David F Tolin

Hartford Hospital · Anxiety Disorders Center

Over the 20 years since the criteria for empirically supported treatments (ESTs) were published, standards for synthesizing evidence have evolved and more systematic approaches to reviewing the findings from intervention trials have emerged. Currently, the APA is planning the development of treatment guidelines, a process that will likely take many...

Hoarding disorder (HD), previously considered a subtype of obsessive-compulsive disorder (OCD), has been proposed as a unique diagnostic entity in DSM-5. Current models of HD emphasize problems of decision-making, attachment to possessions, and poor insight, whereas previous neuroimaging studies have suggested abnormalities in frontal brain regions...

This article offers a practice-friendly review of conceptualizing and treating hoarding based on biological and psychological research. Although hoarding has commonly been conceptualized as a variant of obsessive-compulsive disorder, research suggests a more complex pattern of overlap with attention deficit-hyperactivity disorder, organic brain dis...

Cognitive-behavioral therapy (CBT) is effective for a range of psychiatric disorders. However, it remains unclear whether CBT is superior to other forms of psychotherapy, and previous quantitative reviews on this topic are difficult to interpret. The aim of the present quantitative review was to determine whether CBT yields superior outcomes to alt...

Introduction Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts. Methods St...

Individuals with hoarding disorder (HD) have difficulty parting with personal possessions, which leads to the accumulation of excessive clutter. According to a proposed biphasic neurobiological model, HD is characterized by blunted central and peripheral nervous system activity at rest and during neutral (non-discarding) decisions, and exaggerated...

Obsessive-compulsive and related disorders include obsessive-compulsive disorder, hoarding disorder, body dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder. This volume reviews the phenomenology and epidemiology of each of the disorders. Next, it reviews how the disorders are maintained, from bio...

Obsessive-compulsive and related disorders include obsessive-compulsive disorder, hoarding disorder, body dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder. This volume reviews the phenomenology and epidemiology of each of the disorders. Next, it reviews how the disorders are maintained, from bio...

Emerging research in animal models and healthy women indicates that the sex hormone estradiol may moderate fear of extinction. There is limited research on estradiol in exposure-based therapy among clinically anxious women. The current pilot study aimed to address this gap by comparing exposure outcomes in women with panic disorder (PD) who had hig...

Background: Symptoms of ADHD are common in individuals with hoarding disorder (HD). It remains unclear whether these attentional symptoms reflect high co-occurrence rates of ADHD and HD, or whether inattentive symptoms can be conceptualized as intrinsic to the HD syndrome. In addition, inattention (vs. hyperactivity) in particular, appears to be re...

Objective: Cognitive behavioral therapy (CBT) is efficacious for hoarding disorder (HD), though results are modest. HD patients show an increase in activity in the dorsal anterior cingulate cortex (dACC) when making decisions. The aim of this study is to determine whether CBT's benefits follow improvements in dACC dysfunction or abnormalities prev...

The objective of the present study was to examine the reliability and validity of a new semi-structured interview for pediatric psychiatric disorders, which is needed as existing interviews do not cover the full range of anxiety, mood, and obsessive-compulsive disorder (OCD)-related disorders. Three hundred eleven child patients (aged 10–17) were a...

The aim of the present study was to examine self-report, peripheral nervous system, and central nervous system correlates of naturally-occurring, chronic hyperventilation (HV, assessed by hypocapnia or low resting state low end-tidal CO2), and to examine the additional effect of acute, experimentally-induced HV in anxious and healthy participants....

Purpose of Review Exposure therapy is an effective treatment for anxiety-related disorders, but many individuals do not achieve full symptom relief, and return of fear is a common occurrence. Understanding how exposure therapy works enables further development of strategies to improve its effectiveness. Recent Findings Recent studies have examined...

Current research suggests obsessive-compulsive disorder (OCD) co-occurs in around 20% of people with hoarding disorder (HD). The article discusses the theoretical conceptualization of co-occurring HD and OCD (HD+OCD), highlighting similarities between the disorders that may contribute to comorbidity, such as potentially overlapping etiological fact...

The present paper aims to elaborate on the original cognitive-behavioral model of hoarding disorder (HD; Frost & Hartl, 1996) by incorporating the results of recent research on biological and psychological contributors to HD. According to the proposed model, HD is characterized by several vulnerability factors that are thought to increase the likel...

Background and Objectives While cognitive–behavioral therapy is a highly efficacious treatment for anxiety, additional research is needed to identify adjunctive interventions that may augment treatment outcome. Design In response to the COVID-19 pandemic, we conducted an open feasibility trial of brief (i.e., four 75- to 90-minute sessions) mindfu...

Background Widely used psychotropic medications obsessive-compulsive disorder (OCD) may change the volumes of subcortical brain structures, and differently in children vs. adults. We measured subcortical volumes cross-sectionally in patients finely stratified for age taking various common classes of OCD drugs. Methods The ENIGMA-OCD consortium sam...

Military populations are disproportionally affected by posttraumatic stress disorder (PTSD) and may experience less benefit from first line psychotherapies for PTSD relative to civilians. We examined the efficacy of exposure therapy among Veterans and active duty military personnel across various control conditions and tested potential treatment-re...

The conceptual overlap between intolerance of uncertainty (IU) and anxiety sensitivity (AS) has gained recent attention, with researchers theorizing that IU may lead individuals to have greater difficulty tolerating the uncertainty about feared consequences of anxiety-related symptoms. Research has indicated that AS may mediate the relationship bet...

Larger thalamic volume has been found in children with obsessive-compulsive disorder (OCD) and children with clinical-level symptoms within the general population. Particular thalamic subregions may drive these differences. The ENIGMA-OCD working group conducted mega- and meta-analyses to study thalamic subregional volume in OCD across the lifespan...

Exposure therapy is an evidence-based treatment for numerous anxiety-related disorders. This entry briefly describes how exposure therapy is conducted, provides an overview of exposure therapy for specific anxiety-related disorders, reviews prominent theories about how exposure therapy works, and discusses future directions in the study and practic...

Posttraumatic stress disorder (PTSD) is associated with high morbidity and functional impairment in the absence of effective treatment. Exposure therapy for PTSD is a trauma-focused treatment that typically includes in vivo and/or imaginal exposure. The goal of this meta-analysis was to examine the overall efficacy of exposure therapy for PTSD comp...

This chapter discusses the nature and clinical characteristics of hoarding disorder, a debilitating condition that runs a chronic course without treatment and can lead to significant functional impairment and cost to society. Prevalence estimates for hoarding disorder range from 1.5% to 6% of the general population, and it tends to co-occur with de...

(Appeared originally in Depression and Anxiety 2015; 32:158-166).

Objective: Higher thalamic volume has been found in children with obsessive-compulsive disorder (OCD) and children with clinical-level symptoms within the general population. Particular thalamic subregions may drive these differences. The ENIGMA-OCD working group conducted mega- and meta-analyses to study thalamic subregional volume in OCD across t...

Objectives: In this study, we examined the degree of generality and specificity of OC beliefs are moderated by gender among individuals with OC disorders. Methods: The diagnostic groups consisted of: (1) individuals with obsessive-compulsive disorder (OCD; N = 398); (2) individuals with other anxiety disorders (N = 104); and (3) undergraduate st...

Prior research suggests that estradiol may moderate fear extinction in animal models and humans. Based on these findings, estradiol may also moderate cognitive reappraisal, which is theorized to be an important mechanism of change in extinction-based therapy (exposure therapy). We compared cognitive restructuring (CR) skills acquisition and outcome...

Background: Cognitive behavioral therapy (CBT) is an effective treatment for youth with anxiety and related disorders, with a 59% remission rate at post-treatment. Results of reviews and meta-analyses indicate that treatment gains are maintained across long-term follow-up, at least in terms of symptom improvement. Less is known about relapse, defi...

Objectives. Obsessive-compulsive (OC) symptom severity is associated with intensity of OC related beliefs, and we examined generality and specificity of OC beliefs among individuals with OC disorders. Further, we tested gender moderation across the groups. Methods. The diagnostic groups consisted of: (1) individuals with obsessive-compulsive disord...

Cognitive-behavioral therapy (CBT) is a first-line treatment for anxiety and related disorders, with large pre-to post-treatment effect sizes. Rates of relapse, or the likelihood that a state of remission will be maintained once treatment is withdrawn, have been relatively neglected in CBT outcome studies. The present meta-analysis aimed to determi...

The present study aimed to examine changes in psychophysiological arousal from baseline to a stressor phase (reactivity) and from the stressor phase to a second resting phase (recovery) in patients with anxiety disorders. Fifty-four adult patients with DSM-5 anxiety disorders (panic disorder, generalized anxiety disorder, or social anxiety disorder...

Background Individuals with hoarding disorder (HD) demonstrate exaggerated subjective distress and hyper-activation of cingulate and insular cortex regions when discarding personal possessions. No prior studies have sought to determine whether this subjective distress is associated with specific profiles of abnormal brain function in individuals wi...

This shorter communication explores the concept of clinically significant change in treatment outcome studies for hoarding disorder. We argue that cross-study comparisons have been hindered due to researchers using different formulations to assess individual change. We propose that researchers adopt a standardized approach to calculating rates of c...

Suicide risk is elevated in psychiatric patients following discharge from inpatient care. Despite this vulnerability, there has been limited research investigating suicide prevention protocols that take into account the unique system characteristics of this setting (e.g., short lengths of stay, crisis stabilization treatment model, multidisciplinar...

No diagnostic biomarkers are available for obsessive-compulsive disorder (OCD). Here, we aimed to identify magnetic resonance imaging (MRI) biomarkers for OCD, using 46 data sets with 2304 OCD patients and 2068 healthy controls from the ENIGMA consortium. We performed machine learning analysis of regional measures of cortical thickness, surface are...

No diagnostic biomarkers are available for obsessive-compulsive disorder (OCD). Here, we aimed to identify magnetic resonance imaging (MRI) biomarkers for OCD, using 46 data sets with 2304 OCD patients and 2068 healthy controls from the ENIGMA consortium. We performed machine learning analysis of regional measures of cortical thickness, surface are...

Hoarding disorder has become an official disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Hoarding disorder affects approximately 1.5% to 5% of the general population, and there is no known literature that has examined the prevalence of hoarding disorder among homeless populations or those living in supp...

Individuals with generalized anxiety disorder (GAD) report poorer quality of life (QOL) than do nonanxious controls. Further, although positive affect (PA) and negative affect (NA) have been shown to predict QOL, no previous literature has tested this relationship in the context of individuals with GAD. In the present study, we evaluated the unique...

Importance Large-scale neuroimaging studies have revealed group differences in cortical thickness across many psychiatric disorders. The underlying neurobiology behind these differences is not well understood. Objective To determine neurobiologic correlates of group differences in cortical thickness between cases and controls in 6 disorders: atten...

Previous studies examining the dose-response curve in psychotherapy have suggested that 11–19 sessions may be necessary for at least 50% of individuals to show clinically significant improvement. However, this curve has not been examined specifically for cognitive-behavioral therapy (CBT) for anxiety disorders, for which a more rapid recovery curve...

Distorted judgments of the value of possessions are believed to drive excessive acquisition and difficulty discarding in hoarding. Aberrant valuation in hoarding disorder may manifest in an exaggerated endowment effect. We tested this supposition in two studies, using between- (Study 1) and within- (Study 2) subjects designs. We used nonparametric...

Objective: Attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and obsessive-compulsive disorder (OCD) are common neurodevelopmental disorders that frequently co-occur. The authors sought to directly compare these disorders using structural brain imaging data from ENIGMA consortium data. Methods: Structural T1-weight...

Hoarding disorder (HD) is a new psychiatric diagnosis in Diagnostic and Statistical Manual of Mental Disorders–Fifth edition and preliminary evidence suggests that cognitive-behavioral treatments are effective in treating this condition. However, it has been demonstrated that individuals with HD generally display poor compliance during treatment, w...

Neuroimaging has played an important part in advancing our understanding of the neurobiology of obsessive-compulsive disorder (OCD). At the same time, neuroimaging studies of OCD have had notable limitations, including reliance on relatively small samples. International collaborative efforts to increase statistical power by combining samples from a...

Hoarding disorder is marked by strong attachments to everyday objects, extreme difficulties discarding, and impairing levels of clutter. We examined the associations between hoarding symptoms and associated clinical features using network analysis in a large sample of individuals with established hoarding disorder (n = 217) and matched healthy cont...

Brain structural covariance networks reflect covariation in morphology of different brain areas and are thought to reflect common trajectories in brain development and maturation. Large-scale investigation of structural covariance networks in obsessive-compulsive disorder (OCD) may provide clues to the pathophysiology of this neurodevelopmental dis...

Biofeedback refers to the operant training of physiological responding. Variants include electromyography (EMG), electrodermal activity (EDA), skin temperature, heart rate (HR) and heart rate variability (HRV), respiratory biofeedback of end-tidal CO2 (ETCO2), electroencephalography (EEG) signal, and blood oxygen-level dependent signal using functi...

This study used archival data from three different research groups and case file data from three independent community organizations to explore how well research samples reflect cases of hoarding that come to community attention. Using data from 824 individuals with hoarding, we found that research volunteers differ from community clients in severa...

Objectives: In clinical trials of pediatric trichotillomania (TTM), three instruments are typically employed to rate TTM severity: (1) the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), (2) the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS), and (3) the Trichotillomania Scale for Children (TSC). These i...

Excessive acquiring is a common symptom of hoarding disorder (HD). Little is known about subjective distress associated with acquiring in HD. The present study examined acquiring-related distress and reactions to cognitive restructuring (CR) in 92 individuals with HD and 66 community control (CC) participants. All participants identified an item of...

An essential criterion for hoarding disorder (HD) is difficulty parting with possessions, but relatively little research has been conducted on responses by people with HD during actual efforts to discard objects. Frost et al. (Behav Res Therapy 85:13–22, 2016) reported quantitative findings from a discarding task comparing those with HD to communit...

Background: Over the past decade, functional neuroimaging studies have found abnormal brain function in several cortical systems when patients with compulsive hoarding behaviors make decisions about personal possessions. The purpose of this study was to use functional magnetic resonance imaging to test a neurobiological model of hoarding disorder...

The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment ou...

Background: Obsessive-compulsive disorder (OCD) is a heterogeneous condition that consists of distinct subtypes, and identification of its core symptoms may inform how to best conceptualize the heterogeneity. Accordingly, we used network analysis to evaluate which symptoms (and associations between symptoms) are most central to OCD symptoms and be...

Capnometry guided respiratory interventions have shown promising results in the treatment of panic disorder, but mechanisms of change are not yet well-understood. The current study examined changes in end-tidal carbon dioxide (ETCO2), anxiety sensitivity, and perceived control as mediators of panic symptom change. Sixty-nine adults with panic disor...

Emotional distress tolerance (EDT) and emotion regulation (ER) appear to be highly relevant to hoarding pathology, as excessive saving and/or acquiring may be motivated by emotional avoidance or other attempts to regulate negative affect. While findings with nonclinical samples have suggested and EDT/ER predicts hoarding symptoms, there is little d...

BACKGROUND Lateralized dysfunction has been suggested in obsessive-compulsive disorder (OCD). However, it is currently unclear whether OCD is characterized by abnormal patterns of brain structural asymmetry. Here we carried out what is by far the largest study of brain structural asymmetry in OCD. METHODS We studied a collection of 16 pediatric dat...

Clinically significant anxiety is associated with an array of attentional symptoms (e.g., difficulty concentrating; unwanted thought) that are subjectively experienced as severe. However, neuropsychological findings are mixed with respect to the presence of cognitive deficits that can account for these symptoms. Contextualizing predictions from est...

Objective: Hoarding disorder (HD) is a common and potentially debilitating psychiatric disorder. Thus far, psychological treatments have yielded modest effects and/or were time-consuming and costly to deliver. The aim of the present study was to test the efficacy of a brief group cognitive-behavioral therapy (CBT) for adults with HD and to test hy...

Background The risk for self-harm in teenagers experiencing psychotic symptoms has been and is an urgent clinical matter, as adolescents in this population are at much greater risk for suicide compared to the same age group in the general population. Researchers have called for investigations into clinical markers specific to psychosis and this age...

Background: The Saving Inventory - Revised (SI-R) is the most widely used self-report measure of hoarding symptom severity. The goal of this study is to establish a firm empirical basis for a cutoff score on the SI-R and to examine the functioning of the SI-R as a screening tool and indicator of hoarding symptom severity across the lifespan. Meth...

Background: Lateralized dysfunction has been suggested in obsessive-compulsive disorder (OCD). However, it is currently unclear whether OCD is characterized by abnormal patterns of brain structural asymmetry. Here we carried out what is by far the largest study of brain structural asymmetry in OCD. Methods: We studied a collection of 16 pediatri...

Behavioral assessment is an important component of evidence-based assessment and treatment in anxiety and related disorders. The purpose of the current study was to validate a behavioral measure of difficulty discarding and acquiring, the core features of hoarding disorder (HD). Seventy-eight patients with a primary diagnosis of HD completed a comp...

Emerging research suggests that hoarding disorder (HD) is associated with abnormal hemodynamic activity in frontal brain regions. Prior studies have not examined intrinsic network connectivity in HD during unstructured “resting state” fMRI. Furthermore, it remains unclear whether previously observed HD abnormalities might be better explained by the...

Generalized anxiety disorder (GAD) is defined in part by excessive and uncontrollable worry. However, little is known about cognitive control abilities in adults with GAD. The present study examined cognitive control over negative and neutral material in a mixed clinical sample of adults with GAD and/or obsessive-compulsive disorder and a compariso...

Cognitive-behavioral therapy (CBT) has been used to address the myriad of problems within cases presenting with school refusal. Although CBT for school refusal shows promise in increasing attendance, results to date have been mixed. Treatment studies on CBT for school refusal differ in regards to the dosage of CBT (i.e. session time and frequency)...

Objective: Brain imaging communities focusing on different diseases have increasingly started to collaborate and to pool data to perform well-powered meta- and mega-analyses. Some methodologists claim that a one-stage individual-participant data (IPD) mega-analysis can be superior to a two-stage aggregated data meta-analysis, since more detailed co...

Anhedonia is a transdiagnostic construct that can occur independent of other symptoms of depression; its role in neuropsychiatric disorders that are not primarily affective, such as obsessive compulsive disorder (OCD), hoarding disorder (HD), and post-traumatic stress disorder (PTSD) has received limited attention. This paper addresses this gap. Fi...

The aim of this study was to investigate health-related quality of life (QoL) in patients with hoarding disorder (HD). Fifty-four patients with a primary diagnosis of HD, and 24 age- and sex-matched healthy control (HC) participants, completed a battery of questionnaires including the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36),...

Difficulty discarding is the core behavioral symptom of hoarding disorder (HD). Patients with HD report greater subjective distress when discarding their own possessions as compared to others’ possessions. To date, no prior studies have examined psychophysiological activation, an objective measure of anxious arousal, during discarding among individ...

Behavioral impulsivity may be a mechanism of hoarding disorder (HD). A commonly used and well-validated measure of impulsivity is the delay and probability discounting task, which consists of making decisions about receiving monetary rewards after varying delay intervals and delivery probabilities. We compared delay and probability discounting and...

Although current cognitive–behavioral models suggest that maladaptive “obsessive beliefs” about threat, responsibility, uncertainty, perfectionism, importance, and control of thoughts contributes to the development of obsessive-compulsive disorder (OCD), the structure of such beliefs is unclear. The current study evaluated a bifactor model of obses...

Anxiety and related disorders are common and cognitive behavior therapy (CBT) has been demonstrated to be an effective treatment for these disorders. However, patients face many barriers to accessing this treatment. Remote delivery of treatment using bibliotherapy-administered CBT (BCBT) has the potential to increase accessibility to evidence-based...

This article reviews the articles in this issue that describe the strategies derived from the inhibitory learning model as applied to exposure therapy for anxiety disorders. The major principles of inhibitory learning are to create and strengthen nonthreat associations in memory (largely by engaging prefrontal cortical regions), and to effectively...

Background Recent evidence suggests that repetitive transcranial magnetic stimulation (rTMS) might be effective in treating generalized anxiety disorder (GAD). Cognitive models of GAD highlight the role of intolerance of uncertainty (IU) in precipitating and maintaining worry, and it has been hypothesized that patients with GAD exhibit decision‐mak...

The aim of the present study was to examine subjective cognitive impairment among adult patients with hoarding disorder (HD). Eighty-three patients with HD and 46 age- and gender-matched healthy control (HC) participants received a diagnostic interview and completed measures of subjective cognitive functioning and motivations for saving behavior, a...