Hoarding disorder is characterized by an inability to better the condition of a living space even when the disorganization in the home threatens someone’s safety. When severe, a hoarder is someone who may not be able to find a free place to sleep or sit in their own home, and who is in danger of tripping or having items topple onto them.
Treatments for hoarding typically involve therapy and lifestyle changes, and may also include medication. It can be a long road, but for those who are motivated to improve their relationships and quality of life, recovery is possible.
What Is Hoarding Disorder?
“Hoarding” is used colloquially as collecting or accumulating large amounts of something (such as money or food).1 When used in this everyday manner, the word “hoarding” does not indicate a psychological problem. The psychological definition of hoarding involves a consistent difficulty with getting rid of possessions because of a perceived need to save them.2 The two definitions for “hoarding” are differentiated by severity and by one’s thoughts and feelings related to their belongings.
Is Hoarding an Anxiety Disorder?
Hoarding is a type of OCD and a subtype of anxiety. Due to hoarding overlapping with both anxiety around letting things go as well as a compulsion to acquire, it is understood as a type of disorder relating mostly to anxiety due to the negative feelings around letting things go.
Hoarding vs. Clutter
An important criterion to differentiate between hoarding versus having clutter or collecting is to determine whether the behavior is interfering significantly with functioning. The individual has a hoarding problem if the collection of items is negatively impacting their social life, education or work, interpersonal relationships, and/or their physical safety.
A person who is a collector, on the other hand, will not feel a significant impact on these spheres of functioning. Furthermore, a collector takes pride in his/her procured possessions and they are organized in a manner that showcases that pride.
Types of Hoarding Disorder
There are a few specific categories that some people with hoarding disorder often gravitate toward, including animals, paper, and food.
Animal hoarding is a specific subtype of hoarding that is prevalent in people with hoarding disorder. Statistics from 2016 cite that approximately 40% of hoarders were also hoarding animals.3 Signs of animal hoarding are the same as the signs of object hoarding. An animal hoarder’s living space will look the same as a general hoarder with the addition of having an abnormal number of pets, usually cats.
The following indicators in the home will stand out:4
- A strong smell of urine; dried feces, urine, and vomit
- Chewed and scratched surfaces on furniture, walls, doors, and floors
- The animals will be malnourished, sickly, and not well socialized
- The hoarder will insist that their pets are happy and healthy even though the pets’ distress and illness are apparent
Another common problem for people with hoarding disorder is the hoarding of papers. This occurs mostly in the form of magazines, catalogs, newspapers, and books, but could be any paper products. If you ask a hoarder about the stacks of articles, they will tell you that they have not read them yet or are planning to read them. A hoarder may tell you that they are saving the items for a project they have interest in and will need the newspapers or magazines for research.
The dates of the periodicals will indicate that they have been waiting to be read for many, many years, and likely decades. The stacks of magazines and newspapers are so high that they present a danger of toppling over. Present in the home and attracted by the paper are bugs and vermin, such as cockroaches, mice, rats, fleas, and bedbugs. These insects and animals present a health hazard to the hoarder. You will also notice structural damage to the walls and floors due to bug and vermin activity.
Food hoarding is often associated with eating disorders. When an eating disorder is ruled out as the cause, it can be observed that food hoarding has all the elements of general hoarding. Food hoarders collect multiples of food items, perhaps due to store sales. The food is disorganized and there is no to little space remaining to use counters, stoves, and other surfaces. The individual is emotionally tied to the food, perhaps based on childhood deprivation due to neglect, poverty, or having lived through a war or economic depression.
Symptoms of Hoarding Disorder
The symptoms of hoarding disorder are clear: The hoarder’s collection of objects is abnormally excessive and does not make sense. Not only are there a lot of possessions in the home, but there will be multiples of an object that are not needed in multiples, like can openers. Any potential or intended organization will probably not be clear to an observer.
Symptoms of hoarding disorder include:
- Acquiring too many belongings
- Incapacity to organize the items in a neat and logical manner
- Assigning emotional importance to their possessions
- Experiencing intense emotional pain and difficulty related to letting go of their belongings
- These behaviors seriously interfere with the quality of the person’s life, including and not limited to, relationships, physical safety, and secure housing
- Despite the threat to the quality of their life, the individual feels unable to change the destructive behaviors
Why Do People Hoard?
Hoarding disorder, like many other psychological conditions, is caused by a combination of genetic predisposition and learned behavior and thinking patterns. The negative and irrational thinking patterns can be the result of habits picked up from a family member. These thinking patterns can also be the result of a difficult emotional situation or trauma.
Causes and risk factors for hoarding disorder include:
- Genetic predisposition
- Having been raised by, or with, a person who is a hoarder
- Irrational thoughts related to objects
- Fear, i.e. of loss of memories and personal connection, or deprivation, of which the object represents
- Poor decision-making ability
- Poor coping skills
- Age, i.e. the older a person is the more severe the hoarding behavior will be
- Poor social supports
- Living alone
- Attention difficulties
- Stressful life event
Complications of Compulsive Hoarding
Hoarding disorder presents many challenges for the individual. The most disconcerting of these is the increased probability of endangerment.
Hoarding behavior puts the individual hoarder and others around them at risk of:
- Physical injury, due to:
- Falling objects
- Tripping over/slipping on possessions
- Fires caused by multiple paper items and disorganization of items
- Illness and disease
- Removal of minor children due to neglect
- Loss of shelter due to:
- Inability to pay bills
- Evictions due to neighbors’ complaints of terrible odors, vermin, and bugs
Are You at Risk for Hoarding Disorder?
There can be many risk factors of hoarding, including:9
- History of family trauma
- Hoarding disorder in the family
- History of mental health issues in the family
- Personal history of anxiety or OCD
- Personality type
- Post-traumatic Stress Disorder (PTSD)
Can Hoarding Disorder Be Prevented?
While there is no proven way to prevent hoarding, there are lifestyle changes you can make to limit your ability to hoard. Clean up as soon as you can when there is a mess or clutter, especially in commonly-used areas of your home. Making a decision to donate something you haven’t used in a set number of years is a good way to keep yourself accountable. Ask your friends and family for help if you are struggling with letting things go and talk to them about it. Seek out a therapist if you are really struggling to let things go before things get out of control.
Diagnosing Hoarding Disorder
Hoarding disorder needs to be diagnosed by a mental health professional. The professional uses the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose an individual. Six criteria need to be met for a hoarding diagnosis.
A mental health professional, during a first diagnostic session, asks questions about the individual’s life today, current symptoms, feelings of distress, goals, and obstacles standing in the way. Questions related to the hoarder’s past experiences, including upbringing, social activity, developmental history, education, career, and medical history are also asked. The professional does a visual assessment of the individual’s appearance and grooming, apparent physical health, and mood.
If the correct questions are asked by the mental health professional, and the hoarder is open about the problem, then the diagnosis can be given. However, often the hoarding is not discovered by the mental health professional in the initial sessions, if ever, because the hoarder does not want to discuss the issue. The individual may only discuss symptoms related to the hoarding, such as depression, guilt, fear, loneliness, or anxiety.
If the mental health professional knows that the individual has a hoarding disorder, or has a suspicion, the individual may be asked to complete one or more assessment scale to confirm a diagnosis of hoarding disorder. The clinical assessment tools used are the Saving Inventory-Revised (SIR), the Hoarding Rating Scale (HRS), and the Clutter Image Rating (CIR).5
It is extremely helpful when possible for a family member or friend to join in the initial assessment session so that an accurate diagnosis can be identified as early as possible. The friend or family member can objectively report the status of the hoarder’s living space, and to the extent to which the clutter is interfering with the person’s life. Photographs of every part of the hoarder’s living space is also most helpful for an accurate diagnosis.
Treatment of Hoarding Disorder
Treatment for hoarding disorder is a long path to recovery. Therapy, such as CBT or motivational interviewing, is often the first line of treatment, as it can help the person discover the need to change from within, and develop the tools necessary to change. Hoarders who are highly motivated to better the quality of their relationships, home environment, and physical safety will be the most successful in treatment.
The most successful treatment for hoarding disorder is a methodical and multifaceted approach. It begins with the hoarder finding motivation to change from within, not from family members. Therapy is the perfect venue to help a hoarder identify and grow their motivation. Once ready, therapy then targets the thoughts and thought patterns that are associated with the objects and behaviors of accumulation and disorganization.
Common types of therapies for treating hoarders include:6
- Cognitive behavioral therapy (CBT): Focuses on identifying and changing the faulty and irrational thinking related to the accumulation, organization, and disposing of objects.
- Motivational Interviewing (MI): Helps individuals align their behaviors with their goals, thereby increasing motivation to make the needed changes.
- Skills training: Teaches hoarders how to make decisions, problem-solve, and organize.
- Group therapy: This can help you learn that you are not alone and give you a place to work through issues in a nonjudgmental way. Community offers a sense of reassurance.
- Family therapy: Families are often impacted by a loved one’s hoarding and this can give you and everyone in the family a space to work through how to navigate the hoarding issues and resolve issues that arise from the hoarding.
Intended Treatment Outcome & Timeline
A successful course of therapy would include the individual steadily sorting through each of his or her possessions. This tactic is more viable than someone else completing this task for the hoarder. The hoarder may accept assistance from another person who works alongside them. However, the hoarder must have full control and say over what will be kept or discarded, and how items will be organized.
The length of time it will take for the living space to be safe, organized, and clean, is dependent on many factors. These factors include how many possessions are in the home; how much time each day is put into organizing; how well the hoarder is able to apply new and rational thoughts; level of motivation towards change; strength of support systems; and whether life situations occur during the treatment that present opportunities for regressions.
There is limited research on medications for hoarding disorder and no consensus on the most effective option.7 In general, psychiatrists will begin a trial of serotonin reuptake inhibitors (SSRIs) that are used to treat obsessive-compulsive disorder (OCD) which is considered a related disorder to hoarding disorder. SSRIs are typically used for at least 12 weeks with a goal of the maximum dose for benefit. This class includes brand names such as Luvox, Zoloft, Prozac, Lexapro, and Paxil.
If these do not work the psychiatrist may add a second medication from the class of atypical antipsychotics, such as Risperdal, Zyprexa, or Seroquel. They may also try medications that help improve decision making and organization skills, such as Aricept since information-processing problems are common in hoarding disorder. Still yet, other medications, stimulants that treat attention deficit hyperactivity disorder, may be prescribed to help improve information processing and attentiveness for the tasks of organizing.
The hoarder must make major and permanent lifestyle changes to successfully manage the disorder. He or she must plan a structured day, every day. Keeping busy and being productive in an intentional, thoughtful, and goal directed way is key in helping manage anxiety and depression. This tactic also keeps thoughts and objects organized.
The individual will benefit from practicing mindfulness daily. Mindfulness exercises will help the hoarder slowdown in his or her thoughts. This enables them time to identify disorganized and irrational thoughts as they occur and then change them in real-time. Slowing down thoughts will also help the individual be aware of triggers to anxiety and depression, and triggers leading to behaviors of collecting and organizing items.
Every day, the individual needs to employ the learned coping skills to help with decision making and organization of their home. Medication may need to continue well after the individual’s home is organized, to address continued symptoms of depression, anxiety, and inattentiveness.
Like most psychological disorders, proper nutrition and exercise are highly recommended as a course of treatment and lifestyle change. Healthy eating and physical activity help manage anxiety, depression, inattention, and other associated disorders and symptoms. The individual will need to continually maintain improved self-care of his or her body, and self-esteem.
How to Get Help
Although hoarding disorder affects an estimated 1.2 million people in the United States, finding a hoarding-specific therapist is not always straightforward.8 Since the disorder is thought to be related to OCD and the majority of those diagnosed also have other disorders such as generalized anxiety disorder and major depressive disorder, it is helpful to search for a mental health professional who has a specialty in working with these problems.9 You can find a qualified therapist by using an online therapist directory that allows you to search by specialty and insurance coverage, or you can find more information from the International OCD Foundation.
Due to hoarders’ symptoms becoming worse as they age, identifying a therapist and psychiatrist who specialize in geriatric mental health is recommended for senior adult hoarders. Visit the American Geriatric Society to find providers.
How to Get Help for a Loved One
Most hoarders are unwilling to go for help. They do not want to change their behavior and they do not want to let go of their possessions. The idea of change instills great fear into these individuals. It is best to remember this as you approach your loved one.
Patience, a non-judgmental demeanor, and plainly showing the hoarder that they have a say and control over what happens to their own belongings and in their treatment is the best way to begin to get help for them. Approach the individual as a helper and not as someone who is telling the hoarder what they must do.
Discuss with the individual issues that they are more likely to be motivated to change as an introduction to the idea of therapy. These may include, for example, the topic of managing sleep problems, a medical issue, feelings of sadness and anxiety, and endangerment of losing housing. Next, ask the individual if it would be okay if you went to the session with them. Lend them support where you can.
Often, family and friends are extremely frustrated and make demands on the individual. Well-meaning family and friends sometimes take charge of the problem by bringing in a cleaning crew to clear out the hoarder’s home. This is typically ineffective.
The individual suffers immense stress during and after the cleaning out process where he or she has all control taken away. The problem, once “solved,” will begin again as the hoarder’s thoughts and behaviors have not changed during the forced cleanout. The only change that occurs is that the individual has experienced intense emotional injury and is likely in a worse place emotionally.
Compared to some of the other psychological disorders, hoarding disorder is less extensively understood. Specifics regarding its causes, treatments, and statistics are approximations. This is because hoarders do not usually seek help.
Here are several statistics about hoarding disorder:10
- 2%-6% of the population suffer from hoarding disorder
- Hoarding disorder affects the population at similar rates, ie. affects gender, race, ethnicity, and cultures around the world the same, and without prejudice
- It is 3 times more common in older adults (over age 55)
- 75% of hoarders have a co-occurring mental health condition, such as major depressive disorder, social anxiety disorder, and generalized anxiety disorder
- 20% of individuals with hoarding disorder also have
- 250,000 animals per year are victims of animal hoarders11
- Genetic factors account for 50% of hoarding tendencies12
For Further Reading
- The International OCD Foundation has a premier website dedicated exclusively to hoarding disorder. The site hosts Information and facts about Hoarding Disorder, charitable work on this issue, as well as links to find mental health professionals.
- Anxiety and Depression Association of America is another leading organization whose website provides facts about Hoarding Disorder and links to mental health professionals, support groups, and other resources.