May 19. 2014 | Beth Gilbert
Hoarding Recognized as Separate Anxiety Disorder
Hoarding disorder was recently classified as a separate disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Prior to this new classification, hoarding disorder was listed as a variant of obsessive-compulsive disorder (OCD) but was not well described.
According to Sanjaya Saxena, MD, director of the Obsessive-Compulsive Disorders Program and Outpatient Psychiatric Services at the University of California in San Diego, “there is a wealth of evidence that demonstrates hoarding disorder may share similarities to obsessive compulsive disorder (OCD) but is not the same thing. Hoarding disorder is a discrete entity of its own. Hoarding disorder is a fairly common disorder and is approximately 1.5 times more common than OCD,” Overall, according to Saxena the disorder affects approximately 2–5% of the population. In the United States, this represents approximately 8–10 million people who meet the diagnostic criteria for the disorder.
Based on the DSM-5 criteria, symptoms of hoarding include but are not limited to excessive acquisition and saving, even if the individual doesn't need or have space for such things. Individuals with hoarding disorder have difficulty discarding possessions, which leads to clutter and congestion in their home, work spaces, or even outside areas. This can compromise the use of rooms, surfaces, and other areas of the home. “Hoarding disorder clearly impacts activities of daily living and causes a significant amount of functional impairment – even risks to physical health in more severe cases, infestations of rodents, falls, mold, dust build up, and fire hazards,” said Saxena.
The reasons for hoarding vary and can be due to items holding sentimental value, compulsive shopping, a perceived need for items (either now or in the future), and an inability to discard items caused by other psychological factors.
Hoarding disorder is treatable with both anti-anxiety and antidepressant medications such as paroxetine, despite lack of FDA approval and/or non-pharmacologic approaches, including cognitive behavioral therapy (CBT) tailored to hoarding disorder. One novel CBT approach combines standard behavioral techniques with cognitive rehabilitation of neurocognitive abilities and has worked well in clinical practice as well as in research studies, according to Saxena.
In addition, Saxena said that some antidepressant and anti-anxiety medications have worked well in clinical trials for treating hoarding disorder such as paroxetine, which has been shown to improve hoarding and associated symptoms in an open label, prospective study conducted by Saxena and colleagues, with the majority of patients responding. However, according to Saxena, studies of paroxetine have demonstrated to not be tolerated that well by some of the older and middle-aged patients, who had adverse effects such as sedation, fatigue, constipation, and sexual side effects.
More recently, Saxena and a colleague evaluated the efficacy and safety of venlafaxine in patients with hoarding disorder. According to Saxena, the reason they decided to evaluate venlafaxine was due to the drug's improved safety profile in older patients as compared to paroxetine, and similar efficacy profile to paroxetine and clomipramine in the treatment of OCD.
The study was recently published in the journal International Clinical Psychopharmacology. “We had 23 of 24 patients complete the study, and one drop out due to the individual moving out of state. In prior research, people with hoarding disorder dropped out of treatment more often. We achieved quite good results, 35% reduction in symptoms, as good as or better than CBT studies,” said Saxena.
A key finding from this study is that venlafaxine produced these results in a shorter time period as compared to novel CBT approaches. Venlafaxine showed improvement within only 12 weeks, whereas CBT studies take ≥26 weeks and require a more involved process.
In addition, the study demonstrated that venlafaxine also helped individuals with other comorbid psychiatric conditions including major depression and other anxiety disorders. “This study, in combination with previous work, indicates that certain medications work pretty well, if not better than CBT, for hoarding disorder. Seventy percent of patients were classified as responders, and that is higher than some studies of other disorders,” said Saxena.
While both paroxetine and venlafaxine showed significant improvements in hoarding and associated symptoms with treatment, Saxena said that placebo-controlled trials are necessary to truly establish the efficacy of a given treatment for a given disorder, and no placebo-controlled trials have yet been done for hoarding disorder. In addition, no other medications have been studied in a formal way for this condition.
Although CBT and paroxetine and venlafaxine have been shown to be effective in treating hoarding disorder, the effects vary among patients, and the combination of the two approaches together is likely to produce the best results as compared to using the approaches individually.
According to Saxena, "the take-home message is that not only is hoarding disorder very common and fairly serious, it is also very treatable. We are currently trying to educate the public about this disorder, as well as government agencies and the medical community, to get them to understand that it is not bad behavior or laziness. It requires neuropsychiatric work up and treatment. Part of the problem was that it was not previously described or categorized as a real disorder, so we are now training people how to treat it and assess it."