Hoarding Disorder | Why Is It So Hard to Let Go of Things?

Hoarding disorder is a psychiatric condition characterized by a persistent difficulty in discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and the distress associated with discarding them. The accumulation of possessions results in clutter that congests and clutters active living areas, substantially compromising their intended use. For a diagnosis to be made, the hoarding must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, including maintaining a safe environment for oneself and others. The behavior is not better explained by the symptoms of another medical condition (e.g., brain injury) or another mental disorder (e.g., obsessive-compulsive disorder). Key features include an emotional attachment to objects, deficits in information processing such as decision-making and categorization, and often, beliefs about the utility or aesthetic value of the items. This condition is distinct from collecting, which is typically organized and does not produce the chaos, distress, and functional impairment seen in hoarding disorder. The severity can range from mild to life-threatening, particularly when the clutter creates fall hazards, fire risks, or unsanitary conditions.

The distinction between hoarding and collecting is critical for diagnosis and understanding. Collecting is a systematic and organized activity. Collectors typically acquire items of a specific category, such as stamps, coins, or art, and they take pride in organizing, displaying, and maintaining their collection. The collection does not clutter living spaces and rarely causes significant distress or functional impairment. In contrast, hoarding disorder involves the accumulation of a large number of items that are often random and of little to no monetary value. The key feature is the disorganization and clutter that renders living spaces unusable. Individuals with hoarding disorder experience significant distress at the thought of discarding items, and their behavior impairs daily life, creates unsafe living conditions, and strains social relationships. While a collector proudly shows their organized items, a person with hoarding disorder often feels shame and embarrassment about the state of their home.

Neuroimaging studies reveal that individuals with hoarding disorder exhibit different patterns of brain activity compared to healthy individuals, particularly in regions related to decision-making, risk assessment, and emotional regulation. Functional magnetic resonance imaging (fMRI) studies show anomalous activity in the anterior cingulate cortex (ACC) and the insula when making decisions about possessions. The ACC is critical for monitoring errors and weighing the potential outcomes of actions, while the insula is involved in processing emotions and bodily sensations. In individuals who hoard, these regions show hyperactivity when faced with discarding items, suggesting a heightened emotional response and impaired decision-making process. This neural signature indicates that for them, letting go of an object is processed by the brain as a significant loss or error, triggering intense negative emotions that reinforce the compulsion to save.

Hoarding disorder is a distinct diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but it frequently co-occurs with other psychiatric conditions. The most common co-occurring disorders are major depressive disorder, social anxiety disorder, and generalized anxiety disorder. A significant percentage of individuals with hoarding disorder also meet the criteria for attention-deficit/hyperactivity disorder (ADHD), which can contribute to problems with organization and executive function. Although previously considered a subtype of obsessive-compulsive disorder (OCD), research has established it as a separate condition. While some individuals with OCD may exhibit hoarding compulsions, the underlying thoughts and motivations are different. In OCD, hoarding is often driven by obsessions, whereas in hoarding disorder, it is linked to a strong emotional attachment to possessions and distress associated with discarding them.

The most effective treatment for hoarding disorder is a specialized form of cognitive-behavioral therapy (CBT). This therapy is multi-faceted and tailored to the specific challenges of hoarding. It includes training in skills for sorting and discarding possessions, making decisions, and organizing. A core component involves cognitive restructuring, where therapists help individuals challenge and reframe their beliefs and emotional attachments to objects. Exposure therapy is also used, where individuals gradually practice discarding items to reduce the associated anxiety and distress. Motivational interviewing is often employed initially to enhance the individual's readiness for change, as insight can be limited. While no medication is specifically approved for hoarding disorder, certain medications like selective serotonin reuptake inhibitors (SSRIs) may be used to treat co-occurring conditions such as depression or anxiety, which can sometimes provide a secondary benefit for hoarding symptoms. Family therapy and peer support groups are also valuable components of a comprehensive treatment plan.