Day # 97: Hoarding Disorder (HD)

Today we will continue our current theme of the "OCD related disorders" which include body dysmorphic disorder (BDD), hoarding disorder (HD), trichotillomania (hair-pulling disorder), and excoriation (skin-picking disorder). Today we will discuss hoarding disorder (HD).

INTRODUCTION 1

• Hoarding disorder (HD) is characterized by an individuals persistent and profound difficulty discarding or parting from one's possessions.

• In contrast to normal collecting / clutter, these behaviors lead to significant clutter/congestion and patients develop significant distress and/or impairment.

• These symptoms have long been described in the literature, but only recently appeared in the DSM-5. Previously it was viewed as a sub-type of OCD or OCPD, but a review of growing literature on hoarding symptoms revealed that many patients with clinical hoarding did not meet diagnostic criteria for either OCD or OCPD, and that it should be included as a separate diagnostic entity.

DIAGNOSTIC CRITERIA 2

• Persistent and profound difficulty discarding possessions, regardless of their value.

• Feel the need to save the items and feel distress associated with discarding the items.

• Results in accumulation of possessions that congest/clutter living areas and compromise their intended use.

• Causes significant distress or impairment in functioning (social, occupational, etc.).

• Symptoms are not better explained by another medical/psychiatric condition.

• Specifiers: 1) hoarding also associated with excessive acquisition of new items that are not needed 2) level of insight (good/fair; poor; absent/delusional).

EPIDEMIOLOGY / PATHOGENESIS 3

• Estimates of point prevalence are ~2-6% with an unclear gender difference, but some data show 1:1.

• Unlike other OCD related disorders, there is a higher prevalence (3x) in older patients (55-94 yo). Average age of first treatment is ~50 yo.

• Preliminary evidence suggest prevalence is higher in "western countries".

• Significant genetic component. ~50% of HD patients also have a hoarding relative.

• Risk factors include stressful/traumatic events preceding the onset of hoarding.

• HD has been associated with impairment in various neuropsychological domains including spatial planning, response inhibition, working memory, and set-shifting.

• Studies have suggested involvement in the ventromedial prefrontal cortex, anterior cingulate cortex, as well as medial temporal regions. The relevant circuitry only partially overlaps with that involved in OCD.

CLINICAL PEARLS 4

• The onset of symptoms can begin in early teenage years or after stressful/traumatic events. Hoarding tends to meet criteria in the 30s-50s, be chronic without appropriate treatment, and often worsens as patient ages.

• An example of a screening question: "To what extent do you have difficulty discarding (or recycling, selling, giving away) ordinary things that other people would get rid of?"

• Consider using a validated questionnaire such as the Hoarding Rating Scale.

• Important questions to consider during evaluation: age of onset; course of symptoms; type and severity of symptoms; extent of insight/impairment; excessive acquisition of new items (~80-90% of HD patients) in addition to hoarding behaviors; range of objects that are hoarded; avoidance behavior; presence of comorbid symptoms/disorders; safety assessment (sufficient space to cook/clean; falls risk; family relationships; suicide).

• Keep in mind that a minority of patients with HD may have uncluttered living areas, but it is typically only because others step in to assist (friends, family members, etc.).

• High comorbidity with major depressive disorder (~75%), anxiety disorders particularly social anxiety disorder, and OCD (~20%).

• A number of neurodevelopment/neurodegenerative conditions are associated with hoarding, notably Prader-Willi syndrome (often hoard food), autism spectrum disorder (restricted interests), and Alzheimer's dementia.

TREATMENT 5, 6, 7

• Treatment for all OCD and related disorders are similar, so we have written a detailed post titled "Treatment of OCD" where we discuss treatment options in detail. Please refer to that post for a more thorough discussion.

• Psychotherapy: Therapy is the mainstay treatment for hoarding disorder. There is a specialized form of CBT for hoarding that is recommended as first-line management. Core elements of treatment include restricting acquiring, practicing sorting and discarding, and cognitive restructuring to challenge thoughts and beliefs about attachment to items. Motivational interviewing is often needed when addressing ambivalence to psychotherapy. In addition to traditional psychotherapy, patients may benefit from "skills training" that helps individuals learn how to organize their belongings, how to problem solve issues that arise in working on their clutter, and how to make decisions about keeping needed items and removing unneeded items that contribute to clutter.

• Pharmacotherapy: SSRIs are first-line medications for OCD and related disorders including hoarding disorder, although the data on pharmacotherapy for OCD has indicated that hoarding symptoms are a predictor of less favorable treatment outcomes with SSRIs. Preliminary results with venlafaxine suggest a good response with hoarding behaviors in some individuals and in one study showed greater benefit when compared to paroxetine. New strategies might include glutamate modulators (memantine, N-acetyl cysteine, glycine, topiramate, lamotrigine) and cholinergic enhancers (donepizil, galantamine). In treatment resistant cases there is limited data that exists for augmentation with antipsychotics. See pharmacotherapy section in the "Treatment of OCD" lesson to see additional options.

CONCLUSION

I hope you found today's lesson helpful. Next lesson we will discuss trichotillomania (hair-pulling disorder) and excoriation (skin-picking disorder).

Resources for today's post include: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, DSMV, and First Aid for the Psychiatry Clerkship.

Bullet Psych is an Amazon Associate and we receive a small commission if you use our links for the purchase of our recommended resources.