Medicines for the Treatment of Hoarding
by Sanjaya Saxena, M.D.
Professor, UCSD Department of Psychiatry
Director, UCSD Outpatient Psychiatric Services
Most psychiatric manuals, like the DSM-IV, list obsessive compulsive disorder (OCD) as its own, single mental health disorder. This means that it is unlike any other kind of mental health disorder but that all of the different kinds of OCD symptoms all fall under the “umbrella” of OCD. For this reason, most of the studies about how OCD works and how it responds to treatment lumped all of the different symptoms of OCD together.
However, large studies of OCD symptoms have actually shown that there are four main kinds of symptoms:
- aggressive, sexual, and religious obsessions with checking compulsions;
- obsessions about evenness and neatness (called symmetry) with ordering, arranging, and repeating compulsions;
- contamination obsessions with washing and cleaning compulsions; and
- hoarding, saving and collecting symptoms.
Studies have shown that each of these symptoms may have genetic differences and that, most importantly, each responds differently in the way that they respond to treatment. This page will discuss the fourth symptom, hoarding, and how and why it responds to different medicines.
Hoarding is when a person acquires too many items and who also has problems getting rid of worthless items even though they appear (to others) to have no value. Hoarding can sometimes be seen in other disorders, such as dementia, autism, and eating disorders, but it is most commonly seen in people with OCD.
As many as 1 in 5 OCD patients are believed to have hoarding symptoms as their main kind of OCD. That means that there are between 600,000 and 1.2 million people who hoard in the United States alone.
For more on hoarding, click the following link overview of hoarding.
Differences Between Hoarding and Non-Hoarding OCD
Many clinicians and researchers believe that compulsive hoarding is either different kind of OCD or a subtype of OCD. Although few studies have directly compared patients with hoarding to patients with non-hoarding OCD, they have found several differences, including:
- Hoarders have more disability in their daily lives than non-hoarders.
- Hoarders show more severe symptoms of anxiety, depression, personality disorders, and family and social problems than non-hoarders.
- In a recent study at our clinic, we also found that hoarders did not respond as well to intensive, multifaceted treatment as non-hoarders did.
- Several studies have shown that hoarders are less likely to be married than those with non-hoarding OCD.
- Hoarders often have less insight or awareness of their symptoms than non-hoarding OCD, making them less likely to seek treatment.
There are also differences in the genetic makeup of hoarding as compared to other kinds of OCD. The hoarding symptom factor seems to have a recessive pattern in the way that it is inherited from parents, while the other three kinds of OCD seem to have a dominant pattern.
Considering all of these differences, the studies seem to suggest that compulsive hoarding syndrome may be a very different kind of OCD that could be caused by different genetic and family factors.
Medicines for Hoarding
There two kinds of treatment that have been shown to work for OCD:
However, studies have shown that compulsive hoarding does not usually respond well to typical OCD medicines. One study looking at 18 cases of compulsive hoarders showed that only 1 out of the 18 who were treated with a variety of SSRIs responded well to the medicines. Nine more had a slight response, but nine others had little to no response at all. Other studies have shown that the more severe a person’s hoarding is, the less likely they will respond to SSRI treatment. Despite this, not prior medicine study has specifically targeted compulsive hoarding.
The only type of treatment that has been found to be broadly effective for the compulsive hoarding syndrome is CBT. This is specifically tailored to its symptoms and associated features. That does not mean that medicines do not have a role in treating this syndrome. They are often necessary. Currently, the usual approach to treating hoarding with medicines is still to start with SSRIs. This is done for several reasons. Firstly, even though hoarding/saving symptoms are statistical predictors of poor response, there are still some hoarders that do respond to SSRIs. Secondly, most hoarders have other OCD symptoms that may respond to SSRIs. These may respond well to SSRI treatment.
If the person with hoarding does not show an improvement even after a doctor has tried using an SSRI at both its highest dose and/or for at least 12 weeks, they may choose to add a second medicine. Some of these medicines may include the antipsychotic medicines:
- risperidone (Risperdal)
- olanzapine (Zyprexa)
- quetiapine (Seroquel)
- haloperidol (Haldol)
- fluphenazine (Prolixin)
However, since no study has ever specifically researched the effects of medicine on hoarding, it is not known if any of these medicines will work for compulsive hoarding.
For those who have hoarding and a coexisting disorder such as bipolar disorder, ADHD, or schizophrenia, other medicines may also need to be used. These disorders can interfere with CBT, so they need to be controlled before CBT for hoarding can start.
Neurobiology of Compulsive Hoarding
Neurobiology refers to how the brain works and how it is structured. Growing evidence is showing that there may be differences in the neurobiology for each kind of OCD. These differences may be why the symptoms, co-occurring disorders, and response to treatments are different in each of the four main types of OCD. If these differences can be study, the brain activity of patients with hoarding was compared to those of non-hoarding OCD patients and those without any psychiatric disorder. The results showed that the patients with hoarding had a unique brain activity pattern when compared to the other two groups.
In hoarders, patients had less activity in a part of the brain (called the posterior cingulated gyrus) that involves visual processing. Differences in the brain activity between non-hoarding OCD patients and hoarding OCD patients, leading researchers to believe that there may be structural brain differences between even non-hoarding and hoarding OCD patients.
The symptoms of compulsive hoarding may be caused by less activity in a part of the brain on the middle surface of the brain called the cingulated cortex. This area connects the emotional part of the brain with the parts that controls higher-level thinking. Lessened activity in these parts of the brain can cause severe problems in making decisions, emotional problems and other thought-based problems seen in hoarders. This lessened activity may also be why compulsive hoarding does not respond as well to standard antiobsessional treatments (such as antidepressants, fluvoxamine, and cingulotomy).
Future Directions for Treatment
It is important that new medicines target brain problems specifically related to hoarding. Since information-processing problems are so often seen in those with hoarding, new medicines should target problems with decision-making, organization, attention, and memory. No study has measured these particular problems in those with hoarding, but if common problems were found in hoarders, targeted treatments may be able to be help.
Some medicines that may work on these problems include cognitive enhancers often used in the treatment of Alzheimer’s disease:
- donepezil (Aricept)
- galantamine (Reminyl)
These medicines have not yet been tried on OCD patients, but are now being tried on some patients with ADHD and Tourette’s syndrome. We plan on testing these medicines, along with the standard drugs, to see if they will work on patients with compulsive hoarding. If they do work, it may make it easier for patients to discard items and organize their time and living space.
Other medicines that may help those with hoarding might be stimulants that are often used in ADHD. Since they improve attention, alertness, and how fast information is processed, those with hoarding might benefit from these medicines. We are now testing the use of stimulants in addition to the standard meds for hoarding.