Hoarding Disorder

Hoarding disorder is persistent difficulty discarding possessions regardless of value, because of perceived need to save and distress at discarding, resulting in cluttered living areas.

• Prevalence 2 to 6%, more common in older adults and the severity increases with age; onset in adolescence.
• Excessive acquisition (buying, free items) in many.
• Associated: executive dysfunction, family history, trauma, ADHD, depression, OCD (distinct), anxiety, dementia.
• Risks: fire, falls, infestation, eviction, social isolation, self neglect.

• Accumulation causing blocked rooms, unusable cooking and sleeping space, poor insight, indecisiveness, perfectionism, emotional attachment to objects.
• Squalor in some; animal hoarding variant.
• Family conflict; reluctance to accept help.

• DSM-5 criteria; Hoarding Rating Scale, Clutter Image Rating; home visit with safety assessment.
• Exclude dementia, psychosis, OCD obsessions, depression, brain injury, Prader-Willi syndrome, frontotemporal disease.
• Medical assessment (cognition testing, MRI if new onset in later life), medication review.
• Assess fire risk, hygiene, capacity, safeguarding.

• CBT specific for hoarding (motivational interviewing, skills training in organisation and decision making, exposure to discarding, 20 to 26 sessions, with home visits) is first line; response about 50%.
• Medication: SSRIs (paroxetine 20 to 60 mg, venlafaxine XR 75 to 300 mg) give modest benefit; stimulants or atomoxetine for comorbid ADHD.
• Harm reduction: clearing exits, fire safety, pest control, falls prevention.
• Multi agency approach (housing, social care, environmental health); avoid forced clearance without therapy (high relapse).
• Support groups and family education.