Merck Manual

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Hoarding Disorder

By

Katharine A. Phillips

, MD, Weill Cornell Medical College;


Dan J. Stein

, MD, PhD, University of Cape Town

Last full review/revision Jun 2018| Content last modified Jun 2018
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Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty results in the accumulation of possessions that congest and clutter living areas to the point that the intended use of the areas is substantially compromised.

Hoarding disorder often begins at a mild level during adolescence and gradually worsens with age, causing clinically significant impairment by the mid-30s. At any given point in time, an estimated 2 to 6% of people have this disorder.

Symptoms and Signs

Hoarding disorder is typically chronic, with little or no waxing and waning of symptoms or spontaneous remission.

Patients have a strong need to save items, and they experience significant distress when parting with the items or contemplating parting with them. Patients accumulate a large number of items for which they have inadequate space; the items congest and clutter the living space so much that large areas become unusable, except for storing hoarded items. For example, stacks of hoarded newspapers may fill the sink and cover the countertops and stove in the kitchen, preventing these areas from being used to prepare meals.

Hoarding symptoms often impair social, occupational, or other areas of functioning. For example, patients may not allow other people, including family members, friends, and repairmen, into the house because they are embarrassed by the clutter.

Hoarding can result in unsafe living conditions (eg, by creating a fire hazard or increasing the risk of falls) and may lead to eviction or legal problems.

Animal hoarding is a form of hoarding disorder in which patients accumulate a large number of animals and do not provide adequate nutrition, sanitation, and veterinary care despite deterioration of the animals (eg, weight loss, illness) and/or environment (eg, extreme overcrowding, highly unsanitary conditions).

Degree of insight varies. Some patients recognize that the hoarding-related beliefs and behaviors are problematic; others do not.

Diagnosis

  • Clinical criteria

Hoarding is distinguished from transient accumulation and clutter (eg, as when property is inherited) by its persistence and other features; in addition, patients resist giving away or selling hoarded items. Collectors (eg, of books or figurines), like hoarders, can acquire and keep a large number of items, but in contrast to hoarding, collections are organized and systematic and do not significantly impair functioning or the safety of the home environment.

Diagnostic criteria for hoarding disorder include the following;

  • Patients have persistent difficulty discarding or parting with possessions, regardless of their actual value.

  • The difficulty discarding is due to the perceived need to save the items and to the distress associated with discarding them.

  • The accumulated possessions congest and clutter active living areas (ie, not basements or storage areas) and substantially compromise the intended use of these areas.

  • The hoarding causes significant distress or impairs social, occupational, or other areas of functioning.

Treatment

  • SSRIs

  • Cognitive-behavioral therapy

SSRIs may be helpful, although data on their efficacy are limited.

Cognitive-behavioral therapy that is tailored to treat the specific hoarding symptoms may also be helpful. For example, it focuses on helping patients discard items, refrain from acquiring new possessions (if excessive acquisition is a problem), and improve their decision-making abilities.

Motivational techniques are often needed to encourage patients to participate and stay in treatment.

Key Points

  • Hoarding is usually a chronic disorder in which hoarders accumulate possessions that congest and clutter active living areas, making these areas impossible to use as intended and sometimes unsafe.

  • Discarding possessions causes patients with hoarding disorder significant distress.

  • Treat using cognitive-behavioral therapy that is tailored to treat specific hoarding symptoms and/or an SSRI.

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