Hoarding disorder

Hoarding has been depicted on TV as a rare and debilitating disorder, often exploited and sensationalized for dramatic effect. However, hoarding disorder is more common than you may think, with approximately 2.5% of the population affected by the condition.

To put it in perspective, this makes hoarding more prevalent than obsessive-compulsive disorder (OCD), a better-known disease with which it is often confused.

While other problems may receive more serious consideration, hoarding disorder deserves our attention. It causes serious impairment in social and emotional functioning, is difficult to treat, and can even become a public health issue. Here is what you need to know about assessing and treating hoarding disorder.

Summary

• Hoarding disorder is more common than many realize (affecting ~2.5% of people) and can significantly impair social, emotional, and daily functioning.
• It is distinct from OCD as individuals with hoarding disorder feel emotional attachment and comfort from possessions, often with limited insight into the problem.
• Causes are multifactorial, including genetics, cognitive challenges, trauma, and emotional regulation difficulties, with symptoms often worsening over time.
• Treatment is complex and typically requires a combination of approaches (CBT, motivational interviewing, in-home support, and community involvement) rather than therapy alone. Using an EHR can help therapists manage documentation and treatment plans.

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What is Hoarding Disorder?

The criteria for hoarding disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) are as follows:

1. Difficulty letting go of material possessions, regardless of their value.
2. The difficulty is related to the distress experienced with discarding items.
3. The difficulty discarding possessions results in the accumulation of items that clutter the person’s living areas and significantly compromise their intended use.
4. The hoarding behavior causes clinically significant impairment in social, occupational, and other areas of functioning.
5. The majority of people with hoarding disorder also display the need to acquire items that are not necessary or for which there is no available space.

Note: Many individuals with hoarding disorder lack insight into their troubles. They may be aware of clutter, but do not always perceive it as a significant issue. In fact, hoarding possessions might give them considerable joy.

Frequently, others notice the problem first. When hoarding is revealed, it can lead to shame and reluctance to allow others into the home. This often results in social isolation and safety concerns.

Required home repairs may go unaddressed, increasing risks due to unsafe clutter and potential pest infestations. Because of embarrassment, individuals rarely report their hoarding, causing the disorder to be underdiagnosed.

Diagnosing Hoarding Disorder

Although a therapist interview is probably the most common way hoarding is diagnosed, several more formal assessment instruments have been developed to aid therapists.

These include:

• The Saving Inventory-Revised (SIR) is a self-report measure that has three subscales assessing clutter, acquisition, and difficulty throwing items away.
• The Hoarding Rating Scale is a brief screening tool that provides a rough measure of hoarding behavior.
• The Clutter Image Rating uses pictures of different degrees of clutter to help identify if the problem has reached clinical significance.

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How is hoarding different from OCD?

Hoarding disorder is often confused with OCD. This is largely because hoarding used to be classified as a subtype of OCD in the DSM-4 and was not given its own distinct diagnosis until the DSM-5 was published.

To further add to the confusion, the ICD-10 also lists hoarding as a subtype of OCD, but has changed this for the ICD-11.

Although people with OCD can exhibit hoarding behavior, there are a few key differences:

• Motivation. Individuals with hoarding disorder feel an attachment to their items and are distressed at the thought of discarding possessions. “One man’s trash is another man’s treasure” perfectly applies to them. People with OCD, in contrast, are motivated by fears of something bad happening if they get rid of their property.
• Emotions. People with hoarding disorder find comfort in collecting possessions, while people with OCD feel anxiety from their intrusive thoughts.
• Insight. People with hoarding disorder frequently do not recognize they have a problem, while those with OCD usually know their thoughts are irrational.

Causes and risk factors

The causes of hoarding are complicated and appear to be due to a combination of factors:

Genetics

Most people with the disorder have a first-degree relative who also suffers from hoarding. Most cases develop in adolescence and the severity of hoarding symptoms increases as people age. This is why the hoarding behavior is frequently not discovered until individuals reach middle age or older.

Cognitive deficits

Executive functioning deficits contribute to the development of hoarding disorder. Difficulties in organization, namely categorizing and decision-making, seem to play a prominent role in hoarding behavior.

Trauma or grief

The death of a loved one, getting divorced, and sexual abuse have all been associated with the development of hoarding disorder. Approximately half of the individuals who hoard linked the onset of hoarding behavior to stressful life events.

Emotional regulation challenges

Hoarding behavior can be used as a coping mechanism by people who have difficulty regulating emotion. Due to a lack of other emotion regulation skills, people learn to rely on objects for comfort. This also makes it difficult to discard them because they have not developed other ways to deal with emotional distress.

Comorbid psychiatric conditions

The comorbidity of hoarding disorder with other mental health problems is quite high. Over 70% of individuals who have hoarding disorder have another psychiatric condition. The diagnoses with the highest comorbidity are major depression, generalized anxiety disorder, and ADHD.

Treatment approaches to hoarding disorder

Many hoarders avoid treatment due to shame and embarrassment. For those who seek treatment, the results are mixed at best. While some treatments help, and new treatments show a lot of potential, no treatments so far have exhibited the ability to reduce hoarding to sub-clinical levels.

The following are the most common treatment options:

• Cognitive-behavioral treatment (CBT) is the most popular treatment for hoarding disorder. CBT involves cognitive restructuring and behavioral interventions, such as exposure and response prevention. CBT does significantly reduce symptoms, but hoarding behavior usually remains at clinical levels after therapy is complete. It has been suggested that the cognitive components of CBT may not be the best fit for hoarders because they rely on flexible thinking in individuals with cognitive deficits.
• Motivational interviewing (MI) is often used in conjunction with other treatments. Individuals with hoarding disorder tend to want to avoid confronting negative emotions and treatment in general. MI is used to help increase motivation toward treatment and combat rates of attrition.
• Psychologist Catherine Ayers has created a hybrid treatment for hoarding, called cognitive rehabilitation and exposure/sorting therapy (CREST). It is a mix of exposure, executive functioning training, and cognitive therapy, attempting to address the many facets of hoarding disorder. Although a new treatment, it has shown some provisional success.
• Peer-run CBT groups and compassion therapy are also promising interventions. These treatments emphasize peer support and the destigmatization of hoarding behavior. Because shame is such an integral part of hoarding, compassion and support are powerful antidotes. Buried in Treasure Workshops are an example of such a treatment.
• Because of the difficulty of treating hoarding behavior in the office, in-home coaching is becoming a more frequent component of treatment. After all, what can be more effective than using exposure and coping techniques in the environment where hoarding occurs?
• Family and community interventions are also increasingly utilized as a component of treatment. Family members work with professional organizers and community organizations (e.g., health department, fire department) to address decluttering, public health, and safety issues within the home.
• Selective serotonin reuptake inhibitors (SSRIs) are often prescribed to treat hoarding disorder because they work well for OCD. Unfortunately, they have not been as effective in treating hoarding behavior. It has been theorized that stimulant medication might display more effectiveness because hoarding disorder may have more in common with ADHD than it does with O

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How can therapists create a treatment plan for hoarding?

Hoarding disorder is a multifaceted disease that causes severe impairment in several areas of functioning. However, traditional therapy alone has shown limited success in treating hoarding disorder.

Instead, a combination of therapy, support groups, family/community interventions, and in-home coaching appears to better alleviate hoarding behavior. As a result, therapists may need to play caseworker and initiate an all-hands-on-deck approach to helping the client utilize different resources.

Treatment plan goals need to reflect gradual behavioral (e.g., decluttering, discarding) and cognitive (e.g., decision-making, thought restructuring) alterations that can be tolerated for lasting change. Because hoarding is a treatment-resistant condition, therapists also need to prepare for relapse prevention.

How EHRs can help with documentation

Modern EHR/practice management platforms (such as TheraPlatform) assist greatly with documentation by providing HIPAA‑compliant, integrated systems for note entry, storage, scheduling, and billing.

They allow therapists to:

• Use and customize templates (e.g., SOAP, DAP, and others) or build their own to streamline note writing and ensure consistency.
• Link notes to treatment plans, goals, and session history so client progress is easily tracked over time.
• Utilize e-fax and secure document sharing via client portal to safely exchange information with clients or other providers while maintaining confidentiality.
• Leverage dictation and telehealth transcription, which can automatically convert sessions into therapy or assessment notes, saving time and reducing manual entry.
• Take advantage of AI features that streamline documentation by automatically populating intake form data into assessment templates and generating complete therapy and assessment notes from the information you provide, all with a single click.

Meanwhile, AI‑assisted note tools are emerging which can further help clinicians by:

• Automatically transcribing session audio (if permitted) and highlighting key moments (e.g. emotional shifts, major themes).
• Suggesting draft notes or filling in objective or assessment sections based on observed data, freeing up clinicians’ time.
• Supporting consistency and reducing missing components in notes, which helps from both clinical, legal, and insurance perspectives.

Together, structured SOAP‑type notes, good EHR platforms, and smart AI tools support better therapeutic outcomes, more efficient workflows, and stronger accountability.

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References

Ayers, C. R., Castriotta, N., Dozier, M. E., Espejo, E. P., & Porter, B. (2014). Behavioral and experiential avoidance in patients with hoarding disorder. Journal of behavior therapy and experimental psychiatry, 45(3), 408–414. https://doi.org/10.1016/j.jbtep.2014.04.005

Frost, R. O., Steketee, G., & Williams, L. (2000). Hoarding: a community health problem. Health & social care in the community, 8(4), 229–234. https://doi.org/10.1046/j.1365-2524.2000.00245.x

International OCD Foundation. Clinical assessment of hoarding disorder. https://hoarding.iocdf.org/professionals/clinical-assessment

International OCD Foundation. Treatment of HD-Medication. https://hoarding.iocdf.org/professionals/treatment-of-hoarding-disorder/treatment-of-hd-medication/

Mutual Support Consulting, LLC. (2022). The buried in treasures workshop. https://www.mutual-support.com/the_buried_in_treasures_workshop

Landau, D., Iervolino, A. C., Pertusa, A., Santo, S., Singh, S., & Mataix-Cols, D. (2011). Stressful life events and material deprivation in hoarding disorder. Journal of Anxiety Disorders, 25(2), 192–202. https://doi.org/10.1016/j.janxdis.2010.09.002

Postlethwaite, A., Kellett, S., & Mataix-Cols, D. (2019). Prevalence of hoarding disorder: A systematic review and meta-analysis. Journal of affective disorders, 256, 309-316. https://doi.org/10.1016/j.jad.2019.06.004

Sordo Vieira, L., Guastello, A., Nguyen, B., Nutley, S. K., Ordway, A., Simpson, H., Zakrzewski, J., Archer, C., Liu, N., Jean Gilles, M. E., Nosheny, R., Weiner, M., Mackin, R. S., & Mathews, C. A. (2022). Identifying psychiatric and neurological comorbidities associated with hoarding disorder through network analysis. Journal of Psychiatric Research, 156, 16–24. https://doi.org/10.1016/j.jpsychires.2022.09.037

Substance Abuse and Mental Health Services Administration (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. DSM-5 Hoarding Disorder. https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t29

Weir, K. (2020, April 1). Treating people with hoarding disorder. Monitor on Psychology, 51(3). https://www.apa.org/monitor/2020/04/ce-corner-hoarding