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July 3, 2019

There seems to be a certain fascination about hoarding in the U.S., at least judging by the TV shows featuring this behavior. But for healthcare professionals, hoarding disorder isn’t a laughing matter. It’s often a puzzle they must sort out in order to help their patients or clients. First off, it should not be called hoarding; it is officially called Hoarding disorder and was included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), replacing the conceptualization of extreme hoarding in DSM-IV as a form of obsessive-compulsive disorder. However, as a more specified mental disorder, there is less research available on hoarding disorder and its treatment compared with many disorders. People with hoarding disorder excessively save items that others may view as worthless. They have persistent difficulty getting rid of or parting with possessions, leading to clutter that disrupts their ability to use their living or work spaces. Hoarding is not the same as collecting. Collectors look for specific items, such as model cars or stamps, and may organize or display them. People with hoarding disorder often save random items and store them haphazardly. In most cases, they save items that they feel they may need in the future, are valuable or have sentimental value. Some may also feel safer surrounded by the things they save. Other facts are hard to come by, but the latest review of literature finds that hoarding disorder occurs in an estimated 2 to 6 percent of the population. Some research shows hoarding disorder is more common in males than females and it is also more common among older adults (ages 55 to 94), although other experts dispute this claim. Typically, the main reason that those with hoarding disorder receive a clinical consultation is because of comorbid mental disorders. The most common comorbid mental disorders are: generalized anxiety disorder (31 to 37 percent); major depressive disorder (26 to 31 percent); obsessive-compulsive disorder (15 to 20 percent); panic disorder (17 percent); social anxiety disorder (14 percent); and posttraumatic stress disorder (14 percent). In addition, symptoms typical of attention-deficit/hyperactivity disorder, particularly inattention, are also commonly reported. Treatment of hoarding disorder is very, very complex. A literature review through May 2019 provided this summary and recommendations:
  • Risks due to hoarding (fire or tripping/falling over accumulated possessions), should be addressed at the beginning of treatment. In high risk situations, forcible action may be needed such as removing children or elderly individuals from the home to ensure their safety.
  • Patients with hoarding disorder should be assessed for co-occurring mental disorders, especially affective and anxiety disorders, which are common in individuals with hoarding disorder. These disorders, if present, should be treated.
  • First line treatment is cognitive-behavioral therapy (CBT) developed specifically to treat the disorder rather than medication or other psychosocial interventions. The availability of this intervention is limited to a handful of specialist academic centers.
  • If there’s a nonresponse to a full course of CBT, the person should be further evaluated for an unidentified co-occurring disorder, a need for more intensive exposure to discarding, or the presence of excessive acquisition that has not been adequately addressed. Participating in a mutual help group may be useful.
  • Patients who remain resistant to psychosocial interventions, or who lack access to them, can be provided a trial of a serotonin-reuptake inhibiting medication, particularly in patients with comorbid mood or anxiety disorders. However, there are a lack of controlled clinical trials testing the efficacy of this approach in individuals with primary hoarding disorder.
For a complete read of this literature review, see Hoarding disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis.