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6 Diagnostic Features of Hoarding Disorder

6 Diagnostic Features of Hoarding Disorder


  • Individuals with hoarding disorder (HD) typically experience significant impairment in several aspects of daily functioning, including psychosocial, occupational, and family domains. Clinically, HD must be distinguished from other neuropsychiatric disorders. It should be noted that while HD can occur independently of other disorders, up to 75% of individuals with HD have at least one other co-occurring psychiatric condition. These may manifest with prominent hoarding behaviors described here in the differential diagnosis for hoarding symptoms. View the slides in PDF format.


  • Maladaptive beliefs that possessions being accumulated are necessary; often, emotional attachment to objects or need to keep objects to “aid memory”; positive emotions for collecting/acquiring reinforce the behavior; distress is associated with having to discard items, not urge to control thoughts; insight is variable, from good to very poor; symptom onset is in adolescence; impairment typically begins in later adulthood.


  • Hoarding behaviors often associated with OCD themes such as contamination or fear of harm; distress arises from need to perform hoarding compulsions or associated hoarding obsessions rather than from difficulty discarding; symptoms are typically ego-dystonic; insight typically good (although can vary); symptom onset and impairment typically coincide.


  • Item accumulation is the result of delusions or other negative symptoms; items collected likely serve a specific purpose in these delusions, even if it is not the intended use of the object; insight typically poor.


  • Clutter is the result of low energy and lack of motivation to clean and/or organize rather than a result of difficulty discarding; excessive acquiring not likely present.


  • In the case of neurodevelopmental disorders (including autism spectrum disorders and intellectual disability), patients have difficulty discarding items. This is typically due to extreme attachment to specific objects or types of objects rather than generalized difficulty with discarding.


  • Cognitive inability to properly organize objects/discard; may also see collectionism of specific objects (eg, cigarette butts, bottles, etc); onset is later in life, although can precede neurocognitive dysfunction.


  • People with HD can experience social isolation, divorce, separation or alienation from family members and friends, risk of eviction and homelessness, removal of children or elders from the household by government officials, risk of death and injury due to clutter, structural instability and fire, health risks due to unsanitary living environments, and financial stressors due to excessive acquisition. HD is associated with high levels of medical disability and work impairment, as well as anxiety and depression. Patients often complain of difficulties with memory, decision-making, categorization, and symptoms consistent with the inattentive subtype of ADHD.

  • Cognitive-behavioral therapy (CBT) is considered the first-line treatment for HD and focuses on:

    • Confronting maladaptive belief patterns and behaviors related to hoarding

    • Managing emotional distress related to discarding

    • Exposures aimed at actively discarding objects and avoiding acquisition of

    new objects

    • In some cases, addressing problems related to information processing


  • Pharmacotherapy for HD has been even less well studied than the therapies. The majority of the available data are based on studies that investigated the treatment response of hoarding symptoms in OCD. Interpretation of these studies has also been limited by the lack of randomized, double-blind, controlled trials.


  • For more information, see Hoarding Throughout the Life Span, by Carol A. Mathews, MD and Ryan McCarthy, on which this slideshow is based.

View the slides in PDF format.

Comments

Diagnostic Features of Hoarding Disorder
September 22, 2017, By Ryan McCarty and Carol A. Mathews, MD. Comment by Doug Berger, MD, PhD, Tokyo, Japan.

Hoarding Disorder is likely a possible symptom of many different psychiatric or neurological disorders. Just like cough can be a symptom of many different disorders.

[At least] 75% of HD patients are said to have co-occurring psychiatric disorders (i.e., ADHD, MDD, OCD) that all have a wide span of symptoms while HD is basically a one-symptom disorder. Ergo, HD is a symptom of another disorder made into a disorder itself for the purposes of making a label until another more comprehensive label can be found, and thus being able to bill insurance companies for fees. The HD label is also somewhat pejorative such that there is some ethical issue in labeling person with a diagnostic name they don’t need, they can still be called, “Major Depression with Hoarding Symptoms.”

Doug Berger, MD PHD,
US Board-Certified Psychiatrist
Tokyo Japan

Douglas @

My schizophrenic mother always collected female gender baby dolls n kept them hid n would sneak them out n nurture them n talk to them late at night or when no one around. Many years later we discovered she gave up a baby girl for adoption the day it was born. She never even held it once. She was so ashamed when we found out but by telling her I'm so happy to have a sister n no reason to have any shame her psychiatriac disorder improved!

Linda @

I am confused about the slides. Are obsessive-compulsive disorder, schizophrenia/psychosis, mood disorders, neurodevelopmental disorders, and neurocognitive disorders presented as differential diagnoses, or as subtypes of hoarding disorder? Where does ADHD fit in? Are the treatment recommendations only for the slide labeled "Hoarding disorder," or do the same treatment recommendations apply to any case of excessive clutter regardless of which type of disorder is thought to underlie it?

Jim @

Hoarding Disorder is likely a possible symptom of many different psychiatric or neurological disorders. Just like cough can be a symptom of many different disorders.

[At least] 75% of HD patients are said to have co-occurring psychiatric disorders (i.e., ADHD, MDD, OCD) that all have a wide span of symptoms while HD is basically a one-symptom disorder. Ergo, HD is a symptom of another disorder made into a disorder itself for the purposes of making a label until another more comprehensive label can be found, and thus being able to bill insurance companies for fees. The HD label is also somewhat pejorative such that there is some ethical issue in labeling person with a diagnostic name they don’t need, they can still be called, “Major Depression with Hoarding Symptoms.”

Doug Berger, MD PHD,
US Board-Certified Psychiatrist
Tokyo Japan

Douglas @

Nicely done

Michael @

What are some of the current potential or suggested pharm treatments?

Suzannah @

what is currant tx ?!

ludmilla @

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