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Hoarding disorder requires a thorough exploration of risk, including falls and fires, as well as a screen of differential diagnoses that may co-exist.
Key Knowledge
Key Knowledge
●Hoarding involves persistent difficulty discarding possessions, irrespective of their actual value
●Causes significant distress or impairment in functioning
●Insight is often poor
●Associated with safety risks (fire, falls, unsanitary conditions)
What is Hoarding Disorder?
ICD-11 defines hoarding disorder (6B24) as an accumulation of possessions due to excessive acquisition and difficulty discarding possessions, regardless of their actual value. The accumulation of possessions results in living spaces becoming cluttered to the point that their use or safety is compromised. It can be active (getting free items or buying) or passive (accumulation of flyers / mail).
Core features include:
●Persistent difficulty discarding possessions: Due to strong urges to save items, distress about getting rid of them, or beliefs about needing to save items.
●Accumulation of possessions: Clutter that fills up and compromises the use of areas within the home.
●Clinically significant distress or impairment: In social, occupational, or other important areas of functioning, including maintaining a safe environment.
Common features:
●Strong emotional attachment to possessions
●Belief that items may be useful or valuable in the future
●Fear of losing important information or memories
●Disorganisation and difficulty categorising or organising items
●Indecisiveness
●Perfectionism (difficulty categorising items “perfectly”)
●Avoidance (procrastination, difficulty initiating tasks)
Insight:
●Insight ranges from good (recognising the problem) to absent (delusional beliefs about possessions).
●Many people have poor insight and do not see hoarding as a problem.
Safety and health risks:
●Fire hazard (blocked exits, flammable materials)
●Falls and injury (clutter on floors, stairs)
●Structural damage (excessive weight)
●Unsanitary conditions (inability to clean, pest infestation, rotting food)
●Social isolation
Differential Diagnosis for Hoarding Disorder
1. Obsessive-compulsive disorder (OCD)
Key distinctions: In OCD, hoarding may occur but is driven by reducing the distress arising due to obsessions (e.g., fear of contamination spreading if items are touched). Hoarding disorder is not about intrusive, unwanted thoughts or compulsions, but rather about attachment to possessions and an inability to get rid of them. Even in OCD with little insight, the behaviour is unwanted or distressing whereas in Hoarding disorder, it can be associated with enjoyment. Importantly, as per ICD-11, hoarding disorder is now a separate diagnosis from OCD.
2. Schizophrenia or other psychotic disorders
Key distinctions: Hoarding in psychosis may be driven by delusions (e.g., belief items are needed for a mission) or disorganisation/negative symptoms. There can be irrational thoughts in hoarding disorder held to a delusional intensity but this would be restricted to fear of discarding items or that items have special importance despite evidence to the contrary. Explore positive psychotic symptoms such as hallucinations and/or thought disorder to distinguish between the two.
3. Depression
Key distinctions: Clutter in depression is usually due to apathy, low energy, and lack of motivation, rather than difficulty discarding. There is no distress associated with discarding items and addressing the depression typically improves the clutter.
4. Dementia
Key distinctions: In dementia, hoarding may occur due to confusion, memory loss, or executive dysfunction. Onset is later, and there are other cognitive impairments. Hoarding in dementia is secondary to cognitive decline.
5. Autism spectrum disorder
Key distinctions: People with ASD may have difficulty discarding due to rigidity or attachment to routines. However, ASD would also present with deficits in social communication and reciprocal social interactions. .
Risk Assessment in Hoarding Disorder
To self:
●Fire risk – build up of flammable materials, inability to escape in a fire
●Falls and injury – Clutter, blocked pathways, items piled unsafely
●Structural damage – Excessive weight causing floor collapse
●Unsanitary conditions – Inability to clean, pest infestation, mould, rotting food, health hazards
●Social isolation – Shame, embarrassment, reluctance to allow visitors into the home
●Eviction or legal action – Landlord or council intervention
●Loss of utilities – Gas, electric, or water shut off due to unsafe conditions
●Self-neglect – Inability to use kitchen or bathroom leading to impact on nutrition and hygiene
To others:
●Fire risk to neighbours (particularly in flats or terraced houses)
●Pest infestation spreading to adjacent properties
●Children or vulnerable adults co-living in hoarded homes are at risk (safeguarding concern)
From others:
●Possible vulnerability to exploitation given mental state.
Communication Tips
Think CASC: Hoarding requires a non-judgmental approach. The person may feel ashamed or defensive, or have poor insight.
Opening non-judgmentally:
●”I’d like to understand a bit about your living situation. Can you tell me about your home?”
Exploring difficulty discarding:
●”Do you find it hard to throw things away or get rid of things?”
●”What makes it difficult to discard things?”
●”What goes through your mind when you think about getting rid of something?”
●”How do you feel when you try to throw something away?”
Exploring accumulation and clutter:
●”Can you describe what your home looks like at the moment?”
●”Are there rooms you can’t use for their intended purpose, like the kitchen or bathroom?”
●”Can you move around freely in your home, or are some areas blocked?”
●”Are you able to use your bed, oven, sink, loo etc., without difficulty?”
Exploring acquisition:
●”Do you find it hard to resist free items or bargains?”
●”How often do you buy new things?”
Impact on functioning and safety:
●”How does this affect your daily life?”
●”Are you able to have visitors? How do you feel about people coming into your home?”
●”Have there been any concerns about safety e.g., fire risk, falls, cleanliness?”
●”Has anyone, such as family, landlord, council, expressed concern about your living conditions?”
Insight:
●”Do you see this as a problem, or do others see it as a problem?”
●”How do you feel about the idea of throwing away some of these items?”
Screen for comorbidities:
●Depression: mood, energy, motivation
●Anxiety: generalised worry, social anxiety (embarrassment about home)
●OCD: intrusive thoughts, compulsions
●Psychosis: delusions about possessions
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the SpR in the community mental health team. You have been asked to assess Mr Leonard Price, a 42-year-old, at home. He was referred by his housing association following complaints from his neighbours about smell and a rat infestation. Mr Price lives alone in a one-bedroom housing association flat. He has a history of depression treated with Citalopram 20mg daily for the past eight years.
Please take a psychiatric history and perform a risk assessment.
Scenario Summary:
Leonard Price is a 42-year-old man with hoarding disorder. Over the past 15 years, he has accumulated vast quantities of items (newspapers, magazines, packaging, “useful” objects) to the point where his flat is un-inhabitable. The kitchen and bathroom are inaccessible, pathways are narrow, he has a rat infestation, and it is causing a fire hazard. He experiences significant distress at the thought of throwing away these items, believing he may need them in future. He has poor insight and becomes defensive when the severity is questioned. His hoarding worsened after his wife’s death 12 years ago. He is socially isolated and has pre-existing depression. Environmental Health are threatening enforcement action. There are significant safety concerns (fire risk, falls, unsanitary conditions, a rat infestation) but he refuses help to clean his property.
Actor Brief:
You are Leonard Price, a 42-year-old. You live alone in a one-bedroom ground-floor flat in a housing association block. You’ve lived there for 23 years. You’re here because the housing association and the council have been “harassing” you about the state of your flat. Neighbours have complained, and environmental health came round two weeks ago, took photos, and said it’s a “health hazard.” You think they’re overreacting.
Your flat is full, yes, but everything in there is useful or might be needed. You’ve got newspapers and magazines going back years because you never know when you might need to look something up. You’ve got packaging, boxes, plastic bags, all reusable. You’ve got spare parts, tools, wires, electronics. You used to fix things for people, so you keep these components. You’ve got letters, bills and documents that you can’t throw away; you might need them. It’s not rubbish, it’s all organised in your mind. Other people just don’t understand.
You can’t get into the kitchen or bathroom easily; the rooms are full, so you’ve been using the microwave in the hallway for food. The toilet is accessible, but you have to navigate carefully. There are narrow pathways through the flat. The bedroom is piled high, so you sleep in an armchair in the living room. The front door only opens about a foot because of the items stacked behind it. The environmental health officer said the fire service couldn’t get in if there was an emergency, but you think that’s dramatic.
It’s been building up over the years. It started slowly, keeping newspapers, not throwing things away, but it’s gotten worse over the past 15 years or so. It got much worse after your wife, Linda, died 2 years ago. She used to keep things tidy, but after she died, you just couldn’t bear to throw anything away. Everything feels important. When you try to discard something, you feel anxious and panicky, what if you need it? What if you’ve thrown away something valuable or irreplaceable? So, you just keep everything.
You don’t have visitors anymore. Your daughter Alison lives in Birmingham. She visited two years ago and was horrified by the state of the flat. She wanted to help clear it out, but you refused, and you argued. She still calls occasionally, but she’s given up trying to visit. You used to have friends from the engineering society, but you stopped inviting people over years ago because you were embarrassed. You don’t go out much, you get food delivered and mostly stay in.
You’ve been on citalopram 20mg for depression for about eight years, prescribed by your GP. Your mood is low and you feel lonely, guilty and ashamed, but you’re not suicidal. You sleep poorly, waking early. You have little appetite and have lost weight, though you’re not sure how much. You don’t drink alcohol and take no recreational drugs. You don’t have any other medical problems.
You’re defensive during the interview. You’re here because you’ve been told you have to be, but you don’t think you have a problem, or at least, you don’t think it’s as bad as people are making out. When asked about the state of the flat, you minimise it: “It’s a little cluttered, but it’s not dirty.” You become irritated if the interviewer suggests it’s a health or safety risk. You insist you know where everything is and that it’s all useful. However, if asked directly about how difficult it is to throw things away, you admit it causes you a lot of distress and you feel overwhelmed by the thought of clearing anything.
You’re not hostile, though, just guarded. As the interview progresses and the doctor is non-judgmental, you soften slightly and might admit that you’re lonely, that you miss Linda, and that you know deep down things have gotten out of hand, but you don’t know how to fix it. You’re terrified the housing association will evict you or force a clearance, which would feel like a violation.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
●Elicit the core features of hoarding disorder: persistent difficulty discarding possessions due to a perceived need to keep items and distress associated with discarding, resulting in accumulation that clutters living spaces and compromises their use and safety
●Assess the severity and functional impact.
●Explore the factors maintaining the hoarding behaviour, including beliefs about the value or necessity of items, emotional attachment, fear of waste or loss, and avoidance of decision-making.
●Differentiate hoarding disorder from other conditions including OCD (hoarding is ego-syntonic, not driven by intrusive thoughts), depression (clutter in depression is due to apathy/low motivation/low energy, not attachment to items) and psychosis.
●Assess insight empathetically, recognising that most people with hoarding disorder have poor insight and do not perceive the behaviour as problematic, which has significant implications for engagement and treatment.
Communication
A good candidate will:
●Adopt a non-judgmental, empathic approach throughout.
●Explore the timeline and context sensitively, understanding that hoarding often has roots in loss, trauma, or significant life transitions, and that expressing curiosity about these factors can be therapeutic.
●Recognise and validate the emotional difficulty of the situation; loneliness, shame, fear of eviction, while still maintaining focus on the clinical assessment and risk management priorities
Video Example
Contributors:
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
Dr Mohammad Lalji is a Psychiatry Speciality Registrar specialising in General Adult Psychiatry.
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Frost, R. O., & Steketee, G. (2014). The Oxford handbook of hoarding and acquiring. Oxford University Press.
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
Related Articles:
Mania History Taking: https://psychpanda.com/mania/
OCD History Taking, Risk & Management: https://psychpanda.com/ocd/
Understanding & Assessing Delusions: https://psychpanda.com/delusions/