Hoarding disorder, also known as compulsive hoarding, is a persistent difficulty discarding or parting with possessions due to a perceived need to save them. Excessive accumulation of items, regardless of actual value, occurs. Hoarding often creates clutter and congestion in living areas that compromises their intended use. Excessive acquisition leads to accumulated items that cover the living areas of the home and cause significant distress or impairment (Frost & Hristova, 2011). Hoarding is a complex phenomenon and a challenging problem. This article examines the prevalence and common characteristics of hoarding disorder.
Prevalence of hoarding disorder
Hoarding disorder was recognized as a distinct disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013 after being considered a symptom of obsessive-compulsive disorder (OCD) for many years. Therefore, early prevalence estimates focused on hoarding among OCD patients rather than the general population. More recent studies have examined the prevalence of hoarding disorder itself.
General population
In the past decade, large epidemiological studies have estimated the prevalence of hoarding disorder in the general population. The results indicate that hoarding occurs in approximately 2-6% of the population (Nordsletten et al., 2013; Timpano et al., 2011).
Some key prevalence findings:
- A study of over 7000 people in Germany found a hoarding disorder prevalence of 5.8% based on DSM-5 criteria (Timpano et al., 2011).
- A Norwegian epidemiological study of over 1800 individuals estimated a hoarding disorder prevalence of 2.7% (Nordsletten et al., 2013).
- A study in the UK surveyed over 7000 people and determined a prevalence of hoarding behavior that caused distress or impairment consistent with DSM-5 hoarding disorder was 2.3% (Fullana et al., 2013).
The variability in estimates is likely due to differences in assessment methods, diagnostic criteria, sample characteristics, and cultural factors. But overall, studies suggest that 2-6% of the general population exhibits clinically significant hoarding behavior.
Older adults
Hoarding appears to be more common in older adults compared to younger adults. Two major studies found:
- Nearly 4% of older adults over 55 years old reported symptoms consistent with hoarding disorder, compared to around 1% of younger adults (Ayers et al., 2014).
- Clinically significant hoarding behavior was present in 4.6% of adults over 55 versus only 2.2% of adults 35-44 years old (Fullana et al., 2013).
The increased hoarding prevalence with age may be due to a longer time to accumulate possessions, or perhaps a cohort effect reflecting values of saving and thrift in older generations.
Gender
Research consistently shows a higher prevalence of hoarding disorder in men compared to women in the general population. Key findings include:
- 5.8% of men versus 3.7% of women met DSM-5 hoarding criteria in a UK study (Fullana et al., 2013).
- Male gender predicted hoarding behavior in a large Norwegian sample (Nordsletten et al., 2013).
- Excessive hoarding was present in 5.6% of older males versus 3.4% of older females over 55 years old (Ayers et al., 2014).
The reasons for greater hoarding among men are not well understood but may involve socialization around saving possessions, responsibilities for handling household clutter, neurological differences, or other factors.
Hoarding symptoms
Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, leading to clutter that disrupts functioning. Diagnostic criteria in the DSM-5 includes (American Psychiatric Association, 2013):
- Difficulty discarding items due to strong urges to save them.
- Distress associated with discarding.
- Excessive accumulation of items, even of limited value or usefulness.
- Cluttered living areas that cannot be used as intended.
- Significant distress or impairment in functioning due to hoarding.
Hoarding symptoms typically start gradually and get worse over time as clutter accumulates. Severe cases may pose health risks like fire hazards, falls, poor sanitation, and inability to prepare food (Frost et al., 2011). Hoarding leads to extensive functional impairment at home, work, and in social relationships.
Saving and acquisition
People who hoard have an excessive need to save possessions. This is driven by beliefs that items are valuable, have emotional significance, or will be needed in the future. New items are constantly acquired, often impulsively or unnecessarily. Reasons for saving include (Steketee & Frost, 2003):
- Sentimental attachment to possessions.
- Belief in the potential usefulness or value of items.
- Concerns about waste or losing important information.
- Desire to be prepared for any contingency.
People who hoard may even save what others consider trash, like junk mail or food containers. Their saving goals exceed their living space, leading to clutter buildup over time.
Clutter
Clutter is the hallmark of compulsive hoarding. Possessions accumulated over many years fill up living spaces. Clutter often spreads to occupy all available areas, including:
- Rooms: bedrooms, living room, kitchen, office, etc.
- Furniture: counters, tables, chairs, sofas, beds, floor.
- Appliances: stove, sink, bathtub, refrigerator.
Clutter makes it very difficult to use living spaces and appliances for their intended purposes. Severe clutter creates navigational obstacles, causes falls, and impedes activities like cooking, sleeping, and bathing. It may prevent entrance to or exit from the home in extreme cases.
Difficulty discarding
A core feature of hoarding disorder is great difficulty discarding or parting with possessions due to intense reluctance or anxiety (Steketee & Frost, 2003). Reasons for saving are often irrational but feel very powerful and real to the individual. Even trash or worthless items evoke distress at the thought of discarding them. Common beliefs include:
- “I might need this someday.”
- “I could fix this or it could become useful.”
- “I can’t waste anything that could have value.”
- “This has important memories or emotions attached to it.”
Letting go feels like losing a part of oneself or destroying something meaningful. Discarding even small amounts of things may take hours due to paralyzing indecisiveness. Severe distress, procrastination, and avoidance occur when faced with cleaning up clutter.
Comorbid conditions
Hoarding disorder commonly co-occurs with other mental health conditions, including:
Depression and anxiety
Up to 75% of people with hoarding disorder also have major depressive disorder, and up to 48% have an anxiety disorder like generalized anxiety or social anxiety (Frost et al., 2011). The social isolation, home impairments, and shame resulting from hoarding likely contribute to depression and anxiety. Difficulty organizing and decision-making in hoarding may also be linked to executive functioning deficits associated with anxiety and depression.
ADHD
Studies report that 15 to 35% of people with hoarding disorder also have attention deficit hyperactivity disorder (ADHD) (Hall et al., 2013). Impulsivity is a well-known feature of ADHD that may underlie buying, acquiring free things, and grabbing items without thought during hoarding. Indecisiveness in hoarding resembles ADHD struggles with prioritizing and organizing tasks. Genetic and neurobiological overlaps may also contribute to the hoarding-ADHD link.
OCD
Hoarding was considered a symptom of OCD until the DSM-5 recognized it as a distinct disorder. Up to 20% of people with OCD exhibit hoarding behavior (Pertusa et al., 2008). Compulsive acquisition and difficulty discarding resemble OCD compulsions. Excessive doubts about decisions to discard possessions also overlap with obsessions in OCD. Around 20% of people with hoarding disorder also have OCD.
Treatment
Hoarding can be treated through psychotherapy, medication, and community supports. Key options include:
Cognitive behavioral therapy (CBT)
CBT is considered the first-line psychosocial treatment for hoarding. It helps identify and restructure maladaptive thoughts about possessions and build skills to organize and make decisions about clutter (Muroff et al., 2011). Goals include improving decision-making, developing sustainable organizing systems, and gradually practicing discarding. Motivational interviewing and harm reduction approaches are often incorporated.
Decluttering assistance
Many people with hoarding need hands-on help from family, friends, or professionals to sort, organize, and remove large amounts of clutter. Having an assistant provides support for the difficult process of deciding what to discard. Cleanouts staged over many small sessions may be more tolerable than one large purge. Ongoing maintenance help prevents re-cluttering.
Medications
Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine are sometimes prescribed to alleviate anxiety and obsessive thoughts related to hoarding. ADHD medications like stimulants may also reduce distractibility and impulsivity. But research on medication efficacy is limited, and medication alone is typically inadequate treatment.
Home modifications
As a last resort, people with severe hoarding may require family or authorities intervening to clean and make their home habitable. Social services provide referrals for housing assistance, legal advocacy, home repairs, housekeeping, and meals. Hoarding task forces in some communities coordinate multi-agency supports.
Outlook
Hoarding disorder causes significant impairment in daily functioning and quality of life. With adequate treatment and support, people with hoarding can learn to manage their symptoms and live more comfortably at home. Cognitive behavioral therapy provides long-term skill-building. Medication and in-home supports address additional needs. A compassionate, patient approach yields the best outcomes. Ongoing monitoring and follow-up help maintain decluttering gains over time. While challenging, hoarding disorder is treatable, and recovery is possible.
Conclusion
Hoarding disorder affects approximately 2-6% of the general population based on recent epidemiological studies. Prevalence increases with age, with nearly 4% of older adults exhibiting hoarding behavior. Men have a higher rate of hoarding than women. Core symptoms include difficulty discarding possessions, excessive accumulation, and severe clutter in living spaces. Saving and acquisition tendencies underlie these problems. Hoarding commonly co-occurs with depression, anxiety, ADHD, and OCD. Treatment is available through cognitive behavioral therapy, medications, in-home supports, and multi-agency collaborations. With proper treatment and ongoing assistance as needed, people with hoarding can declutter their homes and regain functional living space.
