Background
Hoarding is defined as the persistent difficulty discarding or parting with possessions regardless of their actual value. The difficulty is due to a perceived need to save the items and to distress associated with discarding them. Hoarding disorder or pathological hoarding occurs when possessions are accumulated to such an extent that they congest active living areas so much so that their use is substantially compromised. Hoarding disorder is often best assessed by a home visit, where household living areas often appear like the image below.
This photo shows the cluttered living space of a compulsive hoarder. Courtesy of Wikimedia Commons.
The problem of excessive accumulation of material goods has been recognized since antiquity and epitomized by Diogenes who was known for saving and recycling (among other things). Although many healthy individuals collect material goods (e.g., stamps, porcelain dolls) and others have difficulty parting with objects due to their sentimental or material value, it has also been recognized that a small proportion of individuals in our society accumulate to such an extent that it impacts on their ability to use the living areas of their homes, causes distress, places them in danger and/or restricts their quality of life.
Diagnostic criteria (DSM5)
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) criteria for hoarding disorder is as follows: [1]
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Persistent difficulty discarding or parting with possessions, regardless of their actual value
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This difficulty is due to a perceived need to save the items and to distress associated with discarding them
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Difficulty discarding leads to an accumulation of possessions that congest and clutter living areas and substantially compromises their intended use
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The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
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The hoarding is not attributable to another medical condition
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The hoarding is not better explained by the symptoms of another mental disorder
Pathophysiology
The neuroanatomical correlates of hoarding disorder need further investigation, but neuroimaging studies have implicated the fronto-limbic circuits of the brain. [2]
Functional neuroimaging of patients with hoarding disorder has revealed hypometabolism in the cingulate cortex [3] and greater activation of the left precentral gyrus, right orbitofrontal cortex and bilateral ventromedial prefrontal cortex. [4, 5]
Etiology
The cause of hoarding is unknown. Although many patients will report a family history of hoarding, genetic studies have pointed towards several different genes. There are also various psychological theories based on the excessive sentimental attachment that patients with hoarding have towards their possessions, [6] difficulty initiating and completing tasks, [7] indecisiveness, and impaired memory confidence. In late-onset hoarding, some patients report traumatic life events as precipitants, such as grief and loss. [8]
Epidemiology
The overall prevalence of hoarding disorder is approximately 2.6%, with higher rates for people older than 60 years and people with other psychiatric diagnoses, especially anxiety and depression. [9, 10] Community surveys estimate the point prevalence of clinically significant hoarding in the United States and Europe to be approximately 2%–6%. [1]
The disorder affects both males and females, but some studies have reported a significantly greater prevalence among males. [1]
Prognosis
The course of hoarding tends to be chronic and progressive with symptoms starting in the teens and severity increasing with age. [8]
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This photo shows the cluttered living space of a compulsive hoarder. Courtesy of Wikimedia Commons.
