A 41-year-old woman agrees to talk with the physician at her husband's insistence. She says, "I've always had trouble throwing things away, especially magazines, newspapers, and old clothes. I constantly worry that I may need the items again or will want something after throwing it out." Her husband is concerned that the large piles in their house continue to grow, making it difficult to move around or find a place to sit. He says, "The house has become unlivable; we never have friends or family over because it is too embarrassing. Maybe she acts this way because she was poor growing up, but I don't know how we can continue to live like this." The patient has attempted to clean rooms or throw things away on many occasions but always becomes severely anxious at the thought of parting with various items. She has no problems with sleep, appetite, concentration, or motivation. Which of the following is the most appropriate next step in management?
This patient has characteristic symptoms of hoarding disorder, a new disorder in DSM-5 that is distinct from obsessive-compulsive disorder. Hoarding disorder is characterized by accumulation of a large number of possessions that may clutter living areas to the point that they are unusable. Patients experience intense distress when attempting to discard possessions regardless of their actual value. Social isolation due to embarrassment (eg, being unable to invite people to their homes) may also occur. Extreme cases may be associated with unsanitary conditions and fire risk due to blocked exits.
Cognitive-behavioral therapy (CBT) specifically targeted to hoarding behaviors is the most effective treatment. Specific techniques include education, motivational interviewing, skills training in organization and decision-making, cognitive restructuring of dysfunctional thoughts, and gradual exposure to discarding possessions. Although selective serotonin reuptake inhibitors (SSRIs) are often tried based on their efficacy in treating obsessive-compulsive disorder, their efficacy in treating hoarding behavior without obsessive-compulsive disorder is limited. SSRIs can be considered as an adjunct to CBT and can be helpful in treating comorbid depression and anxiety disorders.
(Choice A) Attempting to assist the patient in sorting and discarding objects would likely exacerbate her anxiety and should be performed only as part of a comprehensive CBT program.
(Choice B) Clomipramine is a tricyclic antidepressant used as a second-line treatment in obsessive-compulsive disorder due to its less favorable side effect profile.
(Choices C and F) Treating the patient's anxiety pharmacologically with a benzodiazepine (eg, clonazepam) would not address her underlying hoarding disorder. Antipsychotics (eg, quetiapine) are not indicated in the treatment of hoarding disorder.
(Choice E) Psychodynamic psychotherapy emphasizes the role of unconscious mental processes in producing symptoms with the goal of developing insight. It has not been shown to be effective for hoarding disorder.
Educational objective:
Hoarding disorder is characterized by difficulty discarding possessions regardless of their actual value. It is best treated with cognitive-behavioral therapy.