Hoarding Disorder

Hoarding Disorder is an obsessive-compulsive and related disorder characterized by persistent difficulty discarding or parting with possessions (regardless of their actual value) due to a strong perceived need to save the items. There is also associated distress associated with discarding these items.

• There is an estimated community prevalence of 2 to 6%.^[1]
• The prevalence in the OCD population is about 30%.
• The rate and severity of hoarding disorder increases with each decade of life – hoarding symptoms are three times more prevalent in older adults (ages 55+) compared with younger adults (30s to 40s).^[2]
  • The mean age of emergence of hoarding symptoms is age 13, but the average age of treatment is at age 50.^[3]
• Epidemiological studies suggest that males have a greater prevalence, but clinical samples suggest a female predominance.^[4]
  • Females tend to display more excessive acquisition and excessive buying.^[5]

• The course of illness is typically chronic.^[6]
• Individuals typically have a low marriage rate and high divorce rate.
• Approximately 80%-90% of individuals with hoarding disorder display excessive acquisition. Most commonly, this is in the form of excessive purchases, followed by acquisition of free items (e.g. - leaflets, items discarded by others).^[7]
• Individuals may commonly live in unsanitary conditions due to the severely cluttered spaces.^[8]
  • In severe cases, hoarding can put individuals at risk for fire, falls (especially in older individuals), and poor sanitation
• Conflict with neighbours and local authorities is common, and individuals with severe hoarding disorder have been involved in legal evictions.^[9]

• Approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder.
  • The most common comorbid conditions are major depressive disorder (up to 50% of cases), social anxiety disorder (social phobia), and generalized anxiety disorder.
• Approximately 20% of individuals with hoarding disorder also have symptoms that meet diagnostic criteria for obsessive-compulsive disorder (OCD).
• Mood and anxiety comorbidities are often the initial reason for consultation, as individuals are unlikely to spontaneously endorse hoarding symptoms.^[10]
• Individuals may struggle with indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and distractibility.

• Individuals with hoarding disorder often retrospectively report stressful and traumatic life events preceding the onset of the disorder or causing an exacerbation.^[11]
• Hoarding behaviour is familial, with about 50% of individuals reporting having a relative who also hoards.
• Twin studies suggest that approximately 50% of the variability in hoarding behaviours is attributable to additive genetic factors.^[12]

Persistent difficulty discarding or parting with possessions, regardless of their actual value.

This difficulty is due to a perceived need to save the items and to distress associated with discarding them.

The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g. - family members, cleaners, authorities).

The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

The hoarding is not attributable to another medical condition (e.g. - brain injury, cerebrovascular disease, Prader-Willi syndrome).

The hoarding is not better explained by the symptoms of another mental disorder (e.g. - obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

• Individuals with hoarding disorder are typically distressed if they are unable to or are prevented from acquiring items.^[13]
• The main reasons given for these difficulties are due to the perceived utility or aesthetic value of the items or strong sentimental attachment to the possessions.
  • Some individuals may feel responsible for the fate of the possessions and go to great lengths to avoid being wasteful
  • Others may state a fears of losing important information (e.g. - thinking an old instruction manual needs to be kept “just in case”).
• The most commonly saved items are newspapers, magazines, old clothing, bags, books, mail, and paperwork, but virtually any item can be saved.
• The hoarded items are not limited to things that most other people would define as useless or of limited value – many will collect and save large amounts of valuable items as well, which may be found in piles mixed with other less valuable items.

Animal hoarding is a special manifestation of hoarding disorder, and is defined as the accumulation of a large number of animals and a failure to provide the minimal standards of nutrition, sanitation, and veterinary care and to act on the deteriorating condition of the animals (including disease, starvation, or death) and the environment (e.g. - severe overcrowding, extremely unsanitary conditions).^[14]

Since children and adolescents typically do not control their living environment and discarding behaviors, the possible intervention of third parties (e.g. - parents keeping the spaces usable and thus reducing interference) should be considered when making the diagnosis of hoarding disorder in this population.^[15]

• The pathophysiology of hoarding is not well understood. Positron emission tomography imaging suggests lower glucose metabolism in the posterior cingulate gyrus and cuneus in OCD with compulsive hoarding.^[17]

There is inconsistent evidence for the role of medications, particularly SSRIs in the treatment of hoarding.^[18] In general, for people who do respond, the responses to SSRIs are poorer than those with OCD alone. The current approach is to attempt a trial of SSRIs or CBT, which can be helpful for hoarding.

• The effectiveness of medications such as SSRIs are controversial, and some treatments have investigated the role of citalopram and escitalopram.^[19]
• Venlafaxine has been studied in small open-label trials.^[20]

• Individuals with hoarding disorder are at very high risk for fires in the home and falls! There is also high risk for infestations (bed bugs, lice, etc.)
• Clinicians should consider the individuals mobility, frailty, medical conditions, and visual or hearing impairment as part of safety planning
• Other safety considerations include whether individuals have the ability to enter and exit the home, rooms, kitchen, bathrooms, and fire escapes. Hygiene, risk of infection, and air quality are also major issues.
• It is important to ensure individuals have available access to emergency services.
• A forced “clean out” is the last resort (i.e. - when there is a serious fire risk or health hazard) – it is important to build rapport and consider risk management approach if possible, and gradually reduce these risks over time.^[23]