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date: 12 December 2019

(p. 364) (p. 365) The Structured Interview for Hoarding Disorder (SIHD; v. 2.0)©

(p. 364) (p. 365) The Structured Interview for Hoarding Disorder (SIHD; v. 2.0)©

King’s College London, Institute of Psychiatry and the Karolinska Institutet, Stockholm

Permissions: The authors hold the copyright but the scale is free to use by researchers and clinicians who have an interest in hoarding disorder.

Citation: If you use the instrument, please cite it appropriately as follows: Nordsletten, A. E., Fernández de la Cruz, L., Pertusa, A., Reichenberg, A., Hotopf, M., Hatch, S. L., & Mataix-Cols, D. (2013). The Structured Interview for Hoarding Disorder (SIHD): Development, further validation, and pragmatic usage. Journal of Obsessive-Compulsive and Related Disorders, 2 (3), 346–350.

Correspondence: For any correspondence regarding the SIHD, please contact Dr Pertusa (alberto.pertusa@kcl.ac.uk) or Professor Mataix-Cols (david.mataix-cols@ki.se).

Instructions for the rater

The questions contained in this interview relate to each of the 6 criteria needed to evaluate the presence of hoarding disorder and its two specifiers. These questions appear in bold print and should be asked during the course of the interview, whereas the text in italics is present only to assist the rater. For a diagnosis of hoarding disorder all 6 criteria must be endorsed. If any of the criteria are not met, the diagnosis can be ruled out. The specifiers are only relevant for individuals endorsing all diagnostic criteria.

It is important to carefully distinguish hoarding disorder from nonpathological collecting, as well as from the general medical and DSM-5 conditions that may result in the accumulation of possessions (e.g., brain injury, obsessive-compulsive disorder, autism spectrum disorder, etc.). Therefore, this interview should ideally be used as a complement to a more comprehensive assessment of the patient’s medical history and psychopathology. If in doubt about the endorsement of a specific criterion, the rater should complete the interview and consider all available information before rendering a diagnosis. Special sections are provided at the end of this document to assist with some of the most common differential diagnoses.

Ideally, the interview should be conducted directly with the sufferer and in the person’s home. If the individual of interest is not available or refuses to be interviewed, this interview may be administered to a reliable informant. This approach may also be employed for cases presenting with poor or absent insight, where the subject’s responses may significantly conflict with the reality of the hoarding behavior. In cases where there is a strong clinical suspicion of HD (e.g., based on familial or legal reports), paired with poor insight on the part of the hoarding individual, the interviewer should use his or her clinical judgment to determine the relevance of each criterion.

If a home visit is not possible, photographs of the person’s home environment may be helpful to assess the presence of clinically significant clutter (Criterion C). The presence of clutter may also be quantified with other available instruments such as the Clutter Image Rating Scale1. On the Clutter Image Rating Scale, a room score greater than 4 is usually indicative of clinically significant clutter, however this is only for guidance and all available information needs to be taken into account.

Criterion A

Persistent difficulty discarding or parting with possessions, regardless of their actual value.

Do you experience difficulty discarding or parting with possessions? This may include throwing away, selling, giving away, recycling, and so on.

  • YESgo to next question

  • NOhoarding disorder not present

How long have you had this problem? ___________________months/years.

If hoarding is a persistent problem that has been present for a long period of timeCriterion A is presentgo to next question

(p. 366) If hoarding has been present for a relatively short period of time (i.e., only a few weeks or months), inquire about temporary factors that may account for the difficulties discarding (e.g., recent inheritance of a large number of possessions, moving to a different home). If the hoarding behavior can be entirely explained by these circumstanceshoarding disorder not present

What items do you find most difficult to discard? Please list items below (both valuable and worthless items should be taken into account for the diagnosis).

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

If CRITERION A is present, place a check in the circle and go to CRITERION B

Criterion B

This difficulty is due to a perceived need to save items and to distress associated with discarding them.

Do you intentionally keep these items (are they important/ useful for you)?

Do you generally feel distressed or upset when discarding possessions?

These questions are intended to evaluate whether the accumulation of objects is intentional/active and whether the discarding process causes distress (or would cause distress, in cases where discarding is entirely avoided). Where the accumulation is due to passive accumulation, or where the discarding process does not cause distress, the hoarding may be subclinical or attributable to an alternative psychopathology.

  • If YES to both of the above questions → CRITERION B is present

  • If NO to any of the above questions → hoarding disorder not present

If CRITERION B is present, place a check in the circle and go to CRITERION C

Criterion C

The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).

Do you have a large number of possessions that congest and clutter the main rooms in your home? Note that “clutter” refers to the presence of a large number of items that are lying about in a disorganized way. The question refers to the key living spaces such as bedrooms, kitchen, or living room. Here exclude garages, attics, lofts, basements, and other areas that may commonly be cluttered in the homes of nonhoarding individuals.

To meet Criterion C, active living spaces that are necessary for everyday life must be cluttered to the extent that their use is substantially compromised. If unclear, ask about the level of obstruction for particular rooms or domestic activities:

Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home?

  • Kitchen (sink, fridge, worktop, etc.):

    __________________________________________

    __________________________________________

  • Bathroom (sink, toilet, shower/bathtub, etc.):

    __________________________________________

    __________________________________________

  • Bedroom (bed, wardrobe, drawers, etc.):

    __________________________________________

    __________________________________________

  • Living room (sofa, chairs, table, floor, etc.):

    __________________________________________

    __________________________________________

  • Other (halls/corridors/stairs; difficult to walk through due to piles of items):

    __________________________________________

    __________________________________________

    • YESCRITERION C is present

    • NOgo to the next question

Have other people (such as family members or local authorities) helped you to remove (or forcibly removed) some of your possessions? If so, how cluttered was your house/room before their intervention? Explore to what extent the living spaces are currently clutter free because of the intervention of other people. If this is the case, the criterion can be endorsed in the absence of significant clutter.

  • YESCRITERION C is present

  • NOhoarding disorder not present

If CRITERION C is present, place a check in the circle and go to CRITERION D

Criterion D

(p. 367) The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

Do the difficulties discarding or the clutter cause you distress? Note that some individuals with poor insight may not acknowledge being distressed, though any attempts to discard possessions by third parties will result in distress or anger.

Do the difficulties discarding or the clutter interfere with your family life, friendships, or ability to perform well at home or work? Note that the impairment may only be apparent to those around an individual with poor insight.

  • If YES to one or both of the above questions → CRITERION D is present

  • If NO to both questions → hoarding disorder not present

If CRITERION D is present, place a check in the circle and go to CRITERION E

Criterion E

The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

Do you have any general medical conditions, a history of head injury or cerebrovascular disease? Review past medical history for neurological dis-orders and inquire about history of severe head trauma. Some relevant conditions include traumatic brain injury, surgical resection for the treatment of a tumor or seizure control, cerebrovascular disease, infections of the central nervous system (e.g., herpes simplex encephalitis), or neurogenetic conditions such as Prader-Willi syndrome. If appropriate and available, additional investigations (e.g., EEG, CT, MRI, neuropsychological assessment) may be useful to help confirm the presence of brain damage.

  • YESgo to next question

  • NOCRITERION E is not present

Did you have difficulties with discarding/clutter before you became ill? Try to establish whether there is a clear temporal link between the medical condition and the onset of the hoarding behavior.

  • YESCRITERION E is present

  • NOif hoarding clearly preceded by a general medical conditionhoarding disorder not present

If CRITERION E is present, place a check in the circle and go to CRITERION F

Criterion F

The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

Ideally, this interview should be administered in the context of a full psychopathological assessment. If this is not available, ask the interviewee or informant about current or past psychiatric diagnoses. Note current and lifetime mental dis-orders here:

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

The presence of another mental disorder does not preclude the diagnosis of hoarding disorder. However, hoarding disorder is not diagnosed if the symptoms are judged to be secondary to or a direct consequence of another mental disorder, such as:

  • Obsessions or compulsions in obsessive-compulsive dis-order.

  •  Special or circumscribed interests in Autism Spectrum Disorder or intellectual disability.

  • Decreased energy, psychomotor retardation or fatigue in Major Depressive Disorder.

  • Delusions or negative symptoms in Schizophrenia Spectrum or other psychotic disorders.

  • Cognitive deficits in a Neurocognitive disorder such as frontotemporal lobar degeneration or Alzheimer’s Disease.

If another mental disorder is present, it is useful to establish the temporal relation with the onset of hoarding symptoms.

(p. 368) PLEASE SEE APPENDIX FOR FURTHER GUIDANCE ON THE DIFFERENTIAL DIAGNOSIS WITH OBSESSIVE-COMPULSIVE DISORDER AND AUTISM SPECTRUM DISORDER.

If CRITERION F is present, place a check in the circle

If all six criteria are met, the diagnosis of hoarding disorder should be coded.

If hoarding disorder is present, please place a check mark in the circle.

Specifiers

Specifiers

If hoarding disorder has been diagnosed, assess the presence of Excessive Acquisition and determine the Degree of Insight.

Excessive Acquisition Specifier

If the difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

Do you often acquire free items that you don’t need or for which you have no available space at home?

  • YES

  • NO

Do you often buy items that you don’t need, you can’t afford, or for which you have no available space at home?

  • YES

  • NO

Do you sometimes steal things that you don’t need, you can’t afford, or for which you have no available space at home?

  • YES

  • NO

If YES to any of the above 3 questions, With Excessive Acquisition should be coded.

Please place a check mark in the circle.

Insight Specifier

With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

With absent or delusional insight: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

To what extent do you think that your saving behavior (including your difficulties discarding, the resulting clutter, and the excessive acquisition) is problematic? If in doubt, refer back to information provided by the subject during the interview. If a reliable informant is present, check for discrepancies between the subject’s and the informant’s report and assess degree of insight accordingly.

  • Good/Fair insight

  • Poor insight

  • Absent/Delusional insight

Risk Assessment

This section helps the rater document any possible risks associated with problematic hoarding behavior. Please check whether the following are present:

Fire hazard

  • Are there flammable materials near a heat source?

  • Are there electrical hazards?

Blocked exits

  • Is the door that allows entry and exit to the house clear?

  • Are there additional doors within the property that are blocked?

Risk of falling

  • Is there a lack of clear pathways, impeding movement throughout the property?

  • Is it necessary to climb piles of objects in order to move between rooms or access objects?

Insects, infestations

  • Is there any evidence of insects (visible individuals, swarms, cobwebs, droppings)?

  • Are there any rodents or other infestations present?

Unhygienic conditions

  • Is there human or animal waste/vomit in the property?

  • Is there moldy or rotten food or dirty food containers in the kitchen or other areas of the property?

  • (p. 369) Is the sink, washbasin, bathroom, shower, or bathtub clogged or notably dirty?

  • Is there standing water anywhere in the property (sink, tub, basement, other)?

  • Does the property emit a strong odor?

Neglect of children, elder, or disabled people

  • If there are children, elders, or disabled people present, is there sufficient space to permit routine care and activities (e.g., a functioning kitchen, a place to eat meals, access to a shower or bathtub)?

  • If there are children present, is there sufficient space for them to sleep, play, or do school homework?

Animal hoarding

  • Are there starving, neglected, or maltreated animals on the premises?

Additional notes (please write any additional information that may be useful for risk assessment)

APPENDIX: DIFFERENTIAL DIAGNOSIS ASSISTANT

APPENDIX: DIFFERENTIAL DIAGNOSIS ASSISTANT

HOARDING AS A SYMPTOM OF OBESESSIVE-COMPULSIVE DISORDER

This section will assist the rater in assessing whether the hoarding behavior is better conceptualized as a symptom of Autism Spectrum Disorder (ASD). First, establish whether ASD is present (independently of the hoarding). If there is an established diagnosis of ASD, then ask the following questions:

Are your discarding difficulties caused by a specific obsession or fear?

  • YES (more likely in OCD)

  • NO

If hoarding is mainly driven by prototypical obsessionsHoarding disorder probably not present (hoarding likely to be a symptom of OCD)

Some examples of obsessions include:

  • Not discarding for fear of contaminating self or others.

  • Superstitious thoughts about discarding, for example, fear of something bad happening to a loved one if certain items are discarded.

  • Intense feelings of incompleteness.

  • Saving to maintain a record of all life experiences.

Is it difficult for you to discard things because this triggers endless rituals (e.g., washing or checking rituals)?

  • YES (more likely in OCD)

  • NO

If hoarding is the result of persistent avoidance of onerous compulsionsHoarding disorder probably not present (hoarding likely to be a symptom of OCD)

Do you enjoy/find it comforting to acquire possessions and being around them?

  • YES

  • NO (more likely in OCD)

Are you emotionally attached to most of the items you save?

  • YES

  • NO (more likely in OCD)

Do you save items mainly because they are valuable/beautiful or they may come in handy in the future?

  • YES

  • NO (more likely in OCD)

Do you keep body products (feces, urine, nails, hair, used diapers) or rotten food?

  • YES (more likely in OCD)

  • NO

Individuals with hoarding disorder are more likely to report that their hoarding behavior is pleasurable/comforting, that they are emotionally attached to their saved objects, or that they save due to a belief that their items will prove handy in the future. The retention of body products or rotten food is, conversely, more often seen in OCD.

REMEMBER that both OCD and hoarding disorder may be diagnosed at the same time when severe hoarding symptoms appear concurrently with other typical symptoms of OCD but are judged to be independent from these symptoms. In case of diagnostic uncertainty, we recommend diagnosing OCD only.

Hoarding as a Symptom of Autism Spectrum Disorder

This section will assist the rater in assessing whether the hoarding behavior is better conceptualized as a symptom of Autism Spectrum Disorder (ASD). First, establish whether ASD is present (independently of the hoarding). If there is an established diagnosis of ASD, then ask the following questions:

(p. 370) Are the objects you save generally confined to a single, specific (circumscribed) area of interest?

A circumscribed interest, as seen in ASD, is typified by an intense interest in a specific, narrow, and often unusual topic. These interests may result in the accumulation of many similar objects, which are unified as exemplars of this area of interest. Individuals with hoarding disorder are more likely to accumulate a wide range of objects (e.g., not confined to a single area of interest, or unified by a highly specific characteristic). A lack of organization is, furthermore, more typical in hoarding disorder.

  • YES (more likely in ASD).

  • NO

If yes to the preceding question: What is the area of interest?

Do the objects you save largely share a particular, physical characteristic (e.g., material, texture or shape)?

  • YES (more likely in ASD)

  • NO

In ASD, the gathering of many like objects may signal an unusual, sensory preoccupation.

Examples of such preoccupations include intense fascinations with:

  • Visual stimuli (e.g., shiny objects, blinking lights, the motion of liquid – such as the rotation of water being flushed).

  • Auditory stimuli (e.g., the sound of a vacuum clean-er).

  • Tactile stimuli (e.g., smooth surfaces).

Do you enjoy organizing and classifying your possessions?

  • YES (more likely in ASD)

  • NO

If yes to the preceding question: Could you tell me a bit about your organizing system?

A focus on uniformity and order with one’s possessions is common to ASD. Unlike with OCD, in ASD this organization process should be egosyntonic and pleasurable.

If hoarding is primarily the result of a circumscribed interest, sensory preoccupation, or a desire to save/classify informationHoarding disorder probably not present (hoarding likely to be a symptom of ASD).

REMEMBER that both ASD and Hoarding disorder may be diagnosed at the same time when severe hoarding symptoms appear concurrently with other typical symptoms of ASD but are judged to be independent from these symptoms. In case of diagnostic uncertainty, we recommend diagnosing ASD only.

Notes:

(1) Frost, R. O., Steketee, G., Tolin, D. F., Renaud, S. (2008). Development and validation of the Clutter Image Rating. Journal of Psychopathology and Behavioral Assessment, 30(3), 193–203.