Hoarding Disorder

Two processes operate together in hoarding disorder. The first is continuous acquiring, the second is the inability to discard. Sometimes the person acquires a great deal, sometimes very little, but nothing can be let go. Over time the home, a room, a storage area, a balcony, a car, or a workspace becomes a place taken over by objects.

These objects may be old bills, boxes, bags, clothing, magazines, spare parts, gifts, electronic items, or anything set aside as 'might be useful one day.' An object that looks meaningless from the outside may carry for the person a sense of possible use, a memory, a responsibility, or safety.

A collection can be an organized, selective interest that does not impair functioning. In hoarding disorder, living space narrows, decision-making becomes harder, and attempts to discard produce intense distress.

Those close to the person often think 'let us clear the house and the problem will be solved.' Yet forced attempts to discard usually produce panic, anger, a sense of betrayal, and relational rupture. Because the quantity of objects is only the visible surface. The problem lies in the meaning placed on objects, the difficulty of making decisions, the fear of making a mistake, the expectation of future regret, and sometimes a lack of insight.

The person thinks 'it might be needed later.' Discarding may feel like acting irresponsibly. The object may be seen as connected to a memory or to identity. Because the decision-making process is so exhausting, the person may choose not to sort anything at all. Objects can provide a sense of safety and soothe a feeling of emptiness.

Hoarding disorder requires clinical attention when living spaces become unusable, when there is a risk of fire or falls, when hygiene and health are compromised, when family relationships are worn down, when the economic burden increases, or when the person experiences intense distress because of the situation.

Differential diagnosis matters. In psychotic disorders, objects that are hoarded may be assigned unrealistic special meanings. Dementia, severe depression, obsessive compulsive disorder, attention deficit, the autism spectrum, and traumatic losses may also accompany the picture. For this reason, assessment is not made by looking at a photograph of the home alone. The person's history, beliefs, functioning, and safety risk are considered together.

The most useful approaches in hoarding disorder are generally cognitive behavioral interventions specific to this problem, motivational interviewing, decision-making skills, sorting practice, a plan to reduce acquiring, and collaboration with family members.

Safety risk is assessed first. Fire, falls, hygiene, and emergency access areas are reviewed. The gap between the life the person wants to live and the life they are currently living is discussed. Work begins from small areas. Trying to transform the whole home in a single day is usually not therapeutic. Discarding behavior is worked on gradually. The decision-making capacity is retrained. Those close to the person adopt an approach that is not judgmental but has clear boundaries and keeps safety in focus.

In hoarding disorder the goal is not to forcibly empty a person's life, but to return their living space to their own service. The growth of freedom in decision-making is just as healing as the reduction of objects.