Hoarding disorder is a new classification in the DSM-5 and is part of the ‘obsessive-compulsive and related disorders’. Hoarding disorder is a complex behavioral disorder characterized by persistent difficulty disposing of or parting with possessions regardless of their actual value. People with hoarding disorder excessively keep items that others consider worthless. They have persistent difficulty getting rid of or parting with their belongings, leading to clutter in their home or apartment that interferes with their ability to use their living or work space. Collecting is not the same as collecting. Collectors look for specific items, such as model cars, coins or stamps, and can organize or display them. People with a collecting disorder often collect anything and everything. They often keep things that they think they will need in the future.
- What is hoarding disorder?
- Prevent
- DSM-5 classification criteria and symptoms
- Criteria
- Specifications
- Risk factors and causes of hoarding disorder
- Differential diagnosis
- Examination and diagnosis
- Treatment of hoarding disorder
- Combination
- Therapy and coaching
- Cognitive behavioral therapy
- Complications
- Prognosis
- Prevention
Apartment of a compulsive collector / Source: Joke, Wikimedia Commons (CC BY-SA-3.0)
What is hoarding disorder?
Pathologically collecting things and having difficulty getting rid of belongings is known as hoarding disorder. Unlike ‘normal hoarding’, hoarding disorder or pathological hoarding leads to increasing disorder in the apartment or home of the person suffering from it. Those involved can sometimes accumulate so much stuff in their home that the actual use of the living space is no longer possible. For example, the person can no longer cook, enter his bedroom, or sit in a chair.
Collecting also leads to increasing limitations in social and/or occupational functioning. The task of getting rid of some or all of the items makes the person concerned feel very uncomfortable. Even the thought of having to part with some of these items triggers aversive emotional responses in pathological collectors, such as bad mood, anxiety or irritability.
Most items that are collected would be considered worthless by other people, but those who suffer from collecting disorder do not see them as clutter and experience an overwhelming need to keep these items because they may need these items in the future, due to the sentimental attachment to the things, or the aesthetic nature of them.
Prevent
Hoarding disorder affects an estimated 2 to 6% of the population, with an even ratio between men and women. The condition is 3 times more common in the elderly (> 55 years) than in younger adults. In most cases the disorder is progressive.
Manual for the Classification of Mental Disorders (DSM-5) / Source: DSM-5
DSM-5 classification criteria and symptoms
What are the symptoms of hoarding disorder and what are the classification criteria according to DSM-5?
Criteria
The classification criteria according to DSM-5 are:
- A A persistent effort to get rid of or part with possessions, regardless of their actual value.
- B This effort arises from a strongly felt need to keep certain objects, and from the suffering associated with disposing of these objects.
- C The effort to get rid of belongings leads to the accumulation of a large number of belongings that get in the way and create so much clutter that the living spaces can hardly be used for their proper function. If areas have been tidied, this is only thanks to the intervention of third parties (such as a family member, cleaner or agency).
- D Collecting causes clinically significant distress or impairment in social or occupational functioning or in functioning in other important areas (including maintaining a safe environment for oneself and others).
- E The collection cannot be attributed to a general medical condition (such as brain damage, cerebrovascular disease or Prader-Willi syndrome).
- F The collecting is not better explained by the symptoms of another mental disorder (such as obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or other psychotic disorder, cognitive deficit in neurocognitive disorder, or limited interests in autism spectrum disorder).
Specifications
Please specify if:
- With excessive acquisition . When the effort to get rid of possessions involves overacquiring items that the person does not need or has no room for. In roughly 80-90% of people with a hoarding disorder, the disorder is accompanied by excessive acquisition of things.
Please specify if:
- With a good or reasonable sense of reality. The data subject acknowledges that his or her views and actions regarding collection pose a problem.
- With little sense of reality. The person concerned largely assumes that his or her views and actions regarding collection do not pose a problem, despite evidence to the contrary.
- With missing sense of reality/delusional beliefs. The data subject fully believes that his or her views and actions regarding collection are not problematic, despite evidence that they are.
The living room of a compulsive collector / Source: Maschinenjunge, Wikimedia Commons (CC BY-SA-3.0)
Risk factors and causes of hoarding disorder
Risk factors of hoarding disorder include:
- Temperament: Indecisiveness is a prominent characteristic of people with this disorder.
- Environment: Looking back, people with hoarding disorder often report that a psychotraumatic life event occurred at the beginning of the disorder or when it worsened.
- Genetics and Physiology: Gathering behavior is familial.
One of the causes may be the fear of loss. Someone who buys something or receives a gift from someone associates a pleasant memory with the object. For the collector who has never or rarely received affection or approval in his life, that memory through possession may be the only thing he can cling to. A memory he doesn’t want to lose anymore. This is how the mess gradually piles up. He collects everything that brings back a pleasant memory. Under no circumstances does he want to throw any of these memories in the trash for fear that the only pleasant thing in his life will leave him.
The disorder can also be the result of trauma, that is, a mental wound or an event that has thrown him off balance. In this context, people also speak of complicated grief or an adjustment disorder.
Differential diagnosis
The classification of hoarding disorder is not assigned when it is judged that the symptoms are a direct result of:
- Somatic disorders, such as brain injury, surgical treatment of a tumor or epilepsy, cerebrovascular disorders, central nervous system infection, or neurogenetic disorders such as Prader-Willi syndrome.
- Neurobiological developmental disorders such as an autism spectrum disorder (ASD) or an intellectual disability (intellectual development disorder).
- Schizophrenia spectrum and other psychotic disorders, where the collecting is a direct result of delusions or negative symptoms of schizophrenia or another psychotic disorder.
- Depressive episode, in which collecting objects is a direct result of psychomotor slowing, fatigue or loss of energy due to the depression.
- Obsessive-compulsive disorder (OCD), in which collecting objects is a direct result of the obsession and compulsive characteristic of this disorder, such as fear of contamination or doom, or a sense of incompleteness (such as loss of identity or the need to complete all document and preserve life experiences).
- Neurocognitive disorders, where collecting is the direct result of, for example, frontotemporal dementia or Alzheimer’s disease.
Examination and diagnosis
The psychiatrist or psychologist examines what is wrong with you. An assessment for hoarding disorder may include questions such as:
- Do you have trouble throwing away (or recycling, selling, or giving away) items that most other people would throw away?
- How difficult is it to use the rooms and surfaces in your home because of the clutter or number of belongings?
- To what extent do you buy things or collect free things that you don’t need or don’t have enough space for?
- To what extent does hoarding, collecting, acquiring and clutter affect your daily functioning?
- To what extent do these symptoms disrupt your school, work, social or family life?
- How much distress do these symptoms cause you?
Permission may also be requested to consult referees, such as friends and family, to make a diagnosis. Questionnaires (rating scales) can also be used to assess the level of functioning.
Some people with hoarding disorder recognize that they have a problem accumulating possessions; others may not see a problem or seriously downplay it.
In addition to the core characteristics of difficulty throwing away and excessive clutter accumulation, many people with hoarding disorder also have associated problems such as indecisiveness, perfectionism, procrastination, disorganization, and distractibility. These associated characteristics can contribute greatly to their functioning and the overall severity of their problems.
Many people with hoarding disorder also experience other mental health disorders, including depression, anxiety disorders, attention deficit/hyperactivity disorder (ADHD), or alcohol use disorder.
Treatment of hoarding disorder
Combination
In the Netherlands, the treatment of hoarding disorder often consists of:
- psychoeducation
- reducing the amount of stuff you take with you
- cognitive therapy
- learning to arrange and organize
- getting rid of things and relapse prevention
Therapy and coaching
Many experts consider treatment by a cognitive behavioral therapist in combination with coaching from a home counselor or coach to be most suitable for treating and supporting people with hoarding disorder. A coach does not intervene personally, but only advises. An organizational plan is drawn up together with the practitioner, which the client applies at home under the guidance of the home counselor or coach. This also involves training on accelerating decision-making skills. Drawing up organizational or work plans and providing support in adhering to them often helps the client to better structure their daily tasks. Because collectors still suffer from shame and guilt, admonitions are usually not helpful. Instead, small progress should be recognized and rewarded.
Cognitive behavioral therapy
Compulsive collecting is often treated with cognitive behavioral therapy, a combination of behavioral therapy and talk therapy. The first thing you learn is to resist the compulsive impulses. Any negative emotions that arise should not be pushed away. The individual learns to identify the thoughts or beliefs associated with keeping clutter and transform them into rational thoughts.
Complications
Hoarding disorder can cause several complications, including:
- Increased risk of falls.
- Risk of accident and injury or being trapped by sliding or falling objects.
- Conflicts and quarrels in the family.
- Limitations in occupational or social functioning.
- Conflict with the neighbors or the neighborhood.
- Loneliness and social isolation.
- Unsanitary conditions that pose a risk to health.
- Fire hazard.
- Legal issues, such as eviction.
Prognosis
Many people who receive treatment for hoarding disorder learn to manage their belongings. Learning new behaviors makes them feel less anxious. Treatment may reduce their need or urge to keep objects. Reducing these symptoms leads to a better quality of life.
Prevention
Because in 2023 relatively little is known about the cause of hoarding disorder, there is no known way to prevent someone from developing this disorder. As with many mental health conditions, early intervention and treatment can prevent the disorder from worsening.
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