Hoarding in obsessive-compulsive disorder: results from the OCD Collaborative Genetics Study

Hoarding behavior occurs frequently in obsessive-compulsive disorder (OCD). Results from previous studies suggest that individuals with OCD who have hoarding symptoms are clinically different than non-hoarders and may represent a distinct clinical group. In the present study, we compared 235 hoarding to 389 non-hoarding participants, all of whom had OCD, collected in the course of the OCD Collaborative Genetics Study. We found that, compared to non-hoarding individuals, hoarders were more likely to have symmetry obsessions and repeating, counting, and ordering compulsions; poorer insight; more severe illness; difficulty initiating or completing tasks; and indecision. Hoarders had a greater prevalence of social phobia and generalized anxiety disorder. Hoarders also had a greater prevalence of obsessive-compulsive and dependent personality disorders. Five personality traits were independently associated with hoarding: miserliness, preoccupation with details, difficulty making decisions, odd behavior or appearance, and magical thinking. Hoarding and indecision were more prevalent in the relatives of hoarding than of non-hoarding probands. Hoarding in relatives was associated with indecision in probands, independently of proband hoarding status. The findings suggest that hoarding behavior may help differentiate a distinct clinical subgroup of people with OCD and may aggregate in some OCD families. Indecision may be a risk factor for hoarding in these families.     

Sex-specific clinical correlates of hoarding in obsessive-compulsive disorder

Little is known about whether the clinical correlates of hoarding behavior are different in men and women with obsessive-compulsive disorder (OCD). In the current study, we evaluated the association of hoarding with categories of obsessions and compulsions, psychiatric disorders, personality dimensions, and other clinical characteristics separately in 151 men and 358 women with OCD who were examined during the OCD Collaborative Genetics Study. We found that, among men but not women, hoarding was associated with aggressive, sexual, and religious obsessions and checking compulsions. In men, hoarding was associated with generalized anxiety disorder and tics whereas, among women, hoarding was associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, nail biting, and skin picking. In women but not men, hoarding was associated with schizotypal and dependent personality disorder dimensions, and with low conscientiousness. These findings indicate that specific clinical correlates of hoarding in OCD are different in men and women and may reflect sex-specific differences in the course, expression, and/or etiology of hoarding behavior in OCD.     

Hoarding in obsessive compulsive disorder: results from a case-control study

Hoarding occurs relatively frequently in obsessive-compulsive disorder (OCD), and there is evidence that patients with hoarding symptoms have more severe OCD and are less responsive to treatment. In the present study, we investigated hoarding symptoms in 126 subjects with OCD. Nearly 30% of the subjects had hoarding symptoms; hoarding was twice as prevalent in males than females. Compared to the 90 non-hoarding subjects, the 36 hoarding individuals had an earlier age at onset of, and more severe, obsessive-compulsive symptoms. Hoarders had greater prevalences of symmetry obsessions, counting compulsions, and ordering compulsions. Hoarders also had greater prevalences of social phobia, personality disorders, and pathological grooming behaviors (skin picking, nail biting, and trichotillomania). Hoarding and tics were more frequent in first-degree relatives of hoarding than non-hoarding probands. The findings suggest that the treatment of OCD patients with hoarding symptoms may be complicated by more severe OCD and the presence of co-occurring disorders. Hoarding appears to be transmitted in some OCD families and may differentiate a clinical subgroup of OCD.     

Do traumatic events influence the clinical expression of compulsive hoarding?

Traumatic experiences have been posited as one potential catalyst for the abrupt onset of obsessive-compulsive symptoms including compulsive hoarding. To determine whether traumatic life events (TLEs) might influence the expression of compulsive hoarding in obsessive-compulsive disorder (OCD), interview responses to the Posttraumatic Stress Disorder module of the Structured Clinical Interview for DSM-IV (SCID) were examined in 180 individuals with OCD. Compared to individuals with OCD who did not meet criteria for hoarding, participants classified as hoarders (24% of the sample) were significantly more likely to have reported at least one TLE in their lifetime. Patients who met criteria for hoarding and who had also experienced TLEs had significantly greater hoarding symptom severity than those hoarders not exposed to trauma. This association was found to be robust. That is, the relationship between TLEs and hoarding symptom severity was not better accounted for by age, age of OCD onset, depressive symptoms, general OCD symptomatology, or mood and anxiety comorbidity. Closer examination revealed that the clutter factor of compulsive hoarding (and not difficulty discarding or acquisitioning) was most strongly associated with having experienced a traumatic event.     

The status of hoarding as a symptom of obsessive-compulsive disorder

Hoarding is considered by many to be a symptom of obsessive-compulsive disorder (OCD). Yet although it is observed in people with OCD, hoarding symptoms also appear in a number of other psychological and psychiatric conditions. The present studies were conducted using samples of OCD patients, patients with other anxiety disorders, and a non-clinical sample to further elucidate the relationship between hoarding and OCD. Across two investigations, we found that (a) whereas OCD patients had higher scores than the other groups on non-hoarding symptoms, this was not the case for hoarding symptoms; (b) hoarding tended to correlate more weakly with other OCD symptoms (e.g., washing, checking) than these other symptoms intercorrelated; (c) items measuring hoarding had the weakest factor loadings when a measure of OCD symptoms was submitted to factor analysis; (d) hoarding symptoms were not correlated with global OCD or anxiety severity, whereas other OCD symptoms were; and (e) hoarding did not show consistent relationships with OCD-related cognitive variables. These results do not support a specific relationship between hoarding and OCD; and they call into question hoarding's status as a specific symptom of OCD. Results are also discussed in terms of the importance of functional assessment of hoarding and OCD symptoms.     

Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls

Hoarding is a symptom of obsessive compulsive disorder (OCD), as well as a diagnostic criterion for obsessive compulsive personality disorder (OCPD). One recent study suggests that people who suffer from compulsive hoarding report more general psychopathology than people who do not [Frost, R.O., Krause, M.S., & Steketee, G. (1996). Hoarding and obsessive compulsive symptoms. Behavior Modification, 20, 116-132]. The present study addressed whether persons with OCD hoarding exhibit more depression, anxiety, OCD and personality disorders symptoms than community controls, OCD nonhoarders, or other anxiety disorder patients. Disability was also examined. Hoarding subjects were older than the other three groups, but age did not account for any of the differences observed among the groups. Compared to controls, OCD hoarding, nonhoarding OCD and anxiety disorder patients showed elevated YBOCS scores, as well as higher scores on depression, anxiety, family and social disability. Compared to nonhoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on anxiety, depression, family and social disability. Hoarding subjects had greater personality disorder symptoms than controls. However, OCD hoarding subjects differed from OCD nonhoarding and anxiety disorder subjects only on dependent and schizotypal personality disorder symptoms. The findings suggest that hoarding is associated with significant comorbidity and impairment compared to nonhoarding OCD and other anxiety disorders.     

Experimental manipulation of NEO-PI-R items.

Research assessing the relationship of the Five-factor model (FFM) of personality to personality disorder symptomatology has generally been consistent with theoretical expectations. Three exceptions, however, have been failures to confirm predicted associations of the NEO-Personality Inventory-Revised (NEO-PI-R) Conscientiousness scale with obsessive-compulsive personality disorder symptomatology, the NEO-PI-R Agreeableness scale with dependent symptomatology, and the NEO-PI-R Openness scale with schizotypal symptomatology. It was the hypothesis of this study that these findings might be due in part to a relative emphasis on adaptive rather than maladaptive variants of these domains of personality functioning within the NEO-PI-R. This hypothesis was tested by experimentally altering NEO-PI-R items to reverse their implications for maladaptiveness. The predicted correlations of the FFM were confirmed with the experimentally altered items in a sample of 86 adult psychiatric outpatients.     

Experimental Manipulation of NEO-PI-R Items

Research assessing the relationship of the Five-factor model (FFM) of personality to personality disorder symptomatology has generally been consistent with theoretical expectations. Three exceptions, however, have been failures to confirm predicted associations of the NEO-Personality Inventory-Revised (NEO-PI-R; Costa & McCrae, 1992b) Conscientiousness scale with obsessive-compulsive personality disorder symptomatology, the NEO-PI-R Agreeableness scale with dependent symptomatology, and the NEO-PI-R Openness scale with schizotypal symptomatology. It was the hypothesis of this study that these findings might be due in part to a relative emphasis on adaptive rather than maladaptive variants of these domains of personality functioning within the NEO-PI-R. This hypothesis was tested by experimentally altering NEO-PI-R items to reverse their implications for maladaptiveness. The predicted correlations of the FFM were confirmed with the experimentally altered items in a sample of 86 adult psychiatric outpatients.     

Onset of obsessive-compulsive disorder: premorbid conditions and prodromal phase

This article focuses on the clinical onset of obsessive-compulsive disorder (OCD), specifically addressing the age of onset, gradual and acute onset, and whether there are some types of premorbid conditions or a prodromal phase that predispose individuals to the onset of OCD. Clinical and epidemiological studies have come to different conclusions regarding age at onset as well as regarding differences between the sexes. Data gleaned from research to date have demonstrated a relationship between OCD and obsessive-compulsive personality disorder (OCPD), although OCPD does not appear to be the more prevalent personality disorder among patients with OCD. Preliminary research has suggested that Axis I disorders may predispose individuals to OCD onset; however, the significance of this relationship remains to be clarified. Evidence of the association between OCD and subthreshold obsessive-compulsive syndrome suggests that these disorders lie on a continuum of severity, with some cases developing OCD while others do not.     

Does obsessive-compulsive personality disorder belong within the obsessive-compulsive spectrum?

It has been proposed that certain Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders share overlapping clinical features, genetic contributions, and treatment response and fall within an "obsessive-compulsive" spectrum. Obsessive-compulsive personality disorder (OCPD) resembles obsessive-compulsive disorder (OCD) and other spectrum disorders in terms of phenomenology, comorbidity, neurocognition, and treatment response. This article critically examines the nosological profile of OCPD with special reference to OCD and related disorders. By viewing OCPD as a candidate member of the obsessive-compulsive spectrum, we gain a fresh approach to understanding its neurobiology, etiology, and potential treatments.     

Obsessive-compulsive disorder: boundary issues

The boundaries between obsessive-compulsive disorder (OCD) and other neuropsychiatric disorders remain unresolved and may well differ from one disorder to another. Endophenotypes are heritable, quantitative traits hypothesized to more closely represent genetic risk for complex polygenic mental disorders than overt symptoms and behaviors. They may have a role in identifying how closely these disorders are associated with another and with other mental disorders with which they share major comorbidity. This review maps the nosological relationships of OCD to other neuropsychiatric disorders, using OCD as the prototype disorder and endophenotype markers, such as cognitive, imaging, and molecular data as well as results from demographic, comorbidity, family, and treatment studies. Despite high comorbidity rates, emerging evidence suggests substantial endophenotypic differences between OCD and anxiety disorders, depression, schizophrenia, and addictions, though comparative data is lacking and the picture is far from clear. On the other hand, strong relationships between OCD, Tourette syndrome, body dysmorphic disorder, hypochondriasis, grooming disorders, obsessive-compulsive personality disorder, and pediatric autoimmune neuropsychiatric disorders associated with streptococcus are likely. Studies designed to delineate the cause, consequences, and common factors are a challenging but essential goal for future research in this area.     

Clarifying the convergence between obsessive compulsive personality disorder criteria and obsessive compulsive disorder

In this study we examined the convergence between obsessive-compulsive personality disorder (OCPD) criteria and obsessive-compulsive disorder (OCD). Baseline assessments of 629 participants of the Collaborative Longitudinal Personality Disorders Study were used to examine the associations between OCPD criteria and diagnoses of OCD. Three of the eight OCPD criteria--hoarding, perfectionism, and preoccupation with details--were significantly more frequent in subjects with OCD (n = 89) than in subjects without OCD (n = 540). Logistic regressions were used to predict the probability of each OCPD criterion as a function of Axis I diagnoses (OCD, additional anxiety disorders, and major depressive disorder). Associations between OCD and these three OCPD criteria remained significant in the logistic regressions, showing unique associations with OCD and odds ratios ranging from 2.71 to 2.99. In addition, other anxiety disorders and major depressive disorder showed few associations with specific OCPD criteria. This study suggests variability in the strength of the relationships between specific OCPD criteria and OCD. The findings also support a unique relationship between OCPD symptoms and OCD, compared to other anxiety disorders or major depression. Future efforts to explore the link between Axis I and Axis II disorders may be enriched by conducting analyses at the symptom level.     

Clinical features of tic-related obsessive-compulsive disorder: results from a large multicenter study

OBJECTIVE: To evaluate the clinical features of obsessive-compulsive disorder (OCD) patients with comorbid tic disorders (TD) in a large, multicenter, clinical sample.MethodA cross-sectional study was conducted that included 813 consecutive OCD outpatients from the Brazilian OCD Research Consortium and used several instruments of assessment, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Yale Global Tic Severity Scale (YGTSS), the USP Sensory Phenomena Scale, and the Structured Clinical Interview for DSM-IV Axis I Disorders. RESULTS: The sample mean current age was 34.9 years old (SE 0.54), and the mean age at obsessive-compulsive symptoms (OCS) onset was 12.8 years old (SE 0.27). Sensory phenomena were reported by 585 individuals (72% of the sample). The general lifetime prevalence of TD was 29.0% (n = 236), with 8.9% (n = 72) presenting Tourette syndrome, 17.3% (n = 141) chronic motor tic disorder, and 2.8% (n = 23) chronic vocal tic disorder. The mean tic severity score, according to the YGTSS, was 27.2 (SE 1.4) in the OCD + TD group. Compared to OCD patients without comorbid TD, those with TD (OCD + TD group, n = 236) were more likely to be males (49.2% vs. 38.5%, p < .005) and to present sensory phenomena and comorbidity with anxiety disorders in general: separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, impulse control disorders in general, and skin picking. Also, the "aggressive," "sexual/religious," and "hoarding" symptom dimensions were more severe in the OCD + TD group.ConclusionTic-related OCD may constitute a particular subgroup of the disorder with specific phenotypical characteristics, but its neurobiological underpinnings remain to be fully disentangled.     

Hoarding Disorder and a Systematic Review of Treatment with Cognitive Behavioral Therapy

Until recently, compulsive hoarding has been treated as a type of obsessive-compulsive disorder with mixed results. Little research exists on the efficacy of behavioral interventions specifically designed to treat hoarding disorder, and most existing research is limited with regard to the numbers of participants, their ethnic and cultural diversity, and study replication; therefore, the generalizability of findings is limited. This article reviews the prevalence of hoarding disorder, cognitive behavioral therapy treatment approaches, and measurement of symptoms. A systematic review compares the efficacy of various CBT methods, with particular attention to comparing therapy that is traditionally used to treat OCD with those designed specifically to treat hoarding disorder. Only clinical studies using CBT interventions designed to treat hoarding associated with OCD or hoarding disorder were included. Studies included participants of all ages, and articles were published in peer-reviewed journals. Case studies were excluded. After a comprehensive search and removing duplicates from databases and references, 65 articles were reviewed, of which 12 met criteria for review. Preliminary results demonstrate improvement in hoarding symptoms with CBT interventions that are both for OCD and those designed to specifically treat hoarding disorder; however, when compared to each other, the efficacy of these treatments is inconclusive, thus more research is needed.     

The role of cognitive factors in the pathogenesis of obsessive-compulsive symptoms: a prospective study

Cognitive models of obsessive-compulsive disorder (OCD) posit that specific kinds of dysfunctional beliefs (e.g., pertaining to responsibility and the significance of intrusive thoughts) underlie the development of this disorder. The present study was designed to prospectively evaluate whether dysfunctional beliefs thought to underlie OCD act as a specific vulnerability factor in the pathogenesis of obsessive-compulsive symptomatology. Eighty-five individuals were prospectively followed over a period of time thought to be associated with an increased onset of OCD symptoms -- childbirth and the postpartum. The majority of these new mothers and fathers experienced intrusive infant-related thoughts and performed neutralizing behaviors similar to, but less severe than, those observed in OCD. Scores on a measure of dysfunctional beliefs thought to underlie OCD predicted the development of obsessive-compulsive symptoms after controlling for pre-existing OCD symptoms, anxiety, and depression. Dysfunctional beliefs also predicted the severity of checking, washing, and obsessional OCD symptom dimensions, but not neutralizing, ordering, or hoarding symptom dimensions. These data provide evidence for specific dysfunctional beliefs as risk factors in the development of some types of OCD symptoms.     

A comparison of clinical features in trichotillomania and obsessive-compulsive disorder.

Trichotillomania (TM) recently has been conceptualized as a variant of obsessive-compulsive disorder (OCD). However, no systematic data have compared the clinical features of these two disorders. Here we report data from 8 TM and 13 OCD patients which suggest important clinical differences between groups. First, TM patients reported a significantly greater degree of pleasure during hair-pulling than OCD patients reported during performance of ritualistic behaviors. Second, TM was accompanied by significantly fewer associated obsessive-compulsive symptoms. Third, the groups differed with regard to other clinical features including anxiety, depression, and personality characteristics. We conclude that TM is not conceptualized best as a variant of OCD.     

Hoarding and its relation to obsessive-compulsive disorder

Although hoarding is observed in some patients with obsessive-compulsive disorder (OCD), it has not been shown to share a specific relation with OCD. Across two studies, we found that (a) whereas the classic OCD symptoms of checking, rituals, and contamination intercorrelated consistently strongly with one another, hoarding related only moderately to both these OCD symptoms and to depression; (b) OCD patients were distinguished from both other patients and non-patients by classic OCD symptoms, but not by hoarding; and (c) whereas OCD symptoms showed consistent relations with Negative Affect, hoarding largely was uncorrelated with this dimension. These results do not support a specific OCD-hoarding relation but rather call into question the trend of considering it a specific symptom of OCD.     

Obsessive-compulsive disorder and the five-factor model of personality: distinction and overlap with major depressive disorder

Research on individual differences in obsessive-compulsive disorder (OCD) has focused largely on analogue models with participants experiencing sub-clinical obsessions and/or compulsions. Few studies have examined the association between normal, dimensional personality traits and obsessive-compulsive symptomatology in a clinical sample. The purpose of this study was to examine personality differences in patients with a primary diagnosis of OCD (n = 98) or major depression (n = 98) using the domains and facets of the five-factor model of personality (FFM). Patients completed the self-report version of the Revised NEO Personality Inventory (NEO PI-R). When contrasted with community controls (Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual, Psychological Assessment Resources, Odessa, FL, 1992), participants with OCD were found to differ across the domains (and facets) of neuroticism, extraversion, and conscientiousness and the facets of openness and agreeableness. Further, when compared to depressed participants, those with OCD were found to be more extraverted, agreeable, conscientious and less neurotic. With the exception of the conscientiousness domain (and facets), these significant differences were maintained even after controlling for depression severity. These results highlight the unique associations between trait domains and facets of the FFM and OCD.     

Separating hoarding from OCD

There is confusion about the status of excessive hoarding. In particular, there is an unresolved question about whether or not it is a manifestation of obsessive-compulsive disorder (OCD). There are some definite similarities between ‘compulsive’ hoarding and OCD, but they are outweighed by the differences between them. It is proposed that the matter can be clarified by separating hoarding from OCD, and that this would advance clinical work and research.     

强迫症诊断研究的新变化

临床实践与相关研究表明,强迫症的诊断标准已不能满足复杂的临床工作需要。首先,有关患者的自知力以及主观痛苦程度等诊断指标需要进一步修订。其次,就强迫症的核心症状而产生的争议,研究者提出应重新考虑强迫症、焦虑障碍、强迫谱系障碍和囤积障碍这四个概念之间的从属关系和诊断标准。未来研究应考虑从认知神经科学的视角探索强迫症的核心症状和病理机制,为强迫症的诊断标准提供新的依据。