As a visiting nurse in the 1970s-1990s I recall a subset of clients who lived almost as prisoners in their homes. They were hoarders and their lifestyle and reality were yet to make a hit on reality TV or even be discussed by providers. I recall as a nursing manager in home health when a new nurse asked to speak to me about the clutter in the home of a new patient she was seeing. He was a retired fireman and lived alone in a suburban split level house. I remember thinking that he probably had some dirty dishes in his sink and this was freaking the newbie out. I took that back when I made a shared visit with her and found him to be sleeping on a small cot in his living room which was covered in floor to ceiling boxes of food, canned goods and old mail. We had to struggle to walk on a narrow pathway to his bathroom where his tub was filled with broken TV sets and old radios. The sink was full of hardware and cooking utensils. He was unable to go upstairs because the staircase was full of old magazines. With lots of urging, we got him to agree to have the fireman he worked with come and help him clean out the house and part with all of the clutter. It was very painful and conflicted for him and for his friends. This patient and a few others led me to an interest in hoarding disorders. In the material below I share some information about the disorder and its treatment.
The cause of hoarding disorder is unknown. Although many patients report a family history of hoarding, genetic studies have pointed toward several different genes. Numerous psychological theories concerning the etiology of hoarding disorder point to characteristics often displayed by hoarders, including difficulty initiating and completing tasks, excessive sentimental attachment to possessions, indecisiveness, and impaired memory confidence. In late-onset hoarding, traumatic life events may act as precipitants.
Hoarding disorder has a significantly greater prevalence among males than among females.
Congested and cluttered living areas are a diagnostic criterion for hoarding disorder, and conducting a home visit and viewing photos of the main living areas are frequently the best ways to assess hoarding disorder. It may also be helpful to speak to friends and family members because hoarders often lack insight into their disorder and frequently do not view their condition as harmful or abnormal. Visits to the residence demonstrate the importance of firsthand observations. If home visits are not conducted, clinicians may fail to comprehend the full extent of the clutter.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, hoarding involves a persistent difficulty discarding or parting with possessions, regardless of their actual value, due to a perceived need to save the items and to distress associated with discarding them. It often leads to an accumulation of possessions that congest and clutter living areas and substantially compromise their intended use. It causes clinically significant distress or impairment in social, occupational, or other important areas of functioning and is not attributable to another medical condition or better explained by the symptoms of another mental disorder.
The disorder does have a high rate of co-occurrence with depressive and anxiety disorders as well as with attention-deficit/hyperactivity disorder (ADHD). Indeed, the thought of discarding one’s possessions can create intense anxiety in the hoarder. Hoarding disorder may also occur as part of obsessive-compulsive disorder (OCD), in which individuals have obsessions in relation to certain items and compulsions to collect these objects.
Hoarding can also occur as a part of organic states such as dementia, cerebrovascular accidents, or alcohol-related brain disorders. In these cases, the hoarding is relatively new in onset and much more disorganized, with more prominent squalor. As in chronic hoarding, patients typically lack insight into their disorder, making input from friends and neighbors critical to diagnosis. Medical review and examination is indicated for acute-onset cases.
Cognitive Behavioral Therapy or CBT, the primary form of psychological therapy for hoarding disorder, typically involves weekly sessions over 20-26 weeks. These sessions often incorporate home visits with a therapist combined with between-session homework. Home visits are particularly valuable for monitoring the patient’s progress. A study of persons with hoarding disorder who received 26 individual sessions of CBT, including frequent home visits, over a 7- to 12-month period found that adherence to homework assignments was strongly related to symptom improvement. Online CBT sessions that give patients access to educational resources on hoarding, cognitive strategies, and a chat group have shown promising results.
Selective serotonin re-uptake inhibitors (SSRIs) and serotonin/nor-epinephrine re-uptake inhibitors (SNRIs) are most commonly used to treat hoarding disorder. Treatment response to pharmacotherapy is similar to the response in OCD. In addition, pharmacologic treatment of a coexisting anxiety or depressive disorder may be indicated.