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
• 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.