Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty results in the accumulation of possessions that congest and clutter living areas to the point that the intended use of the areas is substantially compromised.
Hoarding disorder often begins at a mild level during adolescence and gradually worsens with age, causing clinically significant impairment by the mid-30s. At any given point in time, an estimated 2 to 6% of people have this disorder (1). It is equally prevalent in females and males.
General reference
1. Samuels JF, Bienvenu OJ, Grados MA, et al: Prevalence and correlates of hoarding behavior in a community-based sample. Behav Res Ther 46(7):836-844, 2008. doi: 10.1016/j.brat.2008.04.004
Symptoms and Signs of Hoarding Disorder
Hoarding disorder is typically chronic, with little or no waxing and waning of symptoms or spontaneous remission.
Patients have a strong need to save items, and they experience significant distress when parting with the items or contemplating parting with them. Patients accumulate a large number of items for which they have inadequate space; the items congest and clutter the living space so much that large areas become unusable, except for storing hoarded items. For example, stacks of hoarded newspapers may fill the sink and cover the countertops and stove in the kitchen, preventing these areas from being used to prepare meals.
Hoarding symptoms often impair social, occupational, or other areas of functioning. For example, patients may not allow other people, including family members, friends, and repairmen, into the house because they are embarrassed by the clutter.
Hoarding can result in unsafe living conditions (eg, by creating a fire hazard or increasing the risk of falls) and may lead to eviction or legal problems.
Animal hoarding is a form of hoarding disorder in which patients accumulate a large number of animals and do not provide adequate nutrition, sanitation, and veterinary care despite deterioration of the animals (eg, weight loss, illness) and/or environment (eg, extreme overcrowding, highly unsanitary conditions).
Degree of insight varies. Some patients recognize that the hoarding-related beliefs and behaviors are problematic but many do not.
About 80 to 90% of people with hoarding disorder also excessively acquire items (eg, books, magazine subscriptions [1]).
Symptoms and signs reference
1. Frost RO, Tolin DF, Steketee G, et al: Excessive acquisition in hoarding. J Anxiety Disord 23(5):632-639, 2009. doi: 10.1016/j.janxdis.2009.01.013
Diagnosis of Hoarding Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
Hoarding is distinguished from transient accumulation and clutter (eg, as when property is inherited) by its persistence and other features; in addition, patients resist giving away or selling hoarded items. Collectors (eg, of books or figurines), like hoarders, can acquire and keep a large number of items, but in contrast to hoarding, collections are organized and systematic and do not significantly clutter needed living space and compromise their intended use or impair functioning or the safety of the home environment.
Diagnostic criteria for hoarding disorder include the following;
Patients have persistent difficulty discarding or parting with possessions, regardless of their actual value.
The difficulty discarding is due to the perceived need to save the items and to the distress associated with discarding them.
The accumulated possessions congest and clutter active living areas (ie, not basements or storage areas) and substantially compromise the intended use of these areas.
The hoarding causes significant distress or impairs social, occupational, or other areas of functioning.
Treatment of Hoarding Disorder
Cognitive-behavioral therapy
Limited role of pharmacotherapy
Cognitive-behavioral therapy that is tailored to treat the specific hoarding symptoms is usually first-line therapy. However, clinical trials for cognitive-behavioral therapy have shown mixed results (1, 2). Therapy focuses on helping patients discard items, refrain from acquiring new possessions (if excessive acquisition is a problem), and improve their decision-making abilities.
Motivational techniques are often needed to encourage patients to participate and stay in treatment.
There are no randomized trials supporting the use of pharmacologic therapies for the treatment of hoarding disorder. Pharmacologic interventions may be more effective for patients with comorbid conditions (eg, anxiety disorders). Several small observational studies of patients with hoarding disorder who were treated with a selective serotonin-reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI) had a reduction in hoarding severity (3, 4).
Treatment references
1. Rodgers B, McDonald S, Wootton BM: Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis. J Affect 290:128-135, 2021. doi: 10.1016/j.jad.2021.04.067
2. Bodryzlova Y, Audet S-B, Bergeron K, et al: Group cognitive-behavioural therapy for hoarding disorder: Systematic review and meta-analysis. Health Soc Care Community 27(3):517-530. doi: 10.1111/hsc.12598
3. Saxena S, Sumner JInt Clin Psychopharmacol 29(5):266-2, 2014. doi: 10.1097/YIC.0000000000000036
4. Saxena S, Brody AL, Maidment KM, et alJ Psychiatr Res 41(6):481-487, 2007. doi: 10.1016/j.jpsychires.2006.05.001
Key Points
Hoarding is usually a chronic disorder in which hoarders accumulate possessions that congest and clutter active living areas, making these areas very difficult to use as intended and sometimes unsafe.
Discarding possessions causes patients with hoarding disorder significant distress.
Treat using cognitive-behavioral therapy that is tailored to treat specific hoarding symptoms. If cognitive-behavioral therapy is not effective, a trial with an SSRI or SNRI can be considered, especially if the patient has potentially responsive comorbidity.
