Hoarding

It's usually objects which might be bought, picked up off the street or out of a skip, or even stolen.

Some people hoard a large number of animals, often believing they are rescuing them. But their animals are often kept in poor conditions and suffer.

A more recent problem is data hoarding. People find that they can't delete emails, which keep building up.

The difference is really between hoarding and collecting. Many of us enjoy collecting things, but organise them well. The items we collect are often seen as interesting or valuable by other people. 

People who hoard tend to collect things that others see as useless or of little value.

Some people may have a large number of possessions and live in cluttered, messy or neglected conditions.  However, such things would not usually be considered a problem, unless they disrupt people's lives.

Hoarding can be an illness in its own right, known as hoarding disorder (see below). 

Hoarding can also be part of another health problem:

• Physical illness – can lead to tiredness and disorganisation.
• Dementia – memory problems can interfere with someone’s ability to organise themselves and their belongings.
• Depression – can make you lose interest in your normal activities, make it hard to concentrate and make it hard to make decisions.
• Alcohol and drug misuse – can affect your ability to look after yourself.
• Schizophrenia – unusual beliefs and a lack of organisation can lead to hoarding.
• Bipolar disorder – can make you shop too much, and will interfere with your organisation.
• Learning disability – can lead to problems with thinking and memory.
• Autism and related disorders – collecting things can be a source of comfort.
• Obsessive Compulsive Disorder (OCD) – you don't feel attached to your hoarded items, but you do fear what will happen if you throw them away. About 1 in 20 people with OCD have a problem with hoarding.  

Hoarding disorder

Hoarding disorder can be diagnosed when there is no other illness to account for the problem.  People with hoarding disorder often strongly believe that their hoarded items are valuable.  They may call them a “collection”, even though the large number of items and their disorganisation means that individual things are inaccessible.

Until recently, hoarding disorder was thought to be a form of OCD. As hoarding disorder has only recently being recognised as a separate condition, there is not much research into the problem.

Many people with hoarding disorder have had a deprived childhood, but this is not always the case.   The average age when people with hoarding disorder come to that attention of services is 50 years.  By this time the problem is usually well-established.

It is thought that some people are more likely to become hoarders because of their personality.  For example, they might be perfectionist or reclusive.  They may then start to hoard after a major stress or change in their lives.

It can be dangerous in a number of ways:

• A home can become infested with mice, rats or cockroaches, often as a result of hoarding food.
• Hoarded belongings might catch fire.
• The sheer amount of belongings can block your way out of the house – you can't escape.
• It can make cooking or eating at home difficult
• It can cause severe structural damage to a house or flat.
• Piles of possessions can collapse and crush you  - perhaps even kill you.

So, severe hoarding can be a risk to others as well to yourself.

Many people feel just too ashamed or embarrassed to talk about it – but it's best to get help as soon as you (or someone else) realise(s) that it is a problem.

It's often a relative or a neighbour who notices that hoarding is problem. 

It can be a difficult issue to ask someone about. Others can become quite critical of people who hoard, but the hoarding is the problem, not the person.

It can be helped effectively, but also compassionately and sensitively.

A number of organisations may be involved - health, social services, the fire service.  They will usually visit the person’s home.

The person who is hoarding might refuse to let anyone assess the situation properly. If this happens:

• mental health legislation can be used, if there is a psychiatric disorder
• public health legislation can be used, if there is a risk to that person or other people.   

When such legislation is used, there is always a balance between someone’s individual rights and the public's right to health and safety.

If it is a symptom of another illness, the first thing to do is to start treatment for that illness.

If there is no other illness, there are two main types of treatment for hoarding disorder: psychological therapy and medication. Some people need both, others get better with just psychological therapy.

Psychological therapy

Cognitive behavioural therapy (CBT) is the most effective psychological treatment. It can help you to change the thoughts and feelings that drive you to hoard.

There are several stages:

• Getting to trust your therapist. Things can be difficult to talk about, so it can take a little time to open up to someone new.  
• The therapist then helps you to understand what makes it difficult for you to throw things away.
• You then agree to not hoard more items during the treatment. There is no point clearing things away if you replace them with others.
• You and your therapist start clearing out items together. You will find that the longer you spend thinking about it, the more difficult it becomes.
• The therapist helps you to look at your thoughts and feelings about possessions.

As hoarding has often been going on for years, treatment can take a long time. The aim is to use the 3 Rs – Reduce, Recycle and Reuse.

Medication

Selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications which are used to help anxiety and obsessional problems. They also seem to help people who hoard. Improvement usually happens slowly over weeks or even months.

Research continues into other medications which might be helpful in hoarding disorder. 

One group of drugs blocks the action of dopamine, a chemical in the brain. They can be used with SSRI medication if the SSRI alone does not seem to be helping enough.

George was in his 50s.  He had been a perfectionist since childhood.  He was sent to boarding school when he was 10 years old. 

He was unhappy and lonely and he began to collect small items from home, like sweet wrappers.  On leaving school he successfully studied for a law degree. 

Shortly afterwards his mother, Sarah, died.  George found this a very difficult time and was comforted by collecting things which reminded him of his family home, or his mother - even newspapers containing the name Sarah. 

His hoarding gradually took over his life, and finally stopped him from working.  At times he could throw items away, but they soon began to build up again.  He lived in a large house, every room of which became filled from floor to ceiling. 

The living room ceiling was bent under the weight of papers in the bath above.  His bedroom was full, so he slept in a chair in the living room.  He moved around the house through narrow passages between the piles of items. 

He could not use the bath, so had to wash in the kitchen sink. He could only get to one ring on his cooker and the house was infested with insects, mice and rats.

George was encouraged by his family and GP to seek help for his hoarding, and he was referred to the local mental health service.  He was anxious and ashamed at first, but over a few weeks felt comfortable with his therapist. 

Because the problem had been going on for so long, he started to take SSRI medication.  After a month he felt ready to allow the therapist to visit his home and start work on helping him to get rid of stuff. 

George continued to throw things out between visits, and after 5 weeks felt that he could continue on his own.  He would visit the clinic from time to time when he ran into problems. After a year he had cleared his house. 

He organised repairs and hired a company to clean the whole house and get rid of the vermin.

George was much happier.  He was able to take up voluntary work and returned to education to re-establish his legal skills

Hoarding and how to approach it – guidance for Environmental Health Officers and others.  (PDF)

Holroyd S, Price H.  Chartered Institute of Environmental Health, revised 2012.

A review of hoarding and its impact from an environmental health perspective.

OCD Action: A charity that provides support and information for those with OCD and hoarding, and their families and carers.

OCD-UK: A charity that provides support and information for those with OCD and their families and carers.

Triumph over OCD and Phobia: A charity which runs a network of self-help therapy groups for people with OCD and other anxiety disorders.

References

• Compulsive Hoarding and OCD: two distinct disorders?  Saxena S. American Journal of Psychiatry, 2007;164:1435.
• Hoarding behaviour: building up the ‘R factor’. Gaston RL, Kiran-Imran F, Hassiem F, Vaughan J.   Advances in Psychiatric Treatment, 2009;15:344-353.
• Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder CG31.  National Institute for Health and Care Excellence, 2005.
• Treatment of Compulsive Hoarding.  Saxena S, Maidment KM. Treatment of Compulsive Hoarding. Journal of Clinical Psychology, 2004; 60:1143-54.

This leaflet was produced by the Royal College of Psychiatrists Public Education Editorial Board.

Series Editor: Dr Philip Timms

Authors: Karen Smith, Dr Lynne Drummond, Dr Suhana Ahmed and Dr Jim Bolton

This leaflet reflects the best available evidence available at the time of writing.