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Hoarding

Hoarding disorder is a psychiatric condition defined by persistent difficulty discarding or parting with possessions, irrespective of their objective value, due to a strong perceived need to retain them and distress associated with letting go.^[1]^[2] This leads to excessive accumulation of items, resulting in cluttered living spaces that impair their functional use, such as cooking, cleaning, or safe navigation, and often causes significant personal distress or functional impairment.^[3]^[4] First recognized as a distinct diagnosis in the DSM-5 in 2013, it is classified under obsessive-compulsive and related disorders, though it differs from obsessive-compulsive disorder in lacking primary obsessions or compulsions tied to hoarding behaviors.^[5]^[6] Epidemiological studies estimate the prevalence of hoarding disorder at approximately 2.5% in the general population, with rates ranging from 1.5% to 6% across meta-analyses, showing no significant gender differences but increasing with age, particularly elevated among those over 60.^[7]^[8] The disorder frequently co-occurs with other psychiatric conditions, including major depression, anxiety disorders, and attention-deficit/hyperactivity disorder, affecting over 60% of cases.^[9] Etiological research points to multifactorial origins, including genetic vulnerabilities, neurobiological factors such as executive function deficits in decision-making regions of the brain, and environmental triggers like early trauma or loss, though no single cause predominates and adaptive saving behaviors can escalate pathologically under stress.^[10]^[2] Beyond individual suffering, hoarding imposes substantial societal costs, including health hazards from clutter-related fires or infestations, eviction risks, and economic burdens from cleanup and lost productivity, underscoring its public health implications.^[11] Effective interventions, such as cognitive-behavioral therapy focused on decision-making skills and exposure to discarding, show modest success rates, highlighting ongoing challenges in treatment efficacy.^[1]

Behavioral Hoarding

Definition and Distinctions

Hoarding disorder, classified in the DSM-5 under obsessive-compulsive and related disorders, is defined by persistent difficulty discarding or parting with possessions, irrespective of their actual value, due to a perceived need to save items and distress associated with discarding them.^[1] This leads to excessive accumulation of items that congest and clutter active living areas, substantially impairing their intended use and causing clinically significant distress or impairment in social, occupational, or other areas of functioning.^[3] The condition typically emerges by early adulthood, with symptoms worsening over time, and affects approximately 2-6% of the population based on community surveys.^[2]^[12] Behavioral hoarding, the focus of this category, specifically involves the compulsive acquisition and retention of inanimate objects, distinguishing it from animal hoarding, which entails over-accumulation of pets leading to neglect, or financial hoarding, characterized by excessive saving of money or assets without spending on necessities.^[13] Unlike normative saving behaviors, where individuals retain functional items for practical utility without clutter or distress, hoarding features emotional attachments to even worthless objects, indecisiveness, and avoidance of discarding decisions.^[4] Key distinctions exist between hoarding disorder and collecting: collectors selectively acquire specific categories of valued items, organize them systematically for display or appreciation, and derive pleasure without functional impairment, whereas hoarders accumulate indiscriminately, resulting in disorganized clutter that blocks living spaces and evokes anxiety over potential future needs.^[14]^[15] Hoarding also differs from mere clutter, which may arise from temporary disorganization or laziness but lacks the persistent saving urges and discarding distress central to the disorder; in hoarding, the volume and chaos preclude normal household activities like cooking or sleeping in designated areas.^[1] Furthermore, while hoarding symptoms can co-occur with obsessive-compulsive disorder (OCD), it was separated in DSM-5 due to distinct neural underpinnings, poorer response to standard OCD treatments like exposure therapy, and lower insight into the irrationality of behaviors compared to OCD compulsions.^[5]^[16]

Symptoms and Impairment

Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, irrespective of their actual value, due to a perceived need to save the items and distress associated with discarding them.^[1] This leads to the excessive accumulation of items that congest and clutter active living areas, such as kitchens, bedrooms, and bathrooms, thereby preventing their normal intended use.^[3] The hoarding behaviors must cause clinically significant distress or impairment in social, occupational, or other areas of functioning, distinguishing the disorder from mere collecting or eccentricity.^[1] Common symptoms include strong urges to acquire new possessions, indecisiveness about what to keep or discard, excessive emotional attachment to items regardless of utility, and avoidance of decisions involving disposal.^[17] Individuals often justify retention by anticipating future needs or fearing waste, even for worthless or redundant objects like newspapers or containers.^[2] Associated cognitive features encompass deficits in attention, organization, categorization, and problem-solving, which exacerbate decision-making challenges in sorting and discarding.^[18] Perfectionistic tendencies may further contribute, as individuals delay discarding until certain of the "right" decision, perpetuating accumulation.^[9] Impairments from hoarding are multifaceted and severe. Clutter compromises safety and hygiene, increasing risks of falls, fires, pest infestations, and health hazards from mold or unsanitary conditions.^[19] Functionally, living spaces become unusable—beds for sleeping, kitchens for cooking, or pathways for movement—leading to reliance on alternative, often unsafe, arrangements.^[1] Socially, embarrassment over clutter prompts avoidance of visitors, straining relationships and fostering isolation; family conflicts and evictions are common outcomes.^[20] Occupationally, hoarding correlates with reduced productivity and higher disability rates across domains like self-care and community participation, comparable to burdens in schizophrenia or chronic medical conditions.^[19] Empirical studies indicate hoarders exhibit lower global functioning and quality of life than those with non-hoarding obsessive-compulsive disorder.^[20]

Causes and Mechanisms

Hoarding disorder arises from a complex interplay of genetic, neurobiological, and psychological factors, with empirical evidence indicating multifactorial etiology rather than a single cause. Twin studies estimate that genetic influences account for approximately 50% of the variance in hoarding behaviors, higher than for many other psychiatric traits.^[10] ^[21] Genome-wide association studies further identify genetic overlaps with schizophrenia and autism spectrum disorder, suggesting shared polygenic risks that contribute to hoarding proneness.^[22] Neuroimaging research reveals distinct brain dysfunctions in hoarding disorder, separate from obsessive-compulsive disorder, including reduced activity in the anterior cingulate cortex and orbitofrontal regions implicated in decision-making and error detection.^[23] Functional MRI studies demonstrate emotional dysregulation, with heightened amygdala responses to possessions and impaired prefrontal control over attachment-related decisions, linking affective processing deficits to persistent saving urges.^[24] Glucose metabolism analyses show lower activity in the posterior cingulate and dorsal anterior cingulate cortices among individuals with hoarding symptoms comorbid with OCD, pointing to disrupted self-referential and attentional networks.^[9] Psychological mechanisms center on maladaptive information processing and emotional attachment, where individuals experience intense distress from discarding due to perceived future utility or sentimental value, often exacerbated by perfectionism and indecisiveness.^[10] Cognitive impairments in sustained attention, categorization, and executive function perpetuate clutter accumulation by hindering organization and decision-making.^[18] ^[25] Trauma exposure, such as loss or abuse, correlates with stronger hoarding beliefs, particularly emotional attachment to items as proxies for security, though not all cases involve identifiable stressors.^[26] Early family modeling of saving behaviors may reinforce these patterns, but prospective longitudinal data remain limited.^[27]

Diagnosis and Prevalence

Hoarding disorder is diagnosed according to criteria outlined in the DSM-5, published by the American Psychiatric Association in 2013. The core features include persistent difficulty discarding or parting with possessions, irrespective of their actual value, driven by a perceived need to save items and a strong urge to retain them, accompanied by distress associated with discarding.^[1]^[28] This leads to the accumulation of possessions that congest and clutter active living areas to the extent that their intended use is compromised or precluded.^[3] The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, and the hoarding cannot be attributable to another medical condition (e.g., brain injury), not better explained by neurodevelopmental disorders like intellectual disability, or confined to collecting items like books without significant clutter or impairment.^[1]^[6] Specifiers include the level of insight into the disorder (good, fair, or poor/absent) and whether symptoms have been present since childhood or adolescence.^[1] Diagnosis requires clinical assessment, often using structured interviews or scales like the Saving Inventory-Revised or Hoarding Rating Scale, to differentiate hoarding disorder from related conditions such as obsessive-compulsive disorder (OCD), where hoarding was previously subsumed but is now distinct due to limited response to standard OCD treatments and differing neural correlates.^[28] Comorbidities are common, including major depressive disorder, anxiety disorders, and ADHD, which must be ruled out as primary explanations for the hoarding behavior.^[5] Epidemiological studies estimate the prevalence of hoarding disorder in the general adult population at approximately 2.5%, with a range of 1.5% to 6% across community samples.^[7]^[8] A 2019 meta-analysis of 38 studies reported a pooled prevalence of 2.5% (95% CI: 1.7-3.6%), with no significant gender differences, though rates increase with age, reaching up to 6% in individuals over 60.^[7]^[8] Lifetime prevalence is similarly around 2.6%, and the disorder affects individuals across socioeconomic levels, though it is underrecognized due to sufferers' limited insight and reluctance to seek help.^[8]^[29] Prevalence appears comparable in Western and limited non-Western samples, but data from diverse cultural contexts remain sparse.^[30]

Treatment and Interventions

Cognitive Behavioral Approaches

Cognitive behavioral therapy (CBT) is the most empirically supported psychological intervention for hoarding disorder, targeting core maintaining factors such as maladaptive beliefs about possessions, emotional attachments to items, and decision-making deficits.^[31] The foundational cognitive-behavioral model of hoarding, proposed by Frost and Hartl in 1996 and refined by Steketee and Frost, posits that hoarding arises from interactions among information-processing impairments (e.g., attention biases toward possessions and poor categorization), excessive acquisition driven by avoidance of negative emotions, and avoidance of discarding due to fears of loss or responsibility for waste.^[32] This model emphasizes causal pathways where faulty cognitions—such as perfectionistic beliefs that items must be used or saved for future utility—perpetuate clutter accumulation, leading to functional impairment.^[33] Standard CBT protocols for hoarding, developed by Steketee and Frost, typically span 26 sessions delivered individually or in groups, incorporating motivational enhancement to address ambivalence, psychoeducation on hoarding mechanisms, and targeted skills training.^[25] Key techniques include cognitive restructuring to challenge beliefs (e.g., disputing the idea that discarding an item equates to discarding a memory), graduated exposure to discarding practices to reduce anxiety tolerance, and behavioral experiments to test acquisition urges by implementing rules like "one in, one out."^[34] Organizing skills training focuses on categorization and storage systems to improve decision-making efficiency, while in-home sessions facilitate real-time application and reduce reliance on abstract motivation.^[35] These elements aim to disrupt the cycle of avoidance and reinforcement, with empirical support from randomized controlled trials demonstrating superiority over waitlist controls in reducing hoarding severity by 20-30% on standardized measures like the Saving Inventory-Revised.^[36] Meta-analytic evidence confirms CBT's efficacy, with a 2015 review of nine trials reporting a moderate Hedges' g effect size of 0.57 for symptom reduction, though outcomes vary by delivery format—individual CBT yielding larger gains than group approaches.^[31] An updated 2021 meta-analysis of 17 studies reinforced these findings, showing sustained improvements in clutter and discarding at 6-12 month follow-ups, albeit with persistent residual symptoms in 40-60% of participants, indicating CBT as partially effective rather than curative.^[37] Mechanisms of change include reductions in saving cognitions and improved executive functioning, as evidenced by neuroimaging studies post-CBT revealing normalized activity in decision-related brain regions like the anterior cingulate cortex.^[38] However, high dropout rates (up to 25%) and limited long-term data highlight needs for adherence strategies and combined interventions, with ongoing trials exploring home-based decluttering augmentations to enhance real-world generalization.^[39]^[40]

Pharmacological and Adjunctive Methods

No medications have been approved by the U.S. Food and Drug Administration specifically for the treatment of hoarding disorder, and pharmacotherapy is generally considered adjunctive to cognitive behavioral therapy rather than a standalone intervention.^[41] Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, have been investigated due to hoarding disorder's overlap with obsessive-compulsive disorder, where these agents show efficacy; however, prospective studies indicate only modest symptom reduction in hoarding patients, with response rates often lower than in non-hoarding obsessive-compulsive disorder cases.^[42] ^[43] For instance, a trial of paroxetine in patients with prominent hoarding symptoms reported a mean symptom decrease of approximately 31%, but global functioning improvements were limited.^[44] Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine extended-release have shown preliminary promise in open-label trials. In a 12-week study of 24 adults with hoarding disorder, venlafaxine at doses up to 300 mg daily led to a 36% reduction in hoarding severity scores on the Saving Inventory-Revised, with a large effect size (Cohen's d = 1.1) and improvements in associated disability.^[45] ^[46] Despite these findings, the open design and small sample limit generalizability, and controlled trials are lacking. Other agents, such as atomoxetine (a norepinephrine reuptake inhibitor typically used for attention-deficit/hyperactivity disorder), have demonstrated potential in reducing hoarding symptoms and enhancing executive function in case series, with symptom improvements correlating to decreased patient disability; however, evidence remains anecdotal or from small-scale studies without placebo controls.^[47] Adjunctive non-pharmacological methods often complement medication trials by addressing practical barriers to treatment adherence and symptom management, such as comorbid conditions like depression or anxiety that exacerbate hoarding. These may include motivational interviewing to enhance engagement or structured home visits for decluttering support, though empirical support for their isolated efficacy is sparse and typically integrated within broader cognitive behavioral frameworks.^[9] Ongoing research explores novel serotonergic agents like vortioxetine for cognitive aspects of hoarding, but phase II trials have not yet established superiority over existing options.^[48] Overall, pharmacological approaches yield inconsistent results across studies, with effect sizes smaller than those for psychotherapy, underscoring the need for larger randomized controlled trials to clarify their role.^[47]

Outcomes and Recent Developments

Cognitive behavioral therapy (CBT) specifically adapted for hoarding disorder (CBT-HD) demonstrates moderate efficacy in reducing symptoms, with meta-analyses reporting pre-to-post-treatment effect sizes of 0.70 to 0.82 for hoarding severity and clutter levels, though most patients exhibit persistent impairment post-treatment.^[31]^[40] Pharmacological interventions, such as selective serotonin reuptake inhibitors (SSRIs), yield limited benefits, with no medications approved by regulatory bodies like the FDA for hoarding disorder and effect sizes often indistinguishable from placebo in controlled trials.^[47]^[41] Adjunctive psychosocial approaches, including group therapy and skills training, produce effect sizes ranging from 0.86 to 1.41, but no single modality shows superiority, and relapse rates remain high without sustained support.^[49]^[50] Recent developments emphasize multimodal enhancements to standard CBT-HD. A 2023 randomized controlled trial protocol investigates augmenting group CBT with in-home decluttering sessions over 10 weeks, aiming to address residual symptoms by combining therapeutic insight with practical intervention in the hoarding environment.^[39] Emerging "sensory CBT" strategies, incorporating imagery rescripting to rehearse discarding outcomes, have shown preliminary promise in alleviating decision-making avoidance linked to sensory sensitivities in hoarding.^[51] Neuroimaging research from 2024 reveals that successful group CBT correlates with increased activity in brain regions tied to decision-making and emotional regulation, such as the anterior cingulate cortex, suggesting potential biomarkers for treatment response.^[52] Despite these advances, systematic reviews through 2025 underscore the need for larger trials, as average symptom reductions hover around 25%, with full remission uncommon and comorbidities like depression complicating long-term outcomes.^[53]^[54]

Historical Development

Early Observations and Cultural Views

Hoarding behaviors, often depicted as excessive accumulation of valuables, appear in ancient literature as cautionary tales of greed and folly, such as parables in the New Testament where servants entrusted with talents either invest them productively or bury them out of fear, leading to condemnation of the latter.^[55] In classical antiquity, accumulators of treasure were commonly portrayed as misers whose isolation from society stemmed from pathological attachment to possessions, a view reinforced in mythological narratives where hoarding symbolized hubris or divine disfavor.^[56] The early Catholic Church further stigmatized acquisitiveness as a vice akin to avarice, one of the seven deadly sins, equating unchecked accumulation with spiritual corruption that prioritized material over communal or divine obligations.^[56] Medieval European literature continued this negative framing, with Dante Alighieri's Inferno (c. 1320) placing hoarders alongside spendthrifts in the fourth circle of Hell, pushing massive weights against each other in eternal futile opposition to symbolize the imbalance of excess retention versus waste.^[57] By the late Middle Ages and into the Renaissance, hoarding emerged as a recurring character trait in literary works across Europe, spanning over 700 years, often to intrigue readers with depictions of eccentric isolation or moral decay rather than as isolated pathologies.^[57] These portrayals typically emphasized hoarding's social costs, such as family estrangement or community revulsion, without attributing it to underlying psychological mechanisms, reflecting cultural norms that valued moderation and circulation of goods.^[57] In the 18th and 19th centuries, early recognitions of compulsive collecting behaviors surfaced in discussions of bibliomania, a fashionable affliction among elites involving obsessive book accumulation that impaired living spaces and relationships, as documented in medical and literary accounts like those by Jean-Baptiste-Joseph Boulliot in 1839.^[58] Cultural attitudes remained largely condemnatory, viewing such habits as deviations from rational thrift, though wartime contexts occasionally reframed hoarding as pragmatic survivalism amid scarcity, as seen in responses to events like the Great Depression where older individuals stockpiled goods from lived memories of deprivation.^[59] Overall, pre-modern views privileged communal utility over individual retention, interpreting extreme hoarding as a moral failing disruptive to social harmony rather than a distinct behavioral syndrome.^[56]

Emergence as a Clinical Disorder

Scientific research on hoarding as a distinct clinical entity gained momentum in the early 1990s, marking a shift from its prior classification as a symptom primarily associated with obsessive-compulsive disorder (OCD) or other conditions like schizophrenia. Prior to this, hoarding was noted in case studies but lacked systematic investigation, often viewed through the lens of OCD criteria in diagnostic manuals such as DSM-IV, where it appeared as a potential feature without dedicated diagnostic status.^[60] ^[25] Empirical studies from 1993 onward, including those by researchers like Randy Frost and Gail Steketee, began quantifying hoarding behaviors through validated scales such as the Saving Inventory-Revised, revealing patterns of excessive acquisition, difficulty discarding, and resultant clutter that impaired functioning independently of OCD obsessions or compulsions.^[61] These efforts established hoarding's prevalence at approximately 2-6% in community samples, far exceeding what could be attributed solely to OCD comorbidity.^[25] Key distinctions emerged from neurocognitive and treatment response data, prompting reevaluation. Unlike OCD, where hoarding responds modestly to exposure and response prevention therapy and selective serotonin reuptake inhibitors (SSRIs), hoarding showed resistance to these interventions, with neuroimaging indicating divergent frontal-striatal circuit involvement and deficits in decision-making and categorization not central to classic OCD.^[62] By 1996, hoarding was conceptually framed as a failure to discard possessions despite recognizing their lack of utility, supported by longitudinal data showing chronic courses starting in adolescence (mean onset 15-19 years) and familial aggregation patterns distinct from OCD.^[63] ^[1] This body of evidence, accumulated through cross-sectional and prospective studies, underscored causal mechanisms like information-processing biases and emotional attachment to objects, rather than purely anxiety-driven rituals.^[17] The culmination of this research trajectory occurred in 2010 when the DSM-5 Obsessive-Compulsive and Related Disorders Work Group formally proposed hoarding disorder (HD) as a standalone diagnosis, based on field trials demonstrating its reliability (kappa >0.60) and validity across cultures.^[64] Published in May 2013, DSM-5 classified HD in the obsessive-compulsive and related disorders chapter, requiring persistent difficulty discarding possessions leading to clutter, distress, or impairment, excluding cases better explained by other medical or psychiatric conditions.^[65] This recognition addressed prior diagnostic overshadowing, where up to 20-30% of OCD cases involved hoarding but represented only a fraction of overall HD prevalence, enabling targeted interventions like cognitive-behavioral therapy adapted for acquisition control and sorting skills.^[60] Post-2013 studies validated the criteria, confirming HD's heritability estimates around 50% and associations with early life stress, further solidifying its status as a discrete disorder rather than a mere variant.^[66]

Broader Contexts and Representations

Economic Hoarding

Economic hoarding denotes the strategic accumulation and withholding of commodities, currency, or other assets from market circulation, often by speculators or firms, to capitalize on expected future price appreciation or to buffer against uncertainty. This practice contrasts with pathological hoarding by prioritizing profit motives or risk aversion over emotional attachments to possessions.^[67]^[68] In commodity markets, hoarding manifests as bulk purchases of storable goods such as grains, metals, or oil, followed by storage to induce scarcity and elevate prices upon resale. For instance, speculators may warehouse agricultural products during harvest seasons, delaying sales until demand outstrips visible supply, thereby amplifying volatility.^[67] Such actions can distort price signals, deterring new production and prolonging shortages, though proponents argue they incentivize supply chain resilience by anticipating genuine disruptions.^[69] Consumer-level economic hoarding surges during crises, driven by rational fears of supply interruptions rather than irrational panic. During the COVID-19 outbreak in early 2020, households in multiple countries stockpiled essentials like toilet paper and canned goods, as initial supply chain halts from factory closures and logistics breakdowns fueled expectations of prolonged scarcity. This behavior, observed globally, temporarily reduced availability for others and prompted retailer purchase limits, yet it also reflected adaptive responses to verifiable risks like border closures and labor shortages.^[70]^[71] Financial institutions exhibit hoarding through liquidity retention, as evidenced in the 2008 global crisis when U.S. banks amassed excess reserves amid counterparty distrust and funding uncertainties. Federal Reserve data indicate that hoarding banks experienced deposit outflows exceeding 10% in late 2008, contrasting with non-hoarders, while overall interbank lending contracted sharply, impeding credit flows and economic recovery.^[72]^[73] Corporations have increasingly hoarded cash reserves since the early 2000s, with non-financial U.S. firms holding over $2 trillion offshore by 2016, motivated by precautionary needs amid regulatory changes, geopolitical tensions, and volatile earnings. This trend, peaking post-Great Recession, correlates with subdued investment despite low interest rates, potentially signaling inefficient capital allocation but also prudent hedging against downturns.^[74] Historically, governments have criminalized hoarding of essentials to curb perceived profiteering, as in the U.S. during the 1930s Great Depression when President Hoover's 1932 anti-hoarding campaign targeted cash withdrawals amid deflationary spirals. Similar prohibitions appeared in wartime economies, such as Greece under Axis occupation in 1941, where hoarding of food amid invasion-induced inflation exacerbated black markets.^[75]^[76] These measures often aimed to stabilize prices but risked suppressing legitimate saving, illustrating tensions between individual incentives and collective stability.^[69]

Cultural and Literary Depictions

Hoarding behaviors have appeared in European literature for over seven centuries, frequently portrayed as a defining character trait linked to eccentricity, greed, or social isolation rather than a clinical disorder.^[57] In Charles Dickens' Bleak House (1853), the rag-and-bone dealer Krook exemplifies this, amassing worthless documents and objects in a chaotic accumulation that satirizes bureaucratic stagnation and ultimately leads to his spontaneous combustion—a dramatic metaphor for the dangers of unchecked possession.^[57] Earlier works, such as medieval texts, often conflated hoarding with miserliness, embedding it in moral tales where accumulators faced divine or narrative retribution for avarice.^[56] In classical mythology and antiquity, hoarding evoked images of dragons guarding treasure or misers burying wealth, reflecting cultural disdain for withholding resources from circulation, a view reinforced by early Christian doctrine condemning acquisitiveness as sinful.^[56] These depictions emphasized economic and moral failings over psychological compulsion, distinguishing them from modern understandings of hoarding as a disorder involving distress from discarding items regardless of value. By the 20th century, literary explorations shifted toward psychological depth; for instance, Randy O. Frost and Gail Steketee's Stuff: Compulsive Hoarding and the Meaning of Things (2010) draws on case studies to frame hoarding as an attachment to objects symbolizing security or loss, influencing subsequent narratives.^[77] Popular media in the late 20th and early 21st centuries amplified hoarding as spectacle, with reality television programs like A&E's Hoarders, which debuted on August 17, 2009, presenting extreme cases of cluttered homes and interventions by professionals.^[78] Similarly, TLC's Hoarding: Buried Alive (2010–2014) focused on family dynamics and cleanup processes, drawing millions of viewers but often prioritizing shock value through rapid camera pans and dramatic confrontations.^[78] Experimental research shows such portrayals heighten stigma, with viewers rating hoarding more negatively after exposure to Hoarders clips compared to neutral or clutter-focused shows like Clean House.^[79] ^[80] Cultural representations occasionally frame hoarding as adaptive thrift or resistance to consumerism, particularly in resource-scarce contexts, where retaining items counters perceived waste—though clinical analyses distinguish this from disorder when accumulation impairs functioning.^[81] Iconic cases like the Collyer brothers, whose 1947 Manhattan home was found buried under tons of debris including newspapers and booby traps, inspired media sensationalism and later influenced shows blending horror with pathology.^[75] Overall, these depictions evolved from literary moralism to televisual interventionism, yet studies critique them for reducing complex behaviors to deviance without addressing underlying causal factors like trauma or neurobiology.^[82]

Controversies and Critiques

Overpathologization of Saving Behaviors

Critics of hoarding disorder diagnosis argue that its criteria risk overpathologizing normative saving behaviors, particularly those rooted in adaptive responses to uncertainty or scarcity, by emphasizing distress and clutter without sufficient regard for contextual functionality. For instance, behaviors like stockpiling essentials during economic hardship or personal loss—common in historical events such as the Great Depression—mirror hoarding symptoms but served survival purposes without inherent pathology.^[83] This perspective highlights how modern diagnostic frameworks, centered on impairment, may conflate rational thrift with disorder when saving does not escalate to extreme disorganization or self-neglect.^[83] Sociological analyses further contend that socioeconomic and environmental factors, such as poverty or housing instability, drive saving urges that are misframed as isolated psychiatric issues, leading to unnecessary medicalization. In such views, hoarding emerges not solely from cognitive deficits but from broader causal chains involving resource deprivation, where accumulated items represent security against future want rather than irrational attachment.^[84] Proponents of alternative socio-criminological approaches suggest reorienting interventions toward societal supports, like economic aid, to address root causes without pathologizing coping strategies that lack severe consequences.^[84] Cross-cultural evidence underscores these concerns, as saving practices vary by societal norms; in contexts like certain East Asian communities, retaining possessions for potential utility or familial duty is culturally endorsed, potentially inflating disorder rates under Western-biased criteria that prioritize minimalism and disposal.^[85] Studies differentiating hoarding from collecting note that the former involves distress and clutter, yet the subjective threshold for impairment invites diagnostic overreach, especially for eccentric or organized accumulators whose behaviors impose no external harm.^[86] Empirical data on prevalence, estimated at 2-6% globally, may thus reflect cultural lenses more than universal pathology, urging caution in applying uniform standards.^[9]

Evolutionary and Adaptive Perspectives

Hoarding behaviors, including food caching and resource storage, are observed across diverse animal species and confer adaptive advantages by mitigating risks of scarcity and environmental unpredictability. For example, Clark's nutcrackers cache up to 30,000 pine seeds per autumn, utilizing advanced spatial memory to recover them during winter, which enhances survival rates in seasonal environments.^[87] Similarly, squirrels employ scatter-hoarding strategies, burying nuts in dispersed locations, with studies showing they retrieve approximately 80% of caches through olfactory and memory cues, thereby buffering against food shortages.^[88] These patterns align with evolutionary bet-hedging theory, where populations evolve mixed strategies—some individuals hoard minimally while others store excess—to optimize long-term reproduction amid idiosyncratic risks like predation and environmental fluctuations such as variable winter severity.^[89] In human evolution, analogous hoarding tendencies likely emerged as fitness-enhancing traits in ancestral environments characterized by intermittent resource availability, such as during glacial periods or migratory hunter-gatherer lifestyles. Archaeological evidence and ethnographic studies of traditional societies indicate practices like drying meat or storing roots in cellars to endure prolonged winters or famines, which parallels animal caching and reduced mortality from starvation.^[90] Evolutionary models suggest that in communitarian groups facing correlated risks, the persistence of high-hoarding phenotypes—despite individual costs in stable times—stabilizes population-level wealth distribution and survival, as excess stores by some members sustain the group during rare but severe scarcities.^[89] Natural selection would favor genetic or behavioral predispositions toward acquisition and retention when resources were unevenly distributed, fostering cognitive biases toward overestimation of future needs.^[88] Contemporary hoarding disorder, however, represents a potential mismatch between these ancestral adaptations and modern abundance, where persistent difficulty discarding items—irrespective of actual utility—leads to functional impairment rather than benefit. While normal hoarding activates during perceived shortages (e.g., economic downturns or pandemics) to secure safety, pathological forms involve emotional attachments to possessions, often linked to neurocognitive deficits in decision-making regions like the frontal and temporal lobes, decoupling the behavior from survival utility.^[90] Theoretical perspectives posit that extreme hoarding may arise from exaggerated expressions of adaptive traits, selected in high-risk Paleolithic contexts but maladaptive in resource-rich settings, though empirical genetic evidence remains limited and does not conclusively link it to direct evolutionary pressures over cultural or developmental factors.^[89]

Societal and Policy Implications

Compulsive hoarding imposes significant societal costs, including heightened risks of fires, pest infestations, and public health threats that extend beyond the individual to neighbors and communities.^[11] In the United States, eviction and cleanup expenses for hoarding cases have ranged from $2,000 to nearly $100,000 per incident, as documented by the San Francisco Task Force on Compulsive Hoarding, often burdening landlords, local governments, or families.^[91] Professional cleanup services for moderate cases typically cost between $3,000 and $10,000, with severe instances exceeding $25,000, reflecting the labor-intensive removal of hazardous materials and biohazards.^[92] Hoarding disorder affects approximately 2.5% of the population and contributes to broader social isolation, familial conflict, and occupational impairment, straining social services and mental health resources.^[25] Family members experience impaired emotional and physical functioning, with relatives reporting heightened stress and enabling behaviors that perpetuate the disorder.^[93] These externalities justify policy interventions, yet treatments like cognitive-behavioral therapy show only moderate efficacy, with relapse common, underscoring the need for sustained, multi-faceted approaches.^[25] Policy responses have evolved toward integrated, community-based strategies, including task forces in jurisdictions like Fairfax County, Virginia, which emphasize public education, inter-agency coordination, and voluntary compliance to address physical, emotional, and safety dimensions without immediate eviction.^[94] Under the U.S. Fair Housing Act, hoarding qualifies as a protected disability, requiring reasonable accommodations before eviction, which complicates enforcement but promotes treatment over punitive measures.^[95] Critics argue that such policies risk overpathologizing adaptive saving behaviors, potentially eroding personal autonomy in resource management, especially in contexts of economic uncertainty where stockpiling serves precautionary functions.^[96] Effective policies must balance individual rights with communal safety, prioritizing evidence-based interventions over coercive cleanups that fail to address underlying cognitive disorganization.^[97] In economic contexts, hoarding of commodities can exacerbate shortages and inflation during crises, prompting anti-hoarding regulations, such as those implemented during the COVID-19 pandemic to curb panic buying and ensure equitable distribution.^[67] However, distinguishing pathological hoarding from rational stockpiling remains challenging, with policies risking unintended incentives for black markets or reduced supply-chain efficiency if overly restrictive.^[98] Overall, societal implications highlight the tension between personal liberty and collective welfare, necessitating policies grounded in empirical assessments of risk rather than stigma-driven responses.^[79]

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This paper seeks to examine the similarities and differences between animal hoarding and compulsive object hoarding, and to inform decisions about its ...
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Is it Hoarding Disorder, Clutter, Collecting, or Squalor?
HD is different from collecting in that collecting is organized and systematic, even though some collectors may have a similar amount of possessions as someone ...
[15]
12 Ways That Hoarders Differ From Collectors | Psychology Today
Sep 27, 2022 · 1. Selectivity: Collectors were focused on particular types of objects, whereas hoarders indiscriminately collected things.
[16]
Hoarding: Obsessive Symptom or Syndrome? - PMC - NIH
Hoarding has long been an associated symptom of OCD and is encountered in 18 to 33 percent of such patients. In a large sample of hoarders with comorbid OCD (N= ...
[17]
Hoarding Disorder: More than just a problem of too much stuff - NIH
Compulsive or problematic hoarding behaviors occur in a variety of neuropsychiatric disorders, including obsessive compulsive disorder (OCD), schizophrenia, ...Missing: empirical | Show results with:empirical
[18]
Information processing in hoarding disorder: A systematic review of ...
Information processing difficulties are said to play a role in maintaining hoarding. There is consistent evidence for deficits in sustained attention and ...
[19]
Hoarding symptoms are associated with higher rates of disability ...
Oct 15, 2022 · Hoarding symptoms are associated with profound disability in all domains of functioning. The burden of hoarding is comparable to that of other medical and ...
[20]
Quality of Life and Functional Impairment in Compulsive Hoarding
Compulsive hoarders were older and had lower global functioning than non-hoarding OCD patients. Both groups had low overall QOL scores across multiple domains.
[21]
Prevalence and Heritability of Compulsive Hoarding: A Twin Study
Oct 1, 2009 · A Heritable Disorder. The results of the twin analyses suggest that genetic factors account for approximately 50% of the variance in compulsive ...
[22]
Meta-analysis of genome-wide association studies of hoarding ...
Nov 15, 2022 · Cross-trait PRS analyses showed that the genetic risk for schizophrenia and autism spectrum disorder were significantly associated with hoarding ...
[23]
Neurobiology and treatment of compulsive hoarding - PubMed - NIH
Neuroimaging and neuropsychological studies indicate that compulsive hoarding is neurobiologically distinct from OCD and implicate dysfunction of the anterior ...
[24]
Hoarding Disorder: MRI Evidence for Emotional Dysregulation
Apr 4, 2025 · Observed brain changes illuminate a link between emotional attachment and decision-making deficits in people with hoarding disorder.
[25]
Treating people with hoarding disorder
Apr 1, 2020 · Hoarding disorder is marked by three characteristics: difficulty discarding objects, disorganization/clutter, and, in some cases, compulsive ...
[26]
How is hoarding related to trauma? A detailed examination on ...
Trauma exposure was associated with stronger hoarding related beliefs, especially emotional attachment to possessions.
[27]
A narrative synthesis of possible causes and risk factors of hoarding ...
Although research has suggested genetic, neurological, psychosocial and emotional factors as possible broad causal factors for hoarding disorder, the cause of ...
[28]
Diagnosing Hoarding Disorder
Diagnosing Hoarding Disorder · Persistent difficulty discarding or parting with possessions, regardless of their actual value. · This difficulty is due to a ...
[29]
Hoarding, Housing, and DSM-5
Dec 1, 2015 · Documenting the diagnosis of hoarding disorder may be difficult, because of hoarders' lack of self-awareness and reluctance to seek help. In ...
[30]
Hoarding disorder in adults: Epidemiology, clinical features ...
Aug 29, 2025 · A prior epidemiologic study including 1698 adults in England found a prevalence of 1.5 percent [8].
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Cognitive behavioral therapy for hoarding disorder: a meta-analysis
Cognitive behavioral therapy for hoarding disorder: a meta-analysis. Depress Anxiety. 2015 Mar;32(3):158-66. doi: 10.1002/da.22327. Epub 2015 Jan 14. Authors.
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A cognitive-behavioral model of compulsive hoarding - PubMed
The purpose of such a model is to provide a framework for the development and testing of hypotheses about compulsive hoarding. In this model hoarding is ...Missing: Steketee | Show results with:Steketee
[33]
COGNITIVE BEHAVIOR THERAPY FOR HOARDING DISORDER ...
Nov 26, 2013 · A cognitive‐behavioral model of hoarding posits deficits in information processing, maladaptive beliefs about and attachments to possessions ...<|separator|>
[34]
Treatment of HD - Cognitive Behavioral Therapy (CBT) - Hoarding
Cognitive behavioral therapy (CBT) is designed for use by mental health clinicians who are treating clients with hoarding disorder (HD).
[35]
An Open Trial of Cognitive-Behavioral Therapy for Compulsive ...
Treatment was based on a cognitive-behavioral therapy manual for compulsive hoarding (Steketee & Frost, 2007). Office sessions typically lasted 1–1.5 hrs ...
[36]
Efficacy and mediators of a group cognitive-behavioral therapy for ...
Results: CBT was efficacious for the symptoms of HD compared with wait list. Saving-related cognitions, but not subjective cognitive impairment, partially ...
[37]
Cognitive behavioral therapy for hoarding disorder - PubMed
Jul 1, 2021 · Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis. J Affect Disord. 2021 Jul 1:290:128-135. doi: 10.1016/j.jad ...
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Changes in neural activity following a randomized trial of cognitive ...
Objective: Cognitive behavioral therapy (CBT) is efficacious for hoarding disorder (HD), though results are modest. HD patients show an increase in activity ...
[39]
Study protocol for a randomized controlled trial of in-home ...
Jul 29, 2023 · Cognitive behavioral therapy for hoarding disorder: an updated meta-analysis. J Affect Disord. 2021;290:128–35. Article PubMed Google Scholar.
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Cognitive Behavioral Therapy For Hoarding Disorder: A Meta-Analysis
Nov 5, 2021 · Cognitive Behavioral Therapy For Hoarding Disorder: A Meta-Analysis ... Review and Network Meta-analysis. Previous · NEXT ARTICLE. Family and ...
[41]
Hoarding disorder - Diagnosis and treatment - Mayo Clinic
Jan 26, 2023 · There are currently no medicines approved by the Food and Drug Administration (FDA) to treat hoarding disorder. Medicines are used to treat ...
[42]
Pharmacotherapy of compulsive hoarding - PubMed
SRIs appear to be as effective for compulsive hoarders as for nonhoarding OCD patients. A case is presented of a compulsive hoarding patient who responded well ...
[43]
Treatment of HD - Medication - IOCDF Hoarding
Treatment of HD – Medication. Research on medications for hoarding disorder (HD) has focused on serotonin reuptake inhibitors (SRI) because they have proven ...
[44]
Atomoxetine for hoarding disorder: A pre-clinical and clinical ...
These trials investigated the effectiveness of paroxetine and venlafaxine in HD patients and found a mean symptoms reduction of 31% and 36% respectively (Saxena ...
[45]
Venlafaxine Extended-Release Treatment of Hoarding Disorder - NIH
The results of this open trial suggest that venlafaxine extended-release may be quite effective for treatment of Hoarding Disorder, with a large effect size, ...
[46]
Hoarding Disorder: Models, Interventions, and Efficacy | Focus
Apr 15, 2015 · Key features of hoarding include difficulty discarding or parting with possessions due to strong urges to save the items.<|separator|>
[47]
Pharmacotherapy for Hoarding Disorder: How did the Picture ... - NIH
Regretfully, there are currently no future studies aiming at seriously testing drugs in HD. Keywords: Hoarding disorder, obsessive-compulsive disorder, drug ...
[48]
Vortioxetine for the Treatment of Hoarding Disorder | ClinicalTrials.gov
Vortioxetine is a novel serotonergic antidepressant with a unique pharmacodynamics profile, reported precognitive effects and proven efficacy for the treatment ...
[49]
Psychosocial interventions for hoarding disorder: a systematic review
Dec 4, 2024 · These psychosocial interventions show improvements in those with HD, with effect sizes ranging from d=0.86 to d=1.41.
[50]
Decluttering Minds: Psychological interventions for hoarding disorder
This study confirms psychological therapies are effective in reducing hoarding symptoms, while indicating no superiority for CBT.Missing: adjunctive | Show results with:adjunctive
[51]
Hoarding disorder: 'sensory CBT' treatment strategy shows promise
Oct 3, 2024 · Rehearsing alternative outcomes of discarding through imagery rescripting shows promise as a treatment strategy for people who hoard.
[52]
Brain changes linked to improvements during hoarding disorder ...
Dec 2, 2024 · Researchers found that adults undergoing group CBT showed increased brain activity in regions associated with decision-making and emotional ...
[53]
A critical review of cognitive behavioural therapy for hoarding ...
Aug 19, 2021 · When treated as its own disorder using cognitive behavioural therapy, individuals report approximately 25% improvement in symptoms on average.
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State of the Science: Hoarding Disorder and Its Treatment
This state-of-the-science review describes the relatively new diagnosis of hoarding disorder (HD), characterized by difficulty discarding possessions and ...
[55]
Treasure Hoards in Ancient Literature - World History Encyclopedia
Dec 13, 2021 · Hoards and hoarders are to be found outside comedy as well. They appear in the New Testament as parables. In one instance, a servant is ...
[56]
Hoarding in History - Oxford Academic
Hoarding became enshrined in mythology, and in classical times, hoarders were viewed as misers. The early Catholic Church labeled acquisitiveness as sinful.
[57]
Historical Portrayal of Hoarding Disorder in European Literature and ...
Nov 2, 2022 · Hoarding was regularly featured as a character trait in numerous European literary works dating back over 700 years.
[58]
Jon Day · Diary: Hoardiculture - London Review of Books
Sep 8, 2022 · The first recognition of something like hoarding disorder was bibliomania, a fashionable disease in the 18th and 19th centuries. As cheap ...<|control11|><|separator|>
[59]
History and Hoarding: Compulsive Consumption Through the Ages
She writes: “The most obvious reason for hoarding is a need for security. Anyone over age 60 remembers the Great Depression and World War II, and may be wary of ...
[60]
Chapter 1. Introduction and History | Psychiatry Online
Dec 5, 2024 · At its core, hoarding is about ownership of objects. But what does it mean to “own” something? This question has interested philosophers for centuries.
[61]
Phenomenology and Epidemiology of Hoarding Disorder
Aug 16, 2023 · In perhaps the first recognition of hoarding as a psychiatric disorder, Russian psychiatry labeled the behavior Plyushkin syndrome. In the ...
[62]
Hoarding behaviour: building up the 'R factor' | Cambridge Core
Jan 2, 2018 · Compulsive hoarders appear to have a different pattern of neurocognitive deficits than non-hoarding people with OCD, and their passive ...
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Hoarding Disorder: A Case Report - PMC - NIH
Jun 28, 2017 · The concept of hoarding was defined in 1996 as a behavioral phenomenon of acquisition of objects and failure to discard objects (1). Compulsive ...
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Hoarding disorder has finally arrived, but many challenges lie ahead
In 2010, the DSM‐5 Obsessive‐Compulsive and Related Disorders Sub‐Workgroup recommended the inclusion of hoarding disorder as a new mental disorder in the ...
[65]
[PDF] Hoarding Officially Recognized as Mental Disorder in May 2013
Hoarding is one of 11 disorders newly classified in fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the first updated ...
[66]
Early life stress in adults with hoarding disorder: A mixed methods ...
This study explores early life stress and hoarding disorder using quantitative and qualitative methods. Findings build on the cognitive behavioral model of ...
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Hoarding: Definition, How It Works with Commodities, and Examples
Hoarding is the purchase and warehousing of large quantities of a commodity by a speculator with the intent of benefiting from future price increases.
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Hoarding - Definition, How It Works, Historical Example
Hoarding is the practice of holding or piling up of assets, namely money, goods, or securities. Preparation for future events causes individuals or companies ...Missing: economic | Show results with:economic
[69]
[PDF] The Law and Economics of Hoarding
Many governments have condemned the practice of "hoard- ing"--particularly when it comes to "essential" commodities like food. Anti-hoarding laws have been ...
[70]
A discussion of irrational stockpiling behaviour during crisis - PMC
Irrational stockpiling, hoarding or panic buying behaviour has been widely reported during major natural disasters and humanitarian crisis all over the world.
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Stephanie Preston: Hoarding is not a strange behavior during times ...
Mar 26, 2020 · Stephanie Preston: Hoarding is not a strange behavior during times of crisis ... The COVID-19 pandemic has rampantly heightened stress and anxiety ...
[72]
[PDF] Bank Liquidity Hoarding and the Financial Crisis
However, as the crisis deepened during the fall of 2008, liquidity hoarders saw a sharp contraction in their core deposits, whereas non- hoarding banks ...
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Uncertainty, Liquidity Hoarding, and Financial Crises
May 6, 2013 · While hoarding can be a rational response of banks to increased future uncertainty, it can also be a very costly form of self-insurance ...
[74]
Why Are Corporations Hoarding Trillions? - The New York Times
Jan 20, 2016 · This strange vogue for corporate hoarding seems to have begun around the turn of the millennium. General Motors is perhaps the most extreme ...
[75]
The Evolution of Hoarding · History and Hoarding
Since the twentieth century, both the behaviours and academic conceptions of hoarding have evolved dramatically.
[76]
5 of the Worst Cases of Hyperinflation in History
Oct 27, 2021 · Germany invaded Greece in 1941, causing prices to shoot up as people began to hoard food and other commodities, fearing shortages or not being ...<|control11|><|separator|>
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Jenny Davidson Chooses the Best Books on Hoarding!
Jun 26, 2014 · A list of five of my favorite books about hoarding: Randy G. Frost and Gail Steketee, Stuff: Compulsive Hoarding and the Meaning of Things.
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Introduction to Hoardiculture | Stanford Humanities Center
Economic theories of hoarding focus on those who accumulate bullion, money, or ... hoarding in clinical psychology are of no direct economic consequence ...Missing: distinction | Show results with:distinction
[79]
Understanding stigma in hoarding disorder: A systematic review
The literature suggests that a significant proportion of people who hoard and their families experience stigma, and HD is stigmatised by the public.
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Experimental investigation of the impact of hoarding depictions in ...
Stigma of hoarding disorder was experimentally investigated. · Stigma ratings increased after viewing a popular HD-related television show. · Certain media ...
[81]
Cultural Perspectives on Hoarding: Necessity or Disorder?
Dec 9, 2024 · For hoarders, discarding such items may feel like losing a part of themselves. Resistance to Waste. Some individuals view hoarding as an ethical ...
[82]
The Disorder of Things: Hoarding Narratives in Popular Media - jstor
Rapid jump cuts are common in interviews with the hoarder. Cameras will zoom in and pan away often. Sometimes the at- titude is heightened by invoking the ...
[83]
Hoarding Instincts - Real Life Mag
therefore, despite ...
[84]
Hoarding Disorder: A Sociological Perspective - MDPI
May 11, 2023 · A more recent meta-analysis revealed that the prevalence of the disorder falls within the range of 1.5% to 6% [8].
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An exploratory study on the lived experiences of hoarding in ... - NIH
It has been suggested that the nature of beliefs which drive hoarding behaviour may have more to do with saving the things rather than difficulties discarding ...
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Hoarding versus collecting: Where does pathology diverge from play?
This review highlights the similarities and differences between hoarding and collecting and offers suggestions for further research in this group.
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We Come by Hoarding Naturally | Psychology Today
Jul 5, 2025 · Hoarding has evolved as a survival strategy, shaped by the pressures of natural selection. From birds and rodents to insects and even marine creatures.
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Your brain evolved to hoard supplies and shame others for doing ...
Mar 27, 2020 · Hoarding is actually a totally normal and adaptive behavior that kicks in any time there is an uneven supply of resources.
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On the evolution of hoarding, risk-taking, and wealth distribution in ...
This paper applies the theory of the evolution of risk-taking in the presence of idiosyncratic and environmental risks to the example of food hoarding by ...
[90]
Does Hoarding Have Evolutionary Roots? | Psychology Today
Aug 12, 2022 · In the DSM-5, hoarding is a separate diagnosis from obsessive-compulsive disorder, although hoarders may also have obsessive or compulsive ...
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[PDF] The Consequences of Clutter - Senate Committee On Aging
“The Economic and Social Burden of Compulsive Hoarding,” Psychiatry Research ... hoarding and accessing mental health and medical health treatment.
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How Much Does Hoarding Cleanup Cost? (What to ... - PuroClean
The average hoarding cleanup cost ranges between $3,000 and $10,000 for moderate cases. Extreme hoarding cases may cost up to $25,000 or more. Factors That ...
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The Impact of Hoarding Disorder on Family Members ... - NIH
Sep 24, 2023 · Altogether, hoarding disorder can impair the social, physical, and emotional functioning of not only the hoarders but also their relatives. Our ...
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Fairfax County's Hoarding Strategies: A Governmental Approach
Increase public awareness of hoarding and its dangers through outreach and education. Ensure an integrated approach to the complex physical, emotional, and ...
[95]
Hoarding Disorder: Situations and Solutions for Property Managers
Nov 29, 2022 · Hoarding disorder is a protected disability under the Fair Housing Act. There are five levels of hoarding, ranging from Level 1: Small, ...
[96]
The Economics of Hoarding - Oxford Academic
In addition, hoarding causes serious social and emotional burdens, as individuals with hoarding disorder struggle to prevent people from entering their home and ...Introduction · Examining Hoarding Through... · Neural Evidence That...
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Implementation and evaluation of a community-based treatment for ...
The objective of this paper was to examine the implementation and effectiveness of a community-based intervention for hoarding disorder (HD)
[98]
The economic and moral case against hoarding - Acton Institute
Jun 23, 2020 · Less hoarding will allow everyone to adjust to the new world we live in without unnecessarily exacerbating the disruption of necessities. It ...Missing: implications | Show results with:implications