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New Guidance to Help Diagnose Hoarding Disorder

Hoarding disorder affects around 1 in 50 (2%) of the population but remains a largely misunderstood mental health condition, said the authors of new guidance, published in the British Journal of General Practice. They added that the condition was only added to the International Classification of Diseases as a separate syndrome in 2019, having previously been classified under obsessive compulsive disorder (OCD).

The experts behind the new guidance, from Anglia Ruskin University (ARU) in Cambridge, explained that their motivation was to help health professionals spot the signs of hoarding disorder and intervene.

Hoarding disorder involves clutter in the home environment taking over living spaces, as well as excessive acquisition and difficulty discarding possessions, and affects an individual's quality of life or that of their family. The NHS described the condition as existing when someone acquires an excessive number of items and stores them in a chaotic manner, usually resulting in unmanageable amounts of clutter, and added that the items can be of little or no monetary value.

The condition is characterised by excessive clutter and difficulty discarding. In turn, this increases the risk of physical, psychological, and social morbidity, leading to reduced quality of life. The safety of those within the household may be put at risk, and strain may be posited on relationships within the household, with extended family and friends, and with neighbours.

It is considered a significant problem if the amount of clutter interferes with everyday living, or if the clutter caused significant distress or negatively affects the quality of life of the person or their family.

Dr Sharon Morein-Zamir, associate professor in psychology and sports science at Anglia Ruskin University in Cambridge and leader of the ARU Possessions and Hoarding Collective, a group of academics and professionals aiming to improve understanding of how people interact with their possessions, and co-author said: "It is really important that doctors and other frontline healthcare professionals are aware that hoarding disorder is a diagnosable medical condition and that it is usually linked to other issues so that proper support can be offered."

Hoarding Disorder 'Sneaks Up On People'

That said, in clinical settings, recognising hoarding symptoms can prove challenging, expressed the authors.

People with hoarding disorder most often suffer from depression, while other comorbidities include OCD and attention deficit hyperactivity disorder, explained the authors. 

They highlighted that the problem of hoarding typically comes to the fore only when patients seek support for other mental health or physical conditions, and hoarding can then act as a barrier to treatment due to concerns about hygiene, safety, or access to the home.

"Typically, hoarding disorder is something that sneaks up on people – it doesn’t happen overnight – and people don’t necessarily recognise they have a problem," Dr Morein-Zamir pointed out. 

Hence hoarding disorders can be challenging to treat , as many people have little awareness of how it's affecting their life or the lives of others, explained the NHS. 

Some of those with the disorder may realise they have a problem, but because of shame or guilt may be reluctant to seek help.

However, the key reason health professionals may not find out about hoarding-related difficulties is patients' limited insight. Where this is poor or absent, the individual is often convinced that their hoarding-related beliefs and behaviours are not problematic, despite evidence to the contrary. 

Decluttering the Problem

The authors explained that diagnosis should consider whether hoarding is secondary to other health problems including mental health conditions, such as schizophrenia, dementia, or physical ailments that limit mobility or the patient's ability to maintain their home environment. 

Possible symptoms of the disorder included keeping or collecting items that may have little or no monetary value, and finding it hard to categorise or organise items. The person may find it hard to make decisions, struggle to manage everyday tasks, become extremely attached to items, and refuse to let anyone touch or borrow them.

"A strong attachment to possessions constituting the hoard, with fear of them being discarded, lost, or forcefully taken away, would suggest hoarding disorder," the authors said. However, if there is no difficulty discarding, a diagnosis of hoarding disorder would not be appropriate they emphasised. 

If healthcare professionals suspect hoarding, they can ask about symptoms in an "equanimous and even indirect manner", and if needed arrange a home visit, said the authors – although in modern day general practice, fewer home visits mean hoarding may remain hidden longer . There are also tools available online, pointed out the authors, such as the clutter image rating scale.

Carefully Consider Clearances

GPs and other healthcare professionals can play a vital role in fostering good communication and coordination with other frontline professionals. Recognising hoarding as an ongoing and chronic mental health condition can help avoid judgement and facilitate engagement from all involved, reassured the authors.

At times, clearing out possessions can be suggested as a solution, and some patients with no hoarding disorder may even welcome this. However, for those with the disorder, clearances can cause distress, worsen their mental health, and only provide a temporary intervention. Hence, clearances should be avoided whenever possible and, if there is no other recourse, should be discussed in advance and conducted with the consent and participation of the individual, recommended the authors. 

Cognitive behavioural therapy and selective serotonin reuptake inhibitor treatment for the disorder is recommended for hoarding disorder by the National Institute for Health and Care Excellence. However, the authors highlighted there is insufficient evidence for their effectiveness, in part because good-quality treatment trials are missing.

"With the chronic nature of hoarding disorder, and at times its seeming intractable nature, harm reduction rather than treatment may be a more feasible approach, considering risk management concerns," suggested the authors. 

"Difficulties related to hoarding are more pervasive than previously thought," they warned, the disorder being associated with considerable psychological, physical, and social harms. 

Dr Cosmo Hallstrom, from the Royal College of Psychiatrists, who is not related to the study, told Medscape News UK: "More people have become aware of hoarding in recent years as a result of TV shows about clearing cluttered homes, but many people don’t know that in more extreme cases it is a diagnosable medical condition." He emphasised it was important that patients were identified and treated as early as possible, and said that it was positive that more was being done to raise awareness of hoarding.

GPs and their teams - alongside a coordinated engagement with a wide variety of existing support services - can lead in the identification and long-term care of these patients.

"If not tackled, it's a problem that will probably never go away," the NHS said.

"The sooner the problem is spotted, the sooner support can be provided," declared Dr Morein.

ARU experts have organised a free conference on Wednesday, 10 May to provide the public with more information about the condition.