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Mental Health

Hoarding disorder (HD)

Persistent inability to discard possessions, often accompanied by excessive acquiring, resulting in severe clutter that precludes normal use of living spaces.

Introduction

Persistent inability to discard possessions, often accompanied by excessive acquiring, resulting in severe clutter that precludes normal use of living spaces.

Classification

Obsessive–Compulsive and Related Disorders (OCRD):

Includes OCD‐like compulsive behaviors, including eating disorders, pathological gambling, and tic/Tourette disorders
  • Trichotillomania
  • Excoriation disorder
  • Body dysmorphic disorder (BDD)
  • Obsessive–compulsive disorder (OCD)
  • Hoarding disorder (HD)
Obsessive–compulsive disorder (OCD) became independent of the Anxiety Disorder group and became a core disorder of the Obsessive–Compulsive and Related Disorders (OCRD) group, which includes some of the disorders of obsessive–compulsive spectrum disorder (OCSD) and the newly presented hoarding disorder (HD). BDD, body dysmorphic disorder. | Nakao, T. and Kanba, S. (2019), Pathophysiology and treatment of hoarding disorder. Psychiatry Clin. Neurosci., 73: 370-375. https://doi.org/10.1111/pcn.12853

Aetiology

Associated psychiatric disorders:

  • Major depression (M/C, up to 50% cases)
  • Attention deficit/hyperactive disorder (ADHD)
  • Poorer general health
Patients with hoarding disorder have biological background and environmental factors, such as loss experiences, that strengthen emotional‐attachment behavior and could have a mutual relationship with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and obsessive–compulsive disorder (OCD) regarding its onset process | Nakao, T. and Kanba, S. (2019), Pathophysiology and treatment of hoarding disorder. Psychiatry Clin. Neurosci., 73: 370-375. https://doi.org/10.1111/pcn.12853

Clinical faetures

Hoarding behaviors usually start at a subclinical level in early adolescence and worsens with each decade. Often the disorder becomes clinically significant only in middle-aged patients, with the distress associated to HD being caused by the intervention of others, such as relatives or local authorities. Stressful or traumatic events may be associated with the onset of hoarding symptoms

Case of a 52-year-old married man, who works as a mechanic. He has no previous history of medical conditions. As a psychiatric background, he reported depressive symptoms following the death of his only son 22 years ago. | Photo taken and provided by patient. Consent for publication obtained. | Vilaverde, D., Gonçalves, J., & Morgado, P. (2017). Hoarding Disorder: A Case Report. Frontiers in psychiatry, 8, 112. https://doi.org/10.3389/fpsyt.2017.00112

Diagnosis

Diagnostic criteria for Hoarding disorder (HD):

Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V)
  1. Persistent difficulty discarding/parting with possessions, regardless of actual value
  2. Difficulty is due to a perceived need to save the items and to distress associated with discarding them
  3. Difficulty discarding possessions results in 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, and authorities)
  4. Hoarding causes clinically significant distress/impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others)
  5. Hoarding not attributable to other medical conditions (e.g., brain injury, cerebrovascular disease, and Prader–Willi syndrome)
  6. Hoarding not better explained by symptoms of other mental disorders (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, and restricted interests in autism spectrum disorder)
If possessions are well organized and have a specific value, the owner is defined as a ‘collector.’ Medical conditions that cause secondary hoarding, such as brain injury, brain vascular diseases, and Prader–Willi syndrome, are excluded from hoarding disorder (HD). When seeing symptoms of obsessive–compulsive disorder (OCD), autism spectrum disorder (ASD), or attention deficit hyperactivity disorder (ADHD), we should perform a differential diagnosis of these disorders. | Nakao, T. and Kanba, S. (2019), Pathophysiology and treatment of hoarding disorder. Psychiatry Clin. Neurosci., 73: 370-375. https://doi.org/10.1111/pcn.12853

Management

Cognitive behavioral treatment (CBT)

Mainstay of treatment that involves assessment and psychoeducation on symptoms, motivation enhancement, cognitive restructuring, exposure to non-acquiring, and discarding and prevention of relapse
  • Psychoeducation
  • Motivational interviewing
  • Classic cognitive techniques focused on dysfunctional beliefs, and exposures targeting sorting and discarding

Pharmacological interventions:

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)

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