Clinical features of obsessive-compulsive disorder with hoarding symptoms: A multicenter study

Journal of Psychiatric Research 46 (2012) 724e732

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Clinical features of obsessive-compulsive disorder with hoarding symptoms: A multicenter study Albina R. Torres a, *, Leonardo F. Fontenelle b, Ygor A. Ferrão c, Maria Conceição do Rosário d, Ricardo C. Torresan a, Eurípedes C. Miguel e, Roseli G. Shavitt e a

Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, Univ Estadual Paulista, Botucatu (SP), Brazil Anxiety and Depression Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro (RJ), Brazil Federal University of Health Sciences of Porto Alegre, Porto Alegre (RS), Brazil d Department of Psychiatry and Psychology, Federal University of São Paulo, São Paulo (SP), Brazil e Department of Psychiatry, University of São Paulo Medical School, São Paulo (SP), Brazil b c

a r t i c l e i n f o

a b s t r a c t

Article history: Received 8 July 2011 Received in revised form 2 February 2012 Accepted 5 March 2012

Background: Factor analyses indicate that hoarding symptoms constitute a distinctive dimension of obsessive-compulsive disorder (OCD), usually associated with higher severity and limited insight. The aim was to compare demographic and clinical features of OCD patients with and without hoarding symptoms. Method: A cross sectional study was conducted with 1001 DSM-IV OCD patients from the Brazilian Research Consortium of Obsessive-Compulsive Spectrum Disorders (CTOC), using several instruments. The presence and severity of hoarding symptoms were determined using the Dimensional Yale-Brown Obsessive-Compulsive Scale. Statistical univariate analyses comparing factors possibly associated with hoarding symptoms were conducted, followed by logistic regression to adjust the results for possible confounders. Results: Approximately half of the sample (52.7%, n ¼ 528) presented hoarding symptoms, but only four patients presented solely the hoarding dimension. Hoarding was the least severe dimension in the total sample (mean score: 3.89). The most common lifetime hoarding symptom was the obsessive thought of needing to collect and keep things for the future (44.0%, n ¼ 440). After logistic regression, the following variables remained independently associated with hoarding symptoms: being older, living alone, earlier age of symptoms onset, insidious onset of obsessions, higher anxiety scores, poorer insight and higher frequency of the symmetry-ordering symptom dimension. Concerning comorbidities, major depressive, posttraumatic stress and attention deficit/hyperactivity disorders, compulsive buying and tic disorders remained associated with the hoarding dimension. Conclusion: OCD hoarding patients are more likely to present certain clinical features, but further studies are needed to determine whether OCD patients with hoarding symptoms constitute an etiologically discrete subgroup. Ó 2012 Elsevier Ltd. All rights reserved.

Keywords: Obsessive-compulsive disorder Hoarding Hoarding dimension Hoarding symptoms Clinical features OCD subtypes

1. Introduction Hoarding is defined as the acquisition of and failure to discard possessions of little use or value to others, usually associated with an important degree of clutter in the living area of the individual’s

* Corresponding author. Departamento de Neurologia, Psicologia e Psiquiatria, Faculdade de Medicina de Botucatu (FMB), UNESP, Distrito de Rubião Jr., Botucatu, SP 18.618-970, Brazil. Tel.: þ55 14 38116260, þ55 14 38116089; fax: þ55 14 38155965. E-mail addresses: [email protected], [email protected] (A.R. Torres). 0022-3956/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.jpsychires.2012.03.005

home (Frost and Gross, 1993). This complex and heterogeneous phenomenon has already been described in a number of neuropsychiatry conditions (Damecour and Charron, 1998; Samuels et al., 2002; Maier, 2004; Grishan et al., 2005; Saxena, 2008; Abramowitz et al., 2008; Pertusa et al., 2010a), including obsessive-compulsive disorder (OCD). Factor analyses of obsessive-compulsive symptoms (OCS) have consistently shown that hoarding characterizes a separate factor or dimension (Bloch et al., 2008). The prevalence of saving or hoarding obsessions and compulsions in OCD patients ranges from 8.6% (Li et al., 2009) to 40% (Lochner et al., 2005) but, among those with hoarding symptoms, only a minority (5%e15%) presents this dimension as the most prominent clinical

A.R. Torres et al. / Journal of Psychiatric Research 46 (2012) 724e732

manifestation (Steketee and Frost, 2003; Saxena, 2007; Pertusa et al., 2010a). The hoarding dimension in OCD has been associated with a range of demographic and clinical characteristics, such as: male sex (Samuels et al., 2002; Iervolino et al., 2009; Matsunaga et al., 2010a), lower rate of marriage (Samuels et al., 2002; Matsunaga et al., 2010a), lower socioeconomic (Samuels et al., 2002, 2008; Wheaton et al., 2008) and educational (Matsunaga et al., 2010b) levels, higher mean age (Frost et al., 2000; Saxena et al., 2002, 2011; Steketee and Frost, 2003; Grisham et al., 2005), earlier age at symptoms onset (Samuels et al., 2002; Saxena et al., 2002; Steketee and Frost, 2003; Fontenelle et al., 2004; Millet et al., 2004; Matsunaga et al., 2010b), insidious type of onset (Samuels et al., 2007), higher number (Samuels et al., 2002) and severity of OCS (Frost and Hartl, 1996; Samuels et al., 2002; Wheaton et al., 2008; Matsunaga et al., 2010b), more severe anxiety (Frost et al., 2000; Saxena et al., 2002; Storch et al., 2007) and depressive symptoms (Frost et al., 2000; Grisham et al., 2005; Wheaton et al., 2008); greater occupational and social impairment (Frost et al., 2000; Saxena et al., 2002; Wheaton et al., 2008; Matsunaga et al., 2010b; Fontenelle et al., 2010), higher frequency of symmetry-ordering symptoms (Fontenelle et al., 2004; Storch et al., 2007; Samuels et al., 2007; Pertusa et al., 2008; Wheaton et al., 2008; Matsunaga et al., 2010b), more history of exposure to traumatic events (Hartl et al., 2005; Cromer et al., 2007; Samuels et al., 2008) and poorer insight (Greenberg, 1987; Frost and Harlt, 1996; Grisham et al., 2005; Storch et al., 2007; Matsunaga et al., 2010a; Murphy et al., 2010). Regarding comorbidity, OCD patients with hoarding symptoms usually present higher number of co-occurring psychiatric disorders (LaSalle-Ricci et al., 2006; Wheaton et al., 2008), particularly social phobia (Samuels et al., 2002, 2007), attention deficit/hyperactivity disorder (ADHD) (Greenberg et al., 1990; Moll et al., 2000; Hartl et al., 2005; Sheppard et al., 2010), eating disorders (Fontenelle et al., 2004), bipolar II disorder (Samuels et al., 2002; Fontenelle et al., 2004), major depression (Winsberg et al., 1999; Samuels et al., 2002) and impulse control disorders (Winsberg et al., 1999; Grisham et al., 2005; Mataix-Cols et al., 2010). Moreover, worse response to treatment has been reported in OCD patients with hoarding symptoms in several studies (Winsberg et al., 1999; Mataix-Cols et al., 2002; Saxena et al., 2002; Abramowitz et al., 2008; Matsunaga et al., 2010b). Finally, specific findings of neuroimaging (Mataix-Cols et al., 2004) and genetic studies (Samuels et al., 2007) have suggested that OCD with hoarding is an etiologically distinct condition. Taken together, these results support the notion that hoarding manifestations might characterize a particularly severe type of OCD or, alternatively, an independent condition called Hoarding Disorder (HD) (Mataix-Cols et al., 2010; Pertusa et al., 2010a). In fact, if one examines the phenomenology of OCD and certain hoarding cases closer, a number of differences emerge. For instance, hoarding-related thoughts may not be experienced as intrusive, repetitive and distressing as OCD obsessions; they frequently result in feelings of grief and anger rather than anxiety (Mataix-Cols et al., 2010). Further, some hoarding-related behaviors are associated with pleasure and reward, and they are frequently unrelated to other prototypical OCD themes (Mataix-Cols et al., 2010). Moreover, unlike OCD, which typically shows a chronic waxing and waning course, hoarding worsens over each decade of life (Mataix-Cols et al., 2010). Accordingly, it has been suggested that hoarding and OCD might co-exist in the same patient and yet be completely independent conditions (Mataix-Cols et al., 2010; Pertusa et al., 2010a). To date, however, only a few studies with relatively small samples have been conducted comparing OCD patients with or

725

without hoarding manifestations (Murphy et al., 2010). The aim of the current study was to compare demographic and clinical characteristics of OCD patients with and without hoarding symptoms from a large clinical sample using a comprehensive assessment package. Differently from previous studies, we used a dimensional instrument that groups together obsessions and compulsions of related content, permitting an evaluation of the severity of each symptom dimension. Additionally, it has seven questions concerning hoarding symptoms, allowing for a more comprehensive assessment of this dimension. We also investigated certain clinical aspects not yet explored in the literature, such as sensory phenomena (due to the previous association of hoarding with tics and symmetry-ordering symptoms) and suicidality (due to the association of hoarding with major depression and posttraumatic stress disorder). Moreover, this large study evaluated relationships adjusted for potential confounders, identifying independent predictors of the expression of hoarding symptoms in OCD. 2. Method 2.1. Subjects The sample was composed of 1001 consecutive OCD patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (CTOC). Participants were recruited from seven Brazilian universities and interviewed between August 2003 and August 2009. OCD diagnosis was determined according to the DSM-IV criteria (APA, 1994) and confirmed using the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Patients with psychotic and organic disorders or any other condition that would impair their understanding of the protocol questions were excluded. Almost all participants were receiving psychotherapy and/or pharmacological treatment, mostly with selective serotonin reuptake inhibitors or clomipramine. All patients were interviewed by trained psychologists or psychiatrists. A complete description of the CTOC implementation and methods was previously published, including the training process, inter-site diagnostic comparability and inter-rater reliability aspects (Miguel et al., 2008). 2.2. Assessment instruments The main instruments of assessment used in the present study were the following: (1) Dimensional Yale-Brown Obsessive-Compulsive Scale (DYBOCS; Rosario-Campos et al., 2006), to evaluate the presence and severity of OCD symptom dimensions. This scale has 88items divided into six dimensions (harm-aggression, sexualreligious, contamination-cleaning, symmetry-orderingcounting, hoarding and miscellaneous). The clinical severity of each dimension (both current and past or worst phase) is evaluated in terms of frequency, distress and interference, with a maximum score of 15, five for each aspect. It also provides an assessment of overall severity of OCD, which ranges from 0 to 15 for symptoms and 0 to 15 for the impairment caused by these symptoms, with a total global score ranging from 0 to 30. Lifetime presence of hoarding obsessions or compulsions was obtained with the DY-BOCS checklist, which includes seven items (described in the first paragraph of the Results section). Although the scale has a brief definition of obsessions and compulsions in the beginning, it focuses on the description of a wide range of possible OCD symptoms, including hoarding manifestations in the 5th section. As the DY-BOCS groups together obsessions and compulsions of related content, even if some patients do not present obsessive thoughts preceding

726

(2)

(3)

(4)

(5)

(6)

A.R. Torres et al. / Journal of Psychiatric Research 46 (2012) 724e732

their hoarding behaviors, the scale is able to identify these symptoms; Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989), to evaluate the severity of obsessions and compulsions; The Structured Clinical Interview for Diagnosis of Axis I according to DSM-IV (SCID-I; First et al., 1995), to evaluate axis I comorbid conditions and to confirm OCD diagnosis; Sensory Phenomena Scale (USPeSPS; Rosario et al., 2009), to evaluate the presence and severity of sensory phenomena preceding or accompanying the compulsions. Sensory phenomena include bodily sensations (usually tactile or muscular-skeletal/visceral) and mental sensations (urges, “energy” that needs to be released, feelings of incompleteness, and "not just right" perceptions). The total score e both current and past-ranges from 0 to 15, with higher scores indicating more severe sensory phenomena; The Beck Depression (BDI) and Anxiety Inventories (BAI), to evaluate depression and anxiety symptoms severity (Beck et al., 1961, 1988). The Brown Assessment of Beliefs Scale (BABS; Eisen et al., 1998), to evaluate the patients’ level of insight regarding OCD symptoms. It has 6 items, each ranging from 0 to 4, the maximum score is 24 and a higher score indicates poorer insight. The instrument also includes a final evaluation of the clinical impression with five categories of insight: excellent, good, moderate, poor and absent, which were dichotomized for the categorical analysis (excellent, good or moderate, and poor or absent).

Traumatic life events were assessed using the SCID-I traumatic stress module. Data on family history was indirectly obtained with the patients using a questionnaire developed by the CTOC, which includes the SCID-I screening questions. Suicidality was investigated with the following “yes or no” questions: Have you ever 1) thought life was not worth living?; 2) wished to be dead?; 3) thought about killing yourself?; 4) made suicidal plans?; 5) attempted suicide?; and 6) do you have current suicidal thoughts? 2.3. Ethical aspects The Research Ethics Committee of Botucatu Medical School (UNESP) approved this research protocol in March 2nd, 2009 (Doc. number 55/09-CEP), after the concordance of the CTOC local leaders of the University Hospitals involved. All subjects signed a written informed consent confirming participation following the assurance that, in case they decided not to participate in the study, this would not interfere with the continuity of their treatment. 2.4. Statistical analysis All analyses were conducted using the STATA 10.0 software (Stata Corporation, 2007). Continuous data were described as mean and standard deviation (SD) and categorical data as absolute (n) and relative values (%). Following the initial descriptive analysis, univariate analyses were performed to compare participants with and without the outcome of interest (lifetime occurrence of hoarding symptoms) with respect to several demographic and clinical characteristics. The Pearson Chi square test was used for the explanatory categorical variables and the Student t test or the ManneWhitney test, as appropriate, for continuous variables. Finally, backward logistic regression analyses (stepwise method, excluding each variable presenting the least significant association) were conducted, to adjust demographic and clinical variables (model 1) and comorbidity findings (model 2), for possible

confounders (Hosmer and Lemeshow, 2000). All variables with a p value < 0.10 in the univariate analysis, except those presenting clinical collinearity with others (e.g. partial and global Y-BOCS scores, mood disorders and major depression) were included in the regression models (detailed information is presented in Table 5). In both models, the mean Variance Inflation Factor (VIF) was also calculated, to determine the presence of multicollinearity, which is usually indicated by values exceeding 10. Crude and adjusted odds ratios (OR) with 95% confidence intervals were also calculated for the presence of other symptom dimensions in patients with hoarding symptoms. A standard p value < 0.05 was adopted to reject the null hypothesis. 3. Results More than half of the sample (52.7%, N ¼ 528) presented hoarding symptoms. Only four patients presented solely with these symptoms, making it impossible to perform any further analyses of this particular subgroup. Hoarding scores were higher than the scores of the other dimensions in 3.7% of the subjects. The most common lifetime hoarding symptom was the obsessive thought of needing to collect and keep things for the future (N ¼ 440, 44.0%), followed by fear of throwing away things for sentimental reasons or just due to an incontrollable urge to collect (N ¼ 405, 40.5%), indecisiveness about which things should be kept or discarded (N ¼ 392, 39.2%), collecting compulsions including the need to pick up objects in the streets or trashcans (N ¼ 372, 37.2%), obsessions about losing things, even if insignificant (N ¼ 266, 26.6%), avoidant behaviors to prevent hoarding rituals (N ¼ 88, 8.8%) and mental rituals related to hoarding preoccupations (N ¼ 83, 8.3%). Among hoarding patients, the mean score for current hoarding symptoms (range from 0 to 15) was 5.98 (SD: 3.83), and for the worst phase was 7.37 (SD: 3.80). In the total sample, hoarding was the least severe dimension, with a mean past score of 3.89 (SD: 4.60; median: 2), compared to 5.68 (SD: 5.65; median: 5) of the sexualreligious, 6.73 (SD: 5.56; median: 8) of the aggressive, 7.62 (SD: 5.49; median: 9) of the contamination-cleaning and 8.76 (SD: 4.75; median: 10) of the symmetry-ordering dimension. The sociodemographic characteristics of the two study groups are presented in Table 1. The hoarding group had a greater prevalence of females, and was older. The severity of both present and past hoarding symptoms, including time spent, distress and interference due to symptoms, was also higher among females (data not shown). Hoarding patients were significantly more likely than nonhoarding patients to be living alone. No other significant demographic differences were identified. Table 2 presents the main clinical features of the sample. Patients with hoarding symptoms presented significantly earlier mean age at OC symptoms onset, and higher mean age at first treatment and at OCD diagnosis. They also presented higher severity of obsessive-compulsive (according to both Y-BOCS and DY-BOCS scores), depressive and anxious symptoms (Beck inventories scores). According to the DY-BOCS, scores regarding time spent with symptoms, distress and interference, as well as those of all other symptom dimensions were higher in the study group (data not shown). Sensory phenomena were also more frequent and more severe among hoarding patients (USPeSPS scores). The Clinical Global Impression also indicated a higher proportion of severe cases among hoarding patients, which also presented higher mean scores in the BABS (i.e, poorer insight). Moreover, they reported more exposure to traumatic life events, more family history of OCS and higher frequency of almost all the suicidal aspects investigated. The crude and adjusted odds ratios for the occurrence of other symptom dimensions in patients with hoarding symptoms are

Table 1 Sociodemographic characteristics exhibited by patients with (OCD þ H) and without (OCD  H) hoarding symptoms.

Age (years) mean (SD)a Sex (female) Marital status Single Married or cohabiting Has child(ren) Lives alone Years of education-mean (SD)a Occupational status Unemployed Working Religion (non catholic) Religious practice (yes)b Ethnicity (non Caucasian) Social classc A/B (higher) C/D/E (lower)

Total n ¼ 1001

OCD þ H n ¼ 528 (52.7%)

OCD  H n ¼ 473 (47.3%)

p value

34.8 (13.0) 569 (56.8%)

35.9 (13.2) 321 (60.8%)

33.7 (12.7) 248 (52.4%)

0.009 0.008

544 377 390 73 14.6

(54.3%) (37.7%) (39.0%) (7.3%) (5.0)

288 190 201 48 14.7

(54.5%) (36.0%) (38.1%) (9.1%) (4.8)

256 187 189 25 14.4

(54.1%) (39.5%) (40.0%) (5.3%) (5.2)

0.89 0.25 0.54 0.02 0.25

154 497 416 547 169

(15.4%) (49.8%) (41.6%) (54.6%) (16.9%)

87 262 221 294 88

(16.5%) (49.7%) (41.8%) (55.7%) (16.7%)

67 235 195 253 81

(14.2%) (49.9%) (41.2%) (53.5%) (17.1%)

0.31 0.95 0.84 0.49 0.85

274 (57.9%) 199 (42.1%)

0.12

554 (55.3%) 447 (44.7%)

280 (53.0%) 248 (47.0%)

Bold values represent the statistically significant results. a Standard deviation, OCD þ H ¼ obsessive-compulsive disorder plus hoarding symptoms group, OCD  H ¼ obsessive-compulsive disorder without hoarding symptoms group, n ¼ sample size, p-value ¼ statistical significance. b When the patient acknowledged having any kind of regular religious practice. c Based on the Brazilian Association of Institutes of Market Research (ABIPEME) socioeconomic criteria.

Table 2 Clinical features exhibited by patients with (OCD þ H) and without (OCD  H) hoarding symptoms.

Clinical course Age at OCS onset e years, mean (SD)a Age at onset obsessions e years, mean (SD)a Age at onset compulsions e years, mean (SD)a Age at symptoms interference,b mean (SD)a Age at first treatment years, mean (SD)a Age at OCD diagnosis, mean (SD) Type of symptoms onset (abrupt: in 1 week) Obsessions Compulsions Clinical severity Y-BOCS e total score, mean (SD)a Y-BOCS e obsessions score, mean (SD)a Y-BOCS e compulsions score, mean (SD)a DY-BOCS e current total score, mean (SD)a DY-BOCS e past total score, mean (SD)a BDI e total score, mean (SD)a BAI e total score, mean (SD)a Sensory phenomena Presencec Current total score, mean (SD)a Worst phase total score, mean (SD)a OCD clinical global impression Borderline or mild severity Moderate severity Severe to extremely severe BABS total score, mean (SD)a Level of insight (poor or absent) Family history of OCS History of traumatic experiences “Suicidality”d Already thought life was not worth living Already wished to be dead Already had suicidal thoughts Already planned how to kill him(her)self Already attempted suicide Current suicidal thoughts

Total n ¼ 1001

OCD þ H n ¼ 528 (52.7%)

OCD  H n ¼ 473 (47.3%)

p value

12.6 13.2 13.0 21.8 29.4 31.0

11.3 12.1 11.7 21.6 30.6 32.1

14.1 14.4 14.5 22.0 28.1 29.6

<0.001e <0.001e <0.001e 0.54e 0.03e 0.002e

(7.3) (8.0) (7.7) (10.6) (12.9) (12.8)

198 (19.8%) 197 (19.7%) 25.5 12.7 12.8 21.1 23.6 16.4 15.9

(7.5) (3.9) (4.1) (6.3) (5.1) (11.2) (11.3)

(6.3) (7.4) (7.0) (10.9) (13.7) (13.3)

82 (15.5%) 85 (16.1%) 26.5 13.2 13.3 21.9 24.3 17.5 17.3

(7.1) (3.6) (3.9) (5.9) (4.8) (11.0) (11.4)

(8.0) (8.4) (8.1) (10.3) (11.9) (12.0)

116 (24.5%) 112 (23.7%) 24.4 12.1 12.3 20.2 22.9 15.2 14.4

(7.8) (4.2) (4.3) (6.5) (5.2) (11.3) (11.1)

0.001 0.003 <0.001e <0.001e <0.001e <0.001f <0.001f 0.001e <0.001e

615 (65.6%) 4.88 (4.62) 5.29 (5.02)

355 (70.3%) 5.21 (4.52) 5.78 (4.96)

260 (60.0%) 4.51 (4.72) 4.71 (5.01)

141 336 524 6.8 118 503 677

(14.1%) (33.6%) (52.3%) (5.5) (11.8%) (50.3%) (67.6%)

62 161 305 7.6 66 285 379

(11.7%) (30.5%) (57.8%) (5.5) (12.5%) (54.1%) (71.8%)

79 175 219 6.0 52 218 298

(16.7%) (37.0%) (46.3%) (5.3) (11.0%) (46.1%) (63.0%)

0.001f 0.46 0.012 0.003

569 438 348 199 104 104

(59.3%) (45.7%) (36.3%) (20.7%) (10.8%) (10.8%)

322 256 199 121 65 63

(60.0%) (50.1%) (38.9%) (23.7%) (12.7%) (12.3%)

247 182 149 78 39 41

(55.1%) (40.6%) (33.3%) (17.4%) (8.7%) (9.1%)

0.013 0.003 0.07 0.017 0.046 0.11

Bold values represent the statistically significant results. a Standard deviation. b Age when symptoms started to interfere on the patient’s functioning. c 63 missing values. d 42 missing values. e Student t test. f ManneWhitney test.

0.001 0.008f <0.001f 0.001

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A.R. Torres et al. / Journal of Psychiatric Research 46 (2012) 724e732

Table 3 Odds ratios (OR) and 95% confidence intervals (95% CI) of the occurrence of other symptom dimensions (according to the DY-BOCS) in OCD patients with hoarding symptoms.

Aggression Sexual-religious Contamination-cleaning Symmetry-ordering Miscellaneous

Crude OR (95% CI)

z

p value

Adjusteda OR (95% CI)

z

p value

2.31 1.91 2.17 3.19 1.81

6.08 5.00 5.30 5.69 3.10

<0.001 <0.001 <0.001 <0.001 0.002

1.80 1.53 1.78 2.68 1.07

3.79 2.89 3.68 4.57 0.32

0.001 0.004 <0.001 0.001 0.75

(1.76e3.02) (1.48e2.46) (1.63e2.90) (2.14e4.76) (1.25e2.65)

(1.33e2.44) (1.15e2.03) (1.31e2.42) (1.76e4.10) (0.70e1.63)

Bold values represent the statistically significant results. a Adjusted for sex, age and the presence of all other dimensions.

presented in Table 3. Except for the miscellaneous dimension, all other dimensions were more likely to occur among hoarding patients, even after adjusting for sex, age and for the effect of each on the other. The independent association, however, was strongest for the symmetry-ordering dimension, followed by the aggressive, contamination-cleaning and sexual-religious dimensions (Table 3). Psychiatric comorbidity findings are presented in Table 4. The following axis I conditions were more frequent among the study group: major depressive disorder (MDD), specific phobia, posttraumatic stress disorder (PTSD), compulsive buying, skin picking, kleptomania, impulsive-compulsive internet use and ADHD. Hoarding patients were more likely than non-hoarding patients to present mood, impulse control and tic disorders in general. No significant differences were identified between the two groups

regarding the prevalence of anxiety, somatoform, eating and substance use disorders, as well as comorbidity in general (Table 4). Table 5 shows the final results of the two logistic regression models conducted, one including demographic and clinical variables and the other all the comorbid disorders that presented a p value < 0.10 in the univariate analysis. In the first model, the following variables remained positively associated with the outcome (mean VIF ¼ 5.22): being older, living alone, higher severity of anxiety symptoms, poorer insight and higher frequency of the symmetry-ordering dimension. Age at symptoms onset and abrupt onset of obsessions (up to 7 days) were negatively associated with the hoarding dimension. Regarding comorbid conditions, major depressive disorder, PTSD, compulsive buying, ADHD and tic disorders remained associated with hoarding symptoms (mean VIF ¼ 1.36).

Table 4 Lifetime comorbid conditions exhibited by patients with (OCD þ H) and without (OCD  H) hoarding symptoms.

4. Discussion

Any comorbid condition Any mood disorder Major depression Dysthymia Bipolar I disorder Bipolar II disorder Any anxiety disorder Generalized anxiety disorder Social phobia Specific phobia Panic disorder/agoraphobia Posttraumatic stress disorder Any impulse control disorder Compulsive buying Skin picking Trichotillomania Kleptomania Intermittent explosive disorder Impulsive-compulsive Internet use Any somatoform disorder Hypochondriasis Body dysmorphic disorder Any eating disorder Anorexia nervosa Bulimia nervosa Binge eating disorder Separation anxiety disorder Alcohol use disorders Drug abuse or dependence ADHDa Any tic disorder Tourette syndrome

Total sample OCD þ H (n ¼ 1001) n ¼ 528 (52.7%)

OCD  H n ¼ 473 (47.3%)

881 609 565 119 38 44 699 343

(88.0%) (60.8%) (56.4%) (11.9%) (3.8%) (4.4%) (69.8%) (34.3%)

469 356 329 70 25 25 382 181

(88.8%) (67.4%) (62.3%) (13.3%) (4.7%) (4.7%) (72.3%) (34.3%)

412 253 236 49 13 19 317 162

(87.1%) 0.40 (53.5%) <0.001 (49.9%) <0.001 (10.4%) 0.16 (2.7%) 0.10 (4.0%) 0.58 (67.0%) 0.07 (34.2%) 0.99

To date, this is the largest study comparing OCD patients with and without hoarding symptoms regarding several demographic and clinical variables. It also contributes to the literature for having used an instrument that addresses the OCD symptom dimensions in a direct manner, with detailed assessment of specific hoarding manifestations. Moreover, a range of other clinical correlates was thoroughly investigated with structured instruments administered by experienced professionals, including the SCID-I for comorbid disorders and the USPeSPS to evaluate subjective experiences associated to repetitive behaviors.

346 314 202 191

(34.6%) (31.4%) (20.2%) (19.1%)

197 186 110 124

(37.1%) 149 (31.5%) 0.054 (35.2%) 128 (27.1%) 0.005 (20.8%) 92 (19.4%) 0.59 (23.5%) 67 (14.2%) <0.001

Table 5 Variables that remained independently associated with hoarding symptoms in the logistic regression.

362 108 167 60 28 75

(36.2%) (10.8%) (16.7%) (6.0%) (2.8%) (7.5%)

215 75 106 37 20 46

(40.7%) 147 (31.1%) 0.002 (14.2%) 33 (7.0%) <0.001 (20.1%) 61 (12.9%) 0.002 (7.0%) 23 (4.9%) 0.15 (3.8%) 8 (1.7%) 0.045 (8.7%) 29 (6.1%) 0.12

30 (3.0%) 175 34 117 114 26 27 80 276 79 35 137 284 88

(17.5%) (3.4%) (11.7%) (11.4%) (2.6%) (2.7%) (8.0%) (27.6%) (7.9%) (3.5%) (13.7%) (28.4%) (8.8%)

23 (4.4%) 96 16 68 64 15 15 46 158 42 21 94 174 47

7 (1.5%)

p value

0.008

(18.2%) 79 (16.7%) 0.54 (3.0%) 18 (3.8%) 0.50 (13.9%) 49 (10.4%) 0.21 (12.1%) 50 (10.6%) 0.44 (2.8%) 11 (2.3%) 0.61 (2.8%) 12 (2.5%) 0.77 (8.7%) 34 (7.2%) 0.37 (29.9%) 118 (24.9%) 0.08 (7.9%) 37 (7.8%) 0.94 (4.0%) 14 (3.0%) 0.38 (17.8%) 43 (9.1%) <0.001 (32.9%) 110 (23.3%) 0.001 (8.9%) 41 (8.7%) 0.90

Bold values represent the statistically significant results. a Attention deficit/hyperactivity disorder.

Demographic and clinical variables

Adjusteda OR (95% CI)

z

p value

Age Lives alone Age at OCS onset Abrupt onset of obsessions Anxiety symptoms severity (BAI inventory) Level of insight (BABS score) Symmetry-ordering dimension

1.02 1.79 0.95 0.61 1.02

(1.01e1.03) (1.03e3.13) (0.93e0.97) (0.43e0.86) (1.01e1.03)

2.84 2.05 4.75 2.85 3.08

0.004 0.04 <0.001 0.004 0.002

1.05 (1.02e1.07) 2.36 (1.52e3.67)

3.47 3.88

0.001 <0.001

Lifetime comorbid axis I disorders

Adjustedb OR (95% CI)

Major depressive disorder Posttraumatic stress disorder Compulsive buying Attention deficit/hyperactivity disorder Tic disorder

1.52 1.50 1.98 1.99

(1.17e1.97) (1.07e2.11) (1.27e3.08) (1.34e2.95)

3.17 2.34 3.02 3.43

0.002 0.019 0.003 0.001

1.54 (1.15e2.05)

2.94

0.003

Bold values represent the statistically significant results. a Also adjusted for sex, abrupt onset of compulsions, total Y-BOCS score, depressive symptoms severity, sensory phenomena, family history of OCS, traumatic life events and suicidal plans (Mean VIF ¼ Variance Inflation Factor: 5.22). b Also adjusted for: social phobia, specific phobia, skin picking, kleptomania, impulsive-compulsive internet use and separation anxiety disorder. (Mean VIF ¼ Variance Inflation Factor: 1.36).

A.R. Torres et al. / Journal of Psychiatric Research 46 (2012) 724e732

Although intended to shed some more light on the hoarding phenomenon from a perspective of a treatment seeking OCD population, it is important to acknowledge that the current study was not designed to differentiate the types of hoarding and the study group may have included some HD cases. However, we have several reasons to believe that they probably represent a small minority of the participants. First, studies suggest that HD is underrepresented in treatment seeking OCD samples (Mataix-Cols et al., 2010). Accordingly, only 0.4% of our sample exhibited hoarding as the only clinical manifestation. In addition, hoarding scores were lower than the scores of all the other dimensions in 96.3% of the subjects, corroborating a previous report that the severity of hoarding symptoms is usually milder in hoarding secondary to OCD as compared to HD (Matsunaga et al., 2010b). The lifetime prevalence of hoarding symptoms in this sample (52.7%) was higher than that described in previous studies with OCD clinical samples, which varied from 8.6% to 40% (Saxena et al., 2002, 2011; Samuels et al., 2002; Fontenelle et al., 2004; Lochner et al., 2005; Cromer et al., 2007; Labad et al., 2008; Storch et al., 2007; Wheaton et al., 2008; Li et al., 2009; Matsunaga et al., 2010a, 2010b). This finding may be due to the fact that hoarding symptoms were investigated with a direct dimensional interview, which includes seven items evaluating hoarding obsessions or compulsions. Previous studies have used the Y-BOCS checklist, which contains only two questions concerning these symptoms. Self-report measures in some studies may also have underestimated the prevalence, due to embarrassment or lack of insight (Wheaton et al., 2008). Nonetheless, compared to the other symptom dimensions, the average severity of hoarding symptoms (3.89) was quite low, and it was the most severe dimension in less than 4% of the subjects. These findings support the assumption that many people with OCD display hoarding symptoms, but hoarding is a severe problem for only a minority of them (Pertusa et al., 2010a). In contrast, for patients with HD, there is usually a high degree of impairment and burden associated with these symptoms. Therefore, it would be crucial for both the OCD and the hoarding literature to check whether DY-BOCS hoarding symptoms differ quantitatively and qualitatively between healthy individuals from the general population, OCD patients with hoarding and patients with HD. Although it has been suggested that self-reported hoarders exhibit the same hoarding-related cognitions as normal individuals (Pertusa et al., 2008), the case for OCD hoarding patients remains unclear. 4.1. Univariate analyses The hoarding group presented an earlier age at onset of both obsessions and compulsions, as previously described (Samuels et al., 2002; Fontenelle et al., 2004; Millet et al., 2004; Matsunaga et al., 2010a), but were older when first treated and when diagnosed with OCD. Earlier onset and later treatment seeking were also reported by other authors (Saxena et al., 2002; Steketee and Frost, 2003) and may be related to the insidious onset, to poor insight or to higher symptom severity. In agreement with other studies, clinical severity was higher among hoarding patients, including obsessive-compulsive, depressive and anxious symptoms (Frost et al., 1995, 2000; Samuels et al., 2002; Saxena et al., 2002; Grisham et al., 2005; Storch et al., 2007; Wheaton et al., 2008; Matsunaga et al., 2010b). An interesting and innovative finding was the higher frequency and severity of sensory phenomena among OCD hoarding individuals. Baer (1994) suggested that these patients suffered with an inner sense of imperfection or that their actions were never satisfactorily achieved. Pertusa et al. (2010b) reported that among ten OCD cases

729

with prominent hoarding symptoms, half presented “not just right” and “incompleteness” feelings motivating their behaviors. Urges to pick up things with a certain shape or texture from the streets or to buy certain objects in order to feel “just right” were described by Pertusa et al. (2008). Of note, sensory phenomena have also been previously associated with tic disorders (Prado et al., 2008). Hoarding patients also more frequently reported exposure to traumatic experiences (Hartl et al., 2005; Cromer et al., 2007; Samuels et al., 2008; Saxena et al., 2011; Landau et al., 2011). In a community study (Samuels et al., 2008), certain childhood adversities (e.g. excessive physical discipline, a parent with heavy alcohol use or other psychiatric problems) were associated with hoarding behaviors. Crime victimization was more often reported by compulsive hoarders than non-hoarders by Saxena et al. (2011), while Cromer et al. (2007) found that OCD hoarding patients not only reported more stressful life events, but that the number of these events was related to hoarding severity. Family history of OCS was more frequently reported by hoarding patients. In fact, several authors have demonstrated a stronger familiality (Hasler et al., 2007; Saxena, 2008; Taberner et al., 2009) and a differential pattern of transmission (Leckman et al., 2003) of hoarding, compared to other OCD symptom dimensions. Suicidal thoughts, plans and attempts were also more frequent among hoarding patients, may be due to the higher global severity or to the higher frequency of major depressive disorder (MDD) and PTSD (Marshall et al., 2001). A previous CTOC study (Torres et al., 2011) identified an independent association between the hoarding dimension and suicide plans. Even after adjustment for sex and age, hoarding symptoms remained associated with all other dimensions. This finding supports the notion that, when occurring in the context of OCD, hoarding manifestations are not isolated, but related to all other symptoms of this heterogeneous condition (Wheaton et al., 2008). Nevertheless, the strongest association occurred with symptoms of the symmetry-ordering-counting dimension, consistent with findings of several studies (Fontenelle et al., 2004; Storch et al., 2007; Samuels et al., 2007; Hasler et al., 2007; Pertusa et al., 2008; Wheaton et al., 2008; Matsunaga et al., 2010b). In fact, in the first OCD factor analysis conducted by Baer (1994), one of them included symmetry and hoarding symptoms. Fontenelle et al. (2004) speculated that this association may reflect either a common neuroanatomical basis or secondary behaviors; e.g. the need to count and organize collected objects according to specific rules. Excessive need to maintain control over possessions and extreme distress when other people touch or move them without permission is an overlapping feature of both ordering and hoarding (Steketee and Frost, 2003; Mataix-Cols et al., 2010). Regarding comorbidities, hoarding behaviors have been considered particularly linked to impulse control disorders (Maier, 2004; Grisham et al., 2005; Mataix-Cols et al., 2010; Winsberg et al., 1999), because they usually involve a sense of gratification or reward (Frost et al., 1995; Hartl et al., 2005). This is a controversial issue, as other authors (Pertusa et al., 2010a; Mataix-Cols et al., 2010) postulate that only when hoarding manifestations are independent from OCD they are more “gratifying”. 4.2. Multivariate analyses The demographic variables that remained associated with hoarding obsessions and/or compulsions were being older (Frost et al., 2000; Saxena et al., 2002, 2011; Grisham et al., 2005), and living alone. As the cross sectional design does not permit inferences concerning the direction of causality, hoarding patients could end up living by themselves because of these symptoms or also have these manifestations reinforced by the fact that they lived

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alone. The same finding was reported by Ayers et al. (2010) while studying older adults with hoarding symptoms. Greater difficulties in establishing or maintaining family relationships may also be due to the higher severity of OCD symptoms or to comorbid conditions. In agreement with other studies, the clinical features that remained associated with the hoarding dimension in the regression model were: higher severity of anxious symptoms (Frost et al., 2000; Saxena et al., 2002; Storch et al., 2007), poorer insight (Greenberg, 1987; Frost and Hartl, 1996; Grisham et al., 2005; Storch et al., 2007; Matsunaga et al., 2010a, 2010b) and presence of symptoms of the symmetry-ordering dimension (Samuels et al., 2002, 2007; Fontenelle et al., 2004; Storch et al., 2007; Hasler et al., 2007; Pertusa et al., 2008; Wheaton et al., 2008; Matsunaga et al., 2010b). Besides age at onset, an abrupt onset was negatively associated with hoarding; in other words, hoarding patients more frequently presented an insidious or intermediate onset. The axis I comorbidities that remained more frequent in the study group were: MDD (Winsberg et al., 1999; Samuels et al., 2002), PTSD (LaSalle-Ricci et al., 2006), compulsive buying (Winsberg et al., 1999; Frost et al., 2009; Mueller et al., 2009), ADHD (Greenberg et al., 1990; Moll et al., 2000; Hartl et al., 2005; Sheppard et al., 2010) and tic disorders (Baer, 1994; Diniz et al., 2006). The more severe depressive symptoms and the higher rates of MDD verified in this study suggest that negative affect may be a finding more related to hoarding in the context of OCD (Grisham et al., 2005; Wheaton et al., 2008). Although most individuals that are exposed to traumatic experiences do not develop PTSD, this condition is directly related to trauma, and trauma was more frequent among hoarding patients, indicating a possible role of psychosocial determinants. The psychodynamic hypothesis underlying this finding suggests that stressful experiences possibly generate insecurity feelings and consequent emotional attachment to possessions, in order to try to regain a sense of security, comfort and control over the environment (Frost and Gross, 1993; Frost et al., 1995; Samuels et al., 2008; Landau et al., 2011). A close association between compulsive buying and hoarding was also described in a population-based sample (Mueller et al., 2009). It is conceivable that material deprivation early in life may be associated with both compulsive buying and hoarding, although there is more evidence for emotional deprivation (Mataix-Cols et al., 2010). In an internet survey (Frost et al., 2009), 61% of 878 self-identified hoarders met the criteria for compulsive buying, which has been more associated with HD than with OCD-related hoarding (Pertusa et al., 2010b). The finding of a higher prevalence of ADHD among hoarding patients is in agreement with a recent study (Sheppard et al., 2010) in which 11.8% of the childhood-onset OCD participants met criteria for ADHD, 42% of which presented hoarding symptoms (compared to only 29% of participants without ADHD). In fact, in the above study, hoarding was the only variable independently associated with ADHD (OR ¼ 9.54). More symptoms of inattention and hyperactivity were also found by Hartl et al. (2005) in hoarders, compared to normal controls. Tolin and Villavicencio (2011) recently described that inattentive symptoms of ADHD predicted severity of clutter, difficulty in discarding and acquiring. The independent association of hoarding with tic disorders has been demonstrated by other authors (Baer, 1994; Millet et al., 2004; Diniz et al., 2006; Samuels et al., 2007) and suggests that the dopaminergic system may play a central role in hoarding, as already shown in animal studies (Kelley and Stinus, 1985; Herman et al., 1986; Kalsbeek et al., 1988). Interestingly, a recent heritability study (Mathews and Grados, 2011) demonstrated a strong genetic association of OCD with both TS and ADHD, but not between TS and ADHD. Noteworthy, tic disorders have also been previously related to symmetry-ordering symptoms (Pertusa et al., 2010a) and to

sensory phenomena (Prado et al., 2008). “Incompleteness” or “not just right” feelings have also been associated with tic-related phenomena in a recent study by Murphy et al. (2010). The present results seem to reinforce the view that OCD is a developmental disorder reflecting a constant interplay of genetic and environmental factors. The association of hoarding not only with early OCS onset, but also with other disorders that present an early onset (e.g. ADHD, tic disorders) suggest an impact of etiological factors acting early in life. Some clinical features described in pediatric OCD, such as poorer insight, less obsessions, more sensory phenomena and symmetry-ordering symptoms, point in the same direction. Recent findings also indicate that etiologic models for psychiatric illnesses need to take into account the influence of genetic factors on life experiences (Kendler and Baker, 2007). Accordingly, some of the findings discussed here may reflect genetic influences occurring in early developmental phases that predispose, for example, to ADHD and hoarding manifestations, which enhance the probability of exposure to traumatic events and, later, to the occurrence of PTSD and major depression. Therefore, longitudinal studies investigating genetic and environmental risk factors associated with hoarding symptoms in OCD are warranted. Although previously seen almost exclusively as a manifestation of OCD or an obsessional personality trait, hoarding is a multifaceted phenomenon, which may occur in other disorders, and, according to more recent evidence (Grisham et al., 2005; Pertusa et al., 2008, 2010a; Mataix-Cols et al., 2010), also as a “standalone” condition (HD). Further epidemiological and clinical research comparing OCD-related hoarding symptoms and HD symptoms with regard to several aspects, including prevalence rates, cognitive styles and treatment response, is particularly warranted. The present study was not designed to compare these two clinical conditions, which are considered to present differences in etiological mechanisms and functionality (Mataix-Cols et al., 2004, 2010). Interestingly, some common features between them have also been observed, as compared to OCD patients without hoarding, patients with anxiety disorders and community controls (Pertusa et al., 2008). For example, individuals with both OCD-related hoarding and HD were older, more likely to be female and to live alone, to report history of traumatic experiences and family history of OCD, besides presenting similar degree of clutter. OCD hoarders, however, sometimes collected bizarre items (e.g. used dippers, rotten food) and 28% reported typical obsessive fears or doubts underlying their hoarding behaviors (Pertusa et al., 2008). Therefore, phenomenological, etiological, nosological and therapeutic aspects of hoarding symptoms constitute exciting and challenging areas of research, and this study contributes to the field from the perspective of a treatment seeking OCD sample. 4.3. Limitations Certain limitations should be considered when interpreting these results. The group of patients presenting hoarding symptoms may have included a mix of individuals who have either OCD hoarding (without HD) or OCD with comorbid HD. Nevertheless, the vast majority of these individuals exhibited multiple OCD symptoms and not severe hoarding symptoms. These characteristics indicate that the latter subgroup, if present, probably constitutes a minority within the study group. The sample was composed of outpatients receiving treatment in tertiary services, who may present higher severity compared to other OCD clinical and epidemiological populations; thus, the external validity of this study may be limited to some extent. The cross sectional design only describes associations between the dependent and independent variables; no causal relations can be inferred and reverse causality is a possibility for some associations. Additionally, recall

A.R. Torres et al. / Journal of Psychiatric Research 46 (2012) 724e732

bias may be an issue for the data collected retrospectively. Another potential limitation is that data on personality disorders and treatment response were not collected, and these aspects have been considered important in previous studies with compulsive hoarders. Even with a large sample, some analyses may have been underpowered, particularly involving co-occurring conditions that are rarer among OCD patients. 5. Conclusions The results obtained are consistent with previous studies conducted in other countries, indicating that not only are hoarding manifestations common among OCD patients, but also that they are related to all other symptom dimensions, particularly the symmetry-ordering-counting dimension. Moreover, OCD hoarding patients are more likely to present specific clinical features, such as an earlier and more insidious onset, more severe anxiety symptoms, worse insight, and certain comorbidities (depression, PTSD, compulsive buying, ADHD and tic disorders). This clinical profile may be related to more specific etiologic mechanisms. A complex interplay of biological and environmental factors probably underlies the great diversity of clinical manifestations of this intriguing and debilitating disorder. Further research combining phenomenological aspects with genetic, neuropsychological, neuroimaging and treatment studies will shed more light on the etiologic determinants of all OCD symptoms. Whether OCD with hoarding symptoms represents a distinct subtype of the disorder, which should be specified in the diagnostic formulation, is still a matter of debate. Role of funding sources This study was supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, grant 2005/55628-8 to Dr. Miguel) and from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ, grant 573974/2008-0 to Dr. Miguel). These are Brazilian governmental agencies for research support, which had no interference whatsoever in the study planning and execution. Contributors Dr. Torres designed the study and participated in all the steps of the preparation process, including analyses and first draft. All authors contributed with the protocol preparation and literature searches. All authors contributed to the article writing and have approved the final version of the manuscript. Conflict of interest None. Acknowledgments We thank Aristides V. Cordioli, MD, PhD; Katia Petribu, MD, PhD; Christina H. Gonzalez, MD, PhD; Maria Alice de Mathis, MsC and all colleagues from the Brazilian Research Consortium of Obsessive-Compulsive Spectrum Disorders (CTOC) for their support and help with data collection. References Abramowitz JS, Wheaton MG, Storch EA. The status of hoarding as a symptom of obsessive-compulsive disorder. Behaviour Research and Therapy 2008;46: 1026e33. American Psychiatric Association. Diagnostic and statistical manual of mental disorders e DSM-IV. 4th ed.; 1994. Washington, DC.

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