What is hoarding disorder

A hoarding disorder is where someone collects an excessive number of items, stores them in a chaotic manner and has difficulty letting go or throwing out things that are out of date or no longer functioning. The items can be of little or no monetary value and usually result in unmanageable amounts of clutter. Often, people who hoard have difficulty moving around their home because of the number of things they have accumulated. The person may even no longer be able to maintain or clean their home.

Hoarding often creates such cramped living conditions that homes may be filled to capacity, with only narrow pathways winding through stacks of clutter. Countertops, sinks, stoves, desks, stairways and virtually all other surfaces are usually piled with stuff. And when there’s no more room inside, the clutter may spread to the garage, vehicles, yard and other storage facilities.

Currently hoarding disorder is considered a subtype of obsessive compulsive disorder (OCD), hoarding is characterized by three core features ¹⁾:

1. The acquisition of a large number of possessions;
2. The failure to discard a large number of possessions; and
3. Living in spaces that are sufficiently cluttered as to preclude their intended use.

The prevalence of hoarding disorder is approximately 5.3 percent; hoarding is twice as common in men and almost three times as common in people over the age of 55 ²⁾. Moreover, hoarding disorder is disproportionately seen among low-income populations and frequently leads to hazardous conditions, impaired functioning and increased health risks. As such, there is great need for clinicians to intervene to prevent and treat this potentially devastating condition.

Hoarding is considered to be a significant problem if:

• the amount of clutter interferes with everyday living – for example, the person is unable to use their kitchen or bathroom and cannot access rooms.
• the clutter is causing significant distress or negatively affecting the person’s quality of life or their family’s – for example, they become upset if someone tries to clear the clutter and their relationships with others suffer.

Hoarding disorders are challenging to treat, because many people who hoard frequently don’t see it as a problem, or have little awareness of how it’s impacting their life or the lives of others. Many others do realize they have a problem, but are reluctant to seek help because they feel extremely ashamed, humiliated or guilty about it.

It’s really important to encourage a person who is hoarding to seek help, as their difficulties discarding objects can not only cause loneliness and mental health problems, but also pose a health and safety risk. If not tackled, it’s a problem that will probably never go away.

Hoarding vs Collecting

Many people collect items such as books, baseball cards, model cars, antiques or stamps as a hobby or for sentimental reasons and this isn’t considered a problem. The difference between a “hoard” and a “collection” is how these items are organized.

A collection is usually well-ordered and the items are easily accessible. A hoard is usually very disorganized, takes up a lot of room and the items are largely inaccessible.

For example, someone who collects newspaper reviews may cut out the reviews they want and organize them in a catalogue or scrapbook. Someone who hoards may keep large stacks of newspapers that clutter their entire house and it’s not actually possible to read any of the reviews they wanted to keep.

Why someone may hoard

The reasons why someone begins hoarding aren’t fully understood.

Hoarding can be a symptom of another condition. For example, someone with mobility problems may be physically unable to clear the huge amounts of clutter they have acquired. People with learning disabilities or people developing dementia may be unable to categorize and dispose of items.

Mental health problems associated with hoarding include:

• Severe depression (50.7 percent)
• Psychotic disorders, such as schizophrenia
• Generalized anxiety disorder (24.4 percent)
• Social phobia (23.5 percent)
• Obsessive compulsive disorder (OCD) (18 percent)

Hoarding disorder participants were more likely than people with obsessive compulsive disorder (OCD) to have experienced a traumatic event in adult or childhood but were not more likely to be diagnosed with post-traumatic stress disorder (PTSD). Over one-quarter of the hoarding disorder participants met the criteria for the inattentive subtype of attention deficit hyperactivity disorder (ADHD) and 78.3 percent of the hoarding disorder patients had acquisition-related impulse control problems such as compulsive buying, acquiring free things or kleptomania, both significantly higher rates than the obsessive compulsive disorder (OCD) participants.

With nearly 75 percent of the hoarding disorder participants meeting the criteria for severe depression or generalized anxiety disorder, doctors are trying to find out if the onset of these disorders resulted from the significant burden and impairment of hoarding disorder, or if they play a role in the development of hoarding disorder ³⁾. Similarly, acquisition-related impulse control problems were seen among a substantial majority of the hoarding disorder patients, suggesting that they may not be comorbidities but rather part of the hoarding phenotype itself. While close to 50 percent of hoarding disorder patients reported experiencing a traumatic event, only 23 percent developed post-traumatic stress disorder (PTSD). Thus, clinicians are trying examine whether hoarding served some function (for example, possessions are a source of comfort, acquisition of items distracts from traumatic events), which then buffered the experience of the traumatic event and prevented the development of PTSD ⁴⁾. Future diagnostic assessments should utilize updated classification models and take into account these associations in order to inform treatment planning.

In some cases, hoarding is a condition in itself and often associated with self-neglect. These people are more likely to:

• live alone
• be unmarried
• have had a deprived childhood, with either a lack of material objects or a poor relationship with other members of their family
• have a family history of hoarding
• have grown up in a cluttered home and never learned to prioritize and sort items

Many people who hoard have strongly held beliefs related to acquiring and discarding things, such as: “I may need this someday” or “If I buy this, it will make me happy”. Others may be struggling to cope with a stressful life event, such as the death of a loved one (bereavement).

Attempts to discard things often bring up very strong emotions that can feel overwhelming, so the person hoarding often tends to put off or avoid making decisions about what can be thrown out.

Often, many of the things kept are of little or no monetary value and may be what most people would consider rubbish. The person may keep the items for reasons not obvious to other people, such as sentimental reasons, or feeling the objects appear beautiful or useful. Most people with a hoarding disorder have a very strong emotional attachment to the objects.

An increasing amount of research suggests the three core features of hoarding (excessive acquisition, difficulty discarding and clutter) are largely derived from impaired decision-making ⁵⁾. Broadly defined as indecisiveness, this underlying characteristic of hoarding, as well as hoarding severity and onset, were assessed in a sample of 887 self-identified hoarders through a web-based survey. In order to examine potential biological and non-biological relative interactions, these constructs were also evaluated among 120 spouses and 295 adult children of the self-identified hoarders. Within the sample of self-identified hoarding participants, 75 percent met the proposed criteria for hoarding disorder and all indecisiveness measures were correlated with hoarding severity. Moreover, indecisiveness predicted each of the core features of hoarding above and beyond depression, anxiety and obsessive compulsive disorder (OCD) symptoms, and indecisiveness was uniquely associated with age of onset of hoarding symptoms, with higher levels of indecisiveness associated with earlier onset. Depression accounted for unique variance in clutter, distress and interference, but not for two core features of hoarding (excessive acquisition and difficulty discarding), suggesting that depression may relate to the consequences of hoarding behavior but not its core features. As predicted, participants with hoarding were more indecisive than their adult children and spouses and the adult children reported more indecisiveness than the spouses. Unexpectedly, spouses scored significantly higher on the clutter feature of hoarding when compared to the adult children.

By demonstrating that indecisiveness is uniquely associated with the onset of hoarding as well as hoarding severity this study reinforces that decision-making problems play a major role in hoarding. Incorporating decision-making skill building into hoarding treatment may prove to be an important step to increasing treatment effectiveness.

Why hoarding disorder is a problem

A hoarding disorder can be a problem for several reasons. It can take over the person’s life, making it very difficult for them to get around their house. It can cause their work performance, personal hygiene and relationships to suffer.

The person hoarding is usually reluctant or unable to have visitors, or even allowing tradesmen in to carry out essential repairs, which can cause isolation and loneliness.

The clutter can pose a health risk to the person and anyone who lives in or visits their house. For example, it can:

• make cleaning very difficult, leading to unhygienic conditions and encouraging rodent or insect infestations
• be a fire risk and block exits in the event of a fire
• cause trips and falls
• fall over or collapse on people, if kept in large piles

The hoarding could also be a sign of an underlying condition, such as obsessive compulsive disorder (OCD), other types of anxiety, depression and potentially more serious conditions, such as dementia.

What you can do if you suspect someone is hoarding

If you think a family member or someone you know has a hoarding disorder, try to persuade them to come with you to see a doctor or mental health professional as soon as possible. Some communities have agencies that help with hoarding problems. Check with the local or county government for resources in your area.

This may not be easy, as someone who hoards might not think they need help. Try to be sensitive about the issue and emphasize your concerns for their health and wellbeing.

Reassure them that nobody is going to go into their home and throw everything out. You’re just going to have a chat with the doctor about their hoarding to see what can be done and what support is available to empower them to begin the process of decluttering.

Your doctor may be able to refer you to your local community mental health team, which might have a therapist who’s familiar with issues such as obsessive compulsive disorder (OCD) and hoarding.

It’s generally not a good idea to get extra storage space or call in the council or environmental health to clear the rubbish away. This won’t solve the problem and the clutter often quickly builds up again.

As hard as it might be, if your loved one’s hoarding disorder threatens health or safety, you may need to contact local authorities, such as police, fire, public health, child or elder protective services, or animal welfare agencies.

Hoarding disorder complications

People who hoard often buy too much, so as to keep up with their compulsion, which can result in financial hardship and/ or relationship problems. Hoarding can lead to living in squalid conditions, which is a health hazard. Compulsive buying and hoarding has links to OCD and depression.

Hoarding disorder can cause a variety of complications, including:

• Increased risk of falls
• Injury or being trapped by shifting or falling items
• Family conflicts
• Loneliness and social isolation
• Unsanitary conditions that pose a risk to health
• A fire hazard
• Poor work performance
• Legal issues, such as eviction

Many people with hoarding disorder also experience other mental health disorders, such as:

• Depression
• Anxiety disorders
• Obsessive-compulsive disorder (OCD)
• Attention-deficit/hyperactivity disorder (ADHD)

Hoarding disorder causes

It’s not clear what causes hoarding disorder. Genetics, brain functioning and stressful life events are being studied as possible causes.

Risk factors for hoarding disorder

Hoarding usually starts around ages 11 to 15, and it tends to get worse with age. Hoarding is more common in older adults than in younger adults.

Risk factors include:

• Personality. Many people who have hoarding disorder have a temperament that includes indecisiveness.
• Family history. There is a strong association between having a family member who has hoarding disorder and having the disorder yourself.
• Stressful life events. Some people develop hoarding disorder after experiencing a stressful life event that they had difficulty coping with, such as the death of a loved one, divorce, eviction or losing possessions in a fire.

Hoarding disorder signs and symptoms

Someone who has a hoarding disorder may typically:

• keep or collect items that may have little or no monetary value, such as junk mail and carrier bags, or items they intend to reuse or repair (see below)
• find it hard to categorize or organize items
• have difficulties making decisions
• struggle to manage everyday tasks, such as cooking, cleaning and paying bills
• become extremely attached to items, refusing to let anyone touch or borrow them
• have poor relationships with family or friends
• having a tendency toward indecisiveness, perfectionism, avoidance, procrastination, and problems with planning and organizing

Hoarding can start as early as the teenage years and gets more noticeable with age. Many people seem to start problematic hoarding in older age.

As the person grows older, he or she typically starts acquiring things for which there is no immediate need or space. By middle age, symptoms are often severe and may be harder to treat.

Problems with hoarding gradually develop over time and tend to be a private behavior. Often, significant clutter has developed by the time it reaches the attention of others.

Items people may hoard

Some people with a hoarding disorder will hoard a range of items, while others may just hoard certain types of objects.

Items that are often hoarded include:

• newspapers and magazines
• books
• clothes
• leaflets and letters, including junk mail
• bills and receipts
• containers, including plastic bags and cardboard boxes
• household supplies

Some people also hoard animals – dozens or even hundreds of pets, which they may not be able to look after properly. Animals may be confined inside or outside. Because of the large numbers, these animals often aren’t cared for properly. The health and safety of the person and the animals are at risk because of unsanitary conditions.

More recently, hoarding of data has become more common. This is where someone stores huge amounts of electronic data and emails that they’re extremely reluctant to delete.

Excessive acquiring and refusing to discard items results in:

• Disorganized piles or stacks of items, such as newspapers, clothes, paperwork, books or sentimental items
• Possessions that crowd and clutter your walking spaces and living areas and make the space unusable for the intended purpose, such as not being able to cook in the kitchen or use the bathroom to bathe
• Buildup of food or trash to unusually excessive, unsanitary levels
• Significant distress or problems functioning or keeping yourself and others safe in your home
• Conflict with others who try to reduce or remove clutter from your home
• Difficulty organizing items, sometimes losing important items in the clutter

People with hoarding disorder typically save items because:

• They believe these items are unique or will be needed at some point in the future
• The items have important emotional significance — serving as a reminder of happier times or representing beloved people or pets
• They feel safer when surrounded by the things they save
• They don’t want to waste anything

Hoarding disorder diagnosis

People often don’t seek treatment for hoarding disorder, but rather for other issues, such as depression or anxiety. To help diagnose hoarding disorder, a mental health professional performs a psychological evaluation. In addition to questions about emotional well-being, you may be asked about a habit of acquiring and saving items, leading to a discussion of hoarding.

Your mental health professional may ask your permission to talk with relatives and friends. Pictures and videos of your living spaces and storage areas affected by clutter are often helpful. You also may be asked questions to find out if you have symptoms of other mental health disorders.

For diagnosis, your mental health professional may use the criteria for hoarding disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association ⁶⁾.

Hoarding disorder treatment

It’s not easy to treat hoarding disorders, even when the person is prepared to seek help, but it can be overcome.

However, many people don’t recognize the negative impact of hoarding on their lives or don’t believe they need treatment. This is especially true if the possessions or animals offer comfort. If these possessions or animals are taken away, people will often react with frustration and anger and quickly collect more to help fulfill emotional needs.

The main treatment for hoarding disorder is cognitive-behavioral therapy (CBT). The therapist will help the person to understand what makes it difficult to throw things away and the reasons why the clutter has built up.

This will be combined with practical tasks and a plan to work on. It’s important that the person takes responsibility for clearing the clutter from their home. The therapist will support and encourage this.

There are currently no medications approved by the Food and Drug Administration (FDA) to treat hoarding disorder. Research continues on the most effective ways to use medications in the treatment of hoarding disorder. Antidepressant medicines called selective serotonin reuptake inhibitors (SSRIs) have been shown to help some people with hoarding disorders, particularly if they also have anxiety or depression.

Cognitive behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT) is a type of therapy that aims to help you manage your problems by changing how you think (cognitive) and act (behavior). It encourages you to talk about how you think about yourself, the world and other people, and how what you do affects your thoughts and feelings.

Regular sessions of cognitive-behavioral therapy (CBT) over a long period of time are usually necessary and will almost always need to include some home-based sessions, working directly on the clutter. This requires motivation, commitment and patience, as it can take many months to achieve the treatment goal.

The goal is to improve the person’s decision-making and organizational skills, help them overcome urges to save, and ultimately clear the clutter, room by room.

The therapist won’t throw anything away, but will help guide and encourage the person to do so. The therapist can also help the person develop decision-making strategies, while identifying and challenging underlying beliefs that contribute to the hoarding problem.

The person gradually becomes better at throwing things away, learning that nothing terrible happens when they do so, and becomes better at organizing items they insist on keeping.

At the end of treatment, the person may not have cleared all their clutter, but they will have gained a better understanding of their problem. They will have a plan to help them continue to build on their successes and avoid slipping back into their old ways.

Despite promising results, individual cognitive-behavioral therapy (CBT) is an intensive and costly treatment for those suffering from hoarding disorder. Group cognitive-behavioral therapy for hoarding disorder has been found to have somewhat inferior results to individual cognitive-behavioral therapy, perhaps due to the less structured interventions studied thus far. This study ⁷⁾ of 35 individuals with hoarding disorder sought to gauge the effectiveness of group cognitive-behavioral therapy (CBT) that attempted to maintain the structured protocol successful in studies of individual cognitive-behavioral therapy (CBT). Participants were enrolled in 16 or 20 sessions of group cognitive-behavioral therapy (CBT) and completed various assessment measures of hoarding, anxiety, depression and psychosocial functioning at pre- and post-treatment. Because home visits are challenging in real-life treatment settings, treatment in this study did not include clinician home visits, as did previous studies assessing group CBT for hoarding disorder. Significant improvements in hoarding symptoms, as well as depression, anxiety and quality of life indicators, were found among participants pre- to post-treatment. These results were comparable to studies of individual cognitive-behavioral therapy (CBT) and superior to previous group cognitive-behavioral therapy (CBT) studies.

Children with hoarding disorder

For children with hoarding disorder, it’s important to have the parents involved in treatment. Sometimes called “family accommodation,” over the years, some parents may think that allowing their child to get and save countless items may help lower their child’s anxiety. Actually it may do the opposite, increasing anxiety.

So, in addition to therapy for the child, parents need professional guidance to learn how to respond to and help manage their child’s hoarding behavior.

Lifestyle and home remedies

In addition to professional treatment, here are some steps you can take to help care for yourself:

• Stick to your treatment plan. It’s hard work, and it’s normal to have some setbacks over time. But treatment can help you feel better about yourself, improve your motivation and reduce your hoarding.
• Accept assistance. Local resources, professional organizers and loved ones can work with you to make decisions about how best to organize and unclutter your home and to stay safe and healthy. It may take time to get back to a safe home environment, and help is often needed to maintain organization around the home.
• Reach out to others. Hoarding can lead to isolation and loneliness, which in turn can lead to more hoarding. If you don’t want visitors in your house, try to get out to visit friends and family. Support groups for people with hoarding disorder can let you know that you are not alone and help you learn about your behavior and resources.
• Try to keep up personal hygiene and bathing. If you have possessions piled in your tub or shower, resolve to move them so that you can bathe.
• Make sure you’re getting proper nutrition. If you can’t use your stove or reach your refrigerator, you may not be eating properly. Try to clear those areas so that you can prepare nutritious meals.
• Look out for yourself. Remind yourself that you don’t have to live in chaos and distress — that you deserve better. Focus on your goals and what you stand to gain by reducing clutter in your home.
• Take small steps. With a professional’s help, you can tackle one area at a time. Small wins like this can lead to big wins.
• Do what’s best for your pets. If the number of pets you have has grown beyond your ability to care for them properly, remind yourself that they deserve to live healthy and happy lives — and that’s not possible if you can’t provide them with proper nutrition, sanitation and veterinary care.