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ADHD Science episode 8 with Giacomo Grassi
173 Plays1 year ago
We talked to Giacomo Grassi, Psychiatrist and ADHD researcher in Firenze, about the surprising relationship between hoarding and ADHD.
His paper is here: https://www.sciencedirect.com/science/article/abs/pii/S002239562300417X
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Transcript
Introduction of Hosts and Topic
00:00:08
Speaker
Hello! Hello! And welcome to the ADHD Science Podcast. I am Tess Davie and I'm here with Max Davie. And I'm Max Davie and I'm here with Tess Davie. Well, isn't that wonderful? Isn't that a coincidence? Yeah. We realised that we've forgotten to start the episodes off by introducing ourselves, so that's who we are. Yes. In case there was any question about that. Why do we have the same name, Tess?
00:00:30
Speaker
what?! you know i never realized that this is my dad um yeah so today we are here with
00:00:38
Speaker
Yes, I didn't want to risk saying it in case I was wrong. This is one of my favorite episodes that we've recorded. I had a really good time. He's got some really interesting stuff to say so stay tuned for that.
Is Hoarding Linked to ADHD or OCD?
00:00:53
Speaker
Yes, we're going to talk about hoarding which is such an interesting topic and something that I've always associated with other conditions other than ADHD but
00:01:06
Speaker
Giacomo really makes a really good case that it's a very, very important part of ADHD and very closely aligned to ADHD, and that we should maybe think differently about it. Come on, no spoilers. Well, I think... Anyway, that's what they say. Tell people what you're going to say, say it, and then tell people what you've said, because... Well, stay tuned to the outro. We're going to recap what you've just heard us say. It's possible. All right. Enjoy. On with the interview.
00:01:35
Speaker
Right, welcome. Here we are with Giacomo Grassi from the Brain Centre for Enzi. Welcome, Giacomo. Thank you very much for joining us this morning.
00:01:45
Speaker
Thank you, Max. Now, this paper, just to give you a spoiler, this is one of those papers when I read through the little Google alert I get for ADHD. Sometimes I read through the abstracts and I kind of knew that. This is one of those papers when I'm like, I did not see that coming. So I'm really excited to meet you, but also to talk about your specific paper today on hoarding. So do you want to get started,
Research Insights on Hoarding Disorder
00:02:10
Speaker
Tess? Yes, absolutely. So in your research, what question were you answering?
00:02:15
Speaker
Actually, our reason start with the idea, I mean, the first question was, is it really hoarding so frequent in OCD patient? Because actually, as I work as a clinician mainly, and I see both OCD patient and ADHD patient, and since many years, the impression was that hoarding disorder was a really common comorbidity
00:02:42
Speaker
in ADHD people more than in OCD people. So that was the first question. Is it really so frequent in OCD people, respect to ADHD people? And we noticed that there was no status in the literature directly comparing this comorbidity on ADHD and OCD population.
00:03:04
Speaker
And actually, maybe I could spend a few words on them. Just to come back. So we've got a comparison of the ADHD population, the OCD population and hoarding. We probably don't need to define for our audience ADHD now, but it's worth just, there's, OCD is one of those conditions where there's such misunderstanding about what it is. And there's, I don't know if you come across, I'm a little bit OCD.
00:03:30
Speaker
which is one of the most annoying things that people say related to the mental health issue ever and then there's what hoarding actually is because I think hoarding is another one of those things well I'm a bit of a hoarder what actually what you mean when you say those things would be really helpful okay with okay it makes sense to clarify the things yes but OCD old people said I'm a bit obsessed but usually they refer to
00:03:53
Speaker
OCPD, Obsessive Compulsive Personality. That kind of, you like, you are a bit rigid, you like symmetry, things in a certain way, things could be just right. But having OCD, it's different stuff. I think OCD is having obsession. So those, there are distressing in some way.
00:04:13
Speaker
Those that are not controlled, that make you anxious, that cause you distress, and then you have compulsion.
Understanding OCD vs Hoarding
00:04:21
Speaker
So, compulsions are everything you can do, could be an act or could be a mental, another thought, to decrease the anxiety or the distress of the session.
00:04:31
Speaker
So having OCD, it's having obsession and compulsion. The thing that I think is crucial is that it's not that it's external like it's coming in from, but it almost feels external to yourself. It's an unwelcome addition to your own psychology. It's not something that's comforting to do these things. It's something that's distressing and unpleasant to do these things. Sure. I imagine the classical example now, if I had the doubt, did I close the door? Okay.
00:04:59
Speaker
It's a normal thought, but imagine that after you check, again, you have this thought and you know that you're close, already close, but you have a lot of anxiety and you have to check again. This is really obsession and compulsion. Having a beat of obsession and compulsion, actually, it's not a disorder. I think one-third of the worldwide people
00:05:20
Speaker
obsession and compulsion. We all have obsession and compulsion. And probably it's something also that helped our evolution. But if you have it, if you have too much of them, if you have many of them in time of time consuming, many, and all these thoughts compromise your daily life, you can speak about disorder. So having sometimes some obsession and compulsion, it's not a disorder. So usually many people could experience this.
00:05:46
Speaker
But it's another stuff from the people saying, okay, I'm a manic of ordering, I'm a manic of the clean of this. When people speak like this, it's another stuff. It's not another stuff.
00:06:00
Speaker
And hoarding, again, hoarding, it's not, it's something really different from people making, for example, collection or don't like to take many things to have many things in their house. Hoarding, it's something related to the difficulties in discarding objects and things. That's really the core of hoarding disorder.
00:06:24
Speaker
That also most people with what we call ordinary go-to also have excessive acquisition. So are people that usually take a lot of stuff and they have difficulty in discarding, but not all. I mean, it's not mandatory. Even in a DSM-5 excessive acquisition, it's like a specifier. It's not a core symptom of the diagnosis. Really the core, it's difficulties in discarding and the result should be that you have
00:06:52
Speaker
problem in your house because all the things that you're not able to discard accumulate in your house and clutter your living space. So again, in that context, it became a disorder. So people that really, I mean, I think there is a popular show in Italy, it's, I don't know, it's, I don't know if you have in the UK a TV show about hoarding people. We do, and I can't, to be honest, I can't remember, it's cold. I don't know, I don't think I can. I don't know the English title.
00:07:22
Speaker
Anyway, I know that there's a lot of content on social media of like people cleaning. And, and again, the stereotype are of extreme ordering disorder. But actually, ordering disorder, it's something I mean, really quiet, I mean, that it's not so stereotype. Okay, I mean, but the thing is, not having difficulty getting rid of things that you are you like, because you bought them because you like them.
00:07:50
Speaker
presumably, and having having difficulties getting rid of stuff that you like, it is, to an extent, normal, and in a very typical kind of behavior. So to where do we draw the line? Where do we say this is a problem? But that's really a good point, because really, the border is that
00:08:13
Speaker
that you have difficulties in discarding independently of the value.
ADHD and Hoarding: A Connection?
00:08:18
Speaker
It could be something that has an economic value, an emotional value, or no value. The problem is that you have difficulties in discarding
00:08:27
Speaker
everything. And of course, for the things that have an economic value, it's much difficult for the thing that they have effective behaviors that much difficult, but the problem is that holding people have difficulties in making decisions and balancing their decisions. So I have my, maybe I cannot choose anymore the kitchen because it's full of stuff. I have to discard things.
00:08:51
Speaker
that maybe have an economic value, but I'm not able to do it. So I don't choose the kitchen and I hoard it with like restaurant delivery stuff because my kitchen is full of stuff and I'm not discard them. It's this kind of difficulties. And that's why actually, and we will see, and that was the idea of the paper and the literature in this field that decision making, executive function and attention are really,
00:09:21
Speaker
core aspects of hoarding disorder, and that's why probably the link with ADHD. But in the beginning, hoarding disorder, I mean, hoarding disorder, it's a quite new diagnosis in the Nosography, International Nosography. It was 2013 when the DSM-5 came out that hoarding finally became a separate disorder.
00:09:47
Speaker
Before that date, it was just considered a subtype of OCD. Yes. So that's the thing that we need to make clear to listeners is that both in the popular imagination and also in medical diagnosis, and you use the word nesography, which is essentially classification of conditions and classifications of symptoms. But both in the popular imagination and also in medical classification, hoarding and OCD were closely related, closely learned.
00:10:18
Speaker
At the beginning, they were the same things. I mean, having hoarding was like subtype of symptom of OCD, because if you have OCD, you can have different kinds of symptoms. You can have doubts and then you can check. You can have fear of get infected and whoosh. And you can have also obsession about if I discard things, if I throw away these things, something bad could happen. And this is like what we call an hoarding symptoms in OCD. But then,
00:10:49
Speaker
One, in the clinical trial for OCD, a fact, a clear fact came out that patient with OCD and what we call at that time hoarding did not respond well to the medication that usually works in OCD patient. So, hoarding disorder became over the decades from the early 2000, a subtype of OCD that was considered really a resistant subtype.
00:11:18
Speaker
That's why some researchers start styling it as a separate disorder, making the hypothesis, maybe it's something different. We are calling OCD something that is not. And that's why we arrived in 2013 to the idea that ordering disorder is something different. And today you could have OCD with hoarding symptoms. And in that case, you have obsession about hoarding. So you have
00:11:42
Speaker
those that make you anxious about things you acquired or you have to discard, and then compulsion. And then you could have hoarding, that it's a different stuff in which you don't have obsession, you don't have compulsion, and you have the hoarding criteria so that if people is in this kind of things that result in clutter in your house.
00:12:02
Speaker
So that is the picture today. And that's why hoarding disorder has been considered in the OCD spectrum. If you look to the DSM-5 and the ICD hoarding disorder, it's still considered something in the OCD spectrum.
00:12:18
Speaker
My paper, it's the last of a series. I mean, I didn't discover anything. As usual in research, you never discover anything, something could explode. But I just systemized the idea. I did the right paper at the right time, taking all the knowledge we already have. No, because other researchers before me start investigating, start noticing that
00:12:47
Speaker
even in hoarding patients, in patients with primary hoarding disorder, ADHD was very common, was a very common comorbidity. So the studies were on patients with a primary diagnosis of hoarding disorder. And looking to their childhood, this researcher noticed that they had really a high degree of
00:13:07
Speaker
ADHD and specifically the more attentional ADHD. So people with a story of more problematic attentional symptoms. And this is quite consistent across several studies. And this makes sense because ordering disorders, neuropsychological studies of ordering disorder show that ordering people have problems with attention and executive function
Prevalence of Hoarding in ADHD Patients
00:13:34
Speaker
that we know are core aspects of ADHD.
00:13:37
Speaker
and taking mine. The problem of hoarding people is, for example, if I had to organize all the clutter I have and to decide what to discard, I have to use many executive functions. Executive functions are the functions like organization, planning, visual-special organization, decision-making, impulsivity. All these functions are used when I have, for example, to say, okay, today I want to, it's Sunday, I want to order,
00:14:07
Speaker
My house, I have to discard many things, I have to throw away many newspapers, I didn't read, I never read, but I have to use this function. So that was the link on a neuropsychological perspective. And then we had the data that hoarding patient had a lot of comorbidity with ADHD. What was interesting, there was like a few studies investigating hoarding disorder in patient with ADHD, but clinically it's something that
00:14:36
Speaker
me, I mean, I spent many years and I still doing research on the OCD spectrum. So for me, it was quite common to ask to ADHD patients that I see every day, how is your house? I mean, how is your room? And the average answer is it's a house. It's a lot of stuff. And always the idea is that because
00:15:00
Speaker
I don't mind, I mean, I don't have gratification reward if I order things so I don't mind and I leave it here. But then we noticed that there are many patients that are something more than this. Many patients saying, even when I try to order things, I struggle because I have difficulties in discarding. And there was, and so the idea was we started, we did the first study actually,
00:15:29
Speaker
before I start working with the brain center for ants in my previous relation, we did like a clinical, a preclinical and clinical studies. So the idea was, let's try to treat ordering patient with medication that are used for ADHD, starting from that. Okay. And we published a paper was, I think 2015 or 16 on journal of psychiatry research, the same journal where we published this paper.
00:15:55
Speaker
Now, and we did a preclinical studies trying atomoxetin, that is a non-stimulant agent for ADHD. And that time was like the most commonly used in Italy for adults, because in Italy for treating ADHD with medication, it's very complicated. Okay, we're still, we have just now today, we have just methylphenidate. At that time, we have methylphenidate and atomoxetin. So we try atomoxetin in patient with hoarding.
00:16:24
Speaker
disorder and in a preclinical model, a mouse model of compulsivity. That is the marble bearing test. I don't go deep on that, but we don't mind about that. But in a small sample, I think there was like 11 patients, something like that. Now I don't remember exactly that. We have like a good response on hoarding symptoms using alcohol. Just to go back, you found that
00:16:51
Speaker
treating people with hoarding disorder who don't necessarily have a formal diagnosis of ADHD, but treating them with ADHD type medication kind of works. Yeah. Yeah. That was like really preliminary and really on a small sample, people followed. So it was like a pilot study. But that was something that corroborate the idea, support the idea that probably attention, executive function, hoarding, ADHD, there is a link probably.
00:17:20
Speaker
Then another study, I think two years ago, came out about a group by Morin Zamir that is another researcher really involved in the field that show like 22% I think of prevalence of organ-disorder comorbidity in a sample of patients with ADHD. And that was another big data because it's allowed.
00:17:45
Speaker
They can mind that order and disorder in the general population, it's something around probably 2.5%. So having 22% in ADHD population, it's a lot. It means that something is going there in that field. So what we did with our research was a very simple thing. So we see OCD people, we see ADHD people, we have samples of LT controls that we use for doing research and we put together these three samples.
00:18:12
Speaker
patient with adult patient with a primary diagnosis of ADHD, adult patient with a primary diagnosis of OCD, and health controls. And what we did, we assessed hoarding disorder across these three groups. And what we found is that hoarding disorder, it's much more common in ADHD people than in OCD and health controls. What do we think if we consider
00:18:40
Speaker
the diagnosis, the form of diagnosis, both if we look just to symptoms. So even having subtractional symptom of organ disorder, it's something much common in ADHD people than in OCD. And it's something much common, like 32% of comorbidity in ADHD, 8% in OCD and 4% in anti-control. So something really different. Wow. Yes. That was a wow moment. That is wow.
00:19:09
Speaker
So we, I mean, we, you know, you've done, you've given such a loose exposition of your work. We haven't really had a job to kind of jump in. What do you, what's your reaction to that test? I just told you, wow. Wow. I mean, that is
00:19:24
Speaker
I mean, I don't I don't know what to say you put me on the spot here. But I guess my thought process is that it kind of feels like something that is like has been sitting there waiting to be found out about for so long. Yeah, yeah. And lots of people with ADHD thinking Oh, have I
00:19:44
Speaker
got OCD as well because I have difficulty with this or I'm, you know, I've got this difficulty with hoarding, whereas actually it's just part of their ADHD in a sense.
00:19:56
Speaker
Go on. Do you find that a lot of women, because I know women have a quite a difficult time getting diagnosed with ADHD, do you find that they tend to be more diagnosed with hoarding? So the people who were diagnosed with hoarding but not ADHD, do you find that that was more women than men? Because I was just thinking that. That's a great question.
00:20:17
Speaker
That's a great question because, of course, there will be something different between them, probably. Actually, in our study, there was, I mean, in general, we see much female than male. And that's, I mean, adults, because the population in which we found this, it's a spatial population of ADHD people. So it's adults that received in their adulthood for the first time the diagnosis of ADHD.
00:20:45
Speaker
That in Italy, it's a very common population because since there is not such a big culture about ADHD since the last years, many people have not been diagnosed during the childhood, otherwise. So we had an adult clinic and we see this kind of patient. And the most common phenotype, it's really female
00:21:07
Speaker
young female with anxiety, comorbidity that spent many years in psychotherapy and doing other treatment. And in the end, we diagnosed ADHD that was like the starting point of their trajectory. So we see more, we see a lot of wording in female, and we see less male that are less likely to report this hoarding problem in general and to report problem in general.
00:21:35
Speaker
We still don't have data about if there is statistical difference. I'm just going to ask an ignorant question, not knowing anything about hoarding disorder, really. What is the gender distribution of hoarding disorder in the general overall hoarding disorder population? Is it skewed male, female? It's something, I mean, there are conflicting studies, but it's something it's quite balanced up to now.
00:22:01
Speaker
But the problem is that we don't have many really general population studies. It's really difficult to study. And people with organ disorder in clinical study, they don't come to the psychiatric office. No one with organ disorder, I mean.
00:22:15
Speaker
I remember for the first study to find 11 patients with the primary diagnosis of hoarding disorder. It took like years because we were collecting very slowly and was like people that actually their primary diagnosis were hoarding, but they also had comorbidities, anxiety, or mood.
00:22:32
Speaker
Yes, because most people will have ADHD. It looks like a lot of people will have ADHD. Sure. And also, it's something that came out since it seems that it came out since the childhood and the early adolescence.
00:22:50
Speaker
it's something probably linked to the neurodevelopmental trajectory too and that's why probably also an hypothesis there is this comorbidity with ADHD because probably both are like neurodevelopmental and as ADHD all everything it's neurodevelopmental people grow up grow up with that disorder and try find their coping strategies to cope with that so the most the less severe form
00:23:21
Speaker
people think it's something, okay, I'm like this, I'm a bit overboard and it's not a disorder, it's like I am. Yeah, exactly. Next question, do you think? Yes. The next question is, what does this mean for people who work with ADHD people? So that can be like clinicians, the people, like the people with ADHD, carers, anything like that. So what are the implications for people looking after ADHD people of this study?
00:23:48
Speaker
All right, that's the following question we are trying to answer too, because actually now we still didn't publish, we are finalizing another study in which we compare the cognitive and clinical phenotype of ADHD patients with comorbid, hoarding disorder, and without hoarding disorder.
00:24:12
Speaker
Because, and the data, I mean, still unpublished, we have to do peer review. So, I mean, just to discuss, I mean, the point, but what we found, it's that in general, ADHD people with heart and disorder are more complex phenotypes. So, more severe cognitive dysfunction, especially we found in the executive function and attentional problems.
00:24:39
Speaker
and a greater functional impairment. And that was in line with some data, some previous data on ADHD people with hoarding. So it has several implications because it means that ADHD patients with hoarding are more severe, more complex in general. And having hoarding as a negative, it seems that it has a negative impact on the functioning and the quality of life of this patient.
00:25:06
Speaker
So, I mean, I think that the important things of our study, it's against stress, the factor that we have to look to holding symptom in these people.
Can ADHD Medication Help with Hoarding?
00:25:15
Speaker
It's a simple question that as clinician, we have to ask to people. Then what to do with that? How to treat that? It's a huge question. And of course, guys, I don't have the answer. But I have my ideas. We can think as my ideas. It's my opinion.
00:25:36
Speaker
I think that probably there are two roads we have to test. One, it's we need trials, controlled trials and properly made trials about ADHD medication in the effect of anti-ADHD medication on hoarding symptoms. And we need trial on both patient with hoarding disorder as a primary diagnosis and people with ADHD.
00:26:02
Speaker
Again, we are running a third study because we are collecting the long-term data about patient treated with methylphenidate. We are like a sample of 50 patients and we are collecting data of the effect of methylphenidate on this, but it's like a naturalistic study. So we really need trials about that. And this could be one road. So we could discover that maybe treating ADHD with medication, with the proper medication could also have hoarding.
00:26:30
Speaker
And this could be something important because also for hoarding disorder today, there are no medication indicators. Okay. We don't have studies on the hoarding disorder. We know that probably certain allergic agents don't work properly and we don't have clear psychotropic treatment that clearly are effective. And the other, on the other hand, we should try to think about psychotherapy or coaching or neuropsychological coaching intervention.
00:27:00
Speaker
for this kind of patient. Because if this patient with herding have more executive dysfunction, we have maybe to target this executive dysfunction and we can do it with like coaching neuropsychological coaching and this kind of approaches. Yeah. So just to cut that a little bit. We talked, we've talked a few times on this on the podcast about executive function. And you've sort of explained it as a kind of planning and organizing and just, I sort of think of it as a getting shit done function, basically.
00:27:30
Speaker
And coaching, although it's not evidence based, is something that's often reached for, for people who are struggling with their executive function, just to kind of almost to have another person to scaffold their executive function. I think that's often how it works.
00:27:48
Speaker
So just to sort of, does that all sort of make sense with you in terms of what you meant? But actually I was wondering, because it's often, there's a kind of folk understanding that there's something traumatized about hoarders or there's something that, you know, they can't let go of things because they have something missing in their lives. Is there anything to that scientifically or is that just a kind of popular myth?
00:28:16
Speaker
Ah, no, it's not popular. I mean, there is some studies showing that people with hoarding probably have much trauma in their early, I mean, history, respect to contour patient, but this is also the case for ADHD. And I think there are, and again, I mean, because if we look, we know there are studies showing that early trauma affect
00:28:44
Speaker
the development of attentional networks and executive function networks. And so I think this is really interesting. There are not many studies about that, but I have the chance to read something about that. And again, probably having a trauma, it's a risk factor for several circuitry that are in common. So if I have a trauma and I have attentional and executive function alteration trajectory,
00:29:12
Speaker
because of the trauma, then if I have maybe a genetic predisposition to this compulsive impulsive disorder, maybe I can develop both. So that's why I think that the gain trauma, of course, is something to look to. And in both, I mean, the population, both in ADHD and a hoarding people.
00:29:30
Speaker
I mean, I think one of the things just thinking about our listeners, you know, if you are an ADHD person and you're hoarding, it doesn't mean that you are, there's some trauma in your life that you're just not acknowledging or that you're not kind of addressing. Yeah, I was wondering if it was less that it, the trauma could cause the hoarding, but more that like if the hoarding already existed, but wasn't that noticeable, that it could make it just a lot worse? Is that, would you say that that was relevant?
00:29:58
Speaker
I think, yeah, that's probably one model. I mean, the model are today that probably trauma can exacerbate. It's something that can exacerbate the disorder. But I mean, this is a general model, I think, for all our disorder, that trauma is something that goes where you already have a vulnerability of some way.
Impact of Early Trauma on ADHD and Hoarding
00:30:19
Speaker
Yeah. OK. So I also had a question about, Cazalia, you mentioned that you thought that hoarding was probably caused by people.
00:30:28
Speaker
over acquiring things because they like them. Do you find that that is the case? Because I kind of had the impression that sometimes it can happen because of the impulsivity of ADHD and the compulsions of OCD, because of you like look at something like, Oh, I really like this, you kind of look at it and you go, I have to have this.
00:30:48
Speaker
So how impulsivity of ADHD people can play a role in this? That is the question. Actually, we found an interesting thing in our new study that is still unpublished. Unfortunately, I have to speak about unpublished data. It's not so polite. But when we look to the difference of wording symptom, in ADHD patients with clear comorbidity of wording and without, we notice that ADHD people that don't have a diagnosis of wording
00:31:17
Speaker
differentiate themselves from healthy controls because of excessive acquisition. So excessive acquisition, it's probably something of ADHD and it's not something so specific of hoarding disorder. Just to get that, just to roll that back for me for my benefit, if you can have ADHD, even if you don't have hoarding disorder, you're likely to have excessive acquisition as well. Yeah. If you use, we use the scale. To explain to a lot of my babies.
00:31:47
Speaker
We've got two whole cupboards of board games at once. We've got them in the eye, we've got them in the garage. We haven't got them in the garage anymore. I'll do that. I think in general, I mean, it's really there is a bit of overlap. So the next step, I mean, we really have to
00:32:15
Speaker
to look clinically to each patient, because if we just look to excessive acquisition, difficulty discarding things separate, can be I think, we don't get to the point for each patient. There's all kinds of individual things going on here, isn't there? You know, personal background, family history. Well, there's also the economic thing of, you know, if you have someone who's got ADHD in a low income country, they just may not have the ability, even if they wanted to acquire, or maybe they're acquiring things that are
00:32:44
Speaker
very different. I mean, it may be that account hoarding, you know, think about somebody in India who, for example, who's got hoarding disorder and ADHD, that may look very different. I'm sure they would have the same in some way, some features, but it would look very different if somebody who's got, who hasn't got the income to acquire stuff. Free the inks, paper, bills, everything.
00:33:05
Speaker
And also there is the digital wording that it's actually it's not much studied, but it's another thing so that clinically I see in patients. I mean, I never did a study on about that, but.
00:33:16
Speaker
Many people tend to hoard on like downloading films, movies, series thing. They will never, they will never see it. It's a collection. Yes. Yeah. When you see people with like 2 million photos in their camera roll and you're like, why did you get rid of something? That's a really good point. Exactly. Having sort of, not grown up, but lived through the kind of
00:33:40
Speaker
you know, the downloading boom of, you know, everyone was downloading from Napster or whatever, various websites a few years ago. And then people would have, you're right, people would have these ridiculously huge, you know, the one thing you'd have to buy would be a massive external disk drive. And you'd have, you know, 4,000 movies on it, just because you could have 4,000 movies on it. No, because you're never going to watch them. No.
00:34:07
Speaker
I have in mind a patient I see a few days ago was a young patient, 22, I think, and I text him and he didn't notice the text was like, come 15 minutes for the appointment, something like this, because, and he said, no, doctor, I didn't see it because my phone, it's not working because now it's crashed because I'm full of photos. So I don't have any G guts, right? It's not working anymore. So.
00:34:33
Speaker
And then we discuss about that part. Yes, I make a picture of everything, all the dishes I eat, everything. And I cannot discard because I have to choose which one to discard. How can I choose this? I can make a selection. And again, I think these are holding symptoms. And the other thing that takes out, because tidying and sorting things is boring. And if you're a person with ADHD, as a person with ADHD, anything which is boring is
00:34:59
Speaker
relatively unpleasant and almost painful, almost in a way. I mean, not quite painful, but so unpleasant that it's aversive. But actually, in a way, it almost strips out some of that. If what you can't get rid of is some photos, but actually, that doesn't take long to get. It kind of goes to the core of, I just can't get rid of these objects. I just can't
00:35:21
Speaker
And also, but if you've got lots of photos because you're requiring them, as long as it can take ages. Yeah, that's true. Because you have to sift through it all. Yeah, the longer you leave it, the more photos you get, and then you kind of end up in a spiral. So it is quite similar. You've still got this very boring thing of sifting through. Do you have to do... I did wonder, because you mentioned the low income pool, which I thought was really interesting, but I wanted to look at it still in Western society, but the differences between someone who's
00:35:50
Speaker
very well off and someone who is in the low-income household, even in the UK, would look very different. Because if you're in a low-income household and you have all this stuff and you want to get rid of it, you might have that extra feeling of, I'm losing out on this. But if you're really well off, you'll be... Because you can just get it again.
00:36:13
Speaker
If you throw it away, you can just get it again. Yeah, that's true. And also the other thing is if you've got a big, you've got a big enough house, you can hold it like, I mean, you know, we're privileged, but my, my, my, my, my excessive buying before gets not actually caused us not to be able to have dinner because I don't have to pile them up on the dining room table, for example. Yeah.
00:36:36
Speaker
But I'm thinking to this too, Kate, because I see in my experience both a low-income patient and a high-income patient. And the high-income patient, I remember, he both liked several garages.
00:36:48
Speaker
that in Florence are quite expensive. We live in Florence, okay? Buying a garage is like buying a big couch. Because parking for car, it's more important than living in a house in Florence. And so he was buying several garages, like three or four. And still, since he bought another one, he said, okay, I can collect other things because now I have a new garage. Actually, the disorder was like words and words and words.
00:37:18
Speaker
So, but of course, yes. It's a double impact, isn't it? Because you can acquire more, but it causes you less. Well, obviously it's all very individual, but with more money you can acquire more, but it also does you less damage to not get rid of it. That's true.
00:37:37
Speaker
Yeah, that's that's I think a good point because actually if you the age anic problem I gene in a small house with another morning. It's much big problem. Yeah That's a good point on a low income is much more must be much more of a problem Yeah, I mean it can go in either direction. I imagine right? Yeah. Yeah interesting very interesting kind of
00:38:03
Speaker
in mixing up the socioeconomic and the neuropsychological. That's exactly what we're doing. Well, I take sociology and psychology, so this is what I do. This is how you roll. Okay, nice.
00:38:15
Speaker
But that's a good tip. We will look to that. Thank you. That's a good thing. If you're a clinician and you're looking at somebody and it sort of goes back to what's up the point that Tess made is if you've got somebody who's got hoarding problems and I'm thinking more of a primary care person, maybe not get to a psychiatrist, someone with who's got some difficulty with hoarding may actually just in the UK go to a GP. If you are in that situation, maybe a GP should think,
00:38:41
Speaker
Think about ADHD as a possible background condition for somebody who's having problems with hoarding. I think that probably is quite an important implication because like you said, Tess, there probably are people out there, particularly in the UK, at least women, who are not being picked up and their hoarding is being put down to whatever else. Whereas in fact, it's a symptom of ADHD. No, I don't know if it's in the UK, but in Italy, I mean, thinking about ADHD
00:39:11
Speaker
We have, I think the DGP have to take in mind about narrow developmental disorder goes together. So if you really see someone with hoarding OCD and this, think also about ADHD, because really they are co-linked. But that's, I mean, that's a message that's going to take years to get through to everyone in the field. And that's one of the things that I suppose we're trying to do a little bit to kind of raise awareness of.
00:39:36
Speaker
ADHD UK, the UK ADHD charity. Shall we go on to our next question? Yes. So what does this mean for ADHD people themselves? Like, what can we do? Yeah, what can we do as ADHD people? Actually, I think working, I mean, the
00:40:04
Speaker
The treatment is used for the CBT treatment. It's used for organ disorder. It's tried to gradually, gradually expose to discarding things. So one thing that an ADHD person could be, is start trying to organize and to start from the last things they, to make a graduation of the things they have, they think they have less value and try to discard them.
00:40:32
Speaker
immense step by step. It's like a progressive exposure that similar what we do in the spectrum. And I think it's really important that we talk about value and I kind of implicitly say, you've mentioned this before, but I want to bring it out to the
00:40:48
Speaker
four we're not just talking about financial value here we're also talking about emotional value and that is another that's a valid kind of value sentimental value a shirt you've had since you were five you know you don't fit in it anymore but it's still there yes it's still there and you're like maybe i can make a pillow out of this but you're never going to
00:41:06
Speaker
no no yes craft is a great one isn't it because you can always make something but you never do the amount of unfinished projects that i see some people acquiring you know they've got they've started and knitting hey stop yes no that's true i mean we all i think we i think you know it's a very common life experience and i suppose we mustn't
00:41:31
Speaker
It's more common than ADHD people, but probably there's lots of people listening who don't have ADHD who may have a bit of a hoarding tendency. And maybe this advice is probably useful for all of them as well. There has to be a big difference between symptoms of hoarding and hoarding tendencies, which I assume are common in
00:41:52
Speaker
like a lot of people with ADHD, an actual like hoarding disorder. Yes, of course. Absolutely. Yes, exactly. And it's just, I don't know, where does that line fall? Because I know you mentioned it's when it starts to obstruct their every like what you need to do to like their basic functions, essentially. Yeah. Well, I think that's a good start, isn't it? And in terms of drawing that line? Yes, it's it's what when when you're struggling in function, but also when you are
00:42:22
Speaker
when these things are distressing you because actually the difference from think about the collection is someone that it's really egosynthetics having things and even if you're not cluttered and the hurting people when it's a disorder it's like something that it's distressing you're also on an emotional side not just the functional I mean not just the function it's okay I have to discard but I cannot okay it's something also that
00:42:51
Speaker
that in some way it's distress. It's what holding patients says. And that's one of the parts that differentiate it from compassion. It's not that. If you look to people... So their own inability to not discard things is causing them directly distress. Them, not a people. That is really important. That's a really important distinction.
00:43:12
Speaker
And, and, and yes, of course, it's, it's the big difference. And then the difference from people that do like professional collection is those people are really that love collection, the heart collection, I think collection. If you look like in a superficial way, they looks like big orders, but everything is egosyntonic, the acquisition, it's egosyntonic. Everything is really, it's a tremendous word, I think I know what it means. egosyntonic.
00:43:40
Speaker
Yeah, it's something that you do in a pleasurable way. It's not something that it's like perceived that's negative or unpleasant to your brain. It's like those things that you do in a pleasurable way. That's the big difference for example, if I'm obsessed by a person or I love a person.
00:44:01
Speaker
You have the thoughts of that person, always the thought in your mind, but if you love that person, if you fall in love with the person, it's something pleasurable. So we say it's zego-syntonic. If you have the idea of that person, it's something bad for you, or if you see that person something bad will happen, it's more egotistonic and it's more an obsession. So that's just to say. Egotistonic is my new favorite word.
00:44:29
Speaker
Well, I don't know. I think I'm going to say ego because it just makes you make sense to me. Well, I also really like eggs. Okay, wow. Vocabulary has been enriched.
00:44:47
Speaker
And we've learnt a lot about hoarding. When you come into contact with hoarding patients, do you find that the hoarding tends to manifest most in clothing, like leftovers in the fridge, collections? What kind of things do people tend to hoard the most?
00:45:03
Speaker
It's very a lot. In my experience, it's very, really a lot. Clothes, of course. That's a good point. Now I'm thinking about that. I see difference according to the economic income. So people with tired economic income, clothing, things, they both think stuff, unusable things. And I have in mind severe hoarding patient with less income than taking things from the trash in the streets, like bad clothes or
00:45:33
Speaker
clothes that I throw away, or I have in mind, also people collecting pants, no? The finished pants. When the pants are not finished, maybe you can write just a few lines. And I remember a patient has like 2,000, 3,000 pants. And it was collecting all the pants.
00:45:56
Speaker
almost empty, no? Because when I was challenging with him, no, I'm saying, okay, but they're happy. You cannot. No, doctor, they're not empty. I can still write some words with which one. But to use them, no, I don't choose. I have too much. I have the new pen, so I don't mind about this. I want to store this for the future, no? That's kind of, of challenge. Shall we do our last question? Yes. So what is your next question? What are you planning to look into next?
00:46:26
Speaker
My big question is what we can do pharmacologically for this patient and do will methylphenidate or stimulants in general can help hoarding? I have my clinical impression but still when we will look to data we will have something and then hopefully I hope to publish this data and to stress people that can do proper trial to do this trial. And it would be a real help because it sounds like
00:46:57
Speaker
Because if you've got, you know, just to reemphasise, 30% of ADHD patients will have a degree of, will have a diagnosable hoarding disorder. That's huge. If we extrapolate your data, that's a huge number of people, given that ADHD is actually really common, who could potentially be helped.
00:47:19
Speaker
Again, probably the frequency, if we look to a clinical diagnosis, maybe it will be something less, but it's still something between 20 and 30 and the stress that we have to look toward the aged people. I think that's really the take-home message. Excellent. Well, I think we can leave it there, don't you, Tess? I think I've...
00:47:38
Speaker
I did have one more question. Yeah, go for it. A lot of the people who we have on the podcast are from the UK. So I don't really tend to think about this as much. But because you're from Italy, do you think that there is like a big cultural difference in this? Good question. That is something we have to look in the future. Maybe someone will have to compare our data with something during the same in the UK. Actually, our study, I mean, the other study, the only other study about
00:48:06
Speaker
hoarding in ADHD was made in the UK by the More and Zamir group. So and we had similar results. So at least for the prevalence, it's probably not. But then for the clinical fever types of feature, we have to look more different. You mentioned about what it would look like for somebody in India. And you mentioned that the way that people are like the time that people are diagnosed is very different in Italy. And I just thought, yeah, yeah, yeah. I mean, I think that's a big question. It would be very difficult to answer. So there's, you know,
00:48:34
Speaker
Something to return to, another date. Another day with a very big team. Absolutely right. We're doing a global morning ADHD. I'll just call up everyone with ADHD all around the world, all their phone numbers. Have you? Yeah. When you get diagnosed with ADHD, even when you're not diagnosed, I just get a little notification on my phone. Can't get rid of the patients though. Well, that's because your phone's not really working properly.
00:49:05
Speaker
All right. Thank you very, very much for joining us. It's been extremely educational and useful. Thank you. Thank you to you. It's been a pleasure to be invited to be here. Thank you very much. And bye-bye. Goodbye. Bye. Bye-bye.
00:49:27
Speaker
Right, so that was Giacomo. Who of course was talking about hoarding. Hoarding, yes. I know I like to hammer home the message. The link to, not a copy, because we can't post a copy, because we can't post you a copy, because we haven't got enough stamps. I also don't have your address. Yeah, we will post a link to Giacomo's paper in the show notes, as well as any social media that he is happy to share.
00:49:53
Speaker
and so you can look find out for yourself if If the events and issues current covered in this podcast have affected you in any way Which they may have done and please just especially if it's positive, please let us know if it's positive Please please do let us know go to the ADHD UK website We've got lots and lots of Facebook groups where we prepare posting this anything on ADHD UK You can leave us a comment. We will read all the comments. We will
00:50:23
Speaker
take them on board if you want us to make things better. But yes, in the meantime... In the meantime? Merry Christmas? If you don't celebrate Christmas, happy holidays. Enjoy the break. We way well have another episode for Christmas. But anyway... Well, we'll see you then! He doesn't tell me these things. It's always never a bad idea to miss wish people a Merry Christmas. I wish you a Merry Christmas no matter when you're listening to this. Yes, very good point. Alright, bye! Bye!