How Hoarding Disorder Is Diagnosed

Clutter is common, but for 2 to 6% of Americans it’s more than just clutter: it’s the sign of a mental health condition called hoarding disorder.

Hoarding disorder is usually diagnosed through an examination of symptoms and behaviors, which you’ll learn more about in this article.

A senior woman in her 60s at home, sitting in a messy, cluttered room, looking away with a serious expression.

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Professional Screenings

Hoarding disorder is usually diagnosed by a healthcare provider or mental health professional after reviewing a person’s symptoms and behavior.

The process can start with a primary healthcare provider, with a referral to a mental health professional as needed. It can also be addressed directly with a mental health professional such as a psychiatrist.

DSM-5

To meet the criteria for a diagnosis of hoarding disorder as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):

  1. A person must exhibit 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 of 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 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% 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.

In more basic terms, a person with hoarding disorder exhibits these three key features:

  1. They exhibit significant and ongoing difficulty parting with possessions, regardless of their value or how the items are discarded (throwing them away, selling them, donating them, etc.). They have a perceived need to keep these items, and getting rid of them would cause distress.
  2. Extreme clutter greatly impacts living space, and they are unable to use that space for its intended purpose. The conditions may also be unsanitary or unsafe.
  3. They are unable to function normally in day-to-day life, including:
  • Health problems
  • Problems with work performance or attendance
  • Financial problems
  • Housing instability/eviction
  • Social isolation
  • Emotional distress
  • Family stress

The healthcare provider or mental health professional will also note:

  • If the person also exhibits excessive acquisition of non-essential items (buying, “curb shopping,” theft, etc.)
  • The degree to which the person recognizes and acknowledges that their hoarding behavior is a problem

Discussion of Symptoms

The healthcare provider will ask the person questions about their thoughts, beliefs, and behaviors surrounding hoarding. These might include:

  • Do you find it difficult to part with things that most other people would get rid of?
  • How difficult is it to use the rooms and surfaces in your home because of the clutter?
  • Do you frequently buy or acquire things that you do not need or don’t have space for?
  • How does your hoarding behavior (saving/accumulating items, clutter) affect your daily functioning, and to what extent?
  • How much do these behaviors negatively affect areas of your life such as school, work, or your social/family life?
  • How much distress do these symptoms cause you?

A Team Effort

It is sometimes difficult for people with hoarding disorder to recognize that their behaviors are problematic.

The healthcare provider or mental health professional may ask friends, family, or other people close to the person to answer questions and discuss the person’s symptoms either in person or via a questionnaire.

Medical Exam

While the diagnosis for hoarding disorder is based on symptoms, the healthcare provider may do an exam to see if there are other health problems happening alongside or as a result of hoarding disorder. This can include:

  • Getting a medical history, including mental health and substance use
  • Getting a family medical history, including mental health and substance use
  • Measuring height and weight (to check for significant changes which could indicate a health concern)
  • Checking vital signs such as heart rate and blood pressure
  • Performing a physical examination, including listening to the heart and lungs, feeling organs, looking in ears and throat, etc.
  • Reviewing current medications, including over-the-counter medications and herbal supplements
  • Discussing your overall lifestyle and environment
  • Observing your attitude and behavior
  • Allowing time to ask and answer questions

Labs and Tests

There are no lab tests for hoarding disorder. The healthcare provider may order blood or urine tests if they suspect another medical condition or to see if the hoarding disorder has affected a person’s health.

Hoarding behavior can be caused by a brain injury. If this is the case, the healthcare provider may do image scans of the brain.

Self/At-Home Testing

While screening tools are usually administered by a healthcare professional, they can be completed on your own at home.

These tools are not a substitute for a consultation with a professional, but they can indicate a need to book an appointment with a healthcare provider or mental health expert to discuss further steps.

Clutter Image Rating Scale (CIR)

The Clutter Image Rating (CIR) shows a series of images depicting rooms in various stages of clutter. The person selects the image on the scale that best represents the state of the main rooms in the home. This allows for standardized definitions of clutter and minimizes subjective descriptions.

The CIR can be accessed here.

Saving Inventory—Revised (SIR)

This 23-item questionnaire was designed to measure three features of hoarding disorder:

  • Excessive acquisition
  • Difficulty discarding
  • Clutter

The SIR questions can be found here, while the scoring key is found here.

Hoarding Rating Scale (HRS)

The Hoarding Rating Scale is a five-item scale that includes questions about:

  • Clutter
  • Difficulty discarding
  • Excessive acquisition
  • Distress and impairment caused by hoarding 

A score of 14 or higher on the HRS indicates a probable hoarding disorder diagnosis, and a professional assessment is needed.

You can find the HRS here.

Questionnaire

This questionnaire by the International OCD Association is meant to be taken at home to see if an appointment with a professional is advised.

Do you:

  1. Have difficulty getting rid of items?
  2. Have a large amount of clutter in the office, at home, in the car, or in other spaces (e.g., storage units) that makes it difficult to use furniture or appliances or move around easily?
  3. Often lose important items like money or bills in the clutter?
  4. Feel overwhelmed by the volume of possessions that have “taken over” the house or workspace?
  5. Find it difficult to stop taking free items, such as advertising flyers or sugar packets from restaurants?
  6. Buy things because they are a “bargain” or to “stock up”?
  7. Avoid inviting family or friends into the home due to shame or embarrassment?
  8. Refuse to let people into the home to make repairs?

A “yes” answer to at least one of these questions indicates the need to see a healthcare provider or mental health professional for a full hoarding disorder screening.

Determining Subtypes

Animal hoarding is a subtype of hoarding disorder. It involves accumulating a large number of animals and:

  • Failing to provide minimal standards of nutrition, sanitation, and veterinary care
  • Failing to act on the deteriorating condition of the animals (including disease, starvation, or death)
  • Failing to act on the conditions of the environment (severe overcrowding, extremely unsanitary conditions)
  • (Often) being unaware of the negative effects of the collection on their own health and wellbeing and on that of other family members

Differential Diagnosis

Hoarding Disorder vs. Obsessive-Compulsive Disorder

Until the DSM-5 was published in 2013, hoarding disorder was considered a subtype of obsessive-compulsive disorder (OCD). A 2010 review of studies on OCD and hoarding disorder provided evidence that hoarding disorder is dissimilar enough to OCD to have its own diagnosis.

While OCD and hoarding disorder are related and occur together in up to 20% of people with hoarding disorder, there are some key differences that lead to hoarding disorder being classified as a distinct condition:

  • Most people with hoarding disorder don’t have classic OCD symptoms such as intrusive, recurrent thoughts.
  • Different clinical profiles
  • Different functional neuroimaging profiles
  • Different responses to treatment
  • OCD rates tend to be stable at about 2% in all age groups, with severity staying relatively static over time, while hoarding disorder appears to be progressive with the overall prevalence between 2 to 4%, increasing to over 6% in individuals age 55 or older and severity worsening over time.

Comorbidity

Comorbid mental health conditions are common in people who have hoarding disorder.

In individuals with hoarding disorder:

  • Approximately 50% have a depressive disorder
  • 25% have generalized anxiety, social anxiety, or attention deficit/hyperactive disorder-inattentive type
  • 20% have OCD

Emerging Research

Some studies have indicated that cognitive deficits play a role in hoarding symptoms, but more research is needed to address inconsistencies and understand the specific nature of these deficits.

Studies are also being conducted to explore the possible neurophysiological (characteristics of nerve cells as they receive and transmit information) aspects of hoarding.

Resources

If you or a loved one is struggling with hoarding, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database.

Summary

Hoarding disorder is a mental health condition where people accumulate a large number of belongings. For a definitive diagnosis, people must see a healthcare provider.

A Word From Verywell

While some people are aware of their hoarding behavior and acknowledge that it is problematic, others have difficulty recognizing that they may have hoarding disorder.

If you think you may have hoarding disorder, book an appointment with your healthcare provider or see a mental health professional to establish a diagnosis and create a treatment plan.

If loved ones have approached you with concerns about your hoarding behavior, it is worth listening to them and seeking the advice of a professional.

Hoarding disorder can have many negative effects on health and wellbeing, but with treatment it can be managed.

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Article Sources
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