Hoarding

Clinical Description

Hoarding is the acquisition of and failure to discard a large number of possessions. It involves substantial distress or impairment in the ability to use living areas of the home for their intended purposes. Hoarding is surprisingly common and is potentially seriously disabling. Significant hoarding has recently been shown to occur in 2-5% of the general population.

Prior to DSM-5, hoarding was mentioned in DSM-IV-TR only in the context of Obsessive Compulsive Personality Disorder (OCPD), but the text suggested that serious hoarding behavior should be considered a form of OCD. Its high prevalence and serious consequences, together with research on its distinctiveness from OCD and OCPD, have led researchers to classify it as a distinct disorder in DSM-5 (“Hoarding Disorder”).

Diagnosis

The DSM-5 Diagnostic Criteria for Hoarding Disorder require that the person have persistent difficulty discarding possessions, regardless of their actual value, and that the difficulty is due to a perceived need to save the items. In addition, the person is required to have significant distress or psychosocial impairment due to the hoarding. On a practical level, the DSM-5 diagnosis further requires that the hoarding symptoms result in the accumulation of possessions that congest, clutter, and compromise living areas. As with most the DSM-5 disorders, Hoarding Disorder is only an appropriate diagnosis if the symptoms are not due to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi Syndrome) or another psychiatric disorder (e.g., lack of energy or motivation in depression, delusions in a psychotic disorder, or cognitive deficits in dementia).

The DSM-5 diagnosis allows for several specifiers to be added to the diagnosis of Hoarding Disorder. For example, one specifier is "with excessive acquisition” and applies if the person has difficulty discarding possessions and has excessive acquisition of items that are not needed or for which there is no available space.

Another specifier is whether the person has good, fair, or poor insight (i.e., the person recognizes that hoarding is problematic or the person is generally convinced that hoarding is fine despite evidence to the contrary). In the case of a person who is completely convinced that hoarding is not problematic despite evidence to the contrary, they would receive the specifier of “no insight.”

The desire to retain objects of value, either sentimental or financial, is a common feeling. With Hoarding Disorder, however, the difficulty discarding possessions seems driven by fears of losing important things. What is considered worthless or worn-out varies considerably from person to person. The nature of items saved by people who hoard indicates that they are not limited to worthless or worn-out things. The most frequently hoarded items include clothes, newspapers, and magazines. Many of these items, especially clothes, are frequently new and never worn. In some cases, the home may be full of new things that have never been removed from their original packaging or have price tags still attached.

The central feature of Hoarding Disorder is the intention to save possessions. The clutter that results is due to purposeful saving and reluctance to discard. Items are saved because they have sentimental significance, for their potential usefulness, or because they have more intrinsic aesthetic value. The nature of emotional attachment is reflected in the reaction to getting rid of a possession. The emotion experienced by people with hoarding when confronted with the prospect of losing one or more items is either anxiety or a feeling of impending grief. Associated with this is the tendency to assign human-like qualities to possessions. Another form of emotional attachment concerns a sense of comfort and security provided by possessions. The thought of getting rid of a possession appears to violate feelings of safety.

The major consequence of hoarding is disorganized clutter, which elicits great concern from family, friends, and even the broader community. The cluttered space is often unusable and unsanitary, and finding important items may be nearly impossible. In some cases, family members keep the living space from being cluttered, and in such cases, the individual can still receive a diagnosis of Hoarding Disorder if there is sufficient distress of other impairment generated by the behavior.

People who hoard experience distress largely due to the consequences of the behavior (for example, conflict with family members over the clutter) and not the thoughts or behaviors themselves. As such, people with hoarding often display limited insight into the consequences of their acts. Research suggests that functioning is impaired in a variety of domains. People are often unable to use living spaces in the home and in severe cases appliances are not functional and utilities such as water and electricity are shut off. Hoarding poses a serious public health burden (for example, fire hazards, infestations) as well as costs to the public in the form of involvement by social service agencies.

 
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