Psychiatry · Year 3 · from Psychiatry

Case 3: Hoarding Disorder

Patient Demographics

  • Age: 62 years old
  • Sex: Female
  • Occupation: Retired librarian

Chief Complaint

Brought by adult daughter: "The city is threatening to condemn her house. You can barely walk through it."

History of Present Illness

The patient's daughter brings her to the clinic after receiving a citation from the city regarding unsafe living conditions in the patient's home. The patient has accumulated large quantities of possessions over the past 20 years since her husband's death. Rooms are filled floor to ceiling with newspapers, magazines, books, clothing, kitchenware, and various items purchased at yard sales. Only narrow pathways remain to navigate the home. The kitchen is unusable due to clutter, and she eats only takeout food. One bathroom is completely inaccessible; she uses the other, though it is also severely cluttered. She sleeps in a recliner because her bedroom is filled with items. She experiences significant distress at the thought of discarding possessions, stating each item has "potential usefulness" or "sentimental value." She acquires new items regularly, attending yard sales and accepting free items. She has refused her daughter's offers to help clean, becoming angry and distressed when items are touched. She does not see the accumulation as a problem, stating "I know where everything is." The daughter reports her mother has become increasingly isolated, declining visits because she is embarrassed about the home's condition.

Mental Status Examination

Appearance: Elderly woman, somewhat disheveled, clothing clean but wrinkled

Behavior: Cooperative but defensive when discussing possessions, becomes tearful when daughter mentions discarding items

Speech: Normal rate and volume

Mood: "Fine, everyone is overreacting"

Affect: Defensive, anxious when discussing belongings, otherwise euthymic

Thought Process: Linear, goal-directed, detailed when discussing possessions

Thought Content:

  • Strong emotional attachment to possessions
  • Beliefs about usefulness/need for items
  • Denial of severity of hoarding
  • No suicidal or homicidal ideation
  • No overt delusions (beliefs are exaggerated but not bizarre)

Perceptions: No hallucinations

Cognition: Alert, oriented x4; MoCA 26/30 (minor executive function deficits)

Insight: Poor - does not see hoarding as problematic

Judgment: Impaired by hoarding behaviors

Psychiatric Workup

Screening Tools:

  • Saving Inventory-Revised (SI-R): 72 (severe; clinical cutoff is 41)
  • Clutter subscale: 28
  • Difficulty discarding: 24
  • Acquisition: 20
  • Clutter Image Rating Scale: 8/9 (severe)
  • PHQ-9: 8 (mild depression)
  • MoCA: 26/30

Assessment of Living Conditions:

  • Fire hazard due to blocked exits
  • Fall risk due to narrow pathways
  • Unsanitary conditions (unable to clean properly)
  • No working kitchen
  • Social isolation

Diagnosis

Hoarding Disorder with Good or Fair Insight (F42.3)

DSM-5 Criteria:

  • Persistent difficulty discarding possessions regardless of actual value - present
  • Perceived need to save items and distress discarding - present
  • Accumulation of possessions that congest living areas - present (severe)
  • Hoarding causes clinically significant distress or impairment - present (safety hazard, social isolation, legal issues)
  • Not attributable to medical condition (e.g., brain injury, cognitive decline)
  • Not better explained by another mental disorder

Insight specifier: Fair insight - recognizes some difficulty but underestimates severity

Specifier: With excessive acquisition - present (yard sales, accepting free items)

Treatment Plan

Pharmacotherapy:

  • Start sertraline 50 mg daily
  • Titrate to 150-200 mg (limited evidence for medications in hoarding, but SSRIs may help)
  • May reduce anxiety about discarding

Psychotherapy (First-line):

  • CBT for Hoarding Disorder (specialized protocol)
  • Components:
  • Motivational interviewing (enhance motivation for change)
  • Skills training (organization, decision-making, categorization)
  • Exposure to discarding (gradual practice letting go of items)
  • Cognitive restructuring (challenge beliefs about possessions)
  • Acquiring prevention (reduce incoming items)

Practical Intervention:

  • In-home therapy sessions (essential for hoarding)
  • Sorting practice with therapist support
  • Start with less emotionally significant items
  • Clear pathways for safety first
  • 15-30 minutes daily sorting practice

Address Immediate Safety:

  • Work with city to develop remediation plan
  • Clear pathways to exits as immediate priority
  • Coordinate with Adult Protective Services if self-neglect
  • Consider professional organizer with hoarding experience

Family Involvement:

  • Educate daughter about hoarding disorder
  • Family should not discard items without patient consent (causes trauma)
  • Support groups for family members

Prognosis:

  • Hoarding disorder is chronic and difficult to treat
  • CBT produces modest but meaningful improvement
  • Relapse prevention is essential
  • Treatment may require years

Follow-up:

  • Weekly therapy sessions
  • Home visits
  • Regular assessment of living conditions

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