To discard or not to discard: the neural basis of hoarding symptoms in obsessive-compulsive disorder

Abstract

Preliminary neuroimaging studies suggest that patients with the 'compulsive hoarding syndrome' may be a neurobiologically distinct variant of obsessive-compulsive disorder (OCD) but further research is needed. A total of 29 OCD patients (13 with and 16 without prominent hoarding symptoms) and 21 healthy controls of both sexes participated in two functional magnetic resonance imaging experiments consisting of the provocation of hoarding-related and symptom-unrelated (aversive control) anxiety. In response to the hoarding-related (but not symptom-unrelated) anxiety provocation, OCD patients with prominent hoarding symptoms showed greater activation in bilateral anterior ventromedial prefrontal cortex (VMPFC) than patients without hoarding symptoms and healthy controls. In the entire patient group (n = 29), provoked anxiety was positively correlated with activation in a frontolimbic network that included the anterior VMPFC, medial temporal structures, thalamus and sensorimotor cortex. Negative correlations were observed in the left dorsal anterior cingulate gyrus, bilateral temporal cortex, bilateral dorsolateral/medial prefrontal regions, basal ganglia and parieto-occipital regions. These results were independent from the effects of age, sex, level of education, state anxiety, depression, comorbidity and use of medication. The findings are consistent with the animal and lesion literature and several landmark clinical features of compulsive hoarding, particularly decision-making difficulties. Whether the results are generalizable to hoarders who do not meet criteria for OCD remains to be investigated.

Hoarding disorder: a new diagnosis for DSM-V?

“…[5,23] Whereas OCD symptoms are mediated by elevated activity in specific orbitofronto-striatalpallidal-thalamic circuits, [67] compulsive hoarding symptoms seem to be mediated by partially distinct fronto-limbic circuits involving the cingulate cortex, ventromedial prefrontal cortex, and limbic structures. [5,18,23,25] Similar results were obtained in com-pulsive hoarding samples with [18] and primarily without [25] OCD, but more research is needed before firm conclusions can be drawn. Interestingly, these preliminary results are consistent with the animal and human lesion literature, which also implicate the ventromedial prefrontal cortex and subcortical limbic structures in hoarding behavior.…”

“…[5,7,[18][19][20][21][22][23][24][25][26][27] Several clinician and self-administered measures also have been developed to reflect these criteria and are now widely used in the field, including the Saving InventoryRevised, [28] the Hoarding Rating Scale, [29] and the UCLA Hoarding Severity Scale. [30] In light of recent developments and cumulative knowledge gained over the last decade, the original criteria by Frost and Hartl [17] have now been further refined and are listed below: These proposed diagnostic criteria would be accompanied with additional text for clarification.…”

Hoarding symptoms and prediction of poor response to limbic system surgery for treatment-refractory obsessive-compulsive disorder

“…14, 45 The results confirm the emerging view that hoarding has a neurobiological substrate distinct from OCD 5,52 and lend further support to the addition of a separate hoarding disorder in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5). 4 Rück and colleagues, 44 in their previous analysis of the STOCK cohort, reported that the presence and severity of symmetry/order symptoms correlated with worse outcome, and that "…in some analyses, hoarding rather than symmetry/ordering scores appeared as the strongest predictors."…”

“…Score reductions on the Y-BOCS determined clinical outcome. Based on previous findings that the hoarding dimension is particularly linked to worse response to conventional treatments, 32,53 distinct neuroimaging characteristics, 5,46,55 and possibly reduced benefit from neurosurgical interventions, 14,44 we predicted that patients with hoarding symptoms would have worse outcome when compared with nonhoarders.…”

“…Although still tentative, correlations between patterns of obsessive-compulsive symptoms and surgical outcome (using different brain targets) could not only improve surgical protocols, but also provide more direct evidence to support the assumption that symptom dimensions are individually associated with distinct neurobiological substrates. 3,5,17,34,38,39,55 The objective of this study was to further investigate if symptom dimensions influence the treatment outcome of limbic system neurosurgeries for OCD through the analysis of data from 3 different research centers. Specifically, Dimensional Y-BOCS (DY-BOCS) 41 or Y-BOCS-SC scores were used to codify patients into 4 symptom dimensions (as proposed by Bloch and colleagues 10 ): forbidden thoughts, contamination/cleaning, symmetry/ order, and hoarding.…”