DEPRESSION AND ANXIETY 27:556–572 (2010)
HOARDING DISORDER: A NEW DIAGNOSIS FOR DSM-V?
David Mataix-Cols, Ph.D.,1?Randy O. Frost, Ph.D.,2Alberto Pertusa, M.D.,1Lee Anna Clark, Ph.D.,3
Sanjaya Saxena, M.D.,4James F. Leckman, M.D.,5Dan J. Stein, M.D.,6Hisato Matsunaga, M.D.,7
and Sabine Wilhelm, Ph.D.8
This article provides a focused review of the literature on compulsive hoarding
and presents a number of options and preliminary recommendations to be
considered for DSM-V. In DSM-IV-TR, hoarding is listed as one of the
diagnostic criteria for obsessive–compulsive personality disorder (OCPD).
According to DSM-IV-TR, when hoarding is extreme, clinicians should consider
a diagnosis of obsessive–compulsive disorder (OCD) and may diagnose both
OCPD and OCD if the criteria for both are met. However, compulsive hoarding
seems to frequently be independent from other neurological and psychiatric
disorders, including OCD and OCPD. In this review, we first address whether
hoarding should be considered a symptom of OCD and/or a criterion of OCPD.
Second, we address whether compulsive hoarding should be classified as a
separate disorder in DSM-V, weighing the advantages and disadvantages of
doing so. Finally, we discuss where compulsive hoarding should be classified in
DSM-V if included as a separate disorder. We conclude that there is sufficient
evidence to recommend the creation of a new disorder, provisionally called
hoarding disorder. Given the historical link between hoarding and OCD/OCPD,
and the conservative approach adopted by DSM-V, it may make sense to
provisionally list it as an obsessive–compulsive spectrum disorder. An alternative
to our recommendation would be to include it in an Appendix of Criteria Sets
Provided for Further Study. The creation of a new diagnosis in DSM-V would
likely increase public awareness, improve identification of cases, and stimulate
both research and the development of specific treatments for hoarding disorder.
Depression and Anxiety 27:556–572, 2010.
rrrr2010 Wiley-Liss, Inc.
Key words: hoarding; obsessive–compulsive disorder; obsessive–compulsive person-
ality disorder; Anankastic personality disorder; DSM-V; classification; nosology
Published online 24 March 2010 in Wiley InterScience (www.
Received for publication 3 November 2009; Revised 22 February
2010; Accepted 23 February 2010
?Correspondence to: David Mataix-Cols, King’s College London,
PO 69, Institute of Psychiatry, De Crespigny Park, London SE5
8AF, United Kingdom. E-mail: email@example.com
This article is being co-published by Depression and Anxiety and
the American Psychiatric Association.
The authors report they have no financial relationships within the
past 3 years to disclose.
1King’s College London, Institute of Psychiatry, London,
2Department of Psychology, Smith College, Northampton,
3Department of Psychology, University of Iowa, Iowa City,
4Obsessive-Compulsive Disorders Program, University of
California, San Diego, California
5Child Study Center, Yale University School of Medicine, New
6Department of Psychiatry and Mental Health, University of
Cape Town, Cape Town, South Africa
Graduate School of Medicine, Osaka, Japan
8Obsessive–Compulsive Disorder Clinic, Department of Psychia-
try, Massachusetts General Hospital, Boston, Massachusetts
rrrr 2010 Wiley-Liss, Inc.
This article focuses on some of the key issues
pertaining to pathological or compulsive hoarding that
are being considered for the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-V). We first discuss terminological issues and
describe the current status of hoarding in the existing
classification systems (i.e., DSM-IV-TR and ICD-
10).[1,2]We then identify and discuss key issues that
are specifically relevant to DSM-V. Given that research
on compulsive hoarding has increased exponentially
over the last decade, and that it may represent a major
threat to public health, it is time to consider whether it
should be included as a new disorder in DSM-V to
reflect this new knowledge. This article is not intended
to be a comprehensive review of compulsive hoarding,
as other reviews already exist.[3–7]
This article was commissioned by the DSM-V
Anxiety, Obsessive–compulsive Spectrum, Posttrau-
matic, and Dissociative Disorders Work Group. The
recommendations provided in this article should be considered
preliminary at this time and they do not necessarily reflect
the final recommendations or decisions that will be made for
DSM-V, as the DSM-V development process is still ongoing.
Thus, this article’s recommendations may be revised as
additional data and input from other experts are
As some authors (e.g.,) have pointed out, without
further specification, the term ‘‘hoarding’’ is of limited
heuristic value because it can be a symptom of multiple
organic and psychiatric disorders, and thus cannot be
conceptualized as a single nosological entity or effec-
tively guide therapeutic interventions. Bolman and
Katzreportedly used the term ‘‘compulsive hoarding’’
for the first time to describe pathological or excessive
collecting behavior in humans.
‘‘compulsive’’ was originally used in order to differentiate
normal saving and collecting from excessive, impulsive,
and/or pathological hoarding. More recently, the term
‘‘compulsive’’ has been used to describe primary hoard-
ing behavior (i.e., hoarding due to exaggerated fears of
losing items that could be important or valuable or
because of excessive emotional attachment) and distin-
guish it from hoarding that is secondary to other
developmental, neurological, or psychiatric conditions.
For consistency with the literature, we use ‘‘compulsive
hoarding’’ throughout this review, but we later discuss
whether the term ‘‘compulsive’’ is optimal.
Thus, the term
HOARDING IN DSM–IV AND ICD-10
Although hoarding is often considered a symptom of
obsessive–compulsive disorder (OCD), and is included
in most structured interviews and questionnaires of
OCD symptoms, such as the Yale–Brown Obsessive–
Compulsive Scale (Y-BOCS)[9,10]and the Obsessive–
Compulsive Inventory-Revised (OCI-R),it is not
directly mentioned in DSM-IV-TR or in ICD-10 as a
typical symptom of OCD. Instead, ‘‘the inability
to discard worn-out or worthless objects even when
they have no sentimental value’’ is one of the eight
current criteria for Obsessive–Compulsive Personality
Disorder (OCPD) in DSM-IV-TR. By contrast, the
equivalent diagnostic category in ICD-10, Anankastic
Personality Disorder, does not include such a criterion.
When describing the differential diagnosis between
OCPD and OCD, DSM-IV-TR states:
Despite the similarity in names, OCD is usually easily
distinguished from OCPD by the presence of true
obsessions and compulsions. A diagnosis of OCD should
be considered especially when hoarding is extreme (e.g.
accumulated stacks of worthless objects present a fire
hazard and make it difficult for others to walk through
the house). When criteria for both disorders are met,
both diagnoses should be recorded. (p. 728)
OCD section, DSM-IV-TR assumes that, when severe,
hoarding can be a symptom of OCD. This can be
confusing as clinicians may struggle deciding when a
diagnosis of OCD is appropriate, particularly when
hoarding appears in the absence of other prototypical
OCD symptoms. As reviewed below, the majority of
hoarding cases display no other OCD symptoms.
A brief historical review is helpful in elucidating the
reasons for the ambiguous status of hoarding in DSM-
IV-TR as both a criterion of OCPD and a symptom of
OCD. Hoarding as a characterological trait has its
origins more than a century ago in the psychoanalytical
concept of the ‘‘anal character,’’ which later became
today’s OCPD.[12–14]However, hoarding has been a
core diagnostic criterion for OCPD only since DSM-
III-R (see). The idea that extreme hoarding might
warrant consideration of OCD as a diagnosis appears
for the first time in DSM-IV in the differential
diagnosis section of the text for OCPD. That is,
although OCD is mentioned as a differential diagnosis
in DSM-III and DSM-III-R, the passage is very brief
(In OCD there are, by definition, true obsessions and
compulsions, which are not present in OCPD) and does not
So why did hoarding, which originally was an
obsessional personality trait, appear mentioned as a
potential symptom of OCD in DSM-IV? The answer is
possibly related to the inclusion of two hoarding
items in the Y-BOCS symptom checklist,[9,10]which
was used in the DSM-IV field trialand rapidly
became the most widely used rating scale for OCD.
This may well have influenced the wording in DSM-IV
(although it still is unclear why it appeared only in the
personality disorders section and not also in the
557 Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
OCD section) and the development of many other
symptom inventories since, such as the OCI-R
WORKING DIAGNOSTIC CRITERIA FOR
Given the absence of a formal diagnosis for
compulsive hoarding as a syndrome in the official
classification systems and in response to the accumu-
lating knowledge, Frost and Hartldeveloped a set of
diagnostic criteria, which have been widely adopted by
researchers in the field:
(1) The acquisition of and failure to discard a large
number of possessions that seem to be useless or of
(2) Living spaces sufficiently cluttered so as to
preclude activities for which those spaces were
(3) Significant distress or impairment in functioning
caused by the hoarding.
These criteria have been used, or adapted for use, in
multiple psychopathological, epidemiological, neuroima-
ging, and treatment studies over the last decade.[5,7,18–27]
Several clinician and self-administered measures also
have been developed to reflect these criteria and are now
widely used in the field, including the Saving Inventory-
Revised,the Hoarding Rating Scale,and the
UCLA Hoarding Severity Scale.In light of recent
developments and cumulative knowledge gained over the
last decade, the original criteria by Frost and Hartl
have now been further refined and are listed below:
(A) Persistent difficulty discarding or parting with
personal possessions, even those of apparently
useless or limited value, due to strong urges to
save items, distress, and/or indecision associated
(B) The symptoms result in the accumulation of a
large number of possessions that fill up and clutter
the active living areas of the home, workplace, or
other personal surroundings (e.g., office, vehicle,
yard) and prevent normal use of the space. If all
living areas are uncluttered, it is only because of
others’ efforts (e.g., family members, authorities)
to keep these areas free of possessions.
(C) The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning (including main-
taining a safe environment for self and others).
(D) The hoarding symptoms are not due to a general
medical condition (e.g., brain injury, cerebrovas-
(E) The hoarding symptoms are not restricted to the
symptoms of another mental disorder (e.g., hoard-
ing due to obsessions in Obsessive Compulsive
Disorder (OCD), lack of motivation in Major
Depressive Disorder, delusions in Schizophrenia
or another Psychotic Disorder, cognitive deficits in
Dementia, restricted interests in Autistic Disorder,
food storing in Prader–Willi Syndrome).
With Excessive Acquisition: If symptoms are accom-
panied by excessive collecting or buying or stealing of
items that are not needed or for which there is no
Specify whether hoarding beliefs and behaviors are
currently characterized by:
*Good or fair insight: Recognizes that hoarding-related
beliefs and behaviors (pertaining to difficulty dis-
carding items, clutter, or excessive acquisition) are
*Poor insight: Mostly convinced that hoarding-related
beliefs and behaviors (pertaining to difficulty dis-
carding items, clutter, or excessive acquisition) are
not problematic despite evidence to the contrary.
*Delusional: Completely convinced that hoarding-
related beliefs and behaviors (pertaining to difficulty
discarding items, clutter, or excessive acquisition)
are not problematic despite evidence to the contrary.
These proposed diagnostic criteria would be accom-
panied with additional text for clarification. Crucially, a
requirement for the diagnosis of compulsive hoarding
is that the symptoms are not better accounted for
by another mental disorder (including OCD). Note
that excessive acquisition is currently listed as a
potential specifier because, as reviewed below, not all
compulsive hoarders display this symptom. Including
an insight specifier is relevant to hoarding, as many
sufferers underestimate the extent of their difficul-
ties.[3,7]For further discussion on the use and definition
of the term ‘‘insight,’’ see Phillips and Tandon (in
STATEMENT OF THE ISSUES
1. Should compulsive hoarding continue to be men-
tioned as a symptom of another disorder, such as
OCD or OCPD?
1.1. Is compulsive hoarding a symptom of OCD?
1.2. Is compulsive hoarding a symptom of OCPD?
2. Should compulsive hoarding be included as a
separate diagnosis in DSM-V?
3. If hoarding were to be included as a separate
diagnosis, are any changes to its proposed criteria
warranted? For example, might changes be needed
in order to reflect gender, developmental, or cross-
558Mataix-Cols et al.
Depression and Anxiety
4. If a separate disorder is included, what should it be
5. If a separate disorder is included, where should it be
classified in DSM-V?
SIGNIFICANCE OF THE ISSUES
Issue ]1 is important, given that accumulating data
have raised the question of whether or not hoarding
does have a specific relation with OCD and OCPD, and
whether these diagnoses cover all the severe hoarding
cases. Issue ]2 is important, given that recent epide-
miological studies suggest that compulsive hoarding
occurs in 2–5% of the population and can lead to
substantial distress and disability, as well as serious
public health consequences that warrant consideration
as a mental disorder. In this context, it is crucial to
examine the potential advantages and disadvantages of
the creation of a new disorder. Issue ]3 is relevant, given
the focus of DSM-Von establishing clinical criteria that
are broadly applicable to both genders, across the
lifespan, and in different cultural contexts. Issue ]4 is
important, as the name of a potential new disorder
needs to be as accurate and descriptive as possible to
minimize confusion, facilitate communication between
professionals, and also be acceptable to sufferers. Issue
]5, which is relevant to the overall structure of DSM-V
and may well influence the way clinicians conceptualize
and approach disorders, is considered briefly here and
in more detail elsewhere.
A literature search was conducted using the PubMed,
ScienceDirect, Scopus, and PsychLit databases using
the following keywords: hoarding, collecting, packrat,
OCD, OCPD, Anankastic Personality Disorder, im-
pulse control disorders, and compulsive buying. There
was no time limit to the search. Reference sections of
published articles were also examined. The Annotated
Listings of Changes in each DSM, the DSM-IV
Sourcebooks, and the DSM-IV Options Book were
consulted for details of the DSM-III to DSM-IV OCD
criteria revisions. The proceedings and/or monographs
of the preparatory conference series for DSM-V,
particularly the Obsessive–Compulsive Spectrum Disorder
(OCSD) conference, were also used.
SHOULD HOARDING CONTINUE TO BE
MENTIONED AS A SYMPTOM OF ANOTHER
DISORDER, SUCH AS OCD OR OCPD?
Is hoarding a symptom of OCD?.
tualization of hoarding as a possible symptom of OCD
is relatively recent in the history of DSM (since DSM-
IV), but is now included as a symptom in most
clinician- and self-administered measures of OCD
symptom severity. Studies of clinical OCD samples
indicate a prevalence of hoarding (measured with the
two items of the Y-BOCS symptom checklist) of
18–40% in adults and children/adolescents.[17,32–35]
However, hoarding seems to be a clinically significant
problem in fewer than 5% of patients with OCD.[16,36]
Factor and cluster analytical studies have consistently
identified a separate hoarding factor in large samples of
OCD patients.[37,38]A recent meta-analysis of 21
studies involving more than 5,000 individuals with
OCD worldwide confirmed that hoarding is an
independent factor, both in adult and pediatric
samples.This indicates that hoarding has been
consistently identified as a ‘‘distinct entity’’ within
OCD, but this alone does not answer the question of
whether hoarding is an OCD symptom or not. Indeed,
compulsive hoarding could arguably be conceptualized
and classified in a number of ways: as a symptom
dimension or subtype of OCD, a variant of OCD
(when it occurs in the absence of other OCD
symptoms), or as a discrete disorder.
Phenomenologically, compulsive hoarding resembles
OCD in that the avoidance of and difficulties discarding
possessions are driven by fears of losing important items
that the patients feel they may need in the future or feel
emotionally attached to, or fears of making mistakes
regarding what to keep or discard. These fears could be
regarded as functionally similar to ‘‘obsessions,’’ whereas
the avoidance of discarding, urges to save items, and
some acquisition behaviors (compulsive buying and
collecting) could be regarded as similar to ‘‘compul-
sions.’’ Overlapping with some symmetry-related obses-
sions in OCD, touching or moving possessions without
permission provoke distress in many hoarding patients.
Several studies in nonclinical samples have observed
significant correlations (ranging from 0.4 to 0.5)
between measures of hoarding and OCD symptoms
view.[17,39,40]Community hoarding samples (i.e., people
who self-identified as having hoarding problems) report
more symptoms of OCD compared to nonclinical
controls and experience them as more severe and
distressing, suggesting a link between hoarding and
OCD.However, in these studies, the presence of
clinically significant obsessive–compulsive symptoms,
other than hoarding, was not specifically assessed, so
these results also could be explained by the presence of a
significant proportion of patients with a comorbid OCD
among the hoarding groups, given that subsequent
studies have found OCD to be comorbid in 16–35%
individuals with compulsive hoarding.[15,22,41–43]
Although fears of losing personally important or
valuable things resemble ‘‘obsessions’’ and urges to save
or collect items resemble ‘‘compulsions,’’ there are a
number of important phenomenological differences
thoughts related to hoarding are not experienced as
intrusive, but rather as part of the individual’s normal
stream of thought.[39,44–45]
Second, they are not
559Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
repetitive in the same way that typical obsessions are
experienced.[45,46]Third, they are seldom experienced
as distressing or unpleasant.[44,46–48]The distress seen
in hoarding patients comes from the product of the
behavior (clutter) and not from the experience of
ownership of a possession.Fourth, thoughts about
possessions do not lead to an urge to get rid of them or
to perform any ritual.[3,22,46,47,49]Hoarding is rather a
‘‘passive’’ phenomenon whereby intense distress may be
triggered only when sufferers face the prospect of
having to discard their possessions. The term ‘‘pre-
occupation’’ may be more appropriate than ‘‘obses-
sion.’’When directly confronted with having to
discard one of their possessions, individuals who hoard
are as likely to experience grief, or sometimes anger, as
anxiety,[3,46,50,51]emotions seldom seen in response to
typical obsessions. Unlike in OCD, compulsive hoard-
ing symptoms worsen over each decade of life;[19,52]
distress and disability often appear late in the course of
the syndrome and are usually linked to the intervention
of third parties, such as relatives or local authorities.
Fifth, the frequently egosyntonic nature of hoarding
symptoms and more common lack of insight in
compulsive hoarders contrasts with typical OCD
patients,perhaps with the exception of some OCD
patients with predominant symmetry/ordering symp-
toms. Indeed, in some patients with compulsive
hoarding, saving and acquisition are associated with
positive emotions of excitement, pleasure, and euphor-
ia. Moreover, they may contribute to patients’ sense of
self and even life-purpose. Such experiences are rarely
seen in OCD and more closely resemble those found in
impulse control disorders.
Although some patients with OCD present clinically
significant hoarding symptoms, a substantial number of
individuals with severe hoarding do not display other
OCD symptoms. For example, in a sample of 217
patients diagnosed with significant hoarding problems
and generated by community solicitation, only 18%
were diagnosed with concurrent OCD (based on
comorbidity rates with major depression, social phobia,
and GAD were 36, 20, and 24%, respectively.In a
recent epidemiological study of compulsive hoarding
(N5742), none of the participants classed as ‘‘hoar-
ders’’ met diagnostic criteria for OCD,although the
instrument used in this study to determine hoarding
caseness did not assess the broad hoarding phenotype
(including clutter and excessive acquisition) and its
associated interference and distress.
A recent study by Pertusa et al.further examined
this question by recruiting and comparing individuals
with severe hoarding with and without OCD. The
authors recruited OCD patients with prominent
hoarding symptoms (n525), individuals with severe
hoarding without OCD (n527), OCD patients with-
out hoarding (n571), anxious controls (n519), and
community controls (n521). Compulsive hoarding
was diagnosed using the working criteria, described
above. In addition, individuals with severe hoarding
had to score 40 or higher on the Saving Inventory-
Revised,which reflects clinically significant hoard-
ing problems. Participants fulfilling these criteria were
then further divided into two groups according to the
presence/absence of a DSM–IV diagnosis of OCD.
Individuals with severe hoarding were diagnosed as
having OCD only if they endorsed other prototypical
OCD symptoms, or had obsessions/compulsions as
defined in the DSM–IV. The results indicated that the
phenomenology of hoarding behavior was largely
similar in the two hoarding groups. The majority of
participants in both hoarding groups reported hoard-
ing similar types of items and for strikingly similar
reasons (i.e., their emotional or intrinsic value). Even in
most patients with OCD, their hoarding was clearly
unrelated to other ‘‘traditional’’ OCD themes, suggest-
ing that the two phenomena are independent. Another
key finding was that, in about one-fourth of the
individuals with severe hoarding who also met criteria
for OCD (which represented approximately 12% of the
overall sample of hoarding individuals), their hoarding
could be explained as a consequence of true obsessions.
Examples included fear of catastrophic consequences
(e.g., superstitious thoughts, contamination of others)
if items are discarded, need to perform onerous
compulsions (e.g., checking, mental rituals) associated
with the process of discarding that ultimately led to
complete avoidance of discarding, urges to pick up
items with a certain shape/texture from the street, the
need to buy items in certain numbers in order to feel
just right, or to avoid contaminating others.These
patients were also more likely to hoard bizarre items
(such as rotten food, bodily products, etc.), which is
rarely seen when hoarding is unrelated to OCD. The
authors concluded that in most cases (88% of
individuals in their sample; n552) compulsive hoard-
ing is a separate condition, which can co-occur with
OCD as well as with other psychiatric disorders,
although in a minority of cases, hoarding behaviors
can occur as a consequence of—that is, be secondary
to—traditional OCD symptoms. Consensus criteria
that have not undergone study but that may be useful
to identify OCD-related hoarding (i.e., hoarding as a
compulsion) are listed below. A diagnosis of OCD
should be considered if the individual meets all of the
(1) The hoarding behavior is driven mainly by proto-
typical obsessions (e.g., fear of contamination,
superstitious thoughts, intense feelings of incom-
pleteness, or saving to maintain a record of all life
experiences) or is the result of persistent avoidance
of onerous compulsions (e.g., not discarding in
order to avoid endless washing or checking rituals).
(2) The hoarding behavior is generally unwanted and
highly distressing (i.e., the individual experiences
no pleasure or reward from it).
560Mataix-Cols et al.
Depression and Anxiety
(3) The individual shows no interest in the majority of
the hoarded items (i.e., the items do not have a
sentimental or intrinsic value for the individual).
(4) Excessive acquisition is usually not present; if
present, items are acquired or bought because of
a specific obsession (e.g., an urge to pick up items
with a certain shape/texture from the street, the
need to buy items in certain numbers, or to buy
items that have been accidentally touched in order
to avoid contamination of others if they touch these
items) and not because of a genuine desire to
possess the items.
However, the fact that hoarding often appears in the
absence of other significant OCD symptoms does not
fully rule out the possibility that compulsive hoarding
may be a variant of OCD. Similar arguments have been
put forward in other OCD-related disorders, such as
body dysmorphic disorder (BDD)or hypochondria-
sis.[54,55]Like compulsive hoarding, these disorders are
somewhat similar to OCD but also seem sufficiently
distinct. Arguably, the fact that these disorders have
through the various editions of DSM, has contributed
to the greater acceptance for BDD and hypochon-
driasis as separate disorders.
A number of recent correlational studies[15,22,42,56,57]
also suggest that hoarding should not be conceptua-
lized as a symptom of OCD. These studies have found
that correlations between hoarding and prototypical
OCD symptoms are typically in the small-to-moderate
range, comparable to correlations with other non-
OCD measures, such as anxiety and depression. By
contrast, prototypical OCD symptoms show stronger
intercorrelations. For example, Abramowitz et al.
recruited samples of OCD patients (n5225), patients
with other anxiety disorders (n5178), and a group of
unscreened undergraduate students (n51,005), and
found that hoarding tended to correlate more weakly
with other OCD symptoms than the other symptoms
intercorrelated, and that hoarding symptoms were not
correlated with global OCD or anxiety severity,
whereas other OCD symptoms were. A taxometric
analysis of OC symptoms in an unscreened student
sample found that hoarding showed evidence of
taxonicity, indicating that it constituted a discrete
categorical latent subclass, whereas the other OC
symptoms were found to be dimensional, varying by
degrees along a continuum.If replicated, these
findings may be suggestive of distinct etiological
mechanisms in compulsive hoarding and OCD.
hoarding postulates that hoarding is associated with
deficits in information processing, problems with
emotional attachments to possessions, erroneous be-
liefs about possessions, and avoidance and approach
behaviors specific to compulsive hoarding.[3,17]Some
of these deficits are shared with OCD patients while
others differ in severity or are quite distinct. With
respect to information-processing deficits, compared to
OCD patients, compulsive hoarding patients show
significantly greater problems with categorization of
objects,[58,59]attention deficits,and decision-making
difficulties.[40,60]Furthermore, they show a different
pattern of mediation of memory deficits.In contrast
to OCD, compulsive hoarding patients show emotional
attachments to their possessions, sometimes equating
them with their sense of self and well-being, and
occasionally imbuing them with human characteris-
tics.[3,39,44,47,62,63]Although people with compulsive
hoarding problems exhibit excessive responsibility, the
form is different from that observed in OCD and more
closely tied to the fate of the possession rather than
responsibility for harm coming to someone.[45,62]
Characteristics, such as perfectionism and uncertainty,
are common to both compulsive
OCD.[25,39,45,46,50,64]Unlike OCD, however, compul-
sive hoarding patients display no exaggerated beliefs
associated with the importance of or control over
Overlapping with some symmetry-
related obsessions, touching or moving possessions
without permission provokes great distress in hoarding
patients and reflects an excessive desire to maintain
control over possessions.[3,46]Finally, the nature of
avoidance patterns differs somewhat in that compul-
sions in OCD are attempts to avoid, escape, or
neutralize the threat posed by the obsession and are
primarily anxiety driven. In contrast, individuals with
compulsive hoarding avoid discarding possessions and
end up storing them as a way to avoid the experience
of loss, having to make an anxiety-provoking decision,
or making a mistake regarding a possession. Thus,
hoarding behavior is in these individuals driven by a
variety of emotions, including sadness, anger, and
distress, which occur when there is a threat of losing a
possession.[3,17,47,62]Also, distinct from most symp-
toms in OCD, saving and acquiring behaviors are often
positively reinforced in compulsive hoarding by posi-
tive feelings of pleasure, safety, and comfort provided
by acquiring new items or fantasizing about existing
Evidence against the consideration of compulsive
hoarding as a symptom of OCD also comes from
preliminary neuroimaging, genetics, and treatment
outcome studies. A detailed review of this literature is
beyond the scope of this article and can be found
elsewhere.[5–7]Briefly, preliminary evidence suggests
that hoarding symptoms may have a distinct neural
substrate to that of OCD. Compulsive hoarding shows
a unique pattern of abnormal resting state brain
function that does not overlap with that of nonhoard-
ing OCD.[5,23]Whereas OCD symptoms are mediated
by elevated activity in specific orbitofronto–striatal–
symptoms seem to be mediated by partially distinct
fronto–limbic circuits involving the cingulate cortex,
ventromedial prefrontal cortex, and limbic struc-
tures.[5,18,23,25]Similar results were obtained in com-
561Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
pulsive hoarding samples withand primarily with-
outOCD, but more research is needed before firm
conclusions can be drawn. Interestingly, these pre-
liminary results are consistent with the animal and
human lesion literature, which also implicate the
ventromedial prefrontal cortex and subcortical limbic
structures in hoarding behavior.Genetic studies to
date have been conducted in the context of other
disorders,such as Tourette’s
OCD.[34,70–72]Their results have been inconsistent,
but are broadly supportive of the idea that hoarding is
etiologically distinct from OCD. Finally, the fact that
hoarding symptoms tend to be less responsive to
evidence-based treatments for OCD, including expo-
sure and ritual prevention and serotonin reuptake
inhibitors,[7,36,73,74]further supports the idea of differ-
ent etiological mechanisms in compulsive hoarding and
OCD. Table 1 summarizes the differences and simila-
rities between compulsive hoarding and OCD.
Summary and preliminary recommendations: There is a
historical link between OCD and hoarding, and in
some patients with OCD, their hoarding seems
secondary to other OCD symptoms, such as fear of
contamination or harm. In these cases, hoarding can be
conceptualized as a symptom of OCD (i.e., a compul-
sion). However, in the majority of patients with OCD,
hoarding cannot be better accounted for by other OCD
symptoms. When not secondary to other OCD
symptoms, the phenomenological differences between
hoarding and OCD seem to outweigh the similarities.
There may also be important differences in cognitive-
behavioral processes, course of the illness, neurobiolo-
gical substrates, and treatment response. Furthermore,
most hoarders do not have other clinically significant
OCD symptoms, and OCD is not the most common
comorbidity. Thus, the classification of compulsive
hoarding as an OCD symptom only covers a minority
of hoarding cases. A new diagnostic category may be
needed to cover the majority of cases where hoarding
occurs in the absence of, or independently from, other
OCD symptoms. Careful evaluation of hoarding
symptoms and good operational criteria are required
to distinguish hoarding as a compulsion and hoarding
as a separate diagnosis, particularly as some patients
seem to meet diagnostic criteria for both hoarding (as a
separate syndrome) and OCD.
Is compulsive hoarding a symptom of OCPD?
mentioned earlier, ‘‘the inability to discard worn-out or
worthless objects even when they have no sentimental
value’’ is one of the eight current criteria for OCPD in
DSM–IV-TR. This criterion has its origins in the
psychoanalytical clinical descriptions of the ‘‘‘anal’’
character, but has only been a core diagnostic criterion
for OCPD since DSM-III-R (see[7,15]). However, there is
remarkably little empirical evidence to support the
inclusion of hoarding as one of the OCPD criteria. In
fact, the equivalent diagnostic category in ICD-10
(Anankastic Personality Disorder) does not include any
It also is questionable to what extent the current
definition of hoarding in the OCPD criteria (i.e.,
focusing on non-sentimental worthless objects) actually
fits most cases of hoarding that are seen clinically.
Sentimental saving is one of the main reasons for
hoarding in these patients, who often save both
worthless and valuable objects.[3,22,44]
There are at least three relevant questions about the
relation between hoarding and OCPD.
Does the hoarding criterion ‘‘belong’’ with the other
Several studies have examined the
internal consistency and factor structure of the
OCPD construct and provide useful clues regarding
the hoarding criterion. For example, Grilo and co-
workersreported modest intercorrelations (ranging
from .35 to .62) between the eight OCPD criteria in
a sample of 211 outpatients with binge-eating dis-
order. The hoarding criterion showed some of the
smallest correlations (ranging from .19 to .28) with
the remaining OCPD criteria. Furthermore, in a
principal components analysis that yielded three
factors, the hoarding criterion loaded on a separate
factor, together with the miserliness item.Although
the three factors were intercorrelated, the rigidity
and perfectionism factors showed stronger inter-
correlations (r5.51) than either did with the hoard-
ing/miserliness factor (r5.27 and r5.35, respectively).
A subsequent confirmatory factor analysis in a large
sample of 263 patients with binge-eating disorder
found support for both 2- and 3-factor solutions.
The authors suggested that the hoarding and miserli-
ness criteria might be less indicative of OCPD and
that the construct may be improved with their
Hummelen et al.examined data from a large
sample of 2,237 patients from the Norwegian Network
of Psychotherapeutic Day Hospitals; they specialize in
the treatment of personality disorders. They found
modest reliability for OCPD (Cronbach’s a5.57) and
weak correlations between the hoarding criterion and
the other OCPD criteria (range .06–.14). Exploratory
and confirmatory principal components analyses did
not replicate the factor structure reported by Grilo
but, crucially, the hoarding criterion did not load
significantly on any of the resulting factors in either
exploratory or confirmatory analyses. These authors
also concluded that the overall validity of the OCPD
construct could be improved by the removal of the
hoarding and miserliness criteria.
Overall, these and other similar studies[78–80]suggest
that the internal consistency of the OCPD construct is
weak, hoarding and misery items tend to have the
poorest psychometric properties, hoarding correlates
weakly with the remaining OCPD criteria, and validity
of the OCPD construct would be improved by the
removal of these criteria. Accordingly, the DSM-V
Personality and Personality Disorders Workgroup is
currently recommending the exclusion of hoarding as a
major trait or dimension of OCPD.
562Mataix-Cols et al.
Depression and Anxiety
TABLE 1. Differences between compulsive hoarding and OCD
Presence of a diagnosis of OCD
Possible as a comorbid condition (approximately 20% of cases), but OCD not
most frequent comorbidity
Mood and anxiety disorders more frequent
Presence of obsessions as defined in
Yes, in most cases
Fears of losing important things resemble and may be functionally similar to
Absence of intrusive, unwanted and repugnant thoughts, images, or impulses
that are actively resisted
Intense distress often triggered when sufferers face the prospect of having to
Presence of compulsions as defined in
Yes, in most cases
Avoidance of discarding and acquisition behaviors may be functionally similar
Presence of clinically significant hoarding
Possible, but rare (approximately 5% of cases)
Clinician needs to ascertain if hoarding is secondary to other
OCD themes (e.g., fears of contamination or harm) or an
independent (i.e., comorbid) problem. The latter is more
Always. Hoarding due to practical or sentimental reasons
If comorbid with OCD, hoarding not secondary to other OCD symptoms or
magically linked to classic obsessional fears
Presence of a diagnosis of OCPD
Possible, in approximately one-fourth of cases
Possible, in approximately one-third of cases. However, when the hoarding
criterion is excluded, compulsive hoarders are not more likely to endorse
OCPD than other anxiety disorders
Presence of non-OCPD personality disorders (e.g., dependent PD) is more
It varies, but good in most cases
More likely to be poor
Hoarding can be egosyntonic, particularly at the initial stages
Becomes increasingly distressing as clutter increases and third parties intervene
Many sufferers seek help, although this may take several years
Often reluctant to seek help as hoarding not seen as problematic
Local authorities and/or significant others often insist they seek help
This may be due to lack of insight and/or lack of awareness and of adequate
Stability of problem
Symptoms can wax and wane
Stable but worsens over time
Yes (27–47% genetic in adults, higher in children)
Yes (50% genetic in adults)
Large body of evidence
Cingulate cortex and ventral frontal and limbic regions.
Overestimation of threat/responsibility.
Importance/control of thoughts
Perfectionism/need for certainty
Information-processing deficits: decision-making, categorization, organization,
Emotional attachment to possessions
Erroneous beliefs about possessions
Compulsive behavior in OCD is negatively reinforced via
avoidance conditioning (avoiding distress, fearedconsequences, etc.), but there is no positive reinforcement
of OCD symptoms
In hoarding, there is both avoidance conditioning (avoiding loss, etc.) and
positive reinforcement (from acquisition, admiration of possessions,
attaching self-related meanings, and identity to objects)
Treatment response (CBTand SRIs)
Moderate to good
Large body of evidence
Poor to moderate
Adapted from Pertusa et al.and Rachman et al..
563 Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
Is compulsive hoarding in OCD associated with an
increased risk for OCPD?
clinical OCD studies that have examined the relation
between the hoarding items of the Yale–Brown
(Y-BOCS-SC) and the presence of personality dis-
orders. Hoarding was associated consistently with
increased prevalence of several personality disor-
Regarding OCPD, several but not all (see) of
these studies showed that the presence of hoarding
symptoms in OCD was associated with increased
frequency of OCPD, even when the hoarding criterion
was removed from the analyses.[60,81]This would
suggest an association between hoarding symptoms
and the remaining OCPD criteria. However, it is
important to note the limitations of these studies. First,
they recruited samples of OCD patients rather than
compulsive hoarding individuals. Second, hoarding was
ascertained with two items of the Y-BOCS-SC, which
do not capture the different features of the syndrome
(i.e., clutter, acquisition, distress, interference, etc.),
and thus may provide inadequate assessment of the
severity of compulsive hoarding.
To our knowledge, only three studies to date
specifically recruited large samples of compulsive
hoarding individuals and examined the association
between hoarding and OCPD. Frost et al.compared
OCD patients with prominent hoarding symptoms
(n537), nonhoarding OCD patients (n520), anxious
controls (n513), and community controls (n534).
They found equivalent levels of OCPD symptoms in
the three clinical groups. They also found that the
OCD hoarders scored significantly higher than the
OCD nonhoarders on measures of Dependent and
Schizotypal PD, further indicating the lack of any
specific relation between hoarding and OCPD. The
only item on which hoarders scored higher than any of
the other groups was the tendency to get lost in the
details and lose sight of the big picture. Similarly,
Pertusa et al.found that, after the exclusion of the
hoarding criterion, the number of endorsed OCPD
criteria was comparable in OCD patients with promi-
nent hoarding symptoms, severe hoarders without
OCD, OCD patients without hoarding, and anxious
controls. In a just completed study, Frost et al.
found that among a large sample of carefully diagnosed
hoarders (n5217) and nonhoarding OCD patients
(n596), OCPD was diagnosed more frequently among
hoarders than nonhoarding OCD patients when the
OCPD hoarding criterion was used for diagnosis, but
not when it was omitted as a criterion. Patients
diagnosed with hoarding were also significantly more
likely than nonhoarding OCD patients to be diagnosed
with dependent personality disorder. Thus, the specific
association between compulsive hoarding (regardless of
whether it occurs with or without OCD) and OCPD
could be entirely explained by the overlapping item
content. These studies also suggest that hoarding is as
There are a number of
likely to be associated with other personality disorders
as with OCPD.
Is the hoarding criterion of OCPD associated with
an increased risk of OCD?
ined data from an epidemiological study of personality
disorders in the Baltimore area (n5742). Based on the
OCPD hoarding criterion, they estimated the pre-
valence of compulsive hoarding to be 4% (5%
weighted) of the population. They found that none of
the individuals classified as ‘‘hoarders’’ met diagnostic
criteria for OCD. Conversely, none of the 13
participants who were diagnosed with OCD had
pathological hoarding, although 4 of these patients
had subthreshold hoarding behavior.
In the study by Hummelen et al.,several OCPD
criteria, but not the hoarding criterion, were associated
with OCD. Instead, hoarding was associated with
paranoid and dependent personality disorders. Wu
et al.found that neither hoarding nor any of the other
seven OCPD criteria were significantly more frequent in
OCD patients than in general psychiatric outpatients.
Contradicting this finding, however, Eisen et al.found
that the hoarding criterion of OCPD was significantly
more frequent in patients with OCD than in patients with
other emotional disorders. Thus, there are conflicting
results regarding the relation between hoarding and
OCPD, but it is important to note that in all these
studies hoarding was assessed with a single item, so it is
unclear whether individuals endorsing the hoarding
criterion have clinically significant hoarding problems.
Summary and preliminary recommendations: The hoard-
ing criterion of OCPD excludes ‘‘sentimental’’ collecting,
and thus does not fully correspond with the construct of
compulsive hoarding. The available data suggest that the
hoarding criterion has poor psychometric properties and
weak associations with the other OCPD criteria. In
patients with OCD or OCPD, evidence for a specific
association between compulsive hoarding (measured with
a single item) and the remaining OCPD criteria is mixed.
However, recent carefully conducted studies that re-
cruited severe hoarders (with or without comorbid OCD)
indicate that the link between hoarding and OCPD could
be explained largely by the overlapping item content.
They also indicate that hoarding is not more likely to be
associated with OCPD than with other personality
disorders. Thus, our review indicates that exclusion of
the hoarding criterion from OCPD would improve its
internal consistency, bring DSM-V closer to ICD-11, and
remove some of the confusion around hoarding in DSM-
V. This recommendation is in line with the current
thinking of the DSM-V Personality and Personality
Samuels et al.exam-
SHOULD COMPULSIVE HOARDING BE
INCLUDED AS A SEPARATE DIAGNOSIS IN
In this section, we focus on the question of whether
hoarding should be included as a diagnosis in DSM-V.
564Mataix-Cols et al.
Depression and Anxiety
We address several criteria for making this decision,
drawing in part on the DSM-IV definition of mental
disorder, but also including ongoing discussion in the
literature about the importance of diagnostic validity
and clinical utility.
The condition is a behavioral or psychological
syndrome or pattern that occurs in an indivi-
The entity of hoarding has been described in
the literature for more than a century and has its
origins in the psychoanalytical descriptions of the
‘‘anal’’ character.The operational definition and
provisional diagnostic criteria for compulsive hoarding
as a syndrome have been available since 1996 and have
been widely adopted by the field. These diagnostic
criteria have been recently refined (see above) and seem
to have adequate clinical face validity, as they are based
on hundreds of cases from around the world that have
been fairly consistently described.
Prevalence studies using the proposed diagnostic
criteria listed above have not been done. However, a
series of recent epidemiological studies have been
conducted using reliable and valid psychometric
instruments, which closely mirror the proposed diag-
nostic criteria, such as the Savings Inventory-Re-
and the Hoarding
Report.[29,84]The prevalence of clinically significant
compulsive hoarding is estimated to be in the region of
2–5% of the general population.[20–21,42]
The consequences of which are clinically sig-
nificant distress or disability.
provides evidence that compulsive hoarding directly
causes significant distress and/or disability. When
hoarding is severe enough to meet diagnostic criteria,
clutter prevents the normal use of space to accomplish
basic activities, such as cooking, cleaning, moving
through the house, and even sleeping. Interference with
these functions can make hoarding a dangerous
problem, putting people at risk for fire, falling
(especially elderly people), poor sanitation, and health
risks.[3,85–87]In a survey of health department complaints
about hoarding, officers judged hoarding to pose
significant health risks and in 6% of such cases, hoarding
was thought to contribute to the individual’s death in a
house fire.Pathological hoarding also represents a
profound public health burden in terms of occupational
impairment, poor physical health, and social service
For example, the work impairment
index among hoarders significantly exceeds that of all
other anxiety, mood, and substance use disorders.
This study also found that 8–12% of hoarding
participants had been evicted or threatened with eviction
due to hoarding at some point in their lives.A recent
study examined the possible link between lifetime
hoarding problems and homelessness in a randomly
selected sample of 78 homeless people newly admitted
to Salvation Army hostels across several major cities in
the United Kingdom (Mataix-Cols, Grayton, Bonner,
Luscombe, Taylor, and van den Bree, Unpublished
Data). Thirteen individuals (17%) endorsed lifetime
The extant literature
moderate/severe difficulties on at least one item of
the Hoarding Rating Scale-Interviewand 6 (7.7%)
reported that their hoarding problems, particularly
excessive acquisition leading to financial difficulties,
had directly contributed
(Mataix-Cols et al., Unpublished Data). Hoarding also
has a substantial impact on the family members of the
sufferers.In addition to these direct consequences of
hoarding, some indirect consequences have also been
described, such as social isolation or hostility from
neighbors, which further add to the problem. Taken
together, these direct and indirect consequences of
compulsive hoarding are serious enough to warrant its
consideration as a mental disorder.
The proposed syndrome is not merely an
expectable response to common stressors or losses,
or a culturally sanctioned response to a particular
hoarding could be linked to early material deprivation,
but the little research available to date has not strongly
supported this. Frost and Grossfound that hoarders
and non-hoarders did not differ in their responses to
the question, ‘‘When you were young, was there a
period of time when you had very little money?’’ There
was also no difference in ratings of how ‘‘impoverished’’
or ‘‘well-off’’ they described their childhood. Perhaps
emotional rather than material deprivation may be
important in compulsive hoarding.
A number of studies have found abnormally high
levels of trauma or stressful life events among people
who hoard,[42,47,89]and that such events are sometimes
temporally linked to symptom onset or exacerba-
tion.[52,90]However, once symptoms begin, the course
of hoarding is often chronic, with a minority of patients
experiencing a remitting and relapsing course.
Thus, in most cases, there is no evidence that
compulsive hoarding is merely an expectable response
to common stressors or losses.
Saving occurs on a continuum, and collecting
possessions can range from totally normal and adaptive
to excessive or pathological. Most normal children have
collections of some sort.[91–93]For example, a cross-
sectional study among parents reported that their
children began to collect or store objects on average
from 25 to 27 months of age.This behavior then
showed a monotonic increase, at least until the age
of 6, when nearly 70% of normal children display
this trait.However, the term ‘‘compulsive hoarding’’
refers to an extreme form of this behavior, which
and disability (as described in the earlier section).
Pathological hoarding in children seems to be easily
distinguished from normal saving behavior.Thus, it
is clear that it is not simply a culturally sanctioned
The proposed syndrome reflects an underlying
psychological and biological processes underlying
compulsive hoarding has grown exponentially over
to their homelessness
Research into the
565Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
the last decade (Fig. 1), particularly after the publica-
tion of the initial operational definition of compulsive
hoarding by Frost and Hartl.This literature covers a
wide range of topics, including psychopathology,
epidemiology, cognitive-behavioral models, genetics,
neuroimaging, neuropsychology, personality, and treat-
ment (seefor a comprehensive review). For example,
psychological research has found that compulsive
hoarding stems from four overlapping processes: (a)
information-processing deficits relating to decision-
making, categorization, and organization, as well as
memory difficulties; (b) emotional attachment to
possessions; (c) behavioral avoidance; and (d) erroneous
beliefs about the nature of possessions.[3,17]Family
studies have demonstrated that hoarding runs in
families, and a recent twin study has found that this
familiality is due to both genetic and non-shared
environmental factors.Neuroimaging studies have
begun to elucidate the neural correlates of compulsive
hoarding. Resting state functional brain imaging
studies have revealed that compulsive hoarders have
abnormally low activity in the cingulate cortex, as
compared to both normal healthy controls and patients
with nonhoarding OCD.[5,23]Compulsive hoarders
also have abnormal patterns of brain activation during
provocation of hoarding symptoms and decision-
making tasks, compared to controls.[18,25]Neuropsy-
chological studies have shown that compulsive hoar-
ders have deficits in executive functioning, attention,
memory, and categorization.[27,58,61,94]The results of
neuroimaging and neuropsychological studies converge
to reveal that the pathophysiology of compulsive
hoarding involves abnormalities in the neural systems
mediating decision-making, attention, organization,
and emotional regulation.
The syndrome is not solely a result of social
deviance or conflicts in society.
In some cases,
people with hoarding are not distressed by their
behavior, but their families may be distressed about
clutter or expenses, and society may be concerned
about health hazards or other negative consequences of
hoarding. However, given the evidence of associated
impairment and underlying disturbance, it seems clear
that compulsive hoarding is not solely a result of social
deviance or conflicts with society.
The syndrome has diagnostic validity using one
or more set of diagnostic validators.
into compulsive hoarding has been done in the context
of OCD but, increasingly, researchers have focused on
compulsive hoarding as a stand-alone problem. As
noted above, compulsive hoarding differs from OCD
and OCPD in several important ways, but there are
limited data on several of the standard diagnostic
validators being used for DSM-V. Although there is
some evidence that compulsive hoarding differs from
other disorders on diagnostic stability, prior psychiatric
history and patterns of comorbidity, course of illness,
cognitive-emotional correlates, biological markers, and
response to treatment, there are limited or no data on
familial aggregation, environmental risk factors, and
temperament correlates. Although the differences
between hoarding and OCD outweigh the similarities,
until more data become available, an option to be
considered is whether compulsive hoarding should be
coded as a variant of OCD.
The syndrome has clinical utility.
of hoarding as a separate diagnosis has the potential to
increase the usefulness of the nosological system and
improve clinical utility in a number of ways. As
mentioned earlier, compulsive hoarding is a relatively
prevalent problem, representing a substantial burden
for the sufferers, their families, and society at large. Yet,
it remains largely unrecognized and undertreated.
Including hoarding as a separate disorder would
potentially increase public awareness, improve identi-
fication of cases, accuracy of diagnosis, and tailoring of
treatment. In fact, recognizing the unique status of
compulsive hoarding, researchers are already develop-
ing specific psychological interventions for this pro-
blem,[26,74,95,96]as these patients do not respond
optimally to standardized protocols developed for
other disorders, such as OCD.
Including hoarding in DSM-V also would help
reduce the current ambiguities in DSM-IV-TR, where
hoarding is simultaneously considered an associated
symptom of OCD and a diagnostic criterion for
OCPD. This would facilitate professional communica-
tion, as the proposed criteria have face validity and are
easily understood by clinicians. The criteria are also
‘‘patient friendly,’’ as in our experience many compul-
sive hoarders are unhappy with a diagnosis of OCD
and feel they do not fit in OCD patient organizations.
In our view, the potential benefits of creating a new
diagnosis (e.g., improve clinical communication, pro-
vide better patient care, stimulate new research) out-
weigh the potential harms (e.g., hurt particular
Figure 1. Publication trends in human hoarding research until
February 2010. Search performed on PubMed on February 22,
2010. The search included all papers containing the truncated
term ‘‘hoard?’’ in the title, the abstract, or the keyword list.
Animal studies were excluded from the search. Human studies
that included the keyword ‘‘hoard?’’ but were not directly relevant
to the hoarding disorder literature were also excluded. As can be
seen in the figure (red arrow), the publication of the landmark
study by Frost and Hartl,where compulsive hoarding was first
defined operationally, marks an inflexion point in the field.
566Mataix-Cols et al.
Depression and Anxiety
normal behaviors). It seems highly likely that many
sufferers with compulsive hoarding do not present for
treatment at all, in part because there is a lack of public
awareness that the symptoms represent a valid clinical
entity. In our clinical experience, many patients with
compulsive hoarding often receive no diagnosis or an
inaccurate diagnosis in clinical settings. Hoarding
symptoms are often not routinely asked about. Many
compulsive hoarders seek help when they have
substantial comorbidities, particularly OCD, simply
because hoarding has traditionally been associated with
OCD. When this happens, treatment is according to
available treatment guidelines for OCD, but hoarding
symptoms are rarely treated on their own. Treatment
failures are frequent.Although compulsive hoarding
is often complicated by comorbidity, it occurs often in
isolation and is sufficiently disabling on its own to
require specific treatment. The creation of a new
diagnosis in DSM-V would address much of this unmet
need. It would also likely stimulate research into the
etiology and treatment of compulsive hoarding using
an agreed-upon set of diagnostic criteria. Furthermore,
routine exclusion of patients with comorbid compulsive
hoarding would also increase the reliability and
replicability of OCD studies. In fact, many OCD
studies now routinely exclude compulsive hoarders
from their samples.
It is also important to consider the potential
disadvantages of the creation of a new hoarding
disorder. We are not aware of how a diagnosis of
compulsive hoarding could be misused in a way that
might produce harm, nor is this issue mentioned in the
published literature. However, as in many areas of
psychopathology, it can be difficult to establish the
dividing line between normal or/and pathological
behavior, in this case ‘‘eccentric’’ collectionism and
compulsive hoarding. Therefore, there is a potential
risk of ‘‘pathologizing’’ essentially normal behavior. It is
crucial that the proposed diagnostic criteria discrimi-
nate between adaptive and maladaptive degrees of
hoarding behavior. One problem is that many compul-
sive hoarders have limited insight into their problem, at
least initially, and may deny that they have a problem,
let alone a mental disorder. Often, in our experience,
third parties, such as spouses or local authorities, insist
that these individuals seek help. This may raise ethical
issues about coercing people to receive treatment
against their will. The public recognition of hoarding
is changing, as illustrated by the fact that currently
nearly 40% requests for information or help from the
Obsessive Compulsive Foundation are for hoarding-
related problems (Szymanski, August 2009, Personal
Communication). Other important considerations are
the social and economic consequences of a new disorder
with an estimated prevalence between 2 and 5% of the
population. Should all these individuals be in treatment
for compulsive hoarding? What are the financial
implications for the health systems? Careful weighing
be subjectto misuse, pathologize
of the potential harms of creating a new diagnosis
against the potential harms of not creating it is needed.
Several additional considerations may arise when
proposing a new disorder for the nomenclature. These
include: (1) Is there a need for the disorder; for
example, is the syndrome sufficiently common in
clinical or population samples that it merits an
independent category as opposed to being one example
in an NOS category; (2) What is the relation of the
proposed disorder with other DSM-V diagnoses; for
example, is the disorder sufficiently distinct from
other diagnoses?; (3) Are there proposed diagnostic
criteria with clinical face validity, reliability, and
adequate sensitivity and specificity for the proposed
construct?; and (4) Can the criteria be easily imple-
mented in a typical clinical interview and reliably
operationalized/assessed for research purposes? In each
of these cases, as discussed above, there are data to
support the entry of hoarding into the nomenclature.
The differentiation from OCD is perhaps the most
Summary and preliminary recommendations: Compul-
sive hoarding seems to meet the above criteria to
qualify as a new disorder in DSM-V, although data
from some of the standard diagnostic validators being
used for DSM-V are unavailable. There are important
DSM-V, but the potential disadvantages need to be
considered carefully before final decisions are made.
IF HOARDING WERE TO BE INCLUDED AS A
SEPARATE DIAGNOSIS, ARE ANY CHANGES
TO ITS PROPOSED CRITERIA WARRANTED?
FOR EXAMPLE, MIGHT CHANGES BE
NEEDED IN ORDER TO REFLECT GENDER,
DEVELOPMENTAL, OR CROSS-CULTURAL
The above proposed criteria for compulsive hoarding
are widely used and seem to have adequate clinical face
validity, as they are based on hundreds of cases from
around the world that have been fairly consistently
described. The criteria are already being routinely used
in research and clinical settings by a number of groups
in the United States, United Kingdom, Australia, Italy,
Germany, and Japan. However, the reliability, sensitiv-
ity, and specificity of the proposed diagnostic criteria
have yet to be formally researched. It is pertinent to
consider whether the proposed criteria appear to be
suitable for both genders, for a range of developmental
stages, and in different cultures and ethnic groups.
Compulsive hoarding can affect both men and
women. Two epidemiological studies[20,42]found a
higher prevalence among men than among women,
whereas a third study did not.By contrast, clinical
samples are predominantly female.This may suggest
that men are more reluctant to come forward with their
hoarding problems. Nevertheless, the phenomenology
of hoarding is remarkably similar in men and women,
567 Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
and thus the criteria seem to be equally suitable for
both genders (e.g.,).
Clinically significant hoarding problems seem to be
more prevalent in older than younger adults and
children.The approximate mean age of participants
taking part in research studies is around 50 years
(e.g.,). However, there is evidence that hoarding
problems may start several decades before these
individuals present themselves to clinics or research
studies. Although the natural history of compulsive
hoarding remains to be investigated systematically in
prospective studies, several retrospective studies sug-
gest that hoarding symptoms first emerge in childhood
or early adolescence, at an average age of 12–13
(e.g.,[19,39,52,97,98]) and start interfering with indivi-
duals’ everyday functioning by the mid-30s.[22,52,99]
Grisham et al.reported that among the different
symptoms of hoarding, acquisition had a somewhat
later onset than either difficulty discarding or clutter,
possibly due to greater financial and physical indepen-
dence and the means to store a greater volume of
possessions. In this study, recognition of the problem
typically began more than a decade after initial onset.
A recent study of elderly compulsive hoarders found
that the initial reported average age of onset was
29.5 years, although when participants were invited
to systematically review events over the life span,
hoarding problems were recalled to have been present
much earlier, in childhood and adolescence.Thus,
although most work has been done in adult popula-
tions, there is evidence that the seeds of compul-
sive hoarding are present early in life and span well
into the late stages of life. The proposed criteria,
therefore, should be largely suitable across the lifespan,
although they may need to be adapted for children
because they typically do not control their living
environment and discarding behaviors (Storch et al.,
Although most of the work has been done in English-
speaking countries and in predominantly Caucasian
samples, the clinical impression from colleagues
around the world suggests that hoarding is a universal
phenomenon. A recent meta-analysis of 21 studies
involving more than 5,000 individuals with OCD
worldwide confirmed that hoarding seems to be
independent from other OCD symptoms in both
English and non-English speaking countries.This
included studies from geographically and culturally
diverse countries, such as Japan, India, South Africa,
and Brazil. Just as in Western countries, OCD patients
with hoarding symptoms from other countries have
been described as having more severe OCD symptoms,
longer illness duration, lower global functioning,
poorer insight, more comorbidity, and poorer treat-
ment outcome than OCD patients without such
symptoms.[34,97,98,101,102]A recent Japanese study care-
fully examined the characteristics and severity of
hoarding in a large sample of OCD patients.They
found that these patients are very similar to their
Western counterparts in terms of clinical character-
istics, items being hoarded, and extent of clutter.
Therefore, although there are no data suggesting that
the criteria need modification for different cultures,
more research is needed on this issue. For example, it is
unclear if hoarding is as much of a problem in
developing countries as it is in industrialized ones,
in individualistic versus collectivistic cultures, and in
urban versus rural communities (where space may be
less of an issue). Research on different ethnic groups
within Western societies is also lacking.
Summary and preliminary recommendations: Working
been available for more than a decade and have been
suitable for both men and women, but it is unclear
whether the existing criteria may need to be modified for
children and for use in developing or non-industrialized
countries and other cultures or ethnic groups. We
recommend a field trial of the proposed criteria to test
their clarity, reliability, validity, and clinician and patient
acceptability across the lifespan and in a broad range of
cultures and ethnic groups.
IF A SEPARATE DISORDER IS INCLUDED,
WHAT SHOULD IT BE CALLED?
To be consistent with the literature, we have used the
words ‘‘compulsive hoarding’’ throughout this review.
However, although the term compulsive is useful and
has been widely adopted by the field, one major
disadvantage to using it is that it suggests links with
both OCD and OCPD. As we have argued, when not
secondary to other OCD symptoms, hoarding is better
conceptualized as a separate disorder. The proposed
diagnostic criteria are explicit in that all organic and
psychiatric pathology, including OCD, need to be
excluded before such a diagnosis can be made. Thus,
the term compulsive has the potential to be confusing
and should perhaps be removed.
tentatively suggest naming the new disorder ‘‘hoarding
IF A SEPARATE DISORDER IS INCLUDED,
WHERE SHOULD IT BE CLASSIFIED
The fact that most hoarding research has been done
in the context of other disorders, such as OCD or
OCPD, and that there are certain similarities between
hoarding disorder and OCD, may lead to the sugges-
tion that hoarding disorder should be classified along-
side other OC-relateddisorders.
conclusion may be premature as hoarding disorder
may also have links with other groupings of disorders,
such as various emotional disorders and impulse
control disorders (ICDs). For example, depression
and several anxiety disorders (particularly, social phobia
568Mataix-Cols et al.
Depression and Anxiety
and GAD) are frequently comorbid with hoarding
disorder.[7,22,33,41,43,60]Furthermore, hoarding symp-
toms are as strongly correlated with non-OCD
symptoms, such as depression and anxiety,[15,57]sug-
gesting a non-specific link with emotional disorders in
general. Hoarding disorder has particularly strong links
with ICDs. First, the observed egosyntonic nature of
some features of hoarding, particularly excessive
acquisition, suggests an association with ICDs.Many
hoarders feel compelled to collect or acquire free items,
as well as to buy excessively.Approximately 61% of
hoarders engage in excessive buying,[21,103]whereas just
over half excessively acquire free things.[28,103]How-
ever, not everyone with hoarding problems reports
excessive acquisition. For example, 10–20% of a large
sample of hoarders reported acquisition that was within
one standard deviation of the nonclinical mean.In
addition, high rates of hoarding disorder have been
described in samples of compulsive buyers.In a
recent epidemiological study, Mueller et al.reported
significant correlations between compulsive hoarding
and compulsive buying measures, and about two-thirds
of participants classified as having compulsive hoarding
were also deemed as suffering from compulsive buying.
Furthermore, some research suggest that beliefs about
possessions and buying are similar to beliefs of those
with hoarding disorder.
Preliminary data also suggest a link with other
ICDs.[3,33,63,87]For example, Samuels et al.reported
a greater frequency of trichotillomania and skin picking
among OCD patients with hoarding compared to
nonhoarding OCD patients. Frost and co-workers
reported high levels of hoarding symptoms in a sample
of pathological gamblers. An association between
kleptomania and compulsive buying has also been
proposed,and anecdotal experience gathered by
Steketee and Frostsuggests a link between klepto-
mania and hoarding, but clearly more research is
needed. Steketee and Frostspeculated that perhaps
hoarding is part of a broader category of disorders that
are psychopathologies of acquisition, including hoard-
ing disorder, buying, and kleptomania.
A separate review by Phillips et al. (in this issue)
further examines relations between hoarding disorder
and its ‘‘near neighbor’’ disorders, according to the
diagnostic validators provided by the DSM-V Spec-
trum Study Group.
Summary and preliminary recommendations: Hoarding
disorder has ties with OCD, other anxiety and mood
disorders, and impulse control disorders, particularly
compulsive buying. It is currently unclear where
hoarding disorder should be classified in DSM-V. Until
we learn more about its etiology, this decision
necessarily will require expert consensus. For the time
being, given the historical link between hoarding and
OCD/OCPD, the fact that some hoarders are seen in
OCD clinics, and the conservative approach adopted by
DSM-V, it would be reasonable to provisionally list
hoarding disorder as a separate OCSD with a similar
status as BDD or hypochondriasis, if such a grouping of
disorders is included in DSM-V. An alternative to our
recommendation would be to include it in an Appendix
of Criteria Sets Provided for Further Study. This
determination will be guided by forthcoming guidelines
regarding inclusion of disorders in such a section.
Based on the data reviewed above, we draw a number
of conclusions and preliminary recommendations:
1. Clinically significant hoarding is prevalent and can
vary from mild to life threatening. The personal and
public health consequences of hoarding are sub-
stantial and it is generally considered difficult to
treat. These direct and indirect consequences of
hoarding are serious enough to warrant its con-
sideration as a mental disorder.
2. Hoarding as a characterological trait has its origins
more than a century ago in the psychoanalytical
concept of the ‘‘anal character,’’ which later became
today’s OCPD. However, hoarding has been a core
diagnostic criterion for OCPD only since DSM-III-
R. In DSM-IV-TR, hoarding is still listed as one of
the diagnostic criteria for OCPD. The idea that
extreme hoarding might warrant consideration of
OCD as a diagnosis appears for the first time in
DSM-IV in the differential diagnosis section of
OCPD. However, hoarding is not explicitly listed as
a symptom in the OCD section. This creates
confusion as clinicians may experience difficulties
deciding when a diagnosis of OCD is appropriate,
particularly when hoarding appears in the absence
of other prototypical OCD symptoms.
3. Hoarding behavior can occur in the context of
several developmental, neurological, and psychiatric
disorders. In some cases with OCD, hoarding can
be secondary to or explained by other OCD
symptoms, such as fear of contamination or harm.
In these cases, hoarding should be conceptualized as
a compulsion, but probably not as a major (primary)
symptom dimension. This should be explicitly
mentioned in the text accompanying the OCD
section in the DSM-V.
4. In the majority of patients with OCD, hoarding
cannot be better accounted for by other OCD
symptoms. In these cases, the phenomenological
differences between hoarding and OCD outweigh
the similarities. There may also be important differ-
ences in cognitive-behavioral processes, course of the
illness, neurobiological substrates, and treatment
response. Furthermore, most hoarders do not endorse
other clinically significant OCD symptoms, and OCD
is not the most common comorbidity. Thus, when
569Review: Hoarding Disorder: A New Diagnosis for DSM-V?
Depression and Anxiety
hoarding is not a compulsion, its classification as an
OCD symptom may be inadequate and only covers a
minority of severe hoarding cases. A new diagnostic
category is needed to cover the majority of cases
where hoarding occurs in the absence of, or indepen-
dently from, obsessive-compulsive symptoms.
5. The possibility that this form of hoarding may be a
variant of OCD, with unique features, cannot be
fully ruled out. However, although the body of
evidence is still incomplete, the differences between
hoarding and OCD outweigh the similarities.
6. The hoarding criterion of OCPD excludes ‘‘senti-
mental’’ collecting, and thus does not fully corre-
spond with the construct of compulsive hoarding.
The available data suggest that the hoarding
criterion correlates weakly the other OCPD criteria
and that the specific association between compulsive
hoarding (regardless of whether it occurs with or
without OCD) and other OCPD criteria could be
entirely explained by the overlapping item content.
Hoarding is not more likely to be associated with
OCPD than with other personality disorders. We
recommend the exclusion of the hoarding criterion
from OCPD, as this may improve the internal
consistency of this diagnosis, bring DSM-V closer
to ICD-11, and remove some of the confusion
around hoarding in DSM-V. The DSM-V Person-
ality and Personality Disorders workgroup has been
consulted about this and concurs.
7. Compulsive hoarding seems to meet the criteria to
qualify as a new disorder in DSM-V, although data
from some of the standard diagnostic validators
being used for DSM-V are unavailable. In our view,
the potential benefits outweigh the potential harms
of creating a new diagnosis.
8. Working diagnostic criteria for compulsive hoard-
ing as a syndrome have been available for more than
a decade and have been widely adopted by the field.
They seem to be suitable for both genders and
across most of the life span, although they may need
to be adapted for use in children. It is also unclear
whether the proposed criteria will require adapta-
tion or be relevant to developing or non-industria-
lized countries, different cultures or ethnic groups.
We recommend a field trial of the proposed criteria
to test their clarity, reliability, validity, and clinician
and patient acceptability across the lifespan in
different ethnic groups, and in industrialized as well
as non-industrialized countries.
9. If it becomes a separate diagnostic category, we
suggest calling it hoarding disorder in order to
remove any ambiguities and clearly separate it from
hoarding as a compulsion in OCD.
10. If it becomes a separate diagnostic category, the
most appropriate ‘‘neighborhood’’ for hoarding
disorder is unclear as it has ties with several
groupings of disorders, particularly OCD and
impulse control disorders. Until we learn more
about its etiology, the decision will necessarily
require expert consensus. For the time being, given
the historical link between hoarding and OCD/
OCPD, the fact that some hoarders are seen in
OCD clinics, and the conservative approach adopted
by DSM-V, it would be reasonable to acknowledge
hoarding disorder as an OCSD, if such a group is
included in DSM-V. An alternative to our recom-
mendation would be to include it in an Appendix of
Criteria Sets Provided for Further Study.
We are grateful to Drs. Kathy
Phillips, Scott Rauch, Wayne Goodman, and Janardhan
Reddy for their useful comments.
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