Prior to the publication of the DSMâ5, hoarding behaviors were informally considered to be a syndrome or subtype of obsessiveâcompulsive disorder (OCD). However, as evidence mounted about the differences between hoarding and OCD (Pertusa et al., 2010), it became increasingly clear that hoarding represented a unique syndrome that had not been adequately categorized. Epidemiological research has suggested that the prevalence rate of HD is between 2 and 5% (Frost, Steketee, & Williams, 2000; Iervolino et al., 2009; Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009; Samuels et al., 2008), making HD a very common condition.
Understanding the Symptoms of Hoarding Disorder
Difficulty discarding.
The hallmark symptom of HD is reluctance to discard personal possessions, including objects that nonâhoarding individuals might consider to be worthless or having little intrinsic value. Although the reasons for saving objects tend to be similar to those described by nonâhoarding individuals (Frost & Gross, 1993), for individuals with HD these beliefs are more intense and rigid, and applied to a greater number of possessions. Attempts to discard usually cause substantial emotional distress, and therefore are frequently avoided.
Excessive clutter.
Excessive clutter is the most visible feature of compulsive hoarding. Unlike normatively âmessyâ or disorganized individuals, those with HD commonly describe significant difficulty using the living spaces of their homes due to clutter. For example, individuals with HD often have clutter that may cover beds, chairs, or tables, rendering them unusable. In severe cases, the clutter prohibits movement through the house or access to certain parts of the home.
Excessive acquiring.
Although acquiring is not a DSMâ5 diagnostic criterion for HD, research suggests that most individuals with HD do engage in excessive acquiring (Frost, Tolin, Steketee, Fitch, & SelboâBruns, 2009). Excessive acquisition can include compulsive buying, collection of free items, inheritance of items, and rarely, stealing. Many report spending many hours each week searching for and acquiring objects (e.g., excessive shopping, rummaging through trash bins). Individuals with HD therefore may also present with distress related to overspending or debt as a result of compulsive shopping behaviors.
Understanding HoardingâRelated Impairment
Health risks.
Clutter can lead to substantial personal impairment or injury, and has the potential for fatal consequences. Clutterâs interference with basic home functions such as cooking, cleaning, moving through the house, and even sleeping can make hoarding dangerous, increasing the likelihood of fire, falling, poor sanitation, and pest infestation (Steketee, Frost, & Kim, 2001).
Clutter poses a major fire risk both to those who live in the home and to neighbors. A study analyzing residential fires over a 10âyear period indicated that hoarding accounted for 24% of all preventable fire fatalities (Harris, 2010). Blocked egress, such as doors and windows, may prevent individuals from escaping home fires, and can prevent emergency personnel from entering the home when needed.
Elderly individuals in particular may be injured by falling objects or even trapped by collapse of clutter or other structural elements of the home. Health risks to children who live in the home may include the presence of mold, contributing to respiratory difficulties such as asthma. Children or elderly may become ill from keeping and ingesting expired food. Plumbing or heating may be inoperable; or other repairs may be needed but avoided due to concern about others entering the home.
Due to the potential for harm, clutter may lead to protective removal of children or elderly from the home (Tolin, Frost, Steketee, Gray, & Fitch, 2008). Involvement of government agencies, such as child or elderly protective services, fire marshals, police, or public health departments, is not uncommon. Clutter may also lead to threats of eviction by housing authorities.
Psychological impact.
Individuals with HD are likely to be particularly susceptible to isolation. Embarrassed by their clutter or avoidant of criticism, many individuals with HD avoid inviting friends, family, or repair workers to their homes, contributing to social isolation (Rasmussen, Steketee, Tolin, Frost, & Brown, 2014).
HD may also increase rates of intrafamilial conflict and rejection of the hoarding individual. Family members may be upset by excessive time spent on acquiring or in response to financial debt related to compulsive buying. Family members may become frustrated with the patientâs reluctance or inability to change. In one large survey (Tolin, Frost, Steketee, & Fitch, 2008) of family members of hoarding individuals, scores on a measure of rejection of hoarding individuals were higher than family rejection scores for clients with schizophrenia, especially if the hoarding individual was perceived as having little insight into their problem.
Many individuals with HD describe impaired work and role functioning. Individuals who selfâidentified as having HD reported missing more work due to psychiatric reasons than individuals with depression, anxiety disorders, or substance use (Tolin, Frost, Steketee, Gray, et al., 2008).
Hoarding may also have a negative psychological impact on children who are raised in the hoarding environment. In the Tolin, Frost, Steketee, and Fitch (2008) survey, children who identified as having grown up in the home of a parent with HD described lower satisfaction with their childhood than individuals who did not grow up in the cluttered home. Specifically, children raised in the hoarding home reported embarrassment of the home and avoidance of having peers in the home, along with increased conflict within the home.
Financial cost to society.
In addition to the health risks, HD also presents a high financial cost to society. Individuals with HD tend to be high utilizers of services, including medical, mental health, and social welfare services. In one study (Frost, Steketee, & Williams, 2000) approximately 64% of surveyed public health officials reported receiving at least one complaint of hoarding during a fiveâyear period. The majority (88%) of the cases concerned unsanitary conditions. The City of San Francisco conservatively estimated that HD costs service providers and landlords in that city $6.4 million per year (San Francisco Task Force on Compulsive Hoarding, 2009). The Melbourne Fire Department study found that the average cost of firefighting hoardingârelated fires was eight times greater than that of hoardingâunrelated fires (Harris, 2010).
Understanding Comorbidity in Hoarding
Management of hoarding cases tends to be complicated by a high presence of coâoccurring mental health and medical concerns. As many as 92% of individuals with HD meet criteria for coâoccurring psychiatric conditions (Frost, Steketee, & Tolin, 2011). As noted previously, the link between hoarding and OCD is not as strong as previously thought, although a significant minority (approximately 18%) of HD clients will also meet diagnostic criteria for OCD (Frost, Steketee, et al., 2011). Depression and anxiety are highly common among those with HD, with Major Depressive Disorder (53%), Social Anxiety Disorder (24%), and Generalized Anxiety Disorder (24%) among the most common coâoccurring diagnoses in treatmentâseeking HD clients (Frost, Steketee, et al., 2011).
Hoarding is also associated with relatively high rates of personality disorders and maladaptive personality traits. Although excessive saving of potentially lowâvalue items is a criteria for the diagnosis of ObsessiveâCompulsive Personality Disorder (OCPD), most HD clients do not meet criteria for OCPD when the hoarding criterion is removed (Frost, Steketee, et al., 2011). However, Dependent, Avoidant, Paranoid, and Schizotypal Personality Disorders appear fairly common in hoarding samples (Frost, Steketee, Williams, & Warren, 2000; Samuels et al., 2008).
Research increasingly suggests a link between hoarding and AttentionâDeficit/Hyperactivity Disorder (ADHD), or a similar symptom profile. Hoarding clients often report significant problems with attention and executive function that resemble those seen in people with ADHD. Individuals with hoarding symptoms commonly obtain high scores on selfâreport ADHD measures, and in one study, 20% of HD clients, compared to 4% of OCD clients and 3% of community controls, met full DSMâIVâTR diagnostic criteria for ADHD (Frost, Steketee, et al., 2011). These data comport with those of a study of OCD clients, in which those with hoarding symptoms had a risk of ADHD almost 10 times higher than those without hoarding (Sheppard et al., 2010). Studies of neuropsychological performance in hoarding clients have yielded mixed results, although individuals with HD appear to have more specific deficits in the areas of problem solving, organization, and sustained attention (Woody, KellmanâMcFarlane, & Welsted, 2014).
It is important to be aware that hoarding behaviors such as saving, excessive acquiring, or disorganization may be present in a variety of disorders beyond HD. Hoarding behavior has been noted in clients with OCD (Matsunaga, Hayashida, Kiriike, Nagata, & Stein, 2010) and schizophrenia (Luchins, Goldman, Lieb, & Hanrahan, 1992), as well as after certain neurological insults such as damage to prefrontal and orbitofrontal cortex (Eslinger & Damasio, 1985; Volle, Beato, Levy, & Dubois, 2002) and dementia (Hwang, Tsai, Yang, Liu, & Lirng, 1998). Therefore, in cases of severe clutter and saving behavior, it is important to consider whether alternative diagnoses may better explain the hoarding problem. At this point, this manual has not been tested with individuals without a formal diagnosis of HD.
