Context Hoarding disorder (HD), previously considered a subtype of obsessive-compulsive disorder (OCD), has been proposed as a unique diagnostic entity in DSM-5. Current models of HD emphasize problems of decision-making, attachment to possessions, and poor insight, whereas previous neuroimaging studies have suggested abnormalities in frontal brain regions. Objective To examine the neural mechanisms of impaired decision making in HD in patients with well-defined primary HD compared with patients with OCD and healthy control subjects (HCs). Design We compared neural activity among patients with HD, patients with OCD, and HCs during decisions to keep or discard personal possessions and control possessions from November 9, 2006, to August 13, 2010. Setting Private, not-for-profit hospital. Participants A total of 107 adults (43 with HD, 31 with OCD, and 33 HCs). Main Outcome Measures Neural activity as measured by functional magnetic resonance imaging in which actual real-time and binding decisions had to be made about whether to keep or discard possessions. Results Compared with participants with OCD and HC, participants with HD exhibited abnormal activity in the anterior cingulate cortex and insula that was stimulus dependent. Specifically, when deciding about items that did not belong to them, patients with HD showed relatively lower activity in these brain regions. However, when deciding about items that belonged to them, these regions showed excessive functional magnetic resonance imaging signals compared with the other 2 groups. These differences in neural function correlated significantly with hoarding severity and self-ratings of indecisiveness and “not just right” feelings among patients with HD and were unattributable to OCD or depressive symptoms. Conclusions Findings suggest a biphasic abnormality in anterior cingulate cortex and insula function in patients with HD related to problems in identifying the emotional significance of a stimulus, generating appropriate emotional response, or regulating affective state during decision making.
Hoarding disorder (HD) is increasingly viewed as distinct from obsessive-compulsive disorder (OCD). In particular, some researchers have suggested that HD is characterized by substantial problems of neurocognitive function; however, HD patients have not yet been compared to OCD patients in this respect. The aim of the present study was to compare neuropsychological test performance in HD patients (n = 27), OCD patients (n = 12), and healthy controls (n = 26). Consistent with previous research, HD patients showed an attenuated ability to sustain attention and poorer employment of adaptive memory strategies compared to healthy controls. HD and OCD patients did not differ significantly on these measures, although moderate effect sizes suggested that hoarders showed somewhat greater attenuation of attentional capacity. Rates of true impairment on any particular neuropsychological test were fairly low across all three groups, although 67% of HD patients (compared to 58% of OCD patients and 42% of healthy controls) scored in the impaired range on at least one measure (odds ratio = 2.22). Results are discussed in terms of emerging conceptualizations of HD as a distinct illness.
Hoarding Disorder (HD), defined as the acquisition of and failure to discard large volumes of possessions, resulting in clutter that precludes normal use of living spaces, is a common and debilitating condition. Although hoarding has historically been conceptualized as a variant of obsessive-compulsive disorder (OCD), increasing evidence suggests that hoarding might be more closely associated with the symptoms of attention deficit-hyperactivity disorder (ADHD). The aim of the present study was to clarify the relationship between the core features of hoarding (clutter, difficulty discarding, acquiring), OCD symptoms, and ADHD symptoms. HD (N = 39), non-hoarding OCD (N = 26), and healthy control (N = 36) participants underwent careful diagnostic interviewing and completed standardized self-report measures of the core features of hoarding (clutter, difficulty discarding, acquiring), OCD symptoms, negative affect, and the inattentive and hyperactive/impulsive symptoms of ADHD. Multiple linear regressions demonstrated that after controlling for global negative affect, OCD symptoms did not significantly predict any of the core features of HD. Conversely, the inattentive (but not hyperactive/impulsive) symptoms of ADHD significantly predicted severity of clutter, difficulty discarding, and acquiring. These results challenge current conceptualizations of hoarding as a subtype of OCD, and suggest an association with neurocognitive impairment.
Current models of Hoarding Disorder (HD) emphasize problems of decision-making. Evidence for neuropsychological impairment in HD, however, has been mixed. The present study examined whether HD patients show problems of economic reasoning that could be associated with decision-making problems. Forty-two HD patients, 29 obsessive-compulsive disorder (OCD) patients, and 36 healthy control participants completed the Iowa Gambling Task (IGT), a computerized card playing game that assesses participants' ability to learn and utilize a rule of sacrificing short-term gain for long-term gain, and a cognitive dissonance reduction task that measured changes in preference for items (art prints) after selecting or rejecting them. Results showed no deficits on the IGT for HD participants, and no difference in dissonance reduction results after selecting or rejecting items on the dissonance reduction task. Furthermore, performance on these two tasks was unrelated to hoarding symptom severity or self-reported indecisiveness. It is suggested that the problems of cognitive processing in HD patients may be largely related to as-yet understudied processes, including idiosyncratic categorization problems for personally-owned items as well as other aspects of economic reasoning.
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