Section Learning Objectives

• Describe how hoarding disorder presents itself.
• Describe the epidemiology of hoarding disorder.
• Indicate which disorders are commonly comorbid with hoarding disorder.
• Indicate what factors are believed to contribute to the etiology of hoarding disorder.
• Describe the treatment for hoarding disorder.

5.3.1 Clinical Description

In hoarding disorder, the key feature is the persistent over-accumulation of possessions (APA, 2022). While we all obtain items throughout life, individuals with hoarding disorder continue to accumulate items without discarding possessions, regardless of their value or sentiment. This lack of discarding occurs over a long period and is not explained by recent significant stressors (e.g., the individual lost their house in a fire and now keeps everything). For example, last week’s newspaper would likely have no relevance to you or possibly any historical value, but those with hoarding disorder would keep this newspaper despite the lack of value or sentiment.

The most commonly hoarded items are newspapers, magazines, clothes, bags, books, mail, and paperwork (APA, 2022). While these items may be stored in attics and garages, individuals with a hoarding disorder must also have these items cluttering their active living space, to the extent that they impair their ability to use those spaces. Cognitive factors contributing to the need to hold onto these non-sentimental items are fear of losing valuable information and fear of being wasteful. When asked to “clean out” their house or get rid of these items, individuals with hoarding disorder experience significant distress. Individuals with hoarding disorder display indecisiveness, avoidance, procrastination, perfectionism, difficulty planning and organizing tasks, and they are easily distracted.

To be diagnosed, the hoarding behaviors must cause distress or significantly impair their social and occupational functioning. Hoarding disorder can lead to low quality of life and in extreme cases, place the individual at risk for falling, poor sanitation, and other health risks. Family relationships are often strained and conflict with neighbors and local authorities is common (APA, 2022).

5.3.2 Epidemiology

While national studies on the prevalence rate of hoarding within the U.S. and internationally are not available,  hoarding disorder is estimated to have a prevalence of 2.5% (APA, 2022). Clinical samples are more highly represented by females than males and older individuals (over the age of 65 years) are three times more likely to be diagnosed with hoarding disorder than younger adults (APA, 2022).

5.3.3 Comorbidity

Of those diagnosed with hoarding disorder, about 75% have a comorbid mood or anxiety disorder with major depressive disorder, social anxiety disorder, and generalized anxiety disorder being the most common comorbid conditions. Additionally, nearly 20% of clients with hoarding disorder also meet the criteria for OCD (APA, 2022).

5.3.4 Etiology

Approximately 50% of the variability in hoarding behavior is attributed to genetic factors with more than 50% of people who hoard reporting that they have a relative who hoards (APA, 2022).

Nevertheless, environmental factors appear to play a more significant role in the development of hoarding disorder than OCD (Ahmed, et al., 2014; Lervolino et al., 2009). People with hoarding disorder often report stressful or traumatic events leading up to (or exacerbating) their hoarding (APA, 2022). Finally, people with hoarding disorder are commonly indecisive and have first-degree relatives who are indecisive (APA, 2022).

5.3.5 Treatment

Recent research has concluded that, unlike OCD, many individuals with hoarding disorder do not experience intrusive thoughts, nor do they experience urges to perform rituals. Because of this difference, treatment for hoarding disorder has moved away from exposure and response prevention, toward a traditional cognitive-behavioral approach.

Frost and Hartl (1996) believed that individuals with hoarding disorder engage in complex decision-making processes, overanalyzing the value and worth of possessions, thus leading to hoarding the object as opposed to discarding it. Therefore, in addition to having the individual engage in exposure treatment, added components of cognitive restructuring and motivational interviewing are added to address the complex-decision making that is involved in maintaining unnecessary possessions. By discussing motives for keeping items, as well as fears that may be associated with discarding them, clinicians can assist clients in their cognitive processes to ultimately determine the item’s actual worth (Williams & Viscusi, 2016). Unfortunately, due to the distressing nature of having to discard their possessions, many individuals in treatment for hoarding disorder prematurely end treatment, thus never reaching symptom remission (Mancebo, Eisen, Sibrava, Dyck, & Rasmussen, 2011).