Hoarding disorder

Essential (Required) Features:

• Accumulation of possessions that results in living spaces becoming cluttered to the point that their use or safety is compromised. Note: If living areas are uncluttered this is only due to the intervention of third parties (e.g., family members, cleaners, authorities). Accumulation occurs due to both:
• Repetitive urges or behaviours related to amassing items, which may be passive (e.g., accumulation of incoming flyers or mail) or active (e.g., excessive acquisition of free, purchased, or stolen items).
• Difficulty discarding possessions due to a perceived need to save items and distress associated with discarding them.
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Insight specifiers:

Individuals with Hoarding Disorder vary in the degree to which they recognize that hoarding-related beliefs and behaviours (pertaining to excessive acquisition, difficulty discarding, or clutter) are problematic. For example, some can acknowledge that their living space presents a hazard, that many of the items they save are without value and unlikely to be of future use, or that their distress associated with discarding items is not rational, Others are convinced that their hoarding-related beliefs and behaviours are not problematic, despite evidence to the contrary, and the beliefs of some may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (e.g., an individual insists that items that objectively have little or no value are critically important to save or denies that there is any problem with their living space). Insight may vary substantially even over short periods of time, for example depending on the level of current anxiety or distress, such as when a family member or other person forces the individual to discard items. The degree of insight that an individual exhibits in the context of Hoarding Disorder can be specified as follows:

6B24.0 Hoarding Disorder with fair to good insight

• Much of the time, the individual recognizes that hoarding-related beliefs and behaviours (pertaining to excessive acquisition, difficulty discarding, or clutter) are problematic. This specifier level may still be applied if, at circumscribed times (e.g., when being forced to discard items), the individual demonstrates no insight.

6B24.1 Hoarding Disorder with poor to absent insight

• Most or all of the time, the individual is convinced that hoarding-related beliefs and behaviours (pertaining to excessive acquisition, difficulty discarding, or clutter) are not problematic, despite evidence to the contrary. The lack of insight exhibited by the individual does not vary markedly as a function of anxiety level.

6B24.Z Hoarding Disorder, unspecified

Additional Clinical Features:

• Assessment for the diagnosis of Hoarding Disorder may require obtaining additional information beyond self-report such as reports from collateral informants or visual inspection of clutter in the home.
• Generally, items are hoarded because of their emotional significance (e.g., association with a significant event, person, place, or time), instrumental characteristics (e.g., perceived usefulness), or intrinsic value (e.g., perceived aesthetic qualities).
• Individuals with Hoarding Disorder may be unable to find important items (e.g., bills, tax forms), circulate easily inside their home, or even exit their home in the event of an emergency. Ability to prepare food, use sinks or home appliances (e.g., refrigerator, stove, or washing machine) or furniture (e.g., sofas, chairs, beds, tables) may also be compromised.
• Individuals with Hoarding Disorder may experience a range of chronic medical problems, such as obesity, and are exposed to various environmental risks often caused by their hoarding behaviour, including fire hazards, injuries from falling, contamination by rotting perishable foods, and allergies from contact with dust pollen and bacteria.

Boundary with Normality (Threshold):

• Collectors acquire many items that they report being attached to and reluctant to discard. However, they are also more targeted in their acquisitions (e.g., confining their acquisitions to a narrow range of items), more selective (e.g., planning and purchasing only predetermined items), more likely to organize their possessions, and less likely to accumulate items in an excessive manner.

Course Features:

• Hoarding behaviours often begin during childhood or adolescence and persist into later life. Onset after age 40 is rare.
• Hoarding Disorder is typically chronic and progressive.
• The consequences of hoarding become more severe and impairing with age due to accumulation of objects over time or secondary to an increased inability to discard or organize possessions because of the onset of comorbid physical and co-occurring mental disorders.
• Among the elderly, Hoarding Disorder is associated with impairment in a range of life-domains, including unsafe living conditions, social isolation, pathological self-neglect (i.e., poor hygiene), co-occurring mental disorders, and medical comorbidities.

Developmental Presentations

• Hoarding Disorder has its onset in childhood and adolescence (i.e., between the ages of 11 and 15) with prevalence rates reported as high as 2 to 3.7% by mid-adolescence. Later life onset may be a manifestation of the cognitive deficits and behavioural symptoms associated with Dementia (e.g., decreased inhibition or repetitive behaviour) rather than Hoarding Disorder.
• Excessive collecting and accumulation of clutter characteristic of Hoarding Disorder in adults may not be as evident among youth because caregivers may restrict excessive acquisition of objects. As such, hoarding is more likely to be restricted to particular areas (such as a child’s bedroom) and types of materials (such as school-related objects, toys, and food) that the child can most easily access.
• Collecting and saving items is developmentally appropriate behaviour for young children up to the age of six making it more challenging for parents and clinicians to differentiate problematic hoarding from age-appropriate collecting and retaining objects.
• Individuals with Hoarding Disorder are more likely to experience co-occurring mental disorders or comorbid medical conditions, though this varies across developmental periods. Children and adolescents with hoarding symptoms are more likely to have co-occurring mental disorders, such as Obsessive-Compulsive Disorder or Attention Deficit Hyperactivity Disorder. Hoarding symptoms are also more common among youth with Autism Spectrum Disorder or Prader-Willi Syndrome. However, an additional diagnosis of Hoarding Disorder may be appropriate if the symptoms of each disorder require independent clinical attention. Among the elderly with Hoarding Disorder, Depressive Disorders, Anxiety or Fear-Related Disorders, and Post-Traumatic Stress Disorder are the most common co-occurring mental disorders.
• Hoarding occurring later in life has also been correlated with decreased memory, attention, and executive functioning, though the increased rates of co-occurring disorders such as Dementia and Depressive Disorders may also be involved.

Culture-Related Features:

• The nature of what is collected and the meaning, emotional valence, and value that people with Hoarding Disorder assign to their possessions may have cultural significance.
• Cultural values of thriftiness and accumulation should not be mistaken as evidence of disorder. In some cultural environments, saving items for later use is encouraged. This may be especially true in contexts of scarcity or within groups who experienced protracted periods of scarcity. Unless the symptoms are beyond what is expected of the cultural norms, these behaviours should not be assigned a diagnosis of Hoarding Disorder.

Sex- and/or Gender-Related Features:

• Although prevalence rates for Hoarding Disorder are higher for women in clinical samples, some epidemiological studies have reported significantly higher prevalence rates among men.
• Men with Hoarding Disorder are more likely to have co-occurring Obsessive-Compulsive Disorder.
• Although the presenting features of Hoarding Disorder do not vary across gender, women tend to exhibit more excessive acquisition, particularly by means of compulsive buying.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Obsessive-Compulsive Disorder: Individuals affected by Obsessive-Compulsive Disorder may accumulate excessive amounts of objects (i.e., compulsive hoarding). However, unlike Hoarding Disorder, the behaviour is undertaken with the goal of neutralizing or reducing concomitant distress and anxiety arising from obsessional content such as aggressive (e.g., fear of harming others), sexual/religious (e.g., fear of committing blasphemous or disrespectful acts), contamination (e.g., fear of spreading infectious diseases), or symmetry/ordering (e.g., feeling of incompleteness) themes. Furthermore, even in individuals affected by Obsessive-Compulsive Disorder who have poor or absent insight, the behaviour is generally unwanted and distressing, whereas in Hoarding Disorder it may be associated with pleasure or enjoyment. However, if diagnostic requirements for both disorders are met, both diagnoses may be assigned.
• Boundary with Autism Spectrum Disorder: Autism Spectrum Disorder is characterized by restricted interests that may result in object accumulation and may also result in difficulty discarding objects due to distress associated with changes imposed on a familiar environment. However, individuals with Autism Spectrum Disorders display other symptoms that are typically lacking among individuals with Hoarding Disorder, including persistent deficits in social communication and reciprocal social interactions.
• Boundary with Delusional Disorder and other Primary Psychotic Disorders: In Schizophrenia or Other Primary Psychotic Disorders, object accumulation may occur but is typically driven by delusions. Some individuals with Hoarding Disorder lack insight about the irrationality of their thoughts and behaviours to such an extent that convictions of the importance of acquiring and retaining items may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (see Insight specifiers, page __). If these beliefs are restricted to the fear of discarding items or conviction that items have a special importance despite objective evidence to the contrary without a history of other delusions, that is, these beliefs occur entirely in the context of symptomatic episodes of Hoarding Disorder and are fully consistent with the other clinical features of the disorder, Hoarding Disorder should be diagnosed instead of Delusional Disorder. Individuals with Hoarding Disorder do not exhibit other features of psychosis (e.g., hallucinations or formal thought disorder).
• Boundary with Mood Disorders: Unlike individuals with Hoarding Disorder, those with Mood Disorders may exhibit hoarding secondary to depressive or manic symptomatology. In the case of Depressive Disorders, decreased energy, lack of initiative or apathy may lead to object accumulation, which unlike Hoarding Disorder, is done without any intention or purpose. Furthermore, individuals with Depressive Disorders may be indifferent to hoarding objects and display no distress associated with discarding them. In the case of Bipolar Disorders, object accumulation may be secondary to excessive buying that can occur during Manic Episodes. However, those with Bipolar Disorders do not have difficulty discarding or parting with possessions and only very rarely are Manic Episodes of sufficient duration to allow for a substantial amount of clutter to develop in the home.
• Boundary with Eating Disorders: Some individuals diagnosed with Feeding or Eating Disorders may accumulate large quantities of food to allow for binge eating in specific situations (e.g., while at home alone). However, in contrast to Hoarding Disorder, the purpose of accumulation is restricted to the consumption of food. Concerns about being or becoming overweight as well as body image distortions are not present in Hoarding Disorder.
• Boundary with Dementia: The symptoms are not a manifestation of Dementia, in which some individuals accumulate objects as a result of progressive neurocognitive deficit. Unlike Hoarding Disorder, individuals with Dementia display little interest in accumulating objects or distress associated with discarding items. Furthermore, collecting behaviour in Dementia may be accompanied by severe personality and behavioural changes, such as apathy, sexual indiscretions, and motor stereotypies.
• Boundary with Prader-Willi Syndrome: Prader-Willi Syndrome is associated with an increased drive to eat and a range of compulsive symptoms, including food storing. The presence of short stature, hypogonadism, failure to thrive, hypotonia, and a history of feeding difficulty in the neonatal period are helpful for the differential diagnosis with Hoarding Disorder.