Hoarding Disorder

What Is Hoarding Disorder?

Hoarding disorder is a mental health condition characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value, due to a perceived need to save them and distress associated with the thought of getting rid of them. Over time, the accumulation of possessions clogs living spaces to the point where they can no longer be used for their intended purpose, creating health and safety hazards.

2.6%

Source: APA, DSM-5-TR

Hoarding disorder was recognized as a distinct diagnosis in the DSM-5 in 2013, separating it from OCD. While hoarding can occur as a symptom of OCD, the majority of people with hoarding disorder do not have OCD. The two conditions have different underlying mechanisms: OCD-related hoarding is driven by obsessional fears (such as contamination or harm), while hoarding disorder involves strong emotional attachment to objects, difficulty with decision-making, and avoidance of discarding.

Hoarding disorder is significantly underdiagnosed and undertreated. Many people with the condition do not recognize it as a problem or seek help only when forced by health, safety, or legal issues. The condition tends to worsen progressively with age if untreated.

Hoarding vs. Collecting

It is important to distinguish hoarding from collecting. Collectors intentionally seek specific items, organize and display them with pride, and their collections do not impair daily functioning. In hoarding disorder, the acquiring is often unplanned or compulsive, items are disorganized and frequently unused, and the accumulation creates significant functional impairment.

Signs and Symptoms

Severity Levels

What Causes Hoarding Disorder?

Biological Factors

• Brain functioning: Neuroimaging studies show that people with hoarding disorder have abnormal activity in brain regions involved in decision-making (anterior cingulate cortex), emotional regulation (insula), and categorization (ventromedial prefrontal cortex). When deciding whether to discard a personal item, these regions show significantly more activation than in people without the disorder.
• Genetics: Hoarding runs in families. Approximately 50 percent of people with hoarding disorder have a first-degree relative who also hoards. Twin studies suggest a significant heritable component.
• Information processing: People with hoarding disorder often have difficulties with attention, categorization, and decision-making, functions linked to executive processing. These difficulties make organizing and deciding what to keep extraordinarily challenging.

Psychological Factors

• Emotional attachment to objects: Items may serve as emotional anchors, reminders of people, events, or identity. Discarding feels like losing a part of oneself or a connection to the past.
• Beliefs about possessions: Common beliefs in hoarding include the responsibility not to waste, the idea that items might be needed someday, and the belief that each object has unique value or potential.
• Avoidance: The act of keeping everything is partly driven by avoidance of the distressing decision-making process. Not deciding is easier than deciding, even though it leads to accumulation.
• Trauma and loss: Research published in the Journal of Clinical Psychology found that traumatic life events, particularly loss and deprivation, are significantly more common in people with hoarding disorder. Possessions may represent safety, security, or control in the aftermath of trauma.

Social and Environmental Factors

• Isolation: Social isolation both contributes to and results from hoarding. Without regular visitors or social accountability, clutter can accumulate unchecked.
• Material deprivation: Experiences of poverty or scarcity earlier in life can contribute to difficulty letting go of possessions.
• Life transitions: Hoarding often worsens after significant life events such as bereavement, divorce, or retirement.

Evidence-Based Treatments

Hoarding disorder is treatable, but it is generally more challenging to treat than many other conditions. Standard OCD treatments are often insufficient; hoarding-specific interventions are necessary.

Psychotherapy

CBT for Hoarding is the most studied and effective treatment for hoarding disorder. Developed by Gail Steketee and Randy Frost, this specialized protocol addresses the core difficulties of the condition:

• Motivational enhancement: Building and sustaining motivation for change, which can be particularly challenging in hoarding disorder
• Skills training: Teaching organizing, decision-making, and problem-solving skills that address the information-processing difficulties underlying hoarding
• Cognitive restructuring: Challenging beliefs about possessions (e.g., "I might need this someday," "Throwing things away is wasteful")
• Exposure and sorting practice: Gradually practicing discarding items while tolerating the distress, starting with low-value items and progressing to more emotionally significant ones
• Addressing acquiring: Developing strategies to reduce compulsive buying, free-item collecting, and other acquiring behaviors

A randomized controlled trial by Steketee and Frost, published in the Journal of Consulting and Clinical Psychology, found that CBT for hoarding produced significant reductions in hoarding severity, clutter, and difficulty discarding, with 41 percent of participants achieving clinically significant improvement. While this response rate is lower than for some other conditions, it represents meaningful progress for a notoriously difficult disorder.

Motivational Interviewing is often used as a precursor or adjunct to CBT for hoarding because ambivalence about change is common. Many people with hoarding disorder are mandated into treatment or pressured by family members, and their own motivation may be limited. Motivational interviewing helps them explore their own reasons for change and build internal motivation.

Group Therapy for hoarding has shown promising results. Groups provide mutual support, reduce shame through shared experience, and offer accountability. Buried in Treasures groups, based on the self-help book of the same name, have demonstrated effectiveness in community settings.

Home-based interventions that include in-home sessions with a therapist or coach can be more effective than office-based treatment alone. Practicing skills in the actual hoarding environment helps translate therapy gains into real-world change.

Medication

There is no medication specifically approved for hoarding disorder, and SSRIs (which are effective for OCD) have shown limited benefit for hoarding when used alone. However, SSRIs may be helpful when hoarding co-occurs with depression or anxiety. Stimulant medications may be considered when ADHD co-occurs, as treating attention and executive function difficulties can improve organizing and decision-making capacity.

What Does Not Help

• Forced cleanouts: Removing possessions without the person's consent is generally counterproductive. It causes severe distress, damages the therapeutic relationship, and often leads to rapid re-accumulation. Research consistently advises against forced cleanouts except in cases of imminent danger.
• Criticism and pressure: Expressing frustration about the clutter, even when well-intentioned, typically increases shame and defensiveness rather than motivating change.
• Organizing without discarding: Simply organizing existing possessions without addressing the underlying difficulty discarding provides only temporary improvement.

Co-Occurring Conditions

• Depression: Approximately 50 percent of people with hoarding disorder also have major depression. Depression can worsen hoarding by reducing motivation and energy for organizing and discarding.
• Anxiety: Generalized anxiety and hoarding frequently co-occur, and anxiety about making wrong decisions contributes to difficulty discarding.
• OCD: While hoarding disorder is distinct from OCD, approximately 20 percent of people with OCD have hoarding symptoms.
• ADHD: Attention difficulties and impaired executive function in ADHD can directly contribute to hoarding behavior.

When to Seek Help

Consider reaching out to a mental health professional if you:

• Have difficulty discarding items that most people would consider not worth keeping
• Notice that clutter has taken over living spaces in your home
• Feel significant distress at the thought of getting rid of possessions
• Are unable to use rooms in your home for their intended purpose
• Have received complaints from family, landlords, or authorities about clutter
• Experience shame or embarrassment about the state of your home
• Have stopped inviting people over because of clutter
• Notice safety hazards in your home due to accumulation of possessions

Treatment for hoarding disorder requires patience and commitment, but meaningful improvement is achievable. A therapist experienced with hoarding disorder can help you develop the skills and motivation needed to reclaim your living space and quality of life.

Frequently Asked Questions

You can reclaim your living space and your life

A therapist experienced with hoarding disorder can help you build the skills to make decisions about possessions and reduce clutter at a pace that works for you.

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