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

Abstract

Object Recent findings have suggested a correlation between obsessive-compulsive disorder (OCD) symptom dimensions and clinical outcome after limbic system surgery for treatment-refractory patients. Based on previous evidence that the hoarding dimension is associated with worse outcome in conventional treatments, and may have a neural substrate distinct from OCD, the authors examined a large sample of patients undergoing limbic surgery (40 with capsulotomy, 37 with cingulotomy) and investigated if symptom dimensions, in particular hoarding, could influence treatment outcome. Methods Data from 77 patients from 3 different research centers at São Paulo (n = 17), Boston (n = 37), and Stockholm (n = 23) were analyzed. Dimensional Yale-Brown Obsessive Compulsive Scale (Y-BOCS; São Paulo) or Y-BOCS Symptom Checklist scores (Boston and Stockholm) were used to code the presence of 4 well-established symptom dimensions: forbidden thoughts, contamination/cleaning, symmetry/order, and hoarding. Reductions in YBOCS scores determined clinical outcome. Results Mean Y-BOCS scores decreased 34.2% after surgery (95% CI 27.2%–41.3%), with a mean follow-up of 68.1 months. Patients with hoarding symptoms had a worse response to treatment (mean Y-BOCS decrease of 22.7% ± 25.9% vs 41.6% ± 32.2%, respectively; p = 0.006), with no significant effect of surgical modality (capsulotomy vs cingulotomy). Patients with forbidden thoughts apparently also had a worse response to treatment, but this effect was dependent upon the co-occurrence of the hoarding dimension. Only the negative influence of the hoarding dimension remained when an ANOVA model was performed, which also controlled for preoperative symptom severity. Conclusions The presence of hoarding symptoms prior to surgery was associated with worse clinical outcome after the interventions. Patients with OCD under consideration for ablative surgery should be carefully screened for hoarding symptoms or comorbid hoarding disorder. For these patients, the potentially reduced benefits of surgery need to be carefully considered against potential risks.

Intensive residential treatment for severe obsessive-compulsive disorder: Characterizing treatment course and predictors of response

“…In agreement with these findings, prior studies of compulsive hoarders have demonstrated poorer treatment outcomes to a variety of treatment approaches including CBT (Abramowitz et al, 2003b; Rufer et al, 2006), behavioral therapy (Mataix-Cols et al, 2002), pharmacologic (Mataix-Cols et al, 1999), intensive multimodal treatment in the context of a partial hospitalization program (Saxena et al, 2002), and limbic surgery (Gentil et al, 2014). Taken together, these findings support the recent view of compulsive hoarding as a distinct disorder separate from OCD that may require different treatment approaches (Pertusa et al, 2010).…”

Parental bonding and hoarding in obsessive–compulsive disorder

“…Compulsive hoarding is characterized by collecting, and difficulty discarding, large quantities of seemingly useless objects, such that living spaces are cluttered and considerable distress and/or impairment are experienced [4]. Among OCD cases, those with hoarding often have a more severe illness, poorer response to treatment, co-occurring mood, anxiety, and other Axis I disorders, and schizotypal, avoidant, dependent, and obsessive-compulsive personality traits [5-11]. In addition, neurocognitive and neuroimaging studies have found differences in executive functioning, and level of activation in specific brain regions, between OCD cases with and without hoarding [12-17].…”

Transcranial direct current stimulation in obsessive–compulsive disorder: emerging clinical evidence and considerations for optimal montage of electrodes

“…In this regard, Gentil et al (2014) found hoarding symptom to be a predictor of poor response to neurosurgical intervention in OCD [86]. …”