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PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 233 C l i n i c a l r e s e a r c h Compulsive hoarding: current controversies and new directions Jessica R. Grisham, PhD; Melissa M. Norberg, PhD C ompulsive hoarding is a syndrome characterized by excessive collecting and saving behavior that results in a cluttered living space and significant distress or impair- ment.1 In the past decade, there has been a notable increase in research on hoarding, including its phenome- nology, pathophysiology, and treatment approaches. This surge in interest has been coupled with contention regard- ing key aspects of the disorder. These controversies have led to exciting new research that has deepened our under- standing of this complex syndrome. The aim of this article is to describe some of these debated issues, as well as to Compulsive hoarding is a disabling psychological disor- highlight recent advances in compulsive hoarding research. der characterized by excessive collecting and saving behavior. This article reviews four key areas of recent Diagnostic status advances in hoarding research. First, we provide an overview of the evolving controversy regarding the diag- An obvious example of a current debate within hoard- nostic status of hoarding, highlighting accumulating evi- ing research is the question of where hoarding belongs dence that it may be best conceptualized as a separate within our diagnostic nosology. The uncertainty regard- syndrome. Second, we describe advances in our under- ing the most appropriate classification of compulsive standing of the epidemiology, course, and demographic hoarding syndrome has had important consequences for features of compulsive hoarding. Third, we review the our understanding of hoarding, and in some ways has latest findings regarding possible neuropsychological constituted an obstacle to hoarding research. The lack of correlates of the disorder. Finally, we discuss ongoing clear placement within DSMhas led to an underestima- progress and future directions related to the clinical tion of the significance of the burden of disease associ- management of compulsive hoarding. ated with compulsive hoarding, inconsistencies with © 2010, LLS SAS Dialogues Clin Neurosci.2010;12:233-240. respect to an appropriate clinical comparison group in Keywords:hoarding; obsessive-compulsive disorder; saving; collecting; clutter hoarding research, difficulties comparing findings across hoarding studies, and misconceptions regarding which Author affiliations: School of Psychology, University of New South Wales, assessment and treatment models are most relevant to Sydney, Australia hoarding. Address for correspondence:Jessica R. Grisham, School of Psychology, University of In the DSM-IV-TR,2hoarding is described as difficulty New South Wales, Sydney NSW 2052, Australia (e-mail: [email protected]) discarding items, and is listed as one of the eight diag- Copyright © 2010 LLS SAS. All rights reserved 233 www.dialogues-cns.org PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 234 C l i n i c a l r e s e a r c h nostic criteria for obsessive-compulsive personality dis- A recent study by Abramowitz and colleagues15 pro- order (OCPD). Accumulating evidence, however, sug- vided further evidence that although some individuals gests that it is misleading and invalid to classify hoarding with OCD may show hoarding behavior, hoarding is as part of OCPD. When studies examining the prevalence most likely distinct from OCD. Abramowitz and col- of OCPD in hoarding samples exclude the criterion leagues compared OCD patients, patients with other describing difficulty discarding, most studies suggest that anxiety disorders, and unscreened undergraduate stu- hoarding is no more associated with OCPD than it is with dents. OCD patients scored higher on all OCD symp- other Axis II disorders.3,4In addition, hoarding has been toms except hoarding, in which the student group scored found to have the lowest specificity and predictive crite- slightly, but significantly higher than both clinical groups. ria of all eight of the diagnostic criteria for OCPD.5Based Similarly to Wu and Watson,4 Abramowitz and col- on these findings, Saxena et al6argued convincingly that leagues found that the magnitude of the correlations hoarding should be removed from the diagnostic criteria between hoarding and other OCD symptoms was sig- for OCPD. Nevertheless, there is some evidence to sug- nificantly weaker than the magnitude of the correlations gest a link between hoarding and OCPD. A recent study amongst all other OCD symptoms. In addition, the of hoarding within a collaborative OCPD genetics study hoarding items loaded weakly on a unitary OCI-R fac- found that hoarders had a greater prevalence of certain tor. In a second study, Abramowitz et al15 found that OCPD traits, particularly miserliness and preoccupation hoarding was correlated weakly with depression, but not with details.7In addition, several previous studies have with anxiety. Other OCD symptoms showed at least a reported that OCPD is more common in hoarders.8-10 moderate association with anxiety. Due to these recent Thus while the consensus appears to be that hoarding is findings, there is a growing consensus that hoarding inappropriately classified as a criterion of OCPD, the should not be considered as a symptom of OCPD or broader issue of the relation of hoarding to OCPD, as OCD, but as a separate clinical syndrome. well as to other Axis II disorders, remains unresolved. Several researchers have also examined whether there Despite its placement in the Diagnostic and Statistical are important differences between hoarding behavior Manual of Mental Disorders (DSM)-IV, clinicians and seen in the context of OCD and hoarding that occurs researchers typically consider hoarding a symptom or without any other OCD symptoms.3,4,16A recent study subtype of obsessive-compulsive disorder (OCD). For conducted by Petrusa et al3compared individuals with example, the Y-BOCS checklist11lists hoarding obses- severe compulsive hoarding who met criteria for OCD sions and compulsions, and many investigations into (OCD plus hoarding group) with individuals with severe hoarding have involved comparing OCD individuals hoarding who did not meet criteria for OCD (mono- with and without hoarding. This view of hoarding as part symptomatic hoarding). Individuals in the OCD plus of OCD derived from early findings that approximately hoarding group differed from the monosymptomatic one third of individuals with OCD have hoarding symp- hoarding group in several important ways. For example, toms.12-14 More recent studies, however, have found OCD plus hoarding participants were more likely to ample evidence that hoarding should not be conceptu- hoard bizarre items and more likely to report other alized only as an OCD symptom. For example, Wu and obsessions and compulsions related to their hoarding Watson4found that hoarding correlated more weakly than those in the monosymptomatic hoarding group. In with other symptoms of OCD than these other symp- addition, the OCD plus hoarding group endorsed more toms correlated with each other. Moreover, Saxena et al6 cluster C personality traits than the monsymptomatic found that patients who hoard, compared with other hoarding group. OCD patients, had different functional neuroimaging Given that hoarding can occur in the absence of OCD findings, response to treatment, and clinical profiles. In and that it shares some similarity to impulse control dis- a large study of hoarding among OCD patients,7indi- orders (ICDs) such as pathological gambling, pyroma- viduals with hoarding were more likely to have symme- nia, and kleptomania, it may have a place within behav- try obsessions and counting, ordering, and repeating ioral addiction. Although hoarding behavior is compulsions. They also were more likely to have greater sometimes motivated by a desire to reduce anxiety, it illness severity, more difficulty initiating and completing also sometimes appears to be driven by anticipation of tasks, and problems with indecision. pleasure and impaired self-regulation.16Since both anx- 234 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 235 Compulsive hoarding - Grisham and Norberg Dialogues in Clinical Neuroscience - Vol 12 .No. 2 .2010 iety and approach behaviors may play a role in compul- community.22Similarly, information regarding the bur- sive hoarding, a common diathesis may underlie both den of hoarding was based on anecdotal evidence and hoarding and certain impulse control disorders. Samuels small samples. Recent epidemiological studies, however, et al14reported a greater frequency of trichotillomania suggest that compulsive hoarding may be far more and skin picking among hoarding compared with non- prevalent and burdensome in the community than pre- hoarding individuals with OCD. In addition, Frost et al17 viously thought. Data from the Baltimore Epidemiologic found that pathological gamblers reported significantly Catchment Area Follow-up survey suggest that 5% of more hoarding symptoms than light gamblers. the general population experiences clinically significant Although Grant et al18found a low prevalence of ICDs hoarding, while data from the National Comorbidity overall among individuals with obsessive-compulsive Survey Replication indicate that the lifetime prevalence disorder, obsessive-compulsive disorder participants of compulsive hoarding may be as high as 14%.23,24These with a lifetime and current impulse control disorder studies estimated hoarding based upon reports of diffi- were more likely to report hoarding symptoms. In a culty discarding, and did not specifically target clutter recent study, Hayward and Coles19examined the rela- and excessive acquisition, and thus it is unknown tion of hoarding to OCD and ICDs in an undergradu- whether cases met criteria for compulsive hoarding as ate sample, and found that hoarding behaviors were defined by Frost and Hart.l1A recent twin study that uti- related moderately to symptoms of compulsive buying, lized a self-report instrument to assess the broad hoard- and more weakly related to pathological gambling, tri- ing phenotype found that 2% of its sample reported clin- chotillomania, and kleptomania. The possible associa- ically significant hoarding symptoms.25 As symptom tion between hoarding and ICDs is consistent with severity obtained by self-report tends to be lower than McElroy and colleagues’ conceptualization of a com- clinician-rated severity, the current prevalence of clini- pulsive-impulsive spectrum,20but requires further explo- cally significant compulsive hoarding may be somewhere ration. between 2% and 5%. The nosological issues surrounding hoarding will influ- Importantly, a large proportion of individuals who hoard ence its placement in the next edition of the DSM. One report having at least one first-degree relative who expe- position is that compulsive hoarding should be included riences hoarding problems.3,14In a sample of individuals in our diagnostic system as an independent syndrome, with OCD, Samuels and colleagues14 reported that which is sometimes comorbid with OCD. Including probands of individuals with hoarding symptoms were hoarding as a separate syndrome has a number of four times more likely to experience hoarding symptoms important practical advantages, well-summarized by than probands of individuals who did not report hoard- Rachman and colleagues.21For example, it would expand ing symptoms. Genetic factors and unshared environ- the boundaries of the hoarding population to be consis- mental factors may explain this familial connection. In a tent with the data showing a high incidence of hoarding large sample of female twins, genetic factors accounted not associated with OCD. It would also encourage clin- for approximately 50% of the variance in compulsive icians and researchers to use hoarding-specific assess- hoarding, while shared environmental factors encoun- ment tools rather than measures designed for OCD, and tered by twins growing up in the same household did not facilitate the development of new treatment methods for substantially contribute to the other half.25 hoarding. Another possibility is that hoarding may be Recent data suggests that the prevalence of hoarding listed in DSM-5 as both a separate syndrome and as an increases with age. Samuels and colleagues24reported OCD symptom. that hoarding was almost three times more prevalent in individuals over the age of 54 than it was in individuals Epidemiology aged 34 to 44. This finding most likely is due to compul- sive hoarding being a chronic and progressive disorder. Hoarding researchers also have made substantial Hoarding symptoms often develop during childhood or progress in understanding the prevalence and manifes- adolescence, and become clinically significant during tation of compulsive hoarding in the population. Until middle age.26,27Having the means to acquire and accu- very recently, researchers estimated the prevalence of mulate objects as a child may be substantially restricted; hoarding as a subportion of individuals with OCD in the therefore, it may take a decade or more for symptoms to 235 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 236 C l i n i c a l r e s e a r c h become clinically significant. In such cases, progression medical condition.31Third, several clinical and commu- of hoarding symptoms may be slow. In other cases, nity studies have reported a low rate of marriage among hoarding may have a sudden onset in adulthood, such as compulsive hoarders.14,29,32,33Those who are married or after a traumatic life event or brain injury.27,28Fifty-five cohabitating tend to have a lower degree of hoarding percent of Grisham and colleagues’27sample reported severity.31Fourth, hoarding is associated with high rates experiencing a stressful life event at the onset of hoard- of family frustration. Family members who cohabit with ing symptoms, and these individuals had a significantly hoarders report being embarrassed about the condition later age of onset than individuals who did not experi- of their home, arguing about the clutter, and feeling ence a stressful life event. rejection and hostility toward the hoarder.31 Clinical studies have demonstrated that hoarding often In summary, emergent research suggests that the preva- co-occurs with other psychological disorders. In a large lence of compulsive hoarding ranges from 2% to 5%, clinical sample, almost all individuals with a hoarding and men may be more likely to hoard than women. In diagnosis met criteria for another Axis I disorder, and most cases, hoarding is a chronic disorder. Although these individuals had significantly more co-occurring dis- some people may experience a gradual rise in symptoms orders than nonhoarding individuals with OCD.29 throughout their lifetime, others may develop hoarding Compared with nonhoarding individuals with OCD, symptoms quite quickly after a stressful life event. Men hoarders are consistently more likely to meet criteria for and women who hoard may experience different co- social anxiety disorder, bipolar disorder, and pathologi- occurring disorders, yet both genders are likely to expe- cal grooming behavior.7,14,29Hoarders also appear more rience a substantial amount of burden associated with likely to experience an alcohol-use disorder at some their hoarding. point in their lives.24,29A community study has found that the prevalence of co-occurring disorders differs for men Neuropsychological impairment and women. In men, hoarding is associated with gener- alized anxiety disorder and tics, while among women, Neuropsychological research into hoarding did not begin hoarding is associated with social phobia, post-traumatic to build until the last decade. The initial clues that hoard- stress disorder, body dysmorphic disorder, nail biting, ing was related to frontal-lobe dysfunction came from case and skin picking.7 Women and men also may not be reports of pathological collecting and saving that began affected equally by hoarding symptoms. While clinical after a brain injury, typically along with other changes in samples tend to be predominantly female,3,30epidemio- personality and social functioning.34-36In the last decade, logical samples have found that hoarding is twice as two papers presented findings suggesting that hoarding is prevalent in males.24,25The identification of a significant the result of frontal-lobe lesions. In the first report, Hahm prevalence of men who compulsively hoard, and gender- and colleagues36described the case of a 46-year-old Korean specific comorbidity differences, presents a significant man who began unusual collecting behavior after he suf- challenge for developing and engaging all individuals in fered an injury to his left ventromedial prefrontal cortex effective treatment. and caudate. This man had difficulty with social decision- A growing body of research suggests that hoarding is making and judgment processes. In the second report, associated with a lower quality of life. First, hoarding Anderson et al37examined compulsive hoarding behavior appears to occur more frequently in the unemployed within a sample of 86 patients with focal lesions, and found and poor.24,29Although longitudinal studies are needed that 13 of these participants exhibited abnormal collecting to determine if hoarding is a cause or consequence of behavior. Magnetic resonance imaging (MRI) showed that financial insecurity, a recent Internet study indicated that all 13 individuals with hoarding symptoms had damage to hoarding may at least contribute to financial insecurity. the mesial frontal region of the brain, including the right Five percent of the Web sample reported they had been polar sector and anterior cingulate. If excessive collecting fired because of hoarding, and on average, employed and saving behaviors can begin after brain injury, individ- individuals reported seven psychiatric work impairment uals who hoard in the absence of lesions may possess sim- days per month.31Second, hoarding has been linked to ilar deficits in neuropsychological functioning or impaired poorer health status. Individuals who hoard are very self-regulation that contribute to compulsive hoarding likely to be overweight or obese and suffer from a severe symptoms. 236 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 237 Compulsive hoarding - Grisham and Norberg Dialogues in Clinical Neuroscience - Vol 12 .No. 2 .2010 Self-report and laboratory studies of neuropsychologi- discrepancy on the decision-making task in the two stud- cal functioning in hoarding have highlighted potential ies. Future studies may compare hoarding patients with areas of subtle impairment. In a study by Hartl et al, and without other OCD symptoms to nonhoarding hoarding patients reported increased symptoms of atten- OCD patients and community controls in order to clar- tion deficit-hyperactivity disorder (ADHD).38They also ify the source of the decision-making difficulties. have been found to perform worse on certain neu- Another area that remains unresolved is the role of pro- ropsychological tasks, including measures of attention posed categorization problems in hoarding patients.1,46 and nonverbal intelligence,39 memory,40 and decision- Compulsive hoarding patients appear to exhibit problems making.41Deficits in executive function marked by inhi- grouping their possessions into categories, which con- bition, planning, and decision-making difficulties may tributes to the disorganization and clutter that are hall- limit hoarders’ ability to discard and organize their pos- mark features of this disorder.1A few studies have inves- sessions. Although this is an intriguing and rapidly tigated these hypothesized differences in the way hoarding advancing area within hoarding research, there has been patients categorize. Wincze et al47contrasted hoarding par- some inconsistency with respect to the specific pattern ticipants, obsessive-compulsive nonhoarding participants of deficits associated with hoarding. and healthy control participants on categorization tasks. There is some evidence that individuals who compulsively The results of this study suggested that categorization hoard demonstrate significant difficulty making decisions. problems occur only when compulsive hoarders sort their They tend to believe a disproportionate number of their own possessions. In contrast, Luchian et al48found that possessions are very important, and feel paralyzed by nonclinical hoarders also created more categories when seemingly commonplace decisions about what items to categorizing nonpersonal objects. They also took almost discard and what items to keep, which items are valuable, twice as long to sort objects, and found sorting to be more and how to organize the items they decide to keep. These difficult and stressful than did nonhoarding participants. decision-making problems have been associated with Inconsistencies between this study and Wincze et al47may hoarding in several studies using self-report measures.42-44 be due to differences between nonclinical and clinical With respect to laboratory studies, however, research has hoarding participants or because of methodological dif- provided mixed results regarding decision-making deficits. ferences between the two studies. Thus, the circumstances Grisham et al39found that hoarders displayed relatively under which hoarders have categorization difficulties intact decision making on the Iowa Gambling Task rela- remains unknown due to the lack of systematic compar- tive to a clinical and community control groups. A recent isons between personal and nonpersonal objects. study in our laboratory has replicated this finding, show- Despite recent advances in the study of cognitive func- ing that individuals with compulsive hoarding did not tioning among individuals who hoard, many key ques- demonstrate decision-making problems on the comput- tions remain to be addressed. While there is some indi- erized Cambridge Gambling Task.45 cation of deficits in hoarding patients, it is unclear how However, Lawrence et al41found that hoarding symp- reliably these deficits can be identified. It is also uncer- toms were associated with specific decision making tain whether these deficits are present to varying degrees impairments on the same gambling task and that these in all hoarding patients, or a subset of patients. Future deficits were related to the severity of the hoarding research also should provide greater understanding symptoms. Lawrence et al41suggested that hoarders have regarding the specific nature of information processing difficulty deciding whether to save or discard their pos- difficulties and/or cognitive impairment. Finally, it will be session due to general decision-making difficulties. One important as we gain greater understanding of cognitive important difference between the Grisham et al39and difficulties to examine whether these difficulties may be Lawrence et al41 studies was the composition of the remediated in order to improve treatment outcome. hoarding group. In the Grisham et al study, the hoarding group comprised participants who met criteria for com- Treatment pulsive hoarding, regardless of whether they had OCD, while the hoarding group in the Lawrence et al study Research on the treatment of hoarding also has consisted of OCD patients who displayed hoarding advanced significantly in recent years. Several earlier behaviors. This difference in the samples may explain the studies found that hoarding symptoms are negative 237 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 238 C l i n i c a l r e s e a r c h treatment predictors for therapies that have demon- themselves, respectively, and 41% of patients met crite- strated effectiveness for OCD. In serotonergic medica- ria for clinically significant improvement. tion trials for OCD, individuals with hoarding symptoms Given that changes are slow to occur during the treat- typically have poorer outcomes.49-51Only one that has ment of compulsive hoarding, researchers have been examined the effectiveness of selective serotonin reup- examining alternative delivery models in hopes of take inhibitors in reducing obsessive-compulsive symp- increasing the cost-effectiveness of treatment. Using a toms has demonstrated equivalent outcomes for indi- multiple cohort pretest–post-test design, Muroff and col- viduals with and without hoarding symptoms.52Although leagues examined the effectiveness of group CBT using this finding appears promising, the results need to be Steketee and Frost’s treatment manual.32After 16 to 20 qualified. The authors only measured obsessive-com- sessions and two home visits, patients evidenced a mean pulsive symptoms, symptom response was poor in both reduction of 8.6 points on the Saving Inventory-Revised groups (23% to 24% symptom reduction), and individ- (SI-R), which is less than that produced from individual uals with hoarding symptoms took paroxetine for sig- treatment using the same manual (18.7 or 16.9).59,60After nificantly more days. As with pharmacological these investigators modified their research procedures approaches, the presence of hoarding symptoms is a neg- to more thoroughly screen group members and utilized ative predictor of cognitive-behavioral treatment out- a more detailed and structured manual for the group, the come for OCD.53,54Only one third of hoarders with OCD mean SI-R reduction in the final group was 14.25. demonstrate clinically significant improvement in As access to clinicians trained in CBT for compulsive response to exposure and response prevention, while hoarding is limited, a Web-based self-help group has also one half to two thirds of nonhoarders with OCD demon- been examined for its effectiveness. This Web-based treat- strate such improvement.53In response to these disap- ment was also based on Steketee and Frost’s manual58and pointing outcomes, researchers have developed psycho- required individuals to take active steps to reducing their logical treatments for compulsive hoarding that are hoarding behavior within 2 months of membership. After based on Frost and Hartl’s cognitive-behavioral model.1 6 months of memberships, SI-R scores decreased by an Treatments outcomes based on Frost and Hartl’s model average of 6 points. These two group studies suggest that are encouraging, but suggest that many sessions are highly structured, in-person groups may lead to greater required to produce change and that clutter is slow to improvements in hoarding outcomes than less-structured improve. The first case study reported that approxi- groups. Internet treatment approaches are important mately 45 sessions were needed to completely reduce because they have the potential to expand significantly clutter.55After 20 weeks of treatment, Steketee et al56 the number of individuals with hoarding who receive demonstrated a 16% reduction in Y-BOCS scores, while treatment, and thus, ways to improve outcomes achieved Saxena et al57demonstrated a 35% reduction in Y-BOCS from Internet-delivered therapy are much needed. scores after 6 weeks of daily intensive treatment. More effective treatments are warranted for this common Utilizing Steketee and Frost’s58 cognitive-behavioral and disabling disorder. Novel pharmacotherapies, such as treatment manual for compulsive hoarding, Tolin et al59 cognitive enhancers and stimulants, should be evaluated offered 26 individual sessions (in-office sessions and at for their utility with hoarding patients. Cognitive enhancers least one home visit) over a 7- to 12-month period to 14 may improve memory, attention, and overall cognitive individuals. On average, treatment completers (n=10) functioning, while stimulants may improve attention, alert- demonstrated 25% improvement in their clutter and dif- ness, and information-processing speed. Only one case ficulty discarding, and 35% reduction in acquiring. report has been published describing the effects of a stim- Following this open trial, Steketee et al60made minor ulant in an individual with compulsive hoarding. In this modifications to the treatment and examined its efficacy case, a combined treatment of fluvoxamine, risperidone, in a randomized controlled trial. Findings from this trial amphetamine salts, and behavior therapy was used to treat indicated that improvements in hoarding symptoms a 56-year old man diagnosed with OCD, compulsive were greater after receiving 12 sessions of cognitive hoarding, ADHD, and schizotypal personality disorder. behavioral therapy (CBT) than after waiting for a com- Although the patient reported that after treatment he pro- parable period. After 26 sessions of CBT, 68% to 76% crastinated less, kept appointments better, and was less of patients were rated as improved by their therapists or upset when throwing things away, the patient’s clutter did 238 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 239 Compulsive hoarding - Grisham and Norberg Dialogues in Clinical Neuroscience - Vol 12 .No. 2 .2010 not significantly decrease.61In order to determine if stim- Future directions ulants or cognitive enhancers are effective adjuncts for the treatment of compulsive hoarding, systematic, randomized Despite the increased research on compulsive hoarding controlled trials are needed. in recent years, several avenues still require exploration. Overall, research findings indicate that compulsive hoard- Researchers must continue to unravel the complex ers do respond to CBT, although improvements are mod- story of hoarding’s etiology and pathogenesis through erate in comparison with gains observed in nonhoarders additional laboratory studies examining the cognitive, with OCD. A number of methodological limitations, how- emotional, neural, and behavioral features of the disor- ever, curtail these findings. First, there is a lack of properly der. Future research may also help to establish the rela- controlled treatment studies that involve random alloca- tion of hoarding symptoms to OCD, anxiety, ADHD, tion to treatment (CBT or medication) and a placebo and ICDs. Finally, further treatment studies investigat- group. Also, the lack of specificity of the measures used to ing the efficacy of cognitive rehabilitation, behavioral index symptoms makes it difficult to determine whether interventions, Internet applications, and novel medica- improvements are due to changes in hoarding symptoms tion treatments are essential for improving clinical out- or to reductions in nonhoarding OCD symptoms. comes. ❏ REFERENCES 16. Grisham JR, Brown TA, Liverant G, Campbell LA. The distinctiveness of hoarding from other dimensions of obsessive-compulsive disorder. J Anxiety Disord. 2005;19:767-769. 1. Frost RO, Hartl T. A cognitive-behavioral model of compulsive hoard- 17. Frost RO, Meagher BM, Riskind JH. Obsessive-compulsive features in ing. Behav Res Ther.1996;34:341-350. pathological lottery and scratch ticket gamblers. J Gambl Stud. 2001;17:5- 2. American Psychiatric Association. Diagnostic and Statistical Manual of 19. Mental Disorders. 4th ed, Text Revision. Washington, DC: American 18. 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Age of onset of pulsive disorder: Results from the John Hopkins OCD Family Study. Br J compulsive hoarding. J Anxiety Disord. 2006;20:675-686. Psychiatry. 2000;177:457-462. 28. Cromer KR, Schmidt NB, Murphy DL. An investigation of traumatic life 11. Goodman WK, Price LH, Rasmussen SA, et al. The Yale–Brown events and obsessive-compulsive disorder. Behav Res Ther. 2007;45:1683-1691. Obsessive–Compulsive Scale. I. Development, use and reliability. Arch Gen 29. Wheaton M, Timpano KR, Lasalle-Ricci VH, Murphy DL. Characterizing Psychiatry. 1989;46:1006–1011. the hoarding phenotype in individuals with OCD: associations with comor- 12. Frost RO, Krause MS, Steketee G. Hoarding and obsessive-compulsive bidity, severity and gender. J Anxiety Disord. 2008;22:243-252. symptoms. Behav Modif. 1996;20:116-132. 30. Muroff J, Steketee G, Himle J, Frost R. Delivery of internet treatment 13. Rasmussen SA, Eisen JL. The epidemiology and differential diagnosis for compulsive hoarding (D.I.T.C.H.). Behav Res Ther. 2010;48:79-85. of obsessive compulsive disorder. J Clin Psychiatry. 1992;53:4-10. 31. Tolin DF, Frost RO, Steketee G, Gray KD, Fitch KE. The economic and 14. Samuels J, Bienvenu III OJ, Riddle MA, et al. Hoarding in obsessive-compul- social burden of compulsive hoarding. Psychiatry Res. 2008;160:200-211. sive disorder: Results from a case-control study. Behav Res Ther. 2002;40:517-528. 32. Muroff J, Steketee G, Rasmussen J, Gibson A, Bratiotis C, Sorrentino C. 15. Abramowitz JS, Wheaton MG, Storch EA. The status of hoarding as a Group cognitive and behavioral treatment for compulsive hoarding: a pre- symptom of obsessive-compulsive disorder. Behav Res Ther. 2008;46:1026-1033. liminary trial. Depress Anxiety.2009;26:634-640. 239 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 240 C l i n i c a l r e s e a r c h Acaparamiento compulsivo: controversias Collectionnisme compulsif : controverses actuales y perspectivas actuelles et nouvelles orientations El acaparamiento compulsivo es un trastorno psico- Le collectionnisme compulsif est un trouble psy- lógico invalidante, caracterizado por conductas ina- chologique handicapant caractérisé par un com- decuadas de acumular y guardar. Este artículo revisa portement d’épargne et de stockage excessif. Cet cuatro áreas clave de los avances recientes en la article analyse quatre points clés des avancées investigación del acaparamiento. Primero, se entrega récentes de la recherche sur ce sujet. Nous débutons una panorámica de la controversia que se ha desa- premièrement par une synthèse de la controverse rrollado en relación con la condición diagnóstica del en pleine évolution sur le diagnostic de ce trouble : acaparamiento, destacando la evidencia que se ha les arguments sont de plus en plus en faveur d’une acumulado en relación con el hecho que sería mejor meilleure conceptualisation du trouble comme syn- conceptualizarlo como un síndrome independiente. drome à part. Deuxièmement, nous décrivons les Segundo, se describen los avances en la comprensión avancées concernant notre compréhension de son de la epidemiología, el curso y las características épidémiologie, de son évolution et de ses cadres demográficas del acaparamiento compulsivo. démographiques. Troisièmement, nous analysons Tercero, se revisan los últimos hallazgos relacionados les derniers résultats des corrélations neuropsycho- con posibles correlatos neuropsicológicos de este logiques éventuelles du trouble. Enfin, nous discu- trastorno. Finalmente se discute el progreso actual y tons des progrès en cours et des orientations las perspectivas futuras en relación con el manejo clí- futures de la prise en charge clinique du collection- nico del acaparamiento compulsivo. nisme compulsif. 33. Steketee G, Frost RO, Kim HJ. Hoarding by elderly people. Health Soc 48. Luchian SA, McNally RJ, Hooley JM. Cognitive aspects of nonclinical Work. 2001;26:176-184. obsessive-compulsive hoarding. Behav Res Ther. 2007;45:1657-1662. 34. Harlow JM. Recovery from the passage of an iron bar through the 49. Black DW, Monahan P, Gable J, Blum N, Clancy G, Baker P. Hoarding head. Proc Counc Mass Med Soc. 1868;2:327-347. and treatment response in 38 nondepressed subjects with obsessive-com- 35. Eslinger PJ, Damasio AR. Severe disturbance of higher cognition after pulsive disorder. J Clin Psychiatry. 1998;59:420-425. frontal lobe ablation: Patient EVR. Neurology. 1985;35:1731-1741. 50. Mataix-Cols D, Rauch S, Manzo P, Jenike M, Baer L. Use of factor-ana- 36. Hahm DL, Kang Y, Cheong SS, Na DL. A compulsive collecting behav- lyzed symptom dimensions to predict outcome with serotonin reuptake ior following an A-com aneurismal rupture. Neurology. 2001;56:398-400. inhibitors and placebo in the treatment of obsessive-compulsive disorder. 37. Anderson SW, Damasio H, Damasio AR. A neural basis for collecting Am J Psychiatry. 1999;156:1409-1416. behaviour in humans. Brain. 2005;128:201-212. 51. Winsberg ME, Cassic KS, Koran LM. Hoarding in obsessive-compulsive 38. Hartl TL, Duffany SR, Allen GJ, Steketee G, Frost RO. Relationships disorder: a report of 20 cases. J Clin Psychiatry. 1999;60:591-597. among compulsive hoarding, trauma, and attention-deficit/hyperactivity 52. Saxena S, Brody AL, Maidment KM, Baxter LRJ. Paroxetine treatment disorder. Behav Res Ther. 2005;43:269-276. of compulsive hoarding. J Psychiatry Res. 2007;41:481-487. 39. Grisham JR, Brown TA, Savage CR, Steketee G, Barlow DH. 53. Abramowitz JS, Franklin ME, Schwartz SA, Furr JM. Symptom presen- Neuropsychological impairment associated with compulsive hoarding. tation and outcome of cognitive-behavioral therapy for obsessive-com- Behav Res Ther. 2007;45:1471-1483. pulsive disorder. J Consult Clin Psychol. 2003;71:1049-1057. 40. Hartl TL, Frost RO, Allen GJ, Deckersbach T, et al. Actual and perceived 54. Mataix-Cols D, Marks IM, Greist JH, Kobak KA, Baer L. Obsessive-com- memory deficits in individuals with compulsive hoarding. Depress Anxiety. pulsive symptom dimensions as predictors of compliance with and 2004;20:59-69. response to behaviour therapy: Results from a controlled trial. Psychother 41. Lawrence NS, Wooderson S, Mataix-Cols D, David R, Speckens A, Psychosom. 2002;71:255-262. Phillips ML. Decision making and set shifting impairments are associated 55. Hartl TL, Frost RO. Cognitive-behavioral treatment of compulsive hoarding: with distinct symptom dimensions in obsessive-compulsive disorder. a multiple baseline experimental case study. Behav Res Ther. 1999;37:451-461. Neuropsychology. 2006;20:409-419. 56. Steketee G, Frost RO, Wincze J, Greene K, Douglass H. Group and indi- 42. Frost RO, Gross RC. The hoarding of possessions. Behav Res Ther. vidual treatment of compulsive hoarding: a pilot study. Behav Cogn 1993;31:367-381. Psychother. 2000;28:259-68. 43. Frost RO, Shows DL. The nature and measurement of compulsive inde- 57. Saxena S, Maidment KM, V, Vapnik T, et al. Obsessive-compulsive cisiveness. Behav Res Ther. 1993;31:683-692. hoarding: Symptom severity and response to multimodal treatment. J Clin 44. Steketee G, Frost RO, Kyrios M. Cognitive aspects of compulsive Psychiatry. 2002;63:21-27. hoarding. Cognit Ther Res.2003;27:463-479. 58. Steketee G, Frost RO. Compulsive Hoarding and Acquiring: Therapist 45. Grisham JR, Melissa MM, Williams AD, Certoma SP, Kadib R. Categorization Guide. New York, NY: Oxford University Press; 2007. and cognitive deficits in compulsive hoarding. Behav Res Ther. In press. 59. Tolin DF, Frost RO, Steketee G. An open trial of cognitive-behavioral 46. Frost RO, Steketee G. Hoarding: clinical aspects and treatment strategies. therapy for compulsive hoarding. Behav Res Ther. 2007;45:1461-1470. In: Jenike MA, Baer L, Minichiello WE, eds. Obsessive-Compulsive Disorder: Practical 60. Steketee GF, Tolin DF, Rasmussen J, Brown TA. Waitlist-controlled trial of cog- Management. 3rd ed. St Louis, MO: Mosby Yearbook Medical; 1998:533-554. nitive behavior therapy for hoarding disorder. Depress Anxiety. 2010;27:476-484. 47. Wincze JP, Steketee G, Frost RO. Categorization in compulsive hoard- 61. Kaplan A, Hollander E. Comorbidity in compulsive hoarding: a case ing. Behav Res Ther. 2007;45:63-72. report. CNS Spectr. 2004;9:71-73. 240

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PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 233 C l i n i c a l r e s e a r c h Compulsive hoarding: current controversies and new directions Jessica R. Grisham, PhD; Melissa M. Norberg, PhD C ompulsive hoarding is a syndrome characterized by excessive collecting and saving behavior that results in a cluttered living space and significant distress or impair- ment.1 In the past decade, there has been a notable increase in research on hoarding, including its phenome- nology, pathophysiology, and treatment approaches. This surge in interest has been coupled with contention regard- ing key aspects of the disorder. These controversies have led to exciting new research that has deepened our under- standing of this complex syndrome. The aim of this article is to describe some of these debated issues, as well as to Compulsive hoarding is a disabling psychological disor- highlight recent advances in compulsive hoarding research. der characterized by excessive collecting and saving behavior. This article reviews four key areas of recent Diagnostic status advances in hoarding research. First, we provide an overview of the evolving controversy regarding the diag- An obvious example of a current debate within hoard- nostic status of hoarding, highlighting accumulating evi- ing research is the question of where hoarding belongs dence that it may be best conceptualized as a separate within our diagnostic nosology. The uncertainty regard- syndrome. Second, we describe advances in our under- ing the most appropriate classification of compulsive standing of the epidemiology, course, and demographic hoarding syndrome has had important consequences for features of compulsive hoarding. Third, we review the our understanding of hoarding, and in some ways has latest findings regarding possible neuropsychological constituted an obstacle to hoarding research. The lack of correlates of the disorder. Finally, we discuss ongoing clear placement within DSMhas led to an underestima- progress and future directions related to the clinical tion of the significance of the burden of disease associ- management of compulsive hoarding. ated with compulsive hoarding, inconsistencies with © 2010, LLS SAS Dialogues Clin Neurosci.2010;12:233-240. respect to an appropriate clinical comparison group in Keywords:hoarding; obsessive-compulsive disorder; saving; collecting; clutter hoarding research, difficulties comparing findings across hoarding studies, and misconceptions regarding which Author affiliations: School of Psychology, University of New South Wales, assessment and treatment models are most relevant to Sydney, Australia hoarding. Address for correspondence:Jessica R. Grisham, School of Psychology, University of In the DSM-IV-TR,2hoarding is described as difficulty New South Wales, Sydney NSW 2052, Australia (e-mail: [email protected]) discarding items, and is listed as one of the eight diag- Copyright © 2010 LLS SAS. All rights reserved 233 www.dialogues-cns.org PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 234 C l i n i c a l r e s e a r c h nostic criteria for obsessive-compulsive personality dis- A recent study by Abramowitz and colleagues15 pro- order (OCPD). Accumulating evidence, however, sug- vided further evidence that although some individuals gests that it is misleading and invalid to classify hoarding with OCD may show hoarding behavior, hoarding is as part of OCPD. When studies examining the prevalence most likely distinct from OCD. Abramowitz and col- of OCPD in hoarding samples exclude the criterion leagues compared OCD patients, patients with other describing difficulty discarding, most studies suggest that anxiety disorders, and unscreened undergraduate stu- hoarding is no more associated with OCPD than it is with dents. OCD patients scored higher on all OCD symp- other Axis II disorders.3,4In addition, hoarding has been toms except hoarding, in which the student group scored found to have the lowest specificity and predictive crite- slightly, but significantly higher than both clinical groups. ria of all eight of the diagnostic criteria for OCPD.5Based Similarly to Wu and Watson,4 Abramowitz and col- on these findings, Saxena et al6argued convincingly that leagues found that the magnitude of the correlations hoarding should be removed from the diagnostic criteria between hoarding and other OCD symptoms was sig- for OCPD. Nevertheless, there is some evidence to sug- nificantly weaker than the magnitude of the correlations gest a link between hoarding and OCPD. A recent study amongst all other OCD symptoms. In addition, the of hoarding within a collaborative OCPD genetics study hoarding items loaded weakly on a unitary OCI-R fac- found that hoarders had a greater prevalence of certain tor. In a second study, Abramowitz et al15 found that OCPD traits, particularly miserliness and preoccupation hoarding was correlated weakly with depression, but not with details.7In addition, several previous studies have with anxiety. Other OCD symptoms showed at least a reported that OCPD is more common in hoarders.8-10 moderate association with anxiety. Due to these recent Thus while the consensus appears to be that hoarding is findings, there is a growing consensus that hoarding inappropriately classified as a criterion of OCPD, the should not be considered as a symptom of OCPD or broader issue of the relation of hoarding to OCPD, as OCD, but as a separate clinical syndrome. well as to other Axis II disorders, remains unresolved. Several researchers have also examined whether there Despite its placement in the Diagnostic and Statistical are important differences between hoarding behavior Manual of Mental Disorders (DSM)-IV, clinicians and seen in the context of OCD and hoarding that occurs researchers typically consider hoarding a symptom or without any other OCD symptoms.3,4,16A recent study subtype of obsessive-compulsive disorder (OCD). For conducted by Petrusa et al3compared individuals with example, the Y-BOCS checklist11lists hoarding obses- severe compulsive hoarding who met criteria for OCD sions and compulsions, and many investigations into (OCD plus hoarding group) with individuals with severe hoarding have involved comparing OCD individuals hoarding who did not meet criteria for OCD (mono- with and without hoarding. This view of hoarding as part symptomatic hoarding). Individuals in the OCD plus of OCD derived from early findings that approximately hoarding group differed from the monosymptomatic one third of individuals with OCD have hoarding symp- hoarding group in several important ways. For example, toms.12-14 More recent studies, however, have found OCD plus hoarding participants were more likely to ample evidence that hoarding should not be conceptu- hoard bizarre items and more likely to report other alized only as an OCD symptom. For example, Wu and obsessions and compulsions related to their hoarding Watson4found that hoarding correlated more weakly than those in the monosymptomatic hoarding group. In with other symptoms of OCD than these other symp- addition, the OCD plus hoarding group endorsed more toms correlated with each other. Moreover, Saxena et al6 cluster C personality traits than the monsymptomatic found that patients who hoard, compared with other hoarding group. OCD patients, had different functional neuroimaging Given that hoarding can occur in the absence of OCD findings, response to treatment, and clinical profiles. In and that it shares some similarity to impulse control dis- a large study of hoarding among OCD patients,7indi- orders (ICDs) such as pathological gambling, pyroma- viduals with hoarding were more likely to have symme- nia, and kleptomania, it may have a place within behav- try obsessions and counting, ordering, and repeating ioral addiction. Although hoarding behavior is compulsions. They also were more likely to have greater sometimes motivated by a desire to reduce anxiety, it illness severity, more difficulty initiating and completing also sometimes appears to be driven by anticipation of tasks, and problems with indecision. pleasure and impaired self-regulation.16Since both anx- 234 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 235 Compulsive hoarding - Grisham and Norberg Dialogues in Clinical Neuroscience - Vol 12 .No. 2 .2010 iety and approach behaviors may play a role in compul- community.22Similarly, information regarding the bur- sive hoarding, a common diathesis may underlie both den of hoarding was based on anecdotal evidence and hoarding and certain impulse control disorders. Samuels small samples. Recent epidemiological studies, however, et al14reported a greater frequency of trichotillomania suggest that compulsive hoarding may be far more and skin picking among hoarding compared with non- prevalent and burdensome in the community than pre- hoarding individuals with OCD. In addition, Frost et al17 viously thought. Data from the Baltimore Epidemiologic found that pathological gamblers reported significantly Catchment Area Follow-up survey suggest that 5% of more hoarding symptoms than light gamblers. the general population experiences clinically significant Although Grant et al18found a low prevalence of ICDs hoarding, while data from the National Comorbidity overall among individuals with obsessive-compulsive Survey Replication indicate that the lifetime prevalence disorder, obsessive-compulsive disorder participants of compulsive hoarding may be as high as 14%.23,24These with a lifetime and current impulse control disorder studies estimated hoarding based upon reports of diffi- were more likely to report hoarding symptoms. In a culty discarding, and did not specifically target clutter recent study, Hayward and Coles19examined the rela- and excessive acquisition, and thus it is unknown tion of hoarding to OCD and ICDs in an undergradu- whether cases met criteria for compulsive hoarding as ate sample, and found that hoarding behaviors were defined by Frost and Hart.l1A recent twin study that uti- related moderately to symptoms of compulsive buying, lized a self-report instrument to assess the broad hoard- and more weakly related to pathological gambling, tri- ing phenotype found that 2% of its sample reported clin- chotillomania, and kleptomania. The possible associa- ically significant hoarding symptoms.25 As symptom tion between hoarding and ICDs is consistent with severity obtained by self-report tends to be lower than McElroy and colleagues’ conceptualization of a com- clinician-rated severity, the current prevalence of clini- pulsive-impulsive spectrum,20but requires further explo- cally significant compulsive hoarding may be somewhere ration. between 2% and 5%. The nosological issues surrounding hoarding will influ- Importantly, a large proportion of individuals who hoard ence its placement in the next edition of the DSM. One report having at least one first-degree relative who expe- position is that compulsive hoarding should be included riences hoarding problems.3,14In a sample of individuals in our diagnostic system as an independent syndrome, with OCD, Samuels and colleagues14 reported that which is sometimes comorbid with OCD. Including probands of individuals with hoarding symptoms were hoarding as a separate syndrome has a number of four times more likely to experience hoarding symptoms important practical advantages, well-summarized by than probands of individuals who did not report hoard- Rachman and colleagues.21For example, it would expand ing symptoms. Genetic factors and unshared environ- the boundaries of the hoarding population to be consis- mental factors may explain this familial connection. In a tent with the data showing a high incidence of hoarding large sample of female twins, genetic factors accounted not associated with OCD. It would also encourage clin- for approximately 50% of the variance in compulsive icians and researchers to use hoarding-specific assess- hoarding, while shared environmental factors encoun- ment tools rather than measures designed for OCD, and tered by twins growing up in the same household did not facilitate the development of new treatment methods for substantially contribute to the other half.25 hoarding. Another possibility is that hoarding may be Recent data suggests that the prevalence of hoarding listed in DSM-5 as both a separate syndrome and as an increases with age. Samuels and colleagues24reported OCD symptom. that hoarding was almost three times more prevalent in individuals over the age of 54 than it was in individuals Epidemiology aged 34 to 44. This finding most likely is due to compul- sive hoarding being a chronic and progressive disorder. Hoarding researchers also have made substantial Hoarding symptoms often develop during childhood or progress in understanding the prevalence and manifes- adolescence, and become clinically significant during tation of compulsive hoarding in the population. Until middle age.26,27Having the means to acquire and accu- very recently, researchers estimated the prevalence of mulate objects as a child may be substantially restricted; hoarding as a subportion of individuals with OCD in the therefore, it may take a decade or more for symptoms to 235 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 236 C l i n i c a l r e s e a r c h become clinically significant. In such cases, progression medical condition.31Third, several clinical and commu- of hoarding symptoms may be slow. In other cases, nity studies have reported a low rate of marriage among hoarding may have a sudden onset in adulthood, such as compulsive hoarders.14,29,32,33Those who are married or after a traumatic life event or brain injury.27,28Fifty-five cohabitating tend to have a lower degree of hoarding percent of Grisham and colleagues’27sample reported severity.31Fourth, hoarding is associated with high rates experiencing a stressful life event at the onset of hoard- of family frustration. Family members who cohabit with ing symptoms, and these individuals had a significantly hoarders report being embarrassed about the condition later age of onset than individuals who did not experi- of their home, arguing about the clutter, and feeling ence a stressful life event. rejection and hostility toward the hoarder.31 Clinical studies have demonstrated that hoarding often In summary, emergent research suggests that the preva- co-occurs with other psychological disorders. In a large lence of compulsive hoarding ranges from 2% to 5%, clinical sample, almost all individuals with a hoarding and men may be more likely to hoard than women. In diagnosis met criteria for another Axis I disorder, and most cases, hoarding is a chronic disorder. Although these individuals had significantly more co-occurring dis- some people may experience a gradual rise in symptoms orders than nonhoarding individuals with OCD.29 throughout their lifetime, others may develop hoarding Compared with nonhoarding individuals with OCD, symptoms quite quickly after a stressful life event. Men hoarders are consistently more likely to meet criteria for and women who hoard may experience different co- social anxiety disorder, bipolar disorder, and pathologi- occurring disorders, yet both genders are likely to expe- cal grooming behavior.7,14,29Hoarders also appear more rience a substantial amount of burden associated with likely to experience an alcohol-use disorder at some their hoarding. point in their lives.24,29A community study has found that the prevalence of co-occurring disorders differs for men Neuropsychological impairment and women. In men, hoarding is associated with gener- alized anxiety disorder and tics, while among women, Neuropsychological research into hoarding did not begin hoarding is associated with social phobia, post-traumatic to build until the last decade. The initial clues that hoard- stress disorder, body dysmorphic disorder, nail biting, ing was related to frontal-lobe dysfunction came from case and skin picking.7 Women and men also may not be reports of pathological collecting and saving that began affected equally by hoarding symptoms. While clinical after a brain injury, typically along with other changes in samples tend to be predominantly female,3,30epidemio- personality and social functioning.34-36In the last decade, logical samples have found that hoarding is twice as two papers presented findings suggesting that hoarding is prevalent in males.24,25The identification of a significant the result of frontal-lobe lesions. In the first report, Hahm prevalence of men who compulsively hoard, and gender- and colleagues36described the case of a 46-year-old Korean specific comorbidity differences, presents a significant man who began unusual collecting behavior after he suf- challenge for developing and engaging all individuals in fered an injury to his left ventromedial prefrontal cortex effective treatment. and caudate. This man had difficulty with social decision- A growing body of research suggests that hoarding is making and judgment processes. In the second report, associated with a lower quality of life. First, hoarding Anderson et al37examined compulsive hoarding behavior appears to occur more frequently in the unemployed within a sample of 86 patients with focal lesions, and found and poor.24,29Although longitudinal studies are needed that 13 of these participants exhibited abnormal collecting to determine if hoarding is a cause or consequence of behavior. Magnetic resonance imaging (MRI) showed that financial insecurity, a recent Internet study indicated that all 13 individuals with hoarding symptoms had damage to hoarding may at least contribute to financial insecurity. the mesial frontal region of the brain, including the right Five percent of the Web sample reported they had been polar sector and anterior cingulate. If excessive collecting fired because of hoarding, and on average, employed and saving behaviors can begin after brain injury, individ- individuals reported seven psychiatric work impairment uals who hoard in the absence of lesions may possess sim- days per month.31Second, hoarding has been linked to ilar deficits in neuropsychological functioning or impaired poorer health status. Individuals who hoard are very self-regulation that contribute to compulsive hoarding likely to be overweight or obese and suffer from a severe symptoms. 236 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 237 Compulsive hoarding - Grisham and Norberg Dialogues in Clinical Neuroscience - Vol 12 .No. 2 .2010 Self-report and laboratory studies of neuropsychologi- discrepancy on the decision-making task in the two stud- cal functioning in hoarding have highlighted potential ies. Future studies may compare hoarding patients with areas of subtle impairment. In a study by Hartl et al, and without other OCD symptoms to nonhoarding hoarding patients reported increased symptoms of atten- OCD patients and community controls in order to clar- tion deficit-hyperactivity disorder (ADHD).38They also ify the source of the decision-making difficulties. have been found to perform worse on certain neu- Another area that remains unresolved is the role of pro- ropsychological tasks, including measures of attention posed categorization problems in hoarding patients.1,46 and nonverbal intelligence,39 memory,40 and decision- Compulsive hoarding patients appear to exhibit problems making.41Deficits in executive function marked by inhi- grouping their possessions into categories, which con- bition, planning, and decision-making difficulties may tributes to the disorganization and clutter that are hall- limit hoarders’ ability to discard and organize their pos- mark features of this disorder.1A few studies have inves- sessions. Although this is an intriguing and rapidly tigated these hypothesized differences in the way hoarding advancing area within hoarding research, there has been patients categorize. Wincze et al47contrasted hoarding par- some inconsistency with respect to the specific pattern ticipants, obsessive-compulsive nonhoarding participants of deficits associated with hoarding. and healthy control participants on categorization tasks. There is some evidence that individuals who compulsively The results of this study suggested that categorization hoard demonstrate significant difficulty making decisions. problems occur only when compulsive hoarders sort their They tend to believe a disproportionate number of their own possessions. In contrast, Luchian et al48found that possessions are very important, and feel paralyzed by nonclinical hoarders also created more categories when seemingly commonplace decisions about what items to categorizing nonpersonal objects. They also took almost discard and what items to keep, which items are valuable, twice as long to sort objects, and found sorting to be more and how to organize the items they decide to keep. These difficult and stressful than did nonhoarding participants. decision-making problems have been associated with Inconsistencies between this study and Wincze et al47may hoarding in several studies using self-report measures.42-44 be due to differences between nonclinical and clinical With respect to laboratory studies, however, research has hoarding participants or because of methodological dif- provided mixed results regarding decision-making deficits. ferences between the two studies. Thus, the circumstances Grisham et al39found that hoarders displayed relatively under which hoarders have categorization difficulties intact decision making on the Iowa Gambling Task rela- remains unknown due to the lack of systematic compar- tive to a clinical and community control groups. A recent isons between personal and nonpersonal objects. study in our laboratory has replicated this finding, show- Despite recent advances in the study of cognitive func- ing that individuals with compulsive hoarding did not tioning among individuals who hoard, many key ques- demonstrate decision-making problems on the comput- tions remain to be addressed. While there is some indi- erized Cambridge Gambling Task.45 cation of deficits in hoarding patients, it is unclear how However, Lawrence et al41found that hoarding symp- reliably these deficits can be identified. It is also uncer- toms were associated with specific decision making tain whether these deficits are present to varying degrees impairments on the same gambling task and that these in all hoarding patients, or a subset of patients. Future deficits were related to the severity of the hoarding research also should provide greater understanding symptoms. Lawrence et al41suggested that hoarders have regarding the specific nature of information processing difficulty deciding whether to save or discard their pos- difficulties and/or cognitive impairment. Finally, it will be session due to general decision-making difficulties. One important as we gain greater understanding of cognitive important difference between the Grisham et al39and difficulties to examine whether these difficulties may be Lawrence et al41 studies was the composition of the remediated in order to improve treatment outcome. hoarding group. In the Grisham et al study, the hoarding group comprised participants who met criteria for com- Treatment pulsive hoarding, regardless of whether they had OCD, while the hoarding group in the Lawrence et al study Research on the treatment of hoarding also has consisted of OCD patients who displayed hoarding advanced significantly in recent years. Several earlier behaviors. This difference in the samples may explain the studies found that hoarding symptoms are negative 237 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 238 C l i n i c a l r e s e a r c h treatment predictors for therapies that have demon- themselves, respectively, and 41% of patients met crite- strated effectiveness for OCD. In serotonergic medica- ria for clinically significant improvement. tion trials for OCD, individuals with hoarding symptoms Given that changes are slow to occur during the treat- typically have poorer outcomes.49-51Only one that has ment of compulsive hoarding, researchers have been examined the effectiveness of selective serotonin reup- examining alternative delivery models in hopes of take inhibitors in reducing obsessive-compulsive symp- increasing the cost-effectiveness of treatment. Using a toms has demonstrated equivalent outcomes for indi- multiple cohort pretest–post-test design, Muroff and col- viduals with and without hoarding symptoms.52Although leagues examined the effectiveness of group CBT using this finding appears promising, the results need to be Steketee and Frost’s treatment manual.32After 16 to 20 qualified. The authors only measured obsessive-com- sessions and two home visits, patients evidenced a mean pulsive symptoms, symptom response was poor in both reduction of 8.6 points on the Saving Inventory-Revised groups (23% to 24% symptom reduction), and individ- (SI-R), which is less than that produced from individual uals with hoarding symptoms took paroxetine for sig- treatment using the same manual (18.7 or 16.9).59,60After nificantly more days. As with pharmacological these investigators modified their research procedures approaches, the presence of hoarding symptoms is a neg- to more thoroughly screen group members and utilized ative predictor of cognitive-behavioral treatment out- a more detailed and structured manual for the group, the come for OCD.53,54Only one third of hoarders with OCD mean SI-R reduction in the final group was 14.25. demonstrate clinically significant improvement in As access to clinicians trained in CBT for compulsive response to exposure and response prevention, while hoarding is limited, a Web-based self-help group has also one half to two thirds of nonhoarders with OCD demon- been examined for its effectiveness. This Web-based treat- strate such improvement.53In response to these disap- ment was also based on Steketee and Frost’s manual58and pointing outcomes, researchers have developed psycho- required individuals to take active steps to reducing their logical treatments for compulsive hoarding that are hoarding behavior within 2 months of membership. After based on Frost and Hartl’s cognitive-behavioral model.1 6 months of memberships, SI-R scores decreased by an Treatments outcomes based on Frost and Hartl’s model average of 6 points. These two group studies suggest that are encouraging, but suggest that many sessions are highly structured, in-person groups may lead to greater required to produce change and that clutter is slow to improvements in hoarding outcomes than less-structured improve. The first case study reported that approxi- groups. Internet treatment approaches are important mately 45 sessions were needed to completely reduce because they have the potential to expand significantly clutter.55After 20 weeks of treatment, Steketee et al56 the number of individuals with hoarding who receive demonstrated a 16% reduction in Y-BOCS scores, while treatment, and thus, ways to improve outcomes achieved Saxena et al57demonstrated a 35% reduction in Y-BOCS from Internet-delivered therapy are much needed. scores after 6 weeks of daily intensive treatment. More effective treatments are warranted for this common Utilizing Steketee and Frost’s58 cognitive-behavioral and disabling disorder. Novel pharmacotherapies, such as treatment manual for compulsive hoarding, Tolin et al59 cognitive enhancers and stimulants, should be evaluated offered 26 individual sessions (in-office sessions and at for their utility with hoarding patients. Cognitive enhancers least one home visit) over a 7- to 12-month period to 14 may improve memory, attention, and overall cognitive individuals. On average, treatment completers (n=10) functioning, while stimulants may improve attention, alert- demonstrated 25% improvement in their clutter and dif- ness, and information-processing speed. Only one case ficulty discarding, and 35% reduction in acquiring. report has been published describing the effects of a stim- Following this open trial, Steketee et al60made minor ulant in an individual with compulsive hoarding. In this modifications to the treatment and examined its efficacy case, a combined treatment of fluvoxamine, risperidone, in a randomized controlled trial. Findings from this trial amphetamine salts, and behavior therapy was used to treat indicated that improvements in hoarding symptoms a 56-year old man diagnosed with OCD, compulsive were greater after receiving 12 sessions of cognitive hoarding, ADHD, and schizotypal personality disorder. behavioral therapy (CBT) than after waiting for a com- Although the patient reported that after treatment he pro- parable period. After 26 sessions of CBT, 68% to 76% crastinated less, kept appointments better, and was less of patients were rated as improved by their therapists or upset when throwing things away, the patient’s clutter did 238 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 239 Compulsive hoarding - Grisham and Norberg Dialogues in Clinical Neuroscience - Vol 12 .No. 2 .2010 not significantly decrease.61In order to determine if stim- Future directions ulants or cognitive enhancers are effective adjuncts for the treatment of compulsive hoarding, systematic, randomized Despite the increased research on compulsive hoarding controlled trials are needed. in recent years, several avenues still require exploration. Overall, research findings indicate that compulsive hoard- Researchers must continue to unravel the complex ers do respond to CBT, although improvements are mod- story of hoarding’s etiology and pathogenesis through erate in comparison with gains observed in nonhoarders additional laboratory studies examining the cognitive, with OCD. A number of methodological limitations, how- emotional, neural, and behavioral features of the disor- ever, curtail these findings. First, there is a lack of properly der. Future research may also help to establish the rela- controlled treatment studies that involve random alloca- tion of hoarding symptoms to OCD, anxiety, ADHD, tion to treatment (CBT or medication) and a placebo and ICDs. Finally, further treatment studies investigat- group. Also, the lack of specificity of the measures used to ing the efficacy of cognitive rehabilitation, behavioral index symptoms makes it difficult to determine whether interventions, Internet applications, and novel medica- improvements are due to changes in hoarding symptoms tion treatments are essential for improving clinical out- or to reductions in nonhoarding OCD symptoms. comes. ❏ REFERENCES 16. Grisham JR, Brown TA, Liverant G, Campbell LA. The distinctiveness of hoarding from other dimensions of obsessive-compulsive disorder. J Anxiety Disord. 2005;19:767-769. 1. Frost RO, Hartl T. A cognitive-behavioral model of compulsive hoard- 17. Frost RO, Meagher BM, Riskind JH. Obsessive-compulsive features in ing. Behav Res Ther.1996;34:341-350. pathological lottery and scratch ticket gamblers. J Gambl Stud. 2001;17:5- 2. American Psychiatric Association. Diagnostic and Statistical Manual of 19. Mental Disorders. 4th ed, Text Revision. Washington, DC: American 18. Grant JE, Mancebo MC, Pinto A, Eisen JL, Rasmussen SA. Impulse con- Psychiatric Association; 2000. trol disorders in adults with obsessive compulsive disorder. J Psychiatr Res. 3. Pertusa A, Fullana MA, Singh S, Alonso P, Menchon JM, Mataix-Cols D. 2006;40:494-501. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? 19. Hayward LC, Coles ME. Elucidating the relation of hoarding to obses- Am J Psychiatry. 2008;165:1289-1298. sive compulsive disorder and impulse control disorders. J Psychopathol 4. Wu KD, Watson D. Hoarding and its relation to obsessive-compulsive Behav Assess.2009;31:220-227. disorder. Behav Res Ther. 2005;43:897-921. 20. McElroy SL, Keck PE, Phillips KA. Kleptomania, compulsive buying, and 5. Grilo CM, McGlashan TH, Gunderson JG, et al. Internal consistency, binge-eating disorder. J Clin Psychiatry. 1995;56:14-26. intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV 21. Rachman SJ, Elliot CM, Shafran R, Radomsky A. Separating hoarding schizotypal, borderline, avoidant and obsessive-compulsive personality from OCD. Behav Res Ther. 2009;47:520-522. disorders. Acta Psychiatrica Scandinavica. 2001;104:264-272. 22. Steketee G, Frost RO. Compulsive hoarding: current status of the 6. Saxena S. Is compulsive hoarding a genetically and neurobiologically research. Clin Psychol Rev. 2003;23:905-927. discrete syndrome? Implications for diagnostic classification. Am J 23. Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obses- Psychiatry. 2007;164:380-384. sive-compulsive disorder in the National Comorbidity Survey Replication. 7. Samuels JF, Bienvenu Iii OJ, Pinto A, et al. Hoarding in obsessive-com- Mol Psychiatry. 2010;15:53-63. pulsive disorder: Results from the OCD Collaborative Genetics Study. Behav 24. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates Res Ther. 2007;45:673-86. of hoarding behavior in a community-based sample. Behav Res Ther. 8. Frost RO, Steketee G, Williams LF, Warren R. Mood, personality disorder 2008;46:836-844. symptoms, and disability in obsessive-compulsive hoarders: A comparison 25. Iervolino AC, Perroud N, Fullana MA, et al. Prevalence and heritabili- with clinical and nonclinical controls. Behav Res Ther. 2000;38:1071-1081. ty of compulsive hoarding: a twin study. J Am Acad Child AdolescPsychiatry. 9. Mataix-Cols D, Baer L, Rauch S, Jenike MA. Relation to factor analyzed 2009;166:1156-1161. symptom dimensions of obsessive-compulsive disorder to personality dis- 26. Ayers CR, Saxena S, Golshan S, Wetherell JL. Age at onset and clinical orders. Acta Psychiatrica Scandinavica. 2000;102:199-202. features of late life compulsive hoarding. Int J Geriatr Psychiatry. 10. Samuels J, Nestadt G, Bienvenu III OJ, Costa PT, Riddle MA, Liang KY. 2010;25:142-149. Persoanltiy disorders and normal personality dimensions in obsessive-com- 27. Grisham JR, Frost RO, Steketee G, Kim HJ, Hood S. Age of onset of pulsive disorder: Results from the John Hopkins OCD Family Study. Br J compulsive hoarding. J Anxiety Disord. 2006;20:675-686. Psychiatry. 2000;177:457-462. 28. Cromer KR, Schmidt NB, Murphy DL. An investigation of traumatic life 11. Goodman WK, Price LH, Rasmussen SA, et al. The Yale–Brown events and obsessive-compulsive disorder. Behav Res Ther. 2007;45:1683-1691. Obsessive–Compulsive Scale. I. Development, use and reliability. Arch Gen 29. Wheaton M, Timpano KR, Lasalle-Ricci VH, Murphy DL. Characterizing Psychiatry. 1989;46:1006–1011. the hoarding phenotype in individuals with OCD: associations with comor- 12. Frost RO, Krause MS, Steketee G. Hoarding and obsessive-compulsive bidity, severity and gender. J Anxiety Disord. 2008;22:243-252. symptoms. Behav Modif. 1996;20:116-132. 30. Muroff J, Steketee G, Himle J, Frost R. Delivery of internet treatment 13. Rasmussen SA, Eisen JL. The epidemiology and differential diagnosis for compulsive hoarding (D.I.T.C.H.). Behav Res Ther. 2010;48:79-85. of obsessive compulsive disorder. J Clin Psychiatry. 1992;53:4-10. 31. Tolin DF, Frost RO, Steketee G, Gray KD, Fitch KE. The economic and 14. Samuels J, Bienvenu III OJ, Riddle MA, et al. Hoarding in obsessive-compul- social burden of compulsive hoarding. Psychiatry Res. 2008;160:200-211. sive disorder: Results from a case-control study. Behav Res Ther. 2002;40:517-528. 32. Muroff J, Steketee G, Rasmussen J, Gibson A, Bratiotis C, Sorrentino C. 15. Abramowitz JS, Wheaton MG, Storch EA. The status of hoarding as a Group cognitive and behavioral treatment for compulsive hoarding: a pre- symptom of obsessive-compulsive disorder. Behav Res Ther. 2008;46:1026-1033. liminary trial. Depress Anxiety.2009;26:634-640. 239 PAGES_11_AG_1009_BA.qxd:DCNS#45 9/06/10 10:27 Page 240 C l i n i c a l r e s e a r c h Acaparamiento compulsivo: controversias Collectionnisme compulsif : controverses actuales y perspectivas actuelles et nouvelles orientations El acaparamiento compulsivo es un trastorno psico- Le collectionnisme compulsif est un trouble psy- lógico invalidante, caracterizado por conductas ina- chologique handicapant caractérisé par un com- decuadas de acumular y guardar. Este artículo revisa portement d’épargne et de stockage excessif. Cet cuatro áreas clave de los avances recientes en la article analyse quatre points clés des avancées investigación del acaparamiento. Primero, se entrega récentes de la recherche sur ce sujet. Nous débutons una panorámica de la controversia que se ha desa- premièrement par une synthèse de la controverse rrollado en relación con la condición diagnóstica del en pleine évolution sur le diagnostic de ce trouble : acaparamiento, destacando la evidencia que se ha les arguments sont de plus en plus en faveur d’une acumulado en relación con el hecho que sería mejor meilleure conceptualisation du trouble comme syn- conceptualizarlo como un síndrome independiente. drome à part. Deuxièmement, nous décrivons les Segundo, se describen los avances en la comprensión avancées concernant notre compréhension de son de la epidemiología, el curso y las características épidémiologie, de son évolution et de ses cadres demográficas del acaparamiento compulsivo. démographiques. Troisièmement, nous analysons Tercero, se revisan los últimos hallazgos relacionados les derniers résultats des corrélations neuropsycho- con posibles correlatos neuropsicológicos de este logiques éventuelles du trouble. Enfin, nous discu- trastorno. Finalmente se discute el progreso actual y tons des progrès en cours et des orientations las perspectivas futuras en relación con el manejo clí- futures de la prise en charge clinique du collection- nico del acaparamiento compulsivo. nisme compulsif. 33. Steketee G, Frost RO, Kim HJ. Hoarding by elderly people. Health Soc 48. Luchian SA, McNally RJ, Hooley JM. Cognitive aspects of nonclinical Work. 2001;26:176-184. obsessive-compulsive hoarding. Behav Res Ther. 2007;45:1657-1662. 34. Harlow JM. Recovery from the passage of an iron bar through the 49. Black DW, Monahan P, Gable J, Blum N, Clancy G, Baker P. Hoarding head. Proc Counc Mass Med Soc. 1868;2:327-347. and treatment response in 38 nondepressed subjects with obsessive-com- 35. Eslinger PJ, Damasio AR. Severe disturbance of higher cognition after pulsive disorder. J Clin Psychiatry. 1998;59:420-425. frontal lobe ablation: Patient EVR. Neurology. 1985;35:1731-1741. 50. Mataix-Cols D, Rauch S, Manzo P, Jenike M, Baer L. Use of factor-ana- 36. Hahm DL, Kang Y, Cheong SS, Na DL. A compulsive collecting behav- lyzed symptom dimensions to predict outcome with serotonin reuptake ior following an A-com aneurismal rupture. Neurology. 2001;56:398-400. inhibitors and placebo in the treatment of obsessive-compulsive disorder. 37. Anderson SW, Damasio H, Damasio AR. A neural basis for collecting Am J Psychiatry. 1999;156:1409-1416. behaviour in humans. Brain. 2005;128:201-212. 51. Winsberg ME, Cassic KS, Koran LM. Hoarding in obsessive-compulsive 38. Hartl TL, Duffany SR, Allen GJ, Steketee G, Frost RO. Relationships disorder: a report of 20 cases. J Clin Psychiatry. 1999;60:591-597. among compulsive hoarding, trauma, and attention-deficit/hyperactivity 52. Saxena S, Brody AL, Maidment KM, Baxter LRJ. Paroxetine treatment disorder. Behav Res Ther. 2005;43:269-276. of compulsive hoarding. J Psychiatry Res. 2007;41:481-487. 39. Grisham JR, Brown TA, Savage CR, Steketee G, Barlow DH. 53. Abramowitz JS, Franklin ME, Schwartz SA, Furr JM. Symptom presen- Neuropsychological impairment associated with compulsive hoarding. tation and outcome of cognitive-behavioral therapy for obsessive-com- Behav Res Ther. 2007;45:1471-1483. pulsive disorder. J Consult Clin Psychol. 2003;71:1049-1057. 40. Hartl TL, Frost RO, Allen GJ, Deckersbach T, et al. Actual and perceived 54. Mataix-Cols D, Marks IM, Greist JH, Kobak KA, Baer L. Obsessive-com- memory deficits in individuals with compulsive hoarding. Depress Anxiety. pulsive symptom dimensions as predictors of compliance with and 2004;20:59-69. response to behaviour therapy: Results from a controlled trial. Psychother 41. Lawrence NS, Wooderson S, Mataix-Cols D, David R, Speckens A, Psychosom. 2002;71:255-262. Phillips ML. Decision making and set shifting impairments are associated 55. Hartl TL, Frost RO. Cognitive-behavioral treatment of compulsive hoarding: with distinct symptom dimensions in obsessive-compulsive disorder. a multiple baseline experimental case study. Behav Res Ther. 1999;37:451-461. Neuropsychology. 2006;20:409-419. 56. Steketee G, Frost RO, Wincze J, Greene K, Douglass H. Group and indi- 42. Frost RO, Gross RC. The hoarding of possessions. Behav Res Ther. vidual treatment of compulsive hoarding: a pilot study. Behav Cogn 1993;31:367-381. Psychother. 2000;28:259-68. 43. Frost RO, Shows DL. The nature and measurement of compulsive inde- 57. Saxena S, Maidment KM, V, Vapnik T, et al. Obsessive-compulsive cisiveness. Behav Res Ther. 1993;31:683-692. hoarding: Symptom severity and response to multimodal treatment. J Clin 44. Steketee G, Frost RO, Kyrios M. Cognitive aspects of compulsive Psychiatry. 2002;63:21-27. hoarding. Cognit Ther Res.2003;27:463-479. 58. Steketee G, Frost RO. Compulsive Hoarding and Acquiring: Therapist 45. Grisham JR, Melissa MM, Williams AD, Certoma SP, Kadib R. Categorization Guide. New York, NY: Oxford University Press; 2007. and cognitive deficits in compulsive hoarding. Behav Res Ther. In press. 59. Tolin DF, Frost RO, Steketee G. An open trial of cognitive-behavioral 46. Frost RO, Steketee G. Hoarding: clinical aspects and treatment strategies. therapy for compulsive hoarding. Behav Res Ther. 2007;45:1461-1470. In: Jenike MA, Baer L, Minichiello WE, eds. Obsessive-Compulsive Disorder: Practical 60. Steketee GF, Tolin DF, Rasmussen J, Brown TA. Waitlist-controlled trial of cog- Management. 3rd ed. St Louis, MO: Mosby Yearbook Medical; 1998:533-554. nitive behavior therapy for hoarding disorder. Depress Anxiety. 2010;27:476-484. 47. Wincze JP, Steketee G, Frost RO. Categorization in compulsive hoard- 61. Kaplan A, Hollander E. Comorbidity in compulsive hoarding: a case ing. Behav Res Ther. 2007;45:63-72. report. CNS Spectr. 2004;9:71-73. 240

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