Hoarding Disorder DSM-5 Criteria

What is hoarding disorder?

Hoarding disorder is a condition where people have trouble getting rid of items, even if they don't need them. This leads to clutter that makes it hard for them to use their living spaces properly. It often causes stress and problems in daily life, like at work or with friends and family.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), hoarding disorder is listed under obsessive-compulsive and related disorders. People with this disorder may feel very attached to their possessions and become very anxious at the idea of throwing things away.

Hoarding disorder affects roughly 2.6% of people. Higher percentages are seen in individuals over 60 and those with other mental health conditions such as anxiety and depression. The occurrence of hoarding behaviors is similar across various countries and cultures (American Psychiatric Association, 2013b). An early diagnosis is important to address health and safety concerns before they become severe.

How is hoarding disorder diagnosed?

Hoarding disorder is diagnosed by a mental health professional who looks for specific hoarding symptoms, such as difficulty discarding items and excessive clutter. Other features of hoarding disorder include indecisiveness, perfectionism, procrastination, and difficulty organizing, sometimes leading to unsanitary living conditions. Animal hoarding, a specific form of this disorder, involves keeping many animals in poor conditions and is usually accompanied by object hoarding, with more severe unsanitary environments and poorer insight.

Using the DSM-5 criteria, the professional identifies whether the person's behavior fits the definition of hoarding disorder. The evaluation usually involves discussing the person's behavior, living conditions, and the impact of hoarding on their daily life. Sometimes, additional assessments or questionnaires are used to confirm the diagnosis, such as the Structured Interview for Hoarding Disorder, Clutter Image Rating, Saving Inventory-Revised, and Hoarding Rating Scale-Interview.

Hoarding disorder DSM-5 diagnostic criteria

The DSM-5 is the standard guide for diagnosing mental disorders. This manual provides comprehensive criteria for a wide range of mental health conditions. The following are the diagnostic criteria for hoarding disorder (American Psychiatric Association, 2013a):

1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
2. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.
3. 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, or the authorities).
4. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment safe for oneself or others).
5. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
6. 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 defects in major neurocognitive disorder, restricted interests in autism spectrum disorder). 

Specify if: 

• With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. (Approximately 80 to 90 percent of individuals with hoarding disorder display this trait.)

Specify if: 

• With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.
• With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
• With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Differences between DSM-4 and DSM-5

Hoarding disorder was officially introduced in DSM-5. Before that, DSM-4 considered hoarding a symptom of obsessive-compulsive personality disorder, with some extreme cases seen in obsessive-compulsive disorder. Since DSM-4 didn't outline specific criteria for hoarding disorder, direct comparisons can't be made (American Psychiatric Association, 2013b; Substance Abuse and Mental Health Services Administration, 2016).

How is hoarding disorder treated?

Effective treatment for hoarding disorder is necessary as it can significantly improve the quality of life for struggling individuals. Here are the treatments outlined by the American Psychiatric Association:

Cognitive behavioral therapy (CBT)

CBT helps people with hoarding disorder learn to let go of unnecessary items with less stress and improve their organization and decision-making skills.

Medication

While research on medications for hoarding disorder is limited and lacks definitive conclusions, certain medications, such as paroxetine and venlafaxine extended-release, have displayed promising advantages. However, they should be tried only after using CBT.

References

American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders (5th ed.). Pearson.

American Psychiatric Association. (2013b). What is hoarding disorder? https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder

Substance Abuse and Mental Health Services Administration. (2016, June 1). Table 3.29, DSM-5 hoarding disorder. https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t29/