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DAVID MATAIX-COLS, PHD SENIOR LECTURER HEAD, PSYCHOBIOLOGY OF ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS GROUP SECTION

Psychobiology of Anxiety and Obsessive-Compulsive Disorders Group. R e cent advances in compulsive hoarding research. DAVID MATAIX-COLS, PHD SENIOR LECTURER HEAD, PSYCHOBIOLOGY OF ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS GROUP SECTION OF COGNITIVE NEUROPSYCHIATRY. Overview.

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DAVID MATAIX-COLS, PHD SENIOR LECTURER HEAD, PSYCHOBIOLOGY OF ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS GROUP SECTION

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  1. Psychobiology of Anxiety and Obsessive-Compulsive Disorders Group Recent advances in compulsive hoarding research DAVID MATAIX-COLS, PHD SENIOR LECTURER HEAD, PSYCHOBIOLOGY OF ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS GROUP SECTION OF COGNITIVE NEUROPSYCHIATRY

  2. Overview • Clinical features • Relationship to psychiatric disorders (esp. OCD) • How common is compulsive hoarding? • Consequences of compulsive hoarding • Family / genetic studies • Environmental factors • Neurobiology • Conclusions and future directions

  3. Monica

  4. Hoarding as a symptom • Has been described in: • Dementia- mainly frontal type • Brain lesions • Autism & learning disabilities • Genetic disorders (e.g.Prader-Willi) • Eating disorders (mainly food) • Obsessive-Compulsive Disorder (15-40%; severe in 5%) • Obsessive Compulsive Personality Disorder (1 of 8 criteria) • While differential diagnosis is easy in most cases, often hoarding cannot be explained by another neurological or psychiatric disorder

  5. Differential diagnosis with OCD

  6. Differential diagnosis with OCD • 52 severe hoarders • 25 had OCD • 27 did not have OCD • In most hoarders who also had OCD, their hoarding was unrelated to their main OCD symptoms (co-morbidity) • In a minority of cases hoarding was clearly OCD-related (Pertusa et al, AJP 2008)

  7. Compulsive Hoarding Syndrome vs. OCD (Pertusa et al, AJP 2008)

  8. Control+apple+4 (Pertusa et al, AJP 2008)

  9. Conclusion • Hoarding CAN be a symptom of OCD but this is relatively uncommon • Often (wrongly) assumed that the presence of other OCD symptoms = hoarding is an OCD symptom • In fact, hoarding is rarely OCD-related • It does co-occur with OCD (but also depression, social phobia, etc) • Separate syndrome in DSM-V?

  10. Provisional diagnostic criteria for Compulsive Hoarding Syndrome • 1) The acquisition of, and failure to discard large numbers of possessions that appear (to others) to be useless or of limited value • 2) Living or other spaces sufficiently cluttered so as to preclude activities for which those spaces were designed • 3) Significant distress or impairment in functioning caused by the hoarding or clutter • 4)Not explained by another organic or psychiatric disorder (adapted from Frost & Hartl, 1996)

  11. Most commonly hoarded items • Old clothes • Magazines • CDs/Video tapes • Letters • Pens • Old notes • Bills • Newspapers • Receipts • Cardboard boxes • Beads • Wool/fabric • Pins • Clothing rags • Old medication • Old food (canned) • Body products (nails, hair, feces…) * • Used nappies * • Rotten food * • Animals * In the context of OCD only (Pertusa et al, AJP 2008)

  12. Reasons given for hoarding behaviour • Perceived need for the items (intrinsic value) • ‘I may need it some day’ • Emotional attachment to possessions (emotional value) • ‘I feel safe around my possessions’ • Identification with possessions • ‘I feel the object is part of me’

  13. Prevalence and consequences

  14. Prevalence of compulsive hoarding I • Unknown • 15-40% in OCD (5% severe); hoarding is clearly OCD-related in only a minority of those (Pertusa et al 2008) • 3 recent epidemiological studies (1 hoarding item) • American OCPD study (n=742): 4-5% (Samuels et al 2000) • NCS-R study (n=2,073): 14% (Ruscio et al, 2008) • ESEMED study (n=2,500): 2.6% of all sample and 2% of people with no mental disorders (Fullana et al, in preparation)

  15. Prevalence of compulsive hoarding II • 5,000 twins (St Thomas’ Hospital Twin Registry) • Compulsive Hoarding Scale (Tolin et al 2008): 5 items (clutter, difficulties discarding, acquisition, distress, interference) • Empirically derived cut-off points • Approximately 2% have ‘significant’ hoarding • Predominantly women of older age

  16. Hoarding: a substantial cause of disability • Substantial social (C.H.A.O.S.) and occupational impairment (Steketee & Frost, 2003) • Health risks from infestations, falls, fires etc (Steketee & Frost, 2003) • High family and economic burden; high service utilisation (Tolin et al 2008a) • 8-12% evicted or threatened with eviction (Tolin et al 2008b) • Homelessness?

  17. Homelessness: Salvation Army study I • 78 randomly selected homeless people newly admitted to Salvation Army hostels in several major cities in the UK • Administered the HRS-I (Tolin et al submitted) • Thirteen (17%) people endorsed lifetime moderate/severe difficulties on at least one item of the HRS-I • Six (7.7%) participants reported moderate/severe difficulties on at least one item of the HRS-I at the time of the interview and had their possessions ‘stashed away’ • Six (7.7%) participants (all men) reported that their hoarding problems, particularly excessive acquisition leading to financial difficulties, had directly contributed to their homelessness (Mataix-Cols et al, submitted)

  18. Homelessness: Salvation Army study II • 1/3 were homeless as a child but this was not associated with hoarding • Hoarding associated with increased psychological distress (GHQ), traumatic experiences and alcohol use • Conclusions: • Compulsive hoarding may be at least 4 times more frequent among the homeless • May be an important precipitant of homelessness • Detection and intervention may prevent homelessness (Mataix-Cols et al, submitted)

  19. Hoarding in the news

  20. Aetiology

  21. Cognitive-behavioural model (Frost & Hartl, 1996)

  22. Does hoarding run in families? • Approx 50% of hoarders report having a 1st degree relative who hoards (Winsberg et al 1999; Samuels et al 2002; Pertusa et al 2008) • Hoarding highly inter-correlated in sibling pairs with OCD (e.g. Hassler et al 2007; Pinto et al 2008) • Unclear if this familiarity is due to genetic or environmental factors • Twin studies are required

  23. Twin studies Identical twins Fraternal twins Share 50% genes Share 100% genes Assumption: identical environment

  24. Hoarding twin study: Preliminary results • 5,000 twins (St Thomas’ Twin Registry) • Compulsive Hoarding Scale (Frost et al): 5 items • Preliminary results: • Approx. 50% genetic syndrome * controlling for sex and age (Iervolino et al, in preparation)

  25. Traumatic life events in compulsive hoarding • Hoarders reported a greater number of traumatic events compared to healthy controls (Hartl et al, 2005) and to non-hoarding OCD patients (Cromer et al, 2007) • The severity of hoarding symptoms correlated with experience of traumatic life events (Cromer et al, 2007) • Individuals who report a stressful life event at the time of onset of hoarding symptoms showed a significantly later age of onset (Grisham et al, 2006)

  26. Neurobiology ANIMAL STUDIES LESION STUDIES NEUROIMAGING

  27. Hoarding in animal studies • Animal studies have implicated subcortical limbic structures (accumbens, VTA, amygdala, hippocampus, thalamus, hypothalamus) and vMPFC in the mediation of hoarding behaviour • Lesions in these regions impair hoarding behaviour • Electrical stimulation of lateral hypothalamus (promotes feeding) increases hoarding behaviour in rats (Herberg & Blundell, 1967) • Neonatal depletion of dopaminergic meso-cortical projection decreases hoarding in rats (Kalsbeek et al 1988) • Hoarding behavior can be restored to control levels in dopamine-lesion rats by prior treatment with L-dopa (Kelley & Stinus, 1985)

  28. Hoarding in human lesion studies • Phineas Gage ‘developed a great fondness for animals and souvenirs’ (Harlow, 1868; Anderson et al 2005) • Single case studies of brain lesions associated with hoarding implicate ventral PFC (Cohen et al 1999; Hahm et al 2001; Volle et al 2002) • Case series of brain lesion patients implicate ventromedial PFC, frontal pole, anterior cingulate (Anderson et al 2005)

  29. Compulsive hoarding caused by brain damage “The evidence suggests that damage to the mesial frontal region disrupts a mechanism which normally modulates subcortically driven predispositions to acquire and collect, and adjusts these predispositions to environmental context.” (Anderson et al , Brain 2005)

  30. Functional neuroimaging Significant Negative Correlations Between Glucose Metabolism and Hoarding Severity in Patients with OCD (n=45; 12 hoarders) Sagittal 3.0 2.5 2.0 1.5 Zvalue 1.0 0.5 0.0 Dorsal Anterior Cingulate Cortex (Saxena et al, AJP 2004)

  31. Symptom provocation paradigm Imagine that… How anxious do you feel? • Washing x 10 • Checking x 10 • Hoarding x 10 • Aversive x 10 (control) 0-8 0-8 0-8 0-8 Mataix-Cols et al (2004). Arch Gen Psychiatry, 61: 564-76

  32. OCDHOARD study * * Hoarding experiment Aversive control experiment An et al (2008), Molecular Psychiatry

  33. Hoarding vs non-hoarding OCD vs controls No differences in aversive control experiment An et al (2008), Molecular Psychiatry

  34. Treatment response: bad news • In the context of OCD, hoarding consistently predicts poor treatment response: • To SSRIs: Black et al 1998; Mataix-Cols et al 1999; Matsunaga et al 2007; Saxena et al 2002; Stein et al 2008, etc • To CBT: Abramowitz et al 2003; Mataix-Cols et al 2002; Rufer et al 2006 • A recent uncontrolled trial with paroxetine is more promising but has severe limitations (Saxena et al 2007) • Newly developed intensive CBT interventions (> 25 sessions, skilled therapists, home visits) are promising (Tolin et al 2007)

  35. Conclusions I • Hoarding can be a symptom of several neurological / psychiatric conditions, in which case treatment should be according to primary diagnosis • But often it appears in isolation and can be a major source of disability, social exclusion and even homelessness • It is relatively prevalent (approx 2% of population) • It’s highly familial, with both genetic and environmental risk factors likely playing a role

  36. Conclusions II • In animals, hoarding linked with subcortical limbic structures and vMPFC, probably dopamine-related (could explain poor response to SSRIs) • Lesion studies in humans also implicate vMPFC • Must be cautious to extrapolate these findings to non-organic hoarding problems • Neuroimaging studies suggest involvement of similar fronto-limbic networks (distinct from OCD) but results must be taken as very preliminary

  37. Conclusions III • Existing treatments are only moderately effective • A new syndrome with distinctive features and its own diagnostic criteria is proposed for DSM-V • Much research is needed: prevalence, risk factors, etiological mechanisms, prevention and development of new treatments • Involvement of multiple agencies

  38. Acknowledgements Sukkyon An Michael Brammer Miquel A Fullana Vincent Giampietro Alessandra Iervolino Natalia Lawrence Alberto Pertusa Mary L Phillips Marianne van der Bree Funding Wellcome Trust South London and Maudsley NHS Trust Spanish Ministry of Science Marie Curie programme

  39. Ongoing research studies • Institute of Psychiatry (various studies) • Susan Santo, Alessandra Iervolino or Danielle Landau • Tel: 020 7848 0659 • E-mail: s.santo@iop.kcl.ac.uk / a.iervolino@iop.kcl.ac.uk / d.landau@iop.kcl.ac.uk • Cambridge University (neuropsychology of hoarding) • Sharon Morein or Martina Butt • Telephone: 01223 767035/ 764425 • E-mail: sm658@cam.ac.uk / mb690@cam.ac.uk

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