Prevalence, comorbidity and heritability of hoarding symptoms in adolescence: a population based twin study in 15-year olds

Rates of diagnosis and service utilization in veterans with hoarding disorder

Hoarding Disorder (HD) is a prominent and disabling neuropsychiatric condition defined by the inability to discard objects resulting in impairing levels of clutter. The prevalence rate is 2-6 % and increases with age. The aging Veteran population is a high risk group for impairment associated with HD. Medical and psychiatric comorbidities as well as associated rates of disability and poor quality of life are very common in both HD and the related disorder of OCD. We examined rates of HD and OCD diagnoses at the VA San Diego Healthcare System. Data were obtained from medical records for all Veterans with these diagnoses over 8-years and included information on medical and psychiatric care, homelessness services, and Care Assessment Needs (CAN) scores. Rates of diagnosis for both HD and OCD were well below epidemiological estimates. Veterans with HD were older, had higher rates of medical hospital admissions with longer stays; had more cardiac, neurological, and acquired medical conditions; had more psychiatric comorbidities; had more interactions with the suicide prevent team and homelessness services; and had higher CAN scores than Veterans with OCD. The low rate of diagnosis and high services utilization of Veterans with HD demonstrates an area of unmet need.

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.

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.

Genomics of Obsessive-Compulsive Disorder and Related Disorders: What the Clinician Needs to Know

A wealth of evidence has shown that genetics plays a major role in susceptibility to obsessive-compulsive disorder (OCD) and all of its related disorders. Several large-scale, collaborative efforts using modern genomic methods are beginning to reveal the genetic architecture of these traits and identify long-sought risk genes. In this article, we summarize current OCD and related disorder genomic knowledge and explain how to communicate this information to patients and their families. The article concludes with a discussion of how genomic discovery in OCD and related disorders can inform our understanding of disease etiology and provide novel targets for therapeutic development.

Association between attachment and hoarding behavior: Mediation of anthropomorphism and moderation of hoarding beliefs among Chinese adolescents

The impact of insecure attachment on hoarding behavior (HB) has been supported by empirical evidence. However, scant literature has focused on how anthropomorphism (attributing human-like traits, characteristics, or emotions to nonhuman objects) and hoarding beliefs (motivations for ownership) affect the relationship between insecure attachment and HB, especially among Chinese adolescents. Using a cross-sectional study, we reserved 903 participants (561 males, 342 females, M = 20.20, SD = 1.85, age range = 18-24 years) to complete self-report questionnaires about close relationships, anthropomorphism, saving beliefs, and saving inventory to investigate the mediating role of anthropomorphism and the moderating role of hoarding beliefs in the relationship between insecure attachment and HB. Attachment anxiety and avoidance had a positive relationship with HB, and anthropomorphism is a mediating factor in the association between attachment anxiety and HB. In addition, hoarding beliefs moderated the relationship between attachment anxiety and HB. This study further elaborated on the relationships between insecure attachment, anthropomorphism, hoarding beliefs, and HB, which might shed some light on adolescent clinical interventions.

Prevalence and correlates of hoarding behavior and hoarding disorder in children and adolescents

Although hoarding symptoms are reported to begin in childhood and adolescence, the true prevalence of the disorder in this age group is unknown. This study aims to estimate the prevalence of hoarding disorder (HD) in children and adolescents. The present study was planned as a two-stage epidemiological research. In the first stage, the Children's Saving Inventory (CSI) and informed consent forms were delivered to a group of students' parents. In the second stage, one-on-one psychiatric interviews with a physician were planned with the families and children who had hoarding behavior (HB), as described by their parents. The DSM-5-based HD interview and the Development and Well-Being Assessment (DAWBA) diagnostic tool were used to detect prevalence of HD and comorbid psychiatric disorders. A total of 3249 children were included in the study, and 318 children and their parents were evaluated in the second stage. As a result of the second assessment, 32 out of 318 children met the HD diagnostic criteria. The estimated prevalence of HD was 0.98% (95% CI 0.7-1.4). Hoarding disorder was found more frequently in females (F/M = 3/1). After a logistic regression analysis, variables such as female sex and the presence of any psychopathology were identified as independent correlates of HD. More than half (56.2%) of the children diagnosed as having HD also had a comorbid psychiatric disorder. In the present study, the two-stage evaluation method was used in a large pediatric sample to determine the estimated prevalence of HD, as well as the factors associated with the disorder and comorbid psychiatric disorders.

Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in a large sample of adolescents

Few studies have investigated body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in adolescents and how they relate to mental health, quality of life, suicide attempts, and non-suicidal self-harm. We used a quota sampling procedure and contacted 100 secondary centres in the Southeast of Spain, of which 34 participated in the study. A sample of 5,345 adolescents (12–18 years) completed dimensional measures of body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms. The proportion of adolescents with clinically significant symptoms within each symptom type was estimated and associations with other indicators of mental health examined. Clinically significant body-dysmorphic symptoms were reported by 3.7%, hoarding by 0.9%, hair-pulling by 0.7%, and skin-picking by 1.8%. Body-dysmorphic symptoms were more common in girls and in those over 14 years of age. Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were moderately to strongly associated with obsessive-compulsive symptoms, internalizing symptoms, externalizing symptoms, and poor quality of life. Those with significant body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms were much more likely to have attempted suicide and engaged in non-suicidal self-harm during the last twelve months than those without such symptoms. Body-dysmorphic symptoms showed the strongest associations with internalizing symptoms and poor quality of life. Limitations are the sole use of self-report and a sample from only two regions in Spain, but findings suggest that body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms are common and impairing during adolescence.

Elevated levels of hoarding in ADHD: A special link with inattention

Hoarding Disorder (HD) is under recognised and under-treated. Though HD develops by early adulthood, patients present only later in life, resulting in research based largely on samples of predominantly older females. Whilst formerly associated with Obsessive-Compulsive Disorder (OCD), it is now recognised that individuals with HD often have inattention symptoms reminiscent of Attention Deficit/Hyperactivity Disorder (ADHD). Here, we investigated HD in adults with ADHD. Patients in an ADHD clinic (n = 88) reported on ADHD, HD and OCD-related symptoms, and compared with age, gender and education matched controls (n = 90). Findings were assessed independently in an online UK sample to verify replication using a dimensional approach (n = 220). Clinically significant hoarding symptoms were found in ∼20% versus 2% of ADHD and control groups, respectively, with those with hoarding being on average in their thirties and with approximately half being male. Greater hoarding severity was noted even in the remaining patients compared with controls (d = 0.89). Inattention was the only significant statistical predictor of hoarding severity in patients. Similarly, inattention, alongside depression and anxiety were the greatest predictors of hoarding in the independent sample where 3.2% identified as having clinically significant hoarding. Patients with ADHD had a high frequency of hoarding symptoms, which were specifically linked to inattention. HD should be routinely assessed in individuals with ADHD, as they do not typically disclose associated difficulties, despite these potentially leading to impaired everyday functioning. Research in HD should also investigate adults with ADHD, who are younger and with a greater prevalence of males than typical HD samples.

A dimensional perspective on the genetics of obsessive-compulsive disorder

This review covers recent findings in the genomics of obsessive-compulsive disorder (OCD), obsessive-compulsive symptoms, and related traits from a dimensional perspective. We focus on discoveries stemming from technical and methodological advances of the past five years and present a synthesis of human genomics research on OCD. On balance, reviewed studies demonstrate that OCD is a dimensional trait with a highly polygenic architecture and genetic correlations to multiple, often comorbid psychiatric phenotypes. We discuss the phenotypic and genetic findings of these studies in the context of the dimensional framework, relying on a continuous phenotype definition, and contrast these observations with discoveries based on a categorical diagnostic framework, relying on a dichotomous case/control definition. Finally, we highlight gaps in knowledge and new directions for OCD genetics research.

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.

Hoarding disorder is associated with self-reported cardiovascular / metabolic dysfunction, chronic pain, and sleep apnea

Hoarding behaviors are positively associated with medical morbidity, however, current prevalence estimates and types of medical conditions associated with hoarding vary. This analysis aims to quantify the medical morbidity of hoarding disorder (HD). Cross-sectional data were collected online using the Brain Health Registry (BHR). Among 20,745 participants who completed the Hoarding and Clutter and Medical History thematic modules, 1348 had HD (6.5%), 1268 had subclinical HD (6.1%), and 18,829 did not meet hoarding criteria (87.4%). Individuals with HD were more likely to report a lifetime history of cardiovascular/metabolic conditions: diabetes (HD adjusted odds ratio (AOR):1.51, 95% confidence interval (CI):[1.20, 1.91]; subclinical HD AOR:1.24, 95% CI:[0.95, 1.61]), and hypercholesterolemia (HD AOR:1.24, 95% CI:[1.06, 1.46]; subclinical HD AOR:1.11, 95% CI:[0.94, 1.31]). Those with HD and subclinical HD were also more to report chronic pain (HD AOR: 1.69, 95% CI:[1.44, 1.98]; subclinical HD AOR: 1.44, 95% CI:[1.22, 1.69]), and sleep apnea (HD AOR: 1.58, 95% CI:[1.31, 1.89]; subclinical HD AOR:1.30, 95% CI:[1.07, 1.58]) than non-HD participants. For most conditions, likelihood of diagnosis did not differ between HD and subclinical HD. Structural equation modeling revealed that more severe hoarding symptomatology was independently associated with increased cardiovascular/metabolic vulnerability. The assessment and management of medical complications in individuals with HD is a fundamental component in improving quality of life, longevity, and overall physical health outcomes.

The developmental origins of hoarding disorder in adolescence: a longitudinal clinical interview study following an epidemiological survey

Hoarding disorder (HD) is hypothesized to originate in childhood/adolescence but little is known about the presentation of hoarding symptoms in youth and their natural history. In this longitudinal study, we tracked and conducted in-depth psychiatric interviews with twins who participated in an epidemiological survey and screened positive on a measure of hoarding symptoms at age 15. Twins screening positive for clinically significant hoarding symptoms at age 15 (n = 42), their co-twins (n = 33), a group of screen negative twins (n = 49), and their parents underwent a clinical assessment a median of 3 years after the initial screening. The assessment included psychiatric screening, hoarding symptoms and cognitions, in-home or photographic assessment of clutter levels, parental accommodation and familial burden. None of the participants had significant levels of clutter at follow-up and thus did not meet strict criteria for HD. However, twins meeting partial criteria (i.e., DSM-5 criteria A and B) for HD (n = 28) had more psychiatric disorders and scored significantly higher on all measures of hoarding symptoms including researcher-rated levels of clutter in their homes, compared to twins who did not meet partial criteria for HD (n = 46). As currently defined in DSM-5, HD may be rare in young people. A non-negligible proportion of young people who were screen positive on hoarding symptoms at age 15 had substantial hoarding symptoms and other psychopathology at follow-up. Whether and how many of these individuals will develop full-blown HD is unknown but the results offer unique insights about the probable origins of HD in adolescence.

Internet-based hoarding assessment: The reliability and predictive validity of the internet-based Hoarding Rating Scale, Self-Report

The Hoarding Rating Scale, Self Report (HRS-SR) is a 5-item assessment developed to ascertain the presence and severity of hoarding symptoms. This study aimed to evaluate the validity of an online adaptation of the HRS-SR in a remote, unsupervised internet sample of 23,214 members of the Brain Health Registry (BHR), an online research registry that evaluates and longitudinally monitors cognition, medical and psychiatric health status. Convergent validity was assessed among a sub-sample of 1,183 participants who completed additional, remote measures of self-reported hoarding behaviors. Structured clinical interviews conducted in-clinic and via video conferencing tools were conducted among 230 BHR participants; ROC curves were plotted to assess the diagnostic performance of the internet-based HRS-SR using best estimate hoarding disorder (HD) diagnoses as the gold standard. The area under the curve indicated near-perfect model accuracy, and was confirmed with 10-fold cross validation. Sensitivity and specificity for distinguishing clinically relevant hoarding were optimized using an HRS-SR total score cut-off of 5. Longitudinal analyses indicated stability of HRS-SR scores over time. Findings indicate that the internet-based HRS-SR is a useful and valid assessment of hoarding symptoms, though additional research using samples with more diverse hoarding behavior is needed to validate optimal cut-off values.

Serotonin system genes and hoarding with and without other obsessive-compulsive traits in a population-based, pediatric sample: A genetic association study

BACKGROUND

Hoarding, originally only considered a symptom of obsessive-compulsive disorder (OCD), is now categorized as a separate disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We studied candidate serotonergic genes and the distinctness of hoarding in children and adolescents and hypothesized that unique gene variants would be associated with hoarding alone.

METHODS

We examined obsessive-compulsive (OC) traits, including hoarding, in a total of 5,213 pediatric participants in the community. We genotyped candidate serotonin genes (5-HTTLPR polymorphism in SLC6A4 for 2,018 individuals and single nucleotide polymorphisms [SNPs] across genes SLC6A4, HTR2A, and HTR1B for 4,711 individuals). In a previous study conducted by our group in the same sample, we identified a significant association between 5-HTTLPR and hoarding in males. In this study, we examined hoarding more closely by testing the association between serotonin gene variants and hoarding traits with and without other accompanying OC traits.

RESULTS

The [L_G +S] variant in 5-HTTLPR was significantly associated with hoarding alone in males (p-value of 0.009). There were no significant findings for 5-HTTLPR in females. There were no significant findings after correction for multiple comparisons using SNP array data, but top SNP findings suggested that variation downstream of HTR1B may be implicated in hoarding alone in females.

CONCLUSIONS

Our results suggest specific serotonin gene variants are associated with hoarding traits alone, differing between sexes. Top findings are in line with our former study, suggesting that individuals with hoarding alone were driving previous results. Our paper supports hoarding disorder's new designation.

Prevalence of Obsessive-Compulsive Symptoms in Elderly Parkinson Disease Patients: A Case-Control Study

BACKGROUND

The clinical picture of obsessive-compulsive disorder encompasses a broad range of symptoms that are related to multiple psychological domains, including perception, cognition, emotion, and social relatedness. As obsessive-compulsive symptoms (OCS) frequently have an early onset, there are limited data about OCS in older populations (≥65 years) and, in particular, in elderly subjects with Parkinson disease (PD).

OBJECTIVE

This study aimed to estimate the prevalence of OCS using a self-report measure (Obsessive-Compulsive Inventory-Revised) and to identify associated sociodemographic and clinical factors in a sample of elderly PD patients compared to a comparison group of similarly aged healthy volunteers.

RESULTS

The mean age was 74 ± 6 years in the PD patients and 73 ± 7 years in the comparison group. The mean disease duration was 9.6 ± 5.8 years. Among the PD patients, 30.7% reported at least one OCS or a related disorder compared to 21.1% in the comparison group. Hoarding was significantly more common in PD patients than in the comparison group.

CONCLUSIONS

Subclinical OCS were present at a high percentage in both PD patients and comparison group. The OCS phenotype in PD may present differently, as hoarding was more common in PD patients.

Recent Advances in Research on Hoarding

PURPOSE OF REVIEW

The purpose of the following paper is to review recent literature trends and findings in hoarding disorder (HD). Our goal is to highlight recent research on etiology, associated features, and empirically based treatments.

RECENT FINDINGS

Recent literature has added support for cognitive differences as a risk factor for HD; however, there is evidence that individuals with HD may overestimate their level of cognitive impairment. Several associated features have been highlighted in recent studies, including emotion regulation, intolerance of uncertainty and distress intolerance, and attachment. Finally, several psychotherapeutic treatments for hoarding have been recently validated, including group-based therapy and treatments using the cognitive-behavioral model. Although recent research demonstrates that hoarding can be effectively treated with available psychotherapeutic modalities, the effectiveness of current treatments is not as robust as that for other psychiatric disorders and more work is needed in treatment precision.

Hoarding in children and adolescents with obsessive-compulsive disorder: prevalence, clinical correlates, and cognitive behavioral therapy outcome

Hoarding, common in pediatric obsessive-compulsive disorder (OCD), has specific clinical correlates and is associated with poor prognosis. However, there are few studies of hoarding in pediatric OCD. This study estimates the occurrence of hoarding symptoms in a sample of children and adolescents with OCD, investigating possible differences in demographic and clinical variables between pediatric OCD with and without hoarding symptoms. Furthermore, the study investigates whether hoarding symptoms predict poorer treatment outcomes after cognitive behavioral therapy (CBT). The study sample comprised 269 children and adolescents with OCD, aged 7-17 years, from Denmark, Sweden, and Norway, who were all included in the Nordic long-term obsessive-compulsive disorder Treatment Study. All had an OCD diagnosis according to the DSM-IV and were treated with 14 weekly sessions of manualized, exposure-based CBT. Hoarding symptoms and OCD severity were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale and group differences in treatment outcome were analyzed using linear mixed-effect modelling. Seventy-two patients (26.8%) had one or more symptoms of hoarding. Comorbid tic disorders (p = 0.005) and indecision (p = 0.024) were more prevalent among those with hoarding symptoms than those without hoarding symptoms. In addition, youth with hoarding symptoms had a different OCD symptom profile. Having symptoms of hoarding did not affect CBT outcome (p = 0.933). Results from the study suggest that CBT is equally effective for those with and without hoarding-related OCD.

Hoarding Symptoms in Children and Adolescents With Obsessive-Compulsive Disorder: Clinical Features and Response to Cognitive-Behavioral Therapy

OBJECTIVE

Although adult hoarding disorder is relatively common and often debilitating, few studies have examined the phenomenology of pediatric hoarding. We examined the clinical phenomenology and response to cognitive-behavioral therapy (CBT) treatment in youths with a diagnosis of obsessive-compulsive disorder (OCD) with and without hoarding symptoms. Age was tested as a moderator across analyses, given prior findings that the impact of hoarding symptoms may not become apparent until adolescence.

METHOD

Youths (N = 215; aged 7-17 years) with OCD pursuing evaluation and/or treatment at a university-based specialty clinic participated in the current study. Presence of hoarding symptoms was assessed as part of a larger battery. Data from a subset of youths (n = 134) who received CBT were included in treatment response analyses.

RESULTS

Youths with hoarding symptoms did not differ from those without hoarding symptoms with respect to overall OCD symptom severity and impairment. Youths with hoarding met criteria for more concurrent diagnoses, including greater rates of internalizing and both internalizing/externalizing, but not externalizing-only, disorders. Youths with and without hoarding symptoms did not significantly differ in rate of response to CBT. Age did not moderate any of these relationships, suggesting that the presence of hoarding symptoms was not associated with greater impairments across the clinical presentation of OCD or its response to treatment by age.

CONCLUSION

We found no evidence that hoarding is associated with greater OCD severity or poorer treatment response in affected youth. Theoretical and clinical implications of these findings, including future directions for research on testing developmental models of hoarding across the lifespan, are discussed.

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.

Obsessive compulsive disorder with and without hoarding symptoms: Characterizing differences

OBJECTIVE

In recent years there has been some ambiguity about the way hoarding and OCD are related to each other. The present study examines the differences between persons with OCD/hoarding and OCD/non-hoarding and examines which characteristics are associated with the OCD/hoarding group. Information is established about prevalences, socio-demographical characteristics, OCD and related characteristics, OCD subtypes, comorbidity (depression, anxiety disorders and PTSD) and personality traits.

METHODS

Data from baseline assessment of The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study are used. The NOCDA sample consists of 419 participants between 18 and 79 years of age, including participants with current or remitted full DSM-IV-TR criteria for OCD.

RESULTS

Results show that 58 persons (14.3%) are classified as persons with OCD/hoarding and 349 persons (85,7%) are classified as persons with OCD/non-hoarding. OCD/hoarding is independently associated with severity of autism symptoms (p<.001), living without a partner (p<.05) and being less conscientious (p<.05). Persons with OCD/hoarding are not associated with childhood trauma (p=.31), PTSD (p=.91) and AD(H)D, inattentive type (p=.22) and hyperactive type (p=.57).

LIMITATIONS

Causal interferences about associations between the risk indicators and hoarding symptoms were precluded since results were based on cross-sectional data.

CONCLUSION

This study confirmed differences between persons with OCD/hoarding and persons with OCD/non-hoarding. The most relevant outcome of this study was the association between persons with OCD/hoarding and the increased severity of autism symptoms. These results provide a better understanding of persons with OCD/hoarding and have the potential to improve treatment.

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.

Hoarding symptoms and workplace impairment

OBJECTIVES

A prior study found that over 50% of treatment-seeking individuals who hoard incur at least one psychiatric work impairment day (i.e., they are unable to work or are less effective at work due to poor mental health) each month. The aim of the current study was to assess work-related variables associated with workplace impairment in a non-treatment-seeking sample.

DESIGN

Cross-sectional. Self-report questionnaires were administered via Amazon's Mechanical Turk.

METHODS

One hundred and eighty-five employed individuals who reported elevated hoarding symptoms completed questionnaires regarding hoarding symptoms, work engagement, psychiatric work impairment, work control, attention and concentration difficulties at work, and quality of workplace relationships.

RESULTS

Greater workplace control and higher quality workplace relationships were associated with greater work engagement. Greater hoarding symptoms and attention difficulties at work were associated with more psychiatric work impairment days. Work engagement statistically mediated the association between the quality of workplace relationships and work impairment, though mediation was also significant when reversing the mediating and outcome variables.

CONCLUSIONS

Among a community sample of employed individuals, greater hoarding symptoms were associated with greater psychiatric work impairment. Work-related variables, such as co-worker relationships and attention difficulties, contributed additional variance above that accounted for by hoarding symptoms. There were significant associations between co-worker relationships, work engagement, and workplace impairment, though the direction of the mediation model is unclear. Future research should examine factors associated with unemployment in hoarding disorder.

PRACTITIONER POINTS

Clinicians should be aware that greater hoarding severity directly contributes to greater workplace impairment. Clinicians should consider prioritizing the reduction in clutter in living areas that impact one's daily activities and subsequent ability to attend work. Clinicians should assess and treat workplace impairment by helping individuals achieve greater control at work, developing higher quality interpersonal relationships, and improving their attentional abilities.

Presentation and Correlates of Hoarding Behaviors in Children with Autism Spectrum Disorders and Comorbid Anxiety or Obsessive-Compulsive Symptoms

We investigated the presentation and correlates of hoarding behaviors in 204 children aged 7-13 with autism spectrum disorder (ASD) and comorbid anxiety or obsessive-compulsive disorder (OCD) symptoms. Approximately 34% of the sample presented at least moderate levels, and with 7% presenting severe to extreme levels of hoarding. Child gender predicted hoarding severity. In addition, child ASD-related social difficulties together with attention-deficit and hyperactivity disorder symptom severity positively predicted hoarding controlling for child gender and restricted and repetitive behaviors. Finally, child anxiety/OCD symptoms positively predicted hoarding, controlling for all other factors. These results suggest hoarding behaviors may constitute a common feature of pediatric ASD with comorbid anxiety/OCD, particularly in girls and children with greater social difficulties and comorbid psychiatric symptom severity.

Comorbid Hoarding and Obsessive Compulsive Disorder Manifested During Early Childhood

This case report outlines the use of cognitive behavioral therapy (CBT) used to treat an 11-year-old female, “Gabriela,” with comorbid hoarding and obsessive compulsive disorder (OCD). Gabriela participated in treatment involving CBT and exposure and response prevention (ERP) sessions for OCD and hoarding, following a cognitive rehabilitation software program designed for cognitive impairment. Upon completion of the treatment, Gabriela no longer exhibited behaviors consistent with a comorbid hoarding and OCD diagnosis and demonstrated marked improvements in her presenting problems (mental rituals; hoarding items for magical thinking purposes). This case report supports the focus of research, continuing to explore hoarding and comorbidity diagnoses across the life span.

Heritability of hoarding symptoms across adolescence and young adulthood: A longitudinal twin study

Background

Twin studies of hoarding symptoms indicate low to moderate heritability during adolescence and considerably higher heritability in older samples, suggesting dynamic developmental etiological effects. The aim of the current study was to estimate the relative contribution of additive genetic and environmental effects to hoarding symptoms during adolescence and young adulthood and to estimate the sources of stability and change of hoarding symptoms during adolescence.

Methods

Univariate model-fitting was conducted in three cohorts of twins aged 15 (n = 7,905), 18 (n = 2,495) and 20–28 (n = 6,218). Longitudinal analyses were conducted in a subsample of twins for which data on hoarding symptoms was available at both age 15 and 18 (n = 1,701).

Results

Heritability estimates for hoarding symptoms at ages 15, 18 and 20–28 were 41% (95% confidence interval [CI]: 36–45%), 31% (95% CI: 22–39%) and 29% (95% CI: 24–34%) respectively. Quantitative sex-differences emerged in twins aged 15 at which point the heritability in boys was 33% (95% CI: 22–41%) and 17% (95% CI: 0–36%) in girls. Shared environmental effects played a negligible role across all samples with the exception of girls aged 15 where they accounted for a significant proportion of the variance (22%; 95% CI 6–36%). The longitudinal bivariate analyses revealed a significant phenotypic correlation of hoarding symptoms between ages 15 and 18 (0.40; 95% CI: 0.36–0.44) and a strong but imperfect genetic correlation (0.75; 95% CI: 0.57–0.94). The bivariate heritability was estimated to 65% (95% CI: 50–79%).

Conclusions

Hoarding symptoms are heritable from adolescence throughout young adulthood, although heritability appears to slightly decrease over time. Shared environmental effects contribute to hoarding symptoms only in girls at age 15. The stability of hoarding symptoms between ages 15 and 18 is largely explained by genetic factors, while non-shared environmental factors primarily have a time-specific effect. The findings indicate that dynamic developmental etiological effects may be operating across the life span.

Age-Specific Prevalence of Hoarding and Obsessive Compulsive Disorder: A Population-Based Study

OBJECTIVE

Little is known about the age-specific prevalence of hoarding and obsessive compulsive symptoms (OCS), particularly in older age groups. The objectives of this study were to estimate the age-specific prevalence, severity, and relationships between hoarding and OCS in males and females using a large population-based sample.

METHODS

We assessed the age-specific prevalence rates of hoarding disorder (HD) and OC disorder (OCD) in males and females (at various age ranges between 15 and 97 years) from the Netherlands Twins Register (N = 15,194). Provisional HD and OCD diagnoses were made according to Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, criteria using self-report measures. We also assessed hoarding and OCS severity in the various age groups and explored specific hoarding and OCS patterns (e.g., difficulty discarding, excessive acquisition, clutter, checking, washing, perfectionism, and obsessions) with age.

RESULTS

Prevalence of provisional HD diagnoses (2.12%) increased linearly by 20% with every 5 years of age (z = 13.8, p < 0.0001) and did not differ between males and females. Provisional OCD diagnoses were most common in younger individuals and in individuals over age 65. Co-occurring OCD increased hoarding symptom severity (coefficient: 4.5; SE: 0.2; 95% CI: 4.1-4.9; t = 22.0, p < 0.0001). Difficulty discarding for HD and checking behaviors for OCD appeared to drive most increases in these diagnoses in older ages.

CONCLUSION

Increased prevalence and severity of HD with age appears to be primarily driven by difficulties with discarding. Increases in OCD prevalence with older age were unexpected and of potential clinical relevance.

ADHD and executive functioning deficits in OCD youths who hoard

Hoarding is common among youth with obsessive compulsive disorder (OCD), with up to 26% of OCD youth exhibiting hoarding symptoms. Recent evidence from adult hoarding and OCD cohorts suggests that hoarding symptoms are associated with executive functioning deficits similar to those observed in subjects with attention deficit hyperactivity disorder (ADHD). However, while hoarding behavior often onsets during childhood, there is little information about executive function deficits and ADHD in affected children and adolescents. The study sample included 431 youths (ages 6-17 years) diagnosed with OCD who participated in the OCD Collaborative Genetics Study and the OCD Collaborative Genetics Association Study and completed a series of clinician-administered and parent report assessments, including diagnostic interviews and measures of executive functioning (Behavior Rating Inventory of Executive Functioning; BRIEF) and hoarding severity (Hoarding Rating Scale-Interview; HRS-I). 113 youths (26%) had clinically significant levels of hoarding compulsions. Youths with and without hoarding differed significantly on most executive functioning subdomains and composite indices as measured by the parent-rated BRIEF. Groups did not differ in the frequency of full DSM-IV ADHD diagnoses; however, the hoarding group had significantly greater number of inattention and hyperactivity symptoms compared to the non-hoarding group. In multivariate models, we found that overall BRIEF scores were related to hoarding severity, adjusting for age, gender and ADHD symptoms. These findings suggest an association between hoarding and executive functioning deficits in youths with OCD, and assessing executive functioning may be important for investigating the etiology and treatment of children and adolescents with hoarding and OCD.

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.

Clinical Correlates of Hoarding With and Without Comorbid Obsessive-Compulsive Symptoms in a Community Pediatric Sample

OBJECTIVE

We assessed the prevalence and clinical correlates of hoarding, with and without obsessive-compulsive (OC) symptoms, in a community-based pediatric sample.

METHOD

We measured hoarding and OC symptoms using the Toronto Obsessive-Compulsive Scale (TOCS) in 16,718 youth aged 6 to 17 years in the community. We classified participants with high and low symptom counts for hoarding and OC into 4 groups: hoarding+OC; hoarding-only; OC-only; and control (no OC or hoarding symptoms). We compared these 4 groups on parent- or self-reported medical and psychiatric conditions, anxiety symptoms measured with the Child Behavior Checklist (CBCL), and attention-deficit/hyperactivity disorder (ADHD) symptoms measured with the Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN).

RESULTS

Almost 10% of participants were in the high hoarding group. Of these participants, 40% did not fall into the high OC group. The prevalence of reported psychiatric disorders (e.g., ADHD, autism spectrum disorder, obsessive-compulsive disorder) was greater in the hoarding (hoarding+OC and hoarding-only) and OC groups (hoarding+OC and OC-only) than in the nonhoarding (OC-only and control) and non-OC groups (hoarding-only and control), respectively. ADHD, specifically inattentive, symptoms were more common in the hoarding-only than in the OC-only group while anxiety symptoms were more common in the OC-only than in the hoarding-only group.

CONCLUSION

In a community pediatric sample, hoarding symptoms occurred in both the presence and absence of obsessive-compulsive symptoms. Hoarding symptoms alone had some unique clinical correlates, in particular, more inattentive ADHD symptoms and fewer anxiety symptoms. These findings suggest that hoarding is distinct from OC traits in youth.

Cross-Disorder Genetic Analysis of Tic Disorders, Obsessive-Compulsive, and Hoarding Symptoms

Hoarding, obsessive-compulsive disorder (OCD), and Tourette's disorder (TD) are psychiatric disorders that share symptom overlap, which might partly be the result of shared genetic variation. Population-based twin studies have found significant genetic correlations between hoarding and OCD symptoms, with genetic correlations varying between 0.1 and 0.45. For tic disorders, studies examining these correlations are lacking. Other lines of research, including clinical samples and GWAS or CNV data to explore genetic relationships between tic disorders and OCD, have only found very modest if any shared genetic variation. Our aim was to extend current knowledge on the genetic structure underlying hoarding, OC symptoms (OCS), and lifetime tic symptoms and, in a trivariate analysis, assess the degree of common and unique genetic factors contributing to the etiology of these disorders. Data have been gathered from participants in the Netherlands Twin Register comprising a total of 5293 individuals from a sample of adult monozygotic (n = 2460) and dizygotic (n = 2833) twin pairs (mean age 33.61 years). The data on Hoarding, OCS, and tic symptoms were simultaneously analyzed in Mplus. A liability threshold model was fitted to the twin data, analyzing heritability of phenotypes and of their comorbidity. Following the criteria for a probable clinical diagnosis in all phenotypes, 6.8% of participants had a diagnosis of probable hoarding disorder (HD), 6.3% of OCS, and 12.8% of any probable lifetime tic disorder. Genetic factors explained 50.4, 70.1, and 61.1% of the phenotypic covariance between hoarding-OCS, hoarding-tics, and OCS-tics, respectively. Substantial genetic correlations were observed between hoarding and OCS (0.41), hoarding and tics (0.35), and between OCS and tics (0.37). These results support the contribution of genetic factors in the development of these disorders and their comorbidity. Furthermore, tics were mostly influenced by specific environmental factors unshared with OCS and HD.

Three Reasons why Studying Hoarding in Children and Adolescents is Important

Hoarding is traditionally considered a disorder of adulthood but hoarding symptoms often begin in childhood and adolescence. However, there is very little published research into hoarding in youth. As described in this commentary, the study of hoarding in childhood and adolescence is important because hoarding symptoms: 1) often begin in childhood and adolescence; 2) often are chronic and persist into adulthood; and, 3) are associated with a number of negative outcomes and sequelae. Research into hoarding in youth could help identify individuals at risk for chronic and persistent hoarding disorder as well as determine interventions to change their trajectories. Improved understanding of hoarding in children and adolescents could in turn help minimize the negative effect of hoarding on the affected individuals, their families and society.

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.

Hoarding in Children and Adolescents with Obsessive-Compulsive Disorder

Compared to studies in adults, there have been few studies of hoarding in children and adolescents with obsessive-compulsive disorder (OCD). In the current study, we evaluated OCD clinical features, Axis I disorders, and social reciprocity scores in 641 children and adolescents with OCD, of whom 163 (25%) had hoarding compulsions and 478 did not. We found that, as a group, youth with hoarding had an earlier age at onset and more severe lifetime OCD symptoms, poorer insight, more difficulty making decisions and completing tasks, and more overall impairment. The hoarding group also had a greater lifetime prevalence of panic disorder, specific phobia, Tourette disorder, and tics. As measured with the Social Reciprocity Scale, the hoarding group had more severe deficits in parent-rated domains of social communication, social motivation, and restricted interests and repetitive behavior. In a multivariable model, the overall social reciprocity score, age at onset of OCD symptoms, symmetry obsessions, and indecision were independently related to hoarding in these children and adolescents with OCD. These features should be considered as candidate risk factors for the development of hoarding behavior in pediatric OCD.

Partitioning the etiology of hoarding and obsessive-compulsive symptoms

BACKGROUND

Until recently, hoarding was considered an obsessive-compulsive symptom (OCS). However, current evidence suggests that these two phenotypes may be clinically, and perhaps etiologically, distinct. Both hoarding and OCS have a genetic etiology, but the degree of unique and shared genetic contributions to these phenotypes has not been well studied.

METHOD

Prevalence rates were assessed for hoarding and OCS in a sample of adult twin pairs (n = 7906 twins) and their family members from The Netherlands Twin Register (total sample = 15,914). Using Mplus, genetic analyses using liability threshold models were conducted for both phenotypes, for their co-morbidity, and for specific hoarding symptoms (cluttering, discarding and acquiring).

RESULTS

Of the total sample, 6.7% met criteria for clinically significant hoarding; endorsement of all three hoarding symptoms was > or = 79%. Men had slightly higher rates than women. Also, 5.7% met criteria for clinically significant OCS; rates were similar in males and females. Genetic factors accounted for 36% of the variance for hoarding and 40% of the variance for OCS. The genetic correlation between hoarding and OCS was 0.10. There was no evidence of sex-specific genetic contributions for hoarding or OCS. There was evidence for a genetic contribution to all hoarding symptom subtypes. Only cluttering showed evidence of a contribution from the shared environment.

CONCLUSIONS

OCS and hoarding are common in this population-based sample, have prevalence rates similar to those previously reported, and show significant heritability. Genetic factors contributed to the co-morbidity of both traits, although the genetic correlation between them was low.

Genetics of obsessive-compulsive disorder and related disorders

Twin and family studies support a significant genetic contribution to obsessive-compulsive disorder (OCD) and related disorders, such as chronic tic disorders, trichotillomania, skin-picking disorder, body dysmorphic disorder, and hoarding disorder. Recently, population-based studies and novel laboratory-based methods have confirmed substantial heritability in OCD. Genome-wide association studies and candidate gene association studies have provided information on specific gene variations that may be involved in the pathobiology of OCD, though a substantial portion of the genetic risk architecture remains unknown.

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.