In this chapter we examine the idea of Hoarding Disorder. This relatively new diagnosis was first described in the American Psychiatric Association’s Diagnostic and Statistical Manual which was published in 2013. Hoarding Disorder is used to describe hoarding which is associated with an extreme attachment to items which are hoarded. Although people with Hoarding Disorder may suffer from other problems such as depression and anxiety, in Hoarding Disorder it is thought that the hoarding is not due to another diagnosis or problem. However, how Hoarding Disorder can present with other diagnoses, as well as the concept of conditions with increased risk taking and impulsivity and how they can be linked, even in the same person with increased compulsivity and avoidance of risk. Because the concept of Hoarding Disorder has only been described relatively recently, there is a lack of research in this area. Whereas Hoarding Disorder is often described in the elderly or late middle-aged, it is thought to have its roots in childhood. In this chapter we will examine the presentation of Hoarding Disorder in all age groups.

As well as examining the description and diagnosis of Hoarding Disorder, in this chapter we will also look at the risks inherent in the hoarding itself as well as the risk of suicide. Theories and research about the possible causes of Hoarding Disorder will be discussed.

In this chapter we will examine the substantial overlap, similarities, and also connections between people with Hoarding Disorder, Obsessive Compulsive Personality, Attention Deficit Hyperactivity Disorder, and Autism. The importance of ADHD in many people with hoarding will be examined along with a discussion about how the increasing recognition of a link between the two conditions has led to research into new ways of treating Hoarding Disorder. It is also recognised that autism interacts with hoarding as well as ADHD in a number of ways. Some people with autism are unable to tolerate any clutter at all whilst others hoard huge numbers of items due difficulty in decision-making. In addition, a substantial proportion of people with autism also have a diagnosis of OCD. As has already been discussed (Chapter 5), OCD may present with hoarding symptoms due to the nature of obsessive thoughts as well as Hoarding Disorder also.

Different countries, states and provinces have different laws and legal systems. Laws also change with time. There are nevertheless some common threads regarding laws which affect hoarding and what may be your legal rights. In this chapter we will start by examining the various laws which may be relevant for people who hoard in England, Wales and much of the UK. We will then outline the differences from these laws in Scotland and Northern Ireland. Finally, we will mention how hoarding laws vary in Europe and the European Union, Australia, Canada, India, New Zealand and the United States of America

Please note that we are not lawyers and this chapter is meant to be an overview of our understanding of the law as it currently stands. It is aimed at providing a very approximate view of a person’s rights. With any legal issues you or your family may experience, you are strongly advised to consult a solicitor for any legal advice.

In this chapter we discuss that, as well as being the main feature necessary for the diagnosis of Hoarding Disorder, hoarding can also occur as a symptom in many other physical and mental conditions. We will discuss clinical stories of people who have had difficulties with hoarding but will demonstrate how a different type of approach is needed to help them overcome their problems from that described from pure Hoarding disorder. There will then be a brief examination of the overlap between trauma and neurodiversity and hoarding as well as a brief description and discussion of the validity of the concept of Diogenes Syndrome in the elderly.

Examines the concept of hoarding, what it is and how some animals and most people have a tendency to collect items beyond their immediate requirements. The distinction is made between a hoard and a collection. The types of items which are hoarded are discussed along with a description of animal hoarding.

Social aspects of hoarding. We address the stigma of hoarding and how this can be treated by society, along with discussion of the shame and humiliation which prevents many people with hoarding problems from seeking help. This stigma can be reinforced by “helping” agencies who may view it as a “lifestyle choice” rather than a condition which requires help. Then looking at the role the media has played in perpetuating the myth that hoarders should be able to deal with it themselves.

Hoarding is a symptom rather than a distinct diagnosis and may be found in many conditions but there is a specific condition with characteristic features known as Hoarding Disorder. Some possible causes of hoarding are then described followed by a more detailed examination of the diagnosis of Hoarding Disorder

Finally, the chapter examines t what age hoarding arises and introduces the idea of hoarding in childhood.

In this chapter we will examine the psychological treatments that have been found to be helpful for people with Hoarding Disorder. The main approach used is Cognitive Behaviour Therapy (CBT). This may be with an individual or in a group setting. Although, as with much of the research into Hoarding Disorder, the number of studies of high quality are limited, we have good evidence that CBT does work and can have life-changing impacts both on the hoarding and also the depressive symptoms which often accompany Hoarding Disorder. One of the major issues, however, can be the reluctance of people with Hoarding disorder to enter into treatment programmes and then to stick with the programme. There may be many reasons for this reluctance. One recent development which may be hopeful for the future has been using an approach known as Compassion Focussed Therapy in addition to the standard CBT.

In this chapter we will we examine how Obsessive-Compulsive Disorder (OCD) or Obsessive-Compulsive Personality (OCPD) may interact with Hoarding Disorder. It has already been noted that prior to 2013 and the inclusion of a separate diagnosis of Hoarding Disorder in the Diagnostic and Statistical Manual Volume 5 (DSM5-TR) *1 was described and included under the new category of Obsessive-Compulsive and related disorders, people with Hoarding Disorder were included as either having OCD or OCPD. In reality, whereas Hoarding Disorder and symptoms of hoarding are common in both OCD and OCPD, not everyone who has Hoarding Disorder also has one of these conditions. On the other hand, hoarding symptoms may be present in both OCD and OCPD without displaying all of the characteristics of Hoarding Disorder. These distinctions can have an effect on what treatments may work for the individual.

In this chapter we will examine the condition of animal hoarding, The various types of people who may hoard more animals than they are able to care for will be examined. Although some animal hoarders frequently also hoard inanimate objects as well. There are some differences in those who hoard animals and inanimate objects. These differences will be presented and discussed. Socioeconomic factors play a part in people who actively hoard animals, as well as those who inadvertently find themselves overwhelmed by the number of their animals. The management and treatment of animal hoarding is less researched than those who hoard other items and this will be mentioned along with descriptions of the treatments which may be helpful

In this chapter we examine how people with Hoarding disorder can help themselves. This is not a “quick fix” and does take time, commitment, and courage to face up to your problems. We will start by looking at how a ban on new items coming into the property is the first “golden rule” of treatment. We will examine how it can be useful but not essential to have a friend or family member also involved in the process. The principles of discarding objects are discussed with the idea of holding on to objects for the shortest time possible, making an immediate decision and then sticking with it and not going back on that decision. Finally, we will then list helpful resources and groups who may be able to assist you.

In this chapter we examine the difficult problem of trying to offer help and support to a friend or loved one who has Hoarding Disorder. Many people with Hoarding Disorder are reluctant to admit that they have a problem. This may be due to shame and the stigma surrounding the condition, or may be due to a lack of insight as the individual has become so accustomed to this way of living and denies there is a problem. Family members and friends need to be empathetic, patient, and tolerant. Constant nagging is likely to increase resistance and so it is a difficult path between urging them to get help but not causing them to feel persecuted and to cut ties with those trying to help them. If their own health and safety, or that of others is at risk, then we suggest ways in which you can ensure they receive the help they need. At the end of this chapter, we list some of the agencies that can offer help and advice for family, friends, and people living with hoarding problems. While helping a person with hoarding it is imperative you also consider your own health and safety as well as that of the person with hoarding.

In this chapter we will examine the evidence for the various treatments for Hoarding Disorder using medication. The action of the various chemicals in the brain as well as why it is thought they may be useful in Hoarding Disorder is then explored. Full lists of optimal dosage as well as side-effects are given. Finally, the possibility of other medications, which are largely unexplored, but which may be useful in the future, are examined.