The famous reality show Hoarders spans more than 120 episodes and showcases people’s struggles with and treatment for hoarding disorder. Generally, the show selects people to profile based on how extreme the hoarding is, with a crisis (e.g., the threat of eviction) prompt­ing the televised intervention—all of which contribute to the heightened drama typi­cal to reality TV. Meanwhile, increasingly sophisticated targeted-marketing tactics and the commonplace status of superstores that sell products in bulk—with the promise of saving more by buying more—normalize desiring, acquiring, and keeping more stuff.

With such a range of attitudes about accumulation, health care professionals need to sharpen their awareness of hoarding disorder to help those in need.

Know your stuff

Hoarding disorder entered the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013 and affects approximately 2% to 6% of the population.1 Mild signs of hoarding typically start around age 13 and worsen over time, with these behaviors potentially becoming a severe problem for adults in their 50s.1

While most disorders occur before the age of 25, hoarding disorder is difficult to recognize at such an early stage, according to Fugen Neziroglu, PhD, ABBP, ABPP, cofounder and executive director of the Bio-Behavioral Institute in Great Neck, New York, and professor at the Donald and Barbara Zucker School of Medicine.

People with hoarding disorder have three indicators2:

  • They gather and keep numerous items, even those that seem worthless to others.
  • They allow items to clutter their hous­ing so that rooms cannot be used.
  • Their daily lives are negatively impacted by their items.

They also tend to have unique emotional symptoms3:

  • Suspicion of others touching their pos­sessions
  • Embarrassment over their belongings
  • Indecision regarding where to put objects
  • Anxiety about discarding items

Not everyone who displays hoarding behav­iors has hoarding disorder, and various degrees of hoarding disorder exist. Some patients contain their hoarding to one room so that visitors never suspect the person is a hoarder, explains Dr. Neziroglu. Others are organized hoarders, who keep their possessions in labeled and stacked boxes.

Law and hoarder

The first step toward overcoming hoarding disorder is often difficult and uncomfortable for patients.

“[In my experience,] it’s so unusual to have a … hoarder be the one to initiate the treatment,” says Karen Cassiday, PhD, ACT, managing director and clinical psychologist at the Anxiety Treatment Center in Deerfield, Illinois. “Oftentimes, their family or partners are strong-arming them. That’s usually what gets people into treatment—that or they’re in trouble with the law.”

“While hoarders likely recognize [they have] a problem, the fear that once they’re discovered they’re going to be asked to let go is incredibly anxiety provoking,” says Dr. Neziroglu. She notes that the emotional attachment to objects is a chief indication of hoarding disorder.

Those with hoarding disorder have dif­ficulty ridding themselves of excess objects for numerous reasons2:

  • Difficulty organizing their possessions
  • Guilt or anger when considering the disposal of items
  • Belief that their items have feelings
  • Sense of responsibility for the per­ceived feelings of inanimate objects

They may also acquire excessive amounts of objects because they are incapable of pass­ing up bargains or free items.2 Sometimes, a traumatic event will exacerbate hoarding.2

Hoarding can lead to health and safety issues, evictions, and conflicts with family and friends.2

Outside the box

Children of hoarders suffer on various levels.

Dr. Neziroglu, coauthor of Children of Hoarders: How to Minimize Conflict, Reduce the Clutter, and Improve Your Relationship, notes that most children feel sadness over their parents’ situation. “It’s a feeling that the parent has chosen the possessions over them,” she says. As adults, they often become either hoarders or minimalists. While Dr. Neziroglu believes there is a biological pre­disposition to hoarding, she also knows the total impact is larger still: “If you grew up in a hoarder’s home, you … [often] don’t learn how to organize, prioritize, or make decisions.”

Hoarding disorder may also be a comor­bidity of obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), attention-deficit/hyper­activity disorder (ADHD), and depression.3

“I don’t call [those with OCD, ADHD, or depression who have issues with hoard­ing] true hoarders,” says Dr. Neziroglu, since they have no emotional attachment to the objects. Instead, these people may just become distracted due to ADHD, be too exhausted or apathetic to clean as a result of depression, or avoid objects that they feel are contaminated because of OCD.

Less frequently, hoarding may accom­pany psychosis, dementia, Prader-Willi syn­drome (a genetic disorder), or pica (i.e., eating non-food substances).3

Divide and conquer

Treatments for hoarding disorder run the gamut1:

  • Self-help books
  • Support groups
  • Individual talk therapy
  • Medications
  • Group therapy

Internet-based treatments are being studied, and peer-facilitated group treatments may also be effective.1

Patient buy-in is paramount.2 Clearing out a hoarder’s home without permission can cause extreme distress and actually make the problem worse.2

Motivational interviewing is a great way for patients’ treatment to begin, according to Dr. Cassiday: “Get the patient to clarify what is it they really want out of life. Because usually they have great ambitions, and you [can] try to help them see how the way they’re living is preventing [those ambitions] from happening.”

Cognitive behavior therapy is a cor­nerstone of hoarding disorder treatment. Dr. Neziroglu says that cognitive behavior therapy teaches patients to disengage the attachment from the object.

Additionally, trained professionals can teach patients to prioritize and make deci­sions by helping patients sort their items into various boxes (e.g., useful items, donations, garbage, and important documents). A thera­pist (or another mental health professional or both) should help with this process at first, and then the patient can transition to working independently.2

Another strategy is to challenge the hoarder’s beliefs about needing to keep things or acquire new ones.2 For example, Dr. Cassiday reminds patients that books and magazines are available online. Also, “giving away clothes to charities, rather than throw­ing them away, helps,” says Dr. Neziroglu.

Government agencies can connect hoarders with therapy and help with treat­ment. “There are task forces for those who are being evicted [that work] … with thera­pists,” says Dr. Neziroglu.

Additionally, “you have to address the acquisition behaviors,” says Dr. Cassiday. “You practice going to the areas where you would normally acquire things and don’t do anything—let the urge pass. So you just do straightforward exposure therapy. Usually fairly quickly, people can get to where they can resist that urge and stop bringing new stuff in.”

But treatment for hoarding disorder does not end with a purge.

“[Patients] need to keep working at it; they need to do an ongoing relapse pre­vention program,” says Dr. Neziroglu. “If someone doesn’t get treatment or doesn’t get the right treatment,” confirms Dr. Cassiday, “they relapse.”