HOARDING DISORDER

HOARDING DISORDER
D I A G N O S I S , T R E AT M E N T & H A R M R E D U C T I O N
ZOE CRYNS, M.A.,MFT
300.3 HOARDING DISORDER
Definition: Then and Now
“Hoarding has been widely considered to be a subtype of OCD, occurring
among one-third of the people diagnosed with that disorder. Interestingly, when
flipped around by studying those complaining of hoarding, just under ¼ of them
report having OCD[...] research began to suggest that hoarding may be a
disorder all its own” (Frost and Steketee, 2010, p12).
As researchers began to be interested in the background of hoarding several
aspects of the recent criteria began to be formulated.
“Compulsive hoarding as it has been labeled in recent psychological literature,
was defined by Frost and Hartl (1996), as having three main features:
1.  The accumulation of and failure to discard a large number of objects that
seem to be useless or of limited value
2.  Extensive clutter in living space that prevents the effective use of the
spaces, and
3.  Significant distress or impairment caused by hoarding
DSM 5 & CREATION OF HOARDING
DISORDER DIAGNOSIS
Top researchers in the field are: Randy Frost, Ph.D., Gail
Steketee, Ph.D., Michael Tomkins, Ph.D., and David Tolin,
Ph.D.
Research began in earnest when Dr. Randy Frost invited a
patient by the name of Irene to be a part of research of
this disorder.
These top researchers have dedicated their time and
efforts strove to have the creation of the diagnosis
included in the revision efforts of the Diagnostic Statistic
Manual 5 (DSM 5).
The creation of the Hoarding Disorder diagnosis to be
included in the DSM 5 began in earnest in 2007 by Dr.
David Mataix-Cols.
DSM 5 DIAGNOSTIC CRITERIA
A.  Persistent difficulty discarding or parting with possessions, regardless of
their actual value.
B.  This difficulty is due to a perceived need to save the items and to
distress associated with discarding them.
C.  The difficulty discarding possessions results in the accumulation of
possessions that congest and clutter active living areas and
substantially compromises their intended use. If living areas are
uncluttered, it is only because of the interventions of third parties (e.g.,
family members, cleaners, authorities).
D.  The hoarding causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning (including
maintaining a safe environment for self and others).
E.  The hoarding is not attributable to another medical condition (e.g.,
brain injury, cerebrovascular disease, Prader-Willi syndrome).
F.  The hoarding is not better explained by the symptoms of another
mental disorder (e.g., obsessions in obsessive-compulsive disorder,
decreased energy in major depressive disorder, delusions in
schizophrenia or another psychotic disorder, cognitive deficits in major
neurocognitive disorder, restricted interests in autism spectrum
disorder).
DSM 5 HOARDING DISORDER
SPECIFIERS
•  DSM 5 Hoarding Disorder Specifiers:
With Excessive Acquisition
With Good or Fair Insight
With Poor Insight
With Absent Insight/Delusional Beliefs
TREATMENT FOR HOARDING DISORDER
•  Cognitive Behavioral Therapy: Skills Training, Cognitive Therapy; Exposure
Therapy (for acquisition, sorting and discarding items)and Weekly
Homework
•  Motivational Interviewing: Change Talk
•  Office Visits and Home Visits
•  Medications: No medication has been found to treat hoarding; however,
comorbidities include SRI’s for mood and anti-psychotics for organizing
thoughts; severe attention-deficit hyperactivity disorder (ADHD)
medications.
•  Comorbidities: Social Anxiety Disorder, GAD, OCD, ADHD, MDD, Trauma/
Loss
•  Family Support to help rebuild trust and communication
•  Avoid clean-outs without patients permission.
•  Go Slowly; Therapy can last at least one year and beyond. Clients may
be elderly, on Medicare/Medicaid. Therapist must be passionate for this
type of work.
•  Therapist must be clearly okay with dirt, dust, bugs, rodents, feces and
urine odors, mold, garbage, useless/non-working rooms/items such
kitchens (refrigerators, stoves), bedrooms, bathrooms, living rooms, as
well as ongoing frustrations and setbacks.
ASSESSMENT OF HOARDING DISORDER
•  Activities of Living-Hoarding Scale: assesses ability to do
normal tasks where hoarding is involved
•  Clutter Image Rating: Nine images of increasing amount
of clutter for self-reporting of clutter in living room,
kitchen, bedroom
•  Hoarding Rating Scale: assesses difficulty discarding
and/or collecting, difficulty using a room for its purpose,
and impairment experienced due to hoarding
•  Savings Inventory Rating: Assesses within past week the
behavior/need for acquisition, the difficulty of
discarding, and amount of clutter affecting daily living
WHO HOARDS AND HOW DOES THIS
HAPPEN?
•  Hoarding usually begins in early years, however, since children
have less control over their environment, hoarding is less
noticeable. Not until the individual is more independent, does
the hoard begin to manifest as the individual has more
opportunities to accumulate, save, and not discard.
•  Hoarding is brought to attention and diagnosed when family
members are highly affected, when the hoard becomes a fire
hazard, or when the neighborhood becomes affected.
•  Many individuals who hoard have limited insight into their
hoarding problem and fail to see how the hoarding is
affecting theirs and others lives.
•  Hoarding has three distinct categories/values:
•  Intrinsic Value-Hoard items with perception of beauty
•  Instrumental Value-Hoard items with perception of usefulness
•  Sentimental Value-Hoard items with perception of memories
CULTURE, FAMILY & CHILDREN OF
HOARDERS
•  Culture: Hoarding does not distinguish between cultures, social
class, economics, or race. However, it is important to include a
social or cultural context while working with individuals of other
cultures.
•  Family: Hoarding can be generational and a learned
behavior. Lack of insight, inability to organize thoughts,
cognitive deficits, and impaired decision-making contribute to
the formulation of hoarding behavior. Hoarding behavior
affects marital relationship as non-hoarding spouse realizes the
hoard is more important than the relationship as well as the
inability to live in home with the hoard.
•  Children of Hoarders: Shame, unworthiness, lack of
socialization, fear of being found out, lack of skills needed to
organize, clean, discard, feelings of being less important than
the hoard.
•  Gender bias is toward women, however, men are affected as
well.
MAUREEN
RACHEL
A COMPARISON
84 yrs
Slight dementia & limited insight
Lived in assisted living home
Collected papers, flyers,
coupons, held onto mail and
sent charity/lobbyists $$;
•  Had over 1k in overdraft fees
alone
•  Kept food in refrigerator
beyond healthy; kitchen
• 
• 
• 
• 
•  21 yrs
•  Lived at home w/parents
•  Purchased anything art/craft;
collected magazines, held
onto clothes from young
childhood (intrinsic)
•  Limited insight of collecting bx
and inability to discard
•  Father exhibited hoarding
tendencies, w/limited insight
(sentimental); Mother held onto
items beyond use
(instrumental)
•  Mother tripped over hallway
items resulting in compound
fracture of the humerus
MAUREEN
RACHEL
HARM REDUCTION
•  Harm Reduction Theory
•  Perspective is more on environmental health and safety
concerns.
•  Assess Harm Potential- trip & fall; fire hazards; structural damage;
health hazards involving plumbing, animals, insects, mold/mildew
•  L.E.A.P. (Listen, Empathize, Agree, Partner)
•  Features of Harm Reduction Plan
-Build a team
-Set clear realistic goals
-Be flexible, include strategies involving managing the
hoard
-Have a Harm Reduction Contract that spells out the goals,
targets, and agreements. Consider the contract a Living
Document that may change as needed.
HARM REDUCTION TEAM
•  Create team players who have certain qualities. Not all family
members may be suited for a team treatment/harm reduction
approach.
•  Qualities of a team member:
-Patience: Managing a hoarding problem is a lifelong struggle
-Stakeholding: Team member has a stake in the harm reduction
process; landlord, visiting nurse, sibling, spouse, child gets
something out of the HR process- less worry, less conflict,
professional recognition
-Time: Team member has time to participate in HR planning,
advocating, and implementing plan
-No current/ongoing conflicts: To be an effective team player,
the team member must be able to “agree to agree” and not
have an unresolved agenda
-Useful Skills: Repairing, negotiating, problem solving, professional
(counseling, nursing, legal, et al)
HARM REDUCTION PLAN
DO’ AND DON’TS
Do
Don’t
•  Have all team members sign
contract
•  Be flexible for Change to plan
•  Praise loved one for
willingness to participate
•  Emphasize that contract
keeps team on track
•  Include frequency of home
visits & monitor progress
•  Remember to review plan
and make changes needed
•  Expect compromises and
setbacks
•  Argue about the contract; use
LEAP
•  Threaten loved one with an
ultimatum
•  Use contract or process to
intimidate loved one
•  Become rigid about contract
and goals
•  Move ahead with contract until
all team members have signed
•  Give up if team members cannot
agree to sign; Use LEAP to
formulate contract readiness
•  Expect a perfect plan
MAUREEN’S HR TEAM
& PLAN
•  Daughter sought help for
Mother
•  Daughter to attain power of
attorney & take over financial
•  Daughter worked with bank to
have overdraft fees returned
•  Office manager agreed to sort
mail
•  Disconnect stove/oven to
prevent fires; Use only
microwave for heating food
•  Remove area rugs and clutter
•  Hire weekly caregiver for home
visits; clean out refrigerator on
weekly basis, remove mail and
check for outgoing payments
•  Schedule medical physical
RACHEL’S HR TEAM
& PLAN
•  Referred to me by Rachel’s
primary therapist
•  Family Therapy
•  Mother-moral support & setting
goals with Rachel
•  Father chose to not be
involved and did not allow
sentimental items to be
moved/discarded
•  Church friends/support for
heavy lifting and removing
large items from home
•  Professional organizer to help
create craft/office area
OVERALL PROGNOSIS
•  Hoarding is difficult to treat, with majority returning
to old behaviors.
•  Harm Reduction is most helpful, especially in terms
of restoring relationships, children to the home, or
passing fire code violations.
•  Animal Hoarding is especially difficult to treat.
•  Team Treatment includes social worker,
psychologist, psychiatrist, police, fire, etc.
LITERATURE
•  Buried in Treasures; Help For Compulsive Acquiring,
Saving and Hoarding. David F. Tolin, Randy O. Frost &
Gail Steketee. (2007)
•  Compulsive Hoarding and Acquiring; Therapist Guide.
Gail Steketee & Randy O. Frost. (2007)
•  Digging Out; Helping Your Loved One Manage Clutter,
Hoarding, and Compulsive Acquiring. Michael A.
Tompkins, Tamara L. Hartl. (2009)
•  The ICD Guide to Challenging Disorganization. Kate
Varness. (2012)
•  Stuff; Compulsive Hoarding and the Meaning of Stuff.
Randy O. Frost & Gail Steketee. (2010)
•  The Hoarding Handbook; A Guide for Human Service
Professionals. Christiana Bratiotis, Cristina S. Schmalisch,
& Gail Steketee. (2011)