Hoarding disorder — assessment, differential and stepped care (MEQ)

(i) Definition and differentials. HD (OCRD): persistent difficulty discarding due to perceived need to save and distress on discarding, producing clutter that compromises intended use of living areas, with distress/impairment, not better explained by medical or other mental disorder; specify insight and excessive acquisition when present. Here: decades of saving, unusable bed/stove, free-item acquisition, distress at discard, no contamination/checking — classic primary HD. OCD: saving driven by contamination/harm/symmetry obsessions; other OCD themes; can co-occur. ADHD clutter: executive disorganisation without strong save beliefs; person often wants order. Severe domestic squalor: filth/self-neglect cluster, not synonymous with HD and not a DSM diagnosis (Snowdon). Discriminators: attachment quality, onset, cognition, hygiene vs clutter.^[1][2][7][8]

(ii) Assessment. Chronology; item types; acquisition; discard attempts; insight; family conflict; depression/risk. Home visit (gold standard): room-by-room function, exits, fire load, alarms, sanitation. Scales: SI-R (clutter, discarding, acquisition); Clutter Image Rating; ADL-H; squalor indices (HEI/ECCS) if filth. Collateral from family/fire officers. Cognitive screen if any late change.^[3][8]

(iii) Risk and capacity. Immediate risks: blocked egress, fire, falls, inactive alarms. Harm-reduction goals acceptable while engagement builds (pathways, working detectors, safe sleep/cook surfaces). Capacity is decision-specific (e.g. accepting exit clearance vs total property wipe). Assess understanding, appreciation, reasoning, communication. Statutes/guardianship are jurisdiction-specific; least restrictive principle; clutter alone does not automatically equal Mental Health Act criteria everywhere.^[7][8]

(iv) Psychological treatment. Specialised CBT for HD: motivational work; sorting/decision skills; graded discarding exposure; non-acquisition practice; cognitive restructuring of waste/identity/responsibility beliefs; home-based sessions preferred. Evidence: waitlist-controlled CBT trial and meta-analysis support benefit though residual clutter common. Avoid sole forced cleanout or generic counselling.^[4][5]

(v) Medication and multiagency. Pharmacotherapy evidence weaker than OCD: open-label paroxetine and venlafaxine XR signals exist; treat depression (PHQ-9 14) with standard antidepressants to aid engagement; do not promise decluttering from medication alone. Multiagency: fire service, housing, OT, psychology, GP; family psychoeducation against hostile surprise cleanouts; safety review dates; reassess if risk escalates.^[4][6][8]