Hoarding: Drug Treatment

This is the fourth post examining the problem of hoarding. In the first post, I reviewed some of the characteristics of people with animal hoarding behavior.  The second post examined some of the common co-occuring mental disorders in those with hoarding.   The third post looked at some evidence that the BDNF gene status may contribute to hoarding and also be linked in increased risk of obesity.


In this post, I will comment on the use of  pharmacotherapy as a part of a treatment program for hoarding.  Saxena recently published a review of the research literature of drug treatment of hoarding and also outlined results from a small open label study of the drug venlafaxine.  


Saxena reports that his group performed the only study specifically designed to assess the response of compulsive hoarding behaviors to a selective serotonin reuptake inhibitor (paroxetine) compared to a control group of individuals with OCD but no hoarding compulsions.


SSRI drugs have been the most promising group of agents for the treatment of OCD.  However, only about one third of those with OCD report a response approaching remission criteria when treated with an SSRI.  An additional third report partial improvement in symptoms while the remaining third appear to have no response to SSRIs.


There is some anecdotal reports claiming that hoarding symptoms in OCD predict a poorer response of OCD to SSRI therapy.  However, in the Saxena et al study of paroxetine for hoarding the following outcome was noted:

• The OCD response rates were similar in the hoarding (28%) and the non-hoarding (32%) OCD groups
• Hoarding symptoms were reduced by 24% with paroxetine (similar to response size in other OCD symptom clusters)
• There was no finding of a correlation between the severity of hoarding symptoms and treatment response
• A significant number of hoarders (and non-hoarders) were unable to tolerate the higher doses often needed in OCD populations

The Saxena review then summarizes an open-label trial of venlafaxine (Trade name Effexor in the U.S.) in thirteen hoarders.  Venlafaxine is a serotonin reuptake inhibitor as well as a norepinephrine reuptake inhibitor at higher doses.  Preliminary results in this sample suggest good response of hoarding behaviors in some individuals with a trend for greater reduction in hoarding symptoms compared to the paroxetine.

These manuscripts support consideration of use of an SSRI or venlafaxine type antidepressants in those with significant hoarding behaviors.  A comprehensive program that includes drug therapy, individual behavior therapy, family education and assistance with clutter clean up may be needed for the most severe cases of hoarding.


Molecular model of the antidepressant drug venlafaxine is in the public domain from Wikimedia Commons authored by Benjah-bmm27.


Saxena, S. (2011). Pharmacotherapy of compulsive hoarding Journal of Clinical Psychology, 67 (5), 477-484 DOI: 10.1002/jclp.20792

Hoarding Linked to BDNF Gene in OCD

In two previous posts on hoarding, I have reviewed some the pathway and profile of animal hoarding as well as the common mental health problems found with hoarding.

Today I will review a study that provides some insight into potential genetic contributions to hoarding behavior.  Of interest, this genetic link also appears to carry some increased risk for obesity.

Timpano from the University of Miama along with colleagues at Florida State University and the National Institute of Mental Health Intramural programs have recently published a study of 301 subjects with obsessive compulsive disorder (OCD).

In previous posts it was noted that hoarding can occur in the context of OCD but that not all hoarders will meet criteria for OCD.  In the Timpano et al study, subjects started with a diagnosis of OCD and then were grouped into those with hoarding and those without hoarding behaviors.

The hoarding classification status was assigned based upon the subject response to two items found on the Yale Brown Obsessive Compulsive Scale (YBOCS).  One item queried about tending to save objects and second item queried about difficulty discarding objects.  Hoarding subjects were required to endorse both items.

The research team then looked at the subjects and the brain-derived neurotrophic factor (BDNF) status.  BDNF has been a genetic region of interest in a variety of clinical neuroscience conditions including schizophrenia, anxiety and aggression.  Additionally it appears to be involved in memory function and variants of BDNF have been linked to higher rates of obesity.

BDNF appears to serve a role as a central neurological system plasticity factor and modulates both serotonin and glutamatergic neurotransmitter systems.  The BDNF gene codes for a protein that can vary in an region in status of two amino acids valine and methionine.  At this regions, individuals can be assigned one of three genetic types: Val/val, val/met or met/met.

The Timpano et al team found the following key findings:

• About 25% of those with OCD met criteria for being hoarders

• The BDNF val/val genotype was found in 77% of the hoarding group versus only 60% of the non-hoarding OCD group
• The BDNF val/val genotype correlated with increased hoarding symptom severity and BMI
• 45% of the hoarding group met criteria for obesity (BMI >30) versus only 21% of the OCD only group

The authors note that there are animal models of hoarding where hoarding behaviors have been linked to dysregulation of feeding behaviors.  When humans begin to hoard objects, there may also be a overlapping drive to hoard (and consume) food.  The authors note there may be a complex gene mechanism whereby individuals display hoarding, increased body weight and psychopathology as evidence of a "thrifty gene" strategy that may have survival and evolutionary manifestations.

It would be informative to examine the BDNF gene status of hoarders without a diagnosis of OCD.  The authors note that interaction between BDNF and serotonergic function may partially explain some other the BDNF-hoarding-obesity triad.

There role of serotonin in OCD has received significant research attention. In the next post, I will look at the potential for selective serotonergic antidepressants pharmocotherapy in the treatment of hoarding behaviors.

The molecular model of BDNF above is in the public domain from a Creative Commons Attribution-ShareAlike 3.0 file (Wikepedia) authored by Microswitch.

Timpano, K., Schmidt, N., Wheaton, M., Wendland, J., & Murphy, D. (2011). Consideration of the BDNF gene in relation to two phenotypes: hoarding and obesity. Journal of Abnormal Psychology DOI: 10.1037/a0024159

Hoarders: Mental Disorder Profiles

Hoarding is under increased scrutiny in both the public presence and clinical neuroscience research.  Some of this can be attributed to the television show Hoarders.  This show profiles a series of individuals with hoarding behaviors and the attempts made by professionals trying to help them.

If you have seen any of the shows you quickly realize that this problem is easy to assess but difficult to treat.   The effect on family members of hoarders is often extreme.  Family members commonly are driven from the hoarder's home due to increased clutter and concerns about sanitation.

Hoarding is being proposes as a new diagnosis under the fifth edition of the Diagnostic and Statistical Manual.  Clinicians who treat patients with obesessive compulsive disorder (OCD) are aware of hoarding phenomenology (symptoms) as some individuals with OCD will have hoarding behaviors.

Understanding hoarders requires assessment of co-occuring or comorbid mental disorders.  Frost et al have conducted a study of a comorbid disorders in a large series of over 200 individual hoarders and compared them to a group with OCD without problems with hoarding.

Obsessive compulsive disorder is a reasonable mental disorder to compare with hoarding.  Since some individuals (but not all) with OCD will have hoarding, it is helpful to use OCD as a psychiatric control group.  Such a strategy can aid with determining the boundaries (or discriminant validity) between similar conditions.

The authors used a rating scale that I have not heard of before--the Hoarding Rating Scale that rates three key components of hoarding:

• Clutter in the living environment
• Problems with discarding items
• Excessive acquistion of physical objects

As expected the hoarder group had higher rates on all components of the Hoarding Rating Scale.  The two groups had some interesting differences in lifetime prevalence rates for mood, anxiety and ADHD diagnoses as summarized in the chart below:

Hoarders had higher rates of major depression and generalized anxiety disorder than those with OCD.  Additionally they demonstrated significant increase in rates of attention deficit hyperactivity disorder.  

When the two groups were compared on a variety of types of impulse control behaviors, hoarders were much more likely to endorse compulsive buying, a pathological drive to obtain free items and kleptomania.  They were not different than those with OCD in rates of pathological gambling or trichotillomania (a impulse to constant pull out ones own hair).

This study does lend some support for considering hoarding as a distinct disorder separate from OCD.   The high rates of ADHD in this hoarding sample support clinical consideration of this condition in hoarders.  I was surprised by the relatively low rate of substance abuse.

You will likely hear more about research examining those who have hoarding behaviors.  Family, twin and other genetic studies would helpful to tease out where this type of behavior differs for OCD and other mental disorders. Below is a three minute educational video on hoarding from the University of Michigan.



Chart is an original chart from the author adapted from data presented in the Frost et al manuscript listed below. 

Frost RO, Steketee G, & Tolin DF (2011). Comorbidity in Hoarding Disorder. Depression and anxiety PMID: 21770000

Animal Hoarders: Pathways and Profile

This week I will have four blog posts on the topic of hoarding.  This post will focus on the hoarding of animals, followed by posts on mental health disorders in hoarders, a review of manuscript looking a genetic factors in hoarding and then finishing with a review of pharmacotherapy treatment of hoarders.

Hoarding occurs in a variety of forms.  Some individuals with hoarding collect newspapers, clothes or other specific items such as dolls.

One group of hoarders appear vulnerable to collecting animals.  As with all hoarding types, eventually the hoarding gets out of control leading to unsanitary conditions and disruption of interpersonal relationships.

With hoarding of animals, conditions can deteriorate to the point of significant animal malnutrition as owners have escalating costs to feed and provide veterinary care to their animals.  Most complaints to animal welfare agencies about hoarders center around animal health or sanitation associated with the behavior.

Steketee and colleague recently published a description of sixteen individuals with a problem with animal hoarding in the Review of General Psychology.    Although not a large number, it is one of the largest descriptions to data and provides some insight into the pathway and profile of animal hoarders.

For their control group, they interviewed a series of individuals who owned many animals but had no trouble with caring for them.  The animal hoarding case group had all been identified by referral from an animal protection agency that had investigated the hoarding household following a public complaint.

The study used a combined qualitative and quantitative approach with the key findings from the study showing the hoarders:

• Reported poor childhood attachment to their families
• Endorsed a chaotic childhood environment
• Endorsed human characteristics to animals
• Experienced extreme emotional reactions to animal deaths
• Distrusted authority
• Exhibited impaired adult functioning in home maintenance and work performance
• Endorsed more dysfunctional adult human relationships

The authors note their study supports the three pare theoretical model proposed by Patronek and Nathanson for animal hoarding:

1. Failure to development secure human attachments during childhood
2. Poor adult functioning leading to social and work problems with few friends and supportive family members
3. Development of a reliance on animals for emotional comfort

Some similar developmental abnormalities may be found in other hoarder subgroups. Substitution of interpersonal relationships with preoccupation with objects or animals seems to be a common theme.

Photo of young Canadian gosling walking across drive way with worm/grub in mouth courtesy of the author's private files.

Steketee, G., Gibson, A., Frost, R., Alabiso, J., Arluke, A., & Patronek, G. (2011). Characteristics and antecedents of people who hoard animals: An exploratory comparative interview study. Review of General Psychology, 15 (2), 114-124 DOI: 10.1037/a0023484

Patronek GJ, & Nathanson JN (2009). A theoretical perspective to inform assessment and treatment strategies for animal hoarders. Clinical psychology review, 29 (3), 274-81 PMID: 19254818