Hoarding disorder

Hoarding disorder is a mental health condition marked by a lasting inability to let go of possessions, along with a pattern of acquiring unneeded items or things for which there is no room. This leads to living spaces that are heavily cluttered, causing significant distress and problems in daily life, including personal, family, social, educational, or occupational functioning. The urge to acquire is driven by repetitive impulses or behaviors, while the trouble discarding items comes from a perceived need to keep them and the anxiety that arises when trying to throw them away. The buildup of belongings makes living areas unsafe or unusable. The disorder is officially listed in both the ICD-11 and the DSM-5.

An estimated 2% to 5% of adults have hoarding disorder, though it usually starts in childhood. Symptoms tend to worsen with age, as the volume of collected items grows and family members who once helped manage the clutter move away or pass away.

People with hoarding disorder often also have other mental health conditions, such as depression, anxiety, obsessive-compulsive disorder (OCD), autism spectrum disorder (ASD), or attention deficit hyperactivity disorder (ADHD). Other linked factors include alcohol dependence and traits associated with paranoid, schizotypal, or avoidant personalities.

**Diagnosis**

**Distinguishing hoarding from healthy behavior**

Collecting and hoarding can look similar, but they have clear differences. Collecting is a hobby that involves deliberately searching for and acquiring specific items that, when grouped together, create greater meaning, understanding, or value for the collector. Hoarding, on the other hand, is usually disorganized and involves gathering common items that hold little significance for the person collecting them in large amounts. People who hoard keep everyday objects that have no real value or meaning to others, unlike collectors whose items may be valuable to certain people. Most hoarders are messy, with crowded, chaotic living spaces. Most collectors can afford to store their items neatly or have enough room to display them. However, age, mental health issues, or financial problems can sometimes push a collector into hoarding behavior.

**Clinical classification and diagnostic tools**

In the DSM-IV, compulsive hoarding was considered a symptom of obsessive-compulsive personality disorder (OCPD), and some clinical tools, like the Yale–Brown Obsessive–Compulsive Scale, treated it as a sign of OCD. But more recent research found that hoarding is no more specific to OCPD than to other personality disorders in the DSM-IV. In fact, among all eight OCPD criteria, hoarding was the weakest predictor of the disorder. Compulsive hoarding also appears distinct from OCD: although they often occur together and may share genetic risks, they differ in clinical features, brain function, and neurobiology. Because of this evidence, hoarding disorder was given its own diagnosis in the DSM-5, placed in the category of Obsessive-Compulsive and Related Disorders. Researchers noted that this placement might change as more studies on the causes of hoarding disorder are conducted.

The DSM-5 lists six required criteria (A–F) for diagnosing hoarding disorder. Criterion A is a persistent difficulty discarding belongings, even when they have little or no real value. Criterion B says this difficulty must come from a subjective need to keep items and from distress at the thought of getting rid of them. Criterion C states that over time, possessions must accumulate to the point where they block or severely limit the normal use of living spaces, unless others intervene to clear them. Criterion D requires that the behavior causes marked distress or problems in daily life. Criterion E says it cannot be better explained by another medical condition, and criterion F says it cannot be better explained by another mental disorder. The DSM-5 also allows clinicians to specify whether the person shows excessive acquisition behavior. Another specification describes the person’s level of insight into their disorder, which can range from good or fair insight to absent insight or delusional beliefs.

Assessing the severity of hoarding disorder can be tricky. Poor insight may lead someone to underreport how cluttered their home is. On the other hand, people on the obsessive-compulsive spectrum might see minimal mess as deeply distressing and self-identify as hoarders without actually meeting the diagnostic criteria. To get a more objective measure, Frost and colleagues developed the Clutter Image Rating, a visual tool where patients simply pick images that best match their own rooms. This tool has been adopted by organizations like the charity Hoarding UK.

**Treatment**

Cognitive behavioral therapy (CBT) is a common treatment for compulsive hoarding. In CBT, a therapist may help the patient understand why they feel compelled to hoard, learn to organize possessions to decide what to keep or discard, improve decision-making skills, declutter the home during in-person visits with a therapist or professional organizer, and practice relaxation techniques.