Pharmacotherapy for Hoarding Disorder: How did the Picture Change since its Excision from OCD?

This brief review deals with the various issues that contributed to the creation of the new Diagnostic and Statistical Manual condition of hoarding disorder (HD) and attempts at reviewing its pharmacotherapy. It appears that after the newly founded diagnosis appeared in the literature as an autonomous entity, distinct from obsessive-compulsive disorder, drug trials are not being conducted and the disorder is left in the hands of psychotherapists, who on their part, report fair results in some core dimensions of HD. The few trials on HD specifically regard the serotonin-noradrenaline reuptake inhibitor venlafaxine, and, possibly due to the suggestion of a common biological background of HD with attention-deficit/hyperactivity disorder, the psychostimulant methylphenidate and the noradrenaline reuptake inhibitor atomoxetine. For all these drugs, positive results have been reported, but the evidence level of these studies is low, due to small samples and non-blind designs. Regretfully, there are currently no future studies aiming at seriously testing drugs in HD.

Critical Review of the Use of Second-Generation Antipsychotics in Obsessive-Compulsive and Related Disorders.

Currently, all second-generation antipsychotics are approved for schizophrenia. Many are also approved for bipolar disorder, with some also approved as adjunctive treatment for depression and autism-related irritability. Second-generation antipsychotics are increasingly being prescribed for indications other than those approved by the Food and Drug Administration, such as in dementia, anxiety, and post-traumatic stress disorder to name a few. Obsessive-compulsive and related disorders are a group of disorders characterized by preoccupation and repetitive behaviors. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, obsessive-compulsive disorder, body dysmorphic disorder, trichotillomania, hoarding disorder, and excoriation, the latter two being newly designated disorders, fall under obsessive-compulsive and related disorders. Due to a lack of well designed clinical studies specifically addressing the use of second-generation antipsychotics in obsessive-compulsive and related disorders, it is unknown whether these agents are clinically beneficial. Current research describing the pathophysiology of these disorders shows the involvement of similar brain regions and neurotransmitters across the five obsessive-compulsive and related disorders. Despite differences in the receptor binding profiles, second-generation antipsychotics share many common pharmacodynamics properties. This review sought to examine all the published reports of second-generation antipsychotics being used in the management of symptoms of the aforementioned diseases and compile evidence for clinicians who encounter patients who are unresponsive to standard treatment.

[Hoarding Disorder in DSM-5: Clinical description and cognitive approach].

Hoarding disorder is characterized by difficulty discarding or parting with possessions regardless their actual value as well as, in most cases, persistent acquisition of objects. Possessions are accumulated in large numbers that fill up and clutter active living space to the extent that its intended use is no longer possible resulting to significant functional impairment and/or distress. Saving and difficulty discarding appear to be associated to subjective beliefs about the instrumental, sentimental or intrinsic value of objects. Despite significant impact on the individual, the family and the community, until recently hoarding disorder had been a "neglected" clinical phenomenon. The recent research efforts to study and understand this phenomenon led to significant changes regarding the diagnostic status and therapeutic interventions. It was classified as a distinct diagnostic entity in the recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association-5th ed. (DSM-5). Hoarding is not considered a symptom of obsessive compulsive disorder or obsessive compulsive personality disorder anymore and it is now ranked among compulsive spectrum disorders. So far the cognitive model for hoarding disorder is the main, widely accepted, clinically and empirically supported theoretical framework for understanding its features. The cognitive model offers an explanation about the predisposing, onset and perpetuating factors of the disorder as well as the basis for the development of specific therapeutic interventions. The cognitive model conceptualizes hoarding disorder as a result of four factors: personal vulnerability (heredity, early experiences and life events, personality traits, interpersonal difficulties), difficulties in information processing (deficits in attention, memory, executive functions such as decision making and categorization), maladaptive cognitive content (meaning of possessions, emotional attachment to possessions, dysfunctional beliefs in relation to the mnemonic ability and memory importance) through which hoarding behaviors are reinforced and finally installed (positive and negative reinforcement, association with positive or negative emotions e.g. pleasure in relation to acquisition/saving and anxiety or discomfort in relation to discarding). The purpose of this article is to inform about this new disorder giving emphasis on recent data in regard to its phenomenology and provide a detailed description of the cognitive model. Finally, a brief mention on the psychotherapeutic and pharmacological interventions is presented. Hoarding Disorder is a difficult clinical problem to treat. Poor insight, ego-syntonic nature of symptoms and treatment resistance are often reported in patients. Further improvement of the therapeutic interventions in order to improve effectiveness and target the high rate of treatment drop out is needed.

A systematic review and quality assessment of psychological, pharmacological, and family-based interventions for hoarding disorder.

INTRODUCTION: Hoarding disorder (HD) affects at least 1.5% of the population and is considered to be hard to treat. The current study aimed to systematically review the treatments designed to improve HD symptoms and family impact. METHOD: Searches of PsycINFO, MEDLINE, EMBASE, and Web of Science were undertaken. Studies were included if: (i) the study evaluated an intervention for hoarding problems; (ii) outcome measures were reported; and (iii) study results were published in an indexed journal or were a published abstract from a professional/research conference. The quality of the studies was assessed using the Clinical Trials Assessment Measure (CTAM). RESULTS: Twenty studies, comprising 492 participants with clinically significant hoarding symptoms or HD and 21 relatives of individuals with HD, met inclusion criteria. Treatments reviewed included cognitive-behavior therapy, medication, cognitive remediation, and multi-component interventions for relatives. Most studies yielded statistically significant improvements in hoarding symptoms, although reductions were generally modest and many participants remained in the clinical range after treatment. According to the CTAM, most studies were judged to be of low methodological quality. CONCLUSIONS: HD is a chronic and highly burdensome condition for which efficacious treatments are needed. The current evidence base is somewhat limited and of low quality. Further research is needed to improve treatments, identify mechanisms of change, and increase the availability of evidence-based interventions for this group.

[Treating hoarding disorder in a 12-year-old boy].

In this case report hoarding disorder is described in a 12-year-old boy who suffered from obsessive collection of things. The disorder is a separate diagnostic entity in DSM-5, and it will probably be a separate disorder in ICD-11 called hoarding disorder. The disorder is generally considered difficult to treat, but this case report describes significant reduction in hoarding symptoms on cognitive behavioural therapy and treatment with selective serotonin reuptake inhibitors.

Atomoxetine for hoarding disorder: A pre-clinical and clinical investigation.

Despite several studies suggested that inattention and impulsivity-compulsivity could represent two core dimensions of hoarding disorder (HD), only a small case series study investigated the effectiveness of attention-deficit-hyperactivity-disorder (ADHD) medications in HD. The aim of the present study was to target attentional and inhibitory control networks in HD patients through the ADHD medication atomoxetine, moving from a preclinical investigation on an animal model of compulsive-like behavior (marble burying test) to a clinical investigation on both medicated and unmedicated patients with a primary diagnosis of HD without ADHD. Our preclinical investigation showed that acute administration of atomoxetine significantly reduced the compulsive-like behaviours of mice in the marble burying test without affecting neither locomotor activity and coordination nor exploration behaviours. When compared, atomoxetine and fluoxetine showed similar effects on the marble burying test. However, fluoxetine impaired both locomotor and exploratory activity. In our clinical investigation 12 patients were enrolled and 11 patients completed an open trial with atomoxetine at flexible dose (40-80 mg) for 12 weeks. At the endpoint the mean UCLA Hoarding Severity Scale score decreased by 41.3% for the whole group (p = 0003). Six patients were classified as full responders (mean symptom reduction of 57.2%) and three patients as partial responders (mean symptom reduction of 27.3%). Inattentive and impulsivity symptoms showed a significant mean score reduction of 18.5% from baseline to the endpoint (F (1,9) = 20.9, p = 0.0013). Hoarding symptoms improvement was correlated to reduction of patients' disability and increased in their global functioning. These preclinical and clinical data suggest that atomoxetine may be effective for HD and therefore should be considered for future controlled trials.

Hoarding Symptoms Respond to Treatment for Rapid Cycling Bipolar II Disorder.

Although some studies have reported a relationship between hoarding and bipolar disorder, we are unaware of any previous description of how they may interact with each other and how they should be managed appropriately. A 48-year-old male depressed patient with hoarding symptoms and obsessive-compulsive disorder (OCD) was diagnosed with bipolar II disorder after 2 hypomanic episodes. The patient was treated unsuccessfully with different high-dose serotonin reuptake inhibitors and atypical antipsychotics, maintaining a pattern of 6 to 8 discrete, but severe, depressive episodes each year, always in association with a drastic worsening of his OCD and hoarding symptoms. T.he patient did not improve until the dose of the serotonin reuptake inhibitor was decreased and a combination of lamotrigine and methylphenidate was initiated. On this treatment regimen, the patient did not show clinically significant levels of depression or hoarding or other OCD symptoms. This case suggests that, in some patients, (1) hoarding-related cognitions and behaviors may be a part of bipolar depression, (2) the episodic nature of rapid cycling bipolar II disorder may protect against the development of severe clutter, and (3) treatment focusing on bipolar depression (eg, lamotrigine plus methylphenidate) may result in an improvement of hoarding symptoms when these are present in patients with rapid cycling bipolar II disorder.

A meta-analysis of the response of pathological hoarding to pharmacotherapy.

This meta-analysis aimed to identify all studies that have assessed treatment response for pathological hoarding treated with pharmacological agents. Seven studies were identified with a total of 92 participants. Most participants had a diagnosis of obsessive-compulsive disorder. Studies assessed response to serotonin-reuptake inhibitors (SRIs); venlafaxine; methylphenidate; and augmentation of SRIs with quetiapine, minocycline and naltrexone. More than half (ER=0.58, 95% CI=0.37-0.76) of the participants treated with pharmacotherapy responded. This study encourages us to consider the use of SRIs in patients with hoarding disorder. The study also encourages more studies of pharmacotherapy for pathological hoarding, noting that these studies should use validated outcome measures that specifically assess pathological hoarding and novel agents that target the unique neurobiological correlates of pathological hoarding.

Assessment and treatment of hoarding disorder.

OBJECTIVES: To provide a brief selective review of the current literature regarding Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Hoarding Disorder, with an emphasis on its associated risks, assessment and management approaches. CONCLUSIONS: Hoarding disorder is defined by clear diagnostic criteria. It can be a severe and disabling disorder that can pose significant safety risks to the individual and to others. Management is often challenging, due to the poor level of insight that people with hoarding disorder often have. Psychological approaches tend to adapt cognitive-behavioural approaches, in order to specifically target areas such as impaired decision-making and motivation. Several trials of pharmacological agents have been conducted, but the limitations of these studies call for further research.

Hoarding pet animals in obsessive-compulsive disorder.

BACKGROUND: Although severe hoarding symptoms have been considered rare among obsessive-compulsive disorder (OCD) samples, the prevalence of animal hoarding in OCD is unknown. To help clarifying this issue, we searched for cases of animal hoarding among patients attending a university OCD clinic (n=420). METHODS: Chart review. RESULTS: Only two patients from our sample exhibited animal hoarding (<0.5%) and only one of them presented additional obsessive-compulsive symptoms. Both cases also collected inanimate objects, presented low insight, exhibited poor response to serotonin reuptake inhibitors and did not adhere to therapy. CONCLUSIONS: There seems to be a lack of relationship between animal hoarding and OCD. However, further studies with larger numbers of patients are needed to better define their psychopathological profile and more appropriate nosological insertion.

Venlafaxine extended-release treatment of hoarding disorder.

Hoarding disorder, classified as a separate disorder in Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), is a common, chronic, and potentially disabling syndrome that can be difficult to treat. Only one previous study prospectively measured response to pharmacotherapy in compulsive hoarders, finding that hoarders responded as well to paroxetine as did nonhoarding obsessive-compulsive disorder patients. However, paroxetine was not tolerated well in that study, and the overall response was moderate. Therefore, we conducted an open-label trial of venlafaxine extended-release for hoarding disorder. Twenty-four patients fulfilling the DSM-5 criteria for hoarding disorder were treated with venlafaxine extended-release for 12 weeks. All patients were free of psychotropic medications for at least 6 weeks before the study. No other psychotropic medications, cognitive-behavioral therapy, organizers, or cleaning crews were permitted during the study. To measure the severity of hoarding, the Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were administered before and after treatment. Twenty-three of the 24 patients completed treatment. Hoarding symptoms improved significantly, with a mean 36% decrease in UHSS scores and a mean 32% decrease in SI-R scores. Sixteen of the 23 completers (70%) were classified as responders to venlafaxine extended-release. These results suggest that venlafaxine extended-release may be effective for the treatment of hoarding disorder.

Can hoarding be a symptom of social anxiety disorder? A case study.

BACKGROUND: Hoarding is defined as the excessive collection and failure to discard possessions of apparently little value, leading to clutter, distress, and disability. Although patients with hoarding typically may feel ludicrous for not discarding useless, and sometimes bizarre, possessions, we are not aware of any previous description of patients displaying hoarding as a result of social anxiety. METHOD: Single case report. RESULTS: In this article, we describe a patient with severe social anxiety disorder who displayed hoarding as a direct consequence of social anxiety-related beliefs and atypical safety behaviors. CONCLUSIONS: This case is of particular interest to current debates concerning the status of hoarding in new versions of classificatory systems. It also indicates that social anxiety disorder should be included in the list of conditions that needs to be excluded in order to diagnose "primary" hoarding disorder.