Hoarding Disorder is a chronic and progressive psychiatric disorder characterized by persistent difficulty discarding possessions of little or no value, which can render living spaces dysfunctional. Defined as an independent diagnosis in DSM-5, this disorder is closely related to obsessive-compulsive disorder but presents distinct features. Hoarding behavior may cause significant functional impairment, social isolation and health risks.

DSM-5 Diagnostic Criteria for Hoarding Disorder

According to DSM-5, the diagnosis of hoarding disorder requires the following criteria:

• Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to perceived distress associated with discarding or the belief that items may be needed in the future.
• This difficulty results in the accumulation of possessions that congest and clutter living areas, substantially compromising their intended use. If these areas are uncluttered, it is only because of interventions by others.
• The hoarding behavior causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
• The disturbance is not attributable to another medical condition (for example, brain injury).
• The symptoms cannot be better explained by another mental disorder such as obsessive-compulsive disorder or major depressive disorder.

Symptoms of Hoarding Disorder

The main symptoms of hoarding disorder include:

• A tendency to keep unused, broken or unnecessary items,
• Inability to organize or categorize possessions,
• Living spaces (kitchen, bathroom, bedroom) becoming unusable,
• Inability to discard items despite warnings from family, neighbors or landlords,
• Belief that items may be needed in the future,
• Intense feelings of guilt, shame or defensive behaviors,
• Deterioration of social relationships and loneliness.

These symptoms may worsen over time and significantly interfere with daily life. Hoarding disorder is often comorbid with depression, generalized anxiety disorder and attention-deficit/hyperactivity disorder (ADHD).

Etiology of Hoarding Disorder

Hoarding disorder arises from an interaction of biological, psychological and environmental factors. No single cause explains the disorder; instead, it is the product of multiple influences.

Genetic factors play an important role. Family studies show that hoarding behavior is more common among first-degree relatives. Twin studies estimate heritability at around 50%.

Neurobiological findings indicate dysfunction in the prefrontal cortex, particularly in areas related to decision-making and organization. Functional imaging studies reveal hyperactivity in the anterior cingulate cortex and insula in individuals with hoarding disorder. These regions are associated with error detection and emotional salience.

Psychological factors include perfectionism, difficulties with emotional attachment, low stress tolerance and experiences of loss. Following traumatic experiences, hoarding may serve as an attempt to regain a sense of control.

Risk Factors

Risk factors for hoarding disorder include:

• Family history of hoarding,
• Childhood neglect, losses or traumatic experiences,
• Obsessive-compulsive personality traits,
• Social isolation and loneliness,
• Comorbid psychiatric disorders such as ADHD or depression,
• Later onset (often after age 30).

Hoarding disorder occurs at similar rates in men and women, but men are less likely to seek treatment.

Diagnosis

Diagnosis begins with a comprehensive psychiatric evaluation. Clinicians assess reasons for hoarding, onset and progression of the behavior, its impact on living spaces and the individual’s level of insight.

Assessment tools include the Saving Inventory-Revised (SI-R), Hoarding Rating Scale-Interview (HRS-I) and Clutter Image Rating (CIR). Comorbid conditions such as depression, anxiety, OCD and ADHD should also be carefully evaluated.

Treatment of Hoarding Disorder

Treatment of hoarding disorder is often challenging and long-term, but significant improvement can be achieved with appropriate interventions. A multimodal approach addressing biological, psychological and environmental dimensions is required.

1. Psychotherapy (Cognitive Behavioral Therapy – CBT)

CBT is the most researched and effective treatment for hoarding disorder. Therapy includes:

• Restructuring beliefs about the functional value of possessions,
• Identifying automatic thoughts that trigger hoarding behavior,
• Gradual discarding (exposure) and development of decision-making skills,
• Sorting, organizing and reducing items.

Treatment typically involves 20–26 sessions. Homework assignments and in-home interventions (for example, home visits) are integral parts of therapy.

2. Pharmacotherapy

Although hoarding disorder is a distinct diagnosis in DSM-5, pharmacotherapy is usually targeted at comorbid depression, anxiety or OCD symptoms.

Clinical trials have shown improvement with SSRIs (especially paroxetine and citalopram). However, no standardized pharmacological protocol exists specifically for hoarding disorder. Medications are generally used as adjuncts to psychotherapy.

3. Family Support and Psychoeducation

Hoarding often leads to family conflict. Educating family members about the disorder is essential to reduce criticism and foster supportive attitudes. Psychoeducation helps the individual gain insight and increases treatment adherence.

4. Community-Based Interventions

For individuals with severe hoarding, community-based interventions such as home visits, coordination with social services, municipal support and vocational rehabilitation may be necessary. These approaches reduce environmental risks and improve quality of life.

Impact on Daily Life

Hoarding disorder can severely impair quality of life. Cluttered living spaces may lead to neglect of personal care, poor hygiene and increased risk of physical injury. Family relationships suffer, social isolation deepens and work life may be disrupted.

Environmental risks such as house fires, falls and pest infestations also increase. Many patients avoid seeking help or deny that their behavior is problematic, which further complicates treatment.

Hoarding Disorder is a serious and chronic psychiatric condition that poses threats to both physical and mental health. Early intervention, psychoeducation, psychotherapy and pharmacological support when necessary can lead to substantial improvement. Increasing public awareness and strengthening medical and social support systems are essential for effective management of this disorder.