Core diagnostic features

• Persistent difficulty discarding possessions, regardless of actual value.
• Perceived need to save items and marked distress when discarding is attempted.
• Accumulation causes congestion/clutter that compromises the intended use of living spaces.
• Significant distress or impairment in social, occupational or health/safety domains.

Presentations & subtypes

• Mixed-item hoarding (papers, clothing, containers) — most common.
• Specific hoarding (animals, books, collectibles) and animal hoarding with welfare concerns.
• Hoarding with excessive acquisition vs. difficulty discarding predominating.
• Late-onset or worsening hoarding related to cognitive impairment—screen for dementia.

Associated conditions & risk factors

• Comorbidities: depression, generalized anxiety, social anxiety, ADHD and OCD (distinct mechanisms).
• Risk factors: family history, early life stress, indecision/perfectionism and executive dysfunction (planning, organisation deficits).

Assessment checklist

1. History: onset, course, acquisition behaviours, reasons for saving and prior interventions.
2. Home assessment (with consent): degree of clutter, fire/sanitation risk, blocked exits, and animal welfare.
3. Cognitive screening (MoCA/MMSE) if executive dysfunction or late onset suspected.
4. Assess comorbidity, suicidality, self-neglect and functional impact (work, relationships, daily living).

Differential diagnosis

• OCD with hoarding symptoms (typically ego-dystonic obsessions) vs primary Hoarding Disorder driven by perceived need to save.
• Cultural collecting vs pathological hoarding, neurocognitive disorders (dementia), and psychosis when delusional beliefs present.

Evidence-based treatments

• CBT for Hoarding (CBT-H): decision-making training, organisation, graded exposure to discarding, cognitive restructuring and skills practice — often longer and more structured than standard OCD-CBT.
• Skills training: categorisation, problem-solving, and organisational strategies (individual or group formats).
• Assisted decluttering: therapist/support worker–led in-home sessions to practice discarding with motivational techniques.
• Family interventions: education to reduce enabling and to support gradual change without coercion.

Pharmacologic approach

• No medication is specifically licensed for hoarding disorder. SSRIs may help comorbid depression/anxiety but have modest direct effects on hoarding symptoms.
• Consider pharmacotherapy for comorbid conditions and combine with CBT-H for better outcomes.

When to escalate & red flags

• Immediate escalation: fire risk, severe sanitation, animal hoarding with welfare concerns, imminent eviction or inability to care for self.
• Referral to specialist services for suspected dementia, severe chronic hoarding unresponsive to low-intensity care, or complex comorbidity.

Key takeaways

• Hoarding Disorder causes clinically significant clutter and impairment driven by difficulty discarding and attachment to possessions.
• CBT-H combined with skills training and assisted decluttering is the intervention of choice; pharmacotherapy treats comorbidities.
• Use a harm-reduction, collaborative approach — assess safety early and coordinate multidisciplinary support for sustained improvement.