Transcript Slide 1

Hoarding: Symptom of Anxiety Disorder,
OCD Variant, or Distinct Diagnosis….or…Is
DSM-V Becoming Too Cluttered?
Joint Session
American College of Neuropsychiatrists
and
American Osteopathic Academy of Addiction Medicine
Gerald G. Osborn, D.O., M.Phil., dFACN, dLFAPA
Professor & Chair, Dept. of Psychiatry and Behavioral Medicine
Associate Dean for International Medicine
Lincoln Memorial University-DeBusk College of Osteopathic Medicine
Hoarding: Experts and Notorious Cases
 Dates back a century in the literature
 Randy O. Frost, PhD, Professor, Smith College
 Sanjaya Saxena, MD, Professor in Residence, UCSD
Dept. Of Psychiatry
 Gail S. Steketee, PhD, Dean and Professor, Boston
University School of Social Work
 Notorious cases
 Brothers in NYC in 1947
 Agent Rose
Overview of Hoarding
 “Anal character”
 Approximately 2-5% of the population
 15-40% of OCD patients; disabling in 5% of them
 Estimated prevalence is double that of OCD
 Hoarding by animals – rodents, birds (curvids), insects
 Genetic? Compulsive hoarding found to be 50%
genetic in adults
 Runs in families
 Egosyntonic
Overview of Hoarding - Continued
 Mild to life threatening
 Contributed to death in fire in 6% of hoarding cases
in a health department survey
 Abnormally high levels of trauma or stressful life
events – sometimes result in onset or exacerbation
 Other traits – anxiety, perseveration, behavioral
inflexibility, and working memory impairments
 Worsens with age
 Distress and disability often appear late and are often
linked to interventions
Hoarding and OCD
 Included in most measures of OCD symptom
severity
 Included in structured interviews and
questionnaires for OCD symptoms
 Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
Most used
 Inadequate for assessing hoarding
 Obsessive-Compulsive Inventory-Revised (OCI-R)

Hoarding of
Animals
 Comorbid neglect
 Neuropsychological
theories
 Delusional model
 Dementia model
 Addictions model
 Attachment model
 OCD model
Source – Confessions: Animal Hoarding
on Animal Planet
Animal Hoarding - Laws
 All states have laws minimal care standards (e.g.,
food, shelter, veterinary care,
and sanitary conditions) for
animals
 Few states have laws
specifically addressing
animal hoarding – Hawaii,
Vermont, Illinois, and others
Cases of Animal Hoarding
 170 cats; Powell, WY; 8-26-2010
 700 animals (151 dogs, snakes, tortoises, 156
birds, cattle, etc.; ½ dead) ; Reddick, FL; 414-2010
 35 cats; Brooklyn, NY; 1-18-2010
 30 horses; Mitchell, OR; 6-23-2009
 80 rabbits; San Francisco, CA; 6-23-2006
Source: http://www.pet-abuse.com
Shelley has Bird Lung Disease
Source – Confessions: Animal Hoarding on Animal Planet
Jackie –
65 cats
Source –
Confessions:
Animal Hoarding
on
Animal
Planet
Severe Squalor
Diogenes Syndrome
 Self-neglect
 Domestic squalor
 Social withdrawal
 Apathy
 Compulsive
hoarding
 Lack of shame
Source: Hoarders on A&E
Why Hoard?
 Instrumental vs.
sentimental
 Fear of catastrophic
consequences
 Symmetry/ordering
 Excessive checking rituals
 Emotional and/or intrinsic
value of possessions
 Grief and loss
 Developmental scarcity
DSM-IV-TR and ICD-10
 DSM-IV-TR
 Core diagnostic criteria for obsessive-compulsive
personality disorder (OCPD) since DSM III-R

“the inability to discard worn-out or worthless objects even
when they have no sentimental value”
 Extreme hoarding = consider diagnosis of obsessive-
compulsive disorder (OCD)
 May diagnose both OCPD and OCD
 ICD-10
 Anankastic Personality Disorder
 Does not include hoarding as a criterion
Diagnostic Criteria by Frost and Hartl, 1996
 The acquisition of and failure to discard a large
number of possessions that seem to be useless or of
limited value
 Living spaces sufficiently cluttered so as to preclude
activities for which those spaces were designed
 Significant distress or impairment in functioning
caused by the hoarding
Frost RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav
Res Ther. 1996;34:341-350.
Diagnostic Criteria by Frost and Hartl,
Revised, 2010
 Persistent difficulty discarding items
 Accumulation of items, prevent normal use of space
 Clinically significant distress or impairment in social, occupational,
or other important areas of functioning
 Not due to a general medical condition
 Not restricted to symptoms of another mental disorder (due to
obsessions in OCD, lack of motivation in MDD, delusions in
schizophrenia, cognitive deficits in dementia, restricted interests in
autistic disorder, food storing in Prader-Willi Syndrome)
 Specify if
 With excessive acquisition
 Good or fair insight, poor insight, delusional
Source: Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for
DSM-V? Depress Anxiety. 2010;27(6):556-572.
Hoarding Scales
 UCLA Hoarding Severity Scale (UHSS), approximately
2001
 a 10-item, clinician-administered scale
 extent of clutter, urges to save items, excessive
acquisition, difficulty discarding, social and
occupational impairment, slowing, indecisiveness,
and procrastination
 allows additional questions for clarification
Saxena S, Brody AL, Maidment KM, Baxter LR Jr. Paroxetine treatment of
compulsive hoarding. J Psychiatr Res. 2007;41(6):481-487.
Hoarding Scales - Continued
Saving Inventory-Revised,
2004
 Developed to replace
scale developed in 1998
that did not assess
important symptoms
unknown at the time it
was developed
 23 items that examine
discarding, clutter, and
acquisition
Frost RO, Steketee G, Grisham J.
Measurement of compulsive hoarding:
saving inventory-revised. Behav Res
Ther. 2004;42(10):1163-1182.
Clutter Image Rating,
2008
 9 photos of three
rooms (living room,
kitchen, and
bedroom)
 Available at
http://www.oup.com/us/compani
on.websites/umbrella/treatments
/hidden/mforms/?view=usa
Frost RO, Steketee G, Tolin DF,
Renaud S. Development and
validation of the clutter image
rating. J Psychopath Behav Assess.
2008;30:193-203.
Hoarding Scales - Continued
The Hoarding Rating Scale-Interview, 2010
 5 items, semi-structured interview
 Looks at clutter, difficulty discarding, acquisition,
distress and impairment
 Scale of 0-8 for each question
 http://www.ocfoundation.org/uploadedFiles/Hoarding/Resources/Hoa
rding%20Rating%20Scale%20with%20interpret.pdf
Tolin DF, Frost RO, Steketee G. A brief interview for assessing compulsive
hoarding: the Hoarding Rating Scale-Interview. Psychiatry Res. 2010;178(1):147152.
DSM-V Issues
 Separate diagnosis?
 Not restricted to symptom of
another disorder
 Change proposed criteria?
 Reflect gender,
developmental, or crosscultural considerations?
 Call it what?

Include compulsive in the
name?
 Where classify it?


Separate OCSD
Appendix of Criteria Sets
Provided for Further Study
 Symptom of OCD?
 Symptom of OCPD?
 Consequence of/secondary to
OCD?
 Variant of OCD (when it
appears in the absence of
other OCD symptoms)?
 Majority of cases display no
other OCD symptoms
DSM-V
 Link between hoarding and OCPD can be explained mostly by
overlapping item content
 Personality and Personality Disorders Workgroup currently
recommends excluding hoarding as a major trait or dimension
of OCPD
 More in line with ICD-11
 Weak intercorrelations in current OCPD criteria
 Benefits of new diagnosis
 Improve clinical communication
 Provide better patient care
 Stimulate new research

Many current OCD studies exclude hoarders
 Patients are unhappy with current OCD diagnoses
New Diagnosis
 New diagnosis – sufficiently distinct?
 Diagnostic criteria
 Adequate clinical face validity – already established by 100s of cases
 Reliability?
 Adequate sensitivity and specificity?
 Easily implemented in interview and assessed?
 Label normal as abnormal
 Where draw the line?
 Social consequences
 Economic consequences
Source: Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a
new diagnosis for DSM-V? Depress Anxiety. 2010;27(6):556-572.
Neuroimaging
 Pts have developed compulsive hoarding and
collecting behaviors after damage to
 OFC
 mPFC caused by
cerebral hemorrhage from ruptured
anterior communicating artery aneurysms
 Resection of olfactory meningioma
 Frontotemporal dementia

Neuroimaging - Continued
 9 pts w/compulsive hoarding compared to 54
nonhoarding brain-damaged pts
 All hording pts – damage to PRC, mostly in medial and
inferior areas
 Greatest lesion overlap in hoarders

Right mPFC, orbitofrontal pole, anterior cingulate cortext
(ACC) and adjacent white matter1
 Compulsive hoarders had significantly lower
normalized glucose metabolism in the bilateral and
ventral ACC than controls2
Neuroimaging - Continued
 Compulsive hoarding – neurobiologically distinct
disorder w/unique pattern of abnormal brain
function that does not overlap w/ that of
nonhoarding OCD
 Important findings for classifying compulsive
hoarding but also its tx and neurobiology2
1. Anderson SW, Damasio H, Damasio AR. A neural basis for collecting
behaviour in humans. Brain. 2005;128:201-212.
2. Saxena S. Recent advances in compulsive hoarding. Curr Psychiatry
Rep. 2008;10:297-303.
Neuroimaging
 OCD – mediated
by elevated
activity in specific
orbitofrontostriatal-pallidalthalamic circuits
 Compulsive
hoarding –
mediated by
partially distinct
fronto-limbic
circuits involving
the cingulate
cortex, prefrontal
cortex, limbic
structures
Source: Baxter LR Jr. Neuroimaging studies of obsessive compulsive disorder.
Psychiatr Clin North Am. 1992;15(4):871-884.
Scanned while imagining
throwing away items.
Source: An SK, Mataix-Cols D,
Lawrence NS, et al. To discard or not to
discard: the neural basis of hoearding
symptoms in obsessive-compulsive
disorder. Mol Psychiatry. 2009;14(3):318331.
Compared to nonhoarding participants,
hoarding participants
showed greater
activity in left lateral
orbitofrontal cortex
(OFC) and
parahippocampal
gyrus
(PHG).
Source: Tolin DF, Kiehl KA,
Worhunsky P, Book GA, Maltby N.
An exploratory study of the neural
mechanisms of decision making in
compulsive hoarding. Psychol Med.
2009;39(2):325-336.
Scanned while making choices; items were shredded if choice was made to do so.
Comorbidities
 Meta-analysis of 21 studies w/5,000 participants w/OCD –




hoarding an independent factor in adult and pediatric
samples
OCD – 15-35%1, 3
Major depression = 36%
Social phobia – 20%
GAD – 24%2
 Dependent personality disorders
 Paranoia
1. Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a
new diagnosis for DSM-V? Depress Anxiety. 2010;27(6):556-572.
2. Pertusa A, Frost RO, Mataix-Cols. When hoarding is a symptom
 Brain injury
of OCD: a case series and implications for DSM-V. Behav Res Ther.
2010;48:1012-1020.
 Dementia3
3. Steketee G, Frost R. Compulsive hoarding: current status of the
research. Clin Psychol Rev. 2003;23(7):905-927.
25 pts w/severe compulsive
hoarding w/OCD, 27 pts
w/severe compulsive
hoarding w/out OCD, 71
pts w/OCD w/out
hoarding, 19 pts w/anxiety
disorder, & 21 community
participants.
Source: Pertusa A, Fullana MA, Singh S,
Alonso P. Compulsive hoarding: OCD
symptom, distinct clinical syndrome, or
both? Am J Psychiatry. 2008;165:12891298.
Clinical Trial, 2010, Recruiting
 Enhancing Attention in Adults with Compulsive
Hoarding
 New York State Psychiatric Institute and Hartford
Hospital (CT)
 Methylphenidate ER – 18mg/day at start w/increase of
18mg/day per week to reach 72mg/day
 Outcome: improvement in attention based on ADHDSS
(Attention Deficit Hyperactivity Symptom Scale)
 http://www.clinicaltrials.gov/ct2/show/NCT01100268
Hoarding in the Media
Hoarders, A&E, Mondays at 10/9c
http://www.aetv.com/hoarders/index.jsp
Hoarding:
Buried
Alive,
TLC,
Sundays
at 9/8c
http://tlc.discovery.com/tv/hoarding-buried-alive/
Confessions: Animal Hoarding, Animal Planet
Treatment
 Difficult to treat
 May involve confrontive
intervention
 Often long-term
 Cognitive Behavior Therapy
(CBT)
 SRIs – 40-60% respond
 Paroxetine
 Antipsychotic medications
 Cognitive enhancers (AChEl and
NMDA)
Helpful Resources
International OCD Foundation
http://www.ocfoundation.org/
Hartford Hospital website on compulsive hoarding
http://www.compulsivehoarding.org
The Hoarding of Animals Research Consortium
http://www.tufts.edu/vet/hoarding/
Pet-Abuse.Com – report animal cruelty; see http://www.petabuse.com/pages/animal_cruelty/reporting_abuse.php
Stuff: Compulsive Hoarding and the Meaning of Things by
Randy O. Frost and Gail Steketee, Houghton Mifflin
Harcourt, 2010
Acknowledgement
 Dr. Osborn would like to express sincere thanks to Lisa
Travis, MS, EdS, Medical Librarian for LMU-DCOM,
for her assistance in the research and preparation for
this presentation.