LEARNING OBJECTIVES
After reading this article you will be able to:
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• identify the key clinical features, diagnostic criteria and associated comorbidities of hoarding disorder as defined in contemporary classificatory systems
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• describe the major health, safety and functional risks associated with hoarding behaviour and explain how these issues give rise to housing, safeguarding and legal interventions
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• apply an understanding of hoarding disorder to psychiatric assessments undertaken for legal or housing proceedings, including consideration of disability, reasonable adjustments and mental capacity.
Hoarding disorder is characterised by a persistent difficulty discarding possessions, resulting in the accumulation of clutter that congests living areas and causes significant distress or impairment. It is distinguished from ordinary collecting or messiness by the extent of disorganisation and the functional impairment it causes; in severe cases, rooms become unusable for their intended purpose (e.g. beds are no longer available for sleeping, kitchens are no longer usable for cooking) (American Psychiatric Association 2013; World Health Organization 2022).
People with hoarding disorder often form strong emotional attachments to objects. Common justifications for saving items include their potential utility, sentimental value or not wanting to be wasteful; many patients feel responsible for the fate of their possessions and fear losing important information (Frost Reference Frost, Steketee and Tolin2015). When faced with discarding, people with hoarding disorder experience intense distress, which typically leads to avoidance and perpetuates the hoard (Levy Reference Levy, Nett and Tolin2019).
Clutter can significantly disrupt daily functioning by obstructing access to essential living areas, such as beds, kitchens and bathrooms, and by creating safety risks, leading to tripping hazards and fire danger. When clutter prevents normal use of the home, the situation justifies clinical concern. Hoarding disorder is associated with substantial impairment in several domains of functioning (Nutley Reference Nutley, Read and Martinez2022).
Epidemiology of hoarding disorder
Hoarding behaviour is relatively common in milder forms, but only a small proportion of people meet the clinical threshold for hoarding disorder. Epidemiological studies estimate that approximately 2–6% of adults meet criteria for hoarding disorder (Bratiotis Reference Bratiotis, Muroff and Lin2021). Onset often occurs in adolescence (mean age approximately 16 years) and symptoms tend to worsen with age, which means many individuals come to clinical attention in later life (Zaboski Reference Zaboski II, Merritt, Schrack and Gayle2019). Historically, this was often conceptualised within the construct of Diogenes syndrome, a behavioural disorder typically characterised by extreme self-neglect, social withdrawal, hoarding of rubbish or items of little value, poor personal hygiene, refusal of help, lack of shame or concern about one’s living conditions, and a degree of social isolation.
Comorbidity of hoarding disorder with other mental health conditions is high: over 60% have at least one comorbid disorder, including depression and anxiety disorders (Frost Reference Frost, Steketee and Tolin2011; Timpano Reference Timpano, Bainter and Goodman2020). Hoarding was once considered a subtype of obsessive–compulsive disorder (OCD); however, in contrast to OCD, people with hoarding disorder often have limited insight into the problem; they may not be particularly distressed by their hoarding, even when the problem is obvious to others, whereas people with OCD typically experience distress and recognise their symptoms as problematic (Bratiotis Reference Bratiotis and Woody2020).
Recent evidence suggests that hoarding is more strongly associated with attention-deficit hyperactivity disorder (ADHD) than with OCD. One study found that 20% of adults diagnosed with ADHD exhibited clinically significant hoarding symptoms (Morein-Zamir Reference Morein-Zamir, Kasese and Chamberlain2022). A more recent study showed that 32.1% of adults with ADHD met criteria for hoarding disorder, compared with 8% with OCD and 4% of controls (Grassi Reference Grassi, Moradei and Cecchelli2023).
Diagnostic classification
DSM-5
Hoarding disorder first was formally recognised as a separate diagnosis in DSM-5 (American Psychiatric Association 2013); previously, hoarding was only mentioned as a possible symptom of OCD or other conditions. The inclusion in DSM-5 reflected a growing consensus that hoarding has distinct clinical features and requires tailored interventions (Fontenelle Reference Fontenelle and Grant2014) (Box 1).
Hoarding disorder: summary of the DSM-5 diagnostic framework
Hoarding disorder is characterised by a persistent pattern of retaining possessions and experiencing considerable difficulty disposing of them, irrespective of their practical or monetary value. This is commonly associated with a strong belief that items should be kept, and emotional distress when faced with discarding them. The resulting accumulation of belongings interferes with the normal use of domestic spaces, which may become overcrowded or unsuitable for their intended purposes. In some cases, living areas remain usable only because other people have intervened to remove possessions. For a diagnosis to be made, the difficulties must be associated with clinically significant distress or disruption to everyday functioning, including social relationships, occupational activities or household safety. The presentation must not arise directly from another medical or neurological condition, nor should it be better explained by another mental disorder, such as obsessive–compulsive disorder, a psychotic disorder, major depressive disorder or autism spectrum disorder.
Author’s summary of the diagnostic framework in American Psychiatric Association (2013)
ICD-11
Following DSM-5, the publication of ICD-11 also introduced hoarding disorder as a distinct diagnosis (World Health Organization 2022). The ICD-11 diagnostic criteria (Box 2) are similar to those in DSM-5, emphasising the accumulation of possessions due to excessive acquiring or difficulty discarding, leading to cluttered living areas and significant impairment.
ICD-11 definition of hoarding disorder (6B24)
Hoarding disorder is characterised by accumulation of possessions that results in living spaces becoming cluttered to the point that their use or safety is compromised. Accumulation occurs due to both repetitive urges or behaviours related to amassing items and difficulty discarding possessions due to a perceived need to save items and distress associated with discarding them. If living areas are uncluttered this is only due to the intervention of third parties (e.g., family members, cleaners, authorities). Amassment may be passive (e.g. accumulation of incoming flyers or mail) or active (e.g. excessive acquisition of free, purchased, or stolen items). The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019. https://icd.who.int/browse11. Licensed under the Creative Commons Attribution-NoDerivatives 3.0 IGO licence (CC BY-ND 3.0 IGO). The material is reproduced unchanged from the WHO ICD-11 classification and is covered by its Creative Commons licence. No separate permission approval has been obtained or is required for reproduction in accordance with that licence.
Theoretical conceptualisation of hoarding
Cognitive–behavioural model
A foundational theoretical account by Frost and Hartl (Reference Frost and Hartl1996) proposes that compulsive hoarding arises from a combination of vulnerabilities and learned behaviours. In their cognitive–behavioural model, hoarding is conceptualised as a multifaceted problem stemming from four key factors.
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(a) Information-processing deficits: many people with hoarding disorders have difficulty categorising, organising and making decisions about possessions. They may exhibit indecisiveness or attentional problems that lead to procrastination in sorting items.
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(b) Problematic emotional attachments: there is often an exaggerated emotional attachment to personal belongings. Objects may take on anthropomorphic qualities or serve as important sources of comfort and identity, making it painful to part with them.
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(c) Behavioural avoidance: discarding items triggers anxiety or grief, so individuals avoid this by saving everything. Over time, this avoidance of negative feelings reinforces the hoarding behaviour.
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(d) Erroneous beliefs about possessions: people with hoarding disorders frequently hold cognitive distortions, such as ‘I might need this someday’ or ‘Throwing this away would be a terrible mistake’, even for broken or trivial items. These beliefs inflate the perceived value or usefulness of objects beyond reason.
This model has guided much of the subsequent research, and later refinements have highlighted additional contributing factors, such as perfectionism (e.g. needing to find the ‘perfect’ way to dispose of an item), fear of decision-making and dysfunctional attachment styles.
Neurobiological models
Although there are no clear neurobiological models for hoarding disorder, several neuroimaging studies have found differences in specific brain regions between people with hoarding disorder and healthy controls (Mizobe Reference Mizobe, Ikari and Tomiyama2022). In one study, people with OCD exhibiting hoarding behaviours showed significantly greater activation in the bilateral anterior ventromedial prefrontal cortex (VMPFC) when confronted with hoarding-related stimuli, compared with both people with OCD without hoarding behaviours and healthy controls. The heightened activity was specific to hoarding-related anxiety and not observed during general aversive stimuli (An Reference An, Mataix-Cols and Lawrence2009).
Assessment tools and clutter indices
Assessment of hoarding severity is important for clinical management and research. Assessment should include direct observation of the home, as well as clinical interview and structured questionnaires. Clinicians may try to conduct home visits to gauge clutter, but practical constraints and the avoidance by people with hoarding disorder can make this difficult. Key instruments include ‘clutter indices’, which are based on visual rating scales.
Saving Inventory–Revised
The Saving Inventory–Revised (SI-R) (Frost Reference Frost, Steketee and Grisham2004) is one of the earliest and most widely used self-report measures of compulsive hoarding. It is a 23-item questionnaire with three subscales: difficulty discarding, excessive clutter and excessive acquisition. Each item is rated (typically on a 0–4 or 0–5 scale) to produce a profile of hoarding severity. The SI-R has good psychometric properties, with high internal consistency, test–retest reliability and convergent validity with related constructs. The SI-R has been considered the gold-standard self-report measure in hoarding research and has been used to define severity thresholds and track treatment outcomes. However, its length can be a drawback in routine practice, leading some to create shorter versions for quick screening.
Hoarding Rating Scale
The Hoarding Rating Scale (HRS) (Tolin Reference Tolin, Frost and Steketee2010a) is a brief five-item instrument designed to capture the core dimensions of hoarding in a quick interview or self-report format. Each item corresponds to one of the major features of hoarding disorder: clutter, difficulty discarding, excessive acquisition, emotional distress about hoarding, and functional impairment. The HRS has been validated in both interview form (HRS-I) and self-report form, with good test–retest reliability. The brevity of the HRS makes it useful in primary care or screening settings, and research indicates that it is sensitive to change with treatment.
Clutter Image Rating
The Clutter Image Rating (CIR) (Frost Reference Frost, Steketee and Tolin2008), often referred to as a ‘clutter index’, provides an objective, visual measure of clutter severity in key living areas. It consists of sets of standardised photographs of rooms (typically a living room, bedroom and kitchen) at nine levels of increasing clutter, from completely tidy (level 1) to extremely cluttered (level 9). This allows a quantifiable rating of clutter without requiring an in-person home inspection. A rating of level 4 or above typically indicates clinically significant clutter requiring intervention. The CIR is reliable and valid for assessing hoarding (Dozier Reference Dozier and Ayers2015). One advantage of the CIR is that it captures the functional impact of hoarding. Generally, clutter at level 4 or above on the CIR is associated with substantial impairment (for instance, limited mobility in the home, fire hazards), and clinicians may use that threshold to identify when a situation has moved from subclinical hoarding to a disorder requiring active intervention.
Treatment of hoarding disorder
Hoarding disorder is a chronic condition, with many people experiencing a relapsing and remitting or chronically escalating course. Episodes of relapse or exacerbation of symptoms are often precipitated by psychosocial stressors (Tolin Reference Tolin, Meunier and Frost2010b).
Pharmacological treatment
Pharmacological treatment for hoarding disorder has been examined in a relatively small number of studies, and the evidence remains mixed. Earlier work suggested that individuals with hoarding symptoms responded less consistently to serotonergic medication than those with non-hoarding OCD. However, retrospective analyses of OCD cohorts and prospective studies involving individuals with hoarding disorder suggest that this position may be overstated (Saxena Reference Saxena, Frost and Steketee2014). Saxena argued that selective serotonin reuptake inhibitors (SSRIs) can produce improvements in hoarding symptoms comparable to those seen in non-hoarding OCD, and that symptom reduction achieved with medication may be similar in magnitude to that observed with cognitive–behavioural therapy (CBT).
An open trial of venlafaxine extended release also demonstrated reductions in hoarding severity, although the absence of a control arm limits the strength of the conclusions (Saxena Reference Saxena, Frost and Steketee2014). Preliminary exploration of stimulants, based on the association with executive-function deficits, remains inconclusive.
Overall, pharmacotherapy may offer benefit for some individuals, but controlled evidence is limited, and medication is generally used alongside psychological interventions, which remain the primary established treatment for hoarding disorder.
Psychological treatment
Psychological intervention is usually the primary focus in the treatment of hoarding disorder, unless symptoms are secondary to, or significantly driven by, a comorbid condition that responds well to pharmacological treatment, such as major depression or OCD. Psychological treatment can produce meaningful improvements in clutter, discarding behaviour and day-to-day functioning, but progress is usually gradual and requires sustained engagement.
Cognitive–behavioural therapy, adapted specifically for hoarding, is the most established approach. It typically includes psychoeducation, cognitive restructuring, organisational and decision-making skills, and graded exposure to discarding and non-acquiring. In-home sessions are often incorporated to address avoidance and facilitate behavioural change in context.
Response to CBT adapted for hoarding is variable and is often influenced by factors such as insight, comorbidities, avoidance and difficulties with organisation and decision-making. Relapse remains a risk where support is withdrawn prematurely or other stressors are not addressed alongside psychological treatment.
Motivational interviewing is frequently integrated to support engagement, particularly in individuals with limited insight or ambivalence about change. Group-based CBT and peer-led interventions, such as the Buried in Treasures programme (Tolin Reference Tolin, Frost and Steketee2013), offer scalable models with evidence of comparable efficacy. Acceptance and commitment therapy (ACT) has shown emerging promise by targeting psychological flexibility and values-based behaviour. These interventions are typically prolonged and intensive. Optimal outcomes are more likely when treatment is embedded within a coordinated, multidisciplinary model that can address both psychological and environmental complexity.
In practice, treatment planning should be clear, long term and realistic with regard to resourcing. A useful approach is to identify a named clinician or care coordinator who can maintain continuity, build trust, coordinate the relevant agencies and monitor progress over time. Multi-agency management should include baseline assessment of clutter severity and associated risks, detailed assessment and treatment of comorbid conditions, collaboratively agreed decluttering goals, and regular review of mental well-being and cognitive and environmental change. A comprehensive management plan may involve coordinated input from mental health services, housing providers, adult social care, fire services and specialist hoarding support. Outcome measures should include not only symptom change but also functional indicators such as room usability, access for repairs, reduction in fire risk and the person’s ability to engage with support.
The implications of hoarding
Hoarding poses significant health and safety hazards to the individual, cohabitants, neighbours and the broader community. Hoarding disorder lies at the intersection of mental health, legal and public health domains. The legal situation explored in this section relates to UK legislation.
Health and safety risks
Health and safety concerns associated with hoarding provide the primary justification for legal intervention. Hoarded homes often contain fire hazards (e.g. stacks of papers near heat sources), blocked exits, unsanitary conditions (rotting food, animal waste) and infestations of pests. One study found that only 40% of fires in a house with hoarding were contained to the room of origin, compared with a 90% containment rate in average residential fires (Lucini Reference Lucini, Monk and Szlatenyi2009). Hoarding may lead to injury by tripping or the toppling of cluttered piles of belongings. Malodours, infestation and the risk of fire may affect adjacent properties, especially in flats/terraced housing. Hoarding is not just a private issue but a community risk, placing a duty of care on local authorities or landlords to act.
Housing – possession proceedings
Most tenancy agreements include clauses requiring tenants to keep the property in reasonable condition, not cause damage or nuisance, and comply with health and safety standards. Hoarding can breach these terms – for example, causing property damage through neglect, creating fire risks or attracting vermin might be considered a ‘nuisance or annoyance’ to neighbours.
The Housing Act 1985: Schedule 2
For individuals with secure tenancies (local authority tenants), Schedule 2, Ground 3 of the Housing Act 1985 provides a ground for possession (i.e. eviction) where:
‘The condition of the dwelling-house or of any of the common parts has deteriorated owing to acts of waste by, or the neglect or default of, the tenant or a person residing in the dwelling-house and, in the case of an act of waste by, or the neglect or default of, a person lodging with the tenant or a sub-tenant of his, the tenant has not taken such steps as he ought reasonably to have taken for the removal of the lodger or sub-tenant.’
Similarly, for individuals with assured tenancies (generally, housing association tenants) and assured shorthold tenancies (some housing association tenants and all private sector tenants), Schedule 2, Ground 13 of the Housing Act 1988 provides a ground for possession where:
‘The condition of the dwelling-house or any of the common parts has deteriorated owing to acts of waste by, or the neglect or default of, the tenant or any other person residing in the dwelling-house and, in the case of an act of waste by, or the neglect or default of, a person lodging with the tenant or a sub-tenant of his, the tenant has not taken such steps as he ought reasonably to have taken for the removal of the lodger or sub-tenant.’
Discretionary grounds for possession
Breaches of tenancy terms or of the Grounds outlined above are what is known as discretionary grounds for possession: this means that the landlord will need to satisfy the court not only that the ground is made out but also that it would be reasonable to make a possession order. A landlord may struggle to show that it is reasonable to make a possession order if the tenant’s behaviour is evidenced by expert opinion to have arisen in consequence of a hoarding disorder and the landlord cannot demonstrate that they have taken steps to try to assist the tenant to address this behaviour.
The Equality Act 2010: discrimination, proportionate means and reasonable adjustments
Importantly, a hoarding disorder may be considered a disability within the meaning of the Equality Act 2010. Under section 6 of the Act, a disability is defined as a physical or mental impairment that has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities.
Under section 15 of the Act, a person (A) discriminates against a disabled person (B) if:
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(a) A treats B unfavourably because of something arising in consequence of B’s disability, and
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(b) A cannot show that the treatment is a proportionate means of achieving a legitimate aim.
If a landlord issues possession proceedings against a tenant who has hoarding disorder, the tenant may seek to argue that the decision to seek possession amounted to discrimination. Expert psychiatric evidence may assist in establishing that the tenant’s hoarding disorder constitutes a disability within the meaning of section 6 of the Equality Act 2010, and that the hoarding behaviour alleged by the landlord in support of the possession claim arose in consequence of that disability. The landlord will still be entitled to a possession order if they can show that the decision to bring possession proceedings is a proportionate means to achieving a legitimate aim.
It will be particularly difficult for a landlord to show that a possession claim is a proportionate means of achieving a legitimate aim if they have not taken steps to assist the tenant to address their hoarding behaviour, for example by referring the tenant to social services, which may arrange expert support with decluttering.
Alongside this, under section 20 of the Equality Act 2010, landlords have a duty to make reasonable adjustments for tenants with a disability. Reasonable adjustments in the context of an individual with hoarding disorder could include steps such as providing access to an additional storage facility, or support in clearing the property, for example with provision of a skip.
Applications to the Court of Protection: litigation capacity, best interests decisions
When instructing psychiatric experts to consider whether a tenant has a hoarding disorder, housing solicitors will often ask the expert to consider whether the tenant has litigation capacity. The expert will need to consider whether the tenant understands the litigation, but also whether they can weigh and act on advice given. If the tenant has no insight into their hoarding behaviour and cannot address their behaviour, even with help, then it may well be that they do not have litigation capacity. Where a tenant lacks capacity to make decisions about the removal of accumulated possessions, an application to the Court of Protection may be necessary to determine whether such removal would be in their best interests. Depending on the circumstances, an application may be brought by a local authority or another interested party, potentially a social housing provider or private landlord, subject to any requirement to obtain permission to apply.
The Court of Protection case AC and GC [2022] is significant because it balanced human rights with the significant risks related to hoarding disorder, establishing that a 92-year-old with dementia and her son, who had hoarding disorder, could have their home cleaned by authorities, yet ultimately return to it. The ruling highlighted the ‘best interests’ assessment over simply removing individuals.
Avoidance versus non-cooperation
One potential situation is that the tenant expresses a genuine intention to declutter and may agree in principle with treatment, support or legal advice, but is unable to translate this into sustained action. Avoidance can also be a core maintaining feature of hoarding disorder. Missed appointments, refusal of access or repeated failure to complete agreed clearing tasks may be interpreted by landlords or other agencies as non-cooperation. However, these factors may reflect impairments in executive functioning and the anxiety, indecisiveness and distress often inherent to the disorder, or reflect the presence of comorbid conditions such as depression or autism spectrum disorder.
In medico-legal contexts, this distinction is important as a person may be able to describe the issues and repeat advice, yet still be unable to weigh, organise and act on that advice in a consistent way. Such difficulties may therefore be relevant to assessments of litigation capacity.
The courts will always balance the need to protect vulnerable tenants against concerns about the impact on the health and safety of other tenants. In cases where the tenant has a hoarding disorder but is deemed to have capacity and refuses to address their behaviour, even with assistance, then the courts will likely make a possession order. This is particularly the case since the Grenfell Tower tragedy in London, given increased awareness of fire risks in multi-occupancy buildings.
Rates of eviction
Official data on evictions due to hoarding are not captured by local authorities because hoarding is not a specific category in the reportable reasons for eviction (Hanson Reference Hanson and Porter2021). However, a study of self-identified hoarding found that roughly 8–12% of individuals with hoarding behaviour had been evicted or faced eviction due to their hoarding behaviour (Tolin Reference Tolin, Frost and Steketee2008).
Housing – injunction proceedings
Local authority and housing association landlords also have the option of issuing an application in the County Court under the Anti-Social Behaviour, Crime and Policing Act 2014 for an injunction (court order) requiring the tenant to address the clutter. The Act defines anti-social behaviour as ‘conduct capable of causing housing-related nuisance or annoyance’ and therefore can cover hoarding-related behaviour.
However, the Court will not make an injunction order against an individual who lacks the mental capacity to understand the order and/or to comply with the terms (often referred to as ‘Wookey capacity’ following the case of Wookey v Wookey [1991]). Where an individual lacks insight into their hoarding disorder, they may well lack the capacity to comply with the terms of an injunction order requiring them to declutter their property.
The legal issues differ where a person with hoarding disorder occupies privately owned accommodation and there is no tenancy relationship. In such cases, significant concerns may still emerge through safeguarding, environmental health, fire safety or action by a mortgage lender or local authorities. In practice, these cases may engage public law and Court of Protection frameworks.
Health and social care
The Mental Health Act 1983, as amended in 2007, provides the legal framework in England and Wales for the detention and treatment of individuals with mental disorders in hospital, when certain conditions are met. Although hoarding disorder is formally recognised as a mental disorder, its presentation seldom satisfies the statutory criteria for detention for treatment under the Act.
A relevant framework for chronic hoarding cases is the concept of self-neglect in adult safeguarding. Individuals with hoarding disorder may struggle to maintain hygiene or nutritional needs because they are unable to access bathroom or kitchen facilities. The Care Act 2014 explicitly recognises self-neglect (which encompasses severe hoarding) as a condition that may prompt a Safeguarding Adults response by local authorities. Under Section 42 of the Care Act, if a local authority has reason to believe an adult with care and support needs is unable to protect themselves from self-neglect, the authority must make inquiries and decide on action to protect the person. This can lead to a multi-agency plan involving social services, mental health professionals, environmental health and sometimes the courts (via the Court of Protection) to ensure the individual’s well-being and the safety of their environment. The following case vignette is entirely fictitious and developed for educational purposes. Box 3 presents a hypothetical case vignette, developed for educational purposes, illustrating how a multi-agency intervention might be implemented in the management of hoarding disorder.
Case vignette: multi-agency intervention
Ms S is a 54-year-old woman living alone in a three-bedroom terraced house provided by a third-sector social housing organisation. Over several years, she has become increasingly socially isolated, and the property has become severely cluttered. The home contains large numbers of suitcases, prams, electric fans, substantial stockpiles of tinned food and cleaning products, as well as several cats living indoors. Access through the home is severely restricted, with some rooms entirely unusable.
The housing provider raised concerns about the inability to access the gas boiler, which Ms S repeatedly refused owing to anxiety about others entering the property and moving her possessions. The lack of access was assessed as a serious safety hazard, prompting the landlord to initiate possession proceedings under housing legislation. Had the court granted possession, Ms S would have faced eviction and likely homelessness.
A psychiatric assessment was arranged following referral from adult safeguarding. Ms S was diagnosed with hoarding disorder, consistent with ICD-11 criteria, marked by persistent difficulty discarding possessions, emotional distress at the thought of removal and significant impairment in daily living. Her condition was deemed to constitute a disability under the Equality Act 2010, owing to its chronic and substantial impact.
A multi-agency intervention was implemented, involving mental health services, housing officers and a specialist hoarding support worker. With therapeutic input and practical support, Ms S engaged intermittently with a phased decluttering plan, enabling boiler access while remaining in her home.
In cases involving neglect of a child or a vulnerable adult (where hoarding places the individual at risk of harm), a safeguarding referral to the local authority should be considered.
Conclusion
Since the introduction of formal diagnostic criteria, hoarding disorder is now more clearly defined and described, enabling more consistent identification in clinical practice. High rates of psychiatric comorbidity are well documented, and increasing evidence highlights a stronger association with attentional and executive-function deficits than with classic obsessive–compulsive phenomena.
Psychological treatment, particularly cognitive–behavioural interventions adapted specifically for hoarding, remains the primary therapeutic modality. Such interventions are typically prolonged and require sustained engagement. Clinical outcomes are optimised when psychological treatment is delivered in conjunction with practical environmental support and wider social input, reflecting the need for coordinated multidisciplinary intervention. Pharmacotherapy is generally directed towards co-occurring psychiatric disorders rather than core hoarding symptoms.
The legal implications of hoarding disorder are substantial. Severe clutter is associated with increased fire risk, structural damage and public health concerns, bringing individuals with hoarding disorder to the attention of landlords, housing authorities and safeguarding agencies. Hoarding disorder is associated with significant functional impairment, and, for those in rented accommodation, the behaviour may lead to claims for repossession.
In this context, courts are frequently required to balance the vulnerability of the individual against statutory duties to protect neighbours and the wider community. Considerations relating to disability discrimination, the need for reasonable adjustments, and assessments of mental capacity, particularly litigation capacity and the capacity to comply with injunctions, are often central to legal proceedings.
Effective management requires an approach that recognises both the chronic disability associated with the disorder and the potential risks to others. Continued collaboration between mental health services, housing professionals and legal practitioners, alongside further research, will be necessary to improve outcomes for individuals affected by this challenging condition.
MCQs
Select the single best option for each question stem
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1 The features central to the diagnosis of hoarding disorder in ICD-11 include:
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a accumulation of possessions due to sentimental value only
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b clutter that arises exclusively from deliberate acquiring
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c accumulation that compromises the use or safety of living areas
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d distress about clutter in the absence of functional impairment
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e hoarding behaviour occurring only in the context of obsessive–compulsive disorder.
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2 The psychological model most commonly used to conceptualise hoarding disorder is the:
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a psychodynamic conflict model
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b cognitive–behavioural model
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c interpersonal therapy model
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d behavioural activation model
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e social learning model.
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3 A visual rating of clutter severity across key living spaces is given by the:
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a Hoarding Rating Scale (HRS)
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b Yale–Brown Obsessive Compulsive Scale
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c Clutter Image Rating (CIR)
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d Saving Inventory–Revised (SI-R)
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e Mini-Mental State Examination.
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4 Under the Equality Act 2010, hoarding disorder may be considered a disability when:
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a it is accompanied by obsessive–compulsive disorder
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b it leads to a substantial and long-term adverse effect on daily functioning
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c the individual refuses all offers of help
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d the clutter is limited to one room
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e the landlord experiences inconvenience.
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5 In housing proceedings, an assessment of litigation capacity is required when:
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a there is disagreement between landlord and tenant
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b the tenant has limited insight into the consequences of their hoarding behaviour
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c the tenant is unable to pay rent
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d the property requires routine maintenance
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e the local authority initiates a standard inspection.
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MCQ answers
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1 c
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2 b
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3 c
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4 b
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5 b
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this study.
Acknowledgements
Artificial intelligence use: ChatGPT (OpenAI, San Francisco, CA, USA; https://chatgpt.com) was used on 15 May 2025 and in October 2026 to assist with editorial refinement, including tightening phrasing and improving clarity. All suggested amendments were reviewed by the authors, who retain full responsibility for the final manuscript.
Author contributions
A.I., S.A. and A.A. conceived the article, designed the structure and created the case vignette. All four authors drafted the main text and critically revised the manuscript. All authors also reviewed and approved the final version for publication.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
eLetters
No eLetters have been published for this article.