Randomized waitlist-controlled trial of buried in treasures facilitated support groups and in-home uncluttering (BIT+) for hoarding disorder

OBJECTIVE

The Buried in Treasures (BIT) workshop is a promising treatment for hoarding disorder (HD), though many participants struggle with home uncluttering. This randomized waitlist-controlled trial investigated the efficacy of a version of BIT, augmented with in-home uncluttering practice (BIT+).

METHOD

Adults (N = 41) with hoarding disorder were recruited from the community and randomly assigned to BIT+ or waitlist. BIT+ consisted of 16 sessions of the BIT workshop and 10 uncluttering home visits over 18 weeks. Outcome measures included the Saving Inventory-Revised (self-report) and the Clutter Image Rating Scale (self and independent evaluator rated). Between group repeated measures analyses using general linear modeling examined the effect of BIT+ vs waitlist control on hoarding symptoms after 18 weeks. Within group analyses examined pre-post effects for all BIT+ participants combined after 18 weeks.

RESULTS

After 18 weeks, BIT+ participants benefited significantly more than waitlist controls on hoarding severity with large effect size (Cohen's d = 1.5, p < .001). BIT+ was also associated with improvement reductions in hoarding symptoms, clutter, and functional impairment.

CONCLUSIONS

The BIT+ intervention offers promise as a treatment option for hoarding. Adding in-home uncluttering practice may incrementally improve discarding practices. Future controlled trials are warranted.

Hoarding behavior and its association with mental health and functioning in a large youth sample

Hoarding behavior is prevalent in children and adolescents, yet clinicians do not routinely inquire about it and youth may not spontaneously report it due to stigma. It is unknown whether hoarding behavior, over and above obsessive-compulsive symptoms (OCS), is associated with major clinical factors in a general youth population. This observational study included N = 7054 youth who were not seeking help for mental health problems (ages 11-21, 54% female) and completed a structured interview that included evaluation of hoarding behavior and OCS, as a part of the Philadelphia Neurodevelopmental Cohort between November 2009 and December 2011. We employed regression models with hoarding behavior and OCS (any/none) as independent variables, and continuous (linear regression) or binary (logistic regression) mental health measures as dependent variables. All models covaried for age, sex, race, and socioeconomic status. A total of 374 participants endorsed HB (5.3%), most of which reported additional OCS (n = 317). When accounting for OCS presence, hoarding behavior was associated with greater dimensional psychopathology burden (i.e., higher P-factor) (β = 0.19, p < .001), and with poorer functioning (i.e., lower score on the child global assessment scale) (β = - 0.07, p < .001). The results were consistent when modeling psychopathology using binary variables. The results remained significant in sensitivity analyses accounting for count of endorsed OCS and excluding participants who met criteria for obsessive-compulsive disorder (n = 210). These results suggest that hoarding behavior among youth is associated with poorer mental health and functioning, independent of OCS. Brief hoarding-behavior assessments in clinical settings may prove useful given hoarding behavior's stigma and detrimental health associations.

Written Imaginal Exposure for Hoarding Disorder: A Preliminary Pilot Study

ABSTRACT

Hoarding disorder (HD) is marked by difficulty discarding possessions. Many refuse treatment or drop out, which may be due to treatment's incorporation of in-home decluttering, which is feared and avoided. Thus, strategies to prepare patients for decluttering/discarding are needed. Imaginal exposure (IE), or imagining one's worst fears about discarding, could be one such strategy. This pilot preliminarily tested a short-duration IE intervention compared with a control intervention. Over 3 days, adults diagnosed with HD (n = 32) were randomly assigned to either write about and imagine their worst fears about discarding (IE condition) or a neutral topic (control writing [CW] condition). The IE condition showed significant improvements in HD symptoms from preintervention to 1-week follow-up, with medium to large effects; however, the CW condition did as well. Comparing change scores between conditions, the IE condition's improvements were not significantly different than the CW condition's. Overall, IE was helpful in improving HD symptoms, but this pilot did not indicate that it was more helpful than CW. This raises important questions about possible demand characteristics, placebo effects, or regression to the mean, and it has implications for the design and methodology of other studies assessing IE's utility.

Hard to let it go: repetitive negative thinking and hoarding in later life in Japan

Objectives: Hoarding in older adults can have a detrimental effect on daily life. Repetitive negative thinking (RNT) could result in a greater avoidance of discarding and increased saving behaviors; yet, the unique role of RNT on hoarding in older adults remains understudied. This study aimed to investigate whether the intensity of RNT contributes to hoarding in older adults. Methods: Two hundred and sixty-four older adults in Japan (ages 65-86 years, 132 males and 132 females) participated in an online survey. Hierarchical regression analyses were conducted to examine whether RNT could significantly explain the variance of hoarding after controlling for age, sex, years of education, self-reported cognitive impairment, and depression. Results: As we expected, RNT was significantly associated with greater hoarding behaviors, such as excessive acquisition (β = .27, p = .005) and difficulty in discarding (β = .27, p = .003). On the other hand, reflection, repetitive thinking without negative emotional valence, was significantly associated with higher scores on clutter (β = .36 p < .001). Conclusion: Our findings highlight the importance of addressing RNT in the prevention and treatment of hoarding symptoms among older adults, potentially leading to more effective interventions and improved outcomes in managing hoarding behaviors in this population.

Translating and validating the hoarding rating scale-self report into Arabic

BACKGROUND

Hoarding disorder is characterized by a persistent inability to part with possessions due to a perceived need to keep them, regardless of their actual value. Arabic-speaking populations currently lack a validated tool specifically designed to assess hoarding symptoms.

OBJECTIVE

This study aimed to translate, adapt, and validate the Hoarding Rating Scale-Self Report (HRS-SR) into the Arabic-language.

METHODS

The study employed the gold standard approach to translation, involving forward translation by independent translators and back translation review. We conducted a cross-sectional study using an online survey completed by 500 participants from four Arabic-speaking countries. Psychometric analyses included internal consistency, test-retest reliability, convergent validity against generalized anxiety disorder (GAD-7), and confirmatory factor analysis.

RESULTS

With a McDonald's omega and Cronbach's alpha of approximately 0.80, the Arabic translation of the HRS-SR showed acceptable test-retest reliability as well as good internal consistency. The survey also showed strong convergent validity with the 7-item survey for GAD-7. Confirmatory factor analysis supported a one-factor structure, confirming that each item measured the same construct.

CONCLUSION

The HRS-SR is a trustworthy and valid tool for evaluating hoarding symptoms in Arabic-speaking people. This survey could be helpful for both clinical and academic research. Future research should examine cultural variations in hoarding behavior in Arabic-speaking populations and validate the questionnaire in clinical populations.

Reactance, Decisional Procrastination, and Hesitation: A Latent Class Analysis of Clutter Behavior

During the 2019-2020 global pandemic, mandated time at home suggested engagement in personal projects, such as home decluttering. Clutter (an overabundance of possessions) may impede one's quality of life by interfering with space livability and social connections and prompting negative affect and financial problems. The present study explored action-state orientation, psychological reactance, and decisional procrastination with 227 American adults (M age = 49.9 years old). A latent class analysis tested for differences in cognition across groups. Results supported that persons who struggle with clutter reflect clusters or "classes" given their self-reported cognitive processes, with hesitant and indecisive participants experiencing greater negative impacts of clutter than action-oriented and decisive participants. Our findings suggested improving the decision-making and goal-directed capacities of those struggling with clutter may be effective as preventive and/or interventive strategies. Future research might consider when hesitation to initiate challenging tasks and indecision emerge in the decluttering timeline and how those who are prone to these cognitions may be supported in managing their personal possessions.

Animal Protection, Law Enforcement, and Occupational Health: Qualitative Action Research Highlights the Urgency of Relational Coordination in a Medico-Legal Borderland

Simple Summary

In this article, we report on action research in the Canadian province of Alberta, based on forging alliances with officers who enforce federal, provincial, and municipal legislation involving animals. Some of these officers worked in rural areas, and others worked in urban areas. Some mainly enforced Alberta’s Animal Protection Act, while a few specialized in enforcing Canada’s Criminal Code. For the most part, however, participating officers had a mandate to enforce animal-related local bylaws. Such ordinances or rulebooks exist because Alberta’s Municipal Government Act allows local councils to enact legislation regarding domestic and wild animals, particularly as regards people’s health, property, safety, and welfare. Many professionals refer to policies such as these, which are deeply rooted in the western legal tradition, such as “animal control.” Our findings illuminate how animal-control policies and personnel can help to protect domesticated animals, not just people. Even so, our research highlights that animal-control policies as well as animal-protection policies routinely fail to protect officers who enforce legislation involving animals. Furthermore, whenever officers who enforce legislation involving animals work in unsafe conditions, this endangers human as well as non-human lives.

Abstract

Across Canada and internationally, laws exist to protect animals and to stop them from becoming public nuisances and threats. The work of officers who enforce local bylaws protects both domestic animals and humans. Despite the importance of this work, research in this area is emergent, but growing. We conducted research with officers mandated to enforce legislation involving animals, with a focus on local bylaw enforcement in the province of Alberta, Canada, which includes the city of Calgary. Some experts regard Calgary as a “model city” for inter-agency collaboration. Based on partnerships with front-line officers, managers, and professional associations in a qualitative multiple-case study, this action-research project evolved towards advocacy for occupational health and safety. Participating officers spoke about the societal benefits of their work with pride, and they presented multiple examples to illustrate how local bylaw enforcement contributes to public safety and community wellbeing. Alarmingly, however, these officers consistently reported resource inadequacies, communication and information gaps, and a culture of normalized disrespect. These findings connect to the concept of “medico-legal borderlands,” which became central to this study. As this project unfolded, we seized upon opportunities to improve the officers’ working conditions, including the potential of relational coordination to promote the best practices.

Identifying adolescents with hoarding disorder

Hoarding disorder is a relatively new diagnosis in the DSM-5, only just included in the most recent edition. The disorder has piqued the interest of many in the community, in part because of the hit TV show called "Hoarders." Although there is interest, there continues to be relatively few research studies into the causes, treatment, and management of this disorder specifically in adolescences. Yet, in the research that has been published, it often sites the disorder first appearing in adolescents. This paper will discuss the following elements of adolescent hoarding disorder: The potential etiology and risk factors noted in the literature, the DSM-5 criteria for the diagnosis of hoarding disorder, and the characteristic signs and symptoms found in the adolescent presentation, as well as treatment. Finally, it will also include recommendations for healthcare professionals for early screening and treatment.

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.

Psychopathological Comorbid Symptoms in Animal Hoarding Disorder

The main goal of this research is to describe the psychopathological symptoms comorbid to animal hoarding disorder. This is a cross-sectional study with a sample of a 33 individuals sample diagnosed with animal hoarding disorder. For data collection, a Sociodemographic Data questionnaire and a Semi-Structured Clinical Interview were used, based on the DSM-5 Level 1 Cross-Cutting Symptom Measure. The sample consisted of 24 women (72.7%) and 9 men (27.30%), with a prevalence of 64% of the elderly. The mean number of self-reported animals per residence was 41.12 (DP = 24.41), totaling 1357 animals: 915 (68%) dogs, 382 (28%) cats, and 50 (4%) ducks. The results indicated animal hoarding disorder the comorbid psychopathological symptoms of depression (36%), anxiety (36%), memory deficits (27%), mania (21%) and obsessive-compulsive disorder (18%). The analyses revealed a higher occurrence of these symptoms among participants who had hoarded animals for over 20 years.

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.

Pharmacotherapy for Hoarding Disorder: How did the Picture Change since its Excision from OCD?

This brief review deals with the various issues that contributed to the creation of the new Diagnostic and Statistical Manual condition of hoarding disorder (HD) and attempts at reviewing its pharmacotherapy. It appears that after the newly founded diagnosis appeared in the literature as an autonomous entity, distinct from obsessive-compulsive disorder, drug trials are not being conducted and the disorder is left in the hands of psychotherapists, who on their part, report fair results in some core dimensions of HD. The few trials on HD specifically regard the serotonin-noradrenaline reuptake inhibitor venlafaxine, and, possibly due to the suggestion of a common biological background of HD with attention-deficit/hyperactivity disorder, the psychostimulant methylphenidate and the noradrenaline reuptake inhibitor atomoxetine. For all these drugs, positive results have been reported, but the evidence level of these studies is low, due to small samples and non-blind designs. Regretfully, there are currently no future studies aiming at seriously testing drugs in HD.

Can Occupational Therapy Address the Occupational Implications of Hoarding?

Hoarding is often described as a medical disorder, defined by a persistent difficulty in discarding possessions and associated high levels of emotional distress when forced to part with these. This article will discuss how having a different view of hoarding, seeing hoarding as a daily occupation which provides value, purpose, and meaning and with a relationship to self-identity and life purpose, could offer alternate interventions to support an individual who hoards. The article will consider the components of hoarding activity and how these relate to health and wellbeing and doing, being, belonging, and becoming as understood by occupational therapists. The article will consider what occupational therapy, a profession which considers a person's daily occupations, the things that occupy their time and which give meaning to their existence, could offer as an alternative to current hoarding interventions. Proposals for occupational therapy interventions will be suggested which would support occupational choice, support engagement in activities which have more positive outcomes on a person's health, and seek to address barriers which limit engagement and occupational performance in activities within the person's home environment.

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.

Augmenting Buried in Treasures with in-home uncluttering practice: Pilot study in hoarding disorder

Hoarding disorder is characterized by difficulty parting with possessions and by clutter that impairs the functionality of living spaces. Cognitive behavioral therapy conducted by a therapist (individual or in a group) for hoarding symptoms has shown promise. For those who cannot afford or access the services of a therapist, one alternative is an evidence-based, highly structured, short-term, skills-based group using CBT principles but led by non-professional facilitators (the Buried in Treasures [BIT] Workshop). BIT has achieved improvement rates similar to those of psychologist-led CBT. Regardless of modality, however, clinically relevant symptoms remain after treatment, and new approaches to augment existing treatments are needed. Based on two recent studies - one reporting that personalized care and accountability made treatments more acceptable to individuals with hoarding disorder and another reporting that greater number of home sessions were associated with better clinical outcomes, we tested the feasibility and effectiveness of adding personalized, in-home uncluttering sessions to the final weeks of BIT. Participants (n = 5) had 15 sessions of BIT and up to 20 hours of in-home uncluttering. Reductions in hoarding symptoms, clutter, and impairment of daily activities were observed. Treatment response rate was comparable to rates in other BIT studies, with continued improvement in clutter level after in-home uncluttering sessions. This small study suggests that adding in-home uncluttering sessions to BIT is feasible and effective.

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.

The need to consume: Hoarding as a shared psychological feature of compulsive buying and binge eating

INTRODUCTION

Compulsive buying and binge eating are two frequently co-occurring psychiatric conditions. Hoarding, which is the psychological need to excessively gather and store items, is frequently associated with both compulsive buying severity and binge eating severity. In the present study, we explored whether different dimensions of hoarding are a shared feature of compulsive buying and binge eating.

METHOD

Participants consisted of 434 people seeking treatment for compulsive buying disorder. Registered psychiatrists confirmed the diagnosis of compulsive buying through semi-structured clinical interviews. Participants also completed measures to assess compulsive buying severity, binge eating severity, and dimensions of hoarding (acquisition, difficulty discarding, and clutter). Two-hundred and seven participants completed all three measures.

RESULTS

Significant correlations were found between compulsive buying severity and the acquisition dimension of hoarding. Binge eating severity was significantly correlated with all three dimensions of hoarding. Hierarchical regression analysis found that compulsive buying severity was a significant predictor of binge eating severity. However, compulsive buying severity no longer predicted binge eating severity when the dimensions of hoarding were included simultaneously in the model. Clutter was the only subscale of hoarding to predict binge eating severity in step two of the regression analysis.

CONCLUSION

Our results suggest that the psychological need to excessively gather and store items may constitute a shared process that is important in understanding behaviors characterized by excessive consumption such as compulsive buying and binge eating.

"Blended" therapy: The development and pilot evaluation of an internet-facilitated cognitive behavioral intervention to supplement face-to-face therapy for hoarding disorder

Mixed findings regarding the long-term efficacy of cognitive behavior therapy (CBT) for the treatment of hoarding has led to the investigation of novel treatment approaches. "Blended" therapy, a combination of face-to-face (f2f) and online therapy, is a form of therapy that enables longer exposure to therapy in a cost-effective and accessible format. Blended therapy holds many benefits, including increased access to content, lower time commitment for clinicians, and lower costs. The aim of the present study was to develop and evaluate a "blended" treatment program for hoarding disorder (HoPE), involving 12-weeks of face-to-face group therapy, and an 8 week online therapist assisted program. A sample of 12 participants with hoarding symptomology were recruited from the Melbourne Metropolitan area, and were involved in one of two conditions; 12 weeks group therapy +8 weeks online therapy (bCBT) or 12 weeks group therapy +8 weeks waitlist +8 weeks online therapy. Questionnaires were completed at all time points. The 8-week online component consists of 8 CBT-based modules, addressing psychoeducation, goal setting, motivation, relapse prevention and other key components. No significant differences were found over time between the bCBT group and waitlist control group, however trends suggested continued improvement in overall hoarding scores for the bCBT group, when compared to the waitlist control group. There were significant differences in scores from pre-treatment to 28 weeks, suggesting that all participants who were involved in the online intervention showed continued improvement from pre-treatment to post-treatment. This study highlights the potential benefit of novel formats of treatment. Future research into the efficacy of blended therapy would prove beneficial.

Hoarding in the elderly: a critical review of the recent literature

BACKGROUND

Hoarding is now a stand-alone diagnosis in DSM-5. The objective of this review is to critically evaluate the most recent literature on hoarding disorder (HD) in ageing patients.

METHODS

A literature search was conducted using PubMed and PsychINFO to identify papers from 2000 to 2015 that examined HD and hoarding symptoms in late-life participants.

RESULTS

Thirteen studies met inclusion criteria. Selected studies had significant methodological limitations with regard to participant sampling, diagnostic criteria, and methods for identifying co-morbid conditions. Hoarding in the elderly generally had onset before age 40 years, increased in severity after middle age, and was linked with social isolation. Depression was associated with hoarding in 14-54% of geriatric cases. Co-morbid anxiety and PTSD were also found. A variety of medical conditions were more common in seniors with hoarding including arthritis and sleep apnea. Late-life hoarding was associated with deficits in memory, attention, and executive function.

CONCLUSIONS

HD in the elderly has distinct features. A combination of self-neglect, psychiatric and medical co-morbidities, and executive dysfunction may contribute to the progression of hoarding symptoms in the elderly.

Hoarding in Children and Adolescents: A Review

The diagnostic conceptualization of hoarding has recently changed, and yet the application of these changes to hoarding in youth remains to be clarified. In this review we examine the literature on hoarding in youth. We discuss issues related to the assessment of pediatric hoarding, and the nature of hoarding in youth. We consider evidence for hoarding disorder as a distinct diagnosis in youth, and review the relationship between pediatric hoarding and other psychiatric disorders. Finally, we describe preliminary models of treatment for pediatric hoarding. We conclude that there is support for hoarding disorder as a distinct diagnosis in youth. However, more precise and developmentally appropriate assessment tools are needed to provide stronger evidence for this claim and to further our knowledge of prevalence and associated clinical characteristics. Although there is no evidence-based treatment for pediatric hoarding, preliminary evidence from case studies suggests that cognitive and behavioral methods may have promise.

Examining the Link Between Hoarding Symptoms and Cognitive Flexibility Deficits

Executive functioning deficits have been found to underlie primary symptoms of hoarding, such as difficulty discarding belongings and significant clutter. Cognitive flexibility-the ability to inhibit irrelevant material and attend flexibly between different mental sets-may be impaired as well, as individuals experience difficulty staying on task and are often distracted by specific possessions that tend to evoke an exaggerated emotional response. The present study investigated cognitive flexibility deficits via eye-tracking technology as a novel approach. Participants (N=69) with high and low self-reported hoarding symptoms were asked to respond to a series of auditory cues requiring them to categorize a small target number superimposed on one of three distractor image types: hoarding, nature, or a blank control. Across a range of behavioral and eye-tracking outcomes (including reaction time, accuracy rate, initial orientation to distractors, and viewing time for distractors), high hoarding participants consistently demonstrated greater cognitive inflexibility compared to the low hoarding group. However, high hoarding participants did not evidence context-dependent deficits based on preceding distractor types, as performance did not significantly differ as a function of hoarding versus nature distractors. Current findings indicate a pervasive, more global deficit in cognitive flexibility. Those with hoarding may encounter greater difficulty disengaging from previous stimuli and attending to a given task at hand, regardless of whether the context of the distractor is specifically related to hoarding. Implications and future directions for clarifying the nature of cognitive inflexibility are discussed.

A case of digital hoarding

A 47-year-old man presented to our outpatient clinic, preoccupied with hoarding of digital pictures, which severely interfered with his daily functioning. He was formerly diagnosed with autism and hoarding of tactile objects. As of yet, digital hoarding has not been described in the literature. With this case report, we would like to introduce 'digital hoarding' as a new subtype of hoarding disorder. We conclude with differential diagnostic considerations and suggestions for treatment.

Obsessive-compulsive disorder (OCD): Practical strategies for pharmacological and somatic treatment in adults

This narrative review gathers together a range of international experts to critically appraise the existing trial-based evidence relating to the efficacy and tolerability of pharmacotherapy for obsessive compulsive disorder in adults. We discuss the diagnostic evaluation and clinical characteristics followed by treatment options suitable for the clinician working from primary through to specialist psychiatric care. Robust data supports the effectiveness of treatment with selective serotonin reuptake inhibitors (SSRIs) and clomipramine in the short-term and the longer-term treatment and for relapse prevention. Owing to better tolerability, SSRIs are acknowledged as the first-line pharmacological treatment of choice. For those patients for whom first line treatments have been ineffective, evidence supports the use of adjunctive antipsychotic medication, and some evidence supports the use of high-dose SSRIs. Novel compounds are also the subject of active investigation. Neurosurgical treatments, including ablative lesion neurosurgery and deep brain stimulation, are reserved for severely symptomatic individuals who have not experienced sustained response to both pharmacological and cognitive behavior therapies.

Relationship between autistic traits and hoarding in a large non-clinical Chinese sample: mediating effect of anxiety and depression

Researchers and clinical practitioners have found that hoarding appears in many autism patients and that most of these patients show high anxiety and depression. There is no consensus on the relationship between autistic traits and hoarding, and little research concerning the role of negative emotions. This study investigated the relationship between autistic traits and hoarding in a large non-clinical Chinese sample. Participants were 3,229 university students (M age = 20.5 yr., SD = 1.6; 1,839 men) who were recruited in classroom. They completed measures of hoarding, autistic symptomology, anxiety, and depression: specifically the Saving Inventory-Revised, the Autism-Spectrum Quotient, the Zung Self-Rating Anxiety Scale, and The Center for Epidemiological Studies Depression Scale. Mediating effects of anxiety and depression in the correlation between autistic traits and hoarding were also explored. There was a weak but significant correlation between autistic traits and hoarding. Significant mediating effects of anxiety and depression were observed. Hoarding in people with high autistic traits could be influenced by anxiety and depression.

Neuropsychological and neurophysiological insights into hoarding disorder

Hoarding disorder (HD) is associated with significant personal impairment in function and constitutes a severe public health burden. Individuals who hoard experience intense distress in discarding a large number of objects, which results in extreme clutter. Research and theory suggest that hoarding may be associated with specific deficits in information processing, particularly in the areas of attention, memory, and executive functioning. There is also growing interest in the neural underpinnings of hoarding behavior. Thus, the primary aim of this review is to summarize the current state of evidence regarding neuropsychological deficits associated with hoarding and review research on its neurophysiological underpinnings. We also outline the prominent theoretical model of hoarding and provide an up-to-date description of empirically based psychological and medical treatment approaches for HD. Finally, we discuss important future avenues for elaborating our model of HD and improving treatment access and outcomes for this disabling disorder.

Creativity, personality, and hoarding behavior

Compulsive hoarding is a debilitating illness that is characterized by excessive collection of and failure to discard items, irrespective of their uselessness or hazardousness. Anecdotal evidence suggests that individuals who hoard may be more creative than individuals without hoarding behavior; however, this hypothesis has never been tested empirically. In the present study, we examined the relationship between hoarding symptoms and performance on a series of creativity measures. We also explored the extent to which hoarding symptoms were associated with factors such as personality, impulsivity, distress tolerance, and attitudes about money and the environment. Our findings revealed no significant associations between hoarding behavior and any measure of creativity. Hoarding behavior was also unrelated to attitudes about money or concern about the environment. However, consistent with previous research, hoarding tendencies were correlated with higher levels of neuroticism and impulsivity, as well as with lower levels of conscientiousness and distress tolerance. Implications of these findings are discussed.

DSM 5 and child psychiatric disorders: what is new? What has changed?

The significant changes in DSM 5 as these relate to a number of the child psychiatric disorders are reviewed by several authors in this special issue: In this paper we address some of the changes in the conceptual organisation of DSM 5 and specifically focus on anxiety and related disorders. In the case of child and adolescent psychiatry, the most notable feature is that the chapter on Disorders Usually First Diagnosed in infancy, Childhood or Adolescence has been deleted. Instead, a new chapter in DSM 5 describes Neurodevelopmental Disorders which typically manifest early in development. Further, an expectation had been built that DSM would be based on the latest data in neuroscience and that a clear direction towards a mixed dimensional and categorical approach would be evident. This has been the case with some disorders and a notable example is the removal of Obsessive Compulsive Disorder (OCD) from the Anxiety Disorder chapter and placement with other related disorders that share similar neurobiology and treatment response. In this regard, the addition in DSM 5 of a new specifier "tic-related" to OCD is worth noting as there is emerging evidence that differential treatment response exists when tics are associated with OCD. The same situation applies to tics with ADHD, thus presenting the argument for a dimensional approach to Tic Spectrum Disorder (TSD) incorporating categories such as those with tics only, tics with OCD, tics with ADHD etc. to be given due consideration in the future. Another important change that clinicians in the field of child psychiatry will no doubt notice is the demise of the multiaxial classification. Instead, DSM 5 has moved back to a nonaxial documentation of diagnosis with separate notations for important psychosocial and contextual factors as well as level of functioning and disability. Clinicians are urged, however, to continue to recognise the need to understand how symptoms and behaviours might have arisen and assess relevant contextual factors such as the family relationships, quality of care, any history of abuse, and so on. Further, the move to harmonise DSM 5 with the structure of ICD 11 (scheduled for release in 2015) should make understanding and familiarising oneself with the two major classificatory systems easier in the future.

Meta-analysis: hoarding symptoms associated with poor treatment outcome in obsessive-compulsive disorder

DSM-5 recognizes hoarding disorder as distinct from obsessive-compulsive disorder (OCD), codifying a new consensus. Hoarding disorder was previously classified as a symptom of OCD and patients received treatments designed for OCD. We conducted a meta-analysis to determine whether OCD patients with hoarding symptoms responded differently to traditional OCD treatments compared with OCD patients without hoarding symptoms. An electronic search was conducted for eligible studies in PubMed. A trial was eligible for inclusion if it (1) was a randomized controlled trial, cohort or case-control study; (2) compared treatment response between OCD patients with and those without hoarding symptoms, or examined response to treatment between OCD symptom dimensions (which typically include hoarding) and (3) examined treatment response to pharmacotherapy, behavioral therapy or their combination. Our primary outcome was differential treatment response between OCD patients with and those without hoarding symptoms, expressed as an odds ratio (OR). Twenty-one studies involving 3039 total participants including 304 with hoarding symptoms were included. Patients with OCD and hoarding symptoms were significantly less likely to respond to traditional OCD treatments than OCD patients without hoarding symptoms (OR=0.50 (95% confidence interval 0.42-0.60), z=-7.5, P<0.0001). This finding was consistent across treatment modalities. OCD patients with hoarding symptoms represent a population in need of further treatment research. OCD patients with hoarding symptoms may benefit more from interventions specifically targeting their hoarding symptoms.

Prevalence and heritability of obsessive-compulsive spectrum and anxiety disorder symptoms: A survey of the Australian Twin Registry

While past twin studies indicate moderate levels of heritability of "obsessive-compulsive related" and anxiety disorder symptoms, no single study has reported such estimates in the same twin population nor examined potential genetic sex differences. We assessed symptoms of obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, hypochondriasis, panic disorder, social phobia and generalized anxiety disorder in 2,495 adult twins (1,468 female). Prevalence estimates for the corresponding symptom measures were determined using empirically derived cut-off scores. Twin resemblance was assessed by Pearson correlations and biometrical model-fitting analyses, incorporating sex-specific effects, using OpenMx. Prevalence estimates ranged from 1.6% in the symptoms of generalized anxiety to 16.9% for social phobia. Female twins demonstrated significantly higher prevalence rates across all domains with the exception of obsessive-compulsive symptoms. Additive genetic factors accounted for a moderate proportion of the total liability to each symptom domain. Evidence suggesting qualitative genetic sex differences (i.e., distinct genetic influences between genders) was observed for body dysmorphic concern and panic symptoms, while quantitative differences were observed for hoarding and social phobia symptoms, indicating stronger heritability in females. Novel findings in this study include the observation of probable genetic sex differences in liability towards hoarding symptoms and dysmorphic concern, as well as the lack of such differences in hypochondriasis. The trend towards qualitative sex differences in panic symptoms has some intuitive appeal with regard to biological-experimental models of panic.

Hoarding behavior among young children with obsessive-compulsive disorder

Previous research has shown that among the various subtypes of obsessive-compulsive disorder (OCD), adults (e.g. Frost, Krause & Steketee, 1996) and older children and adolescents (Bloch et al., 2009; Storch et al., 2007) with problematic hoarding have distinct features and a poor treatment prognosis. However, there is limited information on the phenomenology and prevalence of hoarding behaviors in young children. The present study characterizes children ages 10 and under who present with OCD and hoarding behaviors. Sixty-eight children received a structured interview-determined diagnosis of OCD. Clinician administered, parent-report, and child-report measures on demographic, symptomatic, and diagnostic variables were completed. Clinician ratings of hoarding symptoms and parent and child endorsement of the hoarding item on the CY-BOCS checklist (Scahill, Riddle, McSwiggin-Hardin, & Ort, 1997) determined inclusion in the hoarding group (n=33). Compared to children without hoarding symptoms (n=35), the presence of hoarding symptoms was associated with an earlier age of primary diagnosis onset and a higher proportion of ADHD and provisional anxiety diagnoses. These results are partially consistent with the adult literature and with findings in older children (Storch et al., 2007). Additional data on clinical presentation and phenomenology of hoarding are needed to form a developmentally appropriate definition of the behavior.

Epidemiology of hoarding disorder

BACKGROUND

Hoarding disorder is typified by persistent difficulties discarding possessions, resulting in significant clutter that obstructs the individual's living environment and produces considerable functional impairment. The prevalence of hoarding disorder, as defined in DSM-5, is currently unknown.

AIMS

To provide a prevalence estimate specific to DSM-5 hoarding disorder and to delineate the demographic, behavioural and health features that characterise individuals with the disorder.

METHOD

We conducted a two-wave epidemiological study of 1698 adult individuals, originally recruited via the South East London Community Health (SELCoH) study. Participants screening positively for hoarding difficulties in wave 1, and who agreed to be re-contacted for wave 2 (n = 99), underwent in-home psychiatric interviews and completed a battery of self-report questionnaires. Current DSM-5 diagnoses were made via consensus diagnostic procedure.

RESULTS

In total, 19 individuals met DSM-5 criteria for hoarding disorder at the time of interview, corresponding to a weighted prevalence of 1.5% (95% CI 0.7-2.2). Those with hoarding disorder were older and more often unmarried (67%). Members of this group were also more likely to be impaired by a current physical health condition (52.6%) or comorbid mental disorder (58%), and to claim benefits as a result of these issues (47.4%). Individuals with hoarding disorder were also more likely to report lifetime use of mental health services, although access in the past year was less frequent.

CONCLUSIONS

With a lower-bound prevalence of approximately 1.5%, hoarding disorder presents as a condition that affects people of both genders and is associated with substantial adversity.

The Relationship of Hoarding Symptoms to Schizotypal Personality and Cognitive Schemas in an OCD Sample

This study examined hoarding symptoms and schizotypal personality traits (SPTs) in 38 patients with obsessive-compulsive disorder (OCD) and explored early maladaptive schemas (EMSs) as partial mediators between hoarding symptoms and schizotypal traits in OCD. Hoarding and symmetry/ordering symptoms were correlated with total schizotypal score on the Personality Disorder Questionnaire-4 (PDQ-4). Hoarding predicted the total number of schizotypal traits on the PDQ-4 after adjusting for symmetry/ordering symptoms. Schizotypal traits but not hoarding symptoms were significantly correlated with the social isolation and mistrust/abuse schemas. Schizotypal traits and hoarding were both associated with the emotional inhibition and emotional deprivation schemas, but neither of these mediated the relationship between schizotypal traits and hoarding. Clinical implications for understanding and treating hoarding and schizotypal personality in OCD are discussed.

A Multitrait-Multimethod Matrix Investigation of Hoarding

Hoarding is a serious and potentially life-threatening mental health problem that, until recently, was considered a subtype of OCD. However, recent research suggests it is distinct and more prevalent than OCD. Three key defining features have emerged in factor analytic studies of hoarding scales: excessive acquisition, difficulty discarding, and excessive clutter. Covariation among these defining features has received limited attention. The primary aim of the current study was to examine the role of the three key features in defining hoarding disorder. Convergent and discriminant validity of the three hoarding factors were examined in a multitrait-multimethod matrix. A secondary aim was to examine the extent to which each hoarding feature distinguished individuals meeting criteria for hoarding from those with OCD and community controls. Although the three-factor model provided an adequate fit for the data and convergent validities were high, the hoarding factors evidenced poor discriminant validity across measures. The findings provide preliminary support for a more parsimonious merging of the clutter, acquisition, and discarding subscales versus parsing out subscale scores. Specifically, the active acquisition of items, buildup of clutter, and difficulty discarding accumulated possessions co-occurred strongly enough to be considered a unidimensional construct. Thus, these symptoms were less attributable to separate phenomena and better conceived as part of a cohesive hoarding phenotype. Each of the three factors discriminated hoarding participants from OCD patients and community controls, but did not discriminate the latter two groups. The findings have implications for treating acquisition as a specifier in DSM-5.