Earn CE credit.

Visit http://www.prolibraries.com/counseling
to purchase and complete the test online.

Assessment & Diagnosis

Received 11/11/14
Revised 02/16/15
Accepted 02/18/15
DOI: 10.1002/jcad.12064

Hoarding Disorder:
Diagnosis, Assessment, and Treatment
Victoria E. Kress, Nicole A. Stargell, Chelsey A. Zoldan, and
Matthew J. Paylo
Hoarding disorder (HD) is a newly added mental disorder in the most recent version of the Diagnostic and Statistical
Manual of Mental Disorders (American Psychiatric Association, 2013). In this article, the symptoms, characteristics,
and features of HD are described, along with diagnosis and assessment strategies. The most efficacious treatments
for counseling clients diagnosed with HD are also discussed.
Keywords: hoarding disorder, diagnosis, assessment, treatment

Hoarding disorder (HD) is a newly added mental disorder in

the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5; American Psychiatric Association
[APA], 2013). In previous editions of the DSM, hoarding
behaviors were formally recognized only as a symptom of
obsessive-compulsive personality disorder (OCPD; MataixCols et al., 2010). Maintaining its connection with obsessivecompulsive features but creating a unique identity, HD is
currently categorized under the Obsessive-Compulsive and
Related Disorders section of the DSM-5.
Characteristics of HD include the urge to acquire and save
objects, a marked inability to discard objects that may have no
apparent value to others, and restricted functioning as a result
of excessive clutter in daily living spaces (APA, 2013). Those
who have HD do not typically discriminate among the items
collected and acquired, and more than half of all individuals
with HD hoard both inanimate (e.g., newspapers) and animate
(e.g., animals) objects (McGuire, Kaercher, Park, & Storch,
2013; Steketee et al., 2011). Although HD has only recently
been formally recognized as a distinct disorder, compulsive
hoarding behaviors have been formally acknowledged in the
counseling literature for over 2 decades (Frost & Gross, 1993).
HD is estimated to be prevalent in approximately 2% to
6% of the general U.S. population (APA, 2013; Samuels et
al., 2008). However, no national epidemiological studies have
been conducted to confirm the true prevalence of this disorder.
Factors such as embarrassment and a lack of insight related
to the severity of the behaviors may confound prevalence
estimates (Ale, Arnold, Whiteside, & Storch, 2014).
Individuals with HD are often resistant to change, and
symptoms may continue throughout their lifetimes (Grisham,

Frost, Steketee, Kim, & Hood, 2006; Wheaton, Cromer,

LaSalle-Ricci, & Murphy, 2008). Left untreated, the severity of symptoms will likely increase with each decade that
passes (Ayers, Saxena, Golshan, & Wetherell, 2010). HD is
more prevalent in the older adult population (i.e., ages 5594
years; APA, 2013), but some more recent studies have reported
that the initial onset of the disorder often occurs in childhood
and adolescence (APA, 2013; Ayers et al., 2010). Nevertheless, the average age of those seeking treatment for HD is 50
years old (Samuels et al., 2008). This is because symptoms
typically become more clinically significant with age (APA,
2013), and the effects of the hoarding often escalate because
of the acquisition of possessions, which occurs over time
(Ayers et al., 2010).

Diagnosis
As mentioned, the first formal set of diagnostic criteria for
hoarding as a disorder was presented in the DSM-5 (APA,
2013). According to the DSM-5, the disorder is characterized by (a) persistent difficulty discarding items that may
or may not have value, (b) the desire to save items in order
for the individual to avoid negative feelings associated with
discarding items, (c) significant accumulation of possessions
that clutter active living areas, and (d) significant distress or
impairment in areas of functioning. The DSM-5 states that HD
symptoms must not be attributed to a medical condition (e.g.,
traumatic brain injury, dementia) or other mental disorders
(e.g., schizophrenia, autism spectrum disorder).
As with other disorders within the Obsessive-Compulsive
and Related Disorders category of the DSM-5 (APA, 2013),

Victoria E. Kress and Matthew J. Paylo, Department of Counseling, Special Education, and School Psychology, Youngstown State
University; Nicole A. Stargell, Educational Leadership and Development, The University of North Carolina at Pembroke; Chelsey
A. Zoldan, Meridian Community Care, Youngstown, Ohio. Correspondence concerning this article should be addressed to Victoria
E. Kress, Department of Counseling, Special Education, and School Psychology, Youngstown State University, 1 University Plaza,
Youngstown, OH 44555 (e-mail: victoriaekress@gmail.com).
2016 by the American Counseling Association. All rights reserved.

Journal of Counseling & Development January 2016 Volume 94

83

Kress, Stargell, Zoldan, & Paylo

specifiers can be used to describe an individuals level of
insight into his or her hoarding behaviors. These specifiers
include with good or fair insight, with poor insight, and with
absent insight/delusional beliefs. Individuals with HD typically have less insight into their behavior and its consequences
than individuals diagnosed with obsessive-compulsive disorder (OCD; Tolin, Fitch, Frost, & Steketee, 2010); that is,
individuals with HD have greater difficulty recognizing that
their behaviors are problematic.
Counselors can also use the specifier with excessive acquisition to describe presentations of HD that are primarily
associated with the excessive acquisition of items. Excessive
acquisition may be related to unnecessary buying (e.g., purchasing extra items just in case), collecting free items, or
obtaining items through stealing (Frost, Tolin, Steketee, Fitch,
& Selbo-Bruns, 2009). Women were more likely to report
excessive buying, whereas men were more likely to report
collecting free items and stealing (Frost, Steketee, & Tolin,
2011; Frost et al., 2009). HD with excessive acquisition is also
more common in adults than adolescents. This may be due to
the increased control of financial resources and living spaces
that comes with adulthood (Ivanov et al., 2013).
HD often presents early in the life span; one study found
that 80% of participants reported a childhood onset of
symptoms (Grisham et al., 2006). Hoarding behaviors have
been documented in children as well. These behaviors are
often less noticeable and cause less impairment because of
parental involvement in the prevention of clutter buildup in
living spaces (Frost, Ruby, & Shuer, 2012). Presentation of
hoarding in childhood often includes excessive attachment
to inanimate objects (e.g., stuffed animals) and attribution
of human characteristics to such objects; these experiences
must be distinct from age-appropriate behavior and involve
the additional symptoms of HD (Plimpton, Frost, Abbey, &
Dorer, 2009).
Popular items hoarded may include newspapers, coffee
cups, statues, decorations, and collectibles (Frost & Gross,
1993). Although those who hoard may collect items that
appear to have no apparent value to others, the items may
hold significant sentimental value to them. The rationale
for hoarding behaviors also frequently revolves around the
perceived potential usefulness or value of items in the future
(Frost et al., 2012).
Animal hoarding involves the acquisition of a large number of animals and is typically associated with poorer insight
(APA, 2013) and a greater severity of dysfunction (Frost,
Patronek, & Rosenfield, 2011). Individuals who engage in
hoarding behaviors frequently attempt to justify their behaviors by citing emotional attachment to items or, in the case of
animal hoarding, an obligation to care for animals (McGuire
et al., 2013). The expressed obligation to care for animals may
exist in the presence of apparent malnutrition and neglect of
the animals. Individuals who inhabit homes where animal

84

hoarding occurs are at an increased risk for health problems,

because improper waste removal may increase the harmful
bacteria in the home and surrounding environment. Those who
hoard animals may have severely limited insight that prevents
them from seeking veterinary care for sick animals, and even
from removing the bodies of dead animals from their homes.
Individuals who engage in animal hoarding typically limit
their acquisition of animals to one species (e.g., cats; Frost
et al., 2012). At the present time, researchers conceptualize
animal hoarding as a subtype of HD, and it meets the current
diagnostic criteria for HD (Frost et al., 2012). Those with HD
who hoard animals are likely to also hoard objects (Steketee
et al., 2011). McGuire et al. (2013) found that although 47%
of those who hoarded objects did not hoard animals, only 2%
of those who hoarded animals did not hoard objects.
As many as 75% of individuals with HD have comorbid
mental health disorders (APA, 2013). HD frequently is
comorbid with depressive disorders and attention-deficit/
hyperactivity disorder (ADHD; Fullana et al., 2013; Hall,
Tolin, Frost, & Steketee, 2013), as well as anxiety disorders
(Grisham, Brown, Liverant, & Campbell-Sills, 2005; Ivanov
et al., 2013). In relation to ADHD, Fullana et al. (2013) suggested that HD tends to be exclusively associated with inattentive symptoms (rather than hyperactivity), whereas Grisham
et al. (2005) suggested that compulsive hoarding symptoms
are associated with both inattentiveness and hyperactivity.
Storch et al. (2007) suggested that children with HD are more
likely to have poor insight, higher rates of panic symptoms,
and tendencies to externalize problems. Despite the proximity of HD and OCD in the DSM-5 (APA, 2013), low rates of
comorbidity have been found between their diagnoses (Hall
et al., 2013; Ivanov et al., 2013). Comorbidities were also
suggested between autism spectrum disorders and HD; however, Ivanov et al. (2013) reported that whereas stereotypic
behaviors seen in autism spectrum disorders may present as
hoarding, individuals with HD are not more likely to have an
autism spectrum disorder diagnosis.
The clinical features of HD are hypothesized to present
similarly across cultures (APA, 2013). Nevertheless, cultural
factors should be explored in the assessment, diagnosis, and
treatment of HD. A lack of material resources (e.g., food, shelter, clothing, money) does not appear to be related to the later
development of HD (Landau et al., 2011); however, individual
motivations for hoarding as a result of past experiences (e.g.,
living in extreme poverty) and legitimate fears of the inability
to pay for the hoarded items in the future should be assessed,
because this may play a role in the behavior.
An additional consideration when working with individuals with HD is the impact that the hoarding behaviors have on
family members and significant others. Those who live with
someone with HD may experience embarrassment because
of cluttered living spaces and frustration with the individuals
inability to cease hoarding behaviors (Ale et al., 2014).

Journal of Counseling & Development January 2016 Volume 94

Hoarding Disorder: Diagnosis, Assessment, and Treatment

Threats of eviction and homelessness as well as diminished
financial resources may place burdens on family members and
significant others who desire to assist a loved one diagnosed
with the disorder. Counseling may be important to those who
have close relationships with clients who have this disorder
(Ale et al., 2014; Tolin, Fitch, et al., 2010).
HD presents unique challenges to those who have the
disorder, but it also has more macrolevel, public safety implications. Because of the excessive accumulation of objects,
HD is associated with fire hazards, pest infestations, toxic
odors, mold growth, food contamination, and unsanitary
living conditions (Bratiotis, 2013; Frost, 2010). Cluttered
homes present an increased risk of falling and medication
misplacement, which could be especially harmful to the health
of older adults (Ayers et al., 2010; Frost, 2010). In addition,
cluttered living spaces may impede access for both fire and
medical first responders during emergency situations (Bratiotis, 2013). Counselors working in hoarding situations must
assess and facilitate client safety before addressing mental
health concerns.
HD is associated with poor overall physical and mental
health, and those with the disorder are more likely to have
comorbid chronic medical conditions (e.g., fibromyalgia,
chronic fatigue syndrome, obesity) and mental health disorders (Tolin, Frost, Steketee, Gray, & Fitch, 2008). In one
study of older adults, 90% of participants with HD reported
having a medical condition compared with 44% of members
of a nonpsychiatric peer comparison group (Ayers, Iqbal, &
Strickland, 2014). Diabetes, sleep apnea, arthritic complications, hematological conditions, and various cardiovascular
problems were also found more frequently in those with HD,
and it was hypothesized that these medical issues may be due
to self-neglect and a lower frequency of visits to a primary
care physician (Ayers et al., 2014). Counselors need to help
clients establish healthy routines in addition to addressing
underlying mental health concerns.
HD also affects communities in terms of the need for public
assistance and community services by individuals with HD.
Individuals with HD reported higher levels of work and role
impairment than even those with depressive and substance
use disorders (Tolin et al., 2008). HD has been associated
with job loss and an increased need for disability benefits
(Tolin et al., 2008). Individuals with HD are often at risk for
eviction, and, therefore, the disorder is highly correlated with
homelessness (Rodriguez et al., 2012). Because of role impairment and environmental safety concerns, child and animal
welfare services may also become involved in cases in which
people have HD (Bratiotis et al., 2013; Steketee et al., 2011).

Assessment
Counselors should approach the assessment of HD with a holistic and multifaceted outlook. Formal self-report measures

and interviews can be used in conjunction with behavioral

tasks and reports from secondhand parties, such as loved
ones and other health professionals (Grisham & Williams,
2014). Counselors must systematically and intentionally
integrate these sources of information to accurately diagnose
and treat HD.
Formal Measures and Interviews
Hoarding behaviors have historically been associated with
OCD and OCPD; thus, measures of obsessive-compulsive
symptomatology have historically been used to assess hoarding behaviors (Frost & Hristova, 2011). Although these measures do not fully assess all of the independent criteria of HD,
they do possess sufficient practical utility. Counselors may
consider using the Saving InventoryRevised (SI-R; Frost,
Steketee, & Grisham, 2004) and/or the Hoarding Rating
ScaleInterview (HRS-I; Tolin, Frost, & Steketee, 2010) to
assess for HD (Mataix-Cols et al., 2010).
The SI-R can be used to assess hoarding behaviors in
clinical and nonclinical samples (Frost et al., 2004). This
inventory consists of 23 questions that are scored on a 5-point
Likert-type scale (0 = none/not at all/never, 4 = almost all/
extreme/very often). The SI-R assesses symptoms of difficulty discarding, presence of clutter, and acquisitionall
symptoms that align with the DSM-5 (APA, 2013) diagnostic
criteria of difficulty discarding, significant accumulation/
clutter, and maintaining items to avoid negative feelings.
The SI-R displayed high internal consistency on the 23
items and on the three subscales (i.e., Difficulty Discarding,
Presence of Clutter, and Acquisition; Frost et al., 2004). The
convergent validity within the measure revealed a high correlation between two of the subscales (i.e., Clutter and Difficulty Discarding; Frost et al., 2004). Additionally, the SI-R
has demonstrated very good testretest reliability, although
replications with larger populations are warranted (Frost et
al., 2004). Comparison studies clearly distinguished total
scores of participants with HD and subscales scores from two
other samples (i.e., participants with OCD without hoarding tendencies and a nonclinical sample; Frost et al., 2004).
Additionally, validation studies between the SI-R and other
hoarding measures exhibited good convergent validity (Frost
et al., 2004). Thus, the SI-R is a reliable and valid measure
with strong clinical utility to assess HD, which requires only
slight variations from the DSM-5 diagnostic criteria (Frost et
al., 2004; Mataix-Cols et al., 2010).
The HRS-I is a semistructured interview consisting of five
rated questions (1 = none, 9 = severe) that reflect hoarding
behaviors (Tolin, Frost, & Steketee, 2010). Specifically, the
interview can assess for the level of difficulty in discarding
possessions, excessive acquisition of objects, emotional distress regarding disposal of items, significant clutter in living
space, and significant impairment of functioning, all of which
directly align with the DSM-5 (APA, 2013) criteria for HD.

Journal of Counseling & Development January 2016 Volume 94

85

Kress, Stargell, Zoldan, & Paylo

Counselors can use additional probing questions based on
their own clinical judgment to arrive at an independent rating
of severity. The HRS-I displayed high internal consistency
with good reliability and validity (Tolin, Frost, & Steketee,
2010). In particular, a validation study was significantly and
highly correlated with the standard measures of hoarding (i.e.,
SR-I and the three subscales; Tolin, Frost, & Steketee, 2010).
Additionally, one preliminary controlled study exploring the
effectiveness of cognitive behavior therapy (CBT) revealed
that HRS-I scores decreased following treatment (Tolin, Frost,
& Steketee, 2007, 2010), and these reductions corresponded
with decreases in SR-I scores. Given these findings, the HRSI is a reliable and valid measure with strong clinical utility
for counselors to assess HD and to measure treatment gains
(Tolin, Frost, & Steketee, 2010).
Behavioral Tasks
To more fully understand clients experiences, counselors may
assign behavioral tasks to clients (Grisham & Williams, 2014).
Individuals with HD often experience negative thoughts and
feelings when faced with discarding items that they find
valuable (APA, 2013; Frost & Hartl, 1996). Behavioral tasks
involve the client engaging in an attempt to discard an item
while being aware of his or her cognitions and behaviors
related to this process. Clients can be invited to identify an
item that is of value but is at the low end of importance. For
example, a client who primarily hoards magazines and newspapers might be able to identify a specific brochure or flyer
that is not as valuable as other possessions. The counselor can
provide the client with a log that tracks the clients thoughts,
feelings, and behaviors when thinking about discarding this
lower risk item.
After explaining the behavioral task process, the counselor
may ask the client to return home and work toward successive
approximations of discarding the item (e.g., the item should
be moved from its typical spot closer to the trash; the item
should be placed in the trash but not emptied; the trash should
be taken to the garage but not put out for disposal; the trash
should be put on the curb for pickup). The client should be
instructed to keep a thought log while doing each of these
activities, and the client should report the success he or she
had in discarding this low-risk item at the next counseling
appointment. The counselor can use this information to identify the severity of symptoms and level of client insight into
the hoarding behaviors, and to begin bringing awareness to
the client about his or her symptoms and the change process
(Grisham & Williams, 2014).
Secondhand Reports
When assessing HD, counselors benefit from consulting
with other professionals and with the clients friends or
family members (Grisham & Williams, 2014). As previously mentioned, there are several health conditions as-

86

sociated with HD, including fibromyalgia, chronic fatigue

syndrome, and obesity (Tolin et al., 2008); therefore, counselors should collaborate with other health professionals
to understand the clients physical health considerations.
Loved ones have an especially unique perspective into
the lives and struggles of individuals with this disorder
(Grisham & Williams, 2014; Tolin, Fitch, et al., 2010).
Counselors, after receiving appropriate client consent,
should consult with family members and friends to integrate any information into their holistic understanding of
the severity and nature of the clients HD symptoms.
Because of the manifestations and symptomatology of
individuals with HD, counselors should integrate multiple
sources of information to ensure an accurate diagnosis of HD.
Counselors can use an objective measure such as the SI-R, or
a more projective measure such as the HRS-I, which requires
a bit of the counselors clinical interpretation to assess the
diagnosis of HD. Additionally, counselors should consider
assigning behavioral tasks to clients to explore the severity
of symptoms and the potential work required to increase
clients awareness and insight around symptomatology. Finally, counselors should work with the clients loved ones or
other health professionals to discover information to which
clients may not have insight. After a thorough assessment
for HD and comorbid disorders, the counselor can make an
informed, accurate diagnosis and begin to use intentional
treatment interventions.

Treatment
Individuals with HD are five times more likely to seek mental
health services than the general population (Tolin et al., 2008).
However, they typically come to counseling for treatment of
comorbid mental health disorders; up to 75% of individuals with
HD have other mental health concerns, especially ADHD (APA,
2013; Fullana et al., 2013; Hall et al., 2013). Clients may have
more favorable treatment outcomes when counselors address
HD and comorbid symptoms simultaneously (Hall et al., 2013).
In addition to treatment complications related to comorbidity,
hoarding behaviors are often deeply ingrained by the time clients
come to counseling (Ayers et al., 2010; McGuire et al., 2013).
Thus, counselors must be patient and persistent when working
toward behavioral change with clients who have HD.
Individuals with HD also seek treatment at the request
of family members or significant others, or as a response to
external threats (e.g., eviction, condemnation; Tolin, Fitch,
et al., 2010). The occurrence of traumatic life events has
been associated with the onset of hoarding behaviors as
well as increased symptom severity (Landau et al., 2011);
thus, trauma may bring these individuals into treatment as
well. Therefore, those who enter treatment for HD may also
need to be thoroughly assessed for trauma history, because
these issues can become potential areas of clinical focus.

Journal of Counseling & Development January 2016 Volume 94

Hoarding Disorder: Diagnosis, Assessment, and Treatment

As counselors diagnose and assess HD in clients, they
should attempt to understand clients behaviors in context.
Counselors should seek to examine clients emotional discomfort, possible social contributors (e.g., avoidance of stressful
experiences), and potential social consequences (e.g., isolation;
Tolin et al., 2008) of clients behaviors. By thoroughly examining clients experiences, counselors can develop a richer, more
comprehensive perspective on clients treatment needs (Kress,
Zoldan, Adamson, & Paylo, 2015). In the following sections,
we discuss the most promising and researched treatments for
use in counseling clients who have HD.
CBT
CBT is considered to be the gold-standard treatment for HD
(Steketee, Frost, Tolin, Rasmussen, & Brown, 2010; Tolin et
al., 2007). However, CBT protocols developed for use with
individuals who have OCD are ineffective with those who
have HD (Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002;
Steketee & Frost, 2003). In multiple studies exploring CBT
for individuals with OCD, hoarding behaviors have been a
consistent predictor of higher dropout rates, poorer outcomes,
and minimal clinical gains compared with those without
hoarding behaviors (Mataix-Cols et al., 2002; Steketee &
Frost, 2003).
As a result, a CBT approach for HD has emerged focusing specifically on clients problematic beliefs and behaviors
related to hoarding, avoidance of emotional distress, and
potential information-processing deficits (Frost & Hartl,
1996; Steketee & Frost, 2007; Tolin et al., 2007). Multiple
nonrandomized wait-list studies suggest that CBT (i.e., specific for HD) is effective in treating HD (Frost et al., 2012;
Steketee et al., 2010; Tolin et al., 2007), although treatment
refusal and noncompliance continue to temper treatment
gains and duration of gains. Additionally, within the current
literature, no treatment differences have been reported based
on gender, race, or ethnicity. These mentioned deficiencies and
difficulties within the literature warrant further exploration
(Steketee et al., 2010).
Cognitive behavior treatment of HD focuses on symptom
reduction in the three major manifestations of hoarding: disorganization, difficulty discarding items, and excessive acquisition. Treatment components include (a) skills training with
reinforcement to enhance problem solving, decision making,
and organization; (b) imagined or direct exposure to distressing stimuli; and (c) cognitive restructuring of hoarding-related
beliefs (Steketee & Frost, 2007; Tolin et al., 2007).
The integration of home visits and motivational interviewing techniques enhances treatment outcomes when a
CBT approach is used (Steketee et al., 2010). Motivational
interviewing techniques are incorporated into this approach to
address poor homework compliance, limited insight, and the
reluctance to continue in treatment, which are characteristic
of the HD population. Steketee and Frost (2007) developed

a protocol and recommended that treatment consist of 26

weekly sessions that include both office and home visits.
In a qualitative study of clinician and client perceptions of
CBT treatment for HD, clients reported that they perceived
home visits that address goal setting, treatment planning,
and generalization of exposure exercises to be the most helpful components of this type of treatment (Ayers, Bratiotis,
Saxena, & Wetherell, 2012). Home visits allow clinicians to
enhance and maintain client motivation, provide help with
discarding and organizing, and assist in applying skills at
home (Muroff, Steketee, Bratiotis, & Ross, 2012). Although
in-home visits are not always feasible for counselors, noncounselor in-home assistance generally enhances treatment
outcomes (Muroff et al., 2012). In addition, peer-facilitated
support groups provide an adjunct service to treatment that
potentially enhances treatment outcomes (Frost et al., 2012).
Both individual and group CBT for HD have been found to
be efficacious in the treatment of those who have HD (Muroff,
Bratiotis, & Steketee, 2011). Group CBT with home visits (Muroff et al., 2012; Steketee, Frost, Wincze, Greene, & Douglass,
2000) and without home visits (Gilliam et al., 2011) have both
demonstrated effective outcomes. Group CBT interventions
may be especially useful in addressing accompanying social
impairment, withdrawal, and even comorbid depressive symptomatology (Muroff et al., 2012). Group CBT approaches, although slightly less effective than individual treatment for HD,
may be a more cost-effective alternative (Muroff et al., 2011).
Family-Based Approaches
As observed in clinical case studies, family-based treatment approaches may be especially useful in cases of HD in
children and adolescents (Ale et al., 2014). Ale et al. (2014)
reported their use of an altered CBT approach that included
parental psychoeducation to train parents to adaptively react
to childrens disruptive behaviors. Ale and colleagues reported
that hoarding behaviors in children were often reinforced by
parents reactions. Therefore, parents should be educated
that giving into a childs hoarding behaviorswhen the
child appears distressed (e.g., tantrums, crying)negatively
reinforces the hoarding behaviors. Parents are encouraged
to modify their behaviors by reacting in ways that attempt to
diminish the childs hoarding behaviors. Positive reinforcement, such as praise, is recommended when the child engages
in positive behaviors. Reward systems may be incorporated
into this treatment approach as well. Ale et al. also suggested
that parents set deadlines for the disposal of certain items
so as to set and reinforce boundaries. No clinical trials have
explored the effectiveness of family-based approaches; thus,
these findings should be approached with caution.
Multidisciplinary Community-Based Approaches
Because HD impairs a variety of life areas, involves the use
of community resources, and often requires the assistance

Journal of Counseling & Development January 2016 Volume 94

87

Kress, Stargell, Zoldan, & Paylo

of professionals from several disciplines, a multidisciplinary
community-based approach may be useful in addressing HD.
Bratiotis (2013) theorized a multidisciplinary approach to
address HD that is similar to the approaches used to address
social problems such as domestic violence and child abuse. In
addition to addressing the medical and mental health needs of
the HD population, home clean-out and professional organizing services are helpful (Bratiotis et al., 2013). As mentioned
earlier, home visits by nonclinicians to provide support and
assistance in organization and clean-out may enhance treatment outcomes (Muroff et al., 2012). Therefore, agencies
may find it helpful to train teams of noncounselors to assist
in these tasks or offer training to family members to enhance
treatment. Bratiotis (2013) reported that the first task force
was formed in 1999 and that 85 hoarding task forces currently exist across Canada, the United States, and Australia.
Because no clinical trials have explored the effectiveness
of multidisciplinary community-based approaches, this approach warrants further research and exploration.
Pharmacotherapy
As of this writing, no randomized controlled trials have tested the
effectiveness of pharmacological interventions for HD; thus, the
pharmacological interventions discussed in this section should
be interpreted with caution (Kress et al., 2015). Although no
medications are currently marketed to treat HD, there is some evidence that hoarding symptoms can improve with the use of some
pharmacological interventions (e.g., Saxena, 2011). Because
of high comorbidity rates with other mental health disorders,
medication may be useful in treating co-occurring symptoms.
Compliance with medication may be especially challenging for
individuals with HD because they are more prone to medication mismanagement given their cluttered living environments.
Saxena (2011) reported that extended-release venlafaxine
(i.e., Effexor XR), a serotonin and norepinephrine reuptake
inhibitor, was effective in improving hoarding symptomatology. Additionally, the selective serotonin reuptake inhibitor
paroxetine (i.e., Paxil) has demonstrated efficacy in improving hoarding symptoms, as well as comorbid depressive and
anxious symptoms (Saxena, Brody, Maidment, & Baxter,
2007). Researchers have yet to explore the combination of
counseling and pharmacological interventions for addressing HD, but early hypotheses indicate that combining both
interventions could be more effective than either treatment
modality alone (Saxena, 2011). In the current literature, no
treatment differences have been reported based on gender,
race, or ethnicity. The deficiencies in the literature and within
these mentioned studies warrant further exploration.

Conclusion
As previously stated, several effective treatments exist for
individuals who have HD. Counselors should consider in-

88

tegrating a comprehensive assessment approach that takes

into consideration multiple aspects of HD (e.g., emotional
discomfort, social contributors, social consequences; Frost,
Steketee, & Tolin, 2011). Counselors should also assess the
clients situational context through the use of self-report measures and interviews used in conjunction with behavioral tasks
and reports completed by secondhand parties and even other
health professionals (Grisham & Williams, 2014). Once the
counselor has thoroughly assessed the functions and dynamics
of the hoarding behaviors, the counselor can then make an
accurate diagnosis and develop a treatment plan.
Counselors may need to temper their own clinical expectations for treatment. Counselors must realize that with
this population, treatment gains often occur slowly and will
require significant dedication and work from the clients
(Kress et al., 2015). In a survey study, mental health professionals reported high levels of frustration when working
with clients who have HD (Tolin, Frost, & Steketee, 2012).
Providers frustrations typically occur secondary to clients
experiencing difficulty in making behavioral changes. Clients
difficulty with making changes and following through on
treatment recommendation can affect the working alliance
and adversely affect both clients and counselors attitudes
toward the counseling experience. The mental health professionals in Tolin et al.s (2012) research reported that clients
with HD had poorer levels of insight, had less awareness, and
engaged in significant therapy-interfering behaviors during
the course of treatment compared with nonhoarding clients
(Tolin et al., 2012). Therefore, counselors should evaluate
and establish realistic expectations for treatment, which may
include intentionally focusing the working alliance throughout
the counseling process; looking for opportunities to increase
clients insight into their behaviors and consequences; using motivational interviewing to increase ambivalence and
change language; answering questions clearly and assigning
homework appropriately; working on goals that are collaborative in nature; and seeking appropriate self-care, supervision,
and consultation throughout the treatment process (Tolin et
al., 2012).
Counselors should seek to possess the appropriate knowledge and skills needed to accurately assess, diagnose, and
treat clients who have HD. Counselors must also foster a
good working relationship throughout the process and look
for opportunities to select collaborative goals in treatment.
Clients with HD may benefit from CBT, family-based approaches, multidisciplinary community-based approaches,
and pharmacotherapy approaches. Finally, counselors
should carefully consider all aspects of the clients hoarding
behaviors, including other comorbid symptoms and difficulties, when determining the best treatment interventions and
relapse plans.
The literature on HD should be approached with caution.
Several limitations have been noted within the HD literature

Journal of Counseling & Development January 2016 Volume 94

Hoarding Disorder: Diagnosis, Assessment, and Treatment

(Frost et al., 2012). First, research participants with HD are
more likely to be female, highly educated, and Caucasian,
which may limit the generalizability of findings to the larger
population (Frost et al., 2012; Hall et al., 2013; Ivanov et al.,
2013). The overrepresentation of female participants in the
HD literature may be associated with gender differences in
treatment-seeking attitudes (Tolin, Frost, & Steketee, 2010).
Additionally, research participants are often seeking treatment for HD or other comorbid mental health disorders. No
randomized controlled studies have addressed the treatment
of HD at this time. Studies of HD have used various designs,
including nonrandomized wait-list control (e.g., Frost et al.,
2012; Steketee et al., 2010), descriptive case study (e.g., Ale
et al., 2014), twin study (e.g., Ivanov et al., 2013), and correlational survey (e.g., Tolin et al., 2008). The majority of
the HD literature has used qualitative correlational design.
Some correlational studies of HD have used a database of
over 8,000 participants reporting hoarding behaviors (e.g.,
Bratiotis et al., 2013; Tolin et al., 2008). Sample sizes in
quasi-experimental studies are generally small, which may
limit the generalizability of results. Thus, additional treatment research is needed on HD. Research studies that involve
greater rigor (e.g., randomized controlled trials) would be
helpful in determining the most efficacious treatments for HD.

References
Ale, C. M., Arnold, E. B., Whiteside, S. P., & Storch, E. A. (2014).
Family-based behavioral treatment of pediatric compulsive
hoarding: A case example. Clinical Case Studies, 13, 921.
doi:10.1177/1534650113504487
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: Author.
Ayers, C. R., Bratiotis, C., Saxena, S., & Wetherell, J. (2012). Therapist
and patient perspectives on cognitive-behavioral therapy for older
adults with hoarding disorder: A collective case study. Aging &
Mental Health, 16, 915921. doi:10.1080/13607863.2012.678480
Ayers, C. R., Iqbal, Y., & Strickland, K. (2014). Medical conditions
in geriatric hoarding disorder patients. Aging & Mental Health,
18, 148151. doi:10.1080/13607863.2013.814105
Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. L. (2010). Age
at onset and clinical features of late life compulsive hoarding.
International Journal of Geriatric Psychiatry, 25, 142149.
doi:10.1002/gps.2310
Bratiotis, C. (2013). Community hoarding task forces: A comparative
case study of five task forces in the United States. Health & Social
Care in the Community, 21, 245253. doi:10.1111/hsc.12010
Bratiotis, C., Steketee, G., Davidow, J., Samuels, J., Tolin, D., &
Frost, R. (2013). Use of services by people who hoard objects.
Best Practices in Mental Health, 9, 3951. Retrieved from http://
essential.metapress.com/content/b171424030120626/
Frost, R. O. (2010). Hoarding: Introduction. Cognitive and Behavioral Practice, 17, 401403.

Frost, R. O., & Gross, R. C. (1993). The hoarding of possessions. Behaviour Research and Therapy, 31, 367381. doi:10.1016/00057967(93)90094-B
Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral model
of compulsive hoarding. Behaviour Research and Therapy, 34,
341350. doi:10.1016/0005-7967(95)00071-2
Frost, R. O., & Hristova, V. (2011). Assessment of hoarding.
Journal of Clinical Psychology, 67, 456466. doi:10.1002/
jclp.20790
Frost, R. O., Patronek, G., & Rosenfield, E. (2011). Comparison
of object and animal hoarding. Depression and Anxiety, 28,
885891. doi:10.1002/da.20826
Frost, R. O., Ruby, D., & Shuer, L. J. (2012). The Buried in Treasures
Workshop: Waitlist control trial of facilitated support groups
for hoarding. Behaviour Research and Therapy, 50, 661667.
doi:10.1016/j.brat.2012.08.004
Frost, R. O., Steketee G., & Grisham J. (2004). Measurement
of compulsive hoarding: Saving InventoryRevised. Behaviour Research and Therapy, 42, 11631182. doi:10.1016/j.
brat.2003.07.006
Frost, R. O., Steketee, G., & Tolin, D. F. (2011). Comorbidity
in hoarding disorder. Depression and Anxiety, 28, 876884.
doi:10.1002/da.20861
Frost, R. O., Tolin, D. F., Steketee, G., Fitch, K. E., & SelboBruns, A. (2009). Excessive acquisition in hoarding.
Journal of Anxiety Disorders, 23, 632639. doi:10.1016/j.
janxdis.2009.01.013
Fullana, M. A., Vilagut, G., Mataix-Cols, D., Duran Adroher, N.,
Bruffaerts, R., Bunting, B., . . . Alonso, J. (2013). Is ADHD
in childhood associated with lifetime hoarding symptoms? An
epidemiological study. Depression and Anxiety, 30, 741748.
doi:10.1002/da.22123
Gilliam, C. M., Norberg, M. M., Villavicencio, A., Morrison,
S., Hannan, S. E., & Tolin, D. F. (2011). Group cognitivebehavioral therapy for hoarding disorder: An open trial. Behaviour Research and Therapy, 49, 802807. doi:10.1016/j.
brat.2011.08.008
Grisham, J. R., Brown, T. A., Liverant, G. I., & Campbell-Sills,
L. (2005). The distinctiveness of compulsive hoarding from
obsessive-compulsive disorder. Journal of Anxiety Disorders,
19, 767779. doi:10.1016/j.janxdis.2004.09.003
Grisham, J. R., Frost, R. O., Steketee, G., Kim, H., & Hood,
S. (2006). Age of onset of compulsive hoarding. Journal
of Anxiety Disorders, 20, 675686. doi:10.1016/j.janxdis.2005.07.004
Grisham, J. R., & Williams, A. D. (2014). Assessing hoarding and
related phenomena. In R. O. Frost & G. Steketee (Eds.), The
Oxford handbook of hoarding and acquiring (pp. 235246).
doi:10.1093/oxfordhb/9780199937783.013.006
Hall, B. J., Tolin, D. F., Frost, R. O., & Steketee, G. (2013). An exploration of comorbid symptoms and clinical correlates of clinically
significant hoarding symptoms. Depression and Anxiety, 30,
6776. doi:10.1002/da.22015

Journal of Counseling & Development January 2016 Volume 94

89

Kress, Stargell, Zoldan, & Paylo

Ivanov, V. Z., Mataix-Cols, D., Serlachius, E., Lichtenstein, P.,
Anckarster, H., Chang, Z., . . . Rck, C. (2013). Prevalence,
comorbidity and heritability of hoarding symptoms in
adolescence: A population based twin study in 15-year olds. Plos
One, 8, E69140. doi:10.1371/journal.pone.0069140
Kress, V. E., Zoldan, C. A., Adamson, N., & Paylo, M. J. (2015).
Obsessive-compulsive and related disorders. In V. E. Kress & M.
J. Paylo (Eds.), Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment (pp.
162193). Columbus, OH: Pearson.
Landau, D., Iervolino, A. C., Pertusa, A., Santo, S., Singh, S., &
Mataix-Cols, D. (2011). Stressful life events and material deprivation in hoarding disorder. Journal of Anxiety Disorders, 25,
192202. doi:10.1016/j.janxdis.2010.09.002
Mataix-Cols, D., Frost, R. O., Pertusa, A., Clark, L. A., Saxena, S.,
Leckman, J. F., . . . Wilhelm, S. (2010). Hoarding disorder: A
new diagnosis for DSM-V? Depression and Anxiety, 27, 556572.
doi:10.1002/da.20693
Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K. A., & Baer, L.
(2002). Obsessive-compulsive symptom dimensions as predictors
of compliance with and response to behaviour therapy: Results
from a controlled trial. Psychotherapy and Psychosomatics, 71,
255262. doi:10.1159/000064812
McGuire, J. F., Kaercher, L., Park, J. M., & Storch, E. A. (2013).
Hoarding in the community: A code enforcement and social
service perspective. Journal of Social Service Research, 39,
335344. doi:10.1080/01488376.2013.770813
Muroff, J., Bratiotis, C., & Steketee, G. (2011). Treatment for hoarding behaviors: A review of the evidence. Clinical Social Work
Journal, 39, 406423. doi:10.1007/s10615-010-0311-4
Muroff, J., Steketee, G., Bratiotis, C., & Ross, A. (2012). Group
cognitive and behavioral therapy and bibliotherapy for hoarding:
A pilot trial. Depression and Anxiety, 29, 597604. doi:10.1002/
da.21923
Plimpton, E. H., Frost, R. O., Abbey, B. C., & Dorer, W. (2009).
Compulsive hoarding in children: Six case studies. International Journal of Cognitive Therapy, 2, 88104. doi:10.1521/
ijct.2009.2.1.88
Rodriguez, C. I., Herman, D., Alcon, J., Chen, S., Tannen, A., Essock,
S., & Simpson, H. B. (2012). Prevalence of hoarding disorder in
individuals at potential risk of eviction in New York City. Journal of Nervous and Mental Disease, 200, 9194. doi:10.1097/
NMD.0b013e31823f678b
Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle,
M. A., Liang, K., . . . Nestadt, G. (2008). Prevalence and correlates of hoarding behavior in a community-based sample.
Behaviour Research and Therapy, 46, 836844. doi:10.1016/j.
brat.2008.04.004
Saxena, S. (2011). Pharmacotherapy of compulsive hoarding.
Journal of Clinical Psychology, 67, 477484. doi:10.1002/
jclp.20792

90

Saxena, S., Brody, A. L., Maidment, K. M., & Baxter, L. R.

(2007). Paroxetine treatment of compulsive hoarding. Journal
of Psychiatric Research, 41, 481487. doi:10.1016/j.jpsychires.2006.05.001
Steketee, G., & Frost, R. (2003). Compulsive hoarding: Current
status of the research. Clinical Psychology Review, 23, 905927.
doi:10.1016/j.cpr.2003.08.002
Steketee, G., & Frost, R. O. (2007). Compulsive hoarding and acquiring: Therapist guide. Oxford, England: Oxford University Press.
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, 476484.
doi:10.1002/da.20673
Steketee, G., Frost, R. O., Wincze, J., Greene, K., & Douglass, H.
(2000). Group and individual treatment of compulsive hoarding: A pilot study. Behavioural and Cognitive Psychotherapy,
28, 259268.
Steketee, G., Gibson, A., Frost, R. O., Alabiso, J., Arluke, A., & Patronek, G. (2011). Characteristics and antecedents of people who
hoard animals: An exploratory comparative interview study. Review of General Psychology, 15, 114124. doi:10.1037/a0023484
Storch, E. A., Lack, C. W., Merlo, L. J., Geffken, G. R., Jacob, M.
L., Murphy, T. K., & Goodman, W. K. (2007). Clinical features of
children and adolescents with obsessive-compulsive disorder and
hoarding symptoms. Comprehensive Psychiatry, 48, 313318.
doi:10.1016/j.comppsych.2007.03.001
Tolin, D. F., Fitch, K. E., Frost, R. O., & Steketee, G. (2010). Family informants perceptions of insight in compulsive hoarding.
Cognitive Therapy and Research, 34, 6981. doi:10.1007/
s10608-008-9217-7
Tolin, D. F., Frost, R. O., & Steketee, G. (2007). An open trial of
cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 14611470. doi:10.1016/j.
brat.2007.01.001
Tolin, D. F., Frost, R. O., & Steketee, G. (2010). A brief interview
for assessing compulsive hoarding: The Hoarding Rating Scale
Interview. Psychiatry Research, 178, 147152. doi:10.1016/j.
psychres.2009.05.001
Tolin, D. F., Frost, R. O., & Steketee, G. (2012). Working with hoarding vs. non-hoarding clients: A survey of professionals attitudes
and experiences. Journal of Obsessive-Compulsive and Related
Disorders, 1, 4853. doi:10.1016/j.jocrd.2011.11.004.
Tolin, D. F., Frost, R. O., Steketee, G., Gray, K. D., & Fitch, K.
E. (2008). The economic and social burden of compulsive
hoarding. Psychiatry Research, 160, 200211. doi:10.1016/j.
psychres.2007.08.008
Wheaton, M., Cromer, K., LaSalle-Ricci, V. H., & Murphy, D.
(2008). Characterizing the hoarding phenotype in individuals
with OCD: Associations with comorbidity, severity and gender.
Journal of Anxiety Disorder, 22, 243252. doi:10.1016/j.janxdis.2007.01.015

Journal of Counseling & Development January 2016 Volume 94

Copyright of Journal of Counseling & Development is the property of Wiley-Blackwell and

its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.