HealthUnderstanding the severity of hoarding

Understanding the severity of hoarding

In order for individuals to meet criteria for hoarding disorder, and not just hoarding symptoms, they must also experience clinically severe impairment as the result of their hoarding symptoms, and the hoarding symptoms must be independent from another medical or mental disorder. Individuals with hoarding disorder often acquire objects through passive means, such as not discarding junk mail or used food containers, but some also have difficulties with excessive acquisition of new possessions.

The following core symptoms characterize hoarding disorder:1

  • Difficulty discarding current possessions
  • Urges to save or obtain additional items
  • Excessive clutter in the home

Adults with hoarding disorder experience significant distress and anxiety when they are forced to discard their current possessions or are unable to save objects that they deem valuable. Further, the clutter resulting from difficulty discarding and urges to save are often so severe that individuals cannot sleep in their bed or use their kitchen.

Symptoms of Hoarding Seen as Early as Childhood

Because hoarding disorder is a recent addition to the DSM-5,1 current estimates of the prevalence of hoarding disorder in geriatric samples vary widely and more systematic epidemiological studies utilizing current hoarding disorder criteria are needed before any definitive estimates of the prevalence of geriatric hoarding disorder can be made.1,2,3 Most studies agree that hoarding symptoms first appear in childhood or adolescence and onset in late life is rare, suggesting that perceived hoarding symptoms (e.g., high clutter levels, repetitive collecting of items) that appear to have onset in late life may be a manifestation of an organic problem, such as a traumatic brain injury, or as a new symptom of another mental disorder, such as Obsessive-compulsive Disorder or depression.4,5

Consequences of Hoarding Disorder In Older Persons

The consequences of hoarding disorder can be particularly dire for geriatric populations. Our research has found that older adults with hoarding disorder may experience poor hygiene and nutrition, and may be at increased risk of injury from falling due to high clutter levels. These patients are also more likely to report the presence of mold and insect infestations in their home.6 Older adults with hoarding disorder also report higher rates of medical problems, including hypertension, stroke, and sleep apnea.7 In addition to these health issues, many older adults with hoarding disorder may experience homelessness at some point in their lives.8

Treating Hoarding Disorder

Hoarding disorder is a serious mental illness with severe consequences for the individuals afflicted, but there is also a growing literature on evidence-based treatments that may help older adults to overcome their hoarding disorder symptoms. Because of the multitude of social and health consequences for older adults with hoarding symptoms, interventions for hoarding disorder may benefit from the addition of case management.

Older adults with hoarding disorder may also be likely to experience executive functioning problems, which may complicate the effectiveness of traditional cognitive-behavioral approaches to hoarding disorder treatment.9,10,11 Our research suggests that the most promising psychotherapeutic intervention for late life hoarding disorder is a combination treatment of compensatory cognitive training and exposure therapy.12 The compensatory cognitive training involves skill acquisition related to to-do lists, calendars, problem solving, and flexible thinking.

Exposure therapy is considered the gold standard for treating Obsessive-compulsive Disorder, a mental disorder with similar etiology.13 Exposure therapy for hoarding disorder is focused on patients’ difficulty discarding their current possessions. Individuals who also have trouble with excessive acquisition may be able to benefit from exposure therapy focused on avoiding the acquisition of new objects as well.

In addition to psychotherapy, there are also some promising pharmaceutical interventions.14 Unfortunately, there has not yet been any investigation of medications for hoarding disorder in older adults.


1. American Psychiatric Association. Diagnostic and statistical manual of mental health disorders: DSM-5 (5th ed.). (Washington, DC: American Psychiatric Publishing, 2013).

2. Samuels, Jack F., O. Joseph Bienvenu, Marco A. Grados, Bernadette Cullen, Mark A. Riddle, Kung-yee Liang, William W. Eaton, and Gerald Nestadt. “Prevalence and correlates of hoarding behavior in a community-based sample.” Behaviour research and therapy 46, no. 7 (2008): 836-844.

3. Timpano, Kiara R., Cornelia Exner, Heide Glaesmer, Winfried Rief, Aparna Keshaviah, Elmar Brähler, and Sabine Wilhelm. “The epidemiology of the proposed DSM-5 hoarding disorder: exploration of the acquisition specifier, associated features, and distress.” The Journal of clinical psychiatry 72, no. 6 (2011): 780-6.

4. Grisham, Jessica R., Randy O. Frost, Gail Steketee, Hyo-Jin Kim, and Sarah Hood. “Age of onset of compulsive hoarding.” Journal of Anxiety Disorders 20, no. 5 (2006): 675-686.

5. Tolin, David F., Suzanne A. Meunier, Randy O. Frost, and Gail Steketee. “Course of compulsive hoarding and its relationship to life events.” Depression and Anxiety 27, no. 9 (2010): 829-838.

6. Ayers, Catherine R., and Mary E. Dozier. “Predictors of hoarding severity in older adults with hoarding disorder.” International psychogeriatrics/IPA (2014): 1-10.

7. Ayers, Catherine R., Yasmeen Iqbal, and Katrina Strickland. “Medical conditions in geriatric hoarding disorder patients.” Aging & mental health 18, no. 2 (2014): 148-151.

8. Rodriguez, Carolyn I., Dan Herman, Jehanny Alcon, Shaofu Chen, Audrey Tannen, Susan Essock, and Helen Blair Simpson. “Prevalence of hoarding disorder in individuals at potential risk of eviction in New York City: a pilot study.” The Journal of nervous and mental disease 200, no. 1 (2012). doi:10.1097/NMD.0b013e31823f678b

9. Ayers, Catherine R., Julie Loebach Wetherell, Dawn Schiehser, Erin Almklov, Shahrokh Golshan, and Sanjaya Saxena. “Executive functioning in older adults with hoarding disorder.” International journal of geriatric psychiatry 28, no. 11 (2013): 1175-1181.

10. Mackin, R. Scott, Patricia A. Areán, Kevin L. Delucchi, and Carol A. Mathews. “Cognitive functioning in individuals with severe compulsive hoarding behaviors and late life depression.” International journal of geriatric psychiatry 26, no. 3 (2011): 314-321.

11. Ayers, Catherine R., Julie Loebach Wetherell, Shahrokh Golshan, and Sanjaya Saxena. “Cognitive-behavioral therapy for geriatric compulsive hoarding.”Behaviour research and therapy 49, no. 10 (2011): 689-694..

12. Ayers, Catherine R., Sanjaya Saxena, Emmanuel Espejo, Elizabeth W. Twamley, Eric Granholm, and Julie Loebach Wetherell. “Novel treatment for geriatric hoarding disorder: an open trial of cognitive rehabilitation paired with behavior therapy.” The American Journal of Geriatric Psychiatry 22, no. 3 (2014): 248-252.

13. March, J., Frances, A., Carpenter, D., & Kahn, D. “The Expert Consensus Guideline Series: Treatment of obsessive-compulsive disorder.” Journal of Clinical Psychiatry 58, Suppl. 4 (1997): 4-6.

14. Saxena, Sanjaya, and Jennifer Sumner. “Venlafaxine extended-release treatment of hoarding disorder.” International clinical psychopharmacology (2014). doi: 10.1097/YIC.0000000000000036

Geriatric Hoarding and Anxiety Researcher at University of California, San Diego

Mary Dozier, B.A., is a second year graduate student in the San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology. Her research focus is on geriatric hoarding and anxiety. Dozier is the author of five peer-reviewed publications and four book chapters on hoarding disorder and obsessive-compulsive disorder across the lifespan.

Research Service, VA San Diego Healthcare System
Psychology Service, VA San Diego Healthcare System
Department of Psychiatry, University of California, San Diego School of Medicine
San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology

Assistant Professor, Department of Psychiatry, Psychotherapy at University of California, San Diego

Catherine Ayers, Ph.D., ABPP, holds dual roles as Division Director at the VA San Diego Healthcare System and Assistant Professor at the University of California, San Diego. She also contributes to the SDSU/UCSD Joint Doctoral Program in Clinical Psychology. Dr. Ayers' research focuses on anxiety disorders and hoarding, with funded projects by the International OCD Foundation and Veterans Health Administration. She has authored 30+ peer-reviewed publications and over ten book chapters on anxiety and hoarding disorders.


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