Hoarding Disorder

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]

• Persistent difficulty discarding or parting with possessions, regardless of their actual value
• This difficulty is due to a perceived need to save the items and to distress associated with discarding them
• Difficulty discarding leads to an accumulation of possessions that congest and clutter living areas and substantially compromises their intended use
• The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• The hoarding is not attributable to another medical condition
• The hoarding is not better explained by the symptoms of another mental disorder

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]

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]

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]

The course of hoarding tends to be chronic and progressive with symptoms starting in the teens and severity increasing with age.[8]

Patients with hoarding typically lack awareness (insight) in relation to their hoarding and are usually urged to seek help by concerned or frustrated relatives. As hoarding can co-occur with major depression and anxiety disorders, screening for hoarding can help detect a problem.[11]

Patients may have cellulitis or skin infections due to living in squalid conditions. They may also have fractures due to falls due to accumulated objects acting as trip hazards.

Object hoarding

Hoarding is distinct from collecting, which is considered a normal behavior.[12] The average collector typically does not show patterns of excessive acquisition or lack of insight into their condition.

The most commonly saved items among object hoarders are newspapers, magazines, old clothing, bags, books, mail, and paperwork. However, the nature of items is not limited to possessions that most people consider useless or of limited value. Many hoarders collect and save valuable items as well.

Object hoarding is distinct from animal hoarding with the most prominent difference being the extent of unsanitary conditions and the poorer insight into animal hoarding.

Animal hoarding

Persons who hoard animals keep an unusually high number of pets in their homes without having the resources or ability to properly care for them. However, these persons have trouble comprehending that they are not adequately providing for the animals and are placing them in harm's way; they believe they are providing good care for the animals. Most individuals who hoard animals also hoard inanimate objects.

An animal hoarder is distinct from a breeder although some hoarders are former breeders who have stopped selling and therefore have accumulated a large number of animals that they cannot care for.

Animal hoarders in the United States can be legally persecuted under state animal cruelty laws. Illinois and Hawaii are the only 2 states at this time to have animal-specific hoarding laws. The Illinois Humane Care for Animals Act was passed in 2001. Violation of Section 3 (which requires the provision of food and water, adequate shelter and protection from the weather, veterinary care, and humane care and treatment) is a misdemeanor; a second or subsequent violation raises the offense to a Class 4 felony.[13] Hawaii outlaws animal hoarding and criminalizes it as a misdemeanor.

Object hoarding

Clutter impairs basic activities such as cooking, cleaning, attending to personal hygiene, sleeping, and moving throughout the living space. Quality of life is significantly impacted in a negative way. Hoarding can put individuals at risk for falling, fire, impaired function, economic burdern, and other adverse effects.

Animal hoarding

Animal hoarding is related to a number of individual and public health and safety concerns.[14, 15]

Animals suffer from overcrowding, malnourishment, and neglect. Humans suffer from poor sanitary conditions, fire hazards, zoonotic diseases, envenomation, and neglect (of themselves and of their dependents). Animal waste poses health risks to both animals and humans. Ammonia levels can be life-threatening.

It is often helpful to visit the home of patients with suspected hoarding or to ask them or their relatives to bring photos of the main living areas to show you.

There are several tools available for assessing patients suspected of having hoarding disorder.

The Activities of Daily Living in Hoarding (ADL-H) scale is a series of questions inquiring about how much clutter interferes with the patient's ability to complete standard daily activities such as bathing, dressing, and preparing meals. Other questions address quality of living conditions and safety and health issues.[17]

The Saving Inventory-Revised is a 23-item scale with 3 subscales: Acquiring, Clutter, and Difficulty Discarding.[18] The first subscale determines the extent of compulsive buying and acquiring of free things. The second subscale assesses the amount of clutter and problems associated with it. The final subscale is used to measure the level of discomfort associated with removing the clutter.

The Saving Cognitions Inventory is a self-report questionnaire consisting of 24 items across 4 subscales that assess the patient's beliefs and attitudes regarding attempts to discard items.

It is important to establish a therapeutic relationship with the patient who may lack awareness of their problem or not be motivated to change their way of life.

Treatment usually involves psychological therapy in the form of cognitive-behavioral therapy (CBT) with weekly sessions over 20 to 26 weeks.[19] Often these sessions incorporate home visits with a therapist[20] combined with between-session homework. A study of persons with hoarding disorder who received 26 individual sessions of CBT, including frequent home visits, over a 7-12 month period, found adherence to homework assignments was strongly related to symptom improvement.[21]

Research on online CBT sessions that give patients access to educational resources on hoarding, cognitive strategies, and a chat-group has shown promising results.[22]

Selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) are most commonly used to treat hoarding disorder. A recent meta-analysis shows that treatment response to pharmacotherapy is similar to the response in obsessive-compulsive disorder (OCD).[23]  Case reports have described success with venlafaxine and paroxetine.[24, 25] Randomized studies are needed.

Class Summary

Several SSRIs have been approved by the FDA for treatment of OCD, including sertraline, fluvoxamine, fluoxetine, and paroxetine.

Fluvoxamine (Luvox, Luvox CR)

Fluvoxamine enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs. It is FDA-approved for OCD in children (8-17 y) and adults.

Sertraline (Zoloft)

Sertraline selectively inhibits presynaptic serotonin reuptake at the neuronal membrane. It is FDA approved for the treatment of OCD, posttraumatic stress disorder, panic disorder, and social anxiety.

Fluoxetine (Prozac)

Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. It is FDA approved for depression, OCD, bulimia nervosa, and panic disorder.

Paroxetine (Paxil, Paxil CR)

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. It is FDA approved for depression, OCD, panic disorder, social and generalized anxiety disorders, and PTSD.

Class Summary

The dual serotonin-norepinephrine reuptake inhibitor antidepressant (SNRI) venlafaxine may also have efficacy in OCD; however, it has not yet been FDA approved specifically for the treatment of OCD.

Venlafaxine (Effexor, Effexor XR)

Venlafaxine is a serotonin/norepinephrine reuptake inhibitor. It may treat depression by inhibiting neuronal serotonin and norepinephrine reuptake. In addition, it causes beta-receptor down-regulation. It is used in the treatment of OCD; however, it is not FDA approved for this indication