Psychological Medicine

Original Articles

An exploratory study of the neural mechanisms of decision making in compulsive hoarding

D. F. Tolina1a2 c1, K. A. Kiehla3, P. Worhunskya1, G. A. Booka1 and N. Maltbya1

a1 The Institute of Living/Hartford Hospital, Hartford, CT, USA

a2 Yale University School of Medicine, New Haven, CT, USA

a3 MIND Institute and University of New Mexico, NM, USA


Background Prior studies have suggested unique patterns of neural activity associated with compulsive hoarding. However, to date no studies have examined the process of making actual decisions about whether to keep or discard possessions in patients with hoarding symptoms. An increasing body of clinical data and experimental psychopathology research suggests that hoarding is associated with impaired decision making; therefore, it is important to understand the neural underpinnings of decision-making abnormalities in hoarding patients.

Method Twelve adult patients diagnosed with compulsive hoarding, 17% of whom also met criteria for obsessive–compulsive disorder (OCD), and 12 matched healthy controls underwent functional magnetic resonance imaging (fMRI) while making decisions about whether or not to discard personal paper items (e.g. junk mail) brought to the laboratory as well as control items that did not belong to them. Items were either saved or destroyed following each decision.

Results When deciding about whether to keep or discard personal possessions, compulsive hoarding participants displayed excessive hemodynamic activity in lateral orbitofrontal cortex and parahippocampal gyrus. Among hoarding participants, decisions to keep personal possessions were associated with greater activity in superior temporal gyrus, middle temporal gyrus, medial frontal gyrus, anterior cingulate cortex, precentral gyrus, and cerebellum than were decisions to discard personal possessions.

Conclusions These results provide partial support for an emerging model of compulsive hoarding based on complications of the decision-making process. They also suggest that compulsive hoarding may be characterized by focal deficits in the processing of reward and changes in reward contingencies, particularly when these are perceived to be punishing.

(Received August 02 2007)

(Revised March 03 2008)

(Accepted March 15 2008)

(Online publication May 19 2008)


c1 Address for correspondence: D. F. Tolin, Ph.D., Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA. (Email: