People with hoarding disorder have persistent difficulty getting rid of or parting with possessions due to a perceived need to save the items. Attempts to part with possessions create considerable distress and lead to decisions to save them. The resulting clutter disrupts the ability to use living spaces (American Psychiatric Association, 2013).
Hoarding is not the same as collecting. Collectors typically acquire possessions in an organized, intentional, and targeted fashion. Once acquired, the items are removed from normal usage, but are subject to being organizing, admired, and displayed to others. Acquisition of objects in people who hoard is largely impulsive, with little active planning, and triggered by the sight of an object that could be owned. Objects acquired by people with hoarding lack a consistent theme, whereas those of collectors are narrowly focused on a particular topic. In contrast to the organization and display of possessions seen in collecting, disorganized clutter is a hallmark of hoarding disorder.
The overall prevalence of hoarding disorder is approximately 2.6%, with higher rates for people over 60 years old and people with other psychiatric diagnoses, especially anxiety and depression. The prevalence and features of hoarding appear to be similar across countries and cultures. The bulk of evidence suggests that hoarding occurs with equal frequency in men and women. Hoarding behavior begins relatively early in life and increases in severity with each decade.
Hoarding disorder can cause problems in relationships, social and work activities, and other important areas of functioning. Potential consequences of serious hoarding include health and safety concerns, such as fire hazards, tripping hazards, and health code violations. It can also lead to family strain and conflicts, isolation and loneliness, unwillingness to have anyone else enter the home, and an inability to perform daily tasks, such as cooking and bathing in the home.
Diagnosing Hoarding Disorder
Specific symptoms for a hoarding diagnosis include (American Psychiatric Association, 2013):
- 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 the 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, or the authorities).”
The hoarding causes major distress or problems in social, work or other important areas of functions (including maintaining a safe environment for self and others).
An assessment for hoarding may include questions such as:
- Do you have trouble parting with possessions (such as discarding, recycling, selling or giving away)?
- Because of the clutter or number of possessions, how difficult is it to use the rooms and surfaces in your home?
- To what extent does your hoarding, saving, acquisition and clutter affect your daily functioning?
- How much do these symptoms interfere with school, work or your social or family life?
- How much distress do these symptoms cause you?
Mental health professionals may also ask permission to speak with friends and family to help make a diagnosis or use questionnaires (rating scales) to help assess level of functioning.
Some individuals with hoarding disorder may recognize and acknowledge that they have a problem with accumulating possessions; others may not see a problem.
Excessive acquisition occurs in the vast majority of cases and—although not a core diagnostic feature—should be carefully monitored. In addition to the core features of difficulty discarding and clutter, many people with hoarding disorder also have associated problems such as indecisiveness, perfectionism, procrastination, disorganization and distractibility. These associated features can contribute greatly to their problems with functioning and the overall severity.
Animal hoarding may form a special type of hoarding disorder and involves an individual acquiring large numbers (dozens or even hundreds) of animals. The animals may be kept in an inappropriate space, potentially creating unhealthy, unsafe conditions for the animals. People who hoard animals typically show limited insight regarding the problem.
Many people with hoarding disorder also experience other mental disorders, including depression, anxiety disorders, attention deficit/hyperactivity disorder or alcohol use disorder.
Causes and Risk Factors
The cause of hoarding disorder is unknown. Due to its recent classification, the neurobiology of hoarding disorder in humans is a newly burgeoning field; making it somewhat premature to draw firm conclusions. Hoarding is more common among individuals with a family member who also has a problem with hoarding. A stressful life event, such as the death of a loved one, can worsen symptoms of hoarding.
Hoarding disorder has a symptom profile, neural correlates, and associated features that differ from OCD and other disorders. A number of information processing deficits have been associated with hoarding; including planning, problem-solving, visuospatial learning and memory, sustained attention, working memory, and organization.
Hoarding behaviors appear relatively early in life and then follow a chronic course. Most studies report onset between 15 and 19 years of age. Early recognition, diagnosis, and treatment are crucial to improving outcomes.
Treatment can help people with hoarding disorder to decrease their saving, acquisition, and clutter, and live safer, more enjoyable lives.
Randomized controlled trials have established cognitive behavioral therapy (CBT) for hoarding disorder as an effective treatment. During CBT, individuals gradually learn to discard unnecessary items with less distress—diminishing their exaggerated perceived need or desire to save these possessions. They also learn to improve skills such as organization, decision-making, and relaxation.
Despite the effectiveness of CBT for hoarding disorder, a substantial number of hoarding disorder cases remain clinically impaired by their hoarding symptoms after treatment.
Regarding medication treatment, studies of hoarding disorder psychopharmacology have been small and open-label, which limit the conclusions that can be drawn from this literature. To date, there are no controlled trials to support efficacy. Despite this, there is some evidence of benefit from paroxetine, venlafaxine extended-release, amphetamine salts, methylphenidate, methylphenidate extended-release, and atomoxetine. There are no data on comparative efficacy between these drugs. These drugs should be considered only after better proven treatments—including cognitive behavioral therapy for hoarding disorder—have been attempted. For some people, medications are helpful and may bring improvement in symptoms.
If you or someone you know is experiencing symptoms of hoarding disorder, contact your doctor or mental health professional. In some communities, public health agencies can assist in addressing problems of hoarding and getting help for individuals affected. In some instances, it may be necessary for public health or animal welfare agencies to intervene.
Hoarding assessment scales:
- Structured Interview for Hoarding Disorder (Nordsletten, et al., 2013)
- Clutter Image Rating (Frost et al., 2008)
- Saving Inventory-revised (Frost et al, 2004)
- Hoarding Rating Scale-Interview (Tolin et al, 2010)
- American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association Publishing, Arlington, VA.
- Postlethwaite, A., Kellett, S., Mataix-Cols, D., 2019. Prevalence of Hoarding Disorder: A systematic review and meta-analysis. J Affect Disord 256, 309-316.
- Nordsletten, A.E., Fernández de la Cruz, L., Pertusa, A., Reichenberg, A., Hatch, S.L., Mataix-Cols, D., 2013. The Structured Interview for Hoarding Disorder (SIHD): Development, usage and further validation. Journal of Obsessive Compulsive and Related Disorders 2(3), 346-350.
- Frost, R., Steketee, G., Tolin, D., Renaud, S., 2008. Development and validation of the Clutter Image Rating. Journal of Psychopathology and Behavioral Assessment 30(3), 193-203..
- Frost, R.O., Steketee, G., Grisham, J., 2004. Measurement of compulsive hoarding: Saving Inventory-Revised. Behav Res Ther 42(10), 1163-1182..
- Tolin, D.F., Frost, R.O., Steketee, G., 2010. A brief interview for assessing compulsive hoarding: The Hoarding Rating Scale-Interview. Psychiatry Res 178(1), 147-152.
Carolyn Rodriguez, M.D., Ph.D.
Randy O. Frost, Ph.D.