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.

Epidemiology
  • 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]
Prognosis
  • 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]
Comorbidity
  • Approximately 75% of individuals with hoarding disorder have a comorbid mood or 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.
Risk Factors
  • 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]
Criterion A

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

Criterion B

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

Criterion C

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).

Criterion D

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).

Criterion E

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

Criterion F

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).

Specifiers

Specify if:

  • With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

Severity Specifier

Specify if:

  • With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviours (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
  • With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviours (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
  • With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviours (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
  • 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]

Hoarding Scales

Name Rater Description Download
Saving Inventory-Revised Clinician/Patient The Saving Inventory-Revised is a 23-item scale with 3 subscales: Acquiring, Clutter, and Difficulty Discarding.[16] The first subscale determines the extent of compulsive buying and acquiring of free things. The second subscale assesses the amount of clutter and problems associated with it. The final subscale is used to measure the level of discomfort associated with removing the clutter. Download
HOMES Multidisciplinary Hoarding
Risk Assessment
Clinician The HOMES Multi-disciplinary Hoarding Risk Assessment provides a structural measure through which the level of risk in a hoarded environment can be assessed. Download
Clutter Image Rating Scale (CIR) Clinician The CIR is a screening tool with three sets of 9 color photographs. Each set depicts a room in the home (living room, bedroom, and kitchen) with varying amounts of clutter (1=least cluttered, 9=most cluttered). Download
  • 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]

Hoarding vs. Collecting

Hoarding disorder differs from the normal collecting of items. In hoarding disorder, there is a large number of possessions that clutter active living areas to the point that the area is substantially compromised (and often poses a fire or safety risk).
    • Hoarding disorder is not diagnosed if the symptoms are judged to be a direct consequence of typical obsessions or compulsions, such as fears of contamination, harm, or feelings of incompleteness in obsessive-compulsive disorder (OCD). Feelings of incompleteness (e.g. - losing one's identity, or having to document and preserve all life experiences) are the most frequent OCD symptoms associated with this form of hoarding.
    • The accumulation of objects can also be the result of persistently avoiding onerous rituals (e.g. - not discarding objects in order to avoid endless washing or checking rituals). In OCD, the behaviour is generally unwanted and highly distressing (i.e. - ego-dystonic), and the individual experiences no pleasure or reward from it. Excessive acquisition is usually not present – if excessive acquisition is present, then items are acquired because of a specific obsession (e.g. - the need to buy items that have been accidentally touched in order to avoid contaminating other people), not because of a genuine desire to possess the items.
    • Individuals who hoard in the context of OCD are also more likely to accumulate bizarre items, such as trash, nails, hair, feces, urine, used diapers, or rotten food. Accumulation of such items is very unusual in hoarding disorder. Only when the severe hoarding appears concurrently with other typical symptoms of OCD and is judged to be independent from these OCD symptoms, both hoarding disorder and OCD may be diagnosed.
    • Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of a degenerative disorder, such as neurocognitive disorder associated with frontotemporal lobar degeneration or Alzheimer's disease. Typically, onset of the accumulating behaviour is gradual and follows onset of the neurocognitive disorder. The accumulating behaviour may be accompanied by self-neglect, alongside other neuropsychiatric symptoms, such as disinhibition, gambling, rituals/stereotypies, tics, and self-injurious behaviors.
  • Other medical conditions
    • Hoarding disorder is not diagnosed if the symptoms are determined to be a direct consequence of another medical condition (see Criterion E), such as traumatic brain injury, surgical resection for treatment of a tumour or seizure control, cerebrovascular disease and/or stroke, infections of the central nervous system (e.g. - herpes simplex encephalitis), or neurogenetic conditions such as Prader-Willi syndrome.
    • Damage to the anterior ventromedial prefrontal and cingulate cortices has been particularly associated with the excessive accumulation of objects. In these individuals, the hoarding behaviours are not present prior to the onset of the brain damage and appears shortly after the brain damage occurs. Some of these individuals appear to have little interest in the accumulated items and are able to discard them easily or do not care if others discard them, whereas others appear to be very reluctant to discard anything.
  • Neurodevelopmental disorders
    • Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of a neurodevelopmental disorder, such as autism spectrum disorder or intellectual disability (intellectual developmental disorder).
    • Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of delusions or negative symptoms in schizophrenia spectrum and other psychotic disorders.
    • Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of psychomotor retardation, fatigue, or loss of energy during a major depressive episode.

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]
  • Cognitive behavioural therapy (CBT) has been found to be effective.
  • Specialized topics in CBT for hoarding includes: psychoeducation, skills training (organizing, decision-making, problem-solving), behavioural exposures (discarding, non-acquiring), and cognitive strategies.[21][22]
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  • 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]
Articles
Research
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
15) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.