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Psychiatry Online

  • Winter 2024 | VOL. 22, NO. 1 Reproductive Psychiatry: Postpartum Depression is Only the Tip of the Iceberg CURRENT ISSUE pp.1-142

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Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation

  • Christiana Bratiotis , Ph.D. ,
  • Jordana Muroff , Ph.D. ,
  • Nancy X.Y. Lin , M.S.W.

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Hoarding disorder is characterized by difficulty parting with possessions because of strong urges to save the items. Difficulty discarding often includes items others consider to be of little value and results in accumulation of a large number of possessions that clutter the home. Cognitive-behavioral therapy (CBT) with exposure and response prevention and selective serotonin reuptake inhibitor medications traditionally used to treat obsessive-compulsive disorder are generally not efficacious for people with hoarding problems. A specialized CBT approach for hoarding has shown progress in reaching treatment goals and has been modified to be delivered in group, peer-facilitated, and virtual models. Research on hoarding remains in the early phases of development. Animal, attachment, and genetic models are expanding. Special populations, such as children, older adults, and people who do not voluntarily seek treatment need special consideration for intervention. Community-based efforts aimed at reducing public health and safety consequences of severe hoarding are needed.

Hoarding has received a great deal of public attention, especially with the proliferation of reality TV shows dedicated to the subject. Popular media portrayals of hoarding present a relatively straightforward issue with a similarly straightforward solution: “just clean it up.” However, in contrast to such sensationalist depictions, hoarding disorder is a recognized mental health condition that has been the subject of systematic empirical study in psychology, psychiatry, and related fields for nearly 2 decades. As early as 1947, Erich Fromm described a “hoarding orientation” in which a person’s security depended on collecting and saving objects. In 1962, Scandinavian psychiatrist Jens Jansen referenced “collector’s mania” to describe older adults who filled their rooms with an overabundance of objects.

acquisition of, and failure to discard, a large number of possessions that appear to be useless or of limited value; living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and significant distress or impairment in functioning caused by the hoarding.

This definition became the foundation for the development of the diagnostic criteria for hoarding disorder. Current conceptualizations of hoarding describe it as a condition that involves the excessive accumulation of possessions in the home, combined with difficulty discarding such items that most other people would not keep ( 2 ).

In 2013, the American Psychiatric Association ( 3 ) recognized hoarding as a unique disorder among obsessive-compulsive spectrum disorders. Six diagnostic criteria must be met for a patient to receive a diagnosis of hoarding disorder, which is currently classified under the code for obsessive-compulsive disorder (OCD; 300.3) ( Box 1 ). Two specifiers provide descriptive ratings for both the acquiring and insight aspects of hoarding.

BOX 1. DSM-5 : Hoarding disorder

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 clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for oneself or others).

The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive defects in major neurocognitive disorder, restricted interests in autism spectrum disorder).

With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. (Approximately 80%–90% of individuals with hoarding disorder display this trait.)

With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders , 5th ed. Arlington, VA, American Psychiatric Publishing, 2013. Copyright 2013 by the American Psychiatric Association.

Historically, hoarding was considered a subtype of OCD, although recent evidence suggests that there are more differences than similarities. Hoarding behaviors have been identified among individuals with anxiety disorders other than OCD, particularly those diagnosed as having generalized anxiety disorder or social phobia ( 4 ). Major depressive disorder, generalized anxiety disorder, and social phobia have also been found to be more prevalent among individuals with hoarding disorder than those with OCD ( 4 ). Another important characteristic of hoarding disorder that differentiates it from OCD is that the person engaging in hoarding is typically not troubled by the symptoms of the disorder, despite the obviousness of the problem to others. In contrast, people with OCD tend to have higher levels of insight, more often expressing distress at the behavioral and cognitive symptoms of the disorder ( 2 ). These differences suggest that hoarding disorder is not a subtype of OCD but rather a distinct condition that is often related to other psychiatric conditions ( 4 ).

Hoarding is a common condition, affecting approximately 2%–6% of the adult population in global north countries ( 5 – 7 ). Epidemiological studies indicate that hoarding occurs in both women and men at similar rates ( 5 ). People with hoarding disorder tend to live alone and are less likely to have family or friends visit their home ( 8 ). In our clinical experience, people who hoard have sometimes reported a preference for being alone with their objects, indicating more reliable relationships with objects than with people. Defining the average age of onset of hoarding is complicated by a lack of consistent diagnostic criteria and varied use of an array of assessment instruments. A recent meta-analysis found that the mean age of onset of hoarding symptoms across studies was 16.7 years ( 7 ). Severity of hoarding symptoms tended to worsen over time.

Treatment of people who hoard is made more complex by substantial clinical comorbidity. More than 60% of people with clinically significant hoarding meet the criteria for at least one co-occurring psychiatric disorder ( 9 ). Studies of hoarding comorbidity have reported particularly high rates of major depressive disorder (50%–52%), generalized anxiety disorder (24%), and social phobia (23%) ( 4 ). The symptomology associated with depressive and anxiety disorders has been suggested to play a role in reinforcing the negative emotional states that maintain hoarding disorder ( 9 ). For example, a person experiencing a major depressive episode that provokes general behavioral deactivation may have difficulty discarding. As such, differentiating hoarding disorder from hoarding symptoms caused by another mental illness can be challenging ( 10 ), and treatment of hoarding disorder is further complicated by substantial clinical comorbidity.

On an individual level, accumulated possessions can result in difficulty completing basic functions, such as socializing, preparing food, bathing, and mobilizing when rooms and hallways become inaccessible from clutter ( 11 ). Recent research indicates that hoarding disorder significantly affects employment because people who hoard take an average of 7 days off from work a month for psychiatric reasons: a number equal to that of people with bipolar and psychotic disorders and significantly higher than for individuals with mood disorders ( 12 ). These negative outcomes also affect those living with the affected individual. Severely cluttered family environments are associated with increased childhood distress, reduced social interaction, and greater family conflict ( 12 ).

It is important to note, however, that hoarding is distinct from other anxiety-based disorders because its implications pose problems not only for the individual with the disorder and their family, but also for broader society ( 2 ). Specifically, problems associated with hoarding behavior provoke health and safety concerns for both the occupant of the home and for those who live nearby, such as neighbors with shared walls ( 13 ). For example, risk of fire increases when combustibles are stored near heat sources or electrical wiring, and blocked exits create safety hazards for residents and emergency responders ( 11 ). A study by Lucini et al. ( 13 ) found that 60% of hoarding-related fires spread beyond its source, in contrast with only 10% of nonhoarding fires.

In addition to fire risk, severe hoarding behavior can also result in degradation of the home, with routine maintenance neglected, and homes becoming squalid, moldy, pest-infected, or structurally unsound because of excessive weight of clutter or water damage ( 11 ). When possessions expand beyond the confines of the home to create unsightly clutter in the backyard or on the front porch, laws and regulations requiring the upkeep of “tidy premises” of a home’s exterior may be violated ( 2 ). Other legal ramifications can include the involvement of child welfare services, older adult and guardianship services, and animal welfare organizations ( 2 , 14 ). Thus, given the social problems that hoarding creates, treatments for this issue expand beyond clinical focus on the person with the diagnosis alone to involving a multiagency approach that targets both the home and the potential impacts on the broader community ( 2 ).

Assessments for Hoarding Behaviors

Given that hoarding is a complex condition with varied symptoms and associated features, both clinicians and patients benefit from a rapid but comprehensive assessment. Establishing a diagnosis of hoarding disorder facilitates conversations about the meaning of this psychiatric condition and enables access to third-party payments for services. Determining the severity of hoarding behaviors (i.e., acquiring, difficulty discarding, clutter throughout the home and in other spaces) helps to establish intervention targets and the potential barriers to treatment. Detailed assessment of the degree of functional impairment from hoarding demonstrates the personal cost to the patient and indicates whether the clinician should be concerned about the patient’s health or safety. It also provides a ready avenue for motivational conversations about resolving frustrating functioning difficulties.

A detailed hoarding interview ( 15 ) facilitates collection of information about hoarding symptoms, as well as general life circumstances, housing conditions, social and family life, history of hoarding, and other problems. It facilitates the development of a conceptual model for each patient’s hoarding symptoms and clarifies where to start the work (e.g., on acquiring habits or on dangerous clutter in particular areas). As the reliability of self-ratings of hoarding severity can be compromised by decreased insight, a multi-informant approach carried out by an expert clinician is generally recommended ( 16 ).

The most commonly used hoarding assessment instruments ( 17 – 31 ), which have all been found to be reliable and valid for use with clinical hoarding populations, are summarized in Table 1 . In addition to these measures that assess hoarding symptom severity as well as clutter, several tools examine the home environment. One example is the HOMES Multidisciplinary Risk Assessment ( 26 ), a brief structured tool that assesses health and mental health difficulties, safety of others, obstacles to movement in the home, as well as structural concerns related to blocked paths, heat sources, and so forth. Another example is the Environmental Cleanliness and Clutter Scale ( 32 ), which is used to score levels of uncleanliness and clutter in one’s living environment. Additionally, the Home Environment Index ( 33 ) examines squalor (e.g., domestic and personal hygiene) among clients with hoarding, as well as the related effects on daily activities and tasks.

a UCLA, University of California, Los Angeles.

TABLE 1. Hoarding assessment instruments a

Behavioral tasks are also used to assess for aspects of hoarding, including acquiring, difficulty discarding, and categorization. Such tasks include computerized tasks of acquiring and discarding (e.g., 34 ), categorization tasks with personal and nonpersonal items (e.g., 35 ), and interpretive bias tasks (based on ambiguous hoarding-related scenarios and hoarding beliefs) ( 36 ). Behavioral measures do not depend on the participant’s level of insight, in contrast to self-report tools, and may enhance understanding of hoarding symptomatology, severity, and underlying factors beyond what is perceived and explicitly reported by the participant.

Models and Mechanisms for Hoarding

Animal models.

Preliminary investigations into using animal models to understand hoarding behavior in humans have begun in a limited capacity. Andrews-McClymont et al. ( 37 ) compared data on human hoarding with hoarding behaviors in a variety of animal species. They found that rodent models of hoarding had the greatest overlap with human traits. Both species’ hoarding behaviors increased with age, and both had evidence of abnormalities in the same regions of the brain ( 37 ).

Neurobiological and Genetic

Hoarding behavior may be due to neuropsychological conditions with specific brain pathology (e.g., dementia, stroke, another medical or mental health condition) or may exist without neuropathology. Studies indicate that the ventromedial prefrontal cortex is linked to hoarding behavior ( 38 ); this region of the brain is involved in decision making as well as emotional processing of rewards and punishments.

Early neuroimaging studies of hoarding were focused on patient samples with OCD. The initial study of hoarding without known brain pathology (nonorganic hoarding) utilized position emission tomography to examine patients with OCD (N=45), including some with (N=33) and some without (N=12) hoarding symptoms, as well as a healthy control group (N=17) ( 39 ). This study found that those with OCD and hoarding showed less glucose metabolism in the posterior cingulate cortex and dorsal anterior cingulate cortex. Such regions are associated with decision making, categorization, and implicit learning ( 40 ).

Other initial studies used functional magnetic resonance imaging (fMRI) with tasks such as imagining discarding a pictured item with patients with OCD with (N=13) and without (N=16) hoarding, as well as a control group (N=21). Study participants with OCD and hoarding showed greater activation in bilateral anterior ventromedial prefrontal cortex compared with the other two groups ( 41 ). These studies are limited in that they included OCD samples, so they may be less generalizable to patients with hoarding disorder who do not also have OCD.

Research focusing on individuals with primary hoarding disorder also used fMRI, which demonstrated abnormalities in brain function in several regions. One study, which included 12 participants with hoarding disorder and 12 healthy control participants, used a decision-making task whereby the participants selected personal (those brought to study by the participant) versus nonpersonal paper items to discard, which were then shredded. During the decision making, patients with hoarding disorder showed greater activation of the lateral orbitofrontal cortex and parahippocampal gyrus compared with the healthy control group ( 42 ).

A larger follow-up study, which included 43 patients with hoarding disorder, 31 patients with OCD, and 33 healthy control patients, incorporated the same decision-making task in which the shredding of discarded paper items occurred at the end of the session ( 43 ). When those with hoarding disorder made decisions about personal items, brain activity was higher in the anterior cingulate cortex and insula, whereas patients with hoarding disorder showed lower brain activity compared with the OCD and control groups when making decisions regarding nonpersonal items ( 43 ). These regions are involved in emotional responses and affective states. These findings suggest that increases and decreases in brain activity varied by the specifics of the task (whether personal items were included) and demonstrated distinctions in abnormalities in brain activity related to OCD and hoarding disorder ( 44 ).

These researchers also conducted a small pilot study ( 43 ) of a simulated discarding and acquiring decision-making task using fMRI with patients with hoarding disorder (N=6) and a healthy control group (N=6). This task replicated abnormalities in activation of the frontotemporal region associated with discarding tasks, as well as some of these same abnormalities when making decisions to acquire. A recent study ( 44 ) of participants with hoarding disorder (N=79) and a control group (N=44), which included images of high- or low-value objects, also found overactivity in the anterior cingulate cortex when participants made decisions regarding personal objects and acquiring objects. Levy et al. ( 45 ) found neurological abnormalities among participants with hoarding disorder even at resting state.

These neuroimaging studies and other research suggest that people with hoarding disorder experience cognitive challenges and related impairments ( 20 , 44 , 45 ). A core component of the cognitive-behavioral model of hoarding ( 15 ) includes challenges with information processing, specifically impairments in the areas of working memory ( 46 ), inattention and distractibility ( 47 , 48 ), self-control ( 49 , 50 ), decision making ( 51 ), as well as categorizing personal belongings ( 35 , 52 ). Such challenges are evidenced through studies that used neuropsychological tests as well as self-report measures ( 20 ). Studies also suggest that cognitive impairments may be specific to hoarding while also being at least somewhat related to comorbid conditions such as anxiety, depression, and stress ( 20 ).

Future studies may examine cognitive (e.g., planning, attention) and affective (e.g., emotion, visceral information, salience, and valence) decision making among those with hoarding disorder as well as cognitive impairments evidenced by neuropsychological tests. Those with poor cognitive confidence or perceived cognitive impairment could also be examined. Enhanced understanding of neurobiological underpinnings may inform the selection of therapeutic targets as well as the development and selection of treatments ( 20 ). Additional research may examine conditions associated with worsened neuropsychological impairment among those with hoarding disorder and whether treatments improve neuropsychological abnormalities.

Hoarding as well as hoarding symptoms showed heritability ranging from 45% to 71%, just below that of OCD (74% with a confidence interval of 60%–83%) ( 53 – 57 ). In a community-based pediatric sample, study findings indicated that the L G +S variant of 5‐HTTLPR was significantly associated with hoarding in men, whereas a trend was shown for variation downstream of HTR1B to be linked with hoarding in women ( 6 ). Associations were evidenced between T-allele carriers and hoarding ( 58 ) as well Val-allele carriers and hoarding ( 59 ). Perroud and colleagues ( 60 ) conducted a genome-side association study with White twins (N=3,410) and found no genome-wide significance; however, two genomic loci on chromosome 5 and 6 showed suggestive evidence for association with hoarding traits. There also appears to be a link between hoarding traits and the glutamatergic system, although further investigation of this relationship is needed ( 61 ).

Research suggests that genetic factors may contribute to the comorbidity of hoarding disorder with other psychiatric conditions. Specifically, Zilhão et al. ( 62 ) found that genetic factors explained 50.4% and 70.1% of the covariance between hoarding disorder and OCD symptoms and Tourette’s disorder, respectively. Specific variations in genes were also significantly correlated between hoarding disorder and OCD symptoms (0.41) and Tourette’s disorder (0.35), suggesting a common genetic basis to these conditions. Current research on the genetics of hoarding disorder is limited, and extensive further study is needed on genetic risk factors and unique genetic signatures of hoarding disorder and other obsessive-compulsive related disorders ( 61 ).

Attachment and Identity

Since our 2015 article ( 63 ), updated research has expanded on the role of attachment and identity issues regarding hoarding etiology. Attachment theory posits that infants form significant bonds to early attachment figures (e.g., their parents) and seek to maintain these attachments that offer protection, safety, and comfort ( 64 ). However, when attachment figures are repeatedly unavailable, individuals may, in turn, develop insecure attachment styles lasting into adulthood. Adult insecure attachment can manifest as either attachment anxiety (i.e., fear of abandonment) or attachment avoidance (i.e., fear of intimacy). Individuals diagnosed as having hoarding disorder have been found to experience both greater attachment anxiety and attachment avoidance compared with nonclinical samples ( 64 ). For those with attachment anxiety, object attachment has been suggested to act as a substitute for interpersonal relationships because relationships with inanimate objects may be perceived as less threatening than with people ( 64 ). Neave et al. ( 65 ) found that attachment anxiety and object attachment were both significant predictors of hoarding symptoms. Noberg et al. ( 66 ) further reported that increased attachment anxiety was correlated with greater distress intolerance and a stronger tendency to anthropomorphize inanimate possessions. Decreased tolerance to distress has, in turn, been linked to increased avoidance behaviors ( 67 ), which may manifest among individuals with hoarding disorder as avoidance of discarding and sorting items, cleaning, or even thinking about the clutter ( 18 ).

There is preliminary empirical evidence of a link between clinical hoarding and self-identity ( 12 , 68 ). Kings et al. ( 12 ) described case reports of people with hoarding behavior who formed strong emotional attachments with possessions that they associated with the identities of others (e.g., a deceased spouse). These possessions could similarly be associated with the person’s perception of individuality (i.e., objects becoming symbols of their personal passions and interests) ( 12 ). Chou et al. ( 68 ) found that aspects of compromised self-identity (e.g., self-criticism and shame) were positively correlated with hoarding symptoms and beliefs. There have also been findings demonstrating a positive association between compulsive buying and a poorly defined sense of identity ( 69 ). These varied findings, although preliminary, suggest that acquired possessions can become integrated with the concept of self-identity among people who hoard.

Cognitive and Behavioral

The cognitive-behavioral model of hoarding ( 24 ) suggests that the primary symptoms of hoarding (i.e., saving, clutter, and acquiring) are caused by certain vulnerabilities (e.g., early life attachment difficulties), information processing problems, thoughts and beliefs about possessions, and positive and negative emotions. There are now several studies that verify the concepts highlighted in the cognitive-behavioral model. These elements include increased emotional reactivity ( 70 ), intolerance of uncertainty ( 71 ), anxiety sensitivity ( 72 ) and impulsivity ( 73 ), greater level of worry concerning the potentially catastrophic consequences of forgetting ( 74 ), and differences in planning and problem solving among people with hoarding disorder compared with control groups ( 74 ). Other factors have only recently been proposed as relevant to the onset and progression of hoarding disorder; these factors include object‐affect fusion ( 75 ) and the involvement of self ( 12 , 76 ).

Insight and Motivation

Many individuals who hoard lack sufficient insight to recognize the extent of their clutter and the negative consequences associated with this accumulation ( 77 ). Some studies have used external observer ratings of hoarding severity to measure insight. In a web-based survey, family members of people who hoard reported significantly higher severity ratings compared with their estimates of how they thought the affected person would rate their own symptoms ( 77 ). Decreased insight can result in increased health and safety risks, family conflict, and involuntary involvement with mandated community agencies ( 26 ). Poor insight has been attributed to early childhood experiences of insecure attached families, resulting in limited opportunities to learn organization and decision-making skills ( 78 ). Preliminary research on the intersection of insight and hoarding suggests that insight is multidimensional, composed of decreased awareness of illness and defensiveness toward interventions forced by family or the community at large. Existing hoarding treatment research has similarly suggested a lack of motivation to correct the problem ( 79 ). Accordingly, individuals with poor or absent insight do not generally seek help for their behavior and may in fact resist uninvited intervention efforts ( 80 ).

Interventions

Cognitive-behavioral therapy (cbt).

CBT is manualized ( 15 ), has been extensively tested ( 81 ), and is presently considered the standard evidence-based treatment for hoarding disorder ( 2 ). CBT is a time-intensive weekly therapy that aims to modify emotions, cognitions, and behaviors related to hoarding ( 2 , 82 ). CBT for hoarding provided on an individual basis often includes components of decision-making training, sorting and discarding exercises, organization training, exposure to nonacquiring cognitive restructuring, and motivational interviewing ( 15 ). Regular home visits are strongly recommended and have been applied in most outcome studies. CBT has been found to be particularly effective at addressing difficulty discarding, reducing clutter volume, and decreasing acquiring behaviors ( 2 , 81 ). CBT primarily has an intrapersonal focus and, therefore, does not necessarily include interventions such as assisting with home cleanup. Accordingly, this treatment also does not specifically target the social consequences of hoarding, such as affected family relations and community-based risks. Finally, because few mental health providers have the expertise required to provide hoarding-specific CBT, the widespread availability of this treatment is limited ( 2 ).

Initially modeled on individual CBT practices, protocols for group-based CBT for hoarding have also been developed and tested. Group CBT is similarly composed of multiweek sessions that provide education about hoarding, decision-making training, organization exercises, and cognitive restructuring in which patients are asked to evaluate their hoarding-related beliefs and are encouraged to take alternative nonhoarding perspectives ( 83 ). Interest in group CBT over individual CBT can be attributed to the general advantages of group-based therapies, including greater social interaction and involvement as well as expected higher cost-efficiency ( 83 ). Bodryzlova et al.’s ( 83 ) meta-analysis found that group CBT resulted in clinically significant improvements (21%–68% across treatment groups) on the severity of cluttering, acquisition, and difficulty discarding.

Peer-facilitated CBT for hoarding is an alternative group treatment that has been found to be as effective as psychologist-led group CBT ( 84 ). The Buried in Treasures workshop is the predominant manualized, peer-facilitated CBT, composed of 15 structured sessions that provide psychoeducation regarding hoarding disorder, motivation enhancement, cognitive restructuring, and discarding exercises ( 85 ). Recent additions to the Buried in Treasures treatment have been made in the form of adding in-home decluttering sessions in the final weeks of the workshop. Linkosvki et al. ( 85 ) found that the addition of these personalized sessions resulted in reductions in hoarding symptoms, clutter, and impairment of daily activities.

Virtual and Blended Therapies

Since our 2015 article ( 63 ), there has been increasing research into technology-supported interventions for hoarding ( 86 ). Such interventions include benefits such as extending access to trained practitioners; flexibility in implementation, content, and personalization; greater ease in scheduling; support and feedback between sessions; and enhanced cost-effectiveness. Several studies have examined the feasibility, acceptability, and effectiveness of integrating empirically supported CBT interventions with web-based self-help ( 87 ), individual and group videoconferencing ( 86 , 88 , 89 ), and “blended” face-to-face with web-based therapist assistance ( 90 , 91 ). These studies show numerous benefits in addition to hoarding symptom improvement that include greater treatment completion rates, shorter duration to complete treatments, as well as strong therapeutic alliance and satisfaction ratings.

There is also increasing interest in the use of virtual reality (VR) to treat hoarding disorder, although research is limited in this area to date. VR has been shown to be effective in the treatment of related disorders such as social phobia, OCD, and generalized anxiety disorder ( 92 ). VR may be particularly beneficial for individuals who have difficulty using mental imagery techniques to visualize everyday settings (such as people with hoarding disorder), and it may serve as an alternative to home visits ( 92 ). A preliminary study ( 92 ) of VR and inference-based therapy in a group format found a significant difference in the posttreatment level of bedroom clutter in the experimental group compared with the control group. Another study that used VR to simulate participants’ home environments without existing clutter found that participants reported higher confidence and motivation to engage in behavior change postimmersion ( 93 ). As technology-based innovations continue to develop and evolve, future studies may more rigorously test web-based and VR interventions for hoarding as well as incorporate other innovations, including deep learning ( 94 ), smartphone applications, and conversational agents ( 86 ).

Compassion-Focused Therapy (CFT)

CFT has recently been identified as an alternative psychotherapeutic treatment for hoarding disorder. CFT uses a variety of interventions to stimulate self-compassion, shift blame away from oneself, and regulate negative emotions that may arise in response to cognitive-restructuring attempts ( 67 ). Mindfulness training is commonly provided as part of CFT to facilitate emotional self-awareness. Multiple studies have found that incorporating CFT techniques into standard CBT programs has resulted in greater treatment effects than those produced by CBT alone for a variety of mental illnesses, including eating disorders, posttraumatic stress disorder, major depressive disorder, personality disorders, and psychotic disorders ( 67 ). Chou et al. ( 67 ) found that the provision of CFT to individuals with hoarding disorder who remained symptomatic after initially receiving CBT resulted in satisfactory treatment feasibility and acceptability among participants. Of the participants who completed the treatment, 77% had severity scores below the cutoff for clinically significant hoarding, and 62% of participants achieved a clinically significant reduction in symptom severity. However, CFT had limited effects in addressing memory concerns and attachment-related issues as well as reducing hoarding-related beliefs.

Coordinated Community Interventions

Severe hoarding behavior commonly results in diverse public health and safety concerns, which in turn, necessitate interventions, resources, and professional expertise from a wide range of sectors, including fire prevention, sanitation, housing, protective services, legal services, health, and mental health ( 11 ). As such, many cities across North America have begun to develop coordinated, community-level responses to hoarding cases in the form of task forces, coalitions, and community networks ( 80 ). The goals of community-based, coordinated initiatives typically include decreasing the incidence of severe hoarding, increasing the physical and mental health of individuals who hoard, and preserving housing ( 26 ).

Case management is an approach that has been commonly used as part of these interdisciplinary efforts. It broadly consists of three interrelated activities: identification of clients, service coordination, and service utilization ( 11 ). Within these broad categories, specific activities can include case finding, assessment, goal setting, service planning, supportive counseling, implementation of service plans, monitoring, and evaluation. These case-management activities are typically used to provide comprehensive social services to vulnerable and marginalized populations and have been found to be well-suited to the complex needs of people who hoard ( 11 ).

Harm Reduction

On the surface, hoarding may appear to be a relatively straightforward problem to address. One could simply hire a service to completely clean out the home or forcefully relocate the person who hoards to another residence. However, existing literature describes involuntary cleanouts as both traumatic to the person who hoards and ineffective in the long run, because they often lead to increased rates of recidivism ( 80 ). As such, community-based responders are increasingly avoiding the use of these more extreme options in favor of framing their service provision through a harm-reduction approach ( 80 ). In harm reduction, the goal is not to eliminate the hoarding behavior itself but rather to decrease or mitigate the risks associated with the behavior ( 95 ). The use of this approach necessitates engagement of the person who hoards in decision-making processes and the development of a supportive and nonjudgmental client-provider relationship. Hoarding response teams that utilize a harm-reduction approach may assist the person who hoards to reduce clutter volume to preserve housing, or even reconfigure possessions into safer configurations, rather than removing them altogether ( 80 ).

As discussed in our 2015 article ( 63 ), although research on the biology and neurophysiology of hoarding suggests a variety of treatment avenues, the present literature on medications has focused primarily on serotonin reuptake inhibitors (SRIs) because of their utility for OCD, with which hoarding disorder was initially conceptualized as a subtype. Some studies on pharmacotherapy for OCD retrospectively examined patients with OCD and hoarding symptoms and found that hoarding was linked to a poorer response to SRI medication ( 96 ); however, others found that hoarding did not have a significant effect on response to pharmacotherapy among those with OCD (e.g., 97 , 98 ). These studies focused specifically on those with OCD and did not include those with hoarding disorder without other OCD symptoms. Given that the majority (>80%) of those with hoarding disorder do not have comorbid OCD ( 4 ), it is essential that studies on medication treatment include the broader population of those with hoarding disorder.

In a prospective study, patients with hoarding (N=32) and those with OCD without hoarding (N=47) received 12 weeks of the SRI paroxetine (41.6±12.8 mg/day), with similar proportions of patients in each group being identified as full responders (hoarding disorder, 27%; OCD without hoarding, 32%) and as partial responders (hoarding disorder, 22%; OCD without hoarding, 15%) ( 99 ). Completers demonstrated a 31% mean symptom improvement on the UCLA Hoarding Severity Scale (UHSS; 24% for the entire sample) ( 18 ); thus, treatment response was similar between the two groups, although most had difficulty tolerating 40 mg of paroxetine, and few reached the target dose. To test a medication that was better tolerated, 24 patients meeting DSM-5 criteria for hoarding disorder received venlafaxine extended release (37.5-mg increments to 225 mg/day) for 12 weeks. Venlafaxine was well tolerated; symptoms improved by a mean of 36% on the UHSS and 32% on the Saving Inventory-Revised (SI-R) ( 21 – 23 ). Of the patients, 70% responded, and hoarding symptoms improved across difficulty discarding, excessive acquisition, clutter, and functioning ( 18 ). However, the effectiveness of serotonergic drugs for treating hoarding disorder remains largely controversial because other studies involving patients with OCD and hoarding symptoms have shown no response to this category of drugs ( 100 , 101 ).

Pharmacological interventions for hoarding disorder have targeted specific hoarding symptoms that maintain disability. For example, a 12-week open trial of 40–80 mg/day (mean of 62.72) of atomoxetine (a drug used for treatment of attention-deficit hyperactivity disorder [ADHD]) resulted in a 41.3% decrease of hoarding severity using the UHSS (39.9% decrease on the SI-R) among participants with hoarding disorder who exhibited inattention and impulsivity symptoms, which have been hypothesized to underlie hoarding behaviors ( 100 ). The patients’ inattentive and impulsivity symptoms showed a mean reduction of 18.5%, which correlated with a reduction in their global functional disability. Of the 12 study participants, six were identified as full responders (average reduction of hoarding symptoms was 57.2%), and three were identified as partial responders (average reduction of hoarding symptoms was 27.3%) using the UHSS. In a small open-label study, four individuals with hoarding disorder without comorbid ADHD were treated with the stimulant methylphenidate extended release. Following 4 weeks of treatment receiving an average of 50 mg of methylphenidate extended release, three of the four participants self-reported ≥50% improvement regarding inattention on the ADHD Symptom Scale. Modest improvements in hoarding symptoms were reported by two participants, with 25% and 32% reductions on the SI-R ( 21 – 23 ), especially on the excessive acquisition subscale ( 102 ).

A recent review of the use of second-generation antipsychotics, such as quetiapine and risperidone, for treating hoarding disorder found no evidence to suggest that they are beneficial to patients with hoarding disorder ( 103 ). One randomized, double-blind, cross-over study examined augmenting selective serotonin reuptake inhibitors (SSRIs) with the opioid antagonist naltrexone among outpatients with OCD who were not responsive to SSRIs or clomipramine for a couple of months; however, their OCD symptoms did not improve ( 104 ). A case study of an individual with hoarding symptoms and bipolar II disorder was not responsive to elevated doses of SRIs and second-generation antipsychotics but was responsive to lamotrigine combined with methylphenidate ( 105 ).

Overall, studies on pharmacotherapy for hoarding disorder remain limited by small sample sizes, designs including open labels, medications in varying classes, predominance of patients with OCD with hoarding symptoms versus a primary hoarding disorder diagnosis, preponderance of participants in midlife, use of measures not specific or validated for hoarding, and little to no replication ( 100 , 106 , 107 ). An outstanding question is the potential value of adding medications to cognitive and behavioral treatments for hoarding. In their meta-analysis, Tolin et al. ( 81 ) reported a significant positive predictive effect of medication for improvement in difficulty discarding but not for overall hoarding severity or other symptoms of hoarding. However, the type of medications varied within and across studies, so the possible augmenting effects of specific medications are not yet clear. Additional research is needed to determine the efficacy of medications for hoarding disorder, alone and in combination.

Special Populations

Children and adolescents.

There remains limited literature on pediatric presentations of hoarding, with the bulk of existing knowledge being borrowed from studies of children with OCD diagnoses ( 108 ). The prevalence of hoarding disorder among adolescents has been estimated at 2% of the adolescent population ( 101 , 108 ). Hoarding symptoms tend to be milder in childhood and increase in severity with age, with symptoms first presenting at an average age of 16.7 ( 7 , 101 , 108 ). Severity of hoarding symptoms tended to worsen over time. Children rarely accumulate clutter at the same levels of adult hoarding because their parents and other adult figures (e.g., teachers) can exert control over the child’s ability to acquire possessions ( 101 , 109 ). Children who hoard typically collect seemingly useless items (e.g., candy wrappers and old school papers). This behavior tends to be accompanied by excessive concern about the location, care, and condition of the objects. Objects are also often personalized, becoming part of the child’s personal identity ( 110 ), resulting in discarding attempts becoming potentially traumatic. Hoarding symptoms among children and adolescents are associated with poor insight, indecision, inattention, poor memory, impaired problem solving and planning, increased avoidance, and comorbid conditions (e.g., Tourette’s disorder and ADHD) ( 101 , 109 ). Youths with OCD and hoarding symptoms have been found to have more severe current and lifetime trajectories of OCD than those without ( 108 ).

Most standardized assessments for adults who hoard have not been normed for use with children. The only exception is the Child Saving Inventory (based on the SI-R), a 23-item scale rated by parents or caregivers on four subscales: discarding, clutter, acquisition, and distress-impairment ( 111 ). With regard to treatment for this population, the effectiveness of hoarding-modified CBT for the adult population has not been widely documented in younger samples ( 101 ). There is also limited literature on pharmacological treatment for pediatric hoarding.

Older Adults

It is estimated that the rate of hoarding among older adults is three times greater than that of the general population (2%–6%) ( 23 ). As previously detailed, hoarding symptoms tend to increase in severity with age. Hoarding behaviors present unique challenges for this population because accumulation of clutter can result in increased risks for fire danger, fall hazards, medication mismanagement, inadequate nutrition, social isolation, impairment in activities of daily living, and overall decreased quality of life ( 23 , 31 ). Sixty-four percent of older adults with hoarding disorder have trouble completing self-care activities, and 81% have risks to general health because of fires, falls, and poor sanitation ( 23 ).

Cognitive impairment, such as difficulty with planning, problem solving, and memory, is often evident among older adults who hoard, further complicating both assessment and treatment efforts. Assessment instruments designed for adults who hoard are generally suitable for assessing hoarding among older adults, unless marked cognitive decline invalidates self-report measures. Given the potential inaccuracies with self-report, is it recommended that a comprehensive assessment also include home visits, reports from social supports, neurocognitive assessment, and evaluation of functional impairment and comorbid psychiatric conditions ( 112 ). Cognitive impairment has been found to result in poorer responses to CBT in other geriatric psychiatric populations ( 23 ). Thus far, cognitive rehabilitation and exposure-sorting therapy, which pairs cognitive training with behavioral exposure, has shown promise for older adults, resulting in clinically significant improvement in hoarding severity ( 23 ). Other common interventions include clutter reduction and harm-reduction strategies.

Nonvoluntary Clients

Since our 2015 article ( 63 ), research remains limited on nonconsensual clients who hoard in community settings. However, new research suggests that most individuals with hoarding behaviors do not voluntarily seek assistance without family or community pressure ( 113 ), with problems recognized during routine building or fire inspections ( 80 ). Individuals’ poor insight often results in a lack of awareness about the implications of their accumulated possessions and rejecting offers of help. Emotional attachment to their belongings may be difficult to overcome, and fear of stigma and societal judgment lead to further social isolation and avoidance of the issue.

Nonvoluntary clients’ poor insight and inconsistent motivation add to the challenge of engaging these individuals in hoarding interventions. These tendencies commonly manifest in procrastination, unresponsiveness to contact attempts by service providers, and cancelled or missed appointments ( 80 ). Some clients may withdraw consent to provider engagement despite initially agreeing to services ( 80 ). In situations in which this ongoing avoidance results in elevated safety concerns or risk of housing loss, service providers may then be required to apply legal sanctions to force compliance ( 80 , 113 ).

As discussed in our 2015 article ( 63 ), family members who live with a person who hoards are exposed to the same health and safety risks. Children of people who hoard are faced with constant disruptions, including loss of functional living space, unsanitary home conditions, social isolation, financial distress, and hostile family dynamics ( 114 , 115 ). The effects of these challenges can have a lifetime impact on children, with the associated psychological distress lasting into adulthood. Recent research indicates that adult children of people who hoard have reported feelings of grief related to the loss of their relationship with their parent, as well as anger stemming from beliefs that their parent who hoards chose possessions over their children ( 115 ). As their parents age, adult children of people who hoard experience additional responsibilities as caregivers.

The level of caregiver burden experienced by the relatives of people who hoard has been found to be comparable with or greater than that reported by family members of people with dementia ( 16 ). Older adults who hoard require greater assistance to complete basic activities of daily living that otherwise would be neglected, a responsibility that often falls on their adult children and other relatives ( 16 ). Relatives of people who hoard also report increased levels of frustration, hopelessness, and distress in response to the hoarding person’s lack of insight, treatment ambivalence, and risk of injury from unsafe living conditions ( 16 , 114 , 115 ). Feelings of shame and embarrassment interfere with family members’ ability to have people visit the home, resulting in risk of social isolation ( 115 ). The negative emotions experienced by family members of people who hoard often culminate in outright rejection of the person who hoards ( 114 , 115 ).

Manualized training programs have also been designed for family members of people who hoard and include components of psychoeducation on hoarding, harm-reduction techniques, communication training, and self-care ( 114 ). One such program is the Family-As-Motivators training, which was conducted in a pilot study over 14 sessions. At pre-, mid-, and posttraining measures, Family-As-Motivators resulted in improved use of coping strategies, decreased feelings of hopelessness, and decrease in self-blame ( 114 ). Another example includes family-focused, harm-reduction programming (i.e., Community Reinforcement and Family Training) ( 95 ), which focuses on improving stressed familial relationships while also encouraging the person who hoards to accept help to manage the hoarding problem. The harm-reduction approach includes five key components: enhance willingness to engage in the harm-reduction approach, assess the potential for harm, build and facilitate a harm-reduction team, plan the harm-reduction approach, and implement and manage the plan.

Conclusions

Frost and Hartl’s ( 1 ) seminal article inspired 25 years (and counting) of empirical study of hoarding. To date, research has focused on identifying specific symptoms and components of hoarding, distinguishing hoarding from OCD, and examining hoarding as a distinct DSM-5 disorder ( 3 ). This inquiry has led to the development of models for understanding hoarding disorder that focus on personal and family vulnerability factors (e.g., family history, comorbidity), information processing challenges (e.g., inattention, categorization, memory), cognitions (e.g., meaning of possessions), positive and negative emotions, biological features, and so forth. Recent investigations of cognitive processing, neurobiological correlates, and genetic aspects of hoarding are advancing the understanding of key elements of hoarding (e.g., discarding, excessive acquiring, clutter) and relevant substrates. More recent neurobiological and genetic studies further illustrate the similarities and distinctions between OCD and hoarding as well as other obsessive-compulsive and related disorders. Future research is needed to examine cognitive and affective decision making as well as cognitive impairments associated with hoarding. Additional studies are also needed to understand impairments associated with hoarding and comorbid conditions. Further study of neurobiological underpinnings of hoarding disorder may enhance the identification and selection of treatment targets and inform treatment development and the personalization of treatments. More extensive research is also needed on genetic factors and hoarding traits, including the genetic signature of hoarding disorder.

Cognitive and behavioral treatment for hoarding delivered individually and in groups have been empirically supported and considered standard care on the basis of the level of benefit at the current stage of research ( 81 ). Technology-supported hoarding interventions show promise, extending access to these evidence-based treatments, trained providers, and peer-support as well as presenting opportunities to further examine key components of hoarding ( 86 ). Additional models have been associated with substantial hoarding symptom improvement, including cognitive rehabilitation treatment for older adults ( 23 ), CFT ( 67 ), motivational enhancement, and harm reduction ( 114 , 116 ). Few pharmacotherapy trials for hoarding disorder have been conducted, and existing medication studies are limited. Future studies that specifically examine participants diagnosed as having hoarding disorder need larger samples sizes that include older adults as well as more robust methodology and replication; designs should also include combining CBT and pharmacotherapy.

Current hoarding models and assessments have mainly focused on adults. Future studies are needed to develop CBT models, hoarding assessments, and interventions for youths ( 117 ). Future studies on hoarding also necessitate more inclusive samples regarding race-ethnicity and further development of assessments that are culturally and linguistically relevant. Because hoarding disorder is a multifaceted problem that spans mental and public health, a multipronged approach may be especially relevant and effective. Although much progress has been made over the past 2 decades, numerous questions still exist regarding the nature of, and optimal interventions for, hoarding disorder; thus, opportunities for many new discoveries, advances, and innovations are ahead.

This article is an update of an article previously published in Focus (Bratiotis C, Steketee G: Hoarding disorder: models, interventions, and efficacy. Focus 2015; 13:175–183).

The authors report no financial relationships with commercial interests.

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  • Historical Portrayal of Hoarding Disorder in European Literature and Its Relationship to the Economic and Personal Circumstances of the Authors Cureus, Vol. 46

psychology essay on hoarding

  • Hoarding disorder
  • Clinical treatment
  • Special populations
  • Community-based response

What’s Causing the Rise of Hoarding Disorder?

Now that the DSM lists severe hoarding as a disorder apart from OCD, psychologists are asking what explains its prevalence.

Someone standing in the room of a hoarder

Reality TV doesn’t need to do much to sensationalize hoarding. Like rubberneckers at a traffic accident, we gaze in horror at “goat paths” hacked between mounds of newspapers, greasy pizza cartons, bills, checks, mustard packets, broken gadgets, old T-shirts, and stained Tupperware. Crawling with rodents and cockroaches, covered in mildew, mold, and bacteria, these mounds are a fire hazard (according to one study , they cause 24 percent of all avoidable fire deaths) and a fall hazard. They build a wall of shame that blocks the entry of family, friends, even a plumber or electrician. How can people live like this? we murmur.

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But many hoarders don’t see their behavior as disordered, and psychology didn’t either—at first. In 2013, the Diagnostic and Statistical Manual of Mental Disorders , the holy book of psychiatric diagnoses, was revised to list severe hoarding as a disorder in its own right. To meet the diagnostic criteria, someone must have acquired an unmanageable, even hazardous number of possessions that appear to be useless or of limited value—yet would cause them severe distress if discarded.

The original understanding of hoarding, however, had nothing to do with clutter; it was financial avarice. King Midas hoarded gold, as did the tight-fisted clergy who, Dante wrote, would be condemned to the fourth circle of hell. Only in the twentieth century did people begin engaging in the eccentric over-accumulation of random, not terribly valuable stuff.

At first, it was called Collyer’s syndrome , in honor of Homer and Langley Collyer, brothers who, between 1909 and 1947, slowly buried themselves in their family mansion in Harlem, filling it inch by inch. By midcentury, as mass production and a postwar economic boom made it possible for people of modest means to acquire more and more objects, Collyer’s syndrome became more widespread. Psychologists decided that hoarding must be a subtype of obsessive-compulsive disorder: a repeated, ritualized action intended to ward off anxiety.

That categorization held for decades—even though clinical hoarding affects up to 6 percent of the world population, twice as many as OCD. A 2010 review by David Mataix-Cols at King’s College London noted that at least 80 percent of people who engaged in extreme hoarding didn’t meet the criteria for OCD. They were more prone to depression than those with OCD. They had more difficulty making decisions. They were far less likely to be aware of their behavior as a problem. Genetic linkage studies showed a different pattern of heritability than OCD, and brain scans showed a different pattern of activation . Drugs that were successful in treating OCD were not effective for hoarding.

Finally, in 2013, hoarding disorder was sprung free of the OCD category. And it can be connected to an array of causes as motley as the stuff that gets hoarded. It shows up on a continuum, spanning everything from an overcluttered home that’s spun out of control to abject squalor. It can extend to the accumulation of live animals (though that’s a very different proposition).

The apartment of a hoarder in New York

In families with two or more members who hoard, researchers have identified an allele on chromosome 14 (in Doberman Pinschers , hoarding’s been linked to chromosome 7). “More than 80 percent of our subjects reported a first-degree relative with similar problems,” note Randy Frost and Gail Steketee, pioneers in this research, in their book Stuff: Compulsive Hoarding and the Meaning of Things. Hoarders might inherit different ways of processing information, they suggest, or “an intense perceptual sensitivity to visual details… [that] give objects special meaning and value to them.”

Other studies suggest non-genetic causes. Hoarding can also accompany certain traumatic brain injuries, Tourette’s syndrome, ADHD, neurodegenerative disorders, generalized anxiety disorder, clinical depression, and dementia. Childhood poverty, interestingly enough, does not seem to be connected with hoarding. But researchers have found a possible link between hoarding and PTSD among Holocaust survivors , and late-onset hoarding has often been linked to loss or trauma. The psychological understanding is that objects are gathered in a futile attempt to fill emotional emptiness—piled up like a barricade to protect oneself against an uncertain future.

If you zoom out from that intimate pain, though, there’s also a big-picture theory: Hoarding is the natural consequence of a consumer society glutted with stuff and running out of landfills.

In “Neurohistory in Action: Hoarding and the Human Past,” the historian Daniel Lord Smail suggests that we stop thinking of biology and culture as separate causes. “Gene expression is intimately tangled up with cultural and individual life circumstances,” he points out. Couldn’t the rise of compulsive hoarding be caused by the ways our physical selves interact with a changing material environment? When we started processing our food, for example, we no longer needed wisdom teeth—so our mouths grew too small to accommodate them. “Social forms and behavioral patterns sculpt the body,” Smail writes.

Monkeys, crows, squirrels, kangaroo rats, and honeybees all hoard—just as humans have for millennia—as an adaptive way to survive a cold winter or a famine. That is not the kind of hoarding that makes it to a reality TV show. “The compulsive hoarding of useless things seems to be characteristic of only the last century or two—and primarily the last few decades,” Smail notes.

In other words, something has changed—in history and culture—to cause hoarding to emerge as a prevalent psychiatric disorder. Objects have taken on, for those who hoard them, individual personalities with outsized emotional significance. They cannot be casually discarded; they are woven into the person’s very sense of self, promoting comments like, “If I throw too much away, there’ll be nothing left of me.”

Acquisition is the first half of the disorder. People fall in love with stuff they don’t immediately need because it’s free, or it reminds them of a particular experience, or they might need it someday, or they could transform it in some cool way and increase its value. These objects accumulate, and people resist parting with them because of their perceived potential, or their sentimental significance, or their triggered memories, or because it’s wasteful to pile up a landfill with some perfectly good object somebody might need someday. Or because the person who’s hoarding simply doesn’t like being told what to do with their stuff.

Even if they want to downsize (which is rare), there’s the overwhelming difficulty of sorting through the mess. People with severe hoarding disorder tend to be easily distracted and have a hard time focusing and concentrating. Paradoxically, they also tend to be perfectionists, so they’ll put off making decisions rather than risk being wrong. And when it comes to their own stuff, they don’t categorize by type. Rather than see an object as a member of a large group (say, one of 42 black T-shirts), they see it as singular, unique, special. Each black T-shirt is perceived apart from the others and carries its own history, significance, and worth. It’s not even categorized for storage (folded with other black T-shirts in a T-shirt drawer), but rather placed on a pile and retrieved spatially (that particular black T-shirt lives about four inches from the bottom of the corner stack). This leads to a deep aversion to someone touching the piles or sifting through them, unwittingly destroying the invisible ordering system.

The apartment of a hoarder in New York

As with any condition that becomes a collective fascination, there’s a chicken-or-the-egg question: Is hoarding disorder increasing or has an increase in media coverage just made us more aware of it? Estimates suggest that as many as 19 million Americans have a hoarding disorder. The first task force on hoarding formed in 1989 in Fairfax County, Virginia. There are now more than 100 such organizations in the U.S. By 2020, more than 15% of the U.S. population is expected to be 65 or older—prime age for hoarding. According to the American Psychiatric Association, hoarding disorder affects three times as many people ages 55 to 94 as it does those ages 34 to 44. The disorder may show up in adolescence, but it’s often intensified in older age , exacerbated by bereavement, divorce, fuzzy thinking, or financial crisis.

People are living longer and aging at home, where they’re free to amass as much stuff as they like. Sometimes that tendency was held in check by a spouse who’s now gone. Sometimes what’s hoarded are the deceased spouse’s belongings. Or those of a child who has long since grown up and moved out. At a point where people are losing their independence—their work, status, connections, sensory acuity, physical strength, and mental sharpness—hoarding can be a way to shore oneself up, to feel safe, consoled, prepared.

An entire industry has sprung up around hoarding: psychologists, researchers, social workers, public health workers, professional organizers, fire marshals, biohazard cleanup companies, haulers. Why does it bother us so much? There’s an instinctive recoil from the pests and contaminants, of course, not to mention the dreaded fights and physical labor if the person who’s hoarding is a family member.

The disorder’s not just incomprehensible to the rest of us, but intractable. People who hoard are often intelligent, well-educated, and creative, and they don’t want to be “fixed.” If their home reaches a point where city officials force help, it’s likely to be filled again soon after it’s been emptied.

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There might be another reason, though, for the general recoil. Several scholars have suggested that hoarding hits a little too close to home . We all do daily battle against an excess of stuff. It flows into our homes, brought by FedEx and the U.S. Postal Service, snagged on Amazon, Facebook Marketplace, Freecycle, or a yard sale, inherited or handed down. It piles up in closets, basements, and garages. Almost 10 percent of American households are renting at least one storage space, often for an overflow of stuff, according to a 2015-16 Self Storage Industry Fact Sheet. It is now possible for every American to stand comfortably, at the same time, under the total canopy of self-storage roofing.

Those of us terrified by this prospect watch episodes of Hoarders or Hoarding: Buried Alive and race to declutter, muttering the KonMari principles as we hunt for sparks of joy amid the detritus. Perhaps Marie Kondo would not have become a multimedia phenomenon in the madly collecting Victorian Age, with its precious cabinets of curiosities, nor in the postwar ’50s, with brightly colored toys and gizmos flying off the factory conveyor belts. But now we are glutted with stuff—and uneasy about the consequences.

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The Oxford Handbook of Hoarding and Acquiring

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3 Phenomenology of Hoarding

Gail Steketee, Ph.D., is Dean and Professor at Boston University's School of Social Work.

Randy O. Frost is the Harold Edward and Elsa Siipola Israel Professor of Psychology at Smith College.

  • Published: 03 February 2014
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Hoarding is characterized by excessive acquisition, difficulty discarding or letting go of objects, disorganization, and resulting clutter. Hoarding symptoms onset during childhood or adolescence and continue in an increasing and chronic course, affecting approximately 4% to 5% of adults. Adults who hoard tend to be unmarried and living alone and may have lower incomes; few gender effects have been identified. Associated features include difficulty with decision making, as well as perfectionism, emotional sensitivity, and strong attachment to objects. Insight is often low, causing problems for treatment and family intervention. Hoarding can cause serious physical (safety, health) and functional (financial, housing, employment) impairment that adversely affects the individual, family members, and the community. Hoarding has been associated with childhood adversity and various stressful life experiences, but not specifically post-traumatic stress disorder. These symptoms and features are reviewed, noting other chapters in this volume that provide more detail regarding various features.

Phenomenology of Hoarding

Historical review of hoarding features.

The history of research on hoarding is relatively short. Early in the twentieth century, descriptions of hoarding behavior appeared as an outgrowth of psychoanalytic theorizing about an anal personality characterized by the three features of obstinacy, orderliness, and parsimony ( Freud, 1908 ). Freud emphasized the retention of feces in his theorizing, whereas Jones (1912) suggested that the parsimony leg of the triad could be represented by the hoarding of possessions. Other early theorists such as Fromm (1947) and Salzman (1973) believed hoarding represented an attempt to exert control over one's environment to create a sense of safety and security. The idea that hoarding was an expression of the parsimony leg of the anal triad led to its inclusion as one of several diagnostic criteria for Axis II obsessive–compulsive personality disorder (OCPD) in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) ( Frost & Steketee, 1998 ). In DSM-IV criteria for OCPD, hoarding was defined as an inability “to discard worn-out worthless objects even when they have no sentimental value” ( APA, 2000 , p. 729).

Although a few investigations of hoarding behavior have relied on this definition (e.g., Samuels et al., 2008a ), research on the phenomenology of hoarding suggests that it is inadequate on several counts. First, the OCPD criterion limits behavior to discarding, but people who hoard report difficulties letting go of possessions by any means, including selling, donating, recycling, or lending ( Mataix-Cols et al., 2010 ). Second, the description of objects as “worn-out or worthless” is not supported by research on the nature of saved items. Rather, people who hoard appear to collect and save all types of objects, including closets full of new clothing never worn (often with original tags attached) and small appliances and purchased items still in their original wrappings ( Frost & Gross, 1993 ). Accordingly, it appears that those with hoarding problems do not limit their saving only to worn-out or worthless objects. Finally, the OCPD definition suggests that hoarded items have no sentimental value, but considerable research suggests that items are saved for sentimental reasons (see Chapter 10 ). In fact, saved items are often described with strong personal identification ( Steketee, Frost, & Kyrios, 2003 ) and emotional attachment ( Kellett & Knight, 2003 ). As noted in Chapter 5 in this volume by Mataix-Cols and colleagues, the DSM-5 definition will correct these errors.

Symptoms of Hoarding

Research on hoarding suggests three primary features as well as secondary or associated features described later in this chapter. Frost and Hartl's (1996) original definition of hoarding still stands up well: they identified the following characteristics: “(1) the acquisition of and failure to discard a large number of possessions that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and (3) significant distress or impairment in functioning caused by the hoarding” (p. 341). The vast majority (80% to 100%) of people with hoarding problems engage in excessive acquisition of possessions, often in the form of buying, acquiring free things, and, less often, stealing (see Chapter 8 for a more complete review). The hallmark feature of hoarding is difficulty discarding or letting go of possessions that are not needed or used. Occasionally, this behavior can appear delusional if the item is disgusting or unsanitary (e.g., bodily products, rotting food). The types of things saved appear to be similar to items most people save ( Frost & Gross, 1993 ). The most frequent categories are clothing, paper items (e.g., magazines, newspapers, books), pens/pencils, music and video items, and containers ( Pertusa et al., 2008 ).

People with hoarding problems also report saving items for the same reasons as those who do not hoard ( Frost & Gross, 1993 ). Three reasons are most common: sentimental, instrumental, and intrinsic ( Frost & Hartl, 1996 ). Many people save items because of their sentimental association with important people or events in their life. The difference between hoarding and nonhoarding individuals lies in the number of items that acquire this sentimental attachment and in the intensity of the attachment. For people who hoard, an exceptionally large number of belongings seem to elicit intense emotions, provoking descriptions of “it feels like part of me” and “getting rid of this would be like losing a piece of my life” ( Steketee et al., 2003 ). Possessions also seem to provide emotional comfort as well as a sense of personal identity that go well beyond what most people report ( Hartl et al., 2005 ; Steketee et al., 2003 ). In some cases, the objects and the emotions seem to fuse so that the object becomes central to the experience ( Kellett & Knight, 2003 ; see Chapter 10 for a fuller description of emotional attachments in hoarding).

Some items are saved because they are perceived as useful. Again, the difference between hoarding and nonhoarding individuals is not the valuation of objects for their utility, but the frequency with which this is applied. For example, Frost and Steketee (2010) described a woman who saved cardboard tubes from toilet paper rolls because they might be useful for art projects. She had no plan to actually use them in that way, but rather wanted to save them for someone else who might do so, even though no such arrangements had been made with anyone else. For people with hoarding problems, ownership seems to carry with it the responsibility to make sure that objects are used and not wasted ( Steketee et al., 2003 ).

To observers and especially family members and friends, the most apparent and serious symptom of hoarding is the clutter that fills the living areas of the home and prevents their normal use. The volume of clutter is usually a metric for the severity of a hoarding problem and typically covers more than 70% of the home living area ( Pertusa et al., 2008 ). In extreme cases, the hoarding individual and those living in the household cannot cook in the kitchen, sit in the living room, or even use that bathroom. However, it is important to recognize that clutter is the result of essential features of hoarding, an environmental consequence of the disordered behavior rather than a causal feature. That is, excessive clutter (“the hoard”) is the result of the excessive accumulation of a large volume of possessions and inability to remove them from the home, as well as from difficulty keeping possessions organized. With regard to the latter feature, most acquired items are piled in the middle of the room with little apparent organization. For example, old newspapers and packaging materials may be mixed with important papers like car titles and overdue bills. Problems with organization appear to be related to information processing deficits that are part of hoarding, including problems with categorization, attention, and decision making (see Chapter 9 ).

Although the objects saved in hoarded homes are similar in character to things saved by most people ( Frost & Gross, 1993 ), the hoarding of animals is an exception. A recent review of the limited research on animal hoarding ( Frost, Patronek, & Rosenfield, 2011 ) suggests both similarities and differences between object and animal hoarding. According to this review, animal hoarding appears to fit new DSM-5 diagnostic criteria for hoarding disorder ( APA, 2013 ), although it is not formally included within this new diagnostic category as research on this problem is limited, and there may be substantial differences between those who hoard objects versus animals (see Chapter 11 for a review of animal hoarding).

Demographic Features

Gender and hoarding.

Only a few studies have described gender differences in how hoarding is experienced. Samuels et al. (2008b) found that men, but not women, with hoarding symptoms had more aggressive, sexual and religious obsessions and checking compulsions. Men and women also differed in other comorbidi-ties. For men, hoarding was associated with tics and generalized anxiety disorder, whereas for women it was related to social phobia, posttraumatic stress disorder, body dysmorphic disorder, and impulse control disorders of nail biting and skin picking. Personality disorder differences were also observed, with women having more schizotypal and dependent personality disorder features as well as low conscientiousness.

However, conflicting findings were reported by Wheaton, Timpano, LaSalle-Ricci, and Murphy (2008) in a sample of patients with OCD examined for symptom subtypes. In that study, hoarding symptoms were associated with more comorbidities for women than for men, women reporting higher frequencies of bipolar I, alcohol and substance abuse, panic disorder, social phobia, and binge-eating. The only comorbidity associated with hoarding for men was a higher frequency of social phobia. In contrast, Labad et al. (2008) failed to find gender differences in comorbid conditions across the hoarding dimension in a sample of patients with OCD.

Since the participants in these studies were all drawn from OCD populations, conclusions are difficult to draw. In the only study reporting on gender and comorbidity in a sample selected for hoarding symptoms, Frost, Steketee, and Tolin (2011) found that among typical comorbid conditions that included major depression, social phobia, generalized anxiety disorders, and OCD symptoms, only the latter were more frequent among men (28%) than among women (15%) with hoarding disorder, but no other gender differences in comorbidities were evident. (Comorbidity is reviewed in more detail in Chapter 7 .)

Marital Status and Living Situation

Growing evidence indicates that hoarding has profoundly negative effects on the family ( Tolin, Frost et al., 2008a ). It is easy to understand how difficult life would be for a spouse who must cope with a sea of possessions filling the home and preventing normal activities. Frost and Gross (1993) first noted that hoarding participants were less likely to be married at the time of the study than nonclinical controls (45% versus 80%). Since then, a number of other studies have reported similar findings.

Kim et al. (2003) found that a very high percentage of elder service clients identified as having hoarding problems had never been married (55%). In a related vein, Tolin et al. (2008b) reported that hoarding participants who were single, divorced, or widowed had more severe hoarding (higher scores on the Hoarding Rating Scale) than those who were married or cohabiting. Consistent with these reports, Pertusa et al. (2008) noted that their sample of hoarding participants was less likely to be married and more likely to live alone than were participants with OCD, other anxiety disorders, or community controls. Three recent studies corroborate these findings. Timpano, Keough, Traeger, and Schmidt (2011) found their hoarding participants less likely to be married than nonhoarding participants, and Landau et al. (2011) found a nonsignificant trend for hoarding participants to more often live alone. Further, Nordsletten, de la Cruz, Billotti, and Mataix-Cols (2013) found that hoarding participants were less likely to be married or partnered than collectors (14% versus 90%) and more likely to be living alone (72% versus 10%). Further, Samuels et al. (2008a) found the prevalence of hoarding higher among never married and widowed individuals than among married or cohabiting people. Torres et al. (2012) and Wheaton et al. (2008) found hoarding patients were more likely to live alone than nonhoarding patients with OCD.

Some research is at odds with the findings reported here. Two studies failed to find differences in marital status or the percentage of people living alone for hoarding and nonhoarding participants ( Bulli et al., in press ; Mueller, Mitchell, Crosby, Glaesmer, & deZwaan 2009 ). In addition, Timpano et al. (2011) failed to find differences in marital status for OCD sample populations with and without hoarding. Overall, however, the preponderance of the evidence favors the conclusion that people with clinically significant hoarding are less likely to be married and more likely to live alone compared with other clinical and nonclinical individuals.

Two studies have reported educational differences for hoarding compared with other samples. Landau et al. (2011) observed that their hoarding participants had less education than nonclinical participants (but more education than nonhoarding OCD participants. Also, Nordsletten et al. (2013) found lower levels of education among hoarding participants compared with a control group of collectors. However, most studies have not reported differences in education between hoarding and OCD or nonclinical samples ( Frost, Steketee, & Tolin, 2011 ; Hartl et al., 2005 ; Pertusa et al., 2008 ) or any association between hoarding and education level in OCD samples ( Torres et al., 2012 ; Wheaton et al., 2008 ). Nor have any of the population-based studies that reported on education level found any association with hoarding ( Bulli et al., in press ; Mueller et al., 2009 ; Samuels et al., 2008a ; Timpano et al., 2011 ). Thus, the weight of evidence indicates that hoarding is not associated with lower education. Perhaps the positive Nordsletten et al. finding resulted from elevated education levels among collectors rather than a lower level in hoarding participants compared with other clinical and nonclinical groups.

Few studies have reported on incomes in samples with hoarding problems, and conflicting findings have emerged across these studies with the largest samples. In their large Internet sample of hoarding participants, Tolin et al. (2008b) observed that the majority found paying bills difficult and nearly 40% reported incomes below the poverty line. Moreover, over 20% had failed to file an income tax return in at least 1 of the past 5 years. In population-based studies, Samuels et al. (2008a) found hoarding more prevalent among lower-income participants, but Mueller et al. (2011) found no income differences between hoarding and nonhoarding participants. Studying patients with OCD, Wheaton et al. (2008) found lower income levels among participants with versus without hoarding symptoms. Finally, in carefully diagnosed clinical samples recruited for hoarding and for OCD, Frost et al. (2011) found no difference in income between these groups. Given the varying recruitment strategies, it is difficult to find a pattern in these data, although some findings suggest that hoarding may be tied to lower income.

The relatively low rate of unemployment (5.8%) among a large sample of people with clinically significant hoarding (e.g., Tolin et al., 2008b ) suggests that underemployment would not account for lower incomes. More research is needed to determine whether hoarding symptoms have a significant impact on income.

Other Characteristics of Hoarding

Several other characteristics are closely associated with hoarding and considered to play an important role in the disorder. Difficulty making decisions has been linked to hoarding in a variety of studies and has been suggested to be a key underlying characteristic of people with hoarding problems ( Frost & Hartl, 1996 ). Decision-making difficulties have been associated with each of the core features (acquisition, difficulty discarding, clutter), contributing to hoarding independently of depression, anxiety, and OCD symptoms ( Frost, Tolin, Steketee, & Oh, 2011 ). Further, decision-making problems may be a familial trait characteristic of hoarding families ( Samuels et al., 2007 ). Chapter 9 by Timpano and colleagues provides a detailed review of information processing difficulties in hoarding.

Perfectionism has also been suggested as an important characteristic in hoarding ( Frost & Hartl, 1996 ). This was evident in higher scores for people with hoarding on measures of perfectionism compared with community controls ( Frost & Gross, 1993 ), as well as correlations of perfectionism with hoarding severity and hoarding-related beliefs ( Steketee et al., 2003 ). Further, perfectionism predicted hoarding severity independent of other OCD-related beliefs ( Tolin, Brady, & Hannan, 2008 ). (Chapter 16 in this volume provides more information on this topic.)

In addition, limited research findings suggest that anxiety sensitivity, emotional reactivity, and excessive attachment may be characteristic of some people with hoarding disorder. For example, in nonclinical samples, hoarding was found related to anxiety sensitivity ( Coles et al., 2003 ) and distress tolerance ( Timpano et al., 2009 ). Nedelisky and Steele (2009) studied a small sample of patients with OCD to determine whether those with hoarding symptoms may have an unusual attachment to objects compared with those without hoarding. Their findings provide preliminary evidence that people who hoard, especially women, have more emotional over involvement with inanimate objects and lower levels of such involvement with people than those without hoarding and that hoarding severity was correlated with increased dysfunction in these areas. Wheaton and colleagues’ Chapter 7 also addresses some of these issues and notes the need for further research to clarify the nature of these features and their relationship to specific hoarding symptoms.

Personal, Family, and Community Consequences of Hoarding

Hoarding symptoms appear to range from mild to quite severe (e.g., Timpano et al., 2013a ). In very severe cases, hoarding can have dramatic consequences, putting people at risk for falling, fire, and serious illness. In a survey of health departments in Massachusetts, Frost et al. (2000) found that not only was hoarding linked to health problems but also, in 6% of identified hoarding cases, a life was lost due to fire. A recent study of residential house fires in Melbourne, Australia, during the last decade indicated that while fewer than 0.025% of house fires involved hoarding, these fires accounted for 24% of fire-related deaths during that decade ( Lucini, Monk, & Szlatenyi, 2009 ). People with serious hoarding problems report considerable emotional distress ( Frost & Gross, 1993 ), impairment in normal daily activities ( Frost, Hristova, Steketee, & Tolin, 2013 ), and a lower quality of life ( Saxena et al., 2011 ).

Hoarding appears to provoke considerable financial problems for individual sufferers as well. In a survey of 864 self-identified participants with hoarding, nearly 6% reported being fired from their employment because of hoarding ( Tolin et al., 2008b ). Nearly two-thirds of the sample reported losing at least 1 work day per month due to psychiatric impairment, and hoarding participants averaged 7 impairment days during the previous month, more than most psychiatric groups reported in the National Comorbidity Study ( Kessler et al., 2001 ). Hoarding participants in the Tolin et al. study also reported significant problems with cluttered work spaces and difficulty finding things. Other financial problems were apparent from this study as well: More than 20% of hoarding participants did not file an income tax return in at least one of the previous 5 years.

The financial costs of hoarding to the community can be enormous. Nearly 80% of hoarding cases investigated by health departments involved multiple agencies and required multiple visits by health officials ( Frost et al., 2000 ). The San Francisco Task Force on Compulsive Hoarding (2009) estimated annual costs to landlords and social service agencies in the city to be over $6 million. In the Melbourne study of house fires, the cost of fire damage was eight times greater in hoarded homes than homes without significant clutter ( Lucini et al., 2009 ). Maintaining suitable housing is also challenging for people with serious hoarding behaviors. In the Tolin, Frost et al. (2008b) sample, nearly 8% of hoarding participants and more than 12% of hoarding family members reported that they had been evicted or threatened with eviction due to the hoarding. Hoarding appears to increase the risk of homelessness. Rodriguez et al. (2012) reported that nearly one-quarter of clients seeking help from an eviction intervention service met SI-R criteria for hoarding.

The health of people with hoarding problems can also be at risk from unsanitary conditions in the home (see Chapter 12 ). Exactly how many hoarding cases involve squalid living conditions is not clear, but hoarding and squalor do appear to be related and the combination may increase the risk for health problems. Hoarding is also associated with a wide variety of medical problems and conditions including obesity and other chronic illnesses such as diabetes, high blood pressure, ulcers, and others ( Tolin et al., 2008b ).

Hoarding also places considerable burden on families as well. Social service agencies have removed children, elders, or pets from the home due to the severity of hoarding for as many as 1 in 25 people with hoarding ( Tolin et al., 2008b ). In addition, compared with those who did not live in a hoarded home during childhood, those who did reported a less happy childhood, more difficulty making friends, greater embarrassment about the home, not having others visit them, and substantial family arguments and strain ( Tolin et al., 2008a ). These difficulties appeared to be more severe and long lasting if the person lived with their hoarding parent when they were younger than 10. In general, family members of people who hoard developed high levels of frustration, rejection, and hostility toward their hoarding relative ( Tolin et al., 2008a ), comparable to levels shown toward family members suffering from severe mental illness such as schizophrenia. These findings suggest that the negative impact of growing up in a hoarded home is strong and persists into adulthood. As noted earlier, hoarding may also reduce the likelihood of getting and staying married.

Clinicians have commonly rated their clients with hoarding as having limited or poor insight into the presence or seriousness of their symptoms ( DeBerardis et al., 2005 ; Frost, Krause, & Steketee, 1996 ; Matsunaga et al., 2005 ), interfering with their ability to seek treatment ( Abramowitz e al., 2003 ; Saxena & Maidment, 2004 ), and contributing to premature discontinuation ( Mataix-Cols et al., 1999 ). Family members rated their hoarding relative as having “poor insight” or “delusional” thinking in the majority of cases ( Tolin, Fitch, Frost, & Steketee, 2010 ). However, according to a large-sample Internet study of hoarding, the overwhelming majority of people reported interest in seeking treatment for their hoarding problems if it were available, suggesting some degree of insight for most people with clinical hoarding symptoms ( Tolin et al., 2008a ). Complicating the understanding of insight in hoarding is confusion over how to define lack of insight (not knowing or acknowledging the existence of a problem) versus overvalued ideas about the importance of possessions ( Frost, Tolin, & Maltby, 2010 ). Worden and Tolin provide a fuller review and discussion of insight in hoarding in Chapter 19 , and Tompkins and Hartl discuss insight in relation to familial interactions about hoarding in Chapter 23 .

Several initial attempts to establish the prevalence of hoarding in the population relied on inaccurate definitions and methods of measuring hoarding, but they did provide an initial glimpse into the frequency of hoarding-related phenomena. Ruscio, Stein, Chiu, and Kessler (2008) examined National Comorbidity Study data to establish prevalence rates for OCD and specific OCD symptoms. Interviewers asked about specific obsessions (defined as “unpleasant thoughts, images or impulses”) and compulsions (“repeated behaviors or repeated mental acts that you felt compelled to do”). Hoarding “obsessions” and/or “compulsions” were detected in 14.4% of the sample. This finding is difficult to interpret since hoarding symptoms do not fit well with these definitions of obsessions or compulsions, nor did the severity assessment clarify whether the hoarding symptoms themselves, versus other OCD symptoms, met clinical criteria.

A similar definition for hoarding was used by Fullana et al. (2010) using data from the European Study of the Epidemiology of Mental Disorders, a project involving cross-sectional interviews with representative households in six European countries. They found a prevalence rate of 2.6% for hoarding “compulsions,” with no differences by gender. As with the Ruscio et al. (2008) study, however, the definition and assessment of hoarding symptoms did not conform to current conceptualizations of hoarding, nor was there any attempt to verify hoarding status with validated measures.

Samuels et al. (2008a) examined the frequency with which participants in an epidemiological study of personality disorders endorsed hoarding symptoms. The study involved a probabilistic sampling of adults in east Baltimore; 742 were interviewed. Embedded in the interview were several questions intended to determine the presence of the hoarding criterion from the DSM-IV Obsessive Compulsive Personality Disorder section: “unable to discard worn-out or worthless objects even when they have no sentimental value” ( APA, 1994 ). Using this definition, 3.7% met criteria for “pathological” hoarding. Adjusting for population demographics resulted in a weighted prevalence rate of 5.3% overall, with twice as many men as women represented. Again, their definition of hoarding did not conform to current conceptualizations of the disorder, and the researchers did not confirm hoarding status with established measures.

Dong, Simon, and Evans (2012) examined the prevalence of self-neglect and hoarding in a representative sample of elderly residents as part of the Chicago Health and Aging Project. The prevalence of hoarding was 4.1% to 5.4% for men and did not vary across the three older age groups in the study (65 to 74, 75 to 84, and older than 85). For women, the prevalence rate declined across the age groups from 5.0% to 3.5% to 2.3%. The authors did not specify how hoarding was assessed other than indicating that trained interviewers collected the data.

To date, four studies have examined the population prevalence of hoarding using well-established definitions and validated assessments. In the United Kingdom, Iervolino et al. (2009) examined over 5000 participants in the adult twin registry using the self-report version of the Hoarding Rating Scale ( Tolin et al., 2010 ), which assesses the main symptoms of hoarding, including distress and functioning. Severe hoarding symptoms were found in 2.3% of the sample with the prevalence in men nearly twice that for women (4.1% versus 2.1%). Mueller et al. (2009) selected a representative sample of the German population to establish a prevalence rate for compulsive hoarding. Using a German version of the Saving Inventory–Revised ( Frost et al., 2004 ) and a criterion of 2 standard deviations above the mean, they reported a point prevalence rate of 4.6% and did not find differences by gender. In a further study of a representative German sample, Timpano et al. (2011) used a German version of the Hoarding Rating Scale and the proposed DSM-5 criteria for hoarding disorder. Applying the same cutoff (17) on the HRS as Iervolino et al. (2008), they reported a prevalence of 6.7%. When they applied the new DSM-5 criteria (without the acquisition item from the HRS), they found a slightly lower rate of 5.8%. The rate at which participants met the DSM-5 hoarding criteria in combination with the acquisition specifier was 3.9%. No gender differences emerged. Finally, in a sample of over 1000 Italian participants, Bulli et al. (in press) used an established cutoff score (41) on the Italian Saving Inventory–Revised ( Melli, Chiorri, Smurra, & Frost, 2013 ) to determine hoarding status and reported a prevalence rate of 6.0%. Again, there were no gender differences in prevalence.

The four studies just described provide the best estimate of hoarding prevalence based on up-to-date definitions and measures of hoarding. In these studies, the prevalence of hoarding ranged from 2.3% to 6%, and only one of the four studies found gender effects. While not conclusive, it appears that the presence of hoarding behavior does not vary by gender, despite the fact that women predominate in most clinical studies of hoarding cases ( Frost, Steketee, & Tolin, 2011 ; Pertusa et al., 2008 ; Saxena et al., 2002 ; Tolin et al., 2008a , 2008b ). Perhaps women are more likely to volunteer for research studies involving hoarding and are more willing to seek treatment for the problem.

Culture and Hoarding

Although the majority of research on hoarding has been conducted in the West, reports of hoarding have appeared in most other parts of the world, including China ( Alcon, Glazier, & Rodriguez, 2011 ), Japan ( Matsunaga et al., 2010 ), Turkey (Tukel et al., 2005), India ( Chakraborty et al., 2012 ), and Iran ( Mohammadzadeh, 2009 ). Even in countries where no research on hoarding has been done, news accounts of hoarding are common. For instance, a recent story about a hoarding case in Korea describes the problem as common ( Baker & Tai, 2012 ). In Singapore, one news organization has been following a hoarding case for several years ( Kang, 2012 ).

Despite its seeming ubiquity, estimates of the relative frequency of hoarding across countries have been hampered by sample and measurement problems. Many such studies include only patients already diagnosed with OCD. Since only a fraction of people with hoarding disorder are comorbid for OCD ( Frost et al., 2011 ), such estimates are undoubtedly inaccurate. Furthermore, many such studies also rely on the YBOCS checklist to indicate hoarding. The YBOCS checklist has limited validity as a measure of hoarding (see Chapter 18 ). Nevertheless, these studies provide some indication of hoarding outside of the West. For instance, Matsunaga et al. (2010) report hoarding frequencies of 32% among patients with OCD in Japan. They conclude that the prevalence and correlates of hoarding among Japanese patients with OCD are similar to those found in the West. Tukel et al. (2005) found that 11% of 116 OCD cases in Istanbul reported hoarding symptoms. Rates of hoarding among patients with OCD in Brazil have varied from 16% using the YBOCS ( Fontenelle et al., 2004 ) to 53% using a modified version (DY-BOCS; Torres et al., 2012 ). In Spain, Fullana (2004) reported that up to 30% of patients with OCD endorsed hoarding symptoms.

Several studies outside of the United States and United Kingdom have used well-validated measures of hoarding. Chakraborty et al. (2012) used the SI-R in a sample of Indian patients with OCD and reported a 10% frequency of clinical hoarding. Similarly, Fontenelle et al. (2010) reported that 17% of patients with OCD in Brazil met criteria for hoarding based on the SI-R. Two population-based studies in Germany and using validated measures of hoarding reported frequencies of clinically significant hoarding of 4.8% and 5.8% ( Mueller et al., 2009 ; Timpano et al., 2011 ). Similarly, a study in Italy reported a prevalence rate of 6% using the SI-R ( Bulli et al., in press ).

Two studies have attempted to compare hoarding across countries. Fullana et al. (2010) reported on the frequency and associated features of OCD symptoms dimensions in the general population across 6 European countries (Belgium. France, Germany, Italy, the Netherlands, and Spain). OCD dimensions (including hoarding) were assessed via a clinical interview. The overall rate of hoarding (2.6%) was similar to rates observed in other epidemiological studies of hoarding (e.g., Iervolino et al., 2009 ). The frequency varied somewhat across countries with higher frequencies observed in Belgium, France, and Italy and lower frequencies in the Netherlands. Questions about the validity of the hoarding measure make these findings tentative.

In the only other study comparing rates across countries, Timpano et al. (2013b) examined hoarding and impulsivity in university students in the United States and Germany. Using the SI-R, 6% of the U.S. sample and 8% of German students met criteria for clinically significant hoarding. Moreover, the pattern of relationships between hoarding and impulsivity were similar across the two samples suggesting that hoarding and its associated features may be similar across U.S. and European cultures.

To date, very little attention has been paid to the role of culture in hoarding. However, reports of serious hoarding behavior have surfaced across the globe, and existing research suggests that the prevalence and characteristics of hoarding are similar across cultures. More research will be needed to confirm this impression.

A number of studies have suggested that hoarding is associated with an early age of onset during childhood or adolescence. In patients with previously diagnosed OCD, some studies have found the presence of hoarding symptoms associated with an earlier onset compared with those with OCD and no hoarding ( Fontenelle, Mendlowicz, Soares, & Versiani, 2004 ; Millet et al., 2004 ; Rosario-Campos et al., 2005 ; Samuels et al., 2002 , 2008a ; Torres et al., 2012 ; Tukel et al., 2005). However, several studies have failed to find earlier onset among patients with OCD and hoarding ( Cromer et al., 2007 ; Hasler et al., 2007 ; Lochner et al., 2005 ; Mathews et al., 2007 ; Samuels et al., 2007 ). It is difficult to draw firm conclusions from these studies as the data are based on patient volunteers from OCD clinics who also reported having hoarding symptoms. Furthermore, the severity of hoarding was rarely specified, nor whether non-OCD hoarding patients were included in the samples. Given recent findings that only a small percentage (less than 20%) of people recruited for hoarding symptoms also have comorbid OCD ( Frost, Steketee, & Tolin, 2011 ), these studies are unlikely to adequately represent people with hoarding as their primary problem. Fortunately, several studies of age of onset in hoarding have relied on participants recruited specifically for their hoarding symptoms rather than for OCD.

Grisham, Frost, Steketee, Kim, and Hood (2006) developed an assessment interview for age of onset that involved marker recollections from each decade of life (“Think of an event that occurred in this decade”). They used the marker to prompt recollections of the severity of acquisition, difficulty discarding, and clutter at that time. Participants rated the severity of each symptom (none, mild, moderate, severe) during each decade surrounding the recalled event. Among the 51 hoarding participants in their sample, mild hoarding symptoms began by age 12 for 60% of the sample and by age 18 for 80%. Mean duration until onset was 13.4 years. According to most reports, moderate symptoms began in their 20s and severe symptoms a decade later. Excessive acquisition occurred later than difficulty discarding or clutter.

Tolin et al. (2010) found a similar age of onset in a large sample of hoarding individuals ( N = 751) recruited from the web, using a similar procedure to identify severity of hoarding at 5-year intervals across the lifespan. Seventy percent of the sample reported onset of mild hoarding symptoms between ages 11 and 20, with very few reporting onset after age 40. Onset of moderate or severe hoarding occurred significantly later: only 33% reporting moderate to severe hoarding as early as age 20, whereas 75% reported onset of moderate or severe hoarding by age 40.

Landau et al. (2011) asked 44 hoarding participants the age at which each hoarding symptom (excessive acquisition, difficulty discarding, and clutter) began and became significant. The initial onset ages were 16 for acquisition, 18 for difficulty discarding, and 21 for clutter. Clinically significant hoarding for each of these symptoms began at ages 32, 35.5, and 30, respectively. Although onset was very slightly later than reported in the Grisham et al. and Tolin et al. studies, the timeframe of onset in adolescence and young adulthood was confirmed.

However, two studies reported somewhat older average ages of onset. In a sample of 52 hoarding participants, Pertusa et al. (2008) found that diffi-culty discarding began at an average age of 20, excessive acquisition at 26, and clutter from 25 to 31. In this study, onset age was determined by single-item general questions about the onset of significant difficulty discarding, acquisition problem, and clutter. Ayers, Saxena, Golshan, and Wetherall (2010) also found a somewhat older average onset age of 29.5 when they asked a small number ( N = 18) of elderly hoarding participants to respond to the question, “When did your hoarding start?” Interestingly, when Ayers and colleagues utilized Grisham et al.'s method of asking for recollection event markers by decade with the same participants, the sample reported a considerably younger age of onset: 44% reported onset earlier than 10 years old, and 39% reported an onset between 11 and 20. The remaining 3 participants reported an onset in their 20s.

Thus, overall, it appears that hoarding onsets relatively early in life, mainly during childhood and teen years, with some beginning their symptoms in their early to mid 20s. From a methodological standpoint, strategies that evaluate specific hoarding symptoms by decade using memory aids appear to trigger earlier onset recall than merely asking participants when their symptoms began. Nonetheless, additional research is needed to verify onset age for symptoms of collecting, difficulty discarding, and clutter from a prospective point of view. Interestingly, a prospective web-based study of college students by Muroff, Bratiotis, and Steketee (2012) indicated the presence of subclinical or clinical hoarding markers in 33% of a sample of 4364 undergraduates, and 5.4% met diagnostic criteria for hoarding disorder based on DSM-5. More research regarding onset may aid in eventual prevention strategies.

Existing studies suggest that hoarding is a chronic condition. Grisham et al. (2006) found that only 14% of their sample of 51 hoarding participants remitted after onset. In a small sample of elderly hoarding participants ( N = 18), all reported a worsening course ( Ayers et al., 2010 ). In a large sample Internet study ( N = 751), Tolin et al. (2010) found that 73% of cases followed a chronic course, 21% reported increasing severity, 5% had a fluctuating course with relapses and remissions, and fewer than 1% indicated an improving course.

The relationship of hoarding severity to age is somewhat unclear. Although the onset of hoarding symptoms typically was reported to occur before age 20, most research samples are much older in clinical psychopathology and treatment studies ( Pertusa et al., 2008 ; Saxena et al., 2002 , 2011 ; Steketee, Frost, Tolin, Rasmussen, & Brown, 2010 ; Tolin & Villavicencio, 2011 ) and in social and health service cases ( Frost et al., 2000 ). In research studies reporting on volunteer samples with self-reported hoarding problems, the median age is typically between 50 and 60, in contrast to comparable samples of people who self-identify with OCD where current age is typically between 30 and 40 years old ( Frost et al., 2011 ). Elder service agencies are often the first to identify hoarding problems ( Ayers et al., 2010 ), giving the mistaken impression that hoarding is especially prevalent among the elderly when, in fact, the symptoms were clinically problematic at a much earlier age.

In any case, findings from studies of the association between hoarding and age are conflicting. Research on volunteers recruited for hoarding has indicated that sometimes severity was correlated with age ( Tolin et al., 2010 ), and sometimes not ( Reid et al., 2011 ; Tolin et al., 2008b ). In samples recruited for OCD symptoms, again, some studies have reported that hoarding severity is related to age, even after controlling for other variables ( LaSalle-Ricci et al., 2006 ; Torres et al., 2012 ), but other studies have found no age differences between OCD cases with and without hoarding ( Cromer et al., 2007 ; Fontenelle et al., 2004 ; Wheaton et al., 2008 ). Epidemiological studies have been equally conflicting. Samuels et al. (2008a) found hoarding to be nearly three times as prevalent among older adults (55 to 94) than younger ones (33 to 44), but four other epidemiological studies have failed to find associations between hoarding status and age ( Bulli et al., in press ; Fullana et al., 2010 ; Mueller et al., 2009 ; Timpano et al., 2011 ). This discrepancy may result from Samuels et al.'s definition of hoarding based on the DSM-IV criteria for OCPD (difficulty discarding worthless or worn-out things), which is not consistent with standard assessments for hoarding used in the other studies. In any case, the several findings described support the conclusion that hoarding begins early, worsens over the following decade or two, and then remains relatively stable at moderate to severe levels into old age.

Traumatic and Stressful Life Events

One feature that may affect onset is the experience of traumatic or stressful life events. A number of studies have found a higher frequency of traumatic and stressful life events among people with hoarding problems. Hartl et al. (2005) found a higher incidence of trauma among hoarding versus nonclinical participants. In particular, hoarding participants reported greater frequencies of having had something taken from them by force, being physically roughly handled, and having experienced forced sexual activity and/or forced intercourse both before and after age 18. Tolin et al. (2010) found a significant positive relationship between stressful life events and hoarding severity, with more than 90% experiencing a loss of or change in relationships, 75% reporting past interpersonal violence, and 61% describing loss or damage to possessions.

Samuels et al. (2008a) found several childhood adversities to be significantly and independently related to hoarding status. Childhood experiences of a home break-in or excessive physical discipline were both related to the presence of hoarding symptoms independent of demographic and other comorbid variables. In a related vein, Saxena et al. (2011) reported that hoarding participants scored higher on the “victim” scale of the Quality of Life measure. Compared with nonhoarding OCD participants, their hoarding sample had more than twice the rate of victimization from a violent crime (9% versus 4%) and more frequent victimization from nonviolent crime (23% versus 15%). Hoarding participants also reported lower “satisfaction with safety,” feeling less safe on their neighborhood streets, and less protected from being robbed or attacked.

Several studies using OCD samples with and without hoarding have reported similar findings. Torres et al. (2012) noted more history of trauma in hoarding versus nonhoarding patients with OCD. Cromer et al. (2007) found significant correlations between a standard self-report measure of hoarding (Saving Inventory Revised; see Grisham, Chapter 18 ) and the number of traumatic experiences, even after controlling for age, onset age, depression, anxiety, and OCD severity. Traumatic experiences were most closely associated with clutter rather than with acquiring or difficulty discarding, suggesting that clutter might serve a protective function for some people who hoard. Landau et al. (2011) reported a higher frequency of traumatic and stressful life events in hoarding participants compared with OCD participants and nonclinical controls. Frost et al. (2011) also reported greater frequencies of traumatic events in patients with hoarding disorder compared with those diagnosed with OCD. Interestingly, in both of these studies, although there were significant differences in the frequency of traumatic life events, no elevation in formal PTSD diagnoses was detected. Frost et al. (2012) have suggested that perhaps hoarding symptoms buffer the development of full-blown PTSD, consistent with findings related to security and safety beliefs associated with hoarding ( Frost & Hartl, 1996 ; Steketee et al., 2003 ).

Several investigations have linked the occurrence of traumatic events to the onset of hoarding symptoms. Grisham et al. (2006) reported that 55% of the hoarding sample reported a stressful (positive or negative) life event at the onset of their hoarding, though most were family or hoarding-related events such as threatened eviction. Those who reported a stressful life event around the time of onset had a later onset age for hoarding symptoms than participants without stressful events in both the Grisham et al. (2006) and Tolin et al. (2010) studies. Landau et al. (2011) found initial onset linked to stressful life events in only 21% of hoarding cases, whereas 32% of participants connected their hoarding to more ongoing and chronic situations, and the largest portion (46%) identified no link between onset and stressful events. The onset of clinically significant hoarding showed even less of a connection, with only 14% tying their hoarding to a stressful event.

Several investigations using nonclinical populations have reported correlations between hoarding severity and stressful life events ( Timpano et al., 2011 ) and related constructs. Specifically, greater anxiety sensitivity and lower distress tolerance among nonclinical hoarding participants may suggest that people who hoard are more sensitive or reactive to traumatic events ( Coles et al., 2003 ; Timpano et al., 2009 ). No research has linked these constructs to hoarding severity or the extent of trauma in hoarding, however.

Conclusions

Hoarding disorder is now a well-defined disorder in the 2013 DSM-5, characterized by attachment to and difficulty parting with objects, disorganized clutter, and associated impairment and distress. The hallmark features of this disorder are well established across multiple studies, with the exception of the role of past or present acquisition, which occurs at a very high frequency but may not be essential to defining the condition, although it appears to be an important target for treatment. The rate of marriage appears to be low, with many people who hoard living alone, some with lower incomes. Overall, research has identified very few sex-linked features, although there may be some differences with regard to comorbid conditions, but the nature of these differences remains inconsistent in existing research.

Several studies have established that hoarding symptoms commonly begin during childhood or adolescent years, with some people experiencing onset in early adulthood but very few later in life. Although definitive longitudinal research has not yet been conducted, it appears that hoarding runs a chronic and gradually worsening course. Several studies using varying assessment methods and symptom criteria report that clinical hoarding affects somewhere between 3% and 6% of adults in U.S. and European countries. With the establishment of DSM criteria and standardized interview methods for determining caseness, it is likely that clearer information about the prevalence across age groups will become available.

Among the features associated with hoarding are difficulty making decisions, perfectionism, emotional sensitivity, and strong attachment to objects. Research on these aspects is most advanced for executive functioning difficulties as evident from reviews in Chapters 9 (Timpano) and 14 (Slyne and Tolin), but considerably more information is needed to clarify emotional aspects of hoarding, particularly with regard to object attachment, which appears to be a critical aspect of hoarding behavior. Related to these features is the low insight that appears to be characteristic and provokes special challenges for treatment and for family and community interventions. The latter methods are especially important because severe hoarding can result in serious physical (safety, health) and functional (financial, housing, employment) impairment that adversely affects the individual, family members, and the community.

While research to date has shed some light on reasons for onset, the specific linkages to childhood adversity and stressful or even traumatic life experiences remain somewhat unclear. Post-traumatic stress disorder does not occur frequently among people who hoard, but onsets have been tied to adverse childhood experiences that involve victimization, such as having things taken by force and upsetting physical and sexual interpersonal experiences that may include violence. In addition, experiences such as the loss of important relationships and loss or damage to possessions suggest that accumulation of clutter might provide a protective function in response to some of these concerns about security and safety. More research is needed to determine how such experiences are tied to various aspects of hoarding behavior.

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Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation

Hoarding disorder is characterized by difficulty parting with possessions because of strong urges to save the items. Difficulty discarding often includes items others consider to be of little value and results in accumulation of a large number of possessions that clutter the home. Cognitive-behavioral therapy (CBT) with exposure and response prevention and selective serotonin reuptake inhibitor medications traditionally used to treat obsessive-compulsive disorder are generally not efficacious for people with hoarding problems. A specialized CBT approach for hoarding has shown progress in reaching treatment goals and has been modified to be delivered in group, peer-facilitated, and virtual models. Research on hoarding remains in the early phases of development. Animal, attachment, and genetic models are expanding. Special populations, such as children, older adults, and people who do not voluntarily seek treatment need special consideration for intervention. Community-based efforts aimed at reducing public health and safety consequences of severe hoarding are needed.

Hoarding has received a great deal of public attention, especially with the proliferation of reality TV shows dedicated to the subject. Popular media portrayals of hoarding present a relatively straightforward issue with a similarly straightforward solution: “just clean it up.” However, in contrast to such sensationalist depictions, hoarding disorder is a recognized mental health condition that has been the subject of systematic empirical study in psychology, psychiatry, and related fields for nearly 2 decades. As early as 1947, Erich Fromm described a “hoarding orientation” in which a person’s security depended on collecting and saving objects. In 1962, Scandinavian psychiatrist Jens Jansen referenced “collector’s mania” to describe older adults who filled their rooms with an overabundance of objects.

In 1996, Frost and Hartl ( 1 ) defined hoarding as having three main characteristics:

acquisition of, and failure to discard, a large number of possessions that appear to be useless or of limited value; living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and significant distress or impairment in functioning caused by the hoarding.

This definition became the foundation for the development of the diagnostic criteria for hoarding disorder. Current conceptualizations of hoarding describe it as a condition that involves the excessive accumulation of possessions in the home, combined with difficulty discarding such items that most other people would not keep ( 2 ).

In 2013, the American Psychiatric Association ( 3 ) recognized hoarding as a unique disorder among obsessive-compulsive spectrum disorders. Six diagnostic criteria must be met for a patient to receive a diagnosis of hoarding disorder, which is currently classified under the code for obsessive-compulsive disorder (OCD; 300.3) ( Box 1 ). Two specifiers provide descriptive ratings for both the acquiring and insight aspects of hoarding.

DSM-5 : Hoarding disorder

Disorder class: Obsessive-compulsive and related disorders

  • 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 clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for oneself or others).
  • The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
  • The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive defects in major neurocognitive disorder, restricted interests in autism spectrum disorder).

Specify if:

With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. (Approximately 80%–90% of individuals with hoarding disorder display this trait.)
With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders , 5th ed. Arlington, VA, American Psychiatric Publishing, 2013. Copyright 2013 by the American Psychiatric Association.

Historically, hoarding was considered a subtype of OCD, although recent evidence suggests that there are more differences than similarities. Hoarding behaviors have been identified among individuals with anxiety disorders other than OCD, particularly those diagnosed as having generalized anxiety disorder or social phobia ( 4 ). Major depressive disorder, generalized anxiety disorder, and social phobia have also been found to be more prevalent among individuals with hoarding disorder than those with OCD ( 4 ). Another important characteristic of hoarding disorder that differentiates it from OCD is that the person engaging in hoarding is typically not troubled by the symptoms of the disorder, despite the obviousness of the problem to others. In contrast, people with OCD tend to have higher levels of insight, more often expressing distress at the behavioral and cognitive symptoms of the disorder ( 2 ). These differences suggest that hoarding disorder is not a subtype of OCD but rather a distinct condition that is often related to other psychiatric conditions ( 4 ).

Hoarding is a common condition, affecting approximately 2%–6% of the adult population in global north countries ( 5 – 7 ). Epidemiological studies indicate that hoarding occurs in both women and men at similar rates ( 5 ). People with hoarding disorder tend to live alone and are less likely to have family or friends visit their home ( 8 ). In our clinical experience, people who hoard have sometimes reported a preference for being alone with their objects, indicating more reliable relationships with objects than with people. Defining the average age of onset of hoarding is complicated by a lack of consistent diagnostic criteria and varied use of an array of assessment instruments. A recent meta-analysis found that the mean age of onset of hoarding symptoms across studies was 16.7 years ( 7 ). Severity of hoarding symptoms tended to worsen over time.

Treatment of people who hoard is made more complex by substantial clinical comorbidity. More than 60% of people with clinically significant hoarding meet the criteria for at least one co-occurring psychiatric disorder ( 9 ). Studies of hoarding comorbidity have reported particularly high rates of major depressive disorder (50%–52%), generalized anxiety disorder (24%), and social phobia (23%) ( 4 ). The symptomology associated with depressive and anxiety disorders has been suggested to play a role in reinforcing the negative emotional states that maintain hoarding disorder ( 9 ). For example, a person experiencing a major depressive episode that provokes general behavioral deactivation may have difficulty discarding. As such, differentiating hoarding disorder from hoarding symptoms caused by another mental illness can be challenging ( 10 ), and treatment of hoarding disorder is further complicated by substantial clinical comorbidity.

On an individual level, accumulated possessions can result in difficulty completing basic functions, such as socializing, preparing food, bathing, and mobilizing when rooms and hallways become inaccessible from clutter ( 11 ). Recent research indicates that hoarding disorder significantly affects employment because people who hoard take an average of 7 days off from work a month for psychiatric reasons: a number equal to that of people with bipolar and psychotic disorders and significantly higher than for individuals with mood disorders ( 12 ). These negative outcomes also affect those living with the affected individual. Severely cluttered family environments are associated with increased childhood distress, reduced social interaction, and greater family conflict ( 12 ).

It is important to note, however, that hoarding is distinct from other anxiety-based disorders because its implications pose problems not only for the individual with the disorder and their family, but also for broader society ( 2 ). Specifically, problems associated with hoarding behavior provoke health and safety concerns for both the occupant of the home and for those who live nearby, such as neighbors with shared walls ( 13 ). For example, risk of fire increases when combustibles are stored near heat sources or electrical wiring, and blocked exits create safety hazards for residents and emergency responders ( 11 ). A study by Lucini et al. ( 13 ) found that 60% of hoarding-related fires spread beyond its source, in contrast with only 10% of nonhoarding fires.

In addition to fire risk, severe hoarding behavior can also result in degradation of the home, with routine maintenance neglected, and homes becoming squalid, moldy, pest-infected, or structurally unsound because of excessive weight of clutter or water damage ( 11 ). When possessions expand beyond the confines of the home to create unsightly clutter in the backyard or on the front porch, laws and regulations requiring the upkeep of “tidy premises” of a home’s exterior may be violated ( 2 ). Other legal ramifications can include the involvement of child welfare services, older adult and guardianship services, and animal welfare organizations ( 2 , 14 ). Thus, given the social problems that hoarding creates, treatments for this issue expand beyond clinical focus on the person with the diagnosis alone to involving a multiagency approach that targets both the home and the potential impacts on the broader community ( 2 ).

Assessments for Hoarding Behaviors

Given that hoarding is a complex condition with varied symptoms and associated features, both clinicians and patients benefit from a rapid but comprehensive assessment. Establishing a diagnosis of hoarding disorder facilitates conversations about the meaning of this psychiatric condition and enables access to third-party payments for services. Determining the severity of hoarding behaviors (i.e., acquiring, difficulty discarding, clutter throughout the home and in other spaces) helps to establish intervention targets and the potential barriers to treatment. Detailed assessment of the degree of functional impairment from hoarding demonstrates the personal cost to the patient and indicates whether the clinician should be concerned about the patient’s health or safety. It also provides a ready avenue for motivational conversations about resolving frustrating functioning difficulties.

A detailed hoarding interview ( 15 ) facilitates collection of information about hoarding symptoms, as well as general life circumstances, housing conditions, social and family life, history of hoarding, and other problems. It facilitates the development of a conceptual model for each patient’s hoarding symptoms and clarifies where to start the work (e.g., on acquiring habits or on dangerous clutter in particular areas). As the reliability of self-ratings of hoarding severity can be compromised by decreased insight, a multi-informant approach carried out by an expert clinician is generally recommended ( 16 ).

The most commonly used hoarding assessment instruments ( 17 – 31 ), which have all been found to be reliable and valid for use with clinical hoarding populations, are summarized in Table ​ Table1. 1 . In addition to these measures that assess hoarding symptom severity as well as clutter, several tools examine the home environment. One example is the HOMES Multidisciplinary Risk Assessment ( 26 ), a brief structured tool that assesses health and mental health difficulties, safety of others, obstacles to movement in the home, as well as structural concerns related to blocked paths, heat sources, and so forth. Another example is the Environmental Cleanliness and Clutter Scale ( 32 ), which is used to score levels of uncleanliness and clutter in one’s living environment. Additionally, the Home Environment Index ( 33 ) examines squalor (e.g., domestic and personal hygiene) among clients with hoarding, as well as the related effects on daily activities and tasks.

Hoarding assessment instruments a

Behavioral tasks are also used to assess for aspects of hoarding, including acquiring, difficulty discarding, and categorization. Such tasks include computerized tasks of acquiring and discarding (e.g., 34 ), categorization tasks with personal and nonpersonal items (e.g., 35 ), and interpretive bias tasks (based on ambiguous hoarding-related scenarios and hoarding beliefs) ( 36 ). Behavioral measures do not depend on the participant’s level of insight, in contrast to self-report tools, and may enhance understanding of hoarding symptomatology, severity, and underlying factors beyond what is perceived and explicitly reported by the participant.

Models and Mechanisms for Hoarding

Animal models.

Preliminary investigations into using animal models to understand hoarding behavior in humans have begun in a limited capacity. Andrews-McClymont et al. ( 37 ) compared data on human hoarding with hoarding behaviors in a variety of animal species. They found that rodent models of hoarding had the greatest overlap with human traits. Both species’ hoarding behaviors increased with age, and both had evidence of abnormalities in the same regions of the brain ( 37 ).

Neurobiological and Genetic

Hoarding behavior may be due to neuropsychological conditions with specific brain pathology (e.g., dementia, stroke, another medical or mental health condition) or may exist without neuropathology. Studies indicate that the ventromedial prefrontal cortex is linked to hoarding behavior ( 38 ); this region of the brain is involved in decision making as well as emotional processing of rewards and punishments.

Early neuroimaging studies of hoarding were focused on patient samples with OCD. The initial study of hoarding without known brain pathology (nonorganic hoarding) utilized position emission tomography to examine patients with OCD (N=45), including some with (N=33) and some without (N=12) hoarding symptoms, as well as a healthy control group (N=17) ( 39 ). This study found that those with OCD and hoarding showed less glucose metabolism in the posterior cingulate cortex and dorsal anterior cingulate cortex. Such regions are associated with decision making, categorization, and implicit learning ( 40 ).

Other initial studies used functional magnetic resonance imaging (fMRI) with tasks such as imagining discarding a pictured item with patients with OCD with (N=13) and without (N=16) hoarding, as well as a control group (N=21). Study participants with OCD and hoarding showed greater activation in bilateral anterior ventromedial prefrontal cortex compared with the other two groups ( 41 ). These studies are limited in that they included OCD samples, so they may be less generalizable to patients with hoarding disorder who do not also have OCD.

Research focusing on individuals with primary hoarding disorder also used fMRI, which demonstrated abnormalities in brain function in several regions. One study, which included 12 participants with hoarding disorder and 12 healthy control participants, used a decision-making task whereby the participants selected personal (those brought to study by the participant) versus nonpersonal paper items to discard, which were then shredded. During the decision making, patients with hoarding disorder showed greater activation of the lateral orbitofrontal cortex and parahippocampal gyrus compared with the healthy control group ( 42 ).

A larger follow-up study, which included 43 patients with hoarding disorder, 31 patients with OCD, and 33 healthy control patients, incorporated the same decision-making task in which the shredding of discarded paper items occurred at the end of the session ( 43 ). When those with hoarding disorder made decisions about personal items, brain activity was higher in the anterior cingulate cortex and insula, whereas patients with hoarding disorder showed lower brain activity compared with the OCD and control groups when making decisions regarding nonpersonal items ( 43 ). These regions are involved in emotional responses and affective states. These findings suggest that increases and decreases in brain activity varied by the specifics of the task (whether personal items were included) and demonstrated distinctions in abnormalities in brain activity related to OCD and hoarding disorder ( 44 ).

These researchers also conducted a small pilot study ( 43 ) of a simulated discarding and acquiring decision-making task using fMRI with patients with hoarding disorder (N=6) and a healthy control group (N=6). This task replicated abnormalities in activation of the frontotemporal region associated with discarding tasks, as well as some of these same abnormalities when making decisions to acquire. A recent study ( 44 ) of participants with hoarding disorder (N=79) and a control group (N=44), which included images of high- or low-value objects, also found overactivity in the anterior cingulate cortex when participants made decisions regarding personal objects and acquiring objects. Levy et al. ( 45 ) found neurological abnormalities among participants with hoarding disorder even at resting state.

These neuroimaging studies and other research suggest that people with hoarding disorder experience cognitive challenges and related impairments ( 20 , 44 , 45 ). A core component of the cognitive-behavioral model of hoarding ( 15 ) includes challenges with information processing, specifically impairments in the areas of working memory ( 46 ), inattention and distractibility ( 47 , 48 ), self-control ( 49 , 50 ), decision making ( 51 ), as well as categorizing personal belongings ( 35 , 52 ). Such challenges are evidenced through studies that used neuropsychological tests as well as self-report measures ( 20 ). Studies also suggest that cognitive impairments may be specific to hoarding while also being at least somewhat related to comorbid conditions such as anxiety, depression, and stress ( 20 ).

Future studies may examine cognitive (e.g., planning, attention) and affective (e.g., emotion, visceral information, salience, and valence) decision making among those with hoarding disorder as well as cognitive impairments evidenced by neuropsychological tests. Those with poor cognitive confidence or perceived cognitive impairment could also be examined. Enhanced understanding of neurobiological underpinnings may inform the selection of therapeutic targets as well as the development and selection of treatments ( 20 ). Additional research may examine conditions associated with worsened neuropsychological impairment among those with hoarding disorder and whether treatments improve neuropsychological abnormalities.

Hoarding as well as hoarding symptoms showed heritability ranging from 45% to 71%, just below that of OCD (74% with a confidence interval of 60%–83%) ( 53 – 57 ). In a community-based pediatric sample, study findings indicated that the L G +S variant of 5‐HTTLPR was significantly associated with hoarding in men, whereas a trend was shown for variation downstream of HTR1B to be linked with hoarding in women ( 6 ). Associations were evidenced between T-allele carriers and hoarding ( 58 ) as well Val-allele carriers and hoarding ( 59 ). Perroud and colleagues ( 60 ) conducted a genome-side association study with White twins (N=3,410) and found no genome-wide significance; however, two genomic loci on chromosome 5 and 6 showed suggestive evidence for association with hoarding traits. There also appears to be a link between hoarding traits and the glutamatergic system, although further investigation of this relationship is needed ( 61 ).

Research suggests that genetic factors may contribute to the comorbidity of hoarding disorder with other psychiatric conditions. Specifically, Zilhão et al. ( 62 ) found that genetic factors explained 50.4% and 70.1% of the covariance between hoarding disorder and OCD symptoms and Tourette’s disorder, respectively. Specific variations in genes were also significantly correlated between hoarding disorder and OCD symptoms (0.41) and Tourette’s disorder (0.35), suggesting a common genetic basis to these conditions. Current research on the genetics of hoarding disorder is limited, and extensive further study is needed on genetic risk factors and unique genetic signatures of hoarding disorder and other obsessive-compulsive related disorders ( 61 ).

Attachment and Identity

Since our 2015 article ( 63 ), updated research has expanded on the role of attachment and identity issues regarding hoarding etiology. Attachment theory posits that infants form significant bonds to early attachment figures (e.g., their parents) and seek to maintain these attachments that offer protection, safety, and comfort ( 64 ). However, when attachment figures are repeatedly unavailable, individuals may, in turn, develop insecure attachment styles lasting into adulthood. Adult insecure attachment can manifest as either attachment anxiety (i.e., fear of abandonment) or attachment avoidance (i.e., fear of intimacy). Individuals diagnosed as having hoarding disorder have been found to experience both greater attachment anxiety and attachment avoidance compared with nonclinical samples ( 64 ). For those with attachment anxiety, object attachment has been suggested to act as a substitute for interpersonal relationships because relationships with inanimate objects may be perceived as less threatening than with people ( 64 ). Neave et al. ( 65 ) found that attachment anxiety and object attachment were both significant predictors of hoarding symptoms. Noberg et al. ( 66 ) further reported that increased attachment anxiety was correlated with greater distress intolerance and a stronger tendency to anthropomorphize inanimate possessions. Decreased tolerance to distress has, in turn, been linked to increased avoidance behaviors ( 67 ), which may manifest among individuals with hoarding disorder as avoidance of discarding and sorting items, cleaning, or even thinking about the clutter ( 18 ).

There is preliminary empirical evidence of a link between clinical hoarding and self-identity ( 12 , 68 ). Kings et al. ( 12 ) described case reports of people with hoarding behavior who formed strong emotional attachments with possessions that they associated with the identities of others (e.g., a deceased spouse). These possessions could similarly be associated with the person’s perception of individuality (i.e., objects becoming symbols of their personal passions and interests) ( 12 ). Chou et al. ( 68 ) found that aspects of compromised self-identity (e.g., self-criticism and shame) were positively correlated with hoarding symptoms and beliefs. There have also been findings demonstrating a positive association between compulsive buying and a poorly defined sense of identity ( 69 ). These varied findings, although preliminary, suggest that acquired possessions can become integrated with the concept of self-identity among people who hoard.

Cognitive and Behavioral

The cognitive-behavioral model of hoarding ( 24 ) suggests that the primary symptoms of hoarding (i.e., saving, clutter, and acquiring) are caused by certain vulnerabilities (e.g., early life attachment difficulties), information processing problems, thoughts and beliefs about possessions, and positive and negative emotions. There are now several studies that verify the concepts highlighted in the cognitive-behavioral model. These elements include increased emotional reactivity ( 70 ), intolerance of uncertainty ( 71 ), anxiety sensitivity ( 72 ) and impulsivity ( 73 ), greater level of worry concerning the potentially catastrophic consequences of forgetting ( 74 ), and differences in planning and problem solving among people with hoarding disorder compared with control groups ( 74 ). Other factors have only recently been proposed as relevant to the onset and progression of hoarding disorder; these factors include object‐affect fusion ( 75 ) and the involvement of self ( 12 , 76 ).

Insight and Motivation

Many individuals who hoard lack sufficient insight to recognize the extent of their clutter and the negative consequences associated with this accumulation ( 77 ). Some studies have used external observer ratings of hoarding severity to measure insight. In a web-based survey, family members of people who hoard reported significantly higher severity ratings compared with their estimates of how they thought the affected person would rate their own symptoms ( 77 ). Decreased insight can result in increased health and safety risks, family conflict, and involuntary involvement with mandated community agencies ( 26 ). Poor insight has been attributed to early childhood experiences of insecure attached families, resulting in limited opportunities to learn organization and decision-making skills ( 78 ). Preliminary research on the intersection of insight and hoarding suggests that insight is multidimensional, composed of decreased awareness of illness and defensiveness toward interventions forced by family or the community at large. Existing hoarding treatment research has similarly suggested a lack of motivation to correct the problem ( 79 ). Accordingly, individuals with poor or absent insight do not generally seek help for their behavior and may in fact resist uninvited intervention efforts ( 80 ).

Interventions

Cognitive-behavioral therapy (cbt).

CBT is manualized ( 15 ), has been extensively tested ( 81 ), and is presently considered the standard evidence-based treatment for hoarding disorder ( 2 ). CBT is a time-intensive weekly therapy that aims to modify emotions, cognitions, and behaviors related to hoarding ( 2 , 82 ). CBT for hoarding provided on an individual basis often includes components of decision-making training, sorting and discarding exercises, organization training, exposure to nonacquiring cognitive restructuring, and motivational interviewing ( 15 ). Regular home visits are strongly recommended and have been applied in most outcome studies. CBT has been found to be particularly effective at addressing difficulty discarding, reducing clutter volume, and decreasing acquiring behaviors ( 2 , 81 ). CBT primarily has an intrapersonal focus and, therefore, does not necessarily include interventions such as assisting with home cleanup. Accordingly, this treatment also does not specifically target the social consequences of hoarding, such as affected family relations and community-based risks. Finally, because few mental health providers have the expertise required to provide hoarding-specific CBT, the widespread availability of this treatment is limited ( 2 ).

Initially modeled on individual CBT practices, protocols for group-based CBT for hoarding have also been developed and tested. Group CBT is similarly composed of multiweek sessions that provide education about hoarding, decision-making training, organization exercises, and cognitive restructuring in which patients are asked to evaluate their hoarding-related beliefs and are encouraged to take alternative nonhoarding perspectives ( 83 ). Interest in group CBT over individual CBT can be attributed to the general advantages of group-based therapies, including greater social interaction and involvement as well as expected higher cost-efficiency ( 83 ). Bodryzlova et al.’s ( 83 ) meta-analysis found that group CBT resulted in clinically significant improvements (21%–68% across treatment groups) on the severity of cluttering, acquisition, and difficulty discarding.

Peer-facilitated CBT for hoarding is an alternative group treatment that has been found to be as effective as psychologist-led group CBT ( 84 ). The Buried in Treasures workshop is the predominant manualized, peer-facilitated CBT, composed of 15 structured sessions that provide psychoeducation regarding hoarding disorder, motivation enhancement, cognitive restructuring, and discarding exercises ( 85 ). Recent additions to the Buried in Treasures treatment have been made in the form of adding in-home decluttering sessions in the final weeks of the workshop. Linkosvki et al. ( 85 ) found that the addition of these personalized sessions resulted in reductions in hoarding symptoms, clutter, and impairment of daily activities.

Virtual and Blended Therapies

Since our 2015 article ( 63 ), there has been increasing research into technology-supported interventions for hoarding ( 86 ). Such interventions include benefits such as extending access to trained practitioners; flexibility in implementation, content, and personalization; greater ease in scheduling; support and feedback between sessions; and enhanced cost-effectiveness. Several studies have examined the feasibility, acceptability, and effectiveness of integrating empirically supported CBT interventions with web-based self-help ( 87 ), individual and group videoconferencing ( 86 , 88 , 89 ), and “blended” face-to-face with web-based therapist assistance ( 90 , 91 ). These studies show numerous benefits in addition to hoarding symptom improvement that include greater treatment completion rates, shorter duration to complete treatments, as well as strong therapeutic alliance and satisfaction ratings.

There is also increasing interest in the use of virtual reality (VR) to treat hoarding disorder, although research is limited in this area to date. VR has been shown to be effective in the treatment of related disorders such as social phobia, OCD, and generalized anxiety disorder ( 92 ). VR may be particularly beneficial for individuals who have difficulty using mental imagery techniques to visualize everyday settings (such as people with hoarding disorder), and it may serve as an alternative to home visits ( 92 ). A preliminary study ( 92 ) of VR and inference-based therapy in a group format found a significant difference in the posttreatment level of bedroom clutter in the experimental group compared with the control group. Another study that used VR to simulate participants’ home environments without existing clutter found that participants reported higher confidence and motivation to engage in behavior change postimmersion ( 93 ). As technology-based innovations continue to develop and evolve, future studies may more rigorously test web-based and VR interventions for hoarding as well as incorporate other innovations, including deep learning ( 94 ), smartphone applications, and conversational agents ( 86 ).

Compassion-Focused Therapy (CFT)

CFT has recently been identified as an alternative psychotherapeutic treatment for hoarding disorder. CFT uses a variety of interventions to stimulate self-compassion, shift blame away from oneself, and regulate negative emotions that may arise in response to cognitive-restructuring attempts ( 67 ). Mindfulness training is commonly provided as part of CFT to facilitate emotional self-awareness. Multiple studies have found that incorporating CFT techniques into standard CBT programs has resulted in greater treatment effects than those produced by CBT alone for a variety of mental illnesses, including eating disorders, posttraumatic stress disorder, major depressive disorder, personality disorders, and psychotic disorders ( 67 ). Chou et al. ( 67 ) found that the provision of CFT to individuals with hoarding disorder who remained symptomatic after initially receiving CBT resulted in satisfactory treatment feasibility and acceptability among participants. Of the participants who completed the treatment, 77% had severity scores below the cutoff for clinically significant hoarding, and 62% of participants achieved a clinically significant reduction in symptom severity. However, CFT had limited effects in addressing memory concerns and attachment-related issues as well as reducing hoarding-related beliefs.

Coordinated Community Interventions

Severe hoarding behavior commonly results in diverse public health and safety concerns, which in turn, necessitate interventions, resources, and professional expertise from a wide range of sectors, including fire prevention, sanitation, housing, protective services, legal services, health, and mental health ( 11 ). As such, many cities across North America have begun to develop coordinated, community-level responses to hoarding cases in the form of task forces, coalitions, and community networks ( 80 ). The goals of community-based, coordinated initiatives typically include decreasing the incidence of severe hoarding, increasing the physical and mental health of individuals who hoard, and preserving housing ( 26 ).

Case management is an approach that has been commonly used as part of these interdisciplinary efforts. It broadly consists of three interrelated activities: identification of clients, service coordination, and service utilization ( 11 ). Within these broad categories, specific activities can include case finding, assessment, goal setting, service planning, supportive counseling, implementation of service plans, monitoring, and evaluation. These case-management activities are typically used to provide comprehensive social services to vulnerable and marginalized populations and have been found to be well-suited to the complex needs of people who hoard ( 11 ).

Harm Reduction

On the surface, hoarding may appear to be a relatively straightforward problem to address. One could simply hire a service to completely clean out the home or forcefully relocate the person who hoards to another residence. However, existing literature describes involuntary cleanouts as both traumatic to the person who hoards and ineffective in the long run, because they often lead to increased rates of recidivism ( 80 ). As such, community-based responders are increasingly avoiding the use of these more extreme options in favor of framing their service provision through a harm-reduction approach ( 80 ). In harm reduction, the goal is not to eliminate the hoarding behavior itself but rather to decrease or mitigate the risks associated with the behavior ( 95 ). The use of this approach necessitates engagement of the person who hoards in decision-making processes and the development of a supportive and nonjudgmental client-provider relationship. Hoarding response teams that utilize a harm-reduction approach may assist the person who hoards to reduce clutter volume to preserve housing, or even reconfigure possessions into safer configurations, rather than removing them altogether ( 80 ).

As discussed in our 2015 article ( 63 ), although research on the biology and neurophysiology of hoarding suggests a variety of treatment avenues, the present literature on medications has focused primarily on serotonin reuptake inhibitors (SRIs) because of their utility for OCD, with which hoarding disorder was initially conceptualized as a subtype. Some studies on pharmacotherapy for OCD retrospectively examined patients with OCD and hoarding symptoms and found that hoarding was linked to a poorer response to SRI medication ( 96 ); however, others found that hoarding did not have a significant effect on response to pharmacotherapy among those with OCD (e.g., 97 , 98 ). These studies focused specifically on those with OCD and did not include those with hoarding disorder without other OCD symptoms. Given that the majority (>80%) of those with hoarding disorder do not have comorbid OCD ( 4 ), it is essential that studies on medication treatment include the broader population of those with hoarding disorder.

In a prospective study, patients with hoarding (N=32) and those with OCD without hoarding (N=47) received 12 weeks of the SRI paroxetine (41.6±12.8 mg/day), with similar proportions of patients in each group being identified as full responders (hoarding disorder, 27%; OCD without hoarding, 32%) and as partial responders (hoarding disorder, 22%; OCD without hoarding, 15%) ( 99 ). Completers demonstrated a 31% mean symptom improvement on the UCLA Hoarding Severity Scale (UHSS; 24% for the entire sample) ( 18 ); thus, treatment response was similar between the two groups, although most had difficulty tolerating 40 mg of paroxetine, and few reached the target dose. To test a medication that was better tolerated, 24 patients meeting DSM-5 criteria for hoarding disorder received venlafaxine extended release (37.5-mg increments to 225 mg/day) for 12 weeks. Venlafaxine was well tolerated; symptoms improved by a mean of 36% on the UHSS and 32% on the Saving Inventory-Revised (SI-R) ( 21 – 23 ). Of the patients, 70% responded, and hoarding symptoms improved across difficulty discarding, excessive acquisition, clutter, and functioning ( 18 ). However, the effectiveness of serotonergic drugs for treating hoarding disorder remains largely controversial because other studies involving patients with OCD and hoarding symptoms have shown no response to this category of drugs ( 100 , 101 ).

Pharmacological interventions for hoarding disorder have targeted specific hoarding symptoms that maintain disability. For example, a 12-week open trial of 40–80 mg/day (mean of 62.72) of atomoxetine (a drug used for treatment of attention-deficit hyperactivity disorder [ADHD]) resulted in a 41.3% decrease of hoarding severity using the UHSS (39.9% decrease on the SI-R) among participants with hoarding disorder who exhibited inattention and impulsivity symptoms, which have been hypothesized to underlie hoarding behaviors ( 100 ). The patients’ inattentive and impulsivity symptoms showed a mean reduction of 18.5%, which correlated with a reduction in their global functional disability. Of the 12 study participants, six were identified as full responders (average reduction of hoarding symptoms was 57.2%), and three were identified as partial responders (average reduction of hoarding symptoms was 27.3%) using the UHSS. In a small open-label study, four individuals with hoarding disorder without comorbid ADHD were treated with the stimulant methylphenidate extended release. Following 4 weeks of treatment receiving an average of 50 mg of methylphenidate extended release, three of the four participants self-reported ≥50% improvement regarding inattention on the ADHD Symptom Scale. Modest improvements in hoarding symptoms were reported by two participants, with 25% and 32% reductions on the SI-R ( 21 – 23 ), especially on the excessive acquisition subscale ( 102 ).

A recent review of the use of second-generation antipsychotics, such as quetiapine and risperidone, for treating hoarding disorder found no evidence to suggest that they are beneficial to patients with hoarding disorder ( 103 ). One randomized, double-blind, cross-over study examined augmenting selective serotonin reuptake inhibitors (SSRIs) with the opioid antagonist naltrexone among outpatients with OCD who were not responsive to SSRIs or clomipramine for a couple of months; however, their OCD symptoms did not improve ( 104 ). A case study of an individual with hoarding symptoms and bipolar II disorder was not responsive to elevated doses of SRIs and second-generation antipsychotics but was responsive to lamotrigine combined with methylphenidate ( 105 ).

Overall, studies on pharmacotherapy for hoarding disorder remain limited by small sample sizes, designs including open labels, medications in varying classes, predominance of patients with OCD with hoarding symptoms versus a primary hoarding disorder diagnosis, preponderance of participants in midlife, use of measures not specific or validated for hoarding, and little to no replication ( 100 , 106 , 107 ). An outstanding question is the potential value of adding medications to cognitive and behavioral treatments for hoarding. In their meta-analysis, Tolin et al. ( 81 ) reported a significant positive predictive effect of medication for improvement in difficulty discarding but not for overall hoarding severity or other symptoms of hoarding. However, the type of medications varied within and across studies, so the possible augmenting effects of specific medications are not yet clear. Additional research is needed to determine the efficacy of medications for hoarding disorder, alone and in combination.

Special Populations

Children and adolescents.

There remains limited literature on pediatric presentations of hoarding, with the bulk of existing knowledge being borrowed from studies of children with OCD diagnoses ( 108 ). The prevalence of hoarding disorder among adolescents has been estimated at 2% of the adolescent population ( 101 , 108 ). Hoarding symptoms tend to be milder in childhood and increase in severity with age, with symptoms first presenting at an average age of 16.7 ( 7 , 101 , 108 ). Severity of hoarding symptoms tended to worsen over time. Children rarely accumulate clutter at the same levels of adult hoarding because their parents and other adult figures (e.g., teachers) can exert control over the child’s ability to acquire possessions ( 101 , 109 ). Children who hoard typically collect seemingly useless items (e.g., candy wrappers and old school papers). This behavior tends to be accompanied by excessive concern about the location, care, and condition of the objects. Objects are also often personalized, becoming part of the child’s personal identity ( 110 ), resulting in discarding attempts becoming potentially traumatic. Hoarding symptoms among children and adolescents are associated with poor insight, indecision, inattention, poor memory, impaired problem solving and planning, increased avoidance, and comorbid conditions (e.g., Tourette’s disorder and ADHD) ( 101 , 109 ). Youths with OCD and hoarding symptoms have been found to have more severe current and lifetime trajectories of OCD than those without ( 108 ).

Most standardized assessments for adults who hoard have not been normed for use with children. The only exception is the Child Saving Inventory (based on the SI-R), a 23-item scale rated by parents or caregivers on four subscales: discarding, clutter, acquisition, and distress-impairment ( 111 ). With regard to treatment for this population, the effectiveness of hoarding-modified CBT for the adult population has not been widely documented in younger samples ( 101 ). There is also limited literature on pharmacological treatment for pediatric hoarding.

Older Adults

It is estimated that the rate of hoarding among older adults is three times greater than that of the general population (2%–6%) ( 23 ). As previously detailed, hoarding symptoms tend to increase in severity with age. Hoarding behaviors present unique challenges for this population because accumulation of clutter can result in increased risks for fire danger, fall hazards, medication mismanagement, inadequate nutrition, social isolation, impairment in activities of daily living, and overall decreased quality of life ( 23 , 31 ). Sixty-four percent of older adults with hoarding disorder have trouble completing self-care activities, and 81% have risks to general health because of fires, falls, and poor sanitation ( 23 ).

Cognitive impairment, such as difficulty with planning, problem solving, and memory, is often evident among older adults who hoard, further complicating both assessment and treatment efforts. Assessment instruments designed for adults who hoard are generally suitable for assessing hoarding among older adults, unless marked cognitive decline invalidates self-report measures. Given the potential inaccuracies with self-report, is it recommended that a comprehensive assessment also include home visits, reports from social supports, neurocognitive assessment, and evaluation of functional impairment and comorbid psychiatric conditions ( 112 ). Cognitive impairment has been found to result in poorer responses to CBT in other geriatric psychiatric populations ( 23 ). Thus far, cognitive rehabilitation and exposure-sorting therapy, which pairs cognitive training with behavioral exposure, has shown promise for older adults, resulting in clinically significant improvement in hoarding severity ( 23 ). Other common interventions include clutter reduction and harm-reduction strategies.

Nonvoluntary Clients

Since our 2015 article ( 63 ), research remains limited on nonconsensual clients who hoard in community settings. However, new research suggests that most individuals with hoarding behaviors do not voluntarily seek assistance without family or community pressure ( 113 ), with problems recognized during routine building or fire inspections ( 80 ). Individuals’ poor insight often results in a lack of awareness about the implications of their accumulated possessions and rejecting offers of help. Emotional attachment to their belongings may be difficult to overcome, and fear of stigma and societal judgment lead to further social isolation and avoidance of the issue.

Nonvoluntary clients’ poor insight and inconsistent motivation add to the challenge of engaging these individuals in hoarding interventions. These tendencies commonly manifest in procrastination, unresponsiveness to contact attempts by service providers, and cancelled or missed appointments ( 80 ). Some clients may withdraw consent to provider engagement despite initially agreeing to services ( 80 ). In situations in which this ongoing avoidance results in elevated safety concerns or risk of housing loss, service providers may then be required to apply legal sanctions to force compliance ( 80 , 113 ).

As discussed in our 2015 article ( 63 ), family members who live with a person who hoards are exposed to the same health and safety risks. Children of people who hoard are faced with constant disruptions, including loss of functional living space, unsanitary home conditions, social isolation, financial distress, and hostile family dynamics ( 114 , 115 ). The effects of these challenges can have a lifetime impact on children, with the associated psychological distress lasting into adulthood. Recent research indicates that adult children of people who hoard have reported feelings of grief related to the loss of their relationship with their parent, as well as anger stemming from beliefs that their parent who hoards chose possessions over their children ( 115 ). As their parents age, adult children of people who hoard experience additional responsibilities as caregivers.

The level of caregiver burden experienced by the relatives of people who hoard has been found to be comparable with or greater than that reported by family members of people with dementia ( 16 ). Older adults who hoard require greater assistance to complete basic activities of daily living that otherwise would be neglected, a responsibility that often falls on their adult children and other relatives ( 16 ). Relatives of people who hoard also report increased levels of frustration, hopelessness, and distress in response to the hoarding person’s lack of insight, treatment ambivalence, and risk of injury from unsafe living conditions ( 16 , 114 , 115 ). Feelings of shame and embarrassment interfere with family members’ ability to have people visit the home, resulting in risk of social isolation ( 115 ). The negative emotions experienced by family members of people who hoard often culminate in outright rejection of the person who hoards ( 114 , 115 ).

Manualized training programs have also been designed for family members of people who hoard and include components of psychoeducation on hoarding, harm-reduction techniques, communication training, and self-care ( 114 ). One such program is the Family-As-Motivators training, which was conducted in a pilot study over 14 sessions. At pre-, mid-, and posttraining measures, Family-As-Motivators resulted in improved use of coping strategies, decreased feelings of hopelessness, and decrease in self-blame ( 114 ). Another example includes family-focused, harm-reduction programming (i.e., Community Reinforcement and Family Training) ( 95 ), which focuses on improving stressed familial relationships while also encouraging the person who hoards to accept help to manage the hoarding problem. The harm-reduction approach includes five key components: enhance willingness to engage in the harm-reduction approach, assess the potential for harm, build and facilitate a harm-reduction team, plan the harm-reduction approach, and implement and manage the plan.

Conclusions

Frost and Hartl’s ( 1 ) seminal article inspired 25 years (and counting) of empirical study of hoarding. To date, research has focused on identifying specific symptoms and components of hoarding, distinguishing hoarding from OCD, and examining hoarding as a distinct DSM-5 disorder ( 3 ). This inquiry has led to the development of models for understanding hoarding disorder that focus on personal and family vulnerability factors (e.g., family history, comorbidity), information processing challenges (e.g., inattention, categorization, memory), cognitions (e.g., meaning of possessions), positive and negative emotions, biological features, and so forth. Recent investigations of cognitive processing, neurobiological correlates, and genetic aspects of hoarding are advancing the understanding of key elements of hoarding (e.g., discarding, excessive acquiring, clutter) and relevant substrates. More recent neurobiological and genetic studies further illustrate the similarities and distinctions between OCD and hoarding as well as other obsessive-compulsive and related disorders. Future research is needed to examine cognitive and affective decision making as well as cognitive impairments associated with hoarding. Additional studies are also needed to understand impairments associated with hoarding and comorbid conditions. Further study of neurobiological underpinnings of hoarding disorder may enhance the identification and selection of treatment targets and inform treatment development and the personalization of treatments. More extensive research is also needed on genetic factors and hoarding traits, including the genetic signature of hoarding disorder.

Cognitive and behavioral treatment for hoarding delivered individually and in groups have been empirically supported and considered standard care on the basis of the level of benefit at the current stage of research ( 81 ). Technology-supported hoarding interventions show promise, extending access to these evidence-based treatments, trained providers, and peer-support as well as presenting opportunities to further examine key components of hoarding ( 86 ). Additional models have been associated with substantial hoarding symptom improvement, including cognitive rehabilitation treatment for older adults ( 23 ), CFT ( 67 ), motivational enhancement, and harm reduction ( 114 , 116 ). Few pharmacotherapy trials for hoarding disorder have been conducted, and existing medication studies are limited. Future studies that specifically examine participants diagnosed as having hoarding disorder need larger samples sizes that include older adults as well as more robust methodology and replication; designs should also include combining CBT and pharmacotherapy.

Current hoarding models and assessments have mainly focused on adults. Future studies are needed to develop CBT models, hoarding assessments, and interventions for youths ( 117 ). Future studies on hoarding also necessitate more inclusive samples regarding race-ethnicity and further development of assessments that are culturally and linguistically relevant. Because hoarding disorder is a multifaceted problem that spans mental and public health, a multipronged approach may be especially relevant and effective. Although much progress has been made over the past 2 decades, numerous questions still exist regarding the nature of, and optimal interventions for, hoarding disorder; thus, opportunities for many new discoveries, advances, and innovations are ahead.

This article is an update of an article previously published in Focus (Bratiotis C, Steketee G: Hoarding disorder: models, interventions, and efficacy. Focus 2015; 13:175–183).

The authors report no financial relationships with commercial interests.

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  • Hoarding disorder

Hoarding disorder is an ongoing difficulty throwing away or parting with possessions because you believe that you need to save them. You may experience distress at the thought of getting rid of the items. You gradually keep or gather a huge number of items, regardless of their actual value.

Hoarding often creates extremely cramped living conditions with only narrow pathways winding through stacks of clutter. Countertops, sinks, stoves, desks, stairways and all other surfaces are usually piled with stuff. You may not be able to use some areas for their intended purpose. For example, you may not be able to cook in the kitchen. When there's no more room inside your home, the clutter may spread to the garage, vehicles, yard and other storage areas.

Hoarding ranges from mild to severe. In some cases, hoarding may not have much impact on your life, while in other cases it seriously affects your daily functioning.

People with hoarding disorder may not see it as a problem, so getting them to take part in treatment can be challenging. But intensive treatment can help you understand how your beliefs and behaviors can be changed so that you can live a safer, more enjoyable life.

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The first symptoms of hoarding disorder often appear during the teenage to early adult years. You may get and save too many items, gradually build up clutter in living spaces, and have difficulty getting rid of things.

As you grow older, you may continue getting and holding onto things that you may never use and don't have space for. By middle age, the clutter can become overwhelming as symptoms become more severe and increasingly difficult to treat.

Problems with hoarding gradually develop over time and tend to be a private behavior. You may avoid having family, friends or repair workers in your home. Often, major clutter has developed by the time it reaches the attention of others.

Symptoms of hoarding disorder may include:

  • Getting and keeping too many items that you may not have a need for right now and don't have space for.
  • Ongoing difficulty throwing out or parting with your things, regardless of their actual value.
  • Feeling a need to save these items and being upset by the thought of getting rid of them.
  • Building up clutter to the point where you can't use rooms.
  • Trying to be perfect and avoiding or delaying decisions.
  • Problems with planning and organizing.

Getting too many items and refusing to part with them results in:

  • Disorganized piles or stacks of items, such as newspapers, clothes, paperwork, books or sentimental items.
  • Items that crowd and clutter your walking spaces and living areas. Rooms can't be used for the intended purpose, such as not being able to sleep in your bed.
  • Buildup of food or trash to large, unsanitary levels.
  • Distress or problems functioning or keeping yourself, others and pets safe in your home.
  • Conflict with others who try to reduce or remove clutter from your home.
  • Relationship issues, avoiding social activities and employment problems.
  • Difficulty organizing items and sometimes losing important items in the clutter.

With hoarding disorder, items are usually saved because:

  • You believe these items are unique or that you'll need them at some point in the future.
  • You feel emotionally connected to items that remind you of happier times or represent beloved people or pets.
  • You feel safe and comforted when surrounded by things.
  • You don't want to waste anything.

Hoarding disorder is different from collecting. People who have collections, such as stamps or model cars, carefully search out specific items, organize them and display their collections. Collections can be large, but they aren't usually cluttered. Also, they don't cause the distress and problems functioning that are part of hoarding disorder.

Hoarding animals

People who hoard animals may collect dozens or even hundreds of pets. 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 often at risk because of unsanitary conditions.

When to see a doctor

If you or a loved one has symptoms of hoarding disorder, talk with a health care provider or a mental health provider with expertise in diagnosing and treating hoarding disorder 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.

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.

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

Risk factors

Hoarding usually starts around ages 15 to 19. 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 behavior style that includes trouble making decisions and problems with attention, organization and problem-solving.
  • 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 or losing possessions in a fire.

Complications

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.
  • Conditions that aren't clean and can be a health risk.
  • A fire hazard.
  • Poor work performance.
  • Legal issues, such as eviction.

Other mental health disorders

Hoarding disorder also is linked with other mental health conditions, such as:

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

Because little is understood about what causes hoarding disorder, there's no known way to prevent it. However, as with many mental health conditions, getting treatment at the first sign of a problem may help prevent hoarding from getting worse. This is especially important because by the time clutter becomes a noticeable problem, hoarding likely has been going on for a while.

  • Hoarding disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed. Dec. 5, 2022.
  • What is hoarding disorder. American Psychiatric Association. https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder#section_0. Accessed Dec. 5, 2022.
  • Treating people with hoarding disorder. American Psychological Association. https://www.apa.org/monitor/2020/04/ce-corner-hoarding. Accessed Dec. 5, 2022.
  • Hoarding disorder. Merck Manual Professional Version. https://www.merckmanuals.com/professional/psychiatric-disorders/obsessive-compulsive-and-related-disorders/hoarding-disorder. Accessed Dec. 5, 2022.
  • Nakao T, et al. Pathophysiology and treatment of hoarding disorder. Psychiatry and Clinical Neurosciences. 2019; doi:10.1111/pcn.12853.
  • Bratiotis C, et al. Hoarding disorder: Development in conceptualization, intervention, and evaluation. Focus. 2021; doi:10.1016/j.copsyc.2020.07.022.
  • Rodgers N, et al. Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis. Journal of Affective Disorders. 2021; doi:10.1016/j.jad.2021.04.067.
  • Ivanov VZ, et al. The developmental origins of hoarding disorder in adolescence: A longitudinal clinical interview study following an epidemiological survey. European Child and Adolescent Psychiatry. 2021; doi:10.1007/s00787-020-01527-2.
  • Carnevale T. Identifying adolescents with hoarding disorder. Journal of Child and Adolescent Psychiatric Nursing. 2021; doi:10.1111/jcap.12304.
  • Sawchuk CN (expert opinion). Mayo Clinic. Dec. 20, 2022.

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Hoarding Causes: Psychology of Hoarding

Behind the causes of hoarding.

Hoarding causes people to form extreme emotional attachments to inanimate objects and, sometimes, animals. People who suffer from hoarding disorder tend to personify the items they accumulate, attaching human characteristics to them. Frequently, hoarders ( What is hoarding? ) don't even know what they have in their massive piles and stacks of stuff. What's more, they typically don't use the useless items they purchase and accumulate. So what causes hoarding?

The Psychology of Hoarding

If you understand what's behind the psychology of hoarding, it's easier to discern the difference between hoarding disorder and collection or just plain messiness. While specific hoarding causes remain elusive to researchers, new studies have shed some light on this serious mental disorder. The most recent research shows abnormal activity in the decision-making region of hoarders' brains. The abnormal activity shows up when study investigators asked people with hoarding disorder to make a decision about whether or not to keep something or throw it away. Experts say that this area of the brain involves decision-making under ambiguous conditions, risk assessment, and emotional stress.

Oddly, even though the living spaces of hoarders become overrun with debilitating piles of worthless junk, the disorder is related to perfectionism in that it's associated with an intense fear of making the wrong decision.

Although experts still aren't clear about hoarding causes, some factors that may contribute to hoarding, according to Harvard Medical School include:

  • Impulsive behavior patterns
  • Issues with excessive emotional attachment
  • Neurological issues associated with abnormal brain structures
  • Abnormal thinking patterns affecting decision-making

OCD and Hoarding – Separated at DSM-V

OCD and hoarding aren't as closely related as experts once believed. The Diagnostic and Statistical Manual, Fourth Edition – TR (DSM-IV-TR) classifies hoarding as a possible symptom of obsessive-compulsive disorder. But the new DSM-V separates the two, classifying hoarding disorder as a separate diagnosis. Further, OCD used to fall under the umbrella of anxiety disorders. In the new manual, OCD gets its own chapter entitled, Obsessive-Compulsive and Related Disorders . Hoarding disorder appears in the related disorders section of this new chapter.

If it's a separate disorder, why do hoarding and OCD appear together in the new DSM-V? Easy. Although they're now considered two distinct disorders, they're still kissing cousins of a sort.

David Tolin director of the Institute of Living, a mental health center in Connecticut, conducted a research study in which scientists used functional magnetic resonance imaging (fMRI) to study the brain activity in healthy adults, adults with OCD, and adults with hoarding disorder. When asked to make decisions about throwing away pieces of their junk, the brains of hoarders went into anxiety-ridden overdrive. Out of the three groups, the hoarders discarded significantly fewer items than did the healthy people and those with OCD. Interestingly, hoarders had no issues making good decisions about throwing away the junk of others.

The study indicates that, although significant amounts of anxiety are associated with both OCD and hoarding, the distress comes from different root causes and environmental triggers. Researchers still have a long way to go when it comes to isolating the exact hoarding causes, but they continue to make consistent progress toward that end.

article references

APA Reference Gluck, S. (2022, January 10). Hoarding Causes: Psychology of Hoarding, HealthyPlace. Retrieved on 2024, February 21 from https://www.healthyplace.com/ocd-related-disorders/hoarding-disorder/hoarding-causes-psychology-of-hoarding

Medically reviewed by Harry Croft, MD

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With popular reality shows like Hoarders and Hoarding: Buried Alive , this problem has come into great focus. The viewer peeks into the lives of people who are overwhelmed with belongings; every room of a hoarder's house contains mountains of clutter, garbage, and junk that the average person would easily toss. The spectrum from clutter to hoarding is wide, but people can become emotionally attached to their piles of stuff, not willing or able to let anything go.

  • Why People Hoard
  • The Science of Hoarding
  • Who Hoards?
  • How to Help a Person Who Hoards

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According to the American Psychiatric Association, 2 to 6 percent of the U.S. population suffers from hoarding. The tendency to gather and hold onto items can appear as early as one’s adolescent years, often worsening with age. A serious case can result in poor health and safety concerns, and the person who suffers can also develop poor personal hygiene.

There are known risk factors such as experiencing a traumatic event; persistent difficulty making decisions; and having a family member who also hoards. Individuals who have both OCD and hoarding symptoms were more likely to have experienced at least one traumatic life event in comparison to those with OCD alone. The obsessive need to collect and keep material objects may be a way for these sufferers to cope.

• Persistent difficulty discarding or parting with possessions , regardless of actual value.

• Emotional distress over parting with possessions.

• Allowing possessions to accumulate to the point of congesting living space, often requiring intervention by others.

• Allowing hoarding to interfere with day-to-day life, including work or relationships with friends or family.

• Hoarding cannot be better explained by another mental disorder such as brain injury, obsessive-compulsive disorder, or major mental illness

Signs of hoarding behavior can be seen in adolescence , and sometimes in children as young as 6 or 7 years of age. These children are not able to function in their living space, with beds, desks, and closets spilling over with belongings. The difference between hoarding and garden-variety messiness is the emotional reaction they have when they are forced to part with their possessions. Children who hoard feel violated, anxious, and distressed. They also deem their seemingly useless items as valuable, and categorize them for sentimental reasons. I found this bird feather the day I went to the playground. If hoarding is not addressed, it will likely worsen as the child ages.

Sometimes, these possessions take on high attachment value , sometimes even greater than the attachment assigned to the people close to them. In fact, people who hoard will often choose their possessions over friends and family. When throwing out possessions, some sufferers experience intense emotions that are comparable to those experienced when a loved one is lost.

NadezhdaF_Shutterstock

Accumulating belongings may fill an emotional hole left by trauma; it allows individuals to avoid dealing with their pain. Many people who hoard describe a rush when acquiring new items, especially if the item is free or considered a bargain; and these individuals go to great lengths to justify their collections when questioned by others. If a family member or friend removes these belongings without the person’s permission, the person feels violated and anxiety may be triggered.

One study asked participants to make decisions about keeping or chucking items, some belonged to them or some did not belong to them. Researchers found abnormal activity in the anterior cingulate cortex and the insula of the brain, known for decision-making and risk assessment. The people who hoard are unable to make decisions about discarding the items they own.

It is unclear whether hoarding is due to heredity or environment. But half of the people who hoard have a family member who hoards. And there is evidence that links compulsive hoarding to a region on chromosome 14 —which has also been linked to disorders such as Alzheimer's and other cognitive impairments.

Hoarding is a type of compulsion, and it’s estimated that about one in four people with OCD also compulsively hoard . It is also related to obsessive-compulsive personality disorder , attention -deficit hyperactivity disorder, as well as anxiety and depression .

Research from the University of New South Wales has found a link between hoarding behavior and traumatic events , such as loss of a spouse or loss from a natural disaster. People traumatized by such events may show signs of hoarding symptoms at the time of the event or shortly thereafter.

If a person has attention deficit disorder , ADD or ADHD, it does not mean that they have compulsive hoarding behaviors. The disorganization of a person with ADHD or ADD is not related to hoarding. However, a person who hoards may also have or develop attention deficit. And a person who has attention deficit may be at risk of developing hoarding as well.

A person who hoards does not have to be a compulsive consumer, though such shoppers can hoard. Compulsive buyers often purchase items on impulse, these are acquisitions that the person can do without. Spending without adequate reflection can result in storing unopened items in closets as the cycle of buying is perpetuated. As belongings accumulate over time, compulsive buyers may eventually develop a hoarding habit. The relentless shopper generally tries to conceal their habits, whereas the person who hoards does not.

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Research shows that the decision-making process of a person who hoards is seriously compromised. Neuroimaging studies have revealed common traits among people who hoard; this includes having severe emotional attachments to inanimate objects and extreme anxiety when making decisions, even simple ones. A person who hoards finds it gut-wrenching to make the decision of tossing a piece of garbage like a plastic bag, for example.

Compulsive hoarding is more common in  older adults , and it may be more common in men than in women. When compared with adults between the ages of 33 and 44, older people between the ages of 55 and 94 are three times more likely to have this compulsion.

Jamie Feusner at UCLA’s School of Medicine notes that many of these people are single , either because their behavior has driven away those around them or has prevented them from forming meaningful relationships.

A person with compulsive hoarding is not "lazy" about cleaning or organizing their home. For a person with this compulsion, throwing away a paper cup may be dreadfully difficult and stressful . And for such a person, throwing away five cups may require immense courage and hard work. This is not related to messiness .

Animal hoarders have more animals than they can properly care for, but they don’t recognize that there is a problem and they typically continue to adopt more animals. While cats are most commonly hoarded, dogs and other animals are hoarded as well. The health of these animals is often compromised, they may have parasites, poor nutrition , and untreated infectious diseases. The animal hoarder is normally unable to keep up with waste clean-up either. The household becomes so untenable that animal control services as well as law enforcement are often called upon.

Unlike hoarding, collecting has a social aspect. Collectors are proud of what they collect. The collector preserves and maintains these items, giving the collector pleasure; they display the items and show them to people who may also appreciate them. The person who hoards is more haphazard when they acquire things, often they feel an item might be needed in the future.

Nina Lishchuk Shutterstock

Commonly hoarded items can include anything to everything. But whatever it is, the person who hoards assigns value to their items. Such a household can contain objects including paper and plastic bags, cardboard boxes, newspapers, magazines, photographs, household supplies, old food, unused clothing, sports gear, broken appliances. Just about anything can be stockpiled.

The person who hoards also impacts the lives of the people around them. A house can, in fact, become so compromised that it turns into a clear fire hazard or toxic waste site. People with severe hoarding may even find child services and law enforcement at their door.

This disorder is hard to treat. While medication does not appear to reduce the behavior, it may help to reduce symptoms. Medications that treat conditions like depression and anxiety are helpful in about a third of cases. Therapy can help. Randy Frost, a professor of psychology at Smith College and the father of hoarding psychology , along with colleagues, came up with a cognitive-behavioral approach for hoarders. He includes in this therapy: Ask the person who hoards to try throwing away an item as an experiment. Not as a broad policy, but as a small trial. Then the therapist monitors how the sufferer progresses.

Look for support in the form of a clutter buddy or coach. The person should be respectful, compassionate, and have integrity, and would never try to sneak your belongings away. A good clutter buddy has good personal boundaries , and will not try to influence you with their values and beliefs. They may offer you what they have learned about themselves from experience, which is not the same as trying to apply their opinions into your life.

You cannot clean up for a person who hoards . To help this person, you should not interpret their needs and willingness as noncompliance. They will make their decisions when they are able. Do not interpret their readiness or lack thereof as being unmotivated, lazy, difficult, or unappreciative of your efforts. Understand and accept the person who hoards as who they are.

psychology essay on hoarding

Ever wonder about the connection between narcissism and materialism? People who feel empty on the inside are prone to try and fill that void with lots of stuff. But does it work?

psychology essay on hoarding

The scarcely researched phenomenon of human food hoarding is explored in this essay. Its parallel to animal food hoarding is addressed as well as differences.

psychology essay on hoarding

Recent studies suggest a strong association between hoarding and loneliness, but the causal relationship between the two is still unclear.

psychology essay on hoarding

If decluttering your home is hard for you, this may just be the motivation you need.

psychology essay on hoarding

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psychology essay on hoarding

Is the line between collecting and hoarding as big as we think? Researchers identified the key differences through interviews.

psychology essay on hoarding

Storing information and images in virtual formats has made our lives more convenient and efficient. But have there been unfavorable impacts of the shift away from physical things?

psychology essay on hoarding

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psychology essay on hoarding

Some pet owners refuse to admit that animals in their care are suffering. What has gone wrong? And what can be done to help?

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Guest Essay

I’m a Neuroscientist. We’re Thinking About Biden’s Memory and Age in the Wrong Way.

President Biden seated in a chair holding a stack of what looks like index cards.

By Charan Ranganath

Dr. Ranganath is a professor of psychology and neuroscience and the director of the Dynamic Memory Lab at the University of California, Davis, and the author of the forthcoming book “Why We Remember: Unlocking Memory’s Power to Hold On to What Matters.”

The special counsel Robert K. Hur’s report, in which he declined to prosecute President Biden for his handling of classified documents, also included a much-debated assessment of Mr. Biden’s cognitive abilities.

“Mr. Biden would likely present himself to a jury, as he did during our interview with him, as a sympathetic, well-meaning, elderly man with a poor memory.”

As an expert on memory, I can assure you that everyone forgets. In fact, most of the details of our lives — the people we meet, the things we do and the places we go — will inevitably be reduced to memories that capture only a small fraction of those experiences.

It is normal to be more forgetful as you get older. Generally, memory functions begin to decline in our 30s and continue to fade into old age. However, age in and of itself doesn’t indicate the presence of memory deficits that would affect an individual’s ability to perform in a demanding leadership role. And an apparent memory lapse may or may not be consequential, depending on the reasons it occurred.

There is forgetting, and there is Forgetting. If you’re over the age of 40, you’ve most likely experienced the frustration of trying to grasp that slippery word on the tip of your tongue. Colloquially, this might be described as forgetting, but most memory scientists would call this retrieval failure, meaning that the memory is there but we just can’t pull it up when we need it. On the other hand, Forgetting (with a capital F) is when a memory is seemingly lost or gone altogether. Inattentively conflating the names of the leaders of two countries would fall in the first category, whereas being unable to remember that you had ever met the president of Egypt would fall into the second.

Over the course of typical aging, we see changes in the functioning of the prefrontal cortex, a brain area that plays a starring role in many of our day-to-day memory successes and failures. These changes mean that as we get older, we tend to be more distractible and often struggle to pull up words or names we’re looking for. Remembering events takes longer, and it requires more effort, and we can’t catch errors as quickly as we used to. This translates to a lot more forgetting and a little more Forgetting.

Many of the special counsel’s observations about Mr. Biden’s memory seem to fall in the category of forgetting, meaning that they are more indicative of a problem with finding the right information from memory than Forgetting. Calling up the date that an event occurred, like the last year of Mr. Biden’s vice presidency or the year of his son’s death, is a complex measure of memory. Remembering that an event took place is different from being able to put a date on when it happened, which is more challenging with increased age. The president very likely has many memories, even though he could not immediately pull up dates in the stressful (and more immediately pressing) context of the Oct. 7 attack on Israel.

Other “memory” issues highlighted in the media are not so much cases of forgetting as they are of difficulties in the articulation of facts and knowledge. For instance, in July 2023, Mr. Biden mistakenly stated in a speech that “we have over 100 people dead,” when he should have said, “over one million.” He has struggled with a stutter since childhood, and research suggests that managing a stutter demands prefrontal resources that would normally enable people to find the right word or at least quickly correct errors after the fact.

Americans are understandably concerned about the advanced age of the two top contenders in the coming presidential election (Mr. Biden is 81, and Donald Trump is 77), although some of these concerns are rooted in cultural stereotypes and fears around aging. The fact is that there is a huge degree of variability in cognitive aging. Age is, on average, associated with decreased memory, but studies that follow up the same person over several years have shown that although some older adults show precipitous declines over time, other super-agers remain as sharp as ever.

Mr. Biden is the same age as Harrison Ford, Paul McCartney and Martin Scorsese. He’s also a bit younger than Jane Fonda (86) and a lot younger than the Berkshire Hathaway C.E.O., Warren Buffett (93). All these individuals are considered to be at the top of their professions, and yet I would not be surprised if they are more forgetful and absent-minded than when they were younger. In other words, an individual’s age does not say anything definitive about the person’s cognitive status or where it will head in the near future.

I can’t speak to the cognitive status of any of the presidential candidates, but I can say that, rather than focus on candidates’ ages per se, we should consider whether they have the capabilities to do the job. Public perception of a person’s cognitive state is often determined by superficial factors, such as physical presence, confidence and verbal fluency, but these aren’t necessarily relevant to one’s capacity to make consequential decisions about the fate of this country. Memory is surely relevant, but other characteristics, such as knowledge of the relevant facts and emotion regulation — both of which are relatively preserved and might even improve with age — are likely to be of equal or greater importance.

Ultimately, we are due for a national conversation about what we should expect in terms of the cognitive and emotional health of our leaders.

And that should be informed by science, not politics.

Charan Ranganath is a professor of psychology and neuroscience and the director of the Dynamic Memory Lab at the University of California, Davis, and the author of “ Why We Remember: Unlocking Memory’s Power to Hold On to What Matters .”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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  1. The Psychology Behind Hoarding

    The Psychology Behind Hoarding It's estimated that 1 in 50 people struggles with hoarding. This may be why. Posted September 5, 2014 | Reviewed by Kaja Perina Key points Hoarding is...

  2. PDF A psychological perspective on hoarding

    Hoarding is a behaviour that is not confined to humans. No other species, however, comes close to human beings in how we mediate our lives through objects. In understanding hoarding it is useful to keep this in mind and not disconnect the unusual interactions people have with objects generally from the behaviour of people with hoarding ...

  3. Psychological Models of Hoarding

    Hoarding disorder (HD) is a common and complex disorder characterized by comorbidity and significant disability, and it constitutes a distinct disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013).

  4. Treating people with hoarding disorder

    "In many ways, hoarding is an ability to appreciate physical characteristics that goes far beyond what the rest of us can do." That blessing is also a curse. People with hoarding disorder can become overwhelmed by the sheer volume of the stuff they can't let go.

  5. Hoarding: The Basics

    Hoarding Disorder occurs when a person has difficulty discarding items that have no apparent use or value to them. The retaining of these possessions results in excessive clutter and impairs the functioning of the person's living space and, as a result, can harm relationships with others, especially those in the home or wanting to visit.

  6. Hoarding Disorder: Development in Conceptualization, Intervention, and

    Hoarding disorder is characterized by difficulty parting with possessions because of strong urges to save the items. Difficulty discarding often includes items others consider to be of little value and results in accumulation of a large number of possessions that clutter the home. Cognitive-behavioral therapy (CBT) with exposure and response prevention and selective serotonin reuptake ...

  7. What's Causing the Rise of Hoarding Disorder?

    Other studies suggest non-genetic causes. Hoarding can also accompany certain traumatic brain injuries, Tourette's syndrome, ADHD, neurodegenerative disorders, generalized anxiety disorder, clinical depression, and dementia. Childhood poverty, interestingly enough, does not seem to be connected with hoarding.

  8. Recent Advances in Research on Hoarding

    Go to: Abstract Purpose of Review The purpose of the following paper is to review recent literature trends and findings in hoarding disorder (HD). Our goal is to highlight recent research on etiology, associated features, and empirically based treatments. Recent Findings

  9. The Psychology of Hoarding Disorder: Approaches for Treatment

    The diagnosis of hoarding disorder is made when the following criteria are met: 1 A persistent need to save items Clinically significant distress, especially when discarding possessions...

  10. Phenomenology of Hoarding

    The history of research on hoarding is relatively short. Early in the twentieth century, descriptions of hoarding behavior appeared as an outgrowth of psychoanalytic theorizing about an anal personality characterized by the three features of obstinacy, orderliness, and parsimony (Freud, 1908).Freud emphasized the retention of feces in his theorizing, whereas Jones (1912) suggested that the ...

  11. Unpacking hoarding disorder

    Unpacking hoarding disorder | APS. We are aware of phishing scams falsely claiming to be from the APS, urging actions like 'purchasing gift vouchers.'. Exercise caution, as these emails are not legitimate . Psychology Topics Community Members Education About APS. Login. InPsych is the member magazine for the Australian Psychological Society and ...

  12. Compulsive hoarding: current controversies and new directions

    The initial clues that hoarding was related to frontal-lobe dysfunction came from case reports of pathological collecting and saving that began after a brain injury, typically along with other changes in personality and social functioning. 34-36 In the last decade, two papers presented findings suggesting that hoarding is the result of frontal ...

  13. Hoarding Disorder: Development in Conceptualization, Intervention, and

    Historically, hoarding was considered a subtype of OCD, although recent evidence suggests that there are more differences than similarities. Hoarding behaviors have been identified among individuals with anxiety disorders other than OCD, particularly those diagnosed as having generalized anxiety disorder or social phobia ().Major depressive disorder, generalized anxiety disorder, and social ...

  14. Hoarding Disorder: What It Is, Causes, Symptoms & Treatment

    Hoarding disorder is a mental health condition in which a person feels a strong need to save a large number of items, whether they have monetary value or not, and experiences significant distress when attempting to get rid of the items. The hoarding impairs their daily life.

  15. Hoarding disorder

    Prof Jessica Grisham explains the psychology behind the hoarding disorder. For more videos like this subscribe to our channel: http://www.youtube.com/user/un...

  16. Hoarding disorder

    Hoarding disorder is an ongoing difficulty throwing away or parting with possessions because you believe that you need to save them. You may experience distress at the thought of getting rid of the items. You gradually keep or gather a huge number of items, regardless of their actual value.

  17. The Psychology Behind Hoarding

    Here are generally recognized symptoms of hoarding from the Mayo Clinic: Cluttered living spaces. Inability to discard items. Keeping stacks of newspapers, magazines, or junk mail. Moving items ...

  18. Hoarding Causes: Psychology of Hoarding

    Although experts still aren't clear about hoarding causes, some factors that may contribute to hoarding, according to Harvard Medical School include: Impulsive behavior patterns. Issues with excessive emotional attachment. Neurological issues associated with abnormal brain structures. Abnormal thinking patterns affecting decision-making.

  19. Essay On Hoarding

    Compulsive Hoarding disorder: "Hoarding disorder is characterized by the persistent difficulty to discard or part with possessions, regardless of the value others may attribute to these possessions and is associated with significant functional impairment and distress.

  20. Free Essay about Hoarding Disorder

    After watching two sessions: of two different hoarders and two different therapists, I realized that hoarding disorder is a psychological condition that makes an individual find it hard when it comes to discarding or letting go of some possessions.

  21. Hoarding

    Mind the Mess: How We Stop Noticing Everyday Clutter Alan Castel Ph.D. on January 14, 2021 in Metacognition and the Mind We often don't notice the mess that surrounds us. Clutter blindness may be...

  22. Opinion

    Special Counsel Robert K. Hur's report, in which he declined to prosecute President Biden for his handling of classified documents, also included a much-debated assessment of Mr. Biden's ...