Hoarding often coexists with other
psychiatric illnesses like mood disorders, schizophrenia, tic
and attention disorders. There has been a historical
discussion as to if hoarding is separate from obsessive
compulsive disorder or obsessive compulsive personality
disorder.
Keywords: Hoarding, obsessive compulsive disorder,
Diagnostic and Statistical Manual of Mental Disorders
A 60 year old man was referred to the older adult mental
health services for collection of paper and other electrical
appliances in a disorganized manner. He recognized the
collection was more than normal but found it difficult to part
with them even though it was not used. He did not have any
physical health conditions and lived on dairy food, walked
around mostly for his needs. He was treated for depression,
with antidepressants, following the death of his mother and
maintained minimal contact with his sister. Work was done
around decluttering his home and he eventually moved to
supported living.
Introduction
Hoarding is a disorder which is characterized by a
persistent difficulty associated with discarding items, the
desire to save items to avoid negative feelings associated
with discarding them, significant accumulation of possessions
that clutter active living areas and significant distress or
impairment in areas of functioning [1]. Older adults are
at a particularly high risk for hoarding disorder,
prevalence rates approach 6% in individuals over age 60 and
exceed 6% in individuals over age 70 in the Netherlands
study [2]. It can present as a normal behaviour to
pathological behaviour at which point help is sought. Hoarding
was first described with a behavioural concept in 1996. This
model also helped provide insight into a cognitive aspect of
this behaviour [3].
Epidemiology
An epidemiological study in South East London gave a weighted
prevalence of 1.5%. The study also showed that those who had
hoarding disorder were older and more often unmarried. The
group appeared to have a physical health condition or a
comorbid mental disorder. There were reports of contact with
the mental health services in the past. Hoarding disorder
appeared to be seen in both genders [4]. Hoarding Disorders
(HD) appeared to be worse in those with a pre-existing
Obsessive Compulsive Disorder (OCD) [5].
Individuals tend to hoard everyday common items. In some case
odd items like food and others also tend to get stored. There
is strong relation with neurological developmental disorders
like Attention Deficit Hyperactivity Disorder and Autistic
Spectrum Disorder.
Diagnosis and Assessment
The Diagnostic and Statistical Manual of Mental Disorders, 5
th
edition has specified criteria for Hoarding Disorder with the
Disorder class Obsessive Compulsive and Related Disorders. The
rationale being that both the disorders are in the same
spectrum with a common etiopathogenesis.
The cognitive features can be described as preoccupation,
obsessions, overvalued ideas, cognitive deficits and excessive
attachments. Poor insight is also talked about. Cognitive
deficits like attention problems could contribute to decision
making and clutter seen in few with HD. Excessive attachment
due to possible emotional significance, usefulness of the
object or qualities of the object leads to hoarding [6].
The Diagnostic and Statistical Manual of Mental Disorders – 5
th
Edition (DSM-5, American Psychiatric Association, 2013)
defines Hoarding Disorder (HD) as follows:
1. Persistent difficulty discarding or parting
with possessions, regardless of their actual value.
2. This difficulty is due to a perceived need to save the
items and to distress associated with discarding them.
3. The difficulty discarding possessions results in the
accumulation of possessions that congest and clutter active
living areas and substantially compromises their intended
use. If living areas are uncluttered, it is only because of
the interventions of third parties (e.g., family members,
cleaners, authorities).
4. The hoarding causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning (including maintaining a safe environment for
self and others).
5. The hoarding is not attributable to another medical
condition (e.g., brain injury, cerebrovascular disease,
Prader-Willi syndrome).
6. The hoarding is not better explained by the symptoms of
another mental disorder (e.g., obsessions in
obsessive-compulsive disorder, decreased energy in major
depressive disorder, delusions in schizophrenia or another
psychotic disorder, cognitive deficits in major
neurocognitive disorder, restricted interests in autism
spectrum disorder).
The DSM-V also calls for the clinician to specify whether the
individual is also experiencing “excessive acquisition” and to
specify the person’s level of insight (good, fair, poor, or
absent/delusional).
There is a persistent difficulty parting with possessions due
to a perceived need or because of the distress associated with
discarding them. These results in the accumulation of
possessions that congest and clutter active living areas.
Third parties are involved in declutter. Hoarding leads to
clinically significant distress or impairment in social,
occupational, or other important areas of functioning like
maintaining a safe environment safe for oneself or others.
Other medical condition like brain injury, cerebrovascular
disease, Prader-Willi syndrome need to be ruled out.
The hoarding is not better explained by the symptoms of
another mental disorder (e.g., obsessions in
obsessive-compulsive disorder, decreased energy in major
depressive disorder, delusions in schizophrenia or another
psychotic disorder, cognitive defects in major neurocognitive
disorder, restricted interests in autism spectrum disorder)
[7].
Obsessive-Compulsive Inventory and Yale-Brown
Obsessive-Compulsive Scales are some of the general measures
for obsessive compulsive disorder. The Activities of Daily
Living in Hoarding (ADL-H) is used determine how much
clutter interfered with daily activities for people with
hoarding. The Activities of Daily Living in Hoarding (ADL-H)
contains 15 items. The Hoarding Rating Scale-Self-Report
is a 5-item self-report measure that rates the dimensions of
hoarding (clutter, difficulty discarding, excessive
acquisition, distress, and impairment) from 0 (“none”) to 8
(“extreme”). It is designed to provide a global index of
hoarding severity. The Clutter Imaging Tool helps to visualize
how the home looks like.
Treatment
Multi-component psychological therapy is advised
with some evidence for pharmacologic treatment although this
is not robust.
* Education about hoarding
* Goal setting
* Motivation-enhancing techniques
* Organisation and decision-making skills training
* Practice in sorting and discarding objects
* Practice in resisting acquisition
* Cognitive techniques designed to alter dysfunctional
beliefs about the importance of possessions [8].
References
1. Vilaverde D, Gonçalves J, Morgado P. Hoarding Disorder: A
Case Report. Front Psychiatry 2017; Jun 28;8:112.
2. Cath DC, Nizar K, Boomsma D, Mathews CA. Age-Specific
Prevalence of Hoarding and Obsessive Compulsive Disorder: A
Population-Based Study. Am J Geriatr Psychiatry 2017;
Mar;25(3):245-255.
3. Frost RO, Hartl TL. A cognitive-behavioral model of
compulsive hoarding. Behav Res Ther 1996 34(4):341–50.
4. Nordsletten, A., Reichenberg, A., Hatch, S., De la Cruz,
L., Pertusa, A., Hotopf, M., & Mataix-Cols, D.
Epidemiology of hoarding disorder. British Journal of
Psychiatry 2017; 203(6), 445-452.
5. Cath DC, Nizar K, Boomsma D, Mathews CA. Age-Specific
Prevalence of Hoarding and Obsessive Compulsive Disorder: A
Population-Based Study. Am J Geriatr Psychiatry.
2017;25(3):245-255.
6. Fontenelle LF Grant JE. Hoarding disorder: a new diagnostic
category in ICD-11? Brazilian Journal of Psychiatry; Rev.
Bras. Psiquiatr. vol.36 supl.1 Sao Paulo 2014.
7. Substance Abuse and Mental Health Services Administration.
Impact of the DSM-IV to DSM-5 Changes on the National Survey
on Drug Use and Health [Internet]. Rockville (MD): Substance
Abuse and Mental Health Services Administration (US); 2016
Jun. Table 3.29, DSM-5 Hoarding Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519704/table
8.
http://www.psychiatrycpd.co.uk/learningmodules/hoardingdisordersymptoms,d/introduction/learningnotes.aspx