Hoarding disorder: symptoms, causes and treatment

Key points

• In hoarding disorder, discarding possessions is very hard and clutter stops rooms being used normally [1][5].
• Since DSM-5 in 2013 it has been a diagnosis in its own right, not a symptom of OCD [4].
• It differs from collecting and untidiness: difficulty discarding regardless of value, unusable living space, and distress [5].
• Items are kept for reasons that make sense to the person: sentimental attachment, expected future use, identity [2].
• There is no NICE guideline. CBT adapted for hoarding has the best evidence, and the research base is small [1][5].
• Clearing someone’s home without treatment usually makes things worse, and the clutter returns [3].

What hoarding disorder is

Hoarding disorder is a mental health condition in which a person has persistent difficulty getting rid of possessions, whatever they are worth, and often keeps acquiring more [1][5]. Clutter builds until rooms cannot be used for cooking, washing or sleeping, causing distress or making daily life hard to manage [5].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

There is no reliable UK prevalence figure. International estimates are around 2.6 per cent of adults, with higher rates over 60 [5]. It often begins between 15 and 19 and worsens with each decade [5].

Symptoms

Symptoms fall into three linked areas.

Difficulty discarding - Strong anxiety or guilt at the idea of parting with an item, so decisions are postponed [1][2]. - Keeping things others treat as waste: packaging, newspapers, carrier bags, old post [4].

Acquiring - Picking up or buying items that are not needed, with a lift in mood at the moment of acquiring [1].

The home - A bath, bed, cooker or hallway becomes storage, nothing in it can be found, and escape routes get blocked [1][2][6].

Shame and strain on relationships are common [1][2]. Hoarding is commonly confused with OCD, collecting, untidiness, and clutter linked to ADHD or depression, where the difficulty is starting tasks rather than distress at parting with things.

Types

Hoarding disorder has no formal subtypes. It is described by specifiers and presentations.

• With excessive acquiring. Most people with the diagnosis also acquire items they do not need [5].
• Level of insight. Some people recognise the difficulty and others do not, which affects how treatment is approached [5].
• Hoarding within OCD. Items kept because of an obsessive fear are recorded as OCD instead [4].
• Severity. Clinicians describe how far each room is filled, using photograph based clutter scales [3].

Causes and risk factors

There is no single cause, and most people have several factors in their history.

• Hoarding behaviour in a close family member [1].
• Poverty, deprivation, neglect or abuse in childhood [1].
• Perfectionism and social isolation, and grief after a bereavement or another major life change [1].
• Older age, as severity increases over time [5].

The reasons people give for keeping items make the condition make sense.

• Sentimental attachment. Discarding the item feels like losing the memory attached to it [2].
• Future usefulness. The item might be needed, repaired or reused [2][4].
• Identity. The item feels part of who the person is, and possessions give a sense of security [2].

Laziness, low standards and lack of storage are explanations the evidence does not support. None account for the distress people describe when parting with one item [2][3].

How it is diagnosed

A GP is the usual first point of contact, and the diagnosis is normally made by a clinical psychologist or psychiatrist registered with the HCPC or GMC [1]. Hoarding is not on the NHS Talking Therapies self-referral list, so a GP referral is the usual route [10].

Assessment covers how long the difficulty has lasted, which rooms are affected, what happens when discarding is attempted, and other conditions [1][5]. Clinicians often use clutter image rating scales, published by UK charities, to describe rooms without a home visit [3].

The recorded criteria are persistent difficulty discarding possessions regardless of value, accumulation that substantially compromises the intended use of living areas, and significant distress or impairment, not better explained by another condition [4][5].

No reliable waiting time exists for hoarding, as people are seen through general adult mental health services. A diagnosis opens the door to treatment, but does not mean a person lacks mental capacity, and gives nobody the right to clear their home.

Treatment

There is no NICE guideline for hoarding disorder, so UK treatment follows the wider evidence base rather than a national recommendation.

CBT adapted for hoarding has the best evidence and is offered individually or in groups [1][5]. It covers the beliefs behind keeping items, practising decisions on real possessions, sorting at the person’s own pace, and reducing acquiring.

The evidence base is smaller than for depression or anxiety and improvement is often partial [1][4]. Treatment can be slow to start, because many people do not see the accumulation as a problem [4].

Antidepressants are sometimes prescribed where anxiety or depression is present alongside the hoarding [1]. Evidence for medication in hoarding disorder itself is limited [5]. Any decision about medicine is one for a GP or psychiatrist.

Practical decluttering help can sit alongside therapy, but only with the person’s agreement [7]. Clearing a home without their involvement is not treatment and can make things worse [3].

Living with hoarding disorder

Fire risk is the most urgent practical issue. Stored paper and cardboard burn quickly, and overloaded extension leads, the kitchen hob, candles and cigarettes are common ignition points [6]. Keep one clear route from every bedroom to the front door, swap candles for LED ones, and book a free home fire safety visit from your local fire service [6].

Councils usually act through environmental health. An accumulation that harms health or seriously affects neighbours can be a statutory nuisance under the Environmental Protection Act 1990, and a council can serve an abatement notice, prosecute, or clear the property and recover the cost [8].

Most tenants cannot be evicted without a court order and there is always a hearing, so get housing advice when a notice arrives [9].

Adult social care may become involved through safeguarding, because hoarding is sometimes linked to self-neglect under Care Act 2014 guidance, where good practice is gradual and managing risk well counts as a reasonable outcome [7].

Risks are sharpest for older adults, as severity increases with age [5], and clutter that blocks an exit makes safe evacuation more difficult [6]. Day to day, work on one small area rather than a room, photograph sentimental items before letting them go, and ask anyone helping not to move anything without asking [3].

When to speak to a professional

Speak to your GP if any of the following apply.

• A bed, bath, kitchen or main walkway cannot be used normally.
• The thought of discarding a single item causes real distress.
• A landlord, housing officer or environmental health team has written to you.
• There has been a fire, a fall, a leak or an infestation.

Mention hoarding directly, as clutter is often recorded as a housing issue rather than a health one. If you cannot keep yourself safe, contact Samaritans on 116 123, text SHOUT to 85258, or call NHS 111 and choose the mental health option. Call 999 if anyone is in immediate danger.

Common questions

What is the difference between hoarding and collecting?

Collecting is selective, organised and displayed, and a collector can find and use the items [2]. In hoarding disorder items are not selected in that way, are stored without order, and stop rooms being used for their purpose [2][5].

Is hoarding disorder a type of OCD?

No. It was reclassified as a condition in its own right in DSM-5 in 2013 [2][4]. In OCD, saving follows an intrusive thought and works like a compulsion. In hoarding disorder the difficulty is discarding, and the distress comes from parting with the item [4]. The two can occur together.

How can someone help a family member who does not want help?

Small consistent steps work better than pressure. Charities advise against surprise visits, tricking or persuading someone into throwing things away, and calling their possessions junk, because these damage trust and rarely change anything [3]. It helps to ask what support the person wants and to offer to attend a GP appointment [3].

Does clearing the house work?

Not on its own. Clearing without treatment is unlikely to help long term and can make matters worse, because the reasons the items were kept have not changed and the accumulation returns [3]. Where clearance is unavoidable for safety, involving the person in every decision works better [3][7].

Clinical review pending

References

1. NHS. Hoarding disorder. nhs.uk. https://www.nhs.uk/mental-health/conditions/hoarding-disorder/
2. Mind. About hoarding. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/hoarding/about-hoarding/
3. Mind. Hoarding: for friends and family. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/hoarding/for-friends-and-family/
4. OCD-UK. Hoarding Disorder. ocduk.org. https://www.ocduk.org/related-disorders/hoarding-disorder/
5. American Psychiatric Association. What Is Hoarding Disorder? psychiatry.org. https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder
6. London Fire Brigade. Hoarding disorder. london-fire.gov.uk. https://www.london-fire.gov.uk/safety/caring-for-vulnerable-people/carers-and-support-workers/hoarding-disorder/
7. Social Care Institute for Excellence. Self-neglect at a glance. scie.org.uk. https://www.scie.org.uk/self-neglect/at-a-glance/
8. GOV.UK. Statutory nuisances: how councils deal with complaints. https://www.gov.uk/guidance/statutory-nuisances-how-councils-deal-with-complaints
9. Shelter England. Eviction. england.shelter.org.uk. https://england.shelter.org.uk/housing_advice/eviction
10. NHS. NHS talking therapies for anxiety and depression. nhs.uk. https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/nhs-talking-therapies/