New Guide Offers Insights into Hoarding Disorder

Hoarding disorder: evidence and good practices in primary care

With clinical, social, environmental, and legislative considerations, hoarding disorder (HD) poses unique challenges regarding its diagnosis and treatment. Hoarding is characterized by excessive clutter and difficulty discarding. Although many people may report dissatisfaction and difficulties with such symptoms along with excessive acquisition, only when these lead to clinically significant distress and/or impairment in social, occupational, or other important areas of functioning is a diagnosis of HD considered.

Hoarding is associated with significant physical, psychological, and social morbidity leading to reduced quality of life. Even safety can be affected by possessions that congest and clutter active living areas and substantially compromise their intended use. Relationships within the home, with extended family and friends, and even with neighbors, may be affected. Hoarding disorder is found worldwide, with a prevalence of approximately 2% and with similar rates for men and women. Despite the prevalence and considerable personal costs, recognizing and providing appropriate care can be challenging. Only in 2013 was HD included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 1 and in 2019 it was formally included in the International Classification of Diseases (ICD-11, code F42.6B24). Previously, HD was classified within obsessive-compulsive disorders (OCD). However, most HD patients in particular do not show the cardinal OCD symptoms of obsessions and compulsions, with additional evidence of different onset, course, pathophysiology, and treatment responses. This history of classification has hindered research, clinical understanding, and treatment development.

Symptoms and diagnosis

In clinical settings, recognizing hoarding symptoms can be challenging for several reasons. Hoarding behaviors often manifest in early adulthood , but patients and their families typically do not disclose difficulties to health professionals or seek help until decades later, if at all. This is due in part to the insidious nature of the condition along with management of the severity of symptoms by family and caregivers. However, the main reason healthcare professionals may not be aware of hoarding-related difficulties is limited insight. Perception is often poor or absent, such that the individual is convinced that their beliefs and behaviors related to hoarding are not problematic, despite evidence to the contrary.

Although perception serves as a specifier in both DSM-5 and ICD-11 to further clarify the nature of HD, the frequency and severity of impaired perception has not yet been explored. Therefore, patients will not seek help, nor reveal their difficulties when asked, and may not recognize them when explicitly discussed. Additionally, traumatic life events and difficulties are common in people with HD and can lead to social vulnerability, isolation, distrust or fear of engaging with service providers, and housing insecurity. Furthermore, social stigma and feelings of shame , exacerbated by representations in popular media, reduce disclosure even in those with a reasonable or good perception.

Hoarding-related difficulties often come to the fore when patients seek support and treatment for other physical or mental health conditions. Hoarding may also arise as a barrier to other treatments given concerns about hygiene, safety or access to the home. Depression is the most common comorbidity, linked to the high frequency of adverse life events, often characterized by trauma, grief and loss . Other common comorbidities include OCD (18%) and attention deficit hyperactivity disorder, particularly the inattentive type (up to 28%).

The diagnosis should consider whether the hoarding is secondary to other health problems, including mental health conditions such as schizophrenia, dementia, or physical ailments that limit the patient’s mobility or ability to maintain their home environment. A strong attachment to treasure possessions with fear that they will be discarded, lost, or forcibly taken away would suggest HD per se . When there is no difficulty to rule out, the diagnosis of HD would not be appropriate . During the consultation, if GPs suspect accumulation, they can ask about the symptoms in a fair and even indirect manner and, if necessary, arrange a home visit. There are also tools available online, such as the Cluttered Image Rating Scale. Increased awareness of HD can not only help the individual and family support the condition, but also when interacting with service providers in healthcare and beyond.

Treatment and support

Once problems related to hoarding have been identified and assessed, a long-term coordinated support approach can help patients and their families. Preliminary evidence indicates that, although they constitute a small population, the people they accumulate represent a considerable financial burden on services, including local authorities. As healthcare professionals with expertise in physical health, mental health and experience in continuity of care, GPs and other healthcare professionals can play a vital role in fostering good communication and coordination with other healthcare professionals. first line. Additionally, GPs can improve patient care by strategically using local protocols, key contacts and resources available to them and their teams.

GPs may not always be the first port of call, but once involved they can raise concerns and raise awareness of issues, including building psycho-education into freely available resources. Cultivating trust and providing compassion is often essential and requires a long-term relationship. Recognizing HD as an ongoing, chronic mental health condition can help avoid judgment and facilitate engagement for all involved. Sometimes cleaning out possessions may be suggested as a solution. A patient without HD may even appreciate such an intervention.

National Institute for Health and Care Excellence guidelines recommend cognitive behavioral therapy and treatment with selective serotonin reuptake inhibitors for HD, although there is insufficient evidence of their effectiveness. This is partly because there is a lack of good quality treatment trials due to sample heterogeneity and, until recently, no clear diagnostic criteria. There are no HD-specific specialist services and support can vary across the NHS.

Psychological and psychiatric research to date has focused on those with comorbid OCD or those with reasonable insight, so it may not generalize to all patients seen by GPs. Primary care is an integral part of adult protection issues. This is especially important when there are safety concerns for the patient, other people in the home, and, in some cases, those who live nearby, such as neighbors. With the chronic nature of HD and sometimes its apparent untreatable nature, harm reduction rather than treatment may be a more feasible approach, taking into account risk management concerns.

Conclusions

In conclusion, hoarding-related difficulties are more widespread than previously thought, and HD is associated with considerable psychological, physical, and social harm. GPs and their teams can lead the identification and long-term care of these patients alongside coordinated engagement with a wide range of existing support services. Future research can further help develop and evaluate screening tools for hoarding in primary care settings, as well as how GPs can better interact with patients, families and carers.

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Experts from Anglia Ruskin University (ARU) have published new guidance to help doctors correctly diagnose hoarding disorder. Hoarding disorder affects around 2% of the population, but remains a largely misunderstood mental health condition. It was only added to the International Classification of Diseases in 2019, having previously been classified as Obsessive Compulsive Disorder (OCD).

Published in the British Journal of General Practice , the new guide was written by Dr. Sharon Morein and Dr. Sanjiv Ahluwalia of Anglia Ruskin University (ARU) in Cambridge, England, to help health professionals detect the signs of hoarding disorder and intervene.

Hoarding disorder involves clutter in the home environment taking over living spaces, as well as excessive acquisition and difficulty disposing of possessions, and affects an individual’s quality of life. However, it usually arises only when patients seek support for other physical or mental health conditions and can then act as a barrier to treatment due to concerns about hygiene, safety or access to the home.

People with hoarding disorder often suffer from depression, while other comorbidities include obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD).

Dr Morein, Associate Professor of Psychology at Anglia Ruskin University (ARU) and leader of the ARU Possession and Hoarding Collective, said: "Labels can be very useful in the healthcare system and can be the first stage to that people receive the support they need.

"It is really important that doctors and other frontline healthcare professionals know that hoarding disorder is a diagnosable medical condition and that it is usually related to other problems so that appropriate support can be offered.

"Normally, hoarding disorder is something that sneaks up on people, it doesn’t happen overnight, and people don’t necessarily recognize that they have a problem. One of the main difficulties with hoarding disorder is that people "Sufferers often do not seek to help themselves, and it only presents to medical professionals along with other problems. The sooner the problem is detected, the sooner support can be provided."