in decision-making.

Hoarding revisited: there is light at the end of the living room

Since 2013, hoarding disorder has been recognised as a standalone diagnosis in the DSM, affecting an estimated 2–6% of the general population. This article outlines the arguments for and against this separate classification and considers the differentiation of hoarding disorder from normative collecting. It then discusses aetiology, assessment, course and treatment (both psychological and pharmacological interventions). It concludes with a discussion of ethical and legal considerations, in particular the fact that the inclusion of hoarding disorder as a distinct diagnosis in DSM-5 confers specific protections for people with the disorder under the Equality Act 2010.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Object attachment: Humanness increases sentimental and instrumental values

BACKGROUND AND AIMS

People who hoard form intense attachments to their possessions and save items for sentimental and instrumental reasons. Feeling socially excluded may encourage these individuals to anthropomorphize objects (i.e., perceive them as human-like) to fulfill unmet belonging needs, which may increase the sentimental and instrumental values of objects, and then lead to stronger object attachment.

METHODS

We randomly assigned 331 participants with excessive acquisition tendencies to be excluded, included, or overincluded in an online ball-tossing game before presenting them with five objects that had human characteristics. Participants then completed measures assessing anthropomorphism, sentimental and instrumental values, and object attachment.

RESULTS

Inconsistent with this study hypothesis, socially excluded participants did not rate unowned objects as more human-like than the included or overincluded participants; however, stronger anthropomorphism predicted greater instrumental and sentimental values, which then predicted greater object attachment.

DISCUSSION AND CONCLUSIONS

Sentimental and instrumental values may explain how stronger anthropomorphism may lead to greater object attachment. Learning that leads to anthropomorphism may help us better understand object attachment.

Psychological and electrophysiological indices of inattention in hoarding

Individuals with elevated hoarding symptoms report elevated symptoms of ADHD and these symptoms are related to impaired daily functioning. Neuropsychological studies have found specific deficits in attention, and a recent review of attentional data from numerous hoarding studies concluded that inattention likely represents an etiological factor in hoarding, rather than a comorbidity. Our study aimed to examine which symptoms of ADHD, inattention or hyperactivity, are related to hoarding symptom severity, and whether individuals with hoarding symptoms display a neurophysiological marker of poor attention (Theta/Beta Ratio; THBR) that might explain these associations. The THBR indexes theta power relative to beta power in the frontal cortex and is often atypical in individuals with ADHD. We hypothesised that individuals would report more severe problems with inattention and would exhibit an elevated theta/beta ratio relative to a healthy control group. We also predicted that any relationship between hoarding and inattention would be independent of anxiety and depression symptoms. 17 hoarding-symptomatic participants and 16 healthy control participants completed self-report measures relating to ADHD, hoarding and general psychopathology, and then underwent resting measures of electroencephalography (EEG). Individuals with hoarding symptoms reported greater difficulties with inattention and hyperactivity, however they did not exhibit an elevated theta/beta ratio. When taking into account recent anxiety and depression, only inattention predicted hoarding symptom severity. Further investigations may help clarify this association and help inform attention-based treatments for hoarding.

A qualitative analysis of emotion and emotion regulation in hoarding disorder

OBJECTIVE

The role of emotion regulation (ER) has been receiving increased attention in relation to various forms of psychopathology including hoarding disorder (HD). However, questionnaire designs are limited to finding associations of ER with symptoms or symptom groups, without finding out how such constructs might be involved in the disorder.

METHODS

This study was a qualitative investigation of ER in a clinical HD sample (N = 11).

RESULTS

Prominent themes provided support for ER difficulties in hoarding. In particular, difficulties with identifying and describing feelings, unhelpful attitudes toward the emotional experience, the use of avoidance-based strategies, and a perceived lack of effective ER strategies were prominent themes. Furthermore, emotional factors were identified as being associated with the onset and/or exacerbation of hoarding behavior, and possessions and acquiring behavior appeared to serve an ER function.

CONCLUSION

The current paper provides a nuanced account of the role of ER in hoarding difficulties.

Deficits in physiological and self-conscious emotional response to errors in hoarding disorder

Hoarding disorder (HD) has been hypothesized to arise from deficits in error monitoring and abnormalities in emotional processing, but the relationship between error monitoring and emotional processing has not been examined. We examined measures of self-report, as well as behavioral, physiological, and facial responses to errors during a Stop-Change Task. 25 participants with HD and 32 healthy controls (HC) were recruited. Participants reported on number of errors committed and pre/post emotional response to errors. Skin conductance response (SCR) during correct and error commission trials was examined. Facial expression during task performance was coded for self-conscious and negative emotions. HD and HC participants had significantly different error rates but comparable error correction and post-error slowing. SCR was significantly lower for HD during error commission than for HC. During error trials, HD participants showed a significant deficit in displays of self-conscious emotions compared to HC. Self-reported emotions were increased in HD, with more negative and self-conscious emotion reported than was reported for HC participants. These findings suggest that hypoactive emotional responding at a physiological level may play a role in how errors are processed in individuals with HD.

Scared and surrounded by clutter: The influence of emotional reactivity

BACKGROUND

Home visits can improve treatment outcomes for hoarding disorder, but factors influencing the success of home visits remain unknown. As home visits expose individuals to clutter and fear, the present study examined the effect that fear and emotional reactivity have on the relationship between clutter and discarding behaviour.

METHODS

Participants with at least subclinical discarding problems (n = 143) were asked to save or discard personal possessions of varying value following an emotional induction that took place in either a tidy or cluttered context. Participants also completed questionnaires assessing hoarding severity, emotional state, and emotional reactivity, as defined by one's sensitivity, persistence, and intensity of reactions to emotional stimuli.

RESULTS

As expected, participants discarded more items in the presence of clutter and when feeling fearful. However, emotional reactivity moderated the relations between environmental context, acute emotional state, and discarding. Low sensitivity, low persistence, and high emotional intensity negatively influenced discarding in the cluttered context. When feeling fearful, low dispositional emotional intensity negatively influenced discarding in the tidy context.

LIMITATIONS

Individuals in the tidy environment reported higher levels of fear and anxiety than individuals in the cluttered environment after the fear induction. These differences could have contributed to the difference noted between the two contexts when examining the effect of emotional intensity tendencies.

CONCLUSIONS

Providing treatment in an environment more representative of the cluttered home can improve discarding or at the very least give therapists a more accurate picture of what clients do in the context that matters most.

A unique increase in prefrontal gray matter volume in hoarding disorder compared to obsessive-compulsive disorder

Background

Hoarding disorder (HD) is a disease concept newly presented in DSM-5. As far as we know, no studies have examined the structural changes relevant to hoarding by applying the diagnostic criteria of HD in DSM-5. In the present study, we aimed to find abnormalities in gray matter (GM) structures of patients with HD.

Methods

Seventeen patients who met the DSM-5 criteria for HD, 17 obsessive-compulsive disorder (OCD) patients, and 17 healthy controls (HCs) participated in this study. All participants underwent MRI scanning of the brain by a 3.0-Tesla MRI scanner. In a voxel-based morphometric procedure, preprocessed GM structural images were used to compare the three groups. Thereafter we investigated the correlation between the clinical data (age of onset, symptomatic severity) and GM volume.

Results

The HD group showed a significantly increased GM volume compared to the OCD and healthy control groups (p<0.05) in both Brodmann area (BA)10 and BA11. There was no significant difference between OCD and healthy control groups. No significant correlation between the clinical data including age of onset, symptom severity score, and GM volume was observed in HD and OCD groups.

Conclusions

The results might help to explain the inconsistency of previous studies. As with OCD, HD is considered to have cognitive dysfunction as its basis. This result is convincing after considering the clinical features of HD and suggested that structural abnormalities in the prefrontal regions might relate to the pathophysiology of HD.

Relationship between symptom dimensions and brain morphology in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is known as a clinically heterogeneous disorder characterized by symptom dimensions. Although substantial numbers of neuroimaging studies have demonstrated the presence of brain abnormalities in OCD, their results are controversial. The clinical heterogeneity of OCD could be one of the reasons for this. It has been hypothesized that certain brain regions contributed to the respective obsessive-compulsive dimensions. In this study, we investigated the relationship between symptom dimensions of OCD and brain morphology using voxel-based morphometry to discover the specific regions showing alterations in the respective dimensions of obsessive-compulsive symptoms. The severities of symptom dimensions in thirty-three patients with OCD were assessed using Obsessive-Compulsive Inventory-Revised (OCI-R). Along with numerous MRI studies pointing out brain abnormalities in autistic spectrum disorder (ASD) patients, a previous study reported a positive correlation between ASD traits and regional gray matter volume in the left dorsolateral prefrontal cortex and amygdala in OCD patients. We investigated the correlation between gray and white matter volumes at the whole brain level and each symptom dimension score, treating all remaining dimension scores, age, gender, and ASD traits as confounding covariates. Our results revealed a significant negative correlation between washing symptom dimension score and gray matter volume in the right thalamus and a significant negative correlation between hoarding symptom dimension score and white matter volume in the left angular gyrus. Although our result was preliminary, our findings indicated that there were specific brain regions in gray and white matter that contributed to symptom dimensions in OCD patients.

Transcranial magnetic stimulation in obsessive-compulsive disorder: A focus on network mechanisms and state dependence

Background

Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation technique that has shown promise as an adjunct treatment for the symptoms of Obsessive-Compulsive Disorder (OCD). Establishing a clear clinical role for TMS in the treatment of OCD is contingent upon evidence of significant efficacy and reliability in reducing symptoms.

Objectives

We present the basic principles supporting the effects of TMS on brain activity with a focus on network-based theories of brain function. We discuss the promises and pitfalls of this technique as a means of modulating brain activity and reducing OCD symptoms.

Methods

Synthesis of trends and critical perspective on the potential benefits and limitations of TMS interventions in OCD.

Findings

Our critical synthesis suggests the need to better quantify the role of TMS in a clinical setting. The context in which the stimulation is performed, the neural principles supporting the effects of local stimulation on brain networks, and the heterogeneity of neuroanatomy are often overlooked in the clinical application of TMS. The lack of consideration of these factors may partly explain the variable efficacy of TMS interventions for OCD symptoms.

Conclusions

Results from existing clinical studies and emerging knowledge about the effects of TMS on brain networks are encouraging but also highlight the need for further research into the use of TMS as a means of selectively normalising OCD brain network dynamics and reducing related symptoms. The combination of neuroimaging, computational modelling, and behavioural protocols known to engage brain networks affected by OCD has the potential to improve the precision and therapeutic efficacy of TMS interventions. The efficacy of this multimodal approach remains, however, to be established and its effective translation in clinical contexts presents technical and implementation challenges. Addressing these practical, scientific and technical issues is required to assess whether OCD can take its place alongside major depressive disorder as an indication for the use of TMS.

Self-reported executive function and hoarding in adults with obsessive-compulsive disorder

BACKGROUND

Hoarding behavior may distinguish a clinically and possibly etiologically distinct subtype of obsessive-compulsive disorder (OCD). Little is known about the relationship between executive dysfunction and hoarding in individuals with OCD.

METHODS

The study sample included 431 adults diagnosed with DSM-IV OCD. Participants were assessed by clinicians for Axis I disorders, personality disorders, indecision, and hoarding. Executive functioning domains were evaluated using a self-report instrument, the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A). We compared scores on these domains in the 143 hoarding and 288 non-hoarding participants, separately in men and women. We used logistic regression to evaluate relationships between executive function scores and hoarding, and correlation and linear regression analyses to evaluate relationships between executive function scores and hoarding severity, in women.

RESULTS

In men, the hoarding group had a significantly higher mean score than the non-hoarding group only on the shift dimension. In contrast, in women, the hoarding group had higher mean scores on the shift scale and all metacognition dimensions, i.e., those that assess the ability to systematically solve problems via planning and organization. The relationships in women between hoarding and scores on initiating tasks, planning/organizing, organization of materials, and the metacognition index were independent of other clinical features. Furthermore, the severity of hoarding in women correlated most strongly with metacognition dimensions.

CONCLUSIONS

Self-reported deficits in planning and organization are associated with the occurrence and severity of hoarding in women, but not men, with OCD. This may have implications for elucidating the etiology of, and developing effective treatments for, hoarding in OCD.

Hoarding Disorder and Difficulties in Emotion Regulation

The present study aimed to examine self-reported deficits in emotion regulation (ER) among individuals with hoarding disorder (HD). Seventy-seven adult outpatients with HD and 45 age- and gender-matched healthy control (HC) participants received a diagnostic assessment and completed self-report measures of hoarding severity, depression, and anxiety. In addition, participants completed the Difficulties in Emotion Regulation Scale (DERS), which measures lack of emotional clarity (Clarity), difficulty regulating behavior when distressed (Impulse), difficulty engaging in goal-directed cognition and behavior when distressed (Goals), unwillingness to accept emotional responses (Accept), and lack of access to strategies for feeling better when distressed (Strategies). The HD group scored higher on all DERS subscales than did the HC group; self-reported ER deficits remained evident when controlling for baseline depression, anxiety, and stress. The DERS correlated significantly with hoarding severity in the HD group: acquiring was significantly correlated with DERS Impulse, Strategies, and Accept; saving was significantly correlated with DERS Accept. Correlations remained significant when controlling for depression, anxiety, and stress. Results suggest that HD is characterized by self-reported deficits in ER, and that this relationship is not solely attributable to high levels of depression and anxiety.