Compulsive Hoarding (Hoarding Syndrome)

Compulsive Hoarding (Hoarding Disorder) is a psychiatric condition characterized by excessive and unnecessary acquisition of items, inability to discard them, and severe cluttering of living spaces. This condition leads to significant impairments in social, occupational, and other functional areas.

Historical Development

Compulsive hoarding has been addressed through various theoretical approaches throughout history and has gradually emerged as an independent psychiatric diagnosis. One of the earliest psychodynamic interpretations was developed by Erich Fromm in his 1947 work, introducing the concept of the “hoarding orientation.” According to Fromm, this orientation reflects an individual’s attempt to fulfill needs for security, control, and belonging through material objects. Fromm argued that the drive for possession is a fundamental mode of human existence and linked hoarding behavior to the protective and defensive aspects of human nature.^【1】 The cognitive-behavioral model developed by Randy O. Frost and Tamara L. Hartl in 1996 marked a turning point in defining hoarding behavior. According to this model, hoarding is evaluated through three core features: excessive acquisition and inability to discard items with little or no value; significant clutter in living spaces resulting from these items; and the presence of marked distress and functional impairment caused by this condition. This tripartite structure has since been adopted as the foundational diagnostic criterion in subsequent clinical classifications.^【2】

Diagnostic Criteria (DSM-5)

Hoarding disorder is defined by persistent difficulty discarding or parting with possessions, regardless of their actual value, leading to accumulation that clutter living areas. This condition causes significant distress or impairment in social, occupational, or other important areas of functioning. The disorder cannot be better explained by another medical condition or mental disorder. Two key determinants are the presence of excessive acquisition behaviors and the individual’s level of insight regarding the problem (ranging from good to poor insight or even delusional beliefs).

Epidemiology

Hoarding disorder is a common condition affecting approximately 2% to 6% of the adult population, with no significant difference in prevalence between men and women. Individuals with the disorder typically live alone and exhibit social symptoms such as social isolation and reduced visits to their homes. The average age of onset is reported to be 16.7 years, and symptoms tend to worsen over time.

Comorbid Disorders

More than 60% of individuals with hoarding disorder have at least one additional psychiatric disorder. The most commonly reported comorbidities are major depressive disorder (50–52%), generalized anxiety disorder (24%), and social phobia (23%). These co-occurring conditions may contribute to the persistence of negative mood states that reinforce hoarding behaviors.

Neurobiological and Genetic Findings

Neurobiological research has revealed functional abnormalities in brain regions such as the ventromedial prefrontal cortex and the anterior cingulate cortex in individuals with hoarding disorder. Functional magnetic resonance imaging (fMRI) studies have shown increased activation in these regions during decision-making processes related to discarding personal items. Genetic studies indicate that hoarding behaviors have a heritability range of 45% to 71%, similar to that observed in obsessive-compulsive disorder (OCD). Additionally, evidence suggests possible associations between hoarding and certain genetic variants in the serotonin system and genes related to the glutamatergic system.

Psychosocial and Cognitive Model

The development of hoarding disorder may be influenced by the absence or inadequacy of secure attachment figures during early life. This can manifest in adulthood as both attachment anxiety and attachment avoidance. Attachment to objects is thought to serve as an alternative to interpersonal relationships, particularly when perceived threats in social connections are low. Furthermore, hoarding behavior is closely linked to personal identity and self-concept; some individuals identify their possessions as extensions of their personal interests and sense of self.

The cognitive-behavioral model proposes that the core symptoms of hoarding—acquisition, inability to discard, and cluttering—are associated with early attachment difficulties, information processing deficits (e.g., attentional problems, decision-making difficulties), and emotional factors, both negative and positive. Within this framework, cognitive and emotional processes such as emotional oversensitivity, intolerance of uncertainty, anxiety sensitivity, impulsivity, and excessive worry about potential negative outcomes play a significant role.

Insight and Motivation

A significant proportion of individuals with hoarding disorder are unaware of or refuse to acknowledge the negative consequences of clutter and hoarding. This impaired insight can lead to increased health and safety risks, family conflicts, and forced interventions. Reduced insight is thought to be associated with inadequate attachment experiences in early childhood and underdeveloped decision-making skills. Lack of motivation further complicates treatment-seeking behavior and adherence to interventions.

Assessment Tools

Several reliable and valid instruments are available to measure the severity of hoarding behaviors and the level of clutter in living spaces. These include structured interviews such as the Structured Interview for Hoarding Disorder, the UCLA Hoarding Severity Scale, the Hoarding Rating Scale, the Saving Inventory-Revised, and the Clutter Image Rating. Tools such as the HOMES Multidisciplinary Risk Assessment are also used to evaluate environmental hazards in the home. Behavioral tasks are preferred for directly assessing acquisition, discarding, and categorization skills.

Treatment Approaches

The current primary treatment for hoarding disorder is cognitive behavioral therapy (CBT). CBT is a weekly, time-intensive intervention that includes components such as decision-making, sorting, and discarding exercises, organizational training, acquisition restriction, and cognitive restructuring. Home visits are an essential part of treatment. Group-based CBT and peer-supported CBT programs have also been found effective.

In recent years, interest in technology-assisted treatment methods has increased. Internet-based self-help programs, video-conferencing therapies, and hybrid in-person and online approaches are improving access to treatment. Mobile applications, particularly those incorporating home environment simulations, are used to enhance motivation and self-efficacy for behavioral change. Future research is exploring the integration of artificial intelligence, mobile applications, and deep learning technologies into treatment protocols.

Public Health and Legal Dimensions

Hoarding disorder affects not only individuals and their families but also public safety. It can result in fire hazards, structural damage to homes, and deteriorating health conditions. Noncompliance with environmental regulations may also lead to legal sanctions. Therefore, coordination among social services, healthcare institutions, legal authorities, and public safety agencies is crucial in treatment and intervention efforts.

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