Hoarding disorder

Lore & Background

Hoarding disorder typically manifests in childhood, with symptoms worsening in advanced age as collected items grow excessive and family members who would otherwise help maintain clutter levels die or move away. People with the 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 include alcohol dependence and paranoid, schizotypal and avoidant traits. In the DSM-IV, compulsive hoarding was listed as a diagnostic criterium of obsessive–compulsive personality disorder (OCPD), while other instruments considered it a symptom of OCD. However, more recent research found hoarding no more specific to OCPD than to other personality disorders, and it delivered the lowest predictive value for OCPD among all eight diagnostic criteria. Compulsive hoarding also appears distinct from OCD, differentiated by clinical, neurocognitive, and neurobiological parameters, leading to its establishment as its own diagnosis in the DSM-5 within Obsessive-Compulsive and Related Disorders. The DSM-5 describes six obligatory criteria for diagnosis: persistent difficulty discarding belongings even with little value (A); distress at the thought of discarding (B); possessions blocking normal use of living spaces (C); marked distress or impairment (D); not better explained by another medical issue (E) or mental disorder (F). The diagnosis allows specification of excessive acquisition behavior and level of insight, ranging from good or fair insight to absent insight/delusional beliefs.

Reader's Guide

Hoarding disorder represents a significant shift in psychiatric classification, moving from being considered a symptom of other disorders to a distinct diagnosis in the DSM-5. This change was driven by evidence that hoarding is no more specific to obsessive–compulsive personality disorder than to other personality disorders, and that it can be differentiated from obsessive–compulsive disorder by clinical, neurocognitive, and neurobiological parameters. The disorder's placement on the obsessive-compulsive spectrum may be subject to change as more studies on its etiology are needed. Cognitive behavioral therapy (CBT) is a commonly implemented treatment, involving exposure and response prevention, cognitive restructuring, and in-home work with a therapist. Research has shown that CBT protocols addressing motivation, organization, acquiring new clutter, and removing current clutter have promising results. Other therapeutic approaches include motivational interviewing, harm reduction, and group psychotherapy. However, individuals with hoarding behaviors are often described as having low motivation and poor compliance, leading to premature termination or low response to treatment. Clinically assessing severity is challenging because poor insight can lead to underreporting of clutter, while others on the obsessive-compulsive spectrum may perceive minimal litter as deeply distressing and self-report as hoarders without meeting criteria. The Clutter Image Rating, developed and validated by Frost et al., provides a visual measure for more objective evaluation and has been adopted by institutions such as Hoarding UK.

Did You Know?

• Prevalence rates are estimated at 2% to 5% in adults, though the condition typically manifests in childhood.
• In the DSM-IV, compulsive hoarding was listed as a diagnostic criterium of obsessive–compulsive personality disorder (OCPD).
• The DSM-5 diagnosis allows specification of whether the affected individual shows excessive acquisition behaviour and their level of insight.
• The Clutter Image Rating, developed by Frost et al., permits patients to pick images resembling their own rooms for more objective evaluation.