Hoarding disorder: Questions and controversies

Hoarding disorder (HD) is characterized by distress and difficulty letting go of possessions, leading to clutter that congests living spaces and interferes with daily activities. HD is common, with an estimated overall pooled prevalence of 2.5% of the general population. Because it is a relatively newly defined disorder, there are questions and controversies regarding its diagnosis and treatment that warrant exploration. In this manuscript, we clarify diagnostic boundaries between HD and related neuropsychiatric conditions, and consider how both shared and unique features of HD may inform strategies for treatment. We additionally discuss specific manifestations of hoarding behavior (e.g., animal hoarding); review motivations, beliefs, and characteristics that may contribute to hoarding behaviors; examine available evidence regarding the efficacy of different treatment modalities; highlight the challenges of engaging individuals who do not want care; and suggest a potential explanatory model for insight impairment in HD. •Hoarding disorder (HD) is common and impairing.•Disordered object attachment in HD may be related to anxious/insecure interpersonal attachment.•CBT for HD is efficacious, but more tolerable and effective treatments are needed.•Insight impairment in HD may reflect alterations in executive function and the processing of error.