Patients With Obsessive-Compulsive Disorder and Hoarding Symptoms: A Distinctive Clinical Subtype? Leonardo F. Fontenelle, Mauro V. Mendlowicz, Isabela D. Soares, and Ma´rcio Versiani We investigated whether patients with obsessivecompulsive disorder (OCD) and hoarding symptoms can be differentiated from their counterparts with other types of obsessions and compulsions in terms of sociodemographic and clinical features. Ninetyseven patients with OCD were assessed with a sociodemographic and clinical questionnaire, the Structured Clinical Interview for DSM-IV (SCID-I), the YaleBrown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HDRS), and the Global Assessment of Functioning (GAF). Fifteen patients who reported hoarding symptoms in the Y-BOCS checklist (15.6% of the total sample) were compared and contrasted with 82 patients without those symptoms using the Mann-Whitney U test for continuous variables and the Pearson’s goodness-of-fit chi-square test for
categorical ones; Fisher’s exact test was employed when indicated. Hoarders were characterized by (1) higher educational levels (2 ⴝ 7.49; df ⴝ 2; P ⴝ .02); (2) earlier age at onset (Z ⴝ ⴚ2.99; P ⴝ .003); (3) higher rates of symmetry obsessions (2 ⴝ 7.03; df ⴝ 1; P ⴝ .01); (4) greater frequency of ordering (2 ⴝ 10.08; df ⴝ 1; P ⴝ .004); (5) rituals repetition (2 ⴝ 4.42; df ⴝ 1; P ⴝ .03); (6) counting compulsions (2 ⴝ 5.92; df ⴝ 1; P ⴝ .02); and (7) significantly higher rates of comorbidity with bipolar II disorder (2 ⴝ 10.62; df ⴝ 1; P ⴝ .02) and (8) with eating disorders (2 ⴝ 7.42; df ⴝ 1; P ⴝ .02). In conclusion, patients with OCD exhibiting hoarding feature a distinctive sociodemographic and clinical profile. It remains to be investigated whether these phenotypical characteristics are underlined by specific neurobiological mechanisms. © 2004 Elsevier Inc. All rights reserved.
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items and buying “extras” in order not to run out of them), and higher scores on measures of perfectionism, indecisiveness, and obsessive-compulsive symptoms.1 Self-identified hoarders were also more likely to be unmarried, to be in therapy, and to report first-degree relatives who were described as “pack rats.”1 Examples of thoughts that occur when hoarders were deciding whether or not to throw something away included, in order of frequency: “I might need this someday,” “this is too good to throw away,” “this means too much to me to throw away,” and “this may be worth something someday.”1 The types of problems most frequently reported by hoarders were embarrassment, avoidance of inviting others into their homes, difficulties in finding things, and conflict with spouses and/or family members.1
OARDING is defined as the acquisition of and failure to discard possessions of little use or value to others.1 A number of studies have indicated that hoarding occurs across a wide spectrum of severity.1,2 It was proposed that clinically significant hoarding (1) results in living spaces being sufficiently cluttered as to preclude normal use and activities, and (2) creates considerable distress or impairment in functioning.3 Severe hoarding behaviors may result in an inability to complete necessary household functions (e.g., paying bills, cooking), health problems (e.g., dust allergies), conflicts with relatives, social withdrawal, eviction, fire, and even death.1,2,4 Commonly saved items include newspapers, magazines, old clothing, bags, books, mail, notes, and lists.1,3 Although often described as a part of obsessivecompulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD), hoarding was already recognized in a range of pathological conditions, including schizophrenia,5 dementia,6 anorexia nervosa,7 autism,8 Prader-Willi syndrome,9 Diogenes syndrome,10 and bilateral11 and left damage to the orbitofrontal cortex.12 When self-identified hoarders were compared to individuals from the general population, they were found to exhibit increased clutter in their houses, greater concerns with being without possessions when they are needed (e.g., carrying “just-in case”
From the Anxiety and Depression Research Program; and the Ethics Research Program, Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil; Department of Psychiatry and Mental Health, Fluminense Federal University (MSM/UFF) Niteroı´, Brazil; and the Institute of Psychology (IP/UFRJ), Rio de Janeiro, Brazil. Supported by a grant from CNPq (Process #141517/00-0). Address reprint requests to Leonardo F. Fontenelle, M.D., D.Sc., Rua Lopes Trova˜o #88, Apartment 1501, Bloco A, Icaraı´, Nitero´i, RJ, CEP: 24220-071, Brazil. © 2004 Elsevier Inc. All rights reserved. 0010-440X/04/4505-0022$30.00/0 doi:10.1016/j.comppsych.2004.03.005
Comprehensive Psychiatry, Vol. 45, No. 5 (September/October), 2004: pp 375-383
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There is an increasing body of literature suggesting that hoarding behaviors may be associated with a distinct set of neurobiological features. For example, OCD hoarders displayed a family history of hoarding significantly more often than OCD nonhoarders.13 Patients with pathological hoarding also exhibited a pattern of neurocognitive deficits that is distinct from that found in studies investigating patients with OCD in general, with difficulties in using spatial but not verbal encoding strategies.14 While serotonin is thought to be involved in the pathogenesis of OCD in general15 and of hoarding in particular,16 animal studies suggest that dopamine and gonadal steroids may also be especially important in the latter condition.17 Other features, such as limited insight, absence of resistance to the compulsion to hoard, and poor treatment motivation may be common to hoarders.18 Treatment studies also suggest that OCD patients with hoarding symptoms are less responsive to pharmacological treatment,19,20,21 to cognitive-behavioral therapy,22 and to a combination of both.23 Thus, the presence of hoarding symptoms may amount to an etiologically or biologically distinct subgroup or variant of OCD.19 Despite the growing interest in the issue of hoarding in OCD, only a handful of controlled studies (all from the United States) have until now attempted to characterize the profile of the patients suffering from this condition13,23,24 (see Table 1 for a summary of their findings). Given the relatively small size of the samples, their limited geographic scope, and the partially contradictory results, we felt that it would be worthwhile to attempt to replicate these findings and to ascertain whether OCD patients with and without hoarding symptoms from a different sample could also be differentiated on a sociodemographic and clinical basis. METHOD Individuals with OCD were consecutively recruited for an open pharmacological trial by a university hospital outpatient clinic for anxiety disorders. Inclusion criteria comprised: (1) age between 17 and 65 years; (2) having OCD as the most significant current psychiatric diagnosis; and (3) being capable of reading and filling out forms and questionnaires. Exclusion criteria were: (1) significant medical, neurological, and endocrine disorders; (2) current alcohol and drug abuse (patients with a history of alcohol and drug abuse had to be in sustained full remission according to the DSM-IV criteria to get accepted in the study); (3) current psychotic or manic episodes; (4)
personality disorders (diagnosed according to the DSM-IV) that we considered, on clinical grounds, might compromise the participation in the research program (i.e., those with marked paranoid, antisocial, borderline, and histrionic features); and (5) severe sexual disorders that required specialized treatment approaches we could not provide. One hundred eight consecutive patients with OCD were initially assessed. These individuals were either referred by clinicians or spontaneously sought treatment after learning about our OCD program through newspaper advertisements or by word of mouth. Eleven patients were excluded from the study: two male patients with antisocial personality disorder and current alcohol and cocaine abuse; three male patients with severe paraphilias; one male patient with current alcohol, cocaine, and marijuana abuse; one female patient with borderline personality disorder; one male patient with paranoid personality disorder; one illiterate male patient with moderate mental retardation; one illiterate female patient with mild mental retardation and bipolar disorder; and one female patient with schizophrenia. Ninety-seven volunteers with OCD were selected and, after giving their written informed consent, had their diagnosis confirmed by a research psychiatrist (L.F.F.) using the Structured Clinical Interview for DSM-IV, patient version (SCID-I/P).25 All volunteers were assessed by the main author with a questionnaire addressing socio-demographic (such as age, gender, ethnic background, educational level, and occupation) and clinical characteristics (including age and mode of onset, course, subtype of OCD according to the International Classification of Diseases, 10th edition [ICD-10],26 and duration of illness). Initial evaluation also included the Yale-Brown ObsessiveCompulsive Scale (Y-BOCS),27,28 the Clinical Global Impression (CGI),29 the Hamilton Depression Rating Scale-21 (HDRS-21),30 the Beck Depression Inventory (BDI),31 and the Global Assessment of Functioning (GAF).32 Whenever possible, external corroboration for the clinical data was obtained: in our study population, information from significant others was available in 45.8% of the cases. From the original pool of ninety-seven individuals, 79.6% were referred by clinicians while the remaining 20.4% were recruited trough advertisements in newspapers and word of mouth. Clinician-referred subjects did not have more severe OCD than self-referrals, as measured by initial Y-BOCS (t ⫽ ⫺.99; df ⫽ 28.1; P ⫽ .32) and CGI scores (t ⫽ ⫺72; df ⫽ 30.8; P ⫽ .47). After filling out the Y-BOCS symptoms checklist, patients were specifically inquired about the content and form of the reported symptoms in order to ensure whether they were describing true obsessive-compulsive phenomena rather than unrelated symptoms such as worries, depressive thoughts, or nonpathological behaviors. At the time the data were collected, the interviewer was unaware of the final hypothesis of the study. Patients who reported hoarding symptoms in the Y-BOCS checklist (n ⫽ 15) were compared and contrasted with patients without these symptoms (n ⫽ 82) using the Mann-Whitney U test for continuous variables and the Pearson’s goodness-of-fit chi-square test for categorical ones; Fisher’s exact test was employed when indicated.
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Table 1. Main Findings of the Controlled Studies on OCD Hoarders Frost et al. (2000)13
Type and no. of research subjects Patients Controls #1 Controls #2 Controls #3 Demographical and clinical findings Current age
Age at onset Severity of OCD symptoms (Y-BOCS total score) Severity of anxiety symptoms Comorbity with anxiety disorders Severity of depression symptoms Comorbity with mood disorders Comorbity with personality disorders
Level of functioning
37 20 13 34
OCD hoarders OCD nonhoarders w/ “anxiety disorder” “community controls”
OCD hoarders ⬎ OCD nonhoarders ⫽ other controls Not reported OCD hoarders ⫽ OCD non-hoarders ⬎ other controls OCD hoarders ⬎ OCD nonhoarders ⬎ other controls* Not reported OCD hoarders ⬎ OCD nonhoarders ⬎ other controls‡ Not reported
OCD hoarders ⬎ OCD nonhoarders (dependent and schizotypical) OCD hoarders ⬍ OCD nonhoarders (family and social)㛳
Samuels et al. (2002)23
Saxena et al. (2002)24
36 OCD hoarders 54 OCD nonhoarders — —
20 OCD hoarders 170 OCD nonhoarders — —
Not reported
OCD hoarders ⬎ OCD nonhoarders
OCD hoarders ⬍ OCD nonhoarders OCD hoarders ⬎ OCD nonhoarders
Not reported
Not reported
OCD hoarders ⬎ OCD nonhoarders†
OCD hoarders ⬎ OCD nonhoarders (social phobia) Not reported
Not reported
OCD hoarders ⫽ OCD nonhoarders
OCD hoarders ⫽ OCD nonhoarders§
OCD hoarders ⬎ OCD nonhoarders (brief depression and hypomania) OCD hoarders ⬎ OCD nonhoarders (cluster B and OCPD¶)
Not reported
Not reported
OCD hoarders ⬍ OCD nonhoarders (social and occupational)#
Not reported
*As measured with the Beck Anxiety Inventory. †As measured with the Hamilton Rating Scale for Anxiety. ‡As measured with the Beck Depression Inventory. §As measured with Hamilton Rating Scale for Anxiety. ¶Obsessive-compulsive personality disorder. 㛳As measured with the Sheehan Disability Inventory. #As measured with the Global Assessment Scale.
RESULTS
In Table 2, a brief account of some relevant sociodemographic and clinical characteristics presented by each patient with hoarding is provided, including age, gender, age of OCD onset, whether or not hoarding represented a main clinical problem, the cognitive phenomena reported to precede or trigger the compulsions to hoard, axis I psychiatric comorbidities, and the hoarded items. As shown in Table 3, the hoarding group exhibited higher educational levels than their non-hoard-
ing counterparts (2 ⫽ 7.49; df ⫽ 2; P ⫽ .02). Moreover, despite having similar ages at presentation (Z ⫽ ⫺1.04; not significant), hoarders displayed an earlier age of onset of OCD than the other patients (Z ⫽ ⫺2.99; P ⫽ .003). With regard to the clinical phenomenology of OCD, hoarders were characterized by a set of distinctive obsessive-compulsive symptoms, including obsessions with symmetry themes (2 ⫽ 7.03; df ⫽ 1; P ⫽ .01), and ordering (2 ⫽ 10.08; df ⫽ 1; P ⫽ .004), rituals repetition (2 ⫽ 4.42; df ⫽ 1; P ⫽ .03), and
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Table 2. Clinical Descriptions of Patients With OCD and Hoarding Patient No.
Age at OCD Onset
Hoarding as a Main Problem
Triggering Phenomena
1
64, F
16
Yes
Hoarding obsessions
Major depressive disorder
2
27, M
10
Yes
None
Dysthymia
3
41, M
12
Yes
Major depressive disorder
4
28, F
7
Yes
5
27, F
4
Yes
6
42, F
6
Yes
7
22, F
10
Yes
Hoarding and miscellaneous obsessions Aggressive obsessions* Hoarding obsessions Aggressive obsessions Hoarding obsessions
8
59, M
17
Yes
9
51, F
14
Yes
Hoarding obsessions None
10
40, M
10
Yes
None
11
22, F
8
No
12
30, F
7
No
13
29, F
18
No
14 15
33, F 59, F
16 15
Yes No
Hoarding obsessions Religious obsessions Aggressive obsessions None Hoarding obsessions
Psychiatric Comorbidity
Major depressive disorder, bulimia Dysthymia Major depressive disorder, social phobia, GAD Major depressive disorder, dysthymia, specific phobia Major depressive disorder Bipolar II disorder, GAD, specific phobia, bulimia Chronic vocal tic disorder Panic disorder, skin picking
Hoarded Items
Newspapers and magazines, books, mail, clothes, lists and notes, receipts, candles, pens, batteries, strings, plastic bags Newspapers and magazines, books, clothes, lists and notes, fingernail clips Newspapers and magazines, books, mail, clothes, lists and notes, receipts, food, gifts, bottles, glass, boxes, broken objects, plastic bags Newspapers and magazines, books, mail, receipts, bottles, boxes, broken objects Newspapers and magazines, books, mail, lists and notes, business cards, flyers Newspapers and magazines, mail, clothes, notes, receipts Newspapers and magazines, mail, clothes, lists and notes, receipts, broken objects Newspapers and magazines Magazines, books, clothes, receipts, cans, bottles, litter, notes, “succulent plants” Soccer team mugs, cards, miniatures, plate, stuffed animals, dolls, traffic signs, vinyl long-plays, compact disks, Mail, letters, agendas, father’s personal objects
Bipolar II disorder, GAD, binge eating disorder Major depressive disorder
Religious articles Clothes, lists and notes
Dysthymia Major depressive disorder
Bottle caps, cans, plastic bags, rests of food Plastic bags, clothes
Abbreviation: GAD, generalized anxiety disorder. *As defined in the Y-BOCS. These patients collect objects they believe might be used for direct or indirect hetero-aggressive purposes (e.g. collecting pieces of paper in which they believe they might have written down their obsessive ideas about their parents’ death).
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Age (yr) and Gender
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Table 3. Comparison of Sociodemographic and Clinical Characteristics of Patients With and Without Hoarding Symptoms
Sex ratio (F/M) Age (yr) Educational level Primary (0-8 yr) Secondary (9-11 yr) Tertiary (ⱖ12 yr) Age at onset (yr) Y-BOCS CGI BDI HAM GAF Obsessive symptoms Aggressive Contamination Sexual Religious Somatic Symmetry Miscellaneous Compulsive symptoms Checking Washing Rituals repetition Ordering Counting Miscellaneous
OCD Patients Without Hoarding (n ⫽ 82)
OCD Patients With Hoarding (n ⫽ 15)
1.3 33.5 ⫾ 12.6
2.5 37.3 ⫾ 14.1
21.1% 38.2% 40.8% 22.0 ⫾ 14.3 24.5 ⫾ 8.2 5.19 ⫾ .92 23.3 ⫾ 7.4 17.4 ⫾ 6.7 52.2 ⫾ 8.4
0% 21.4% 78.6% 11.3 ⫾ 4.4 26.5 ⫾ 6.3 5.37 ⫾ .83 24.6 ⫾ 10.9 17.5 ⫾ 7.1 51.6 ⫾ 8.4
67.5% 50.0% 18.8% 18.8% 22.5% 16.3% 42.5%
73.3% 60.0% 20.0% 40.0% 20.0% 46.7% 60.0%
1.99 .50 .01 3.31 .04 7.03 1.56
NS NS NS NS NS .01 NS
67.5% 58.8% 43.8% 16.3% 13.8% 33.8%
66.7% 73.3% 73.3% 53.3% 40.0% 53.3%
.004 1.13 4.42 10.08 5.92 2.08
NS NS .03 .004 .02 NS
Test Value
P
.59 ⫺1.04 7.49
NS NS .02
⫺2.99 ⫺.95 ⫺.68 ⫺.05 ⫺.26 ⫺.60
.003 NS NS NS NS NS
Abbreviation: NS, not significant.
counting compulsions (2 ⫽ 5.92; df ⫽ 1; P ⫽ .02). The hoarding group was characterized by significantly higher rates of comorbidity with bipolar II (2 ⫽ 10.62; df ⫽ 1; P ⫽ .02) and with eating disorders (i.e., bulimia nervosa or binge eating disorder) (2 ⫽ 7.42; df ⫽ 1; P ⫽ .02) (Table 4). DISCUSSION
In our study, patients with OCD and hoarding symptoms were characterized, when compared to subjects with nonhoarding OCD, by higher educational levels, an earlier age at onset, a distinctive pattern of predominant obsessive-compulsive symptoms (symmetry obsessions; ordering, rituals repetition, and counting compulsions) and a higher rate of comorbidity with bipolar II and eating disorders. The prevalence of hoarding symptoms in our sample (15.6 %) was in the lower end of the range described in the literature (14.2% to 42%).13,24,33-36
This large variability may reflect the influence of several factors, such as the setting in which the recruitment took place and the predominant subtype of OCD in the sample. It is widely known, for example, that hoarders show poor insight regarding the seriousness of their condition.43 This may lead to under-reporting of hoarding and to low adherence to treatment.22 While the former may explain the lower rates of hoarding in our sample (in which external corroboration was available in only 45.8% of the cases), it is conceivable that the reported low prevalence of hoarding in patients with OCD attending partial hospitalization programs24 may reflect the difficulties these patients find in participating in therapeutic programs that require a more active participation. On the other hand, hoarding is more commonly found in patients with early-onset OCD, a fact that may account for its higher prevalence among children and adolescent suffering from this disorder.35,36 The differences in the composition of the samples make it difficult to draw
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FONTENELLE ET AL Table 4. Comparison of the Rates of Axis I Comorbidity in Patients With and Without Hoarding Symptoms
Any mood disorder Major depressive episode Dysthymic disorder Bipolar II disorder Cyclothymic disorder Any anxiety disorder Panic disorder Agoraphobia Social phobia Specific phobia Post-traumatic stress disorder Generalized anxiety disorder Any eating disorder Bulimia nervosa Binge eating disorder
OCD Patients Without Hoarding (n ⫽ 82)
OCD Patients With Hoarding (n ⫽ 15)
Test Value
P
62.8% 50% 16.7% .0% 1.3% 24.4% 15.4% 7.7% 14.1% 2.6% 1.3% 6.4% 5.1% 2.5% 2.5%
86.7% 53.3% 26.7% 13.3% .0% 20.0% 6.7% .0% 6.7% 13.3% .0% 20.0% 26.7% 13.3% 13.3%
3.21 .05 .84 10.62 .19 .13 .79 1.23 .61 3.54 .19 2.95 7.42 3.67 3.67
NS NS NS .02 NS NS NS NS NS NS NS NS .02 NS NS
definitive conclusions about the rate of prevalence of hoarding behavior among patients with OCD. Only two studies have addressed the issue of the levels of education and functioning in patients with OCD and hoarding. Frost et al.23 found that educational levels in OCD hoarders and nonhoarders were not statistically different. On the other hand, patients with OCD and hoarding symptoms were shown to exhibit increased levels of disability and lower levels of functioning when compared to nonhoarding OCD.23,24 Therefore, the finding that our patients with OCD and hoarding symptoms displayed higher educational and similar functioning levels as compared to their nonhoarding counterparts is puzzling and represents a sharp departure from the literature. Nevertheless, Petribu´ et al.37 had already described that Brazilian patients with OCD, when compared to nonpsychiatric controls from similar sociocultural and economic background, exhibited increased levels of schooling. Thus, it is possible that academic performance is relatively preserved in Brazilian patients with OCD in general and, more particularly, in those individuals with hoarding symptoms. One can only speculate about the reasons for our finding of higher educational levels in patients with hoarding symptoms. First, it is possible that OCD hoarders achieve higher educational levels before they are severely impaired by their symptoms. Frost et al.23 suggested that OCD hoarders may possess a hoarding orientation since
childhood which is recognizable to them but that does not become debilitating until later in life, when they have accumulated a large amount of possessions. Second, OCD hoarders may represent a subgroup of patients with a less malignant profile of neurocognitive deficits. For example, Hartl et al.14 found that, despite showing significant planning and organization problems, hoarders did not exhibit the inability to use verbal learning strategies characteristic of patients with more ordinary OCD. Finally, it is possible the OCD hoarders may display some clinical features that may help them boost their academic performance, either directly (by showing greater interest in newspapers, journals, and books) or indirectly (by exhibiting increased levels of perfectionism).1 We were unable to replicate the findings of previous studies suggesting that patients with OCD and hoarding symptoms were significantly older than patients with OCD without hoarding23,24 and patients with other anxiety disorders.23 However, we found that patients with OCD and hoarding displayed a significantly earlier age at onset of OCD (11.3 ⫾ 4.4 years) as compared to patients with OCD without hoarding (22.0 ⫾ 14.3 years), a finding that had already been described by Samuels et al.13 and is consistent with the aforementioned high prevalence of hoarding behavior among patients with early-onset OCD.23,24 We could not demonstrate the existence of an association between hoarding and greater severity
PATIENTS WITH OCD AND HOARDING
of obsessive-compulsive symptoms, a finding that was previously described by some,13 but not all investigators.23,24 Again, as Frost et al.23 pointed out, it is possible that the requirement of a diagnosis of OCD for inclusion in our study was the responsible for the similarities in frequency and severity of OCD measures among OCD hoarders and nonhoarders. We found that patients with hoarding symptoms exhibited symmetry obsessions, ordering, rituals repetition, and counting compulsions significantly more often than patients without hoarding. Such findings dovetail with those by Samuels et al.13 and by several factor-analytic studies that have suggested that hoarding belongs to a separate dimension of obsessive-compulsive symptoms,37,38 which may include symmetry,40 ordering and arranging,21,40 rituals repetition, and counting rituals.40 In Baer’s study,40 the hoarding factor was also correlated with Tourette’s syndrome, chronic tic disorders, and OCPD. These findings may reflect the existence of a common neuroanatomical basis for these obsessive-compulsive symptoms. Alternatively, they may suggest that the core phenomenon of hoarding may entrain secondary behavioral manifestations. For example, if a patient collects great amounts of a given object, one could expect him to count them and keep them organized according to certain rules. Despite very early descriptions on the existence of associations between the “folie de doute” (madness of doubt) and the “folie circulaire” (circular madness), little attention has been devoted to this complex pattern of comorbidity.41 More recently, bipolar II disorder (according to the DSM-IV criteria) was found to occur in 11% to 16% of patients with OCD.41 Using the SCID-I/P, we found that OCD hoarders were significantly more likely to suffer from bipolar II and eating disorders (i.e., bulimia nervosa plus binge eating disorder) than their nonhoarding counterparts. In the same vein, Samuels et al.,13 employing an adapted version of the Schedule for Affective Disorders and Schizophrenia-Lifetime Anxiety [SADS-LA(R)IV], found that hoarders exhibited significantly higher rates of hypomania, brief depression, social phobia, and pathological grooming behaviors (skin picking and trichotillomania). Taken together, these results sug-
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gest that patients with OCD and hoarding may be more likely than patients with more ordinary OCD to be affected by disorders characterized by significant mood swings (hypomania), anxiety, and impulsive behaviors. Perugi and Akiskal42 have proposed the enlargement of the concept of bipolar II disorders in order to incorporate some forms of mood, anxiety, impulse control, and eating disorders under a hypothetical spectrum of cyclothymic-anxious-sensitive disposition. The patterns of comorbidity found in our study suggest that some of our patients with OCD and hoarding symptoms may belong to this spectrum of disorders. Interestingly, Hantouche et al.41 had already described that patients with OCD and “cyclothymia” (diagnosed with a self-rating scale designed to measure cyclothymic temperament), when compared to “noncyclothymic OCD,” were characterized by a specific pattern of compulsions, including higher frequency of hoarding, compulsions of control, and rituals repetition. Our study has some significant limitations. The first is the relatively small number of recruited hoarders. This is even more problematic considering that only 10 patients exhibited hoarding as a main clinical syndrome. Nevertheless, we have systematically evaluated more than 100 patients with OCD and the prevalence of hoarding in our sample was found to be within the range delimited by previous studies. The association between hoarding and eating and bipolar II disorders has not, to our knowledge, been described before now. However, we acknowledge that, given the small size of our sample, our findings concerning comorbidity need to be viewed with caution. Our sample of hoarders included only four cases of eating disorder (actually, a category resulting from combining the bulimia and binge eating disorder subgroups) and two of bipolar II disorder. A substantially larger sample, providing greater statistical power, is required before any definitive conclusion can be drawn. The use of multiple statistical comparisons represents another potential drawback of our study. Some could argue that a procedure such as Bonferroni correction should be employed in order to minimize type I statistical errors, even at the cost of eliminating the statistical significance of some of our findings. However, given the incipient state of the currently available knowledge on hoarding,
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we felt it would be counterproductive to discard preliminarily some correlations that might be further investigated in future studies. An additional limitation of our study was that external corroboration for clinical data was available for less than half of the sample. As described earlier, hoarders are known to exhibit poor insight and to often fail to recognize that their hoarding behavior is distressing, time-consuming, or interferes with normal functioning. As a consequence, some of our patients with hoarding may not have reported their symptoms simply because they did not recognize them as such.43 This phenomenon may have artificially inflated the number of indi-
viduals included in the nonhoarding group, thus lessening the sociodemographic and clinical differences between hoarders and nonhoarders. Our results are consistent with previous reports suggesting that hoarding may represent a discrete subgroup of OCD, with distinct sociodemographic and clinical features. However, to ensure that hoarding may amount to a real subtype of OCD, one needs to establish whether such phenotypical features correspond to specific neurobiological characteristics. Further studies addressing issues such as the neuropsychology, neuroendocrinology, and neuroimaging of hoarding are needed to clarify these questions.
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