Relationship of Hoarding and Depression Symptoms in Older Adults

Hoarding disorder (HD) is a debilitating neuropsychiatric condition that affects 2%-6% of the population and increases in incidence with age. Major depressive disorder (MDD) co-occurs with HD in approximately 50% of cases and leads to increased functional impairment and disability. However, only one study to date has examined the rate and trajectory of hoarding symptoms in older individuals with a lifetime history of MDD, including those with current active depression (late-life depression; LLD). We therefore sought to characterize this potentially distinct phenotype. We determined the incidence of HD in two separate cohorts of participants with LLD (n = 73) or lifetime history of MDD (n = 580) and examined the reliability and stability of hoarding symptoms using the Saving Inventory-Revised (SI-R) and Hoarding Rating Scale-Self Report (HRS), as well as the co-variance of hoarding and depression scores over time. HD was present in 12% to 33% of participants with MDD, with higher rates found in those with active depressive symptoms. Hoarding severity was stable across timepoints in both samples (all correlations >0.75), and fewer than 30% of participants in each sample experienced significant changes in severity between any two timepoints. Change in depression symptoms over time did not co-vary with change in hoarding symptoms. These findings indicate that hoarding is a more common comorbidity in LLD than previously suggested, and should be considered in screening and management of LLD. Future studies should further characterize the interaction of these conditions and their impact on outcomes, particularly functional impairment in this vulnerable population.

"In an ideal world that would be a multiagency service because you need everybody's expertise." Managing hoarding disorder: A qualitative investigation of existing procedures and practices

Hoarding disorder is characterised by the acquisition of, and failure to discard large numbers of items regardless of their actual value, a perceived need to save the items and distress associated with discarding them, significant clutter in living spaces that render the activities associated with those spaces very difficult causing significant distress or impairment in functioning. To aid development of an intervention for hoarding disorder we aimed to identify current practice by investigating key stakeholders existing practice regarding identification, assessment and intervention associated with people with hoarding disorder. Two focus groups with a purposive sample of 17 (eight male, nine female) stakeholders representing a range of services from housing, health, and social care were audio recorded, transcribed verbatim and analysed thematically. There was a lack of consensus regarding how hoarding disorder was understood and of the number of cases of hoarding disorder however all stakeholders agreed hoarding disorder appeared to be increasing. The clutter image rating scale was most used to identify people who needed help for hoarding disorder, in addition to other assessments relevant to the stakeholder. People with hoarding disorder were commonly identified in social housing where regular access to property was required. Stakeholders reported that symptoms of hoarding disorder were often tackled by enforced cleaning, eviction, or other legal action however these approaches were extremely traumatic for the person with hoarding disorder and failed to address the root cause of the disorder. While stakeholders reported there was no established services or treatment pathways specifically for people with hoarding disorder, stakeholders were unanimous in their support for a multi-agency approach. The absence of an established multiagency service that would offer an appropriate and effective pathway when working with a hoarding disorder presentation led stakeholders to work together to suggest a psychology led multiagency model for people who present with hoarding disorder. There is currently a need to examine the acceptability of such a model.

Transdiagnostic dimensions in obsessive-compulsive and related disorders: associations with internalizing and externalizing symptoms

BACKGROUND

Hierarchical structural models of psychopathology rarely extend to obsessive-compulsive spectrum disorders. The current study sought to examine the higher-order structure of the obsessive-compulsive and related disorders (OCRDs) in DSM-5: obsessive-compulsive disorder (OCD), hoarding disorder (HD), body dysmorphic disorder (BDD), trichotillomania (hair-pulling disorder; HPD) and excoriation (skin-picking) disorder (SPD).

METHODS

Adult patients in a partial hospital program (N = 532) completed a dimensional measure of the five OCRDs. We used confirmatory factor analysis to identify the optimal model of the comorbidity structure. We then examined the associations between the transdiagnostic factors and internalizing and externalizing symptoms (i.e. depression, generalized anxiety, neuroticism, and drug/alcohol cravings).

RESULTS

The best fitting model included two correlated higher-order factors: an obsessions-compulsions (OC) factor (OCD, BDD, and HD), and a body-focused repetitive behavior (BFRB) factor (HPD and SPD). The OC factor, not the BFRB factor, had unique associations with internalizing symptoms (standardized effects = 0.42-0.66) and the BFRB factor, not the OC factor, had small marginally significant unique association with drug/alcohol cravings (standardized effect = 0.22, p = 0.088).

CONCLUSIONS

The results mirror findings from twin research and indicate that OCD, BDD, and HD share liability that is significantly associated with internalizing symptoms, but this liability may be relatively less important for BFRBs. Further research is needed to better examine the associations between BFRBs and addictive disorders.

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.

Factor structure and psychometric properties of the Greek version of Saving Inventory-Revised (SI-R) in a non-clinical sample

Hoarding disorder is a debilitating condition that results from difficulty or inability to discard possessions and the need to save items and leads to cluttered living space. It impedes normal everyday functioning and causes significant distress and dysfunction. The aim of the current study was to validate the Greek version of the Saving Inventory-Revised (SI-R) in a non-clinical sample of 554 Greek adults. Factor structure and psychometric properties were investigated. Common exploratory (EFA) and confirmatory factor analysis (CFA) were used to explore the factor structure of the data. A three-factor solution was emerged for the Greek SI-R Which appears to cover the clinical dimensions of the phenomenon and consists of clutter, difficulty discarding and acquisition dimensions. This finding is in accordance with the original English version as well as other adaptations of the instrument in other languages. Some items cross loaded but such findings of cross loading items are also reported in related literature. The Greek version of the SI-R exhibits satisfactory internal consistency and good test retest reliability (stability). The current study also aimed to gather evidence towards the convergent and discriminant validity of Greek SI-R. Findings showed no correlation with measurements of different constructs such as anxiety, depression and non-hoarding obsessive compulsive symptoms but also only partial correlation with measurements of relative clinical constructs, such as hoarding items in obsessive compulsive inventories. Current findings suggest that the Greek SI-R can be a useful tool in the detection and evaluation of hoarding symptoms in Greek population.

Hypothesis: Compulsive hoarding as an atavism

In this hypothesis paper, we propose that hoarding disorder may be an ancestral mammalian behavior, possibly hard-wired but dormant in present-day humans, that can be activated by traumatic experiences. To support this claim, we describe hoarding in ancestral mammals and provide examples of recurrence of traits, or atavisms, in humans and other mammals, highlighting its implications for neuropsychiatric diseases. We highlight the potential of using shrews as animal models for hoarding behavior and, considering the current knowledge on the molecular underpinnings of the disorder, we also point to limitations of the proposed connection.

Saving inventory - Revised: Psychometric performance across the lifespan

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Unpacking the construct of emotional attachment to objects and its association with hoarding symptoms

BACKGROUND AND AIMS

The appetitive aspects of hoarding disorder, such as the compulsive acquisition and saving of objects, are akin to other behavioral addictions. Underpinning these appetitive features is the strong emotional and sentimental attachments that hoarding sufferers have for their possessions. Different facets of object attachment have been identified including anthropomorphism, insecure object attachment, possessions as an extension of identity, possessions as a repository of autobiographical memories, and possessions as a source of comfort and safety. The aim of this study was to examine the association between each of these facets and hoarding symptoms independent of non-sentimental hoarding beliefs, depression, and anxiety.

METHODS

Participants were 532 individuals recruited via Turkprime who completed online self-report questionnaires on hoarding symptoms, hoarding beliefs, depression, anxiety, and the facets of object attachment. Pearson's correlations and hierarchical multiple regression analyses were conducted.

RESULTS

The results showed that all facets of object attachment were positively correlated with hoarding symptoms. After accounting for other non-sentimental hoarding beliefs, depression, and anxiety, three facets made significant unique contributions to hoarding symptoms: insecure object attachment, anthropomorphism, and possessions as a repository of autobiographical memories.

DISCUSSION AND CONCLUSIONS

Based on these findings, we propose a compensatory model to explain how the different facets of object attachment may be implicated in hoarding. Further research into ways of reducing anthropomorphism, insecure object attachment, and possessions as memories are warranted.

A description of 17 animal hoarding case files from animal control and a humane society

This study describes 17 publicly available cases of animal hoarding, a special manifestation of hoarding disorder. The cases, which included court documents, animal service documents, photographs, and newspaper clippings, were reviewed by Masters-level clinicians and a veterinarian in private practice. The veterinarian rated the animals in the case files for possible neglect. Over half of the homes had signs of object hoarding. The most commonly hoarded animals were cats, dogs, and rabbits. The majority of animals in the cases reviewed required veterinary care. Individuals with animal hoarding often lack insight about the condition of their animals and require community intervention.

Comparing clinical characteristics and treatment outcomes between Veterans and non-Veterans with hoarding disorder

BACKGROUND

Because Veterans have higher rates of mental health conditions and both physical and mental health comorbidities are known to affect treatment outcomes, the purpose of this investigation was to compare the rates of risk factors for poor hoarding treatment outcomes between Veterans and non-Veterans with hoarding disorder (HD). This is the first study to investigate differences between Veterans and non-Veterans with HD.

MATERIAL AND METHODS

Baseline data were used from three different treatment studies of adults with hoarding disorder (n = 159). Demographic characteristics, baseline hoarding symptom severity, baseline medical and psychiatric comorbidities, and treatment attrition and response were compared between Veterans and non-Veterans.

RESULTS

Veterans were significantly less likely to be employed than non-Veterans. Veterans did not report significantly more severe hoarding symptoms at baseline when compared to non-Veterans. Veterans reported having a greater mean number of overall medical and psychiatric comorbidities. Veterans were more likely than non-Veterans to meet criteria for major depressive disorder and post-traumatic stress disorder. There was no significant difference in the rate of attrition between Veterans and non-Veterans and Veterans were not significantly more likely to be classified as treatment responders.

CONCLUSION

Many similarities were observed between the two groups, including demographic characteristics, hoarding symptom severity, and rates of treatment response. Given that Veterans with HD may suffer from greater medical and psychiatric comorbidities, clinicians should ensure that their clients are receiving adequate medical care and that any other psychiatric comorbidities should be addressed in conjunction for treatment with HD.

Unbending mind: Individuals with hoarding disorder do not modify decision strategy in response to feedback under risk

Cognitive-behavioral models of hoarding disorder emphasize impairments in information processing and decision making in the genesis of hoarding symptomology. We propose and test the novel hypothesis that individuals with hoarding are maladaptively biased towards a deliberative decision style. While deliberative strategies are often considered normative, they are not always adaptable to the limitations imposed by many real-world decision contexts. We examined decision-making patterns in 19 individuals with hoarding and 19 healthy controls, using a behavioral task that quantifies selection of decision strategies in a novel environment with known probabilities (risk) in response to feedback. Consistent with prior literature, we found that healthy individuals tend to explore different decision strategies in the beginning of the experiment, but later, in response to feedback, they shift towards a compound strategy that balances expected values and risks. In contrast, individuals with hoarding follow a simple, deliberative, risk-neutral, value-based strategy from the beginning to the end of the task, irrespective of the feedback. This seemingly rational approach was not ecologically rational: individuals with hoarding and healthy individuals earned about the same amount of money, but it took individuals with hoarding a lot longer to do it: additional cognitive costs did not lead to additional benefits.

Psychometric Evaluation of the Saving Inventory-Revised in Older Adults

OBJECTIVES

Hoarding disorder (HD) is a chronic condition characterized by severe impairment in health and functioning for older adults. Researchers and clinicians commonly use the Saving Inventory-Revised (SI-R), a self-report measure validated for the assessment of HD, to establish symptom severity. This study represents the first evaluation of the psychometric properties of the SI-R in a sample of older adults with HD.

METHODS

Participants were 156 older adults with HD and 23 older adults with no psychiatric diagnoses. Demographic and HD symptom severity measures were compared between the two samples. Convergent and discriminant validity was examined in the HD sample. A confirmatory factor analysis was used to test the replicability of the three-factor structure observed in the original sample.

RESULTS

Participants in the HD sample scored significantly higher on the SI-R than did the non-psychiatric sample. The SI-R was significantly correlated with clutter level and symptoms of anxiety and depression. A three-factor model demonstrated poor fit in the HD sample.

CONCLUSIONS

The SI-R can be used to validly assess hoarding severity in geriatric populations.

CLINICAL IMPLICATIONS

Clinicians working with geriatric patients should consider refraining from use of the SI-R subscales as they may be less theoretically distinct in older adults.

Hoarding disorder and the legal system: A comparative analysis of South African and Dutch law

Hoarding is an internationally recognised disability. Those who suffer from hoarding behaviour can be comfortably brought within the definition of disability found in the Convention on the Rights of Persons with Disabilities and should be provided with "reasonable accommodation" where doing so does not place an unjustified burden on others. However, hoarding also poses a threat to public health, and hoarders' behaviour may infringe on the rights of their neighbours and landlords. Thus, through their behaviour, hoarders may ultimately come into conflict with various areas of law, including neighbour law, housing law as well as administrative law. This article examines how hoarding may be addressed by the law in both South Africa and the Netherlands. It seeks to answer to what extent hoarders are provided with "reasonable accommodation" when their behaviour brings them into conflict of the law in these two jurisdictions. It also takes cognisance of the need to balance the provision of "reasonable accommodation" with the rights of neighbours and landlords. Finally, it seeks to assess which of the two jurisdictions provides the most balanced approach to handling hoarding, in light of the need for therapeutic jurisprudence.

Executive Functioning in Participants Over Age of 50 with Hoarding Disorder

OBJECTIVES

The current investigation utilized mid-life and late-life participants diagnosed with hoarding disorder (HD) to explore the relationship between executive functioning and hoarding severity.

DESIGN

Correlational analyses were used to investigate the associations between executive functioning and hoarding severity in nondemented participants. Multiple regression was used to determine if executive functioning had a unique association with HD severity when accounting for depressive symptoms.

SETTING

Participants were recruited from the San Diego area for HD intervention studies.

PARTICIPANTS

Participants were 113 nondemented adults aged 50-86 years who met DSM-5 criteria for HD. The mean age of the sample utilized in the analyses was 63.76 years (SD, 7.2; range, 51-85 years). The sample was mostly female (72%), Caucasian (81.4%), and unmarried (78%).

MEASUREMENTS

Hoarding severity was assessed using the Saving Inventory-Revised and the Clutter Image Rating and depression was assessed using the Hospital Anxiety and Depression Scale. Executive functioning was assessed using the Wisconsin Card Sorting Test (WCST-128) and the Trail Making and Verbal Fluency subtests of the Delis-Kaplan Executive Function System.

RESULTS

Executive function (operationalized as perseveration on the WCST-128) was significantly associated with Clutter Image Ratings. In a multivariate context, executive function and depressive symptom severity were both significant predictors of variance in Clutter Image Rating.

CONCLUSIONS

Our results suggest that executive function is related to severity of HD symptoms and should be considered as part of the conceptualization of HD.

Vallejo-Nágera (1926-1990) and the concept of 'soteric neurosis': a forgotten sketch of hoarding disorder in the obsessive-compulsive spectrum literature

Juan Antonio Vallejo-Nágera, psychiatrist, painter and writer, wrote a widely adopted textbook of psychiatry in Spanish- and Portuguese-speaking countries, particularly during the 1970s, the famous Introducción a la psiquiatría. There, he advanced the concept of soteric neurosis, a condition regarded as a 'mirror image' of phobias and similar to the diagnostic entity described in DSM-5 under the heading of hoarding disorder. Indeed, much earlier than the recent nosological discussions on hoarding, Vallejo-Nágera already reported soteric neurosis to be distinct from obsessive-compulsive disorder and to be associated with excessive attachment to objects and positive affect (pleasure), leading to accumulation, decreased treatment seeking, increasing interference in daily activities and blurred boundaries with normality. Vallejo-Nágera also made several predictions, including the propensity soteric neurosis patients may have towards the development of separation anxiety, obesity and other 'masked' symptoms. In the light of his original and insightful contributions to the concept of hoarding disorder, it would be interesting to assess his hypotheses in future studies.

A meta-analysis of the response of pathological hoarding to pharmacotherapy

This meta-analysis aimed to identify all studies that have assessed treatment response for pathological hoarding treated with pharmacological agents. Seven studies were identified with a total of 92 participants. Most participants had a diagnosis of obsessive-compulsive disorder. Studies assessed response to serotonin-reuptake inhibitors (SRIs); venlafaxine; methylphenidate; and augmentation of SRIs with quetiapine, minocycline and naltrexone. More than half (ER=0.58, 95% CI=0.37-0.76) of the participants treated with pharmacotherapy responded. This study encourages us to consider the use of SRIs in patients with hoarding disorder. The study also encourages more studies of pharmacotherapy for pathological hoarding, noting that these studies should use validated outcome measures that specifically assess pathological hoarding and novel agents that target the unique neurobiological correlates of pathological hoarding.

The UCLA Hoarding Severity Scale: development and validation

BACKGROUND

Effective management of Hoarding Disorder (HD) must begin with assessment of the severity of hoarding symptoms and functional impairment. We sought to validate the UCLA Hoarding Severity Scale (UHSS), a semi-structured, clinician-administered rating scale that measures the severity of both the core symptoms of HD and the associated features of indecisiveness, perfectionism, task prolongation, and procrastination, which are significantly associated with the diagnosis and impairment of HD.

METHODS

Hoarding symptom severity was measured in 62 patients who met DSM-5 diagnostic criteria for HD and 65 normal controls, using the UHSS and the Saving Inventory-Revised (SI-R), a well validated self-report measure of hoarding symptoms.

RESULTS

The UHSS showed significant internal consistency (Cronbach׳s α=.70). Principal components analysis revealed three factors that accounted for 58% of the variance: 1) associated features and functional impairment, 2) clutter volume and social impairment, and 3) difficulty discarding, urges to save, and excessive acquisition. UHSS and SI-R scores were significantly correlated. UHSS and SI-R total and factor scores of HD patients were all significantly different from those of controls.

LIMITATIONS

Inter-rater and test-retest reliability were not assessed. The initial version of the UHSS did not contain rater instructions, so it lacked quantifiable anchor points for ratings.

CONCLUSIONS

The UHSS showed internal consistency, construct validity, convergent validity, and known groups discriminant validity. The UHSS validly measures the core symptoms, associated features, and functional impairment of patients with HD. Utilizing a valid clinician-administered scale will provide a more comprehensive and accurate clinical assessment of patients with HD.

Hoarding disorder in older adulthood

OBJECTIVE

Hoarding disorder (HD) is a chronic condition associated with moderate to severe impairment in health and functioning. HD has been primarily studied in midlife adults, and there is limited research on HD in late life.

METHODS

In this review, we summarize research on the presentation and characteristics of HD and hoarding symptoms in older adults, including evidence for associated impairment in daily functioning, physical health, and cognitive function. Finally, we review the evidence available for intervention outcomes for treating HD in older adults.

RESULTS

Geriatric HD is characterized by severe functional impairment, medical and psychiatric comorbidities, and cognitive dysfunction.

CONCLUSION

There is a lack of randomized controlled trials investigating evidence-based treatments for geriatric HD.

[A Case with Multiple Comorbidities of Obsessive-Compulsive and Related Disorders]

Obsessive-compulsive and related disorders (OCRDs) have been introduced in a revision to DSM-5 as a novel category that is distinct from other anxiety disorders in DSM-IV. OCRDs consist of 5 primary disorders: obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder (HD), skin picking disorder (SPD), and hair pulling disorder (HPD), which share core clinical features such as preoccupation or recurrent thoughts and/or repetitive behaviors. Repetitive behaviors in BDD and HD can be differentially characterized by the presence of cognitive components associated with preceding anxiety from those in SPD or HPD, which are only observed as motoric components that regulate emotions or alleviate tension. Thus, the validity of the OCRD category and specific interrelationships between each OCRD remain uncertain. In the present study, therefore, we presented a case of multiple comorbidities of OCRDs in order to discuss the nature of the OCRD category. Our patient was a 20-year-old female university student. At the age of 11 years old, she started picking at acne on her face. The psychopathological, and treatment features observed in this case indicated possible interrelationships among OCRDs, especially between cognitive and motoric OCRDs, which supported the clinical utility and continuous nature of this category.

Hoarding in an Asian population: prevalence, correlates, disability and quality of life

INTRODUCTION

Hoarding is defined as the acquisition of, and inability to discard items even though they appear to others to have no value. The objectives of the study were to establish the prevalence of hoarding behaviour among the general population and among individuals with obsessive-compulsive disorder (OCD) in a cross-sectional study conducted in Singapore.

MATERIALS AND METHODS

The Singapore Mental Health Study was a cross-sectional epidemiological survey of a nationally representative sample of residents aged 18 years or older, living in households. The diagnoses of mental disorders were established using Version 3.0 of Composite International Diagnostic Interview (CIDI 3.0). Differences between 3 groups i.e. those diagnosed with lifetime/12-month Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) OCD with hoarding, those diagnosed with lifetime/12-month DSM-IV OCD without hoarding and those with lifetime hoarding behaviour without diagnosis of DSM-IV OCD were determined.

RESULTS

The weighted prevalence of lifetime hoarding behaviour was 2% and that of hoarding among those with OCD was 22.6%. Those who met the criteria for hoarding behaviour alone were associated with lower odds of having obsessions of contamination, harming, ordering as well as compulsions of ordering and other compulsions than those who met criteria for both OCD and hoarding.

CONCLUSION

Hoarders without OCD were less impaired, in terms of comorbid psychopathology, than those with OCD with and without hoarding, and had a higher quality of life versus those with both OCD and hoarding, though still lower than that of the general population.

Hoarding disorder and obsessive-compulsive disorder show different patterns of neural activity during response inhibition

Although hoarding disorder (HD) has been historically conceptualized as a subtype or dimension of obsessive-compulsive disorder (OCD), preliminary evidence suggests that these two disorders have distinct neural underpinnings. The aim of the present study was to compare the hemodynamic responses of HD patients, OCD patients, and healthy controls (HC) during response inhibition on a high-conflict Go/NoGo task that has previously proved sensitive to OCD. Participants comprised 24 HD patients, 24 OCD patients, and 24 HCs who completed a Go/NoGo task during functional magnetic resonance imaging (fMRI). Although behavioral data showed no difference among the groups in Go/NoGo task performance, significant differences in hemodynamic activity were noted. During correct rejects (successful response inhibition), HD patients showed greater right precentral gyrus activation, whereas OCD patients exhibited greater right orbitofrontal activation, as assessed using a region of interest approach. During errors of commission (response inhibition failures), OCD patients, but not HD patients, were characterized by excessive activity in left and right orbitofrontal gyrus. The present results lend further support to the biological distinction between HD and OCD, and they are consistent with previous research suggesting frontal hypoactivity in HD patients during hoarding-unrelated tasks.

The London field trial for hoarding disorder

BACKGROUND

A new diagnostic category, hoarding disorder (HD), has been proposed for inclusion in DSM-5. This study field-tested the validity, reliability and perceived acceptability of the proposed diagnostic criteria for HD. Method Fifty unselected individuals with prominent hoarding behavior and 20 unselected, self-defined 'collectors' participated in thorough psychiatric assessments, involving home visits whenever possible. A semi-structured interview based on the proposed diagnostic criteria for HD was administered and scored by two independent raters. 'True' diagnoses were made by consensus according to the best-estimate diagnosis procedure. The percentage of true positive HD cases (sensitivity) and true negative HD cases (specificity) was calculated, along with inter-rater reliability for the diagnosis and each criterion. Participants were asked about their perceptions of the acceptability, utility and stigma associated with the new diagnosis.

RESULTS

Twenty-nine (58%) of the hoarding individuals and none of the collectors fulfilled diagnostic criteria for HD. The sensitivity, specificity and inter-rater reliability of the diagnosis, and of each individual criterion and the specifiers, were excellent. Most participants with HD (96%) felt that creating a new disorder would be very or somewhat acceptable, useful (96%) and not too stigmatizing (59%).

CONCLUSIONS

The proposed HD criteria are valid, reliable and perceived as acceptable and useful by the sufferers. Crucially, they seem to be sufficiently conservative and unlikely to overpathologize normative behavior. Minor changes in the wording of the criteria are suggested.

Finders keepers: the features differentiating hoarding disorder from normative collecting

OBJECTIVE

A new diagnostic category called Hoarding Disorder (HD) has been proposed for inclusion in DSM-5. It is paramount that this addition does not result in an over-pathologization of normative behavior. Collectors constitute a valid population within which to test the diagnostic boundaries of HD. The current study explored the features that differentiate pathological hoarding from normative collecting.

METHODS

Participants were 29 individuals with a diagnosis of HD and 20 individuals who self-identified as collectors who enrolled in the London Field Trial for HD. A series of semi-structured interviews (often in the participants' homes) were conducted, including a detailed assessment of the typical elements of the collecting process. Participants also completed a battery of self-report questionnaires.

RESULTS

Collectors were more likely than those with HD to be male, partnered, and free of psychiatric conditions or medication. Like those with HD, collectors reported the acquisition of, attachment to, and reluctance to discarding objects. However, the resulting clutter and impairment were minimal in this group and ultimately insufficient to garner an HD diagnosis. Collectors were, additionally, more focused in their acquisitions (e.g., confining their accumulations to a narrow range of items), more selective (e.g., planning and purchasing only pre-determined items), more likely to organize their possessions and less likely to accumulate in an excessive manner.

CONCLUSIONS

There are important quantitative and qualitative differences between HD and normative collecting. For this reason, collectors are unlikely to be inappropriately pathologized by the introduction of HD.

Core OCD symptoms: exploration of specificity and relations with psychopathology

Obsessive-compulsive disorder (OCD) is a heterogeneous condition, comprised of multiple symptom domains. This study used aggregate composite scales representing three core OCD dimensions (Checking, Cleaning, and Rituals), as well as Hoarding, to examine the discriminant validity, diagnostic specificity, and predictive ability of OCD symptom scales. The core OCD scales demonstrated strong patterns of convergent and discriminant validity - suggesting that these dimensions are distinct from other self-reported symptoms - whereas hoarding symptoms correlated just as strongly with OCD and non-OCD symptoms in most analyses. Across analyses, our results indicated that Checking is a particularly strong, specific marker of OCD diagnosis, whereas the specificity of Cleaning and Hoarding to OCD was less strong. Finally, the OCD Checking scale was the only significant predictor of OCD diagnosis in logistic regression analyses. Results are discussed with regard to the importance of assessing OCD symptom dimensions separately and implications for classification.

Approach to hoarding in family medicine: beyond reality television

OBJECTIVE

To review the presentation of hoarding and provide basic management approaches and resources for family physicians.

SOURCES OF INFORMATION

PubMed was searched from 2001 to May 2011. The MeSH term hoarding was used to identify research and review articles related to the neuropsychological aspects of hoarding and its diagnosis and treatment.

MAIN MESSAGE

Hoarding is often a hidden issue in family medicine. Patients with hoarding problems often present with a sentinel event such as a fall or residential fire. Although hoarding is traditionally associated with obsessive-compulsive disorder, patients more commonly have secondary organic disease associated with hoarding behaviour or have hoarding in absence of substantial compulsive traits. Hoarding disorder is expected to be included in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Management is best provided by a multidisciplinary approach when possible, and an increasing number of centres provide programs to improve symptoms or to reduce harm. Pharmacologic management has been shown to be of some help for treating secondary causes. In the elderly, conditions such as dementia, depression, and substance abuse are commonly associated with hoarding behaviour. Attempts should be made to keep patients in their homes whenever possible, but an assessment of capacity should guide the approach taken.

CONCLUSION

Hoarding is more common than family physicians realize. If hoarding is identified, local resources should be sought to assist in management. Assessment and treatment of underlying causes should be initiated when secondary causes are found. It is expected that primary hoarding will be a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

[Hoarding disorder, symptom or separate disorder? Case report]

Hoarding or compulsive hoarding, a severe form of collectionism, is currently described in various psychiatric disorders, including the famous Diogenes syndrome. The lack of remission despite a correct treatment in a patient that we have followed in the brief therapy center in Geneva, has led us to carry out an extensive Medline review, which revealed several interesting points. It seems that excessive hoarding, with a prevalence of 2,3 to 4,6%, has received increasing interest and there is an actual debate of distinguishing hoarding from other disorders. Thus, this field requires further attention to better understand its phenomenology. This case report describes an excessive hoarding disorder confirming the complexity of this trouble and the possibility to consider it as an independent diagnosis.

[Pathological hoarding by children and adolescents]

BACKGROUND

There is a dearth of knowledge and understanding concerning hoarding by children and adolescents. Psychiatrists need to know more about the phenomenon of hoarding since it can be a marker of psychopathology and it sometimes is symptomatic of a psychiatric disorder.

AIM

To review hoarding from an epidemiological and psychopathological perspective and to discuss it in relation to the developmental aspect of the first object acquisition: the transitional object.

METHOD

We conducted a literature search in PubMed, Medline, PsycINFO and the Cochranedatabase using primarily the search term ‘hoarding', but also in combination with the terms: primates, child, adolescent, psych*, klepto*, transitional object, obsessive-compulsive disorder, collecting and attachment.

RESULTS

Both animals and humans engage frequently in collecting and hoarding. Up to 60% of normally functioning children and adolescents are involved in collecting. A strong emotional attachment to possessions may be a response to an attachment problem. Hoarding combined with psychopathology is seen in persons of all ages but the prevalence rates for children and adults are unknown.

CONCLUSION

Hoarding is a worrisome type of behaviour which must be regarded as an indication of serious comorbid psychopathology. It can occur either as a symptom of an existing disorder or as a separate disorder. Finally we recommend that hoarding be included in the diagnostic criteria of the dsm and icd.

Testing the validity and acceptability of the diagnostic criteria for Hoarding Disorder: a DSM-5 survey

BACKGROUND

The DSM-5 Obsessive-Compulsive Spectrum Sub-Workgroup is recommending the creation of a new diagnostic category named Hoarding Disorder (HD). The validity and acceptability of the proposed diagnostic criteria have yet to be formally tested.

METHOD

Obsessive-compulsive disorder/hoarding experts and random members of the American Psychiatric Association (APA) were shown eight brief clinical vignettes (four cases meeting criteria for HD, three with hoarding behaviour secondary to other mental disorders, and one with subclinical hoarding behaviour) and asked to decide the most appropriate diagnosis in each case. Participants were also asked about the perceived acceptability of the criteria and whether they supported the inclusion of HD in the main manual.

RESULTS

Altogether, 211 experts and 48 APA members completed the survey (30% and 10% response rates, respectively). The sensitivity and specificity of the HD diagnosis and the individual criteria were high (80-90%) across various types of professionals, irrespective of their experience with hoarding cases. About 90% of participants in both samples thought the criteria would be very/somewhat acceptable for professionals and sufferers. Most experts (70%) supported the inclusion of HD in the main manual, whereas only 50% of the APA members did.

CONCLUSIONS

The proposed criteria for HD have high sensitivity and specificity. The criteria are also deemed acceptable for professionals and sufferers alike. Training of professionals and the development and validation of semi-structured diagnostic instruments should improve diagnostic accuracy even further. A field trial is now needed to confirm these encouraging findings with real patients in real clinical settings.

Comparison of object and animal hoarding

Recent research has highlighted the prevalence and harmful consequences of hoarding, and investigators have proposed inclusion of hoarding disorder in DSM-5. An unanswered question about the proposed disorder is whether people who hoard animals would meet diagnostic criteria for it. This article discusses the similarities and differences between object and animal hoarding. People who hoard animals appear to meet the basic diagnostic criteria for hoarding disorder. Their homes are cluttered, disorganized, and dysfunctional. They have great difficulty relinquishing animals to people who can more adequately care for them, and they form intense attachments (urges to save) that result in significant impairment. However, they differ from people who hoard objects in several ways. These differences are significant enough to warrant comment in the text description accompanying the diagnostic criteria and consideration as a subtype of hoarding disorder. More research is necessary to determine the exact relationship between object and animal hoarding.

Consideration of the BDNF gene in relation to two phenotypes: hoarding and obesity

The gene coding for the brain derived neurotrophic factor (BDNF) has emerged as an interesting candidate for multiple brain and brain disorder-related phenomena. The primary aim of the present investigation was to consider the relationship between the BDNF Val66Met variant and two phenotypes: compulsive hoarding as a symptom dimension of obsessive-compulsive disorder (OCD), and body mass index (BMI). We examined the BDNF gene in a large (N=301) clinical sample of probands with OCD. Participants were classified as hoarding or nonhoarding using a strict, multimeasure grouping approach. Results revealed that the Val/Val genotype was linked with hoarding classification and more severe hoarding behaviors, as well as greater BMI levels. Hoarding status was also associated with greater BMI scores, with individuals in the hoarding group being far more likely to be classified as obese compared with the nonhoarding group. Our findings may provide a distinct avenue through which hoarding and BMI could be linked. These findings are suggestive of a complex gene, body weight, and psychopathology relationship wherein a primitive, survival "thrifty gene" strategy may be conserved and represented in a subgroup of humans manifesting severe hoarding symptoms.