Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty results in the accumulation of possessions that congest and clutter living areas to the point that the intended use of the areas is substantially compromised. Treatment is primarily with psychotherapy such as cognitive-behavioral therapy.
Hoarding disorder often begins at a mild level during adolescence and gradually worsens with age, causing clinically significant impairment by the mid-30s (1). At any given point in time, an estimated 1.5 to 6% of people have hoarding disorder (2). It is equally prevalent in females and males.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:277-284.
2. Tolin DF, Worden BL, Levy HC. State of the Science: Hoarding Disorder and Its Treatment. Behav Ther. 2025;56(4):667-679. doi:10.1016/j.beth.2025.03.002
Symptoms and Signs of Hoarding Disorder
Hoarding disorder is typically chronic, with little or no waxing and waning of symptoms or spontaneous remission.
Patients have a strong need to save items, and they experience significant distress when parting with the items or contemplating parting with them. Patients accumulate a large number of items for which they have inadequate space; the items congest and clutter the living space so much that large areas become unusable, except for storing hoarded items. For example, stacks of hoarded newspapers may fill the sink and cover the countertops and stove in the kitchen, preventing these areas from being used to prepare meals.
Hoarding symptoms often impair social, occupational, or other areas of functioning. For example, patients may not allow other people, including family members, friends, and repairmen, into the house because they are embarrassed by the clutter.
Hoarding can result in unsafe living conditions (eg, by creating a fire hazard or increasing the risk of falls) and may lead to eviction or legal problems.
Approximately 80 to 95% of people with hoarding disorder also excessively acquire items (eg, books, magazine subscriptions [1, 2]), which contributes to the hoarding problem.
Animal hoarding is a form of hoarding disorder in which patients accumulate a large number of animals and do not provide adequate nutrition, sanitation, and veterinary care despite deterioration of the animals (eg, weight loss, illness) and/or the environment (eg, extreme overcrowding, highly unsanitary conditions).
The degree of insight individuals have about their hoarding varies. Some patients recognize that the hoarding-related beliefs and behaviors are problematic, but many do not.
Symptoms and signs references
1. Frost RO, Tolin DF, Steketee G, et al. Excessive acquisition in hoarding. J Anxiety Disord. 23(5):632-639, 2009. doi: 10.1016/j.janxdis.2009.01.013
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:277-281.
Diagnosis of Hoarding Disorder
Psychiatric assessment
Clinical criteria for diagnosis of hoarding disorder from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) include the following (1):
Persistent difficulty discarding or parting with possessions, regardless of their actual value.
The difficulty discarding is due to the perceived need to save the items and to the distress associated with discarding them.
The accumulated possessions congest and clutter active living areas (ie, not basements or storage areas) and substantially compromise the intended use of these areas.
The hoarding causes significant distress or significantly impairs social, occupational, or other areas of functioning.
Hoarding is distinguished from transient accumulation and clutter (eg, as when property is inherited) by its persistence and other features; in addition, patients resist giving away or selling hoarded items. Collectors (eg, of books or figurines), like hoarders, can acquire and keep a large number of items, but in contrast to hoarding, collections are organized and systematic and do not significantly clutter needed living space and compromise their intended use or impair functioning or the safety of the home environment.
The hoarding must not be better explained by a general medical condition (eg, Prader-Willi syndrome), or by another psychiatric disorder (eg, delusions in schizophrenia). The diagnosis may also include a specifier of the patient's level of insight (good or fair, poor, or absent/delusional beliefs), or of excessive acquisition.
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:277-281.
Treatment of Hoarding Disorder
Cognitive-behavioral therapy
Limited role of pharmacotherapy
Cognitive-behavioral therapy that is tailored to treat the specific hoarding symptoms is usually first-line therapy. However, clinical trials for cognitive-behavioral therapy have shown mixed results (1, 2) and other psychological interventions (such as acceptance and commitment therapy [ACT]) may be equally effective (3). Therapy focuses on helping patients discard items, refrain from acquiring new possessions (if excessive acquisition is a problem), and improve their decision-making abilities.
Motivational techniques are often needed to encourage patients to participate and stay in treatment.
No high-quality studies have examined the use of pharmacotherapy for patients with hoarding disorder (4). Nonetheless, pharmacologic interventions may be of some benefit, especially for patients with potentially responsive comorbid conditions (eg, mood or anxiety disorders) (5). Several small observational studies of patients with hoarding disorder who were treated with a selective serotonin-reuptake inhibitor (SSRI), a serotonin-norepinephrine reuptake inhibitor (SNRI), or atomoxetine showed a reduction in hoarding severity (reuptake inhibitor (SNRI), or atomoxetine showed a reduction in hoarding severity (6–8).
Treatment references
1. Rodgers B, McDonald S, Wootton BM. Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis. J Affect. 290:128-135, 2021. doi: 10.1016/j.jad.2021.04.067
2. Bodryzlova Y, Audet S-B, Bergeron K, et al. Group cognitive-behavioural therapy for hoarding disorder: Systematic review and meta-analysis. Health Soc Care Community. 27(3):517-530. doi: 10.1111/hsc.12598
3. O'Brien E, Laws KR. Decluttering Minds: Psychological interventions for hoarding disorder - A systematic review and meta-analysis. J Psychiatr Res. 2025;181:738-751. doi:10.1016/j.jpsychires.2024.12.029
4. Lin N, Bacala L, Martin S, Bratiotis C, Muroff J. Hoarding Disorder: The Current Evidence in Conceptualization, Intervention, and Evaluation. Psychiatr Clin North Am. 2023;46(1):181-196. doi:10.1016/j.psc.2022.10.007. doi:10.1016/j.jpsychires.2024.12.029
5. Rodriguez CI. Hoarding disorder. In Tasman’s Psychiatry, 5th ed. Tasman A, Riba MB, Schulze TG, Ng CH, Alfonso CA, Lecic- Tosevski D, Kanba S, Alarcon RD, Ndetei DM, eds. Springer Publishing; 2024.
6. Saxena S, Sumner J. Venlafaxine extended-release treatment of hoarding disorder. . Venlafaxine extended-release treatment of hoarding disorder.Int Clin Psychopharmacol. 29(5):266-2, 2014. doi: 10.1097/YIC.0000000000000036
7. Saxena S, Brody AL, Maidment KM, et al. Paroxetine treatment of compulsive hoarding. . Paroxetine treatment of compulsive hoarding.J Psychiatr Res. 41(6):481-487, 2007. doi: 10.1016/j.jpsychires.2006.05.001
8. Piacentino D, Pasquini M, Cappelletti S, Chetoni C, Sani G, Kotzalidis GD. Pharmacotherapy for Hoarding Disorder: How did the Picture Change since its Excision from OCD?. Curr Neuropharmacol. 2019;17(8):808-815. doi:10.2174/1570159X17666190124153048
Key Points
Hoarding is usually a chronic disorder in which hoarders accumulate possessions that congest and clutter active living areas, making these areas very difficult to use as intended and sometimes unsafe.
Discarding possessions causes patients with hoarding disorder significant distress.
Treat using cognitive-behavioral or other psychotherapy that is tailored to treat specific hoarding symptoms. If psychotherapy is not effective, a trial with an SSRI, SNRI, or atomoxetine can be considered.Treat using cognitive-behavioral or other psychotherapy that is tailored to treat specific hoarding symptoms. If psychotherapy is not effective, a trial with an SSRI, SNRI, or atomoxetine can be considered.
