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To the Editor: The intriguing report by Sanjaya Saxena, M.D., et al. on hoarding (1) prompts me to write concerning what I believe is a significant defect in DSM-IV-TR regarding persons who primarily present with hoarding.
My own experience with hoarders is based on having performed close to 800 guardianship evaluations over the last 15 years. Guardianship evaluations are generally performed as home visits. The high prevalence of hoarding in this group is notable.
Dr. Saxena et al. included hoarders within obsessive-compulsive disorder (OCD). Our diagnostic manual defines compulsions as "repetitive behaviors" and gives examples that all have an active motoric or cognitive component. The actions or mental acts "reduce anxiety." Hoarding, I believe, usually arises from inaction. The only anxiety I have observed is when hoarders are threatened by forced clearing. The problem is not so much that these people collect. The problem is that they are unable to discard.
Hoarding in DSM-IV-TR appears only in the description of obsessive-compulsive personality disorder. The "differential diagnosis" for obsessive-compulsive personality disorder does state that OCD should be diagnosed when hoarding is "extreme." Thus, "extreme" hoarding is OCD, and less than "extreme" hoarding is obsessive-compulsive personality disorder. The clinician is further frustrated by being referred to the OCD section but finds the DSM-IV-TR section on OCD totally silent in respect to hoarding. Although DSM-IV-TR accommodates a dual diagnosis of OCD and obsessive-compulsive personality disorder, it clearly discourages diagnosing both conditions: "the clinical manifestations of these disorders are quite different" (p. 462).
One of the significant findings by Dr. Saxena et al. is that there is an anatomic locus for the syndrome of hoarding. This certainly should lead us to conclude that the one place hoarding does not belong is among "personality disorders." Hoarding needs to be explicitly embraced under OCD. To do this, the basic definitions of OCD may need to be modified.
An alternative suggestion is to regard hoarding syndromes as independent of OCD and as part of a new grouping of diagnostic entities titled "disorders of executive function."
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