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Compulsive Hoarding

Compulsive hoarding, or pathological hoarding or disposophobia, is the excessive acquisition of possessions and failure to use or discard them, even if the items are worthless, hazardous, or unsanitary. Compulsive hoarding impairs mobility and interferes with basic activities, including cooking, cleaning, showering, and sleeping. Hoarding can be a symptom of obsessive-compulsive disorder (OCD), but many people who hoard do not have other OCD-related symptoms. Researchers are working to better understand hoarding as a distinct mental health problem.

Symptoms of Hoarding

Hoarding will be included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In DSM-IV-TR, hoarding is listed as one of the diagnostic criteria for obsessive-compulsive personality disorder (OCPD). According to DSM-IV-TR, when hoarding is extreme, clinicians should consider a diagnosis of OCD and may diagnose both OCPD and OCD if the criteria for both are met. It is clear that, in some cases, hoarding can be a symptom of OCD. For example, hoarding secondary to aggressive or contamination obsessions or feelings of incompleteness.

Hoarding Symptoms Include:

  • Cluttered living spaces
  • Inability to discard items
  • Keeping stacks of newspapers, magazines or junk mail
  • Acquiring unneeded or seemingly useless items, including trash
  • Difficulty managing daily activities, including procrastination decision making
  • Difficulty organizing items
  • Excessive attachment to possessions, and discomfort letting others touch possessions
  • Limited or no social interactions

Risk factors associated with hoarding disorder include:

  • A family history of hoarding
  • Stressful or traumatic events
  • Alcohol abuse
  • Social isolation
  • Depression
  • Emotional dysregulation

Complications related to hoarding disorder that may arise over time include:

  • Social withdrawal and isolation
  • Strained family relations
  • Illness due to unsanitary conditions of living quarters
  • Inability to perform daily tasks
  • Poor hygiene
  • Fire hazard
  • Risk of eviction from home
  • Inability to hold down a job

The onset of compulsive hoarding usually occurs in early adolescence, at age 13 or 14, though children as young as 3 years of age have been diagnosed with hoarding disorder. Both environmental and genetic factors seem to play a role in hoarding. Though hoarding has long been associated with OCD, brain scans have shown that the neurobiology of hoarders differs significantly from that of people with OCD. The parts of the brain regulating decision-making, focused attention, motivation, and problem-solving, among other cognitive functions, are significantly compromised in individuals with hoarding disorder, as well as the part of the brain involved in spatial orientation and memory. Because hoarding affects different parts of the brain than OCD, standard treatment procedures and medications used to address OCD are generally not effective in treating people with hoarding disorder.

The most effective treatment option for compulsive hoarding is exposure and response prevention therapy (ERP), a form of cognitive-behavioral therapy (CBT); where hoarders are asked to sift through their clutter and discard whatever they cannot rationally justify keeping. The more the patient discards, the more he or she habituates to the process of sorting & sifting, lowering the person’s anxiety levels when discarding possessions. Selective serotonin reuptake inhibitors (SSRIs) have been used to treat hoarding but have thus far proved ineffective. Medications currently used to treat hoarding include:

Recent research has shown that in most cases hoarding appears to be independent from other neurological and psychiatric disorders, including OCD. These individuals do not experience intrusive thoughts, images, or impulses or repetitive behaviors as defined in the current classification systems and required for diagnosis of OCD. This means that a large proportion of sufferers may remain undiagnosed and thus not receive adequate treatment.


Hoarding – Proposed DSM-5 Addition

The DSM-5 Obsessive-Compulsive Spectrum Sub-Work Group of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group is proposing the creation of a new diagnosis of DSM-5 named “hoarding disorder.” This proposed diagnosis would apply to hoarding that occurs in the absence of, or independently from, other organic or mental disorder.

To meet the currently proposed diagnostic criteria, the person needs to experience persistent difficulties with discarding or parting with possessions, accumulate large amounts of clutter that impede the normal use of their living areas, and experience marked distress and interference in activities of daily living. Furthermore, in the customary hierarchical diagnostic approach of DSM, the clinical needs to rule out any possible organic (for example, brain injury) or other psychiatric disorders (for example, OCD, dementia, psychosis, autism) that could better explain the hoarding behavior. The addition of hoarding in DSM-5 will hopefully increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatment for this problem.

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