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Hoarding disorder: A new obsessive-compulsive related disorder in DSM-5



Obsessive-compulsive disorder (OCD) and related disorders have been the subject of significant revisions in the fifth edition of the Diagnostic and Statistical Manual (DSM-5). One of these major changes has been the removal of OCD from the 'Anxiety Disorders' section and its instalment in a new and distinct Obsessive-Compulsive and Related Disorders (OCRDs) chapter. However, it is the instatement of hoarding disorder (HD) as a new OCRD that marks the most significant change. Previously considered a symptom of OCPD, and subsequently linked to OCD, it is now acknowledged that hoarding can emerge independently from any alternative condition. The present paper provides an updated review of recent investigations supporting the status of HD as an independent nosological entity. Specifically, we will present the new DSM-5 diagnostic criteria and examine the literature pertaining to the psychopathological and phenomenological aspects of the disorder, with particular attention to practical strategies that can help clinicians to recognise and differentiate HD from OCD. Finally, the available assessment and treatment strategies for HD are summarised.
Modern psychopathologies or old diagnoses?
Journal of Psychopathology 2015;21:354-364
Obsessive-compulsive disorder (OCD) and related disorders
have been the subject of significant revisions in the fifth edition
of the Diagnostic and Statistical Manual (DSM-5). One of these
major changes has been the removal of OCD from the ‘Anxi-
ety Disorders’ section and its instalment in a new and distinct
Obsessive-Compulsive and Related Disorders (OCRDs) chap-
ter. However, it is the instatement of Hoarding Disorder (HD) as
a new OCRD that marks the most significant change. Previously
considered a symptom of OCPD, and subsequently linked to
OCD, it is now acknowledged that hoarding can emerge inde-
pendently from any alternative condition. The present paper
provides an updated review of recent investigations supporting
the status of HD as an independent nosological entity. Specifi-
cally, we will present the new DSM-5 diagnostic criteria and
examine the literature pertaining to the psychopathological and
phenomenological aspects of the disorder, with particular atten-
tion to practical strategies that can help clinicians to recognise
and differentiate HD from OCD. Finally, the available assess-
ment and treatment strategies for HD are summarised.
Key words
Hoarding disorder: a new obsessive-compulsive related disorder in DSM-5
U. Albert1, D. De Cori1, F. Barbaro1, L. Fernández de la Cruz2, A.E. Nordsletten2%.BUBJY$PMT2
and Education, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Obsessive-compulsive disorder (OCD) has been the sub-
ject of significant revisions in the fifth edition of the Di-
agnostic and Statistical Manual (DSM-5). One of these
major changes has been the removal of OCD from the
distinct category of Obsessive-Compulsive and Related
Disorders (OCRDs) – a classification which now also in-
cludes body dysmorphic disorder (BDD) (previously in
the chapter of Somatoform Disorder), trichotillomania
(previously classed among the Impulse Control Disorders
and now termed hair-pulling disorder), and two new dis-
disorder (HD), alongside the residual categories of sub-
stance/medication-induced OCRDs, OCRDs due to an-
other medical condition, and other specified OCRDs. All
disorders included in this chapter share similarities with
OCD, although some appear to have a stronger cognitive
component and thus are closer to OCD while oth-
ers mainly consist of body-focused repetitive behaviours
(Figure 1). The 11th revision of the International Classifi-
cation of Diseases (ICD-11) will likely contain a similar
OCDRDs chapter, including HD.
While the introduction of two new disorders in the psy-
chiatric nomenclature is independently noteworthy, it
Obsessive-compulsive and related disorders (OCRDs).
All the disorders are characterized
OCD: Obsessive-Compulsive Disorder; BDD: Body Dysmorphic Disorder; TTM: Trichotillomania (hair-pulling disorder).
Stronger cognitive
Hoarding disorder
Body-focused repetitive
Hoarding disorder: a new obsessive-compulsive related disorder in DSM-5
haviours, classification systems did not characterise this
activity as an independent clinical entity until the publi-
cation of DSM-5. Prior to this, hoarding only appeared
in DSM-IV-TR where it was classed as one of the eight
symptoms/criteria for the diagnosis of obsessive-compul-
sive personality disorder (OCPD) (is unable to discard
worn-out or worthless objects even when they have no
sentimental value )PXFWFS JO UIF UFYU BDDPNQBOZJOH
of OCD should be consideredinstead, or in addition to
that, of OCPD particularly 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). While DSM-IV-TR did not mention hoarding
directly as a symptom of OCD, the manual suggested a
link between such symptoms and OCD1.
In accordance with this nosological approach in DSM-IV-
TR, hoarding has been long considered a behaviour/symp-
tom dimension of OCD, a view that has been supported
by factor analytic studies highlighting the prominence
of hoarding as a distinct symptom dimension of OCD
(e.g.,6 7). The inclusion of hoarding items on measures and
scales specific to OCD, such as the Yale-Brown Obsessive-
Compulsive Scale (Y-BOCS) or the Obsessive-Compulsive
Inventory-Revised (OCI-R), also served to reinforce an as-
includes an entry for hoarding/saving obsessions (worries
about throwing away seemingly unimportant things that
you might need in the future, urges to pick up and collect
useless things) and hoarding/collecting compulsions (sav-
ing old newspapers, notes, cans, paper towels, wrappers,
and empty bottles for fear that if you throw them away you
may one day need them; picking up useless objects from
the street or from the garbage can).
However, alongside and in contrast to these develop-
ments, several studies began to emerge providing evi-
dence that hoarding may represent a clinical entity dis-
tinct from OCD1 8-12. First, several studies emerged (see
neurological and psychiatric conditions beyond OCD,
including dementia, cerebral lesions, schizophrenia, ma-
. Then came crucial clinical studies that noted that the
majority of individuals presenting with prominent hoard-
ing behaviours were not presenting with other obsessive-
compulsive symptoms/dimensions and, ultimately, could
Frost et al.21 found that among 217 individuals with path-
ological hoarding, only 18% had a comorbid OCD diag-
nosis, with comorbidity rates for other, ostensibly unre-
lated disorders ranged considerably higher (e.g. 51% for
is the instatement of HD that marks, perhaps, the most
significant change. Previously classified as a symptom
of obsessive-compulsive personality disorder (OCPD) in
DSM-IV, and only indirectly linked to OCD, it has only
been recently acknowledged that hoarding can emerge
independent of any alternative condition. Its formalisa-
tion as an independent psychiatric condition in DSM-5
and ICD-11 therefore reflects a marked change, and one
ponential growth in the number and quality of investiga-
tions concerned with this behaviour1.
The aim of the present paper is to provide an updated
review of the HD literature. Specifically, we will present
pertaining to the psychopathological and phenomenologi-
cal aspects of the disorder, with particular attention paid
to those aspects that can help clinicians to recognise and
differentiate HD from OCD. In addition, we will also high-
light the psychopathological and clinical features that may
help distinguishing HD and OCD when both conditions
able evaluation and intervention strategies for HD.
Definition and diagnostic criteria of hoarding
Like most human behaviours, saving and collecting pos-
sessions may be viewed along a continuum, with one end
representing common and adaptive behaviours (accumu-
lating and storing resources, collecting), which are wide-
spread phenomena in the general population and are evi-
dent even during infancy and the other end pertaining to
acquisition of possessions and failure to discard them).
The term ‘hoarding,’ which first appeared in a paper by
tinuum, though it has been noted that hoarding behav-
iour may not always be pathological. Modern recogni-
tion of hoarding as a disorder, and the formal definition of
this disorder’s pathological features, began with Frost and
colleagues several decades later . These authors con-
ceived ‘compulsive hoarding’ (a term no longer in use) as
worthless objects, and proposed an operational defini-
tion that would eventually form the basis of the DSM-5
criteria for HD. These early criteria defined ‘compulsive
hoarding’ as: 1. the acquisition of and failure to discard
a large number of possessions that seem to be useless or
of limited value; 2. living spaces sufficiently cluttered so
as to preclude activities for which those spaces were de-
tioning caused by the hoarding5.
Despite the significant burden caused by hoarding be-
U. Albert et al.
subsequent sections, this criterion is particularly essential
for differentiating OCD-related hoarding (hoarding sec-
ondary to obsessions in OCD), where attachment to the
possessions is not typically present, from true HD.
possessions that congest and clutter active living areas
and substantially compromises their intended use (crite-
rion C). Consequences of severe hoarding may be, for
proper and clean bed, or even move from one room to
the other; severe HD poses a broad range of health risks
both for patients and their family members, including risk
of fire, falling, poor sanitation and even being trapped by
a ‘clutter avalanche’.
The hoarding causes significant distress or impairment in
social, occupational, or other areas of functioning (crite-
rion D). Quality of life of patients and family members
is severely affected, and family relationships are often
considerably strained. Often, the person with HD
does not fully recognise the consequences of their hoard-
ing behaviours, and another family member is the help
seeker who asks for the intervention of a mental health
A proper diagnosis of HD requires a differential diagnosis;
cluttered living spaces should not assumed to be a mani-
festation of HD, as they may result from multiple condi-
tions (see Table I) such as brain injury, cerebrovascular
disease, Prader-Willi syndrome (see criterion E), or be the
product (or secondary manifestation) of symptoms of oth-
er mental disorders such as typical obsessive-compulsive
symptoms in OCD, decreased energy in major depressive
disorder, delusions in schizophrenia or another psychotic
disorder, cognitive deficit in major neurocognitive disor-
ders, or restricted interests in autism spectrum disorder
(criterion F). HD should also be differentiated from nor-
mative collecting. Table III (from Nordsletten et al. &
.BUBJY$PMTø) provides some clinical criteria that might
interest concerning the distinction of hoarding and OCD
have included: 1) insights on the phenomenological dif-
ferences between hoarding and ‘classical’ obsessive-
compulsive symptoms9-11, 2) a lack of or modest correla-
tion between hoarding and other OCD dimensions9 22
distinctions in the neural bases for hoarding and OCD
tients with regard to symptomatology, clinical course and
anti-obsessional treatment response. Taken together,
this body of evidence strongly supported a formal move
to distinguish hoarding from OCD, with the introduction
of HD as a distinct clinical entity in DSM-5. The decision
to title this entity ‘hoarding disorder’, rather than ‘com-
pulsive hoarding’ as was initially suggested in the litera-
ture was due to further underline its autonomy from OCD
and to avoid confusion between the two disorders. Still,
despite these distinctions, HD has retained some link to
OCD, with both conditions being contained in the DSM’s
OCRDs chapter.
The DSM-5 diagnostic criteria for HD are reproduced in
Table II. As shown there, the cardinal feature of HD is
a persistent difficulty discarding or parting with posses-
sions (criterion A). Though very similar to Frost’s original
criteria, the DSM version does not specify that items must
be ‘useless’ or of ‘limited value’, with research suggesting
that the most commonly saved items are useful items such
as newspapers, books, bags, clothing and the like9. In the
due to the perceived usefulness or aesthetic value of the
items (intrinsic value – items are valuable or may become
in handy in the future), a strong sentimental attachment
to the possessions (emotional value), the wish to avoid
creating waste, or a combination of these factors.
Also essential for the diagnosis is that the person feels
distressed when confronted with the idea of discarding or
parting with the possessions (criterion B). As detailed in
Prevalence of hoarding behaviours in illnesses other than OCD..
Illness Prevalence of Hoarding Behaviours Authors
Moderate to severe Dementia 22.6%
Hwang et al., 1998 
Prader-Willi syndrome
Velocardiofacial syndrome
Dykens et al., 1996 15
Schizophrenia 5%
Stein et al., 1997 17
Social Phobia 15% 5PMJOFUBM19
GAD 29% 5PMJOFUBM19
Compulsive buying 62% .VFMMFSFUBM
Hoarding disorder: a new obsessive-compulsive related disorder in DSM-5
beliefs and behaviours (pertaining to difficulty discard-
interviewing techniques may be recommended before
cognitive-behavioural therapy.
HD and OCD
As noted in prior sections, hoarding has traditionally
been considered a symptom or symptom dimension
of OCD. This association is not without reason, as a
have been found to display hoarding symptoms.
However, while present in a proportion of cases, only
presents this dimension as the most prominent clinical
hoarding symptoms that emerge as part of OCD and
HD-related thoughts are, in contrast to traditional obses-
and distressing; additionally, HD-related thoughts are as-
sociated with pleasure and reward in most cases, and are
frequently unrelated to other prototypical OCD themes
(while compulsions are usually linked to obsessions in
be helpful in distinguishing common and non-pathologi-
cal collecting behaviour from HD.
Sometimes, a diagnosis of HD can also be suggested
in cases of severe domestic squalor, which tends to be
more frequent in old people. Squalor is frequently asso-
ciated to cases of object acquisition/accumulation due
to ‘organic’ pathology. Cases of ‘organic’ hoarding may
be differentiated from HD on the basis of some phenom-
enological differences that are summarised in Table IV
(from Snowdon et al.).
cessive acquisition and degree of insight (Table II). The
first applies when ‘the difficulty discarding possessions
are not needed or for which there is no available space’;
cessive acquisition  and this subtype has been as-
sociated with more severe hoarding, earlier onset and
higher comorbidity rates'BJMVSFUPBEESFTTFYDFTTJWF
acquisition in treatment has been linked to treatment
failure. An insight specifier is also provided, which
may be used to characterise an HD patient’s level of
insight into their behaviour and its consequences. This
insight specifier is clinically relevant because treatment
strategies depend on whether or not (and to which de-
gree) the individual recognises that hoarding-related
DSM-5 diagnostic criteria for hoarding disorder.
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value
B. This difficulty is due to both a perceived need to save the items and distress at the thought of discarding them
C. The difficulty in discarding possessions results in the accumulation of possessions that congest and clutter active living areas
and substantially compromises their intended use; if living areas are uncluttered, it is only because of the interventions of third
parties (e.g., family members, cleaners, or authorities)
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of function-
ing (including maintaining a safe environment for self and others)
E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, or the Prader-Willi
disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive
deficit in major neurocognitive disorder, or restricted interests in autism spectrum disorder)
Specify if:
there is no available space.
With good or fair insight: the individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or
With poor insight: the individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter,
With absent insight/delusional beliefs: the individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty
U. Albert et al.
contaminate the others because I spread contamination
through items); or relieve feelings of incompleteness or
prototypical obsessive-compulsive symptoms include the
need to discard items in certain ‘lucky’ numbers, or the
need to perform mental compulsions when discarding
any item, so that hoarding appears as an avoidant be-
haviour9 (see Pertusa et al. for a case series of OCD-
related hoarding). In all these cases, hoarding should be
conceptualised as a compulsion, and not as an independ-
ent entity of HD.
It has been suggested that hoarding and OCD might
dependent conditions (comorbid conditions). In such
cases, careful differential diagnoses will be required to
establish which behaviours stem from HD, and which
are secondary to classical, prototypical obsessive-com-
pulsive symptoms9.
Making a diagnosis of OCD and/or hoarding disorder
may be confusing for many clinicians. Consideration
of a few key clinical questions may be helpful for this
differential process: 1) is the hoarding behaviour driv-
en mainly by prototypical obsessions or is it the result
of persistent avoidance of onerous compulsions (more
likely in OCD-related hoarding)?; 2) is the hoarding be-
haviour generally unwanted and highly distressing for
some ways); 2) in HD, symptoms are perceived as ego-
syntonic, unlike hoarding thoughts in OCD, which are
clutter, while it comes from intrusiveness in traditional
urges to get rid of them and/or perform a ritual to relieve
them, while this is not common in HD . Addition-
ally, the drive for keeping items is different in HD and
in OCD-related hoarding; in HD, the hoarding of items
is the result of 1) a fear that the items will be needed in
the future (intrinsic value) or 2) a strong emotional at-
tachment to the possessions. Crucially, individuals with
HD have a genuine desire to possess their items. Such
characteristics stand in strong contrast to the views and
behaviour (Table V).
Hoarding should be viewed as a symptom of OCD only
when it is clearly secondary to typical obsessions, and
the relationship between these obsessional thoughts and
the resulting behaviour (i.e., hoarding) is the same as that
between traditional obsessions and compulsions. To fit
with this definition, the hoarding should either relieve
obsessional doubts (like a checking compulsion; hoard-
ing as preventive of something bad happening); prevent
harm from aggressive obsessions (e.g., something bad
will happen if things get thrown away) or contamination
fears (like preventive or washing compulsions; e.g., I will
Differences between normative collecting and Hoarding Disorder .
Normative collecting Hoarding Disorder
Object content Very focused; objects are bound by a cohesive
theme, with a narrow range of object categories
Unfocused; objects lack a cohesive theme, and
the accumulation contains a large number of dif-
ferent object categories
Acquisition process Structured; planning, searching for items, and or-
ganising the collected items
Unstructured; lack of advance planning, focused
searching and organisation
&YDFTTJWFBDRVJTJUJPO Possible, but less common; primarily bought
items acquired
with both free and bought items acquired
Level of organization High; rooms are functional, and collected items are
arranged, stored, or displayed in an orderly fashion
Low; the functionality of rooms is compromised
by the presence of disorganised clutter
Presence of distress Rare; for the majority of collectors, the activity is
pleasurable, although for a minority, collecting
may result in distress due to factors other than
clutter (e.g. finances)
Required for the diagnosis; distress is often a
forced discarding, or inability to acquire
Social impairment Minimal; collectors have high rates of marriage, and
the majority report forming and engaging in social
relationships as part of their collecting behaviour
Often severe; hoarding disorder is consistently as-
sociated with low rates of marriage and with high
rates of relationship conflict and social withdrawal
Occupational interference Rare; scores on objective measures indicate that
collectors do not have clinically significant im-
pairment at work
Common; occupational impairment increases
with hoarding severity; high levels of work-based
impairment have been reported
Hoarding disorder: a new obsessive-compulsive related disorder in DSM-5
HD: prevalence, aetiological factors
and clinical characteristics
Prevalence estimates of hoarding behaviour are few in
number and have often provided conflicting estimates.
This is due, at least in part, to the only recent formalisa-
tion of diagnostic criteria for HD. Prior to their introduc-
tion, studies evaluating prevalence used their own defi-
does the individual show interest in the majority of the
quisition present (more likely in HD)?1. The Structured
Interview for Hoarding Disorder (SIHD)  provides a
sessing whether the hoarding behaviour is better con-
ceptualised as a symptom of OCD.
Phenomenological differences between accumulating behaviours due to macroscopic brain damage in brain injured or demented
patients and hoarding in HD .
“Organic” object acquisition/accumulation Hoarding Disorder
Onset Generally sudden in cases of brain damage. Can
be more insidious if secondary to a dementing
Insidious. Usually starts in childhood/ad-
olescence and has a long natural history
Ability to discard hoarded items Variable (some are able to discard their pos-
sessions easily or do not care if others discard
them, whereas others are very reluctant)
Inability to discard hoarded items is a
core feature of HD
Nature of acquiring behaviour Generally indiscriminate but can be more selec-
tive (acquisition of specific items – e.g. umbrel-
las – or according to their shape/colour) in some
Items are always acquire/hoarded accord-
ing to their perceived intrinsic, practical,
or emotional value, but can be more in-
discriminate in some cases
Utility of hoarding behaviour Often purposeless (individuals display little or
no interest in the accumulated items) and items
seldom used
More purposeful (items are hoarded for
specific emotional or practical reasons),
although items often not used
Hoarded items Any item, including rotten food Any items, though hoarding of rotten food
is rare
Squalid living conditions and/or
Frequent (especially in cases of dementia) Thought to be relatively uncommon al-
though more research is needed
Associated features Severe personality changes as well as behav-
iours commonly attributable to brain dysfunc-
cial difficulties, theft, stereotypes, tics, and self-
injurious behaviours
No severe personality changes or other
behaviours clearly attributable to brain
shopping and stealing can be present
Cognitive processes and
motivations for hoarding
Hoarding apparently devoid of identifiable cog-
nitive and emotional processes, although more
research is needed
a) information processing deficits: deci-
sion making, categorisation, organiza-
tion, and memory difficulties; b) emo-
tional attachment to possessions; c) be-
havioural avoidance; d) erroneous beliefs
about possessions
Insight and help seeking behaviour Poor or absent insight. Patients seldom seek help Insight ranges from good to poor or ab-
sent. Initially, hoarding behaviour can be
ego-syntonic; it becomes increasingly dis-
tressing as clutter increases. Help seeking
probably related to degree of insight
Prevalence Unknown (<1%) "QQSPYJNBUFMZ
Familial Unknown but anecdotal reports of relatives
independently living in squalor have been re-
Yes. Hoarding tends to run in families and
appears to be moderately heritable
U. Albert et al.
FSø. Using the same scale, Ivanov et al.51 found
clinically-significant hoarding in 2% of adolescent twins.
Timpano et al.52 found a higher prevalence rate (5.8%) in
a representative sample of the German population using
the Hoarding Rating Scale. Mueller et al. found again
PG  TVCKFDUT VTJOH UIF Savings Inventory-Revised.
Meanwhile, in Italy, a recent set of studies reported point
prevalence estimates of self-reported hoarding behaviour
(assessed by the Saving Inventory-RevisedPG BOE
6% in two non-clinical samples. Given this array of
findings, and in the absence of additional work using the
DSM-5 definition of hoarding, the true prevalence of HD
remains unclear. Further studies will be necessary to es-
nitions of clinically meaningful hoarding behaviour and
identified members of populations who fulfil these defini-
tions. Indeed, at present, only one study has evaluated
prevalence using the DSM-5 criteria for HD, reporting a
weighted prevalence of 1.5%. Other studies, using less
restrictive characterisations of hoarding, have generally
lysed data from the Hopkins Epidemiology of Personality
lence of pathological hoarding, measured by means of the
severe hoarding – measured by the self-reported version
of the Hoarding Rating Scale – was estimated to be low-
Hoarding characteristics in patients with Hoarding Disorder versus OCD-related (or secondary) hoarding .
Hoarding Disorder Hoarding as a dimension of OCD
Relationship between hoarding and OC
Hoarding NOT related to obsessions/
Hoarding behaviour is driven mainly by pro-
totypical obsessions or is the result of persis-
tent avoidance of onerous compulsionsa
Checking behaviour associated
with hoarding
Rare and mild Frequent and severe
Obsessions related to hoarding
(i.e. catastrophic consequence or
magical thinking)
No Yes
Mental compulsions related to hoarding
(e.g. need to memorise and recall
discarded items)
No Yes
Egosyntonic/egodystonic Usually egosyntonic: hoarding thoughts are
associated with pleasant feelings of safety
Usually egodystonic: intrusive or unwant-
ed, repetitive thoughts
Presence of OC symptoms other than
No Yes
Distress Comes from clutter (product of behaviour) Comes from intrusiveness
Main reason for hoarding Intrinsic and/or sentimental value Other obsessional themes
Type of hoarding
Common itemsbYes Yes
Bizarre itemscNo Yes
&YDFTTJWFBDRVJTJUJPO Usually present Usually not present
Age at onset of clutter problem (years) &BSMZT .JET
Insight Poor or absent insight frequent Generally good insight, although poor in-
sight may be present
Course of hoarding behaviour Hoarding tend to increase in severity as
the person ages
Hoarding does not increase in severity as
the person ages (usually)
Global severity/interference Usually moderate Usually severe
a Fear of catastrophic consequence, need for symmetry/order, need to perform checking ritual because of the fear of losing an important item, etc.
b Old clothes, magazines, CDs/videotapes, letters, pens, old notes, bills and newspapers, etc.
c Faeces, urines, nails, hair, used diapers, and rotten food, etc.
Hoarding disorder: a new obsessive-compulsive related disorder in DSM-5
Evaluation of hoarding disorder
Hoarding symptoms often need to be specifically asked
about, as many patients do not spontaneously volunteer
this information. Even patients with good insight often
quences of the disorder. The use of some simple screen-
ing questions, such as ‘are the rooms of your home so
full of items that it is hard for you to use these rooms nor-
mally?’, may initiate a fruitful dialogue and can rapidly
lead to the diagnosis.
A formal HD diagnosis requires an interview with a trained
assessor, ideally in the person’s home environment. The
Structured Interview for Hoarding Disorder (SIHD) is
a freely available, validated, semi-structured instrument
that has been designed to assist clinicians with the nu-
anced evaluation of this disorder. The content of this in-
terview maps directly onto the DSM-5 criteria for HD,
with questions relating to each diagnostic criterion and
specifiers. Its suitability for establishing the HD diagnosis
has been demonstrated in several studies, including the
London Field Trial for Hoarding Disorder, which showed
that diagnoses determined using the instrument showed
Because the diagnosis of HD requires the presence of
obstructive clutter (Criterion C), diagnostic assessments
(such as the SIHD) are ideally done in the sufferer’s home
environment. This approach enables the clinician to tan-
of the resulting obstruction/impairment, and determine
the presence of health and safety risks (e.g., fire hazards,
infestations and/or unsanitary living conditions) . To
assist with this process, the SIHD also contains a risk as-
sessment module.
When in-home assessments are not possible, clinicians
These photographs can be used in combination with the
Clutter Image Rating (CIR)59, which consists of a series
of photographs depicting increasingly obstructive levels
of clutter across the bedroom, kitchen, and living room.
When a patient with HD shows limited or absent insight
into their hoarding activity, a situation that may arise in
a substantial proportion of hoarding cases, a multiple-in-
formant approach (e.g., seeking both patient reports and
information available from third parties) may be helpful.
Given that much of this population does not recognise
their problem, clinicians may find that few of their hoard-
ing patients are voluntarily presenting for assessment or
treatment. Accordingly, during the assessment process,
clinicians should be aware that conflicts may arise be-
tween the patient’s account of their behaviour and the
portrait provided by third parties (e.g., patient records, so-
tablish the proportion of the population impacted by this
condition, and whether these proportions differ by key
demographic factors (e.g., age, gender, ethnicity).
With regards to aetiology, the causes of HD are still large-
ly unknown. Twin studies suggest that a predisposition to
the variance in hoarding behaviours attributable to genet-
ic factors and the remaining variation being attributable
to non-shared environment. Candidate genes have yet
to be consistently identified for this disorder. While as-
sociations have been found between traumatic life events
and hoarding symptoms and severity – retrospective stud-
ies have found, for instance, that subjects with HD have
a greater number of life events prospective studies are
lacking and results remain unreliable  . According
to the cognitive-behavioural model of HD, three primary
factors contribute to the emergence of hoarding behav-
iour: 1) beliefs about and emotional attachment to pos-
sessions, 2) avoidance behaviours that develop as a re-
sult of the emotional distress associated with discarding
areas of attention, categorisation, memory and decision
making5 56 57. It is possible that several genetic and psy-
chological vulnerability factors may interact with stress-
ors in order to determine who will develop (and when)
hoarding symptoms. However, further research will be
needed to untangle such predisposing, contributing and
maintaining factors.
Clinical characteristics of HD, such as age at onset or
course of the hoarding symptoms, have primarily been
derived from studies that investigated hoarding with cri-
teria that are not those of DSM-5. Notwithstanding such
limitations, the available literature suggests that hoard-
ing behaviours often begin early in life and tend to in-
crease in severity as the person ages. The threshold for
the diagnosis (interference with the person’s everyday
symptoms continuing to worsen thereafter in the major-
ity of individuals . Comorbidity is common, with
HD clinical samples often presenting with major de-
hyperactivity disorder.
dividual, and is shared by those around them including
family, friends and community members. In a recent
by HD relatives was found to be comparable to or greater
than that reported by relatives of individuals with demen-
tia. Perceived level of squalor, co-habitation with the HD
individual and increasing age of the HD individual were
all significant predictors of carer burden and functional
impairment in relatives.
U. Albert et al.
in the field is growing and results are generally positive
and promising, it also has to be acknowledged that ef-
fective treatments for HD are still far from satisfactory.
Double-blind, psychological and pharmacological pla-
cebo-controlled trials are strongly warranted and needed
in patients with HD.
The inclusion of the new diagnosis of HD in DSM-5 with-
in the OCRDs chapter will help researchers in studying
clinical characteristics of the disorder and implementing
effective treatments for those patients. There is, in fact,
a strong need at present for finding treatment strategies
which are both acceptable by patients and effective in
treating the disorder.
1 .BUBJY$PMT%'SPTU301FSUVTB"FUBMHoarding Disorder:
a new diagnosis for DSM-V?%FQSFTT"OYJFUZ
2 Bolman WM, Katz AS. Hamburger hoarding: a case of sym-
bolic cannibalism resembling Whitico psychosis. J Nerv
 Snowdon J. Accumulating too much stuff: what is hoarding
and what is not."VTUSBMBT1TZDIJBUSZ
 Frost RO, Gross RC. The hoarding of possessions. Behav Res
5 Frost RO, Hartl TL. A cognitive-behavioral model of compul-
sive hoarding.#FIBW3FT5IFS
6 Bloch MH, Landeros-Weisenberger A, Rosario MC, et al.
Meta-analysis of the symptom structure of obsessive-com-
pulsive disorder."N+1TZDIJBUSZ
7 .BUBJY$PMT%3PTBSJP$BNQPT .$ -FDLNBO+'A multi-
dimensional model of obsessive-compulsive disorder. Am J
8 .BUBJY$PMT%1FSUVTB"Hoarding disorder: potential ben-
efits and pitfalls of a new mental disorder. J Child Psychol
9 Pertusa A, Fullana MA, Singh S, et al. Compulsive hoarding:
OCD symptom, distinct clinical syndrome, or both? Am J
 Rachman S, Elliot CM, Shafran R, et al. Separating hoarding
from OCD#FIBW3FT5IFS
11 Pertusa A, Frost RO, Fullana MA, et al. Refining the diag-
nostic boundaries of compulsive hoarding: a critical review.
12 4BYFOB4 Is compulsive hoarding a genetically and neuro-
biologically discrete syndrome? Implications for diagnostic
classification. "N+1TZDIJBUSZ
 Hwang JP, Tsai SJ, Jang CH, et al. Hoarding behavior in
dementia. A preliminary report. Am J Geriatr Psychiatry
cial service reports, consultation with family members).
Discrepancies should be tactfully addressed and clarifi-
cation requested from all relevant sources. Should dis-
clinical judgment in making a diagnostic determination.
Traditionally, hoarding has been treated using approach-
es designed for OCD, with a focus on serotonergic com-
sure and response prevention). This clinical approach,
which is the evidence-based treatment for OCD, has
failed to produce satisfactory results in HD. A recent
meta-analysis confirmed that patients with OCD and
hoarding symptoms are less likely to respond to tradition-
al OCD treatments, this finding being consistent across
treatment modalities61.
In the case of secondary hoarding (i.e., hoarding symp-
cated for OCD should be applied. It may be reasonable
to assume that, in these cases, response will be similar
to that achieved among OCD cases without hoarding
symptoms/behaviours, though this has not been formally
hoarding cases, hence precluding firm conclusions in this
Conversely, when hoarding is conceptualised as an in-
dependent or comorbid disorder (e.g., diagnosis of HD
and OCD) specific treatment strategies for HD should
be applied. Tailored cognitive behavioural therapy for
HD, including education and case formulation, moti-
vational interviewing, skills training for organising and
discarding, and cognitive therapy, has been found to
be effective for hoarders. Several other specific psy-
chological interventions for HD have been developed,
and these treatments may be used when HD is diag-
nosed. A recent meta-analysis confirmed that CBT is
a promising treatment for HD, although there is sig-
nificant room for improvement62. Empowering family
members of subjects with HD with specific training
programs seems to be an effective add-on treatment
as well.
Only two studies have specifically investigated the ef-
fectiveness of pharmacological treatments in HD. Both
JOFFYUFOEFESFMFBTFø65 were positive; however, both are
small, uncontrolled studies and are hampered by meth-
odological limitations (particularly regarding recruitment
and assessment methods).
Although the number of studies investigating treatment
Hoarding disorder: a new obsessive-compulsive related disorder in DSM-5
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 4BYFOB4"ZFST$3.BJENFOU,.FUBMQuality of life and
functional impairment in compulsive hoarding. J Psychiatr
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squalor: a few considerations for DSM-5. %FQSFTT "OYJFUZ
 Frost RO, Tolin DF, Steketee G, et al. Excessive acquisition in
 .BUBJY$PMT % #JMMPUUJ % 'FSOBOEF[ EF MB $SV[ - FU BM
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tive Genetics Study. #FIBW3FT5IFSD
 Wheaton M, Timpano KR, Lasalle-Ricci VH, et al. Charac-
terizing the hoarding phenotype in individuals with OCD:
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 1FSUVTB " 'SPTU 30 .BUBJY$PMT % When hoarding is a
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.BSY.4$PIFO.BOTGJFME+Hoarding behavior in the elder-
ly: a comparison between community-dwelling persons and
nursing home residents*OU1TZDIPHFSJBUS
15 Dykens EM, Leckman JF, Cassidy SB. Obsessions and com-
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 "O4,.BUBJY$PMT%-BXSFODF/4FUBMTo discard or not
discard: the neural basis of hoarding symptoms in obsessive-
compulsive disorder..PM1TZDIJBUSZ
 4BYFOB4#SPEZ"-.BJENFOU,.FUBMCerebral glucose
metabolism in obsessive-compulsive hoarding. Am J Psychi-
25 Tolin Df, Kiehl KA, Worhunsky P, et al. An exploratory study
of the neural mechanism of decision making in compulsive
26 "ZFST$34BYFOB4(PMTIBO4FUBMAge at onset and clini-
cal features of late life compulsive hoarding. Int J Geriatr
27 Grisham JR, Frost RO, Steketee G, et al. Age of onset of com-
pulsive hoarding+"OYJFUZ%JTPSE
28 .BUBJY$PMT%3BVDI4-.BO[P1"FUBMUse of factor-ana-
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29 Stein DJ, Carey PD, Lochner C, et al. Escitalopram in obses-
sive-compulsive disorder: Response of symptom dimensions
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 Tolin DF, Meunier SA, Frost RO, et al. Course of compulsive
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... 6 It was first applied to humans in a 1966 scientific paper, referring to the extreme end of a continuum of accumulating behavior. 7 Subsequently, hoarding has been reported in a number of psychiatric disorders, raising questions about how best to classify such behavior. In the late 1980s, Greenberg described several psychopathological aspects seen in primary hoarding: early onset (in the third decade of life), preoccupation with accumulation to the exclusion of work and family, poor insight, little interest in receiving treatment, and no attempt to curb the compulsion. ...
... Until the 4th revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), hoarding was classified as a symptom of Obsessive-Compulsive Personality Disorder (OCPD), and indirectly related to Obsessive-Compulsive Disorder (OCD). 7 In DSM-5, Hoarding Disorder was classified as an independent disorder. The DSM-5 diagnostic criteria 2 are described in Chart 1. ...
... Normative collecting HD must be differentiated from normative collecting. [7][8][9][10] The habit of acquiring and accumulating objects of a specific type (e.g., stamps, coins, objets d'art) is commonly known as collecting. Collectors are usually methodical individuals who organize, clean, and catalog their items. ...
Full-text available
Hoarding disorder can be defined as a persistent difficulty in discarding items, due to distress associated with such disposal or a perceived need to save items regardless of their actual value. Such behavior must result in the accumulation of clutter, which significantly compromises living conditions, causing distress and/or functional impairment. The most frequently hoarded items are objects and animals. The point prevalence of clinically significant hoarding was estimated to be 1.5 to 2.1% in the general population, and may exceed 6% in the elderly. HD poses a range of health and safety hazards to individuals, especially older adults, generating significant costs to society. The diagnosis of HD is clinical, and should only be established after general medical conditions and other mental disorders that can lead to accumulating behavior have been ruled out. HD appears to follow a chronic, progressive course, and is commonly associated with psychiatric comorbidities. Studies indicate that genetic, familial, cognitive, and traumatic factors are implicated in the etiology of HD. To date, psychotherapies have been the most widely studied therapeutic approaches, but the results of these studies show small effects. Research into pharmacological approaches to HD is still incipient, precluding any conclusions of efficacy. KEYWORDS: hoarding disorder; collecting; psychopathology.
... 6 It was first applied to humans in a 1966 scientific paper, referring to the extreme end of a continuum of accumulating behavior. 7 Subsequently, hoarding has been reported in a number of psychiatric disorders, raising questions about how best to classify such behavior. In the late 1980s, Greenberg described several psychopathological aspects seen in primary hoarding: early onset (in the third decade of life), preoccupation with accumulation to the exclusion of work and family, poor insight, little interest in receiving treatment, and no attempt to curb the compulsion. ...
... Until the 4th revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), hoarding was classified as a symptom of Obsessive-Compulsive Personality Disorder (OCPD), and indirectly related to Obsessive-Compulsive Disorder (OCD). 7 In DSM-5, Hoarding Disorder was classified as an independent disorder. The DSM-5 diagnostic criteria 2 are described in Chart 1. ...
... Normative collecting HD must be differentiated from normative collecting. [7][8][9][10] The habit of acquiring and accumulating objects of a specific type (e.g., stamps, coins, objets d'art) is commonly known as collecting. Collectors are usually methodical individuals who organize, clean, and catalog their items. ...
Full-text available
O transtorno de acumulação (TA) pode ser definido como uma dificuldade persistente de desfazer-se de itens devido ao sofrimento associado com o descarte ou uma necessidade percebida de guardar posses a despeito de seu valor real. Tal comportamento pode resultar no acúmulo de objetos, o que compromete significativamente o uso da moradia, causando sofrimento e/ou prejuízo funcional. Os itens acumulados mais frequentemente são objetos e animais. A prevalência do transtorno é de 1,5 a 2,1% na população em geral, podendo ser maior que 6% em idosos. O TA causa riscos à saúde e à segurança dos indivíduos, especialmente dos idosos, gerando um custo relevante para a sociedade. O diagnóstico de TA é clínico e só deve ser feito após a exclusão de condições médicas gerais e outros transtornos mentais que podem levar ao acúmulo de objetos. O TA parece ser um transtorno de curso crônico e progressivo, comumente associado a comorbidades psiquiátricas. Estudos indicam a participação de fatores genéticos, familiares, cognitivos e de experiências traumáticas na etiologia do TA. A abordagem terapêutica mais estudada até o momento foram as psicoterapias, mas os resultados mostram efeito pequeno. Os estudos farmacológicos existentes são muito incipientes, não permitindo conclusões de eficácia. Geriatr Gerontol Aging. 2018;12(1):54-64
... Epidemiological studies have found the prevalence of hoarding symptoms to range between 2 and 6% in community samples (Timpano et al., 2011;Iervolino et al., 2009;Nordsletten et al., 2013a;Samuels et al., 2008) and a weighted prevalence of 1.5% using the Diagnostic and Statistical Manual of Mental Disorders -Fifth edition (DSM-5) (American Psychiatric Association, 2013) criteria for Hoarding Disorder (HD) (Nordsletten et al., 2013a;Albert et al., 2015). Hoarding was previously classified as a symptom criterion for obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) Pertusa et al., 2008;Frost et al., 2011), however, hoarding now represents a clinically distinct entity (Albert et al., 2015;Mataix-Cols et al., 2010;Mataix-Cols and Pertusa, 2012;Saxena et al., 2002a, b;Pertusa et al., 2012). ...
... Epidemiological studies have found the prevalence of hoarding symptoms to range between 2 and 6% in community samples (Timpano et al., 2011;Iervolino et al., 2009;Nordsletten et al., 2013a;Samuels et al., 2008) and a weighted prevalence of 1.5% using the Diagnostic and Statistical Manual of Mental Disorders -Fifth edition (DSM-5) (American Psychiatric Association, 2013) criteria for Hoarding Disorder (HD) (Nordsletten et al., 2013a;Albert et al., 2015). Hoarding was previously classified as a symptom criterion for obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) Pertusa et al., 2008;Frost et al., 2011), however, hoarding now represents a clinically distinct entity (Albert et al., 2015;Mataix-Cols et al., 2010;Mataix-Cols and Pertusa, 2012;Saxena et al., 2002a, b;Pertusa et al., 2012). Frost et al (Frost et al., 2011) for instance, found that only 18% of individuals with pathological hoarding have a co-morbid OCD diagnosis, and that it occurs with other psychiatric conditions such as major depressive disorder (51%), social phobia (24%), and generalised anxiety disorder (24%). ...
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Background: Hoarding is a disorder characterized by excessive acquisition and persistent difficulty in discarding possessions. The behaviour has adverse emotional, physical, social, financial, and legal outcomes for the person with the disorder and family members, and might pose a significant public health problem. Hoarding has been included as a distinct disorder in the Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5). The prevalence of hoarding disorder is approximately 2-6% globally. The current state of the evidence does not offer clear understanding of the causes of hoarding behaviours. A systematic review of the extant literature was carried out to determine the possible causal factors of hoarding behaviours. Methods: This review is conducted in line with PRISMA guidelines. The following electronic databases: Medline through Ovid, EMBASE and PsycINFO were searched for relevant articles published between January 2000 and November 2018. Only articles published in English language were included. Two reviewers independently scrutinized the studies and included them in this review. Results: Our search strategy returned a total of 396 references. Preliminary findings suggest that individuals with hoarding behaviours may have a genetic susceptibility; abnormal neural activity in the fronto-temporal, para-hippocampal gyrus and insular parts of the brain has also been identified. Traumatic life experiences have also been posited to predispose individuals to hoard. Conclusion: Although the understanding of hoarding disorder hasgrown in recent years, greater efforts are still needed to clarify the etiology and mechanisms of hoarding disorder as these may help in planning of more holistic interventions to treat the problem.
... De acordo com o Manual diagnóstico e estatístico de transtornos mentais, DSM-5 (APA, 2014), estima-se a prevalência do transtorno em aproximadamente 2 a 6% da população geral, sendo mais frequentemente encontrado em adultos solteiros, na meia idade e do gênero masculino (Albert et al., 2015). Entretanto, Muroff e Underwood (2006) observam que, nas amostras clínicas, o TA é mais prevalente em mulheres e pouco comum nas crianças. ...
... Segundo o modelo cognitivo do TA, são as crenças do paciente que mantêm a sua sintomatologia (Schmidt et al., 2014), de modo que a psicoterapia cognitivo-comportamental consista em reduzir o recolhimento descontrolado dos itens (Wheaton, 2016), bem como promover a organização e a desobstrução do ambiente de convívio (Muroff et al., 2014). Juntamente com a exposição gradual ao descarte dos objetos coletados, realiza-se o processo de reestruturação cognitiva (Tolin, Frost, Steketee, & Muroff, 2015) no intuito de identificar os padrões de pensamento disfuncionais que propiciam a acumulação excessiva e impedem o descarte (Albert et al., 2015;. ...
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Accumulation disorder (AD) is characterized by the acquisition of unnecessary items, difficulty in disposing objects, and disorganization of the convivial environment. The case study analyzes personality characteristics and comorbid psychological symptoms in a patient diagnosed with AD. For data collection, a semi-structured interview was used, the Young Schema Questionnaire (YSQ-S2), the Young Parenting Styles Inventory (PSI), the Beck Depression Inventory and the Beck Anxiety Inventory (BDI-II and BAI, respectively), the Lipp Stress Symptoms Inventory (LSSI), and the Rorschach Method. In the results, we observed the presence of Early Maladaptive Schemas (EMS) belonging to the disconnection and rejection domain, suggesting a connection between AD symptoms and negative emotional experiences experienced by the patient during childhood. In the future, new studies with a cross-sectional design are recommended in order to substantiate the results obtained by the present research. © 2017 Instituto Brasileiro de Avaliacao Psicologica. All rights reserved.
... Saving and collecting possessions might be conceptualized along a continuum of common and adaptive habits to pathological and maladaptive behavior. 1,2 Hoarding disorder (HD) is defined as a persistent difficulty in discarding items regardless of value, urges to save items and distress associated with discarding, and the accumulation of possessions which compromise use of the home. 2,3 Epidemiological studies suggest HD to affect around 2.5% of population, with prevalence increases of 20% every 5 years, particularly after age 35. ...
Objective In the present study, we aimed to perform a systematic review evaluating the cognitive performance of patients with hoarding disorder (HD) compared with controls. We hypothesized that HD patients would present greater cognitive impairment than controls. Methods A systematic search of the literature using the electronic databases MEDLINE, SCOPUS, and LILACS was conducted on May 2020, with no date limit. The search terms were “hoarding disorder,” “cognition,” “neuropsychology,” “cognitive impairment,” and “cognitive deficit.” We included original studies assessing cognitive functioning in patients with HD. Results We retrieved 197 studies initially. Of those, 22 studies were included in the present study. We evaluated 1757 patients who were 41 to 72 years old. All selected studies comprised case–control studies and presented fair quality. Contrary to our hypothesis, HD patients showed impairment only in categorization skills in comparison with controls, particularly at confidence to complete categorization tasks. Regarding attention, episodic memory, working memory, information-processing speed, planning, decision-making, inhibitory control, mental flexibility, language, and visuospatial ability, HD patients did not show impairment when compared with controls. There is a paucity of studies on social cognition in HD patients, although they may show deficits. The impact of emotion in cognition is also understudied in HD patients. Conclusion Except for categorization skills, the cognitive performance in HD patients does not seem to be impaired when compared with that in controls. Further work is needed to explore social cognition and the impact of emotion in cognitive performance in HD patients.
... disorder under the heading of OCD and associated disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [8,9]. ...
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Although hoarding symptoms are reported to begin in childhood and adolescence, the true prevalence of the disorder in this age group is unknown. This study aims to estimate the prevalence of hoarding disorder (HD) in children and adolescents. The present study was planned as a two-stage epidemiological research. In the first stage, the Children’s Saving Inventory (CSI) and informed consent forms were delivered to a group of students’ parents. In the second stage, one-on-one psychiatric interviews with a physician were planned with the families and children who had hoarding behavior (HB), as described by their parents. The DSM-5-based HD interview and the Development and Well-Being Assessment (DAWBA) diagnostic tool were used to detect prevalence of HD and comorbid psychiatric disorders. A total of 3249 children were included in the study, and 318 children and their parents were evaluated in the second stage. As a result of the second assessment, 32 out of 318 children met the HD diagnostic criteria. The estimated prevalence of HD was 0.98% (95% CI 0.7–1.4). Hoarding disorder was found more frequently in females (F/M = 3/1). After a logistic regression analysis, variables such as female sex and the presence of any psychopathology were identified as independent correlates of HD. More than half (56.2%) of the children diagnosed as having HD also had a comorbid psychiatric disorder. In the present study, the two-stage evaluation method was used in a large pediatric sample to determine the estimated prevalence of HD, as well as the factors associated with the disorder and comorbid psychiatric disorders.
... It has been suggested that OCD-related hoarding symptoms have different phenotypic features compared to primary hoarding disorder. For example, individuals with primary hoarding disorder may derive pleasure from their hoarding behavior, whereas hoarding in OCD has the purpose of avoiding danger or reducing anxiety caused by an obsession [49]. However, in this study, the impulsivity-related findings of patients with OCD-related hoarding symptoms are in line with previous studies of primary hoarding disorder. ...
ABSTRACT Objective: Hoarding is common in obsessive-compulsive disorder (OCD), and OCD with hoarding may have poorer prognostic features than OCD without hoarding. The aim of this study was to investigate the relationship between multifaceted impulsivity and hoarding symptoms in individuals with OCD. This relationship is important to be able to understand the psychopathological mechanisms of hoarding symptoms in OCD patients. Methods: The study included 136 individuals with OCD classified as OCD with high hoarding symptoms (OCDwHH, n = 41) and OCD with low/none hoarding symptoms (OCDwLH, n = 95), together with 94 healthy control subjects. All the participants completed the Hoarding Rating Scale-Interview, Barratt Impulsiveness Scale-11, Yale-Brown Obsessions and Compulsions Scale, Hamilton Depression Rating Scale, and Hamilton Anxiety Rating Scale. Results: The OCDwHH group had more severe anxiety (p = 0.016) and attentional impulsivity (p = 0.002) than OCDwLH. Attentional impulsivity scores were positively correlated with hoarding symptom scores (p < 0.001). Both attentional and motor impulsivity scores were positively correlated with anxiety levels (p = 0.037, p = 0.045, respectively). In partial correlation analysis, motor impulsivity was positively correlated with the severity of hoarding symptoms controlling for anxiety severity (p = 0.045). In hierarchical linear regression analysis, only attentional impulsivity predicted the severity of hoarding symptoms independently of anxiety, severity of obsessive-compulsive symptoms and motor impulsivity (b = 0.268, Adjusted R2 = 0.114, p = 0.006). Conclusion: Attentional impulsivity is associated with hoarding symptoms in OCD. Future studies that reveal this relationship may contribute to treatment modalities for the OCD patients with hoarding symptoms.
Objective: Cognitive models of Obsessive-Compulsive Disorder (OCD) identified four types of beliefs, which would develop during childhood and play a role in the aetiology and maintenance of OCD: Inflated Responsibility, Threat Overestimation, Importance/Control of Thoughts, Perfectionism/Intolerance of Uncertainty. Whereas research produced consistent evidence in adults that these beliefs constitute vulnerability factors for OCD, no study examined whether the obsessive beliefs prospectively predict OCD symptoms over time in youth. The current study investigated the role of the obsessive beliefs as predictors of OCD symptoms after one year in a large cohort sample of community children and early adolescents prospectively followed-up. Method: Seven hundred and fifty-four children and early adolescents recruited from the community (mean age= 10.87 years, 51.46% females) completed the Obsessive Belief Questionnaire-Child Version (OBQ-CV) as a measure of obsessive beliefs, the Obsessive-Compulsive Inventory-Child Version (OCI-CV) as a measure of OCD symptoms, the Children's Depression Inventory for depression (CDI) at baseline (t0) and at one-year follow-up (t1). A multiple linear regression analysis was run entering the scores on the OBQ-CV and the CDI as predictors and the scores on the OCI-CV at t1 as dimensional outcome. Results: More intense Perfectionism/Intolerance of Uncertainty at t0 (β= 0.17, t= 4.33, p<0.001) and to a lesser extent more intense Threat Overestimation at t0 (β= 0.08, t= 1.97, p<0.05) predicted more severe OCD symptoms at t1 controlling for the effects of depression at t0 (β= 0.19, t= 5.53, p<0.001). Evidence of the predictive effects of the other cognitions at t0 on OCD symptoms at t1 was not found. Conclusions: Perfectionism/Intolerance for Uncertainty and to a lesser Threat Overestimation may be early predictors of OCD symptoms in youth. Early detection and prevention of OCD in children and adolescents could focus on these cognitive vulnerability factors. The current findings appear to raise some doubts about the role of Inflated Responsibility and Importance/Control of Thoughts as cognitive vulnerability factors specific to OCD among youth. Future studies should use clinical interviews to assess the presence of an OCD diagnosis.
Obsessive-compulsive spectrum disorders (also referred to as obsessive-compulsive related disorders; OCRDs) include several psychiatric conditions that are related to, yet distinct from, obsessive compulsive disorder. This diagnostic category includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and other specified/unspecified OCRDs (i.e., misophonia, orthorexia, olfactory reference syndrome). This article provides an overview on the phenomenology, evidence-based assessment, and evidence-based treatment of common OCRDs, offering particular insight into selected OCRDs among children and adolescents. The article highlights future directions for research, and discusses the clinical implications of current and future work that are essential to better understand OCRDs in youth.
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Objectives To estimate prevalence rates of suicide attempts and suicidal ideation in individuals with a principal diagnosis of obsessive-compulsive related disorders (OCRDs); 2. to identify predictors of suicide risk among subjects with OCRDs (where available). Results In BDD, data concerning lifetime suicide attempts are consistent across studies: mean rate is 21.5% (range 9-30.3%). Mean rate of current suicidal ideation is 37.4% (range 26.5-49.7%) and mean rate of lifetime suicidal ideation is 74.5% (range 53.5-85%). BDD-specific factors such as early onset, severity, poor insight and muscle dysmorphia and comorbid disorders increase the risk of suicide attempts or suicidal ideation. Only 2 studies recruited individuals with DSM-5 HD: suicidality appears to be low, with rates of current suicidal ideation comprised between 5% and 10%, although 19% of individuals attempted suicide during their lifetime. Concerning the grooming disorders, lifetime rates of suicide attempts are low as compared to rates in other OCRDs; approximately 40% of individuals, however, reported lifetime suicidal ideation. Conclusions OCRDs taken together may be at risk for suicide attempts and suicidal ideation independently from comorbid disorders (and specifically independently from comorbid OCD); BDD remains the disorder more strongly associated with an increased risk for suicide, followed by HD and then the grooming disorders.
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Hoarding disorder (HD) is associated with significant personal impairment in function and constitutes a severe public health burden. Individuals who hoard experience intense distress in discarding a large number of objects, which results in extreme clutter. Research and theory suggest that hoarding may be associated with specific deficits in information processing, particularly in the areas of attention, memory, and executive functioning. There is also growing interest in the neural underpinnings of hoarding behavior. Thus, the primary aim of this review is to summarize the current state of evidence regarding neuropsychological deficits associated with hoarding and review research on its neurophysiological underpinnings. We also outline the prominent theoretical model of hoarding and provide an up-to-date description of empirically based psychological and medical treatment approaches for HD. Finally, we discuss important future avenues for elaborating our model of HD and improving treatment access and outcomes for this disabling disorder.
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DSM-5 recognizes hoarding disorder as distinct from obsessive-compulsive disorder (OCD), codifying a new consensus. Hoarding disorder was previously classified as a symptom of OCD and patients received treatments designed for OCD. We conducted a meta-analysis to determine whether OCD patients with hoarding symptoms responded differently to traditional OCD treatments compared with OCD patients without hoarding symptoms. An electronic search was conducted for eligible studies in PubMed. A trial was eligible for inclusion if it (1) was a randomized controlled trial, cohort or case-control study; (2) compared treatment response between OCD patients with and those without hoarding symptoms, or examined response to treatment between OCD symptom dimensions (which typically include hoarding) and (3) examined treatment response to pharmacotherapy, behavioral therapy or their combination. Our primary outcome was differential treatment response between OCD patients with and those without hoarding symptoms, expressed as an odds ratio (OR). Twenty-one studies involving 3039 total participants including 304 with hoarding symptoms were included. Patients with OCD and hoarding symptoms were significantly less likely to respond to traditional OCD treatments than OCD patients without hoarding symptoms (OR=0.50 (95% confidence interval 0.42-0.60), z=-7.5, P<0.0001). This finding was consistent across treatment modalities. OCD patients with hoarding symptoms represent a population in need of further treatment research. OCD patients with hoarding symptoms may benefit more from interventions specifically targeting their hoarding symptoms.Molecular Psychiatry advance online publication, 10 June 2014; doi:10.1038/mp.2014.50.
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While collecting may be a normal behaviour, hoarding is a symptom of various psychiatric disorders, including obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). Although anecdotal reports suggest that hoarding is not uncommon in geriatric psychiatry populations, its psychopathological correlates in such samples have not been well characterised. The presence of clinically significant hoarding symptoms was screened for in 100 consecutive patients in a geriatric psychiatry inpatient unit. Both patient and collateral histories were obtained. When hoarding symptoms were present, a detailed history of their phenomenology was obtained by means of a structured questionnaire and the response of hoarding symptoms to treatment during hospitalisation was monitored. Clinically significant hoarding was found in 5/100 subjects. Four of these 5 patients met DSM-IV criteria for schizophrenia (paranoid subtype), with onset of symptoms coinciding with increased symptoms of dementia. The fifth patient met criteria for bipolar disorder (manic episode), also had symptoms of dementia, and had a lifelong history of hoarding. Hoarding behaviours responded to antipsychotic treatment in 3 of the 5 patients. A history of hoarding may be useful in many psychiatric patients, but psychopathological correlates of this symptom are likely to vary with age. In a geriatric psychiatry inpatient population hoarding was associated not with OCD or OCPD, but rather with paranoid schizophrenia and increasing symptoms of dementia. Dopamine blockers appeared useful in decreasing hoarding in some patients, raising interesting questions about the neurobiology of this symptom.
Background: Clutter impeding the normal use of living spaces is a landmark feature of hoarding disorder (HD) but can also be present in other conditions. The assessment of clutter ideally requires home visits, although such assessments are sometimes not feasible. This study examined whether photographs from patients' homes can assist in the diagnostic process. Methods: Thirty-two professionals with experience with hoarding cases were shown pictures from the inside of 10 houses and asked to decide whether the house belonged to a person with HD, a person with obsessive compulsive disorder (OCD), or a healthy collector. Participants also rated different features of the room appearing in each picture (overall amount of possessions, tidiness, functionality, number of different classes of items, and cleanliness). Results: Sensitivity for the HD and collectors' pictures was high, whereas sensitivity for the OCD pictures was substantially lower. Specificity was high for all groups. Rooms belonging to HD individuals were rated as significantly more cluttered, more untidy, less functional, containing a higher number of different classes of items, and being less clean than the rooms from the remaining groups. Conclusions: Photographs may be used to assist clinicians in determining the presence of clinically significant levels of clutter in the event a home visit is not feasible. Although differential diagnosis will usually not be possible from photographs alone, examination of certain characteristics of the environment might provide useful diagnostic clues. Combined with a thorough psychopathological interview, the use of photographs may increase the clinician's confidence in the diagnosis of HD.
Existing psychological and pharmacological interventions for obsessive-compulsive disorder have not been particularly successful for compulsive hoarding, perhaps due in part to poor insight on the part of sufferers. Individuals with compulsive hoarding problems commonly display lack of awareness of the severity of their behavior, sometimes denying that they have a problem and often resisting intervention attempts and failing to follow through with therapeutic assignments. Using an internet-based survey, family and friends of individuals with reported hoarding problems (family/friend informants, N=584) provided ratings of the hoarder’s level of insight. They also made several ratings of the severity of the person’s hoarding behavior, then rated the same items again with regard to how they thought the hoarder would respond to the items. Family/friend informants described the hoarder on average as having fair to poor insight. More than half were described as having “poor insight” or “lacks insight/delusional,” substantially worse insight than found in samples of OCD clinic patients using the same measure. Family/friend informants’ ratings of hoarding severity were significantly greater than were their estimates of the hoarder’s ratings. Hoarders described as showing less distress about the hoarding were described as showing poorer insight. These results suggest that compulsive hoarding is characterized by poor insight into the severity of the problem. Treatment development might need to emphasize strategies to bolster awareness, insight, and motivation.
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.
Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM-5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large-scale study of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures. We compared psychiatric comorbidity in a large HD sample (n = 217) to 96 participants meeting criteria for OCD without HD. High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition-related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition-related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%). These findings form important base rates for developing research and treatments for hoarding disorder.
Traumatic life events and early material deprivation have been identified as potential environmental risk factors for the development of pathological hoarding behavior, but the evidence so far is preliminary and confounded by the presence of comorbid obsessive-compulsive disorder (OCD). This study retrospectively examined the occurrence of traumatic/stressful life events and material deprivation in four well-characterized groups: hoarding disorder without comorbid OCD (HD; n=24), hoarding disorder with comorbid OCD (HD+OCD; n=20), OCD without hoarding symptoms (OCD; n=17), and non-clinical controls (Control; n=20). Participants completed clinician and self-administered measures of hoarding, OCD, depression, psychological adjustment, and traumatic experience. Semi-structured interviews were undertaken to assess the temporal relation between traumatic/stressful life events and the onset and worsening of hoarding symptoms, and to determine the level of material deprivation. Although rates of post-traumatic stress disorder were comparable across all three clinical groups, hoarders (regardless of the presence of comorbid OCD) reported greater exposure to a range of traumatic and stressful life events compared to the two non-hoarding groups. Results remained unchanged after controlling for age, gender, education level, depression, and obsessive-compulsive symptoms. The total number of traumatic life events correlated significantly with the severity of hoarding but not of obsessive-compulsive symptoms. About half (52%) of hoarding individuals linked the onset of hoarding difficulties to stressful life circumstances, although this was significantly less common among those reporting early childhood onset of hoarding behavior. There was no link between levels of material deprivation and hoarding. Results support a link between trauma, life stress and hoarding, which may help to inform the conceptualization and treatment of hoarding disorder, but await confirmation in a representative epidemiological sample and using a longitudinal design.
This study examines the nature, severity and correlates of non-food obsessions and compulsions in 91 people with Prader-Willi syndrome (PWS) aged 5-47 years (mean age = 19 years). Prominent symptoms, seen in 37-58% of the sample, included hoarding; ordering and arranging; concerns with symmetry and exactness; rewriting; and needs to tell, know or ask. A remarkably high proportion of participants had moderate to severe symptom severity ratings; 64% showed symptom-related distress, and 80% showed symptom-related adaptive impairment. The study also compared obsessive-compulsive symptoms in 43 adults with PWS to age- and sex-matched non-retarded adults with obsessive-compulsive disorder (OCD). The PWS and OCD groups showed similar levels of symptom severity and numbers of compulsions; they also showed more areas of symptom similarity than difference. Increased risks of OCD in persons with PWS are strongly indicated. Implications are discussed for pharmacotherapy, behavioral therapy and family support.