Hoarding: OCD cluster or independent disorder?

2013/2014 Ana Cristina Preto Lopes Hoarding: OCD cluster or independent disorder? março, 2014 Mestrado Integrado em Medicina Área: Neurociências Clínicas e Saúde Mental Trabalho efetuado sob a Orientação de: Dr. Ricardo Jorge Silva Assunção Torres Moreira Trabalho organizado de acordo com as normas da revista: Journal of Obsessive-Compulsive and Related Disorders Ana Cristina Preto Lopes Hoarding: OCD cluster or independent disorder? março, 2014 lEponro i'â.iF FÂCUIDÁDE OË MEDICII{ fEJ3ï ul,l'vrnsroÀos Do PoRïo úRrôÁ8É C!frRttúLÀÊ PRcJËïo oE oFçÃo srtraiÌitÁo ?@*thàsiw Eu, abaixo assinado, no mecanográfico f;'?Cr.\r,{*}{, estudante do 6o ano do Ciclo de Estudos Integrado em Medicina, na Faculdade de Medicina da Universidade do Porto, declaro ter atuado com absoluta integridade na elaboração deste projeto de opção. Neste sentido, confirmo que NÃO incorri em plágio (ato pelo qual um indivíduo, mesmo por omissão, assume a autoria de um determinado trabalho intelectual, ou pades dele). Mais declaro que todas as frases que retirei de trabalhos anteriores pertencentes a outros autores, foram referenciadas, ou redigidas com novas palavras, tendo colocado, neste caso/ a citação da fonte bibliográfica, Faculdade de Medicina da Universidade do pono,'dpJçjJo{tf Projeto de Opção do 6o ano - DrcrARAçÃo DE INTEGRTDADE Assinatura conforme cartão de identificação: IEponro Projecto de Opção do 60 ano - DecumçÃo oe ReenoouçÃo ]ruÚPÌ FACULDÂDE DE MËDICINA Ëi;ïl uNrvERsrDADÊ Do poRTo UNIOADE CURRICULÂR f,f 9 J F^T :o" ? 5" 9"Ì 9^t 9 cnnrÃo oe ctoRoÃo ou pASSApoRTe (se estrangeiro) TELEFONE OU TELEMOVEL NOME ruúNrno DE ESTUDANTE DATA DE cotrtclusÃo oesrclrRÇÃo oR Ánen Do PRoJEcro "'í MONOGMFIA (riscar o que não interessa) - Í\ -ì_ . Õc b ,L\*x\-u'\- ry\ \\í\ .:\"r.-f.r=+ÈuU ,/ ORIENTADOR COORIENTADOR (se aplicável) É autorizada a reprodução integral desta efeitos de investigaÉo e de divulgação FMUP. Dissertação/Monografia (riscar o que não interessa) para pedagógica, em programas e projectos coordenados pela Faculdade de Medicina da Universidade do poto,lalOj/ IJo{4 Assinatura conforme cartão de identificaçao' "\,* ,,= a;r rS. -r-- L.d!,l 1 | Aos meus pais e aos meus melhores amigos, que me ajudaram a chegar até aqui. Aos doentes e professores, com quem aprendi sobre Medicina e não só. A José Marcelino Preto: sei que ficarias feliz por me ver onde estou hoje. 1 Hoarding: OCD cluster or independent disorder? Abstract In the last edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) there is a new listed disorder, named hoarding disorder (HD) (American Psychiatric Association, 2013). Until now, hoarding behaviors were viewed as a symptom dimension of obsessive-compulsive disorder (OCD). Hoarding is defined as the extensive acquisition and inability to discard several objects that may appear of limited value to others, resulting in excessive clutter. Several recent investigations suggest that hoarding is clinically, neurobiologically and genetically distinct from OCD, which has implications in treatment and prognosis. It is now consensual that HD is a distinct entity, with a well-defined course of the disorder, a specific presentation of symptoms and a need of a precise treatment, particularly in cognitive and behavioral aspects. The alterations on the new edition of the DSM-V emphasize the need of further research and clarification into a lot of aspects of this new disorder. In this article, we discuss the evidence that enlightens this new classification, as well as some future implications. Keywords: Hoarding Disorder; Obsessive-Compulsive Disorder; Diagnostic and Statistical Manual of Mental Disorders V. 2 Introduction Hoarding disorder is characterized by an excessive acquisition and failure to discard objects of limited value, a cluttered living environment, and significant distress or impairment associated with these symptoms (Frost & Hartl, 1996). In some cases, the severity of these symptoms can reach levels that enable the patients from doing basic daily life activities, such as cooking, eating, moving around their own house or even sleeping (Frost & Hartl, 1996). These situations can achieve scenarios where hoarding becomes a threatening problem that puts people at risk of falls, accidents, sanitary problems and fire (Frost, Steketee, & Williams, 2000; Mogan, Kyrios, Schweitzer, Yap, & Moulding, 2012; G. Steketee, Frost, & Kim, 2001). This condition is associated with an important economic and social burden and is present in approximately 2–5% of the population (Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009; J. F. Samuels et al., 2008). In the United States of America, it is estimated that, in average, patients who suffer from hoarding symptomatology report 7.0 psychiatric work impairment days per month. (Tolin, Frost, Steketee, Gray, & Fitch, 2008). According to the same study, hoarding patients have a broad range of other chronic medical concerns and a five-fold higher rate use of services of mental institutions (Tolin et al., 2008). Historically, hoarding has been considered a personality trait, and more recently, a symptom, or symptom dimension, of obsessive–compulsive disorder (OCD) (Fernández de la Cruz et al., 2013). In the previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), hoarding was considered one of the eight criteria for the diagnosis of obsessive-compulsive personality disorder (OCPD) (American Psychiatric Association, 2000). Also, when in the presence of severe hoarding symptoms, the diagnosis of OCD was required (American Psychiatric Association, 2000). Nevertheless, an important number of individuals with severe hoarding do not demonstrate other OCD symptoms (Pertusa et al., 2008; J. F. Samuels et al., 2008). Recent conceptualizations suggest that, in most cases, hoarding appears to be a sole diagnostic entity named hoarding disorder (HD), which was included in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (MataixCols, Fernandez de la Cruz, Nakao, Pertusa, & Anxiety Obsessive-Compulsive, 2011). Diagnostic criteria for HD include a persistent difficulty discarding or parting with possessions (Criterion A), which is due to a perceived need to save the items and distress associated with discarding them (Criterion B); the accumulation of possessions that clutter active living areas of the home to the extent that their intended use is significantly compromised (Criterion C); marked distress or impairment (Criterion D); 3 and symptoms not being attributable to another medical condition (Criterion E) and/or another DSM-5 disorder (Criterion F) (American Psychiatric Association, 2013). The presence of excessive acquisition and the degree of insight (good, poor or absent) are specifiers for the HD diagnosis (American Psychiatric Association, 2013). The goal of this review article is to address the arguments and the discussion around this new diagnostic entity and to reflect about some of the consequences that this new classification of the referred symptoms implies. Materials and Methods The research of articles for this review was made in three medical databases: PubMed, Scopus and Web of Knowledge. The initial search with the following query “(obsessive-compulsive disorder) AND hoarding” resulted in 1196 abstracts, as follows: 363 from PubMed, 423 from Scopus and 410 from Web of Knowledge. The limits applied to this search were: inclusion of articles written in English, Portuguese and Spanish, and exclusion of editorials and conference articles. After excluding for the repeated references, 529 abstracts remained. The application of the exclusion criteria to the obtained abstracts (studies about obsessive-compulsive personality disorder; studies about animal hoarding) and the research for free full-text articles resulted in 123 articles from which were obtained the references used in this study. Results and Discussion In the last years, a lot of attention has been given to the subject of hoarding and to all the discussion that concerns this. Many are the authors that have studied the hoarding symptoms from a behavioral and clinical point of view, concerning the beliefs and experiences of such patients, the items collected, the presence of stressful life events, comorbidities, quality of life , and the relationship of all previously mentioned with OCD presentation and core features. One of the main focus of such research is the answer to the question whether hoarding is a symptom of OCD or a distinct disorder (Rachman, Elliott, Shafran, & Radomsky, 2009). Behavioral evidence So far, hoarding has been approached as a symptom of OCD and it has been included in most structured interviews and questionnaires to access the symptomatology of OCD (Mataix-Cols et al., 2010). 4 In fact, hoarding can be an OCD symptom, with the evidence showing that it can be related to beliefs about fear of contaminating others, which originates difficulties discarding hoarded items (Pertusa, Frost, & Mataix-Cols, 2010). In spite of this, there is a growing body of evidence and consensus that supports the idea that hoarding is not related to OCD in the majority of the cases, with a percentage as high as 80% of hoarders who don’t exhibit other OCD symptoms (Pertusa et al., 2008; J. F. Samuels et al., 2008). A deep analysis of the psychopathology of hoarding behaviors can reveal that these differ considerably from OCD symptoms, despite the existence of some overlap between them. One important aspect of this consideration is the psychological mechanism of experiential avoidance (EA) in OCD patients and pure hoarders (Fernández de la Cruz et al., 2013). Experiential avoidance can be defined as “the tendency to avoid contact with unwanted internal experiences” (Fernández de la Cruz et al., 2013). Several recent approaches to the conceptualization of hoarding behavior take into account this psychological mechanism. Recent studies have compared the levels of EA between OCD patients who exhibit hoarding behaviors and pure hoarders. Individuals diagnosed with OCD who also reveal a hoarding component of their disorder have reported greater EA beliefs related to their possessions when compared to pure hoarders (Fernández de la Cruz et al., 2013; Gordon, Salkovskis, & Oldfield, 2013). However, non-hoarding OCD individuals demonstrate similar levels of EA when compared to OC hoarders (Fernández de la Cruz et al., 2013). This could lead us to think that EA is not specific of hoarding behaviors, but another study reported that EA levels were greater among hoarders (M. G. Wheaton, Abramowitz, Franklin, Berman, & Fabricant, 2011), which leaves us with discrepant arguments. Hoarders with an OCD diagnosis also appear to report a greater fear of future material deprivation than pure hoarding patients (Gordon et al., 2013). This referenced study also found that OC hoarders have the tendency to report obsessional beliefs related to their belongings, such as a fear of something bad happening if their objects are discarded (Gordon et al., 2013). On the other hand, hoarders who don’t meet criteria for an OCD diagnosis report a greater degree of emotional or intrinsic value attributed to their possessions (Pertusa et al., 2008). Another point that is worth to mention is how hoarding individuals appear to show an ego-syntonic disposition with their symptoms. This statement takes us to reflect about possible differences between the degree of insight of pure hoarders and OCD patients with a hoarding behavior. OCD patients with a hoarding behavior appear to show a lower level of insight into their condition (Jakubovski et al., 2011). Nevertheless, pure hoarders are also characterized by an affected insight of their symptoms, which can be assessed by the 11 Steketee, Kim, & Hood, 2006; Tolin, Meunier, et al., 2010). Another characteristic that is worth mentioning is the level of insight. Hoarders have a much lower level of insight into their problems than OCD patients (Tolin, Fitch, et al., 2010). Concerning the prognosis of OCD and hoarding behaviors, hoarders are faced with a worse prognosis. Pharmacological therapies that are available for hoarding treatment are based on selective serotonin reuptake inhibitors (SSRI’s), which are also used for treatment of classic OCD symptoms (Saxena, 2008). So far, hoarding symptoms don’t seem to respond to such drugs as well as other OCD symptoms (Tolin, 2011b). Cognitive behavioral therapy is also a challenge in hoarding patients, due to the frequent lack of insight that they present. On the other hand, OCD patients only seem to loose insight into their condition in severe presentations of the disorder (Jakubovski et al., 2011). Conclusions In the last decades, hoarding behaviors have been subject to several studies. So far, hoarding has been considered a symptom of OCD, but recent evidence suggests that it may be better classified as an individual entity, hoarding disorder, instead of an OCD cluster. Until this moment, there is not a satisfactory treatment for hoarding behaviors (Tolin, 2011a, 2011b). A better understanding into the hoarding phenomenon may provide advances on pharmacological and cognitive-behavioral treatments. To achieve this, all aspects of this new categorized disorder must be considered, including functional impairment and low quality of life reported by hoarders (Saxena et al., 2011), the fact that these individuals tend to be more often victims of both violent and nonviolent crime (feeling less safe at their homes and neighborhoods) (Saxena et al., 2011), maladaptive beliefs about their possessions (Gordon et al., 2013), as well as other cognitive functions and deficits (Grisham et al., 2010; Hartl et al., 2004). These aspects have been found to differ in hoarding and in classic OCD symptomatology (Jang et al., 2010), which should be considered for the development of more effective treatments of hoarding behaviors (Tolin, 2011a, 2011b). Further research on hoarding as a clinical distinct disorder may help the improvement of the pharmacological treatments and the cognitive behavioral therapies that are currently used. The current criteria for the new classification of hoarding disorder included in the new DSM-V take into to account the description of symptoms (criteria A, B, and C), the level of distress (criteria D) and the exclusion of organic disorders or any other psychiatric disorders (criteria E and F) (American Psychiatric Association, 2013). The 12 degree of insight and the level of acquisition were also included as specifiers (American Psychiatric Association, 2013). These new criteria highlight that a diagnosis of OCD must be ruled out in order to considerer the diagnosis of hoarding disorder. Early research about hoarding disorder has been based on samples of individuals diagnosed with OCD. Considering that fewer than 20% of the total of OCD patients present with hoarding symptomatology (Frost, Steketee, et al., 2012), this represents a clear bias of the findings and conclusions drawn from such works. The use of the new criteria will be helpful in designing more appropriate studies to analyze several unanswered questions and to develop scales that can properly access hoarding disorder, considered that until now hoarding behaviors were assessed within OCD measure scales (Frost et al., 2004), which posed a serious limitation on previous studies. With the advance on hoarding disorder classification made in the last edition of the DSM, the future research and treatments for this condition shall be improved and better directed to the target patients. 13 References American Psychiatric Association(2000). Diagnostic and statistical manual of mental disorders (4th ed.).Washington, DC: American Psychiatric Association (text revision). American Psychiatric Association(2013). Diagnostic and statistical manual of mental disorders (5th ed.).Washington, DC: American Psychiatric Association. Abramowitz, J. S., Schwartz, S. A., Franklin, M. E., & Furr, J. M. (2003). 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F., Meunier, S. A., Frost, R. O., & Steketee, G. (2011). Hoarding among patients seeking treatment for anxiety disorders. J Anxiety Disord, 25(1), 43-48. doi: 10.1016/j.janxdis.2010.08.001 Tolin, D. F., Villavicencio, A., Umbach, A., & Kurtz, M. M. (2011). Neuropsychological functioning in hoarding disorder. Psychiatry Res, 189(3), 413-418. doi: 10.1016/j.psychres.2011.06.022 Torres, A. R., Fontenelle, L. F., Ferrão, Y. A., do Rosário, M. C., Torresan, R. C., Miguel, E. C., & Shavitt, R. G. (2012). Clinical features of obsessive-compulsive disorder with hoarding symptoms: A multicenter study. Journal of Psychiatric Research, 46(6), 724-732. Volle, E., Beato, R., Levy, R., & Dubois, B. (2002). Forced collectionism after orbitofrontal damage. Neurology, 58(3), 488-490. Wheaton, M., Timpano, K. R., Lasalle-Ricci, V. H., & Murphy, D. (2008). Characterizing the hoarding phenotype in individuals with OCD: associations with comorbidity, severity and gender. J Anxiety Disord, 22(2), 243-252. doi: 10.1016/j.janxdis.2007.01.015 Wheaton, Michael G., Abramowitz, Jonathan S., Franklin, Joseph C., Berman, Noah C., & Fabricant, Laura E. (2011). Experiential Avoidance and Saving Cognitions in the Prediction of Hoarding Symptoms. Cognitive Therapy and Research, 35(6), 511-516. doi: 10.1007/s10608-010-9338-7 Wincze, J. P., Steketee, G., & Frost, R. O. (2007). Categorization in compulsive hoarding. Behav Res Ther, 45(1), 63-72. doi: 10.1016/j.brat.2006.01.012 Wu, K. D., & Watson, D. (2005). Hoarding and its relation to obsessive-compulsive disorder. Behav Res Ther, 43(7), 897-921. doi: 10.1016/j.brat.2004.06.013 Agradecimentos Gostaria de agradecer ao Dr. Ricardo Moreira, pela orientação e sugestões prestadas na realização deste trabalho. Gostaria ainda de agradecer a Elisabeta Preto, Francisco Lopes, Paula Neves, Rúben Ausina, Bárbara Araújo, Mariana Mangas e Mariana Ferreira, pela paciência e disponibilidade que tiveram para comigo durante a concretização desta tese de mestrado. AUTHOR INFORMATION PACK 12 Mar 2014 www.elsevier.com/locate/jocrd 1 JOURNAL OF OBSESSIVE-COMPULSIVE AND RELATED DISORDERS AUTHOR INFORMATION PACK TABLE OF CONTENTS . XXX . • Description • Editorial Board • Guide for Authors p.1 p.1 p.3 ISSN: 2211-3649 DESCRIPTION . Journal of Obsessive-Compulsive and Related Disorders (JOCRD) is an international journal that publishes high quality research and clinically-oriented articles dealing with all aspects of obsessive-compulsive disorder (OCD) and related conditions (OC spectrum disorders; e.g., trichotillomania, hoarding, body dysmorphic disorder). The journal invites studies of clinical and non-clinical (i.e., student) samples of all age groups from the fields of psychiatry, psychology, neuroscience, and other medical and health sciences. The journal's broad focus encompasses classification, assessment, psychological and psychiatric treatment, prevention, psychopathology, neurobiology and genetics. Clinical reports (descriptions of innovative treatment methods) and book reviews on all aspects of OCD-related disorders will be considered, as will theoretical and review articles that make valuable contributions. Suitable topics for manuscripts include: The boundaries of OCD and relationships with OC spectrum disordersValidation of assessments of obsessive-compulsive and related phenomenaOCD symptoms in diverse social and cultural contextsStudies of neurobiological and genetic factors in OCD and related conditionsExperimental and descriptive psychopathology and epidemiological studiesStudies on relationships among cognitive and behavioral variables in OCD and related disordersInterpersonal aspects of OCD and related disordersEvaluation of psychological and psychiatric treatment and prevention programs, and predictors of outcome. EDITORIAL BOARD . Editor-in-Chief J. Abramowitz Ph.D., Dept. of Psychology, University of North Carolina at Chapel Hill, 3270 Davie Hall, Chapel Hill, NC 27599-3270, USA, Email: jabr[email protected] Associate Editors J.E. Grant, University of Chicago, Chicago, USA D. Mataix-Cols, Karolinska Institutet, Stockholm, Sweden D. McKay, Fordham University, Bronx, USA D.J. Stein, University of Cape Town, Cape Town, South Africa E.A. Storch, University of South Florida, Tampa, USA S. Taylor, University of British Columbia, Vancouver, Canada Editorial Board Members M. Antony, Ryerson University, Toronto, Canada T.K. Bouman, Rijksuniversiteit Groningen, Groningen, Netherlands J. Calamari, Rosalind Franklin University of Med. and Science, North Chicago, USA C. Carmin, University of Illinois at Chicago, Chicago, USA D.A. Clark, University of New Brunswick, Fredericton, Canada AUTHOR INFORMATION PACK 12 Mar 2014 www.elsevier.com/locate/jocrd 2 J. Cottraux, Hospital Neurologique, BRON CEDEX, France J. Cougle, Florida State University, Tallahassee, USA B. Deacon, University of Wyoming, Laramie, USA D. Denys, Universiteit van Amsterdam, Academisch Medisch Centrum (AMC), Amsterdam, Netherlands G. Doron, New School of Psychology Interdisciplinary Center, Herzliya, Herzliya, Israel D. Dougherty, Harvard Medical School, Charlestown, USA B. Fallon, Columbia University, New York, USA J. Fama, Harvard Medical School, Boston, USA L. Farrell, Griffith University, Mt Gravatt, Australia J. Feusner, University of California at Los Angeles, North Hills, USA N. Fineberg, University of Hertfordshire, Hatfield, UK M. Franklin, Center for the Treatment & Study of Anxiety, Philadelphia, USA R. Frost, Smith College, Northampton, USA D. Gleaves, University of South Australia, Adelaide, Australia W. Goodman, Mount Sinai School of Medicine, New York, USA B. Greenberg, Brown Medical School, Providence, USA J. Grisham, University of New South Wales, Sydney, Australia E. Hollander, Mount Sinai School of Medicine, New York, USA N. J. Keuthen, Massachusetts General Hospital & Harvard Medical School, Boston, USA S. Khanna, , L Koran, Stanford University School of Medicine, Palo Alto, USA J.S Kwon, Seoul National University (SNU), Seoul, South Korea M. Kyrios, Swinburne University of Technology, Hawthorn, Australia H.J. Lee, University of Wisconsin at Milwaukee, Milwaukee, USA A.B. Lewin, University of South Florida (USF) College of Medicine, Tampa, USA C. Lochner, Stellenbosch University, Tygerberg, South Africa J. March, MD, MPH, Duke University Medical Center, Durham, USA G. Melli, Università di Pisa, Firenze, Italy R. Menzies, University of Sydney, Sydney, Australia E. Miguel, Universidade de São Paulo (USP), São Paulo, Brazil R. Moulding, Swinburne University of Technology, Hawthorn, Australia T. Murphy, University of South Florida, St. Petersburg, USA G. Nestadt, Johns Hopkins University School of Medicine, Baltimore, USA K. O'Connor, Université de Montréal, Montreal, Canada B. Olatunji, Vanderbilt University, Nashville, USA P. Oppen, Universiteit van Amsterdam, Amsterdam, Netherlands D. Pauls, Harvard Medical School, Boston, USA K.A. Phillips, Brown University, Providence, USA J, Piacentini, University of California at Los Angeles, Los Angeles, USA C. Purdon, University of Waterloo, Waterloo, Canada A.S. Radomsky, Concordia University, Montréal, Canada E. Rassin, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands S.L. Rauch, Harvard Medical School, Belmont, USA P. Richter, University of Toronto, Toronto, Canada B.C. Riemann, Rogers Memorial Hospital, Oconomowoc, USA K. Rowa, McMaster University, Hamilton, Canada P. Salkovskis, University of Bath, Claverton Down, Bath, UK C. Sica, University of Firenze via di San Salvi 12, Firenze, Italy G. Simos, Community Mental Health Center, Thessaloníki, Greece H Simpson, New York State Psychiatric Institute, New York, USA V. Starcevic, University of Sydney, Sydney, Australia G. Steketee, Boston University, Boston, USA L. Summerfeldt, Trent University, Peterborough, Canada K.R. Timpano, University of Miami, Miami, USA D. Veale, Maudsley Hospital, London, UK S.P. Whiteside, Mayo Clinic, SW Rochester, USA S. Wilhelm, Harvard Medical School, Boston, USA M. Williams, University of Louisville, Louisville, USA D. Woods, University of Wisconsin at Milwaukee, Milwaukee, USA K.D. Wu, Northern Illinois University, Dekalb, USA J. Zohar, Chaim Sheba Med. Center, Ramat Gan, Israel AUTHOR INFORMATION PACK 12 Mar 2014 www.elsevier.com/locate/jocrd 9 Math formulae Present simple formulae in the line of normal text where possible and use the solidus (/) instead of a horizontal line for small fractional terms, e.g., X/Y. In principle, variables are to be presented in italics. Powers of e are often more conveniently denoted by exp. Number consecutively any equations that have to be displayed separately from the text (if referred to explicitly in the text). Footnotes Footnotes should be used sparingly. Number them consecutively throughout the article. Many wordprocessors build footnotes into the text, and this feature may be used. 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