Development and Validation of the Clutter Image Rating
ABSTRACT Few instruments are available to assess compulsive hoarding and severity of clutter. Accuracy of assessment is important to
understanding the clinical significance of the problem. To overcome problems associated with over- and under-reporting of
hoarding symptoms, the clutter image rating (CIR) was developed. This pictorial scale contains nine equidistant photographs
of severity of clutter representing each of three main rooms of most people’s homes: living room, kitchen, and bedroom. The
psychometric properties of this measure were examined in two studies. Internal consistency, test–retest, and interobserver
reliabilities were good and convergent validity with other questionnaire and interview measures was also good. The CIR correlated
more strongly with measures of clutter than with other hoarding and psychopathology scales. The CIR’s very brief pictorial
assessment method makes it useful in clinical and treatment contexts for measuring the clutter dimension of compulsive hoarding.
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ABSTRACT: The cognitive-behavioral approach to hoarding implicates dysfunctional beliefs about possessions (i.e., “saving cognitions”). Acquiring and saving possessions can be conceptualized as avoidance behaviors that prevent feeling the distress provoked by such beliefs in certain situations (e.g., discarding). Experiential avoidance (EA) involves an unwillingness to endure upsetting emotions, thoughts, memories, and other private experiences, and deliberate efforts to control or escape from them. EA has been investigated in several clinical disorders, but to date little investigation of the role of EA in hoarding has been made. The present study examined EA in the prediction of hoarding symptoms. A large sample of unscreened undergraduates completed measures of EA, saving cognitions, and hoarding symptoms. EA predicted the acquisition and clutter components of hoarding even after controlling for saving cognitions and general distress. However, EA was not uniquely associated with the difficulty discarding component of hoarding. Implications for future research are discussed.Cognitive Therapy and Research 01/2011; · 1.70 Impact Factor
Article: Epidemiology of hoarding disorder.[Show abstract] [Hide abstract]
ABSTRACT: Hoarding disorder is typified by persistent difficulties discarding possessions, resulting in significant clutter that obstructs the individual's living environment and produces considerable functional impairment. The prevalence of hoarding disorder, as defined in DSM-5, is currently unknown. To provide a prevalence estimate specific to DSM-5 hoarding disorder and to delineate the demographic, behavioural and health features that characterise individuals with the disorder. We conducted a two-wave epidemiological study of 1698 adult individuals, originally recruited via the South East London Community Health (SELCoH) study. Participants screening positively for hoarding difficulties in wave 1, and who agreed to be re-contacted for wave 2 (n = 99), underwent in-home psychiatric interviews and completed a battery of self-report questionnaires. Current DSM-5 diagnoses were made via consensus diagnostic procedure. In total, 19 individuals met DSM-5 criteria for hoarding disorder at the time of interview, corresponding to a weighted prevalence of 1.5% (95% CI 0.7-2.2). Those with hoarding disorder were older and more often unmarried (67%). Members of this group were also more likely to be impaired by a current physical health condition (52.6%) or comorbid mental disorder (58%), and to claim benefits as a result of these issues (47.4%). Individuals with hoarding disorder were also more likely to report lifetime use of mental health services, although access in the past year was less frequent. With a lower-bound prevalence of approximately 1.5%, hoarding disorder presents as a condition that affects people of both genders and is associated with substantial adversity.The British journal of psychiatry: the journal of mental science 10/2013; · 6.62 Impact Factor
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ABSTRACT: Background Hoarding Disorder (HD), a new diagnostic entity in DSM-5, is associated with substantial functional impairment and family frustration but data from well-characterized samples is lacking. Method Participants were 37 individuals meeting DSM-5 criteria for HD, 55 relatives of individuals meeting criteria for HD, and comparison groups of 51 self-identified collectors and 25 relatives of collectors. All participants completed a clinician-administered diagnostic interview for HD and an online battery of standardized measures of health, well-being, and impairment. Results Substantial functional impairment was found for both HD individuals and their relatives. HD relatives reported significantly greater carer burden and accommodation of hoarding behaviors than relatives of collectors. Perceived level of squalor, co-habiting with, and increasing age of the HD individual were significant predictors of carer burden and functional impairment in the relatives. Limitations The use of self-identified HD individuals may have produced a bias towards participants with relatively good insight. Subjective biases in self-reported symptoms cannot be ruled out, although the use of informant-report data provided some independent validation. Conclusions HD is associated with substantial functional impairment for both sufferers and their relatives. The level of carer burden experienced by HD relatives was comparable to or greater than that reported in the literature by relatives of individuals with dementia. The findings indicate that relatives of individuals with HD may benefit from increased support and suggest that it may be beneficial to involve family members in the treatment of HD.Journal of Affective Disorders 04/2014; 159:7–14. · 3.76 Impact Factor
Development and Validation of the Clutter Image Rating
Randy O. Frost & Gail Steketee &
David F. Tolin & Stefanie Renaud
Published online: 12 September 2007
# Springer Science + Business Media, LLC 2007
Abstract Few instruments are available to assess compul-
sive hoarding and severity of clutter. Accuracy of assess-
ment is important to understanding the clinical significance
of the problem. To overcome problems associated with
over- and under-reporting of hoarding symptoms, the
clutter image rating (CIR) was developed. This pictorial
scale contains nine equidistant photographs of severity of
clutter representing each of three main rooms of most
people’s homes: living room, kitchen, and bedroom. The
psychometric properties of this measure were examined in
two studies. Internal consistency, test–retest, and inter-
observer reliabilities were good and convergent validity
with other questionnaire and interview measures was also
good. The CIR correlated more strongly with measures of
clutter than with other hoarding and psychopathology
scales. The CIR’s very brief pictorial assessment method
makes it useful in clinical and treatment contexts for
measuring the clutter dimension of compulsive hoarding.
Compulsive hoarding consists of the acquisition of, and
failure to discard, large numbers of material possessions
resulting in clutter severe enough to cause emotional
distress, impair functioning, and preclude the use of living
spaces for their intended purposes (Frost and Hartl 1996;
Frost et al. 2000a, b; Samuels et al. 2002, 2007). Hoarding
has been reported in a variety of Axis I and II disorders
including schizophrenia, social phobia, brain injury, de-
pression, eating disorders, organic mental disorder, and
dementia, as well as avoidant, dependent, and obsessive
compulsive personality disorder (Steketee and Frost 2003).
Hoarding behavior has been found in some forms of
developmental disabilities as well, such as Prader–Willi
syndrome (Dykens and Leckman 1996). Most often,
however, it has been considered a symptom of obsessive
compulsive disorder (OCD), occurring in 20–30% of OCD
cases (Steketee and Frost 2003). However, several lines of
evidence suggest that it is either a distinct subtype (e.g.,
McKay et al. 2004) or a separate disorder. A large
percentage of people with hoarding problems experience
no other OCD symptoms (Frost et al. 2006). Hoarding
symptoms do not correlate as highly with other OCD
symptoms as other symptoms do with each other (Wu and
Watson 2005). Furthermore, hoarding may be as prevalent
in patients with other anxiety disorders as it is in patients
with OCD (Meunier et al. 2006). Hoarding patients show
different patterns of cerebral glucose metabolism than do
non-hoarding OCD patients (Saxena et al. 2004). Finally,
treatments that work for other OCD symptoms (both
medications and cognitive behavior therapy) appear less
effective for hoarding (see Steketee and Frost 2003, for a
J Psychopathol Behav Assess (2008) 30:193–203
The Clutter Image Rating (CIR) is available in conjunction with the
following publication: Steketee, G., & Frost, R.O. (2007). Treatment
of compulsive hoarding. New York: Oxford University Press at www.
R. O. Frost (*):S. Renaud
Department of Psychology, Smith College,
Northampton, MA 01063, USA
Boston, MA, USA
D. F. Tolin
Institute of Living and University of Connecticut
School of Medicine,
Storrs, CT, USA
Hoarding can range from mild with little or no interfer-
ence to life threatening, jeopardizing not only the health and
safety of the sufferer, but those living nearby. Health
department officials who have dealt with such cases reported
that hoarding posed substantial health risks (Frost et al.
2000a, b). In 6% of the cases described by these officials,
the hoarding contributed directly to the individuals’ deaths
in house fires. Examples of hoarding cases can be found in
most communities and demonstrate the severity of this little
understood syndrome. For instance, Jack was a 59-year-old
former engineer who spent decades scavenging and buying
sale items he intended to sell for a profit. Once in his home,
however, he was unable to part with them. They overtook
the house leaving him with literally no room to sit or sleep.
His acquisitions also depleted his income, resulting in the
shutting off of all his utilities (electricity, water, and gas).
Eventually, the health department condemned his house as
unfit for habitation. In another case, Jane, a 35-year-old
single mother, was unable to discard anything that entered
her home, even food containers, used band aids, or hair.
The ensuing squalor led local child protective services staff
to remove her two children until she got help.
Research on hoarding has been hampered by a lack of
adequate measures. Many studies (e.g., Abramowitz et al.
2003) have relied on the Yale–Brown Obsessive-Compulsive
Scale (Y-BOCS; Goodman et al. 1989) to assess hoarding.
Unfortunately, the Y-BOCS symptom checklist contains only
two yes/no items corresponding to hoarding obsessions and
compulsions. These categorical judgments convey little
information about the behavior, and the description given
in the checklist does not mention cluttered living spaces as a
symptom. Furthermore, the meaning of the Y-BOCS
responses is distorted by aggregation with other OCD
symptoms before making severity ratings, and the severity
questions do not lend themselves well to accurate assessment
of hoarding. Newer self-report scales for OCD (e.g.,
Vancouver Obsessive-Compulsive Inventory, Thordarson
et al. 2004; Schedule of Compulsions, Obsessions, and
Pathological Impulses, Watson and Wu 2005; Obsessive-
Compulsive Inventory—Revised, Foa et al. 2002) improve
on the Y-BOCS by including more items relevant to
hoarding symptoms. However, they fail to capture the
full range of the problem and have yet to be validated for
hoarding (for example, on the Obsessive-Compulsive
Inventory—Revised, the hoarding subscale was the only
subscale on which healthy controls actually scored higher
than did OCD patients).
The Saving Inventory—Revised (SI-R; Frost et al. 2004)
is a self-report inventory that measures three primary
components of hoarding—difficulty discarding, compul-
sive acquisition, and clutter. The SI-R contains 23 items
which are scored for three subscales and a total score.
Several recent studies indicate that the SI-R is reliable and
can discriminate identified hoarding cases from non-
hoarding controls and non-hoarding OCD cases (Frost
et al. 2004). The subscales also correlate strongly with
measures of hoarding-related beliefs and attachments,
activity dysfunction resulting from hoarding behavior,
and self and observer ratings of clutter in the home and are
sensitive to treatment effects (Coles et al. 2003; Frost et al.
2004; Tolin et al. 2007). Several problems make develop-
ment of additional measurement options beyond the
current self-report inventories important. The literature
on hoarding is replete with cases of patients’ limited
recognition of the problem (Christensen and Greist 2001;
Damecour and Charron 1998; Fitzgerald 1997; Greenburg
1987; Shafran and Tallis 1996). Using various assessment
methods, several studies reported that patients with
hoarding symptoms showed less insight than did other
non-hoarding patients (De Berardis et al. 2005; Frost et al.
1996; Samuels et al. 2007). Reports by public health
officers and by elder service caseworkers indicated that
fewer than 50% of hoarders recognized the severity of
their problem (Frost et al. 2000a; Steketee et al. 2001).
Many hoarding clients appear to ignore or not recognize
the clutter in their homes, despite wading daily through a
foot or more of debris throughout the home (Steketee and
Frost 2003). Such clients often report not noticing the
clutter when home alone, although they recognize it when
the therapist points it out. To the extent that hoarding
patients’ reports are affected by this tendency to underes-
timate the severity of their hoarding behavior and its
consequences, the validity of self-report inventories may
Although poor insight may lead to underestimation of
hoarding behavior, also problematic is the potential for
overestimation of hoarding and clutter in particular. Several
cases have been described in which individuals report
severe hoarding behaviors and clutter in the home, but
home visits failed to find significant clutter (Frost and Hartl
1996; Steketee et al. 2002). A similar pattern occurs in
which some callers who identify themselves as “hoarders”
prove to have relatively mild levels of clutter in their
homes. Thus, variability in the use of the word “clutter” and
in perceptions of clutter may make verbal self-reports of
To resolve the problems associated with self-reports of
the clutter dimension of hoarding behavior, a visual
analogue to measure the severity of clutter in compulsive
hoarding was developed and tested. This nine-point visual
scale, the clutter image rating (CIR), consists of a series of
nine photos of a room with increasing levels of clutter.
Participants select the picture that best represents the clutter
in the rooms of their own home. These pictorial represen-
tations require no descriptive language and avoid the
problem of different definitions of clutter.
194J Psychopathol Behav Assess (2008) 30:193–203
Construction of the CIR
In order to generate the stimulus pictures, a small furnished
apartment was rented and the bedroom, living room, and
kitchen were filled with a wide variety of objects typically
collected by people who hoard (newspapers, boxes, clothes,
dishes, chairs, bottles, cans, books, pillows, televisions, cereal
boxes, food containers, junk mail, etc.). These items were
draped over piles of empty cardboard boxes to increase the
volume of the materials, but only the hoarded materials were
actually visible. The piles were built to within approximately
2 ft of the ceiling to mimic the most severe hoarding cases for
each of the three rooms. Digital color photos were taken of
each room with a wide-angle lens to fully capture the state of
the room. After the first and each subsequent photo, several
boxes beneaththe surface were removedtoreducethe volume
of clutter while keeping materials on the surface as uniform as
possible. This process continued until 30–35 pictures were
taken for each room as the clutter was removed. The final
picture contained no clutter.
Two procedures were employed to select the final set of
nine photos for each room. First, the first author selected 22
of the 30–35 photos per room that appeared to represent the
range of severity from uncluttered to extremely cluttered.
Second, the least and most cluttered photos were used as
bipolar anchors for the scaling task while the remaining
photos were ordered from least to most cluttered. These 20
sequential photos were then grouped into five sequences of
four pictures each. For example, pictures 1, 2, 3, and 4
formed the first group. One photo from each ordered
grouping was randomly selected to create the first set of
five photos. This procedure was repeated until all 20
pictures were assigned. The result was four sets of five
randomly selected photos representing the full range of
clutter levels. The original least and most cluttered photos
were then affixed to each end of a table. The four sets of
photos were used in a scaling task to select photos equally
spaced in level of clutter.
Fourteen college students enrolled in an introductory
psychology course participated in the scaling task. Partic-
ipants were given the first set of five pictures, one after
another, and asked to place each photo on the table at the
appropriate distance relative to the least and most cluttered
ones and to other photos in the set. After participants made
final adjustments to the distances between photos, the
experimenter recorded all distances and removed the
photos. All participants repeated this sequence for each of
the four sets of five pictures. The entire procedure was
repeated for each of the three rooms.
The mean distance from the least cluttered photo was
computed for each of the 20 photos. These means were
graphed and used to select seven photos in addition to the
least and most cluttered ones, so clutter distances were
approximately equal between each of the nine photos. The
resulting CIR scale included three nine-photo sequences
with equal intervals between photos. Each set of photos
depicting the living room, bedroom, and kitchen were
arrayed on a laminated color page shown to research
participants. Two studies were then conducted to examine
the psychometric properties of the CIR.
Fifty-five people attending a workshop on clutter and
hoarding were invited to participate in the study. Eight
declined participation and one signed the consent form but
did not complete any of the measures. The remaining 46
adults (33 women, 10 men, 3 failed to indicate gender)
completed all study materials. Participants’ ages ranged
from 22 to 73 with a mean of 53.3 (SD=12.4). The
majority were attending the workshop because of serious
problems with hoarding and clutter. However, eight
participants indicated they were family members or friends
of people with hoarding problems. All participants com-
pleted the ratings based on their own behavior.
Clutter Image Rating (CIR) The CIR consisted of three
pages of nine color photos representing a range of clutter in
a living room (LR), bedroom (BR) and kitchen (K) as
described earlier. Participants were asked to “select the
picture that comes closest to the level of clutter in the
corresponding room in your home.” Scores ranged from 1
(least cluttered) to 9 (most cluttered). A mean composite
score ranging from 1 to 9 was calculated across the three
rooms for each person. Both composite and room-by-room
scores were examined in this study.
Saving Inventory—Revised (SI-R) As noted earlier, this 23-
item inventory (Frost et al. 2004) had three subscales:
clutter (nine items), difficulty discarding and compulsive
acquisition (7seven items each); items were scaled from
0 to 4. In the current sample the internal consistencies
(Cronbach’s α) ranged from 0.91 to 0.94.
Hoarding Rating Scale (HRS) Five questions from an
interview (Tolin et al., submitted) protocol for obtaining
clinician severity ratings were adapted to a questionnaire
format. The questions asked about (1) difficulty using
rooms in the home due to clutter, (2) difficulty discarding,
(3) problems with collecting things, (4) the amount of
J Psychopathol Behav Assess (2008) 30:193–203 195195
distress and (5) the amount of impairment these problems
cause. These items were used individually in the analyses
Clutter Scale (CS) For each target room, participants were
asked seven questions about the condition of the room
(Hartl et al. 2002). The questions were: “To what extent: (1)
does clutter in the room take up space intended for other
purposes? (2) is the room neat? (3) are objects in the room
efficiently organized? (4) would it be easy to find what one
is looking for in the room? (5) is it difficult to walk through
the room because of the clutter? (6) are the furniture tops
cluttered? and (7) are the floor spaces cluttered?”. Each
question was scored on a seven-point scale with possible
scores ranging from 7 to 49, higher scores reflecting more
clutter. Internal consistencies for CS ratings of the 3 main
rooms and total score were high (Kitchen α=0.91; Living
Room α=0.87; Bedroom α=0.89; Total α=0.94).
The present study was approved by the Institutional Review
Board atSmith College. At the beginning ofthe workshop the
attendees were invited to participate in a study of collecting,
difficulty discarding, and clutter which would include
completion of a set of questionnaires and ratings. Each
participant received a packet of assessment materials includ-
ing questionnaires and CIR pictures which were in a standard
order. Those who wished to participate signed the consent
form and completed the questionnaires at the beginning of the
Mean scores for the SI-R-total (55.1, SD=19.2), clutter
(23.6, SD=8.3), difficulty discarding (17.4, SD=6.7), and
compulsive acquisition (14.1, SD=7.1) in this sample
reflected moderately serious hoarding behavior compared
to earlier samples (see Frost et al. 2004). CIR ratings ranged
from 1 to 8 out of 9 for the bedroom (mean=3.49, SD=
1.7), from 1 to 7 for the living room (mean=3.21, SD=1.7),
but only from 1 to 6 for the kitchen (mean=2.89, SD=1.2).
Intercorrelations among the three CIR rooms were high
(BR-LR r=0.65; BR-K r=0.56; LR-K r=0.71), and the
internal consistency of the CIR composite score was
The CIR composite was highly correlated with both the
SI-R clutter subscale (r=0.72) and HRS clutter ratings
(r=0.82); further, the CIR was more weakly correlated with
other subscales (r from 0.37 to 0.56). Rubin’s Z tests (Meng
et al. 1992) for the differences in the magnitude between
these correlations indicated that the corresponding clutter
correlations were significantly larger than CIR correlations
with other subscales (all p<0.05).
Correlations between the CIR and Clutter Scale for
corresponding rooms (r from 0.69 to 0.81) were larger than
the correlations for non-corresponding rooms (r from 0.45
to 0.71). Six of the 12 comparisons were significantly larger
(p<0.05) than for non-corresponding rooms (Rubin’s Z
tests for differences in dependent correlations) and were
marginally larger for 2 others (p<0.10). Correlation of the
CIR composite with the Clutter Scale total was very large
This initial study indicated that the CIR showed good
internal consistency and good convergent and discriminant
validity. It showed high correlations with other measures of
clutter and weaker correlations with measures of related
constructs including difficulty discarding, compulsive ac-
quisition, and hoarding-related distress and interference.
Further, correlations among the CIR room ratings and self-
reported clutter in corresponding rooms were also high and
generally larger than correlations with non-corresponding
The participants in this study were mostly people with
hoarding problems, but a significant number (17%) did not
have hoarding problems. The resulting distribution of scores
covered the range from no hoarding to severe hoarding, but
is heavily weighted toward people with hoarding problems.
Although findings from Study 1 were promising, partic-
ipants were not formally screened for hoarding symptoms
and the measures against which the CIR was compared
were all questionnaires and pertained only to hoarding
behaviors. Accordingly, a second study was undertaken
with participants who received a full diagnostic interview
and completed various measures of hoarding, OCD,
depression, and anxiety. Participants completed hoarding-
related measures both in the clinic and at home where an
experimenter also completed observational measures.
Adult participants (age 18 and over) were solicited through
public service announcements offering a research/treatment
opportunity. A trained interviewer administered the Anxiety
Disorders Interview Schedule-Lifetime (ADIS-L; Brown
et al. 1994), a structured interview to diagnose anxiety, mood,
196J Psychopathol Behav Assess (2008) 30:193–203
and somatoform disorders. Items on hoarding (HRS)
supplemented the standard ADIS interview. Participants
were included if they received a severity rating of at least
4 (“definitely disturbing/disabling”) on the clutter or
difficulty discarding sections of the HRS hoarding ratings
(see “Study 1” description). Participants were excluded for
suicidal, psychotic or other symptoms requiring hospitali-
zation. Participants were excluded if they presented
evidence of mental retardation, dementia, brain damage,
or severe cognitive dysfunction (score ≥8) on the Orien-
tation-Memory-Concentration test (Katzman et al. 1983).
No one was excluded due to these criteria.
Participants were 75 adults who qualified and completed
the CIR inthe clinic and/or athome. Of these,39 participants
were paid $20 per hour for their participation and 36
completed study measures as a condition of receiving free
cognitive behavioral therapy for hoarding. The therapy was
given as part of an open trial testing a newly developed
treatment program for hoarding. The treatment project was
underway when this project began, but ended before all the
participants needed for this study were collected. Therefore,
39 people were paid for their participation rather than
receiving treatment. Participants were diagnosed with a
range of disorders, including 38 (51%) with major depres-
sive disorder, 14 (19%) with non-hoarding OCD, 19 (25%)
with generalized anxiety disorder, 23 (31%) with social
phobia, and 9 (12%) with specific phobias. Only 6
participants (8%) failed to receive at least one diagnosis.
Consistent with other studies of hoarding participants, most
were Caucasian (91.4%), with 7.4% African American and
1.5% other. Women predominated (51; 68%), the mean age
was 53.0 (SD=10.2, range 25–78), and only 44% were
married or living with a partner. A large percentage of the
participants completed high school (95.6%) and the majority
completed college (58.5%). Only 58% of participants were
employed at least part-time, and a surprisingly large
percentage (15%) described themselves as disabled. Thirty-
three percent of the participants reported incomes below
$20,000, and 30% reported incomes above $50,000. The
number of participants included in specific analyses varied
as a consequence of missingdata. Home visitswere made for
58 participants. Participants declined home visits for a
variety of reasons including distress over having someone
see their home, unsuccessful attempts to arrange a time, and
in one case, the house burned down shortly after the clinic
assessment. There were no differences between sites on any
of the demographic variables (age, gender, education,
Clutter Image Rating The CIR administration and scoring
were as discussed for Study 1. In addition to the three main
rooms (living room, bedroom, kitchen), additional rooms
were rated by the participant in the clinic, the participant
in their home, and the interviewer in the participant’s
home. Raters used the living room pictures as a proxy for
assessing clutter in other locations (second bedroom/den,
dining room, hallway, and car). As described in Study 1, a
composite score was created by calculating the mean
rating across the three rooms displayed in the photos. The
internal consistency (α) for the participant in clinic was
0.80 (n=69), for participant in home it was 0.85 (n=55),
and for therapist at home it was 0.89 (n=56).
Saving Inventory—Revised The SI-R (Frost et al. 2004),
described previously, was administered in the clinic and at
home for a subset of participants. In this sample the internal
consistencies (α) for all three subscales and both contexts
ranged from 0.80–0.89 (n=36–70).
Clutter Scale (CS) To simplify this measure, only three
questions from the CS (Hartl et al. 2002) were examined for
this study: clutter that takes up space intended for other
purposes (no. 1) and occupies furniture tops (no. 6) and floor
spaces (no. 7). These questions demonstrated the highest
item-total correlations and had content more directly related
to clutter. Participants completed the CS in the clinic and at
home, and the interviewer did so in the participant’s home.
Internal consistencies (α) of ratings for the three main rooms
(living room, bedroom, kitchen) were high: participant in
clinic=0.89 (n=66), participant in home=0.88 (n=43), and
therapist in home=0.93 (n=46). Ratings were also made of
additional locations (second bedroom/den, dining room,
hallway, and car).
Beck Depression Inventory—II (BDI–II) BDI-II (Beck et al.
1996) is a 21-item self-report measure of depressive
symptoms with well-established reliability and validity.
Participants completed the BDI-II at their initial session.
The internal consistency (α) in the current study was 0.91.
Beck Anxiety Inventory (BAI) The BAI (Beck et al. 1988) is
a 21-item self-report inventory of symptoms of anxiety with
well-established reliability and validity. Participants com-
pleted the BAI at their initial session. The internal
consistency (α) in the current study was 0.92.
The present study was approved by the Institutional Review
Boards at Hartford Hospital, Boston University, and Smith
College. All participants signed a consent form before data
collection began. Participants were screened by telephone
and invited to come to the clinic for an initial diagnostic
J Psychopathol Behav Assess (2008) 30:193–203197197
assessment. Eligible participants also completed a battery of
measures that day in the clinic. At a home appointment
scheduled 1 week to 3 months later, participants and
therapists/interviewers completed additional measures, in-
cluding the CIR and SI-R.
Scores on the CIR and SI-R
Means, standard deviations, and ranges for the CIR and SI-
R can be found in Table 1, as well as correlations among
the three CIR picture ratings in the clinic. The SI-R scores
indicate substantial hoarding symptoms among these
clinical participants (Frost et al. 2004), noticeably higher
than in the Study 1 sample and spanning the full range of
CIR scores. Mean scores for the participants indicated mild
levels of depression and anxiety (see Table 1).
Reliability of the CIR
Retest reliability analyses for the participant CIR ratings
completed in the clinic and at home for the 3 main rooms of
the home can be found in Table 2. These were not purely
test-retest correlations as they varied across context as well
as time.Consequentlytheycanbeseenasa formofpredictive
validity as well. Correlations ranged from 0.62 to 0.81 for
corresponding rooms, withan average of 0.73. The composite
CIR showed a very high clinic/home correlation (r=0.82),
which was similar to the correlation using only participants
with a retest interval of 2 months or less (r=0.85).
Interobserver correlations of participant and experiment-
er ratings completed concurrently, but without consultation,
at the participant’s home can be found in Table 3. In
addition to observer reliability, these correlations provide
evidence of convergent validity as they compare partic-
ipants’ responses to a presumably objective standard (i.e.,
the experimenter). These correlations ranged from 0.73 to
0.94 for corresponding rooms and 0.94 for the composite
Also in Table 3 are interobserver reliabilities for
participant CIRs in the clinic and experimenter-rated CIRs
at home. Although lower correlations would be expected
because of the three sources of variance examined here
(time, context, and observer), this information is important
to understanding how closely participants’ reports of clutter
in the clinic are likely to match actual clutter in the home.
rooms with an average of 0.75. The composite CIR showed
good participant/experimenter correlation (r=0.78).
To compare the interobserver reliabilities of the CIR
with those of the CS, comparable correlations were
calculated for the CS total score. The correlation between
the CS completed by the client and therapist at home was
0.77. This correlation was significantly smaller than the
correlation between the client and therapist CIR completed
in the home (0.94; z=3.28, p<0.01). Correlation of the CS
completed by the client in the clinic and the therapist at
home was 0.66, and did not differ statistically from the
comparable CIR correlation (0.78, z=1.2, p>0.05).
Convergent Validity of the CIR
The Clutter Scale provided an alternative measure of clutter
specific to each of the rooms measured by the CIR. The
correlations between the Clutter Scale and CIR for each
room are displayed in Table 4 for both the in-clinic
assessment and in home assessment. The correlations for
corresponding rooms ranged from 0.46 to 0.81. The mean
Table 1 Means, standard deviations, ranges, and inter-roomcorrelations for the Clutter Image Rating (CIR), theSaving Inventory—Revised (SI-R),
the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI) in Study 2
Mean SD Range Bedroom Living roomKitchen
198J Psychopathol Behav Assess (2008) 30:193–203
correlation was 0.64, suggesting strong agreement between
these room-specific measures of clutter. Correlations for
home ratings tended to be slightly higher than those for
clinic ratings, and living room correlations were strongest,
followed by composite score correlations. The correlation
between the composite measures (mean value of the CIR
and Clutter Scale) was 0.77 for the home ratings and 0.70
for clinic ratings.
Table 5 shows similar correlations, but this time for the
experimenter’s CIR and Clutter Scale ratings, both con-
ducted in the home. These correlations were very strong,
ranging from 0.64 to 0.83 for the individual rooms and 0.78
for the composite measures.
similar patterns of association, with higher correlations
evident for matching rooms for both experimenter and
participant. A seven-room composite score was highly
correlated with the three-room composite (0.94) and revealed
nearly identical correlations to the three-room composite for
clinic versus home assessments (0.81 vs 0.82) and for
participant versus experimenter (0.93 vs 0.94).
To further study convergent validity, the relationship of
CIR composite ratings to the SI-R completed in the clinic
(see Table 6) was also examined. As expected, the CIR in
clinic and at home was more strongly correlated with
participant ratings of the SI-R Clutter subscale (r=0.57 to
0.63) than with the other SI-R subscales (Rubin’s Z>2.49;
p<0.05 for comparison of correlations).
Over/Underestimates of Clutter/Hoarding
While clinic-based hoarding measures are strongly corre-
lated with home-based measures, differences in magnitude
may occur in relation to the form of measurement (verbal
self-report vs visual analogue; participant vs experimenter).
To test these possibilities, hoarding measures administered
in the clinic (CIR, Clutter Scale, SI-R) were compared to
the same measures given in the home. Table 7 contains
means, standard deviations, and t test values for these
comparisons. The comparison for CIR home and clinic
ratings was not significant (p>0.10), but for the Clutter
Scale, SI-R Clutter and SI-R Discarding subscales signif-
icantly higher scores occurred in the clinic compared to the
home (p<0.04). Differences in participant and experimenter
ratings were not significant for the CIR, but on the Clutter
Scale, participants rated their homes as more cluttered than
did experimenters (p<0.03).
CIR Relationship to Measures of Other Psychopathology
The CIR composite score was significantly but modestly
correlated with the BAI (r=0.26, p<0.05), but not the BDI
(r=0.13, n.s.). Means for both measures reflected mild
severity (BAI mean=10.4, SD=7.0; BDI mean=16.5, SD=
10.7). Interestingly, the SI-R Clutter subscale was also
uncorrelated with the BDI (r=0.21, p>0.05), while the
Difficulty Discarding and Acquisition subscales were
Table 2 Correlations between participant clutter image ratings in the clinic and participant clutter image ratings at home for Study 2
Home CIR Clinic CIR
Living roomKitchen Bedroom Composite
For all r, p<0.01, 05, n=52–54
Table 3 Correlations of clutter image ratings by participants (in the clinic and at home) with clutter image ratings by experimenters (in the home)
for study 2
Experimenter CIR at homeLiving roomKitchenBedroom Composite
Clinic HomeClinicHome ClinicHome Clinic Home
All r significant at p<0.01, n=50–53
J Psychopathol Behav Assess (2008) 30:193–203199199
correlated with it (r=0.28 and 0.28, p<0.05). All three SI-R
subscales were correlated with the BAI, though the
correlation with the SIR Acquisition subscale was higher
(r=0.52, p<0.01) than with the other two (r=0.28 and 0.31,
The present article describes the development and valida-
tion of a visual analogue measure of clutter for use in
research and treatment of compulsive hoarding. This
instrument showed good internal consistency and test-retest
reliability, despite the fact that the retest varied across both
context and time. Inter-observer reliability was excellent.
The CIR demonstrated good convergent validity with other
measures of clutter. It was highly correlated with both
questionnaire and observer measures of room-by-room
clutter, with the strongest relationships evident for
corresponding rooms. Correlations with broader question-
naire and interview measures of hoarding revealed stronger
relationships with the clutter scores than with other dimen-
sions of hoardingsuch as difficulty discarding and acquiring.
Although the CIR photos depict three rooms, using the
living room pictures to assess other rooms in the home
appeared to be successful. The three-room and seven-room
composites were highly correlated and displayed a very
similar pattern of correlations with other instruments. Thus,
measuring clutter in more than the three main rooms
depicted in the photos may not add much meaningful
Because few therapists in typical clinic settings can visit
clients’ homes, it is of special importance to understand the
accuracy of clients’ judgments made in the clinic of their
clutter at home. In fact, participants’ clinic and home CIR
ratings were strongly correlated with each other, and with
clinicians’ ratings of the home at a later time. These
findings suggest that the CIR completed in the clinic is a
good representation of the clutter in the home. Although the
CIR ratings in the home were done independently, it is
possible that the close association between them was due to
nonspecific effects of the experimenter being present when
Table 5 Correlations of experimenter ratings of clutter for Study 2 (both completed in the home)
Clutter scale Clutter image rating
All r significant at p<0.01, n=46–51
Table 4 Correlations of participants’ clutter image ratings and clutter scale scores (in the clinic and at home) for study 2
Clutter scale Clutter image rating
Living room KitchenBedroomComposite
Clinic Home ClinicHomeClinic Home ClinicHome
0.830.56 0.60 0.77
0.600.52 0.39 0.59
0.40* 0.780.47 0.61
0.74 0.570.48 0.70
0.71 0.680.67 0.77
*p<0.05, otherwise all r significant at p<0.01, n=59–68 for clinic ratings and 39–46 for home ratings
200J Psychopathol Behav Assess (2008) 30:193–203
the CIR ratings were being done. However, the relatively
high correlations between the experimenter ratings and
participant ratings done in the clinic (despite the amount of
time separating these ratings) argued against this possibil-
ity. Nonetheless, this may have influenced the magnitude
of these correlations and the size of the discrepancy
Hoarding clients may tend to overestimate clutter on
questionnaire measures. On both the Clutter Scale and the
SI-R clutter subscale, participants rated their clutter as
significantly worse when they completed these measures in
the clinic than when they did so at home. One possible
explanation for this difference could be that participants
cleaned or reduced the level of clutter from the first to the
second administration of the measures. However, no such
difference emerged in the CIR composite, suggesting that
this rating bias stems from the nature of the measuring
instrument (verbal versus visual). It also suggests that the
CIR is not affected by over-reporting in the clinic, which is
characteristic of paper and pencil measures.
The brevity of the CIR administration (less than 5 min)
makes this reliable and valid measure a very useful
screening tool to detect the presence of clinically significant
hoarding symptoms. A cutoff score of 4 or higher can be
used to indicate significant clutter requiring clinical
attention. This measure may also be useful in assessing
outcomes for interventions intended to reduce hoarding
behavior. In an open trial of cognitive-behavior therapy for
hoarding, the CIR was sensitive to treatment effects (Tolin
et al. 2007).
Though the CIR holds promise as a measure of hoarding,
in certain cases it can be misleading. For instance,
occasionally people with hoarding problems live with or
their homes are monitored by others (e.g., spouses, family
members etc.) who prevent the buildup of clutter. In such
cases the CIR, and other measures of clutter, would not
accurately reflect the hoarding problem. Severity of clutter,
as measured by the CIR, is only one dimension of hoarding.
Severity of clutter may assess impairment of living spaces,
but it is not a substitute for problems associated with
difficulty discarding or excessive acquisition.
The absence of a significant correlation between the CIR
and the BDI is interesting in light of the fact that over half
of the sample received a major depressive disorder
diagnosis. Previous studies have been inconsistent with
respect to the relationship between hoarding and affect.
While some have found small or insignificant association
with negative affect or negative temperament (Grisham
et al. 2005; Wu and Watson 2005), others have found
significantly higher levels of depression among hoarding
OCD patients compared to non-hoarding OCD patients
(Frost et al. 2000b; Samuels et al. 2002). One reason for the
inconsistency may be the feature of hoarding emphasized in
each measure. Frost et al. (2004) found a different pattern
of correlation with positive and negative affect for each SI-
R subscale. Findings from the present study also demon-
strated this inconsistency. Like the CIR, the SI-R clutter
scale was not significantly correlated with the BDI while
both the Difficulty Discarding and Acquisition subscales
were. The Acquisition subscale also showed a stronger
Table 7 T tests across contexts for measures of hoarding and clutter for Study 2
MeasureClinic HomeParticipant Experimentert dfpd
Clutter image rating
Clutter image rating
Table 6 Correlations clutter image rating composites (in the clinic and at home) with the Saving Inventory—Revised
Participant /home CIR
J Psychopathol Behav Assess (2008) 30:193–203 201 201
correlation with the BAI than did the other two subscales.
The association of different dimensions of hoarding with
negative affect deserves more research.
There are several limitations to the current study. The
pictures used for the CIR were from relatively small rooms,
they depicted commonly hoarded objects based on the
authors’ experience with hoarding clients, and the pictures
displayed objects that were clean (i.e., not squalid con-
ditions). These issues may limit the extent to which the CIR
can be used for all cases of hoarding. Further research using
the CIR is needed to determine applicability for these
different contexts. Another potential limitation is that home
visits were conducted for a subsample of the participants. It
is possible that those who consented to a home visit were
not representative of all participants. Finally, the clinic-
home correlations cannot be considered pure test-retest
reliabilities since they varied in context as well as time. A
purer form of test-retest reliability would have been to
complete the CIR twice in the same location.
National Institute of Mental Health to the first two authors (R21 MH
068539; R01 MH068007; R01 MH068008).
The authors would like to thank Jennifer West, Allison Kenyon,
Hala Al-Saud, Rebecca Kingston, and Yanique Matthews for their
help in developing and scaling the CIR.
This research was supported by grants from the
Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M.
(2003). Symptom presentation and outcome of cognitive-
behavioral therapy for obsessive-compulsive disorder. Journal
of Consulting and Clinical Psychology, 71, 1049–1057.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An
inventory for measuring clinical anxiety: Psychometric properties.
Journal of Consulting and Clinical Psychology, 56, 893–897.
Beck,A.T.,Steer,R.A.,& Brown,G.K.(1996).Manual for the BDI—
II. San Antonio, TX: The Psychological Corporation.
Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety
disorders interview schedule for DSM-IV. San Antonio, TX: The
Christensen, D. D., & Greist, J. H. (2001). The challenge of obsessive-
compulsive disorder hoarding. Primary Psychiatry 8, 79–86.
Coles, M. E., Frost, R. O., Heimberg, R. G., Steketee, G. (2003).
Hoarding behaviors in a large college sample. Behaviour
Research and Therapy, 41, 179–194.
Damecour, C. L., & Charron, M. (1998). Hoarding: A symptom, not a
syndrome. Journal of Clinical Psychiatry, 59, 267–272.
De Berardis, D., Campanella, D., Gambi, F., Sepede, G., Salini, G.,
Carano, A. (2005). Insight and alexithymia in adult outpatients
with obsessive-compulsive disorder. European Archives of
Psychiatry and Clinical Neuroscience, 255, 350–358.
Dykens, E. M., & Leckman, J. F. (1996). Obsessions and compulsions
in Prader–Willi syndrome. Journal of Child Psychology and
Psychiatry, 37, 995–1002.
Fitzgerald, P. B. (1997). ‘The bowerbird symptom’: A case of severe
hoarding of possessions. Australian & New Zealand Journal of
Psychiatry, 31, 597–600.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R.,
Hajcak, G., et al. (2002). The Obsessive-Compulsive Inventory:
Development and validation of a short version. Psychological
Assessment, 14, 485–496.
Frost, R. O., & Hartl, T.L. (1996). A cognitive-behavioral model of
compulsive hoarding. Behavior Research and Therapy 14, 341–
Frost, R. O., Krause, M. S., & Steketee, G. (1996). Hoarding and
obsessive-compulsive symptoms. Behavior Modification, 20,
Frost, R. O., Steketee, G., & Grisham, J. R. (2004). Measurement of
compulsive hoarding, Saving Inventory—Revised. Behaviour
Research and Therapy, 42, 1163–1182.
Frost, R. O., Steketee, G., Tolin, D., & Brown, T. (2006). Co-
morbidity and diagnostic issues in compulsive hoarding. Paper
presented at the Anxiety Disorders Association of America,
Frost, R. O., Steketee, G., & Williams, L. (2000a). Hoarding: A
community health problem. Health and Social Care in the
Community, 8, 229–234.
Frost, R. O., Steketee, G., Williams, L., & Warren, R. (2000b). Mood,
disability, and personality disorder symptoms in hoarding,
obsessive compulsive disorder, and control subjects. Behaviour
Research and Therapy, 38, 1071–1082.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C.,
Fleischmann, R. L., Hill, C. L., et al. (1989). The Yale–Brown
Obsessive Compulsive Scale. I. Development, use, and reliabil-
ity. Archives of General Psychiatry, 46, 1006–1011.
Greenburg, D. (1987). Compulsive hoarding. American Journal of
Psychotherapy, 41, 409–416.
Grisham, J. R., Brown, T. A., Liverant, G. I., & Campbell-Sills, L.
(2005). The distinctiveness of compulsive hoarding from
obsessive-compulsive disorder. Journal of Anxiety Disorders,
Hartl, T. L., Allen, G. J., Frost, R. O., & Steketee, G. (2002).
Validation of a new measure of clutter to assess room and
photographs. Unpublished manuscript.
Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R., &
Schimmel, H. (1983). Validation of a short Orientation-Memory-
Concentration Test of cognitive impairment. American Journal of
Psychiatry, 140, 734–739.
McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M.,
Radomsky, A., Sookman, D., et al. (2004). A critical evaluation
of obsessive-compulsive disorder subtypes: Symptoms versus
mechanisms. Clinical Psychology Review, 24, 283–313.
Meng, X-L, Rosenthal, R., & Rubin, D. B. (1992). Comparing
correlated correlation coefficients. Psychological Bulletin, 111,
Meunier, S. A., Tolin, D. F., Frost, R. O., Steketee, G., & Brady, R. E.
(2006). Prevalence of hoarding symptoms across the anxiety
disorders. Paper presented at the Anxiety Disorders Association
of America, Miami, FL.
Samuels, J., Bienvenu, O. J., III, Riddle, M. A., Cullen, B. A. M.,
Grados, M. A., Liang, K.-Y., et al. (2002). Hoarding in obsessive
compulsive disorder: Results from a case-control study. Behaviour
Research and Therapy, 40, 517–528.
Samuels, J., Bienvenu, O. J., III, Pinto, A., Fryer, A. J., McCracken, J. T.,
Rauch, S. L., et al. (2007). Hoarding in obsessive compulsive
disorder: Results from the OCD Collaborative Genetics Study.
Behaviour Research and Therapy, 45, 673–686.
Saxena, S., Brody, A. L., Maidment, K. M., Smith, E. C., Zohrabi, N.,
Katz, E., et al. (2004). Cerebral glucose metabolism in obsessive-
compulsive hoarding. American Journal of Psychiatry, 161,
202J Psychopathol Behav Assess (2008) 30:193–203
Shafran, R., & Tallis, F. (1996). Obsessive-compulsive hoarding: A
cognitive-behavioural approach. Behavioural and Cognitive
Psychotherapy, 24, 209–221.
Steketee, G., de Noble, D., Diergerger, A., & Frost, R. O. (2002). Com-
pulsive hoarding among elderly people. Unpublished manuscript.
Steketee, G., & Frost, R. O. (2003). Compulsive hoarding: Current
status of the research. Clinical Psychology Review, 23, 905–927.
Steketee, G., Frost, R. O., & Kim, H-J. (2001). Hoarding by elderly
people. Health & Social Work, 26, 176–184.
Thordarson, D. S., Radomsky, A. S., Rachman, S., Shafran, R.,
Sawchuk, C. N., & Hakstian, A. R. (2004). The Vancouver
Obsessional Compulsive Inventory. Behaviour Research and
Therapy, 42, 1289–1314.
Tolin, D. F., Frost, R.O., & Steketee, G. (2007). An open trial of
cognitive-behavioral therapy for compulsive hoarding. Behaviour
Research and Therapy, 45, 1461–1470.
Watson, D., & Wu, K. D. (2005). Development and Validation of the
Schedule of Compulsions, Obsessions, and Pathological
Impulses. Assessment, 12, 50–65.
Wu, K. D., & Watson, D. (2005). Hoarding and its relation to
obsessive-compulsive disorder.Behaviour Research and Therapy,
J Psychopathol Behav Assess (2008) 30:193–203 203203