Hoarding disorder (HD) is part of a cluster of diagnoses called the obsessive-compulsive and related disorders. Obsessive-compulsive and related disorders are a group of psychiatric conditions that include:
These disorders are characterized by the occurrence of repetitive behaviors, often called compulsions.
These disorders are characterized by the occurrence of repetitive behaviors, often called compulsions. Individuals with obsessive-compulsive disorder might engage in compulsive behaviors such as excessive washing, checking, arranging, or counting. Individuals with body dysmorphic disorder might engage in frequent checking of their appearance in the mirror, or excessive grooming-related behaviors. Individuals with hoarding disorder may engage in excessive acquiring of objects, combined with a strong need to save items. Individuals with trichotillomania engage in excessive hair pulling, and individuals with excoriation disorder engage in excessive skin picking.
In some cases, the obsessive-compulsive and related disorders are also characterized by intrusive, unwanted, or distressing thoughts, called obsessions, which come to mind again and again. People with obsessive-compulsive disorder might have obsessive thoughts about dirt or germs, thoughts of harming others, fears of making mistakes, or distress about things being out of order. People with body dysmorphic disorder have repetitive, negative thoughts about their own appearance. However, people with certain other obsessive-compulsive and related disorders (such as trichotillomania or excoriation disorder) often do not experience obsessive thoughts.
Hoarding disorder is a newly-recognized psychiatric disorder that is thought to affect approximately 2-6% of adults. Although there is clear evidence that hoarding often begins in childhood, there is relatively little research on hoarding in children and adolescents.
Nonetheless, accumulating evidence suggests that prevalence rates in children and adolescents are similar to those seen in adults. It appears that hoarding can exist separately from other aspects of pediatric obsessive-compulsive disorder (OCD).
Hoarding disorder is characterized by three main symptoms:
Sometimes individuals with hoarding disorder also excessively acquire items that are not needed or for which there is no available space. The person may purchase the items (for example from stores or yard sales) or excessively acquire free items (for example, items that have been discarded).
People with hoarding disorder may hoard one type of item (for example, collectible figurines), several types of items, or a wide range of items (including garbage or other items that most people would consider worthless). Some individuals hoard animals with the goal of "saving" or caring for stray or impounded animals. Hoarding behaviors become a clinical problem when they cause distress or when they impair the person's life (for example, by preventing the individual from inviting others to visit, or by causing health and safety problems).
Given that children and adolescents have limited control over their entire home due to parental influences, clutter may be primarily limited to their own bedroom. There is evidence suggesting that excessive clutter and acquisition may occur less frequently in youth, likely due to adults' greater control over their environment and financial resources.
People with hoarding disorder can have varying levels of insight about their symptoms. Some individuals with good insight recognize that their behaviors are problematic. However, other individuals believe that their difficulty discarding and clutter are not problematic at all. These individuals may be less likely to pursue or respond to treatment.
Hoarding severity can range from fairly mild to very severe. In severe cases, hoarding disorder can lead to family strain, impaired social relationships, eviction, illness (due to airborne pathogens), or death (due to house fires or falls). Many people with hoarding disorder have physical health problems and other psychiatric conditions, most commonly depression, anxiety disorders, and attention deficit-hyperactivity disorder.
Children who hoard have significantly impaired social, emotional, and family functioning directly related to their hoarding symptoms. Children with a diagnosis of OCD who hoard have elevated levels of disability and increased comorbidity with other psychiatric conditions compared to children with OCD who do not hoard.
Hoarding disorder is characterized by abnormalities of brain function, particularly in regions associated with reward processing and salience (relevance or importance), which are thought to contribute to symptoms. In addition, certain beliefs (such as "I must not be wasteful," or "I have to save this if I might need it") are thought to contribute to symptoms, as are problems with attention, organization, and executive functioning. Hoarding disorder runs in families and may have a genetic component. However, having a genetic predisposition to hoarding disorder does not necessarily mean that someone will develop the disorder.
At this time, there is no published consensus about the best ways to treat hoarding disorder. Currently, clinical research suggests that the most promising treatment is cognitive-behavioral therapy (CBT). CBT consists of education about hoarding, building motivation, teaching strategies for sorting and discarding possessions, and challenging unhelpful thoughts and beliefs about possessions.
CBT can be conducted individually or in a group setting. The efficacy of these interventions with adults has been investigated primarily with case studies, small pilot studies, or open trials. Very little research has been conducted to develop, test, or implement treatment for hoarding disorder in children and adolescents. To date, there have only been two single case design studies that tested flexibly adapting CBT for the treatment of hoarding in children. Therefore, the current status of these interventions in children is experimental.
A childhood model of hoarding has been proposed that includes that same components of the adult CBT model but also pays particular attention to developmental concerns, including the extreme attachment to and personification of objects that children who hoard tend to develop and the effect of hoarding-related distress on family functioning and parenting. In addition to exposure to discarding possessions, CBT approaches for youth with hoarding would likely incorporate parent management training to reduce accommodation and positive reinforcement strategies to increase children's motivation to engage in treatment.
Regarding medication, no rigorous studies currently exist on the efficacy of pharmacotherapy for hoarding in children and adolescents. However, SSRIs may reduce associated symptoms of anxiety and depression for youth with hoarding who experience these comorbid conditions.
CBT can be conducted individually or in a group setting. The efficacy of these interventions with adults has been investigated primarily with case studies, small pilot studies, or open trials. Very little research has been conducted to develop, test, or implement treatment for hoarding disorder in children and adolescents. To date, there have only been two single case design studies that tested flexibly adapting CBT for the treatment of hoarding in children. Therefore, the current status of these interventions in children is experimental.
A childhood model of hoarding has been proposed that includes that same components of the adult CBT model but also pays particular attention to developmental concerns, including the extreme attachment to and personification of objects that children who hoard tend to develop and the effect of hoarding-related distress on family functioning and parenting. In addition to exposure to discarding possessions, CBT approaches for youth with hoarding would likely incorporate parent management training to reduce accommodation and positive reinforcement strategies to increase children's motivation to engage in treatment.
Regarding medication, no rigorous studies currently exist on the efficacy of pharmacotherapy for hoarding in children and adolescents. However, SSRIs may reduce associated symptoms of anxiety and depression for youth with hoarding who experience these comorbid conditions.