Hoarding disorder (HD) is a mental disorder characterized by persistent difficulty in parting with possessions and engaging in excessive acquisition of items that are not needed or for which no space is available. This results in severely cluttered living spaces, distress, and impairment in personal, family, social, educational, occupational, or other important areas of functioning. Excessive acquisition is characterized by repetitive urges or behaviours related to amassing or buying property. Difficulty discarding possessions is characterized by a perceived need to save items and distress associated with discarding them. Accumulation of possessions results in living spaces becoming cluttered to the point that their use or safety is compromised. It is recognized by the eleventh revision of the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Prevalence rates are estimated at 2% to 5% in adults, though the condition typically manifests in childhood with symptoms worsening in advanced age, at which point collected items have grown excessive and family members who would otherwise help to maintain and control the levels of clutter have either died or moved away.
People with hoarding disorder commonly live with other complex or psychological disorders such as depression, anxiety, obsessive–compulsive disorder (OCD), autism spectrum disorder (ASD), or attention deficit hyperactivity disorder (ADHD). Other factors often associated with hoarding include alcohol dependence and paranoid, schizotypal and avoidant traits.
Diagnosis
Distinguishing hoarding from healthy behavior
Collecting and hoarding may seem similar, but there are distinct characteristics that set the behaviors apart. Collecting is a hobby often involving the targeted search and acquisition of specific items that form—at least from the perspective of the collector—a greater appreciation, deeper understanding, or increased synergistic value when combined with other similar items. Hoarding, by contrast, typically appears haphazard and involves the overall acquiring of common items that would not be especially meaningful to the person who is gathering such items in large quantities. People who hoard keep common items that hold little to no meaning or value to others, unlike some collectors, whose items may be of great value to select people. Most hoarders are disorganized, and their living areas are crowded and in disarray. Most collectors can afford to store their items systematically or to have enough room to display their collections. Age, mental state, or finances have caused some collectors to fall into a hoarding state.
Clinical classification and diagnostic tools In the DSM-IV, compulsive hoarding was listed as a diagnostic criterium of obsessive–compulsive personality disorder (OCPD), while other clinical instruments such as the Yale–Brown Obsessive–Compulsive Scale consider it to be a symptom of obsessive–compulsive disorder (OCD). However, in more recent research, hoarding was found to be no more specific to OCPD than to other personality disorders described by the DSM-IV; in addition, among all eight diagnostic criteria of OCPD, hoarding delivered the lowest predictive value for presence of the disorder. Compulsive hoarding also appears to be distinct from OCD: While being highly comorbid and presumably sharing famillial risk factors, they can be differentiated by clinical, neurocognitive, and neurobiological parameters. Due to this evidence, hoarding disorder was established as its own diagnosis within the new category of Obsessive-Compulsive and Related Disorders in the DSM-5. Researchers involved in this categorization pointed out that the placement on the obsessive-compulsive spectrum may be subject to change as more studies on the etiology of hoarding disorder were needed.
The DSM-5 describes six obligatory criteria, A–F, for the diagnosis of hoarding disorder. It requires persistent difficulty in letting go of belongings, even when they have little or no real value (A). The aforementioned difficulty must be caused by a subjective need to keep items, and by distress at the thought of discarding them (B). Over time, possessions need to build up to the extent that they block or severely limit the normal use of living spaces, unless others step in to clear them (C). The behavior must cause marked distress or problems in daily life (D), and it cannot be better explained by another medical issue (E) or mental disorder (F). In addition to criteria A–F, the DSM-5 diagnosis allows to specify whether the affected individual also shows excessive acquisition behaviour. A second specification concerns the level of insight the individual has into their disorder, ranging from "good or fair insight" to "absent insight/delusional beliefs". Clinically assessing the severity of hoarding disorder may be challenging as poor insight can lead an affected individual to underreport the extent of clutter in their living spaces. Vice versa, other people on the obsessive-compulsive spectrum may perceive minimal litter as a deeply distressing mess, and self-report as hoarders despite not fulfilling the diagnostic criteria. To allow a more objective evaluation, Frost et al. developed and validated the Clutter Image Rating as a visual measure, permitting patients to simply pick the images which resemble their own rooms most closely. This instrument has been adopted by institutions such as the charity Hoarding UK.
Treatment Cognitive behavioral therapy (CBT) is a commonly implemented therapeutic intervention for compulsive hoarding. As part of cognitive behavior therapy, the therapist may help the patient to: Discover why one is compelled to hoard. Learn to organize possessions in order to decide what to discard. Develop decision-making skills. Declutter the home during in-home visits by a therapist or professional organizer. Gain and perform relaxation skills. Attend family or group therapy. Be open to trying psychiatric hospitalization if the hoarding is serious. Have periodic visits and consultations to keep a healthy lifestyle.Roger, Harms W. "Definition". Mayo Clinic. Mayo Foundation for Medical Education and Research, 25 May 2011. Web. 21 Mar. 2012.
This modality of treatment usually involves exposure and response prevention to situations that cause anxiety and cognitive restructuring of beliefs related to hoarding. Furthermore, research has also shown that certain CBT protocols have been more effective in treatment than others. CBT programs that specifically address the motivation of the affected person, organization, acquiring new clutter, and removing current clutter from the home have shown promising results. This type of treatment typically involves in-home work with a therapist combined with between-session homework, the completion of which is associated with better treatment outcomes. Research on internet-based CBT treatments for the disorder (where participants have access to educational resources, cognitive strategies, and chat groups) has also shown promising results both in terms of short- and long-term recovery.
Other therapeutic approaches that have been found to be helpful: Motivational interviewing originated in addiction therapy. This method is significantly helpful when used in hoarding cases in which insight is poor and ambivalence to change is marked. Harm reduction rather than symptom reduction. Also borrowed from addiction therapy. The goal is to decrease the harmful implications of the behavior, rather than the hoarding behaviors. Group psychotherapy reduces social isolation and social anxiety and is cost-effective compared to one-on-one intervention. Group CBT tends to have similar outcomes to individual therapy. Although group treatment often does not include home sessions, experimental research suggests that treatment outcomes may be improved if home sessions are included. Individuals have been shown to discard more possessions when in a cluttered environment compared to a tidy environment. Indeed, a meta-analysis found that a greater number of home sessions improves CBT outcomes.
Individuals with hoarding behaviors are often described as having low motivation and poor compliance levels, and as being indecisive and procrastinators, which may frequently lead to premature termination (i.e., dropout) or low response to treatment. Therefore, it was suggested that future treatment approaches, and pharmacotherapy in particular, be directed to address the underlying mechanisms of cognitive impairments demonstrated by individuals with hoarding symptoms.
Mental health professionals frequently express frustration regarding hoarding cases, mostly due to premature termination and poor response to treatment. Patients are frequently described as indecisive, procrastinators, recalcitrant, and as having low or no motivation, which can explain why many interventions fail to accomplish significant results. To overcome this obstacle, some clinicians recommend accompanying individual therapy with home visits to help the clinician:
Likewise, certain cases are assisted by professional organizers as well.
Epidemiology The prevalence of hoarding disorder is estimated to be between 2 and 6 percent, although some surveys indicate the lifetime prevalence may be as high as 14%. First-degree relatives of those with hoarding disorder are significantly more likely to report hoarding symptoms, and hoarding likely comes about due to a combination of genetic and environmental factors.
Rates of hoarding increase significantly with age, and people over the age of 54 are three times as likely to meet criteria for hoarding disorder. However, hoarding symptoms typically manifest in early childhood, and worsen to the point of becoming clinically significant during middle age. Over half of hoarders report the onset of hoarding as being associated with a traumatic life event, and in this portion of hoarders, the age of onset is much higher. Epidemiological studies have found that hoarding is twice as common in males, although clinical studies on hoarding tend to be predominantly female, suggesting that male hoarders are a significantly understudied and under-treated population.
Hoarding is a significant problem around the world and can pose a public health risk when hoarding escalates enough to damage the integrity of a structure or attract vermin. Accumulated items can block exits during fires and increase the risk of injury. In Japan, hoarder houses are known as , and have become a topic of public alarm in Japanese mass media. In the Eastern United States, they are sometimes called Collyer mansions or Collyers, after the infamous Collyer brothers.
Comorbidity Hoarding does frequently co-occur with OCD. OCD patients with hoarding symptoms were found to display a distinct form of hoarding in which they were more likely to hoard "bizarre items" and perform compulsive rituals associated with their hoarding behavior, such as rituals around checking items or rituals to be performed before discarding them.
Hoarding has been found to be correlated with depression, social anxiety, compulsive grooming disorders such as trichotillomania, bipolar disorder, reduced cognitive and affective empathy, and compulsive shopping. Hoarders have higher than average rates of traumatic past events, particularly those associated with loss or deprivation. Past events which occurred before the onset of hoarding are correlated to a subject's emotional attachment to physical objects, and past events after the onset of hoarding increase a subject's anxiety around memory. Hoarders are also more likely to have a past with alcohol abuse.