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Psychiatric Issues in Hoarding

ClutterIt is common for people to maintain a collection of some sort, usually interesting or valuable, such as stamps, rare books, or coins[1]; however, compulsive hoarding is a disorder much different from normal collecting.[2] Hoarding is characterized by the following: the acquisition of a large number of possessions with no intent to discard, excessive clutter that impedes upon activities for which a living space was designed, and significant distress or impairment caused by the hoarding.[3] With a wide-range of implications, from public health burdens to poor physical health to social service interventions, community public health departments often become overloaded with public complaints regarding the hoarder’s residence and the cost to interfere is high, especially when repetitive clean-outs are needed and repeated visits by local health inspectors are warranted.[4] Efforts to fix the problem on a community level are often diminished by the unavailability and ineffectiveness of mental health services for persons who hoard.[5]

Not only are communities burdened by hoarding behavior, but family dynamics are often strained and the individual is usually living in dangerous and unhealthy situations.[6] Families may feel distress, frustration, and anger towards the hoarder, leading to complete rejection of the family member.3 Meanwhile, the hoarder suffers occupational impairment, eviction or threat of such, having a child or elder removed from the home, and most of all, safety and health problems.[7] When and if help is sought out, it usually occurs after the age of 40, although most hoarding behavior usually begins in the person’s early adolescence.[8] The prevalence of a hoarding disorder is between two and five percent of the general population, and in the United States, between six and 15 million people are affected by hoarding.[9] In fact, hoarding occurs at twice the rate of obsessive-compulsive disorder (OCD) and four times the rate of bipolar disorder and schizophrenia.[10] Usually, it appears to co-occur with major depressive disorder (MDD), social anxiety disorder, generalized anxiety disorder (GAD), attention-deficit/hyperactivity disorder (ADHD), and personality disorders.[11]

Currently, hoarding is included in the DSM-IV-TR as a diagnostic criteria for obsessive-compulsive personality disorder (OCPD)[12]; however, as research grows, evidence separates hoarding from OCD and may become its own disorder in the DSM-V: hoarding disorder (HD).[13] Frost and colleagues recently completed a study that examined 217 hoarders who met the diagnostic criteria for hoarding disorder (HD) that is currently being reviewed for the DSM-V.12 Results found that fewer than 20 percent of participants with HD met criteria for OCD. 12 In fact, MDD was the most frequent comorbid condition, followed by GAD and social phobia.12

Hoarding and its manifestations—acquisition, difficulty with discarding, clutter—are believed to evolve from vulnerabilities based on early life experiences, personality traits, and genetic predisposition.[14] Associated with hoarding are cognitive deficits regarding focusing attention, decision making, organizing, and perception.[15] Therefore, the combination of early life experiences and cognitive deficits lead to misguided beliefs regarding attachments to possessions, and when such possessions are taken away, negative emotions that lead to avoidance behaviors surface.15

There are several tools to help clinicians measure the symptoms and severity of hoarding behavior. There is the SI-R, which is a 23-item self-report questionnaire that assesses the individual’s difficulty with clutter, discarding, and excessive acquisition.[16] The HRS-I assesses the five main features of hoarding—clutter, acquisition, difficulty discarding, distress, and impairment[17]—and the CIR measure in-home clutter severity.[18] There is also the Saving Cognitions Inventory, a 24-item self-report questionnaire that assesses the beliefs of individuals as they attempt to discard items.[19] Once the condition is assessed, treatment normally is based upon a cognitive-behavioral therapy approach, incorporating goal setting, organizing, problem solving, and exposure practice for when clutter is removed from the home.[20]

As there is a high prevalence of hoarding among the general population, with debilitating and hazardous consequences, it is important for research to continue gaining insight into this condition.15 As more is learned about the disorder, more effective treatments can be established.15



[1] Pearce S. On Collecting: An Investigation Into Collecting in the European Tradition. London: Routledge; 1995.

[2] Steketee G, Frost RO. Compulsive Hoarding and Acquiring: A Therapist Guide. New York: Oxford University Press; 2007.

[3] Frost RO, Gross RC. The hoarding of possessions. Behav Res Ther. 1993;31:367-381.

[4] Frost RO, Steketee G, Williams L. Hoarding: a community health problem. Health Soc Care Community. 2000;8:229-234.

[5] Muroff J, Bratiotis C, Steketee G. Treatment for hoarding behaviors: a review of the evidence. Clin Soc Work J. 2010. doi:10.1007/s10615-010-0311-4. 2010.

[6] Tolin DF, Frost RO, Steketee G, Fitch KE. Family burden of compulsive hoarding: results of an internet survey. Behav Res Ther. 2008;46:334-344.

[7] Tolin DF, Frost RO, Steketee G. An open trial of cognitive-behavioral therapy for compulsive hoarding. Behav Res Ther. 2007;45:1461-1470.

[8] Grisham JR, Frost RO, Steketee G, et al. Age of onset of compulsive hoarding. J Anxiety Disord. 2006;20:675-686.

[9] Iervolino AC, Perroud N, Fullana MA, et al. Prevalence and heritability of compulsive hoarding: a twin study. Am J Psychiatry. 2009;166:1156-1161.

[10] Pertusa A, Frost RO, Fullana MA, et al. Refining the diagnostic boundaries of compulsive hoarding: a critical review. Clin Psychol Rev. 2010;30:371-386.

[11] Frost RO, Steketee G, Tolin D, Brown T. Co-morbidity and diagnostic issues in compulsive hoarding. Paper presented at: Annual Meeting of the Anxiety Disorders Association of America 2006; Miami.

[12] Mataix-Cols D, Frost RO, Pertusa A, et al. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010;27:556-572.

[13] Pertusa A, Frost RO, Fullana MA, et al. Refining the diagnostic boundaries of compulsive hoarding: a critical review. Clin Psychol Rev. 2010;30:371-386.

[14] Frost, RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther. 1996;34:341-350.

[15] Otte, S. and Steketee, G. (2011, August 19). Psychiatric Issues in Hoarding: Strategies for Diagnosing and Treating Symptoms of Hoarding. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/mdd/content/article/10168/1932177

[16] Frost RO, Steketee G, Grisham J. Measurement of compulsive hoarding: saving inventory-revised. Behav Res Ther. 2004;42:1163-1182.

[17] Tolin DF, Frost RO, Steketee G. A brief interview for assessing compulsive hoarding: the Hoarding Rating Scale-Interview. Psychiatry Res. 2010;178:147-152.

[18] Frost R, Steketee G, Tolin D, Renaud S. Development and validation of the clutter image rating. J Psychopathol Behav Assess. 2008;30:193-203.

[19] Steketee G, Frost RO, Kyrios M. Cognitive aspects of compulsive hoarding. Cognit Ther Res. 2003;27:463-479.

[20] Steketee G, Frost RO. Compulsive Hoarding and Acquiring: Workbook. New York: Oxford University Press; 2007.

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