Hoarding disorder in a first psychotic episode: a case report

Dear Editor,

We present the case of a 29-year-old male, with no previous personal or family psychiatric history, who was taken by the authorities to the psychiatric emergency department. According to his relatives, he had been isolated at home for the past four years. He spent his days consistently following the same routine: playing on the computer in the living room and watching the neighbours’ movements.

During these four years he accumulated hundreds of food cartons, letters, and newspapers in the living room. Due to this accumulation it was difficult to walk in the room and it was impossible for others to use it.

While collecting his medical history, the patient was defensive and anxious. He claimed to have spent the previous four years working online for several prestigious companies. When directly questioned about family relationships he said “my father now belongs to a religious sect that wants to harm me” (sic). Regarding his accumulation behaviour he stated that “in my living room I can have whatever I want, I like having things around me and throwing them away makes me feel anxious” (sic).

The patient was admitted as an inpatient at the hospital ward and treated with risperidone 4 mg/day. The blood analysis and head computed tomography scan did not show pathological findings. The PANSS (Positive and Negative Syndrome Scale) score was 71 points and the SCL-90- R (Symptom Checklist 90 Revised) showed high scores in the anxiety and paranoid ideation subscales. He was diagnosed according to DSM-5 with schizophrenia (295.9) and hoarding disorder (300.3). At the time of discharge the patient did not present positive symptoms. During follow-up, the patient took the prescribed medication, was able to get a job and developed insight into his pathology. He denied hoarding behaviour and relatives confirmed this.

Hoarding symptoms are now classified in DSM-5 as hoarding disorder (HD), an entity under the category, “Obsessive Compulsive and Related Disorders”¹. This disorder is characterised by persistent difficulty discarding possessions (regardless of their actual value) due to a perceived need to save the items and due to the distress associated with discarding them. This results in the accumulation of possessions that congest active living areas, compromising their use. These behaviours cause clinically significant distress and impairment in functioning.

In a study carried out in a sample of 400 chronic patients with schizophrenia, the authors reported that the percentage of patients manifesting abnormal acquisition behaviour was below 20%². In a more recent study, 5.9% of patients diagnosed with psychotic disorders exceeded the cut-off for the diagnosis of HD³.

Proposed mechanisms for this co-morbidity are serotonin and dopamine deregulation in basal ganglia or the use of hoarding as a strategy for stress relief caused by positive symptoms⁴.

As far as we know this is the first report in literature of HD in a first psychotic episode. This article outlines the need to assess hoarding symptoms according to DSM-5 criteria in psychotic disorders, so as to better understand the relationship between positive symptoms and HD.

References

• ¹
  American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders – DSM-5. 5th ed. Washington: American Psychiatric Association; 2013.
• ²
  Tracy JI, de Leon J, Qureshi G, McCann E, McGrory A, Josiassen RC. Repetitive behaviors in schizophrenia: a single disturbance or discrete symptoms? Schizophr Res. 1996;20(1-2):221-9.
• ³
  Novara C, Bottesi G, Dorz S, Sanavio E. Hoarding symptoms are not exclusive to hoarders. Front Psychol. 2016;7:1742.
• ⁴
  Tonna M, Ottoni R, Paglia F, Monici A, Ossola P, DE Panfilis C, et al. Obsessive-compulsive symptoms in schizophrenia and in obsessive-compulsive disorder: differences and similarities. J Psychiatr Pract. 2016;22(2):111-6.

Publication Dates

• Publication in this collection
  06 June 2019
• Date of issue
  Mar-Apr 2019

History

• Received
  26 July 2018
• Accepted
  15 Feb 2019