ADHD Comorbidities & Related Conditions

What Is Hoarding Disorder? Defining Characteristics, Treatments, and ADHD Link

Hoarding disorder develops from vulnerabilities, information-processing problems, and a perceived need to save items regardless of their value. It may co-occur with ADHD but is distinct from ADHD messiness or clutter.

hoarding disorder, too much stuff,
Old antiques and retro collectibles memorabilia dumped in a huge pile. Garage sale, attic room storage conceptual still life or disposal and recycling of outdated objects. Vintage style filtered photo

Telltale signs of ADHD-like indecision, distractibility, and impulsivity may easily give rise to a disorganized home or office. To an untrained eye, ADHD clutter may resemble hoarding disorder. Differentiating these two related but distinct conditions requires a clear understanding of what hoarding disorder is — and what it is not.

What Is Hoarding Disorder?

Hoarding is an accepted psychiatric diagnosis that develops from vulnerabilities, information processing problems, and beliefs about and attachments to possessions.

The American Psychiatric Association first classified hoarding disorder as a subtype of obsessive-compulsive disorder (OCD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, research has revealed that people with hoarding disorder don’t necessarily exhibit classic OCD symptoms. 1

“Early on in the diagnostic manual, the inability to throw away worthless or worn-out items was diagnostic criteria for obsessive-compulsive personality disorder,” says Randy O. Frost, Ph.D., the Harold Edward and Elsa Siipola Israel Professor Emeritus of Psychology at Smith College in Northampton, Massachusetts. “We’ve learned in the research over the last 20 years that this does not characterize hoarding disorder. People with hoarding disorder save things that others may consider worthless. But they also save everything else that comes into their possession. So, it’s not the actual value that has any determining factor in the definition.”

In 2013, the DSM-5 updated the definition of hoarding disorder to an isolated condition in the OCD spectrum. Four primary inclusion criteria define the nature of hoarding disorder.

[Self-Test: Is Your Clutter and Disorganization Out of Control?]

Hoarding Disorder Criterion #1

A persistent difficulty discarding or parting with possessions, regardless of their actual value.

Individuals with hoarding disorder have difficulty not only throwing things away but also getting rid of them by selling them, donating them, or even loaning them to others. Anything that takes it out of the person’s immediate possession is a difficult behavior for them,” says Frost, who is the co-author of Stuff: Compulsive Hoarding and the Meaning of Things; Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding; and Hoarding Disorder: A Comprehensive Clinical Guide.

“This must be a persistent difficulty,” Frost continues. “It’s not something that happens over a short period, such as when people get inundated with things or if a family member passes away, and they inherit many possessions. This behavior must persist over a long time to be considered a hoarding disorder.”

Hoarding Disorder Criterion #2

A persistent difficulty due to a perceived need to save items and distress associated with discarding them.

“This isn’t something that builds up because someone lacks the motivation or energy to work through all their stuff. There’s a reason why the person is saving this item,” Frost says.

[Free Guide: Getting Organized: A Roadmap for Your ADHD Brain]

Hoarding Disorder Criterion #3

The accumulation of possessions clutters active living areas and substantially compromises the intended use of the space.

“If someone has an attic, garage, or closet full of stuff, but the living areas are unaffected, it would not be hoarding disorder,” he says. “It’s only hoarding disorder if the living areas are cluttered so much that it disrupts the ability to use the space for its intended purposes.”

The caveat is that it is hoarding disorder if living areas are uncluttered only because of third-party interventions (other family members, housecleaners, or authorities).

Hoarding Disorder Criterion #4

Hoarding disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

Hoarding disorder can cause relationship problems, safety concerns, and mental health issues for individuals. It may impact an individual’s ability to work, attend school, take care of themselves or others, and function.

An individual cannot receive a hoarding disorder diagnosis if the hoarding behavior is attributable to another medical condition (e.g., brain injury or cerebrovascular disease) or another DSM-5disorder (e.g., OCD, major depression, psychotic disorder, dementia, or autism spectrum disorder).

In addition, once the hoarding disorder diagnosis is made, the clinician must specify if the disorder is accompanied by excessive acquisition and the level of insight. Someone with good or fair insight into their hoarding behavior will recognize that they have a problem and need to do something about it. Someone with absent insight may deny having or fail to see their hoarding behavior as a problem.

Hoarding Disorder and Comorbidities

Hoarding disorder may co-occur with other conditions. A 2011 study published in the journal Depression and Anxiety found high comorbidity rates for major depressive disorder (slightly more than 50%), followed by anxiety disorders (general anxiety disorder and social anxiety disorder), ADHD, OCD, and post-traumatic stress disorder (PTSD). 2

According to the study, more individuals with hoarding disorder have trauma (49.8%) than have OCD (24.4%).

“I have seen anecdotal situations where individuals start to unclutter, which unmasks trauma symptoms. And in some ways, the clutter insulates individuals from those thoughts and feelings. This an interesting dynamic and certainly something that requires further research,” says Carolyn I. Rodriguez, M.D., Ph.D., Professor, and Director of the Translational Therapeutics Lab in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine.

“We had a case of an individual who had hoarded most of her life,” Frost says. “When she was a young adult, she was sexually assaulted in her bedroom. As her treatment progressed, we found that the closer we got to the bedroom, her more her PTSD symptoms showed up. We had to stop the treatment for hoarding and focus more exclusively on the PTSD, and get those symptoms resolved before returning to the hoarding treatment.”

Hoarding and ADHD

Many ADHD symptoms overlap with hoarding disorder symptoms, but they are distinct disorders.

“Some studies have suggested that there may be some shared vulnerability between hoarding disorder and ADHD, and that inattentive ADHD may predict some of the core features of hoarding disorder,” Rodriguez says. “It’s important to have a careful assessment to determine if clutter motivates more hoarding behaviors or if inattention and other features of ADHD do.” 1

Hoarding disorder and ADHD share various executive function deficits, including weak organization, focus and decluttering skills, and cognitive flexibility — or the ability to adapt to changes in the environment. “This would mean inhibiting irrelevant material coming toward you and being able to shift attention between tasks,” Rodriguez says.

The main difference between an ADHD-clutter problem and a hoarding-clutter problem, Frost says, is that someone with hoarding disorder has a reason for saving items. “It’s not just a function of being unable to organize or unable to get your behavior together to get rid of things. There’s an actual reason why the person’s saving it.”

Can Children Have Hoarding Disorder?

Inattentive ADHD in childhood carries the risk of a future hoarding disorder. A 2016 study published in the Journal of Attention Disorders found childhood inattentive ADHD predicts three core features of hoarding disorder: clutter, difficulty discarding items, and excessive acquisition. 3

“At least one study has found that ADHD in children predicts the development of hoarding, but it doesn’t mean that someone with ADHD will invariably develop a hoarding problem,” Frost says.

Further, the study found that childhood hyperactivity alone does not predict hoarding disorder, but it does predict impulsivity, which is associated with excessive acquisitions. 3

Children with hoarding problems may personify and anthropomorphize objects. “Kids frequently will worry about the feelings of objects,” Frost says. “Personifying objects is the basis for much imaginative play that is a normal part of childhood, but in these cases, it’s quite clear that this is excessive.”

Hoarding behaviors in children, such as reacting strongly to others touching and moving objects, abnormal personification, and having little insight into their behaviors, overlap with ADHD characteristics. Frost and Rodriguez, who co-authored the book Hoarding Disorder: A Comprehensive Clinical Guide, say very little research has been conducted on hoarding behaviors in children.

Treatment for People Who Hoard

Currently, no medication is FDA-approved for the treatment of hoarding disorder, however, Rodriguez cites small, open-label trials studying the use of paroxetine, venlafaxine, and psychostimulants for treating hoarding disorder.

Cognitive Behavioral Therapy (CBT)

Before interventions for hoarding behaviors begin, a person must undergo a careful assessment, which will help the clinician and the patient understand how their hoarding behaviors fit together, says Rodriguez, who recommends cognitive behavioral therapy (CBT) as an effective treatment.

“CBT is one of the most evidence-based treatments available for hoarding disorder,” she says.

A 2010 study published in the journal Depression and Anxiety found CBT benefits people with clinically significant hoarding behaviors. In the study, researchers split participants identified with hoarding disorder into two groups. One group joined the waitlist and received no treatment or interventions. The other group received CBT. After 12 weeks, the researchers found that participants who completed 26 sessions of CBT had significant reductions in hoarding symptoms compared to participants on the waitlist. According to clinical improvement ratings, 68% of patients were considered improved, and 76% rated themselves as improved; 41% were clinically significantly improved. 4

“The best strategy is to find a therapist who knows how to treat hoarding disorder,” Frost says. “The International OCD Foundation has a therapist finder function in which you can find therapists with a specific specialty within a designated mile radius of your home.”

Hoarding Disorder: Next Steps

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “What Is Hoarding vs. ADHD Clutter? Defining Characteristics and Strategies to Help”  [Video Replay & Podcast #417],” with Randy O. Frost, Ph.D., and Carolyn I. Rodriguez, M.D., Ph.D., which was broadcast on August 17, 2022.


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Sources:

1Tolin, D. F., & Villavicencio, A. (2011). Inattention, but Not OCD, Predicts the Core Features of Hoarding Disorder. Behaviour Research and Therapy, 49(2), 120–125. doi.org/10.1016/j.brat.2010.12.002

2 Frost, R. O., Steketee, G., & Tolin, D. F. (2011). Comorbidity in Hoarding Disorder. Depression and Anxiety, 28(10), 876–884. doi.org//10.1002/da.20861

3 Hacker L.E., Park J.M., Timpano K.R., Cavitt, M.A., Alvaro, J.L., Lewin, A.B., Murphy, T.K., & Storch, E.A. (2016) Hoarding in Children With ADHD. Journal of Attention Disorders. 2016, 20(7):617-626. doi.org//10.1177/1087054712455845

4 Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., & Brown, T. A. (2010). Waitlist-Controlled Trial of Cognitive Behavior Therapy for Hoarding Disorder. Depression and Anxiety, 27(5), 476–484. doi.org/10.1002/da.20673

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