The Future of Research and Awareness in Hoarding Behaviour

According to Hoarding UK, hoarding disorder is more common in males; however, more females seek support. Hoarding disorder presents significant challenges for individuals and their families, as it can lead to hazardous living conditions, social isolation and severe emotional distress.

Understanding hoarding behaviour and its underlying causes is crucial for developing effective treatments and support systems. Research into cognitive-behavioural therapies, community-based interventions, and the biological and environmental factors driving hoarding is ongoing. Raising public awareness helps reduce the stigma surrounding the disorder, encouraging those affected to seek help and ensuring that society is better equipped to address this complex issue.

Increased awareness, combined with advancements in research, can improve the well-being of individuals with hoarding disorder and mitigate its broader social impact.

Current Understanding of Hoarding Behaviour

Hoarding disorder is a mental health condition characterised by persistent difficulty in discarding or parting with possessions, regardless of their actual value. This difficulty arises from a perceived need to save items and the distress associated with letting them go. The accumulation of possessions often results in clutter that disrupts the ability to use living spaces as intended, causing significant distress or impairment in social, occupational or other important areas of functioning.

The key features of hoarding disorder include:

• Persistent difficulty discarding items – individuals with hoarding disorder find it extremely challenging to discard or part with possessions, leading to an accumulation of a large number of items.
• Perceived need to save items – this behaviour is driven by a strong perceived need to save items and the associated distress or anxiety when considering discarding them.
• Cluttered living spaces – the clutter often invades living areas to the point where they become unusable for their intended purposes, such as cooking in the kitchen or sleeping in the bedroom.
• Significant distress or impairment – the disorder causes significant distress or impairment in social, occupational, or other important areas of functioning. This can include strained relationships, health risks, or legal issues related to the condition of the home.

Early recognition and intervention can help manage hoarding behaviour effectively, improving quality of life and reducing the associated risks. Recognising the signs and symptoms of hoarding behaviour involves observing a range of behavioural, emotional and physical indicators. Some of the key behavioural signs and symptoms include:

• Persistent difficulty discarding or parting with possessions, regardless of their actual value.
• Excessive acquisition of items that are not needed or for which there is no space.
• Difficulty making decisions about what to keep and what to throw away.
• Avoidance of situations where possessions might be discarded, like cleaning or organising.
• Significant distress or anxiety at the thought of discarding items.

Some of the emotional signs and symptoms include:

• A strong emotional attachment to possessions, seeing them as having sentimental or intrinsic value.
• Feelings of shame, embarrassment, or guilt about the state of their living environment.
• Reluctance or refusal to allow others to see or help with the clutter.

Physical signs in the living environment include:

• Cluttered living spaces.
• Unsafe living conditions.

Social and occupational signs include:

• Social withdrawal and isolation due to embarrassment or fear of judgement about the clutter.
• Difficulty performing daily activities or meeting responsibilities at work, school or in relationships due to the clutter.

Psychological signs include:

• Persistent thoughts about the need to save items or distress associated with discarding them.
• Compulsive acquiring of items, whether through purchasing, collecting free items or hoarding.
• Beliefs that items are needed for future use or have sentimental value, even when this is not objectively the case.

Advances in Research

Recent advancements in understanding the neurobiology and genetics of hoarding behaviour have significantly deepened our understanding of this complex disorder, revealing its underpinnings at both the genetic and neural levels. Hoarding disorder is characterised by excessive accumulation of items and an inability to discard them, leading to clutter and significant distress or impairment.

Several neuroimaging studies have shed light on the brain regions implicated in hoarding. Advances in functional magnetic resonance imaging (fMRI) and structural MRI have provided a clearer picture of the neural circuits involved in hoarding behaviours.

• Abnormalities in the anterior cingulate cortex (ACC) and insula – studies have shown hyperactivity in the ACC and insula in individuals with hoarding disorder, particularly when they are asked to make decisions about discarding items. These brain regions are linked to decision-making, emotional regulation and conflict monitoring. Overactivation in these areas is believed to cause difficulty in making decisions related to discarding, contributing to the characteristic indecisiveness and anxiety seen in hoarding.
• Dysfunction in the orbitofrontal cortex (OFC) – the OFC plays a critical role in processing reward and evaluating the emotional significance of objects. Structural imaging studies have found abnormalities in the volume and functioning of the OFC in individuals with hoarding disorder. The OFC’s dysfunction is thought to contribute to the excessive emotional attachment to objects, making it difficult to discard them.
• Connectivity issues in the default mode network (DMN) – the DMN, which is active during rest and self-referential thought, appears to be dysfunctional in hoarding. Studies have reported altered connectivity between the DMN and other networks involved in decision-making and emotional regulation. These disruptions may underpin the persistent, repetitive thoughts about possessions that are commonly reported by individuals with hoarding disorder.

Hoarding behaviour has also been linked to abnormal emotional processing, particularly concerning fear, guilt and anxiety. Neurobiological studies suggest that people with hoarding disorder have heightened emotional responses to possessions, especially the prospect of losing them. This contributes to the difficulty in discarding items and the distress caused by the thought of doing so.

Genetic research has also progressed, highlighting the heritability and potential genetic markers associated with hoarding. Family studies have shown that hoarding disorder has a strong genetic component. Twin studies estimate that hoarding behaviour has a heritability of about 50%. This suggests that genetic factors play a significant role in the risk of developing the disorder, though environmental factors are also important.

Hoarding disorder was historically considered a subtype of obsessive-compulsive disorder (OCD), and some genetic overlap has been found between the two. Recent genome-wide association studies (GWAS) have begun to identify specific loci that may be associated with hoarding behaviours. For instance, there is evidence that variations in genes related to neuronal development, synaptic plasticity, and immune system function may be associated with hoarding disorder. These findings support the idea that hoarding may have a distinct genetic profile separate from OCD, even though the two conditions can co-occur.

The COMT gene, which affects dopamine metabolism, has been implicated in hoarding disorder. Abnormalities in dopamine signalling pathways may explain the intense value individuals with hoarding place on possessions and the difficulty they experience in discarding items. Dopamine’s role in reward processing may contribute to the emotional significance attached to keeping items.

There is emerging evidence suggesting that inflammation and immune system dysregulation may play a role in hoarding disorder. Some studies have reported higher levels of pro-inflammatory cytokines in individuals with hoarding disorder, indicating that neuroinflammation could contribute to its pathophysiology. This is consistent with findings in other psychiatric conditions, where inflammation is thought to affect brain function and behaviour.

Animal studies, especially those involving rodent models, have been instrumental in advancing the understanding of the neurobiology of hoarding behaviour. Research on animal hoarding behaviours has helped identify brain regions and neurotransmitters that may contribute to compulsive accumulation, providing insights that can be applied to human cases.

The advancements in neurobiology and genetics of hoarding disorder have identified key brain regions, neural circuits and genetic factors that contribute to the development of hoarding behaviours. This growing body of knowledge is essential for creating more effective and personalised interventions for individuals struggling with hoarding disorder.

Treatment Innovations

While cognitive-behavioural therapy (CBT) is the most widely recognised and evidence-based treatment, there are several innovative treatment approaches being explored to enhance outcomes for individuals with hoarding disorder. These therapies aim to address the underlying psychological, emotional and neurological components of the disorder. 

Here are some emerging approaches:

• Compassion-focused therapy (CFT) – CFT helps individuals develop self-compassion, which can reduce feelings of shame, guilt and self-criticism often associated with hoarding behaviours. Many individuals with hoarding disorder have negative self-beliefs and shame related to their living conditions. CFT works to build self-acceptance and emotional regulation, encouraging patients to treat themselves with kindness rather than judgement, which may help them confront hoarding behaviours in a non-threatening manner. Some preliminary studies have shown CFT can help reduce anxiety and depression symptoms in hoarding patients, facilitating progress in discarding and organising possessions.
• Mindfulness-based interventions – mindfulness techniques aim to increase awareness of emotions, thoughts and behaviours without judgement, fostering a more balanced relationship with material possessions. By practising mindfulness, individuals with hoarding disorder may become more aware of their compulsions and the emotional triggers behind their hoarding behaviour. Mindfulness can also help them tolerate the distress associated with letting go of items. Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are commonly integrated into treatments for hoarding disorder. A study found that MBCT helped individuals with hoarding disorder experience reduced anxiety related to discarding items, leading to improved decision-making around possessions.
• Exposure and response prevention (ERP) – ERP, typically used in treating obsessive-compulsive disorder (OCD), involves exposing individuals to the distressing stimuli and helping them resist the compulsion to hoard. The goal is to gradually reduce anxiety related to discarding items by repeatedly facing situations where they must make decisions about their possessions. Over time, this reduces the emotional intensity of the compulsion to hoard. ERP for hoarding can be tailored to include specific challenges, such as confronting fears of discarding or organising items without bringing in new possessions.
• Virtual reality (VR) exposure therapy – VR therapy immerses patients in simulated environments that replicate real-life situations involving their hoarding behaviours, such as cluttered rooms or discarding items. VR allows individuals to face their fears and anxieties in a controlled and safe virtual space. This is particularly useful for hoarding disorder, where in-home interventions can sometimes be impractical. Early studies suggest VR can enhance engagement in therapy by allowing patients to practise skills in a virtual setting before applying them to real life. It can also facilitate ERP by allowing for repeated exposure to distressing situations without needing to physically disrupt the individual’s home.
• Acceptance and commitment therapy (ACT) – ACT focuses on helping individuals accept difficult emotions rather than attempting to eliminate them, while also committing to value-based behaviours. In hoarding disorder, ACT encourages individuals to accept their distress related to discarding items while helping them align their actions with personal values, such as creating a more functional living space or maintaining healthy relationships. Initial studies have demonstrated that ACT can be effective in reducing hoarding symptoms, as it helps individuals tolerate the discomfort of discarding while focusing on long-term goals and values.
• Motivational interviewing (MI) – MI is a client-centred counselling style aimed at enhancing motivation to change by resolving ambivalence. Since many individuals with hoarding disorder lack the motivation to change or are ambivalent about discarding items, MI focuses on eliciting their intrinsic motivation and exploring the consequences of hoarding behaviour. It emphasises collaboration and empathy, which can foster a more trusting therapeutic relationship. MI can be combined with other treatments (like CBT or ERP) to increase engagement and motivation, making it easier for patients to participate in the therapeutic process.
• Neurostimulation techniques – emerging research suggests that neurostimulation techniques, such as Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS), may hold promise in treating hoarding disorder. These techniques involve the non-invasive application of magnetic fields or electric currents to modulate brain activity, particularly in regions associated with decision-making, emotional regulation and impulse control. For hoarding disorder, targeting specific brain regions implicated in obsessive-compulsive behaviour may help regulate dysfunctional thought patterns. While more research is needed, there is some evidence suggesting that TMS can reduce OCD symptoms, and studies are exploring its effectiveness in hoarding.
• Group therapy – group therapy provides a supportive environment where individuals with hoarding disorder can share experiences, receive peer feedback, and practise new skills together. Group formats allow for social learning, where individuals can observe how others cope with similar challenges, reducing feelings of isolation and stigma. It also encourages accountability as group members support each other in their progress. Buried in Treasures (BIT) is a well-known group intervention designed for hoarding. It combines psychoeducation, motivational enhancement, and skills training, and has been found effective in reducing hoarding behaviours.
• In-home cognitive therapy – in-home therapy is a practical approach where therapists or trained professionals work with individuals in their actual living environments to address hoarding behaviours directly. By conducting therapy in the individual’s home, therapists can better understand the specific challenges related to clutter and space and tailor interventions to the client’s unique needs. This approach provides hands-on support, helping clients develop skills to organise, discard and prevent re-accumulation in real time. This method is resource-intensive but can be highly effective as it integrates therapy into the individual’s daily routine and living conditions.
• Animal-assisted therapy – some individuals with hoarding disorder respond positively to animal-assisted therapy, where a therapy animal helps reduce anxiety and stress during therapeutic sessions. The presence of a therapy animal can provide emotional support, reduce social anxiety, and increase engagement in therapy. It can also help individuals with hoarding disorder build trust and connection, which may facilitate progress in dealing with their hoarding behaviour. This can be especially useful for individuals who struggle with social isolation, which is common in hoarding disorder.
• Medication-based interventions – although no medications are specifically approved for hoarding disorder, selective serotonin reuptake inhibitors (SSRIs), like fluvoxamine, are sometimes used due to the overlap between hoarding disorder and obsessive-compulsive disorder (OCD). SSRIs target serotonin pathways in the brain that regulate mood, anxiety and impulse control. They may reduce the emotional distress and compulsive behaviour associated with hoarding. Medication is typically used in conjunction with other therapies, as studies suggest it can reduce hoarding symptoms but is most effective when combined with behavioural interventions.

Cross-disciplinary Collaboration

Collaboration between psychologists, psychiatrists, social workers and other healthcare professionals is crucial in addressing hoarding behaviour due to its complex and multifaceted nature. Hoarding involves emotional, cognitive and behavioural challenges that require a multidisciplinary approach to achieve effective treatment and support. Here’s why collaboration is so essential:

• Psychologists and psychiatrists play key roles in diagnosing hoarding disorder, evaluating co-occurring mental health issues such as depression, anxiety or obsessive-compulsive disorder (OCD). Their combined expertise ensures a thorough understanding of the emotional and psychological factors contributing to hoarding.
• Social workers assess the individual’s social environment, family dynamics and living conditions, helping to identify external stressors or support systems that may impact treatment.
• Holistic treatment planning – psychologists provide cognitive-behavioural therapy (CBT) to address the maladaptive thought patterns and behaviours linked to hoarding. Collaboration with psychiatrists ensures that any necessary pharmacological interventions, such as medications for anxiety or OCD, are integrated into the treatment plan.
• Social workers help navigate resources for community support, financial assistance and housing, ensuring that the individual’s social and environmental needs are addressed. This holistic plan enhances the chances of long-term recovery. Social workers can act as liaisons with local housing authorities or government agencies to prevent eviction or legal consequences while coordinating necessary interventions like cleaning services or relocation.
• Psychologists can help families understand the psychological aspects of hoarding, while social workers facilitate family mediation or counselling, ensuring that family members are part of the recovery process without enabling the hoarding behaviour.
• Community-based support groups and healthcare professionals collaborate to create ongoing support systems that address isolation, which is common among individuals with hoarding behaviour.

Hoarding disorder often requires long-term management. Collaborative teams ensure sustained follow-up, with psychologists monitoring mental health progress, psychiatrists adjusting medication if needed, and social workers ensuring access to community resources and ongoing care. Such coordination is essential to prevent relapse and ensure that improvements in the individual’s living conditions are maintained over time.

In severe cases where the hoarding behaviour creates unsafe living conditions, multidisciplinary teams are essential. Healthcare professionals, such as public health officers or nurses, may need to collaborate with social workers to ensure the safety of the individual and others. A collaborative approach ensures that all aspects of hoarding behaviour, emotional, psychological, social and environmental, are addressed, promoting a comprehensive, sustainable recovery.

Technology and Digital Solutions

Technology plays a significant role in supporting individuals with hoarding disorder, particularly in self-management, therapy and community support. Various technologies, including mobile apps and virtual platforms, are emerging as tools to enhance treatment and management. Here are some ways technology contributes:

• Cognitive-behavioural therapy (CBT)-based apps – since CBT is a key approach to treating hoarding disorder, many mobile apps are designed to help users practise CBT techniques. These apps guide users through strategies like exposure therapy, cognitive restructuring and goal setting.
• Task management and motivation – apps that help with task management and breaking down goals into smaller steps can be beneficial. These include “Clutterbug” or “Decluttr”. These apps offer step-by-step guidance on how to declutter specific areas, motivating users with milestones and reminders. “Tody” or “Habitica” gamified task apps can make organising and decluttering more enjoyable, providing rewards for accomplishing daily tasks related to home organisation. Some apps encourage individuals to record their thoughts and track their emotional responses when decluttering. For example, CBT Thought Record Diary allows users to log their emotions and responses to clutter and to analyse negative thought patterns, helping to reduce the anxiety of parting with possessions.
• Virtual support groups – people with hoarding disorder may feel isolated or stigmatised. Virtual support groups can offer a safe space to share experiences and seek encouragement from others facing similar challenges. Virtual support groups and therapy sessions conducted via platforms like Zoom or Telehealth enable people with hoarding disorder to participate in group therapy from home, offering both privacy and accessibility. Organisations such as Hoarding UK or the International OCD Foundation (IOCDF) run virtual groups that offer both emotional support and structured interventions.
• Virtual reality (VR) therapy – though still in the early stages of research, VR therapy offers promise in hoarding disorder treatment. Simulated environments can be used to recreate the emotional distress experienced by hoarders when discarding objects. This approach allows therapists to work with clients in a controlled environment to overcome their distress before tackling their real-world environments.
• Telehealth and remote therapy – many individuals with hoarding disorder face logistical or emotional challenges that prevent them from seeking face-to-face therapy. Telehealth platforms offer a solution, providing access to licensed mental health professionals specialising in hoarding disorder or related conditions.
• CBT teletherapy – virtual CBT sessions help individuals confront hoarding behaviours through structured interventions. Platforms like BetterHelp and Talkspace offer access to therapists specialising in hoarding disorder. Some apps allow therapists to remotely monitor their patients’ progress through photo or video check-ins, offering encouragement and guidance based on their environment.
• Smart home technology and organisation tools – for individuals overwhelmed by clutter, smart home assistants, such as Google Home or Amazon Alexa, can be programmed to provide reminders, schedule decluttering tasks, and offer verbal encouragement. Additionally, organisational apps can sync with smart devices to create personalised cleaning schedules. Wearable technology can track a user’s physical activity during decluttering and send reminders or encouragement throughout the day. This can help individuals gradually make progress without feeling overwhelmed.
• Artificial Intelligence (AI) and machine learning – apps incorporating AI can analyse hoarding behaviours over time, making personalised suggestions. For example, AI can track how often users interact with specific items or areas of their home, prompting them to declutter frequently touched spaces. AI-powered chatbots, similar to those found in mental health apps like Woebot, could provide on-demand coaching for individuals feeling stuck or anxious about decluttering. These bots can offer instant feedback based on CBT principles.
• Digital tools for collaboration with family and professionals – mobile apps can help individuals share photos or videos of their living spaces with therapists or family members, enabling collaboration on decluttering plans and providing accountability. Tools like Trello or Asana can help organise decluttering tasks, allowing users to work collaboratively with therapists, family or professional organisers by breaking down larger goals into manageable steps.

Some people with hoarding disorder, particularly elderly people, may struggle with using digital tools due to limited technological proficiency. For people with severe hoarding tendencies, even interacting with apps or managing notifications can feel overwhelming, exacerbating the problem rather than alleviating it. Sharing personal information or photos of living spaces can feel intrusive, and maintaining privacy while using these tools is critical.

Technology offers a wide range of tools for managing hoarding disorder, from self-help mobile apps to virtual therapy sessions and online communities. These tools can empower individuals to take gradual steps towards improving their living environments, reducing distress, and fostering a sense of community. However, successful integration of these technologies requires careful consideration of individual needs, privacy concerns, and the potential emotional impact of using such tools.

Community Awareness and Support

Raising awareness helps communities recognise the signs of hoarding disorder earlier. This allows for timely interventions, which can prevent the disorder from worsening. Early intervention can improve treatment outcomes and reduce the negative impact on the individual and their surroundings.

Hoarding disorder is often accompanied by shame and secrecy, making it difficult for individuals to seek help. Increased community understanding can reduce the stigma associated with the disorder, making individuals feel more comfortable discussing their struggles and accessing support. When people in the community are aware of the challenges that hoarding disorder presents, they are more likely to respond with empathy rather than judgement. This can create a supportive environment that encourages individuals to seek treatment and maintain healthier habits over time. 

Individuals with hoarding disorder often isolate themselves due to embarrassment or fear of judgement. A well-informed community can provide social support and reduce isolation, which is important for emotional well-being and recovery. Friends and family members of individuals with hoarding disorder may struggle to understand the condition and how to help. Awareness campaigns can provide them with tools, resources and guidance on how to offer support effectively without enabling unhealthy behaviours.

Here are some useful contacts if you or someone you know is struggling with hoarding behaviours:

Hoarding Disorders UK offer specialist advice for people affected by hoarding behaviours, chronic disorganisation and extreme clutter.

Hoarding UK is the only UK-wide charity that is dedicated to supporting people affected by hoarding behaviours. Their aim is to empower individuals experiencing hoarding behaviours.

Hoarding Support provide information, support and advice for people who hoard and their loved ones. 

Challenges and Future Directions

Hoarding disorder research faces several challenges, including issues like limited funding, access to specialised care, and difficulties in early detection and treatment. Here are some key challenges in hoarding research and care:

• Low prioritisation – mental health funding is often stretched, with hoarding research not receiving as much attention as other more widely recognised disorders like anxiety or depression.
• Small-scale studies – a lack of significant funding leads to smaller, limited-scale studies, often relying on qualitative data, case studies, or small sample sizes, reducing the generalisability of findings.
• Difficulty in securing grants – researchers may face difficulty obtaining grants or other financial support due to the relatively niche status of hoarding compared to other mental health disorders.
• Limited access to specialised care – access to specialised hoarding disorder services is often limited to certain areas, with many regions in the UK lacking professionals trained in treating hoarding disorder.
• Lack of public and clinical awareness – hoarding disorder is still under-recognised, both by the general public and within healthcare services. GPs and mental health professionals may not always be aware of how to identify or treat hoarding disorder effectively, contributing to delayed diagnosis and mismanagement.
• Limited specialist clinics – only a few specialist clinics in the UK, such as those linked to larger research institutions, provide tailored treatment for hoarding disorder. This limits the number of individuals who can access appropriate care.
• Social stigma – many people with hoarding disorder experience shame or fear of judgement, leading to underreporting and reluctance to seek treatment. This reduces the pool of available participants for research and intervention.
• Co-occurring conditions – hoarding disorder often co-occurs with other mental health conditions such as depression, anxiety or OCD. This comorbidity can complicate diagnosis and treatment, making it harder for researchers to isolate and study hoarding-specific challenges.
• Complexities in research methodology – the relatively recent classification of hoarding disorder as a distinct mental health condition means that diagnostic criteria are still being refined. This creates challenges in ensuring consistent definitions and measures across research studies.
• Ethical concerns – gaining access to homes for research purposes can be challenging due to ethical concerns about participant privacy, safety and potential exploitation. This restricts researchers’ ability to study hoarding behaviour in situ.
• Lack of evidence-based interventions – there is a shortage of evidence-based treatment options specifically for hoarding disorder. CBT is often used, but its efficacy varies, and not all individuals with hoarding disorder respond well to this approach. More research is needed to explore alternative or supplementary treatments.
• Lack of training – mental health professionals often lack training specific to hoarding disorder. Even when hoarding is identified, practitioners may not have the skills or tools necessary to provide effective interventions.
• Late diagnosis – hoarding disorder typically manifests in adulthood, often following a long period of progressive symptoms. Research into early detection and prevention is still in its infancy, making it harder to intervene before the condition becomes severe.
• Long-term outcomes – there is limited research on the long-term outcomes of treatments for hoarding disorder. Many studies focus on short-term interventions, making it difficult to understand how to sustain positive outcomes over the long term.
• Social services and housing issues – hoarding can lead to housing problems and unsafe living conditions, resulting in conflicts with social services, landlords and local authorities. Research into how policy and housing services can better support people with hoarding disorder is underdeveloped.
• Legal and ethical challenges – researchers must navigate complex legal and ethical concerns around hoarding, particularly when individuals’ living conditions pose health and safety risks, making it challenging to study the disorder comprehensively.

Conclusion

Advancing research and awareness of hoarding behaviour is essential for improving the lives of those affected by this complex and often misunderstood condition. 

Future research should focus on identifying underlying causes, refining treatment methods, and exploring the interplay between psychological, genetic and environmental factors. Increased awareness, both among professionals and the general public, will reduce stigma, promote early intervention and improve access to resources. Collaboration across disciplines, the use of technology and community engagement will further enhance our ability to address hoarding behaviour effectively, paving the way for more compassionate and evidence-based support systems.