Diagnosis of hoarding

Oct 23, 2018

Compulsive hoarding is a progressive disease. Diagnosis, like in other mental health conditions, is not straightforward.

There are people who hoard but are not compulsive hoarders. These individuals need to be identified when diagnosing the condition.

However, these hoarders over years and after a traumatic life event like a bereavement of depressive episode may turn into compulsive hoarders. (1)

Hoarders often do not realise they have a problem

Most people with compulsive hoarding do not realise they have a problem and seldom seek help.

It may be only family and friends who report with the problem.

Compulsive hoarders often do not understand that by refusing to part with their possessions they are hindering their own life.

There may also be other psychiatric conditions with hoarding like:

Major depression
General anxiety disorder
Social phobia
Post-traumatic stress disorder (PTSD)
Attention Deficit Hyperactivity Disorder (ADHD)
Grooming disorders (Trichotillomania or tearing off one’s own hair, skin picking, nail biting)
Dementia. (1)

This additionally makes diagnosing and treating compulsive hoarders a challenge.

Hoarding in its compulsive form is being considered for inclusion in DSM V as a distinct disorder called “Hoarding Disorder”.

The DSM is the Diagnostic and Statistical Manual of Mental disorders.

The current version is the fourth and the fifth version is expected in a year.

Earlier compulsive hoarding was a part of obsessive compulsive disorders or OCD. (2)

Diagnosis should begin with a thorough assessment of patients' history and clinical presentation. (3)

Thus diagnosing compulsive hoarding involves certain diagnostic criteria in DSM V. These are proposed include (2) –

Continued difficulty in discarding or parting with personal possessions even those which are useless. This is due to strong urges to save items and distress and indecision associated with getting rid of stuff.
The symptoms result in collection of large number of possessions that fill up and encroach on living space.
There may be clinically significant distress and impairment of social, occupational, or other important areas of daily living.
The hoarding is not explained by other conditions like stroke or brain injury.
Hoarding not restricted to the symptoms of other mental ailments like OCD, depressive illness, schizophrenia, dementia, autism etc.
In addition there may be excessive acquisition by buying, stealing or scavenging, lack of awareness that there is a problem or a delusion that the behavior is not worrisome.

Assessment includes (3) –

Looking at the amount of clutter
Assessment of beliefs about possessions
Assessment of information processing, decision making and categorizing difficulties among sufferers
Avoidance behavior assessment - compulsive hoarders may avoid routine tasks such as checking mail, returning calls, or washing dishes or social obligations like paying bills, rent, and taxes
Assessment of daily functioning like sleep wake cycles, daily routines etc.
Assessment of regular and daily intake of medications and willingness to adhere to regular therapy
Assessment of work place and social functioning and interactions
Assessment for other mental ailments like depression, anxiety and specific phobias

Scales used to assess hoarding include (3, 4) –

Saving Inventory-Revised (SIR) scale – This is a 23-item questionnaire that asks about three features of hoarding that include - excessive acquisition, difficulty discarding, and clutter.
Hoarding Rating Scale (HRS) – This is a 5-item interview that can be given to a suspected sufferer as a questionnaire.
The questions ask about clutter, difficulty discarding, excessive acquisition, distress caused by hoarding and impairment resulting from it.

Studies show that a score of 14 or higher indicates a probable hoarding problem.
Clutter Image Rating (CIR) – In this a series of pictures of rooms in various stages of clutter – from completely clutter-free to very severely cluttered are taken.
The suspected sufferer is asked to pick out the picture in each sequence that resembles their own living room, kitchen, and bedroom the closest.