Hoarding: Syndrome or Symptom

Until a few years ago, a person who was known to collect cats would have been called “the crazy cat person”, houses that were filled with stuff were referred to as “cluttered, filthy, or a pen sty.” Today, those expressions have been replaced with the terms: “hoarder or compulsive hoarding”. What is hoarding? Hoarding is the inability to resist acquiring and disposing of possessions, (many of which have limited use or no value) to the point that it compromises movement within the home and renders living areas unusable (Tolin, Frost, & Steketee, 2007). In addition to excessive acquiring, many people with compulsive hoarding often have problems keeping these items organized. Hoarders tend to put things on a stack or pile closest to them, this in turn leads to disorganization; which adds another element into why hoarders are reluctant to throw things away.

Compulsive hoarding is thought to be associated with “obsessive-compulsive disorder and obsessive-compulsive personality disorder” (Pertusa, A, Fullana, M, Singh, S, Alonso, P, et al. 2008). However, recent studies have suggested that hoarding might not be linked to OCD, but rather a syndrome on it own. This paper seeks to address the research surrounding the disorder, hoarding. In particular, this paper will examine recent findings, and problems that support the hypothesis that hoarding is actually a syndrome in itself, and should be classified as an anxiety disorder.

Statement of the Problem:
It is estimated that 1% to 2% of the population has hoarding problems that are severe enough that they affect their quality of their life. “ That’s 3 to 6 million people in the United States, 4 to 9 million people in the European Union, and 64 to 129 million people in the world” (Tolin,D, Frost, R, & Stekette, G, 2007). Yet, because many people who suffer from this disorder often hide their condition, the true prevalence of hoarding is thought to be much higher than current estimates suggest (Tompkins, M, & Hartl, T, 2009).
Mild to moderate hoarding has been associated with people diagnosed with OCD. Mild to moderate hoarding is described as “hoarding common items as a result of their emotional and/ or intrinsic value” (Pertusa, et al, October 2008). However this does not explain why people who have severe/compulsive hoarding show a “different psychopathological profile, which was characterized by the hoarding of bizarre items and the presence of other obsessions and compulsions related to their hoarding…(Pertusa, et al., October, 2008). These differences have lead researchers to hypothesize that compulsive/severe hoarding may not be linked to OCD, but rather a syndrome of its own.
As with any disease or disorder, the first step in knowing how to treat or cure it; is to know what is causing it. For years hoarding has been thought of as a secondary symptom of OCD. If it is not related to OCD then many people have been diagnosed and treated for a disorder that they do not have, which can explain why many people do not respond to treatment. In furthering research in this area it will provide doctors with a better understanding of how to treat and possible cure people who suffer from it.

Literature Review
A search for compulsive hoarding research produced 92 references, both full text and abstract. Further restricting the search to full text and scholarly journals produced a total of 14 articles. In attempting to answer the question of whether hoarding is actually a syndrome and not part of Obsessive Compulsive Behavior reduced the total amount of research articles to four. The article “I Can’t Let Anything Go: A Case Study with Psychological Testing of a Patient with Pathological Hoarding” though relevant in seeking to answer questions about hoarding and its relationship to cognitive problems, (what researcher stated as “cognitive impairments”) was excluded due to the type of study.
Historically, the first documented case of hoarding was discovered in the late 1940’s. Two brother’s Homer and Langley Collyer lived in a Harlem brownstone. Their house contained over 100 tons of trash and was rigged with booby traps. Based on conversations with neighbors it was discovered that the two men “expressed fears of intruders, both realistic and paranoid” (Koretz & Guthril, 2009). Due to the amount of items in the house, Langley Collyer had been crawling through tunnels to take care of his brother Homer (who was paralyzed and blind), and apparently got caught in one of his traps and killed. While Homer was found as soon as the police made their way to his room (he starved to death); Langley was not found until a month later buried under the debris (Koretz & Guthril, 2009).
Hoarding first appeared in the DSM- III in 1980, as one of the criteria for obsessive compulsive personality disorder. The DSM defines OCPD hoarding as the inability “to discard worn-out or worthless objects even when they have no sentimental value” (DSM-IV-TR; p. 729). However, recent evidence has questioned whether it should be included within OCPD for DSM-V because various studies have shown that hoarding is not very closely associated with the other OCPD criteria and that the disorder would be more reliable if it were excluded (Pertusa et al, 2008).
In 1996, Frost and Hartl published the first theoretical account of hoarding based on the limited empirical evidence available at that time. Their model proposed that hoarding resulted from a combination of information-processing deficits, dysfunctional beliefs about and exaggerated emotional attachments to possessions, as well as difficulty with organization. This study marked a change in the trajectory of research on hoarding. Before 1996, fewer than 10 studies had been published on the topic. By 2009, more than 20 articles per year were being published about hoarding. “These studies have covered a wide variety of topics including phenomenology, epidemiology, genetics, brain function, treatment and co-morbidity” (Tolin, Kiehl, Worhunsky, Book, et al, 2009).

Studies involving the use of functional magnetic resonance imaging (fMRI) showed that compulsive hoarders displayed more activity in the lateral cortex and parahippocampal gyrus, when deciding to discard or keep an item. These results suggest that hoarding is possibly due to deficits in the decision-making process (Tolin, Worhunsky, Book, et al, 2009).
Studies suggest that people who hoard have a greater attachment to possessions, compared to non-hoarders. These attachments are associated with beliefs about the meaning and importance of items; for instance some hoarders believe that the items are directly related to their safety, and some feel that these items are part of their identity. Others feel the need to control these items, in doing so they control of their life (Steketee, Frost, & Kyrios, 2003).
Studies showed that people diagnosed with hording and Obsessive Compulsive Disorder have a different psychopathological profile, they tend to collect bizarre items, along with OCD rituals such as rechecking items, needing to perform mental compulsions over and over before discarding items. However, people who are diagnosed as “hoarders without OCD” do not have OCD rituals (Pertusa, Fullana, Singh, et al, 2008).

In “An Exploratory Study of the Neural Mechanisms of Decision Making in Compulsive Hoarding” (Tolin et al, 2008), researchers had noted that previous studies suggested a possible correlation between hoarding and impairments in the decision making process, especially when deciding to keep or discard an object. Due to these findings, researchers wanted to explore “whether the neural regions of interest derived from previous research” would show differences in non-hoarders and hoarders when making real –time decisions about whether to discard their possessions. “It was predicted that when making decisions about their own possessions, hoarding participants would show increased hemodynamic activity in OFC, PFC and ACC compared to control participants” (Tolin et al, 2008).

The subjects of this study were 24 adults; twelve were diagnosed as compulsive hoarders, and a twelve non-hoarder control group. Hoarding subjects were assessed by an experienced Psychologist who specialized in compulsive hoarding, OCD and anxiety disorders. Participants had to meet the “clinical criteria for compulsive hoarding outlines by Frost & Hartl (1996), and had to be their primary diagnosis, with a rating of “moderately to severe” hoarding. Participants (hoarders) were excluded if they had a history of psychotic disorders, suicidal tendencies, substance abuse; hoarding was not their primary disorders, or a neurological disorder. Participants in the control group were disqualified if they had a substance abuse problem, a current Axis I or Axis II disorder, taking psychiatric medications, or have/had a history of neurological disorders. All participants provided “written informed consent” and all procedures were approved by the institutional review board at Hartford Hospital (Tolin et al, 2008).
Participants were asked to bring in paper items such as newspaper and junk mail. In doing so, researchers avoided using items that hoarders had/have emotional attachment to. The control group was asked to do the same; these items were known as: Participant’s Possessions (PP). The items were placed in a clear plastic bin, labeled with the subject’s first name and placed on the right or left visual field. Researchers brought in junk mail/newspapers; they took roughly the same amount, size and type as the subjects, labeled it Experimenter’s Possessions (EP), using their first name and placed them on the opposite side of the visual field. Due to the possibility that participants would not want to discard either a PP or a EP, researchers provided a neutral stimulus (NS). They added two clear bins of red paper that would be discarded (shredded) instead. In this way, researchers could insure that differences noted in the brain where not due to the visual stimulus of seeing an item destroyed. The bins where set up as follows: EP, NS, PP, NS with a shredder, that had been modified (the front cover removed) so that the subjects could see the items being shredded. Both groups underwent “functional magnetic resonance imaging (fMRI) while making decisions about whether to discard or keep an item (Tolin et al, 2008).

Once subjects were placed on the scanner, subjects were presented with either the PP/NS or EP/NS through live video and given eight seconds to decide whether to discard or keep the items by pressing a button; if after eight seconds, the subject decided not to discard a item a NS would be placed in the shredder. Each participant completed six blocks for each PP/NS or EP/NS pair.
Data Analysis:
Behavioral data collected showed that hoarding participants had significantly greater anxiety than did the control group, while deciding to discard both PP items (t 19 = 4.90, p <0.001) and EP items (t 19 = 2.92, p = 0.009). Anxiety levels were higher in regards to hoarders own possessions versus experimenters possessions: (t 9 =3.20, p =0.011). There was no difference in anxiety levels between PP and EP within the control group: (t 10 = 1.29, p =0.226). Further analysis of both groups showed that hoarders discarded significantly fewer PP items than EP items (t 9 = 3.98, p = 0.003); no differences were noted for the control group: (t 10 = 0.41, p = 0.692). Comparing the two groups, compulsive hoarders significantly discarded fewer PP items (t 19 = 4.86, p <0.001); and also less EP items (t 19 = 2.15, p =0.045). The results from this behavioral study showed that hoarders “had selective difficulty discarding their own possession whereas healthy controls did not” (Tolin et al, 2008). fMRI results showed that compulsive hoarder had excessive activation in the “left lateral OFC [MNI coordinates -36, 28, -20 (Brodmann 47)], left amygdale and parahippocampal gyrus extending into thalamus (-12, -8, -12), and left cerebellum (-8, -72, -20) (p, 0.01) when compared to healthy controls”( Tolin et al, 2008). These finding support the theory that hoarding behaviors are cause in part to defects in the decision making process, as the lateral OFC, is a region in the brain that is associated with processing “relative reward value, particularly values that are experienced as punishing”( Tolin et al, 2008). To a hoarder, having to discard a possession can be perceived as a punishment, which causes them great anxiety. Limitations: Although researchers had two comparative groups of the same size; it was a small sample size in relation to the population. The study would have had greater merit if they would have included subjects diagnosed with OCD and hoarding. In this way, they could have compared the fMRI’s results to both groups. Instead, they have left open the question of whether people who are diagnosed with OCD and hoarding would show increased activity in the lateral OFC. Another area of concern is the time limit set by researchers. Though eight seconds would seems like a reasonable amount of time, one has to wonder if the time limit affected the hoarders in a negative way. They had eight second to decide whether to keep or discard an item, the results did not break down each block, so one has to wonder what the results showed. Did the subjects show anxiety with the first items? Did the fMRI show increase activity from the beginning? Is it possible that the subjects did not have enough time to re-group between items, to the point that they were just pushing the button in order to have the test end? Would giving the subjects longer time in between produced different results? Due to the fact that all participants were told what the study detailed, is it possible that some of the hoarding participants brought in items that they would have less trouble discarding? Would the results been different had they not been told what the test detailed, would they have had a more difficult time, if they had brought in different items? Discussion: In “Compulsive Hoarding: OCD Symptom, Distinct Clinical Syndrome, or Both?”(Pertusa, Fullana, Singh, Alonso, et al, 2008), researchers had found that most studies pertaining to the issue of whether compulsive hoarding is a symptom of OCD, or a syndrome, included patients who had a mild or moderate form of hoarding, these studies did not take into account severe/compulsive hoarding. However, some studies the involved severe/compulsive hoarding selected participants, who had been diagnosed with other disorders. Further research has shown that mild and moderate forms of hoarding can be a symptom of another disorder, most notably OCD. Yet recent research has also shown that some people who have been diagnosed as compulsive hoarders have no other disorders. It is due to these new findings that researchers are looking into whether or not compulsive hoarding should be a syndrome of its own. Participants: Researchers chose 163 people to participant in this study, the individuals were divided into the following groups: 25 diagnosed with OCD and hoarding, 27 hoarding without OCD; comparison groups consisted of: 71 with OCD minus hoarding, 19 with anxiety disorder and 21 healthy individuals from the community. The majority of participants (>90) in both hoarding groups, along with anxiety disorder applied per advertisement and support groups, a large majority (60%) in the OCD minus hoarding were recruited from clinical settings (Pertusa, Fullana, Singh, Alonso, et al, 2008).
All participants were interviewed either face to face or by telephone by psychologists or psychiatrists who specialized in OCD. Individuals were excluded if they were <18 or >65 years old, or was diagnosed with bipolar I personality disorder, psychosis, substance abuse, or suicidal tendencies. Participants signed a written form of consent, and were paid for their time. The study was approved by the “Institute of Psychiatry/Maudsley Hospital Ethics Committee, London” (Pertusa, et al. 2008). Seven individuals were excluded because they did not meet the requirements: bipolar 1 (N=2), psychosis (N=1), suicidal tendencies (N=1) or a “suspected dementing process (N=1) (Pertusa, et al, 2008).
Participants were asked to complete the “Dimensional Yale-Brown Obsessive Compulsive Scale” an 88 item checklist of obsession and compulsions; which was divided into six groups: “contamination/cleaning, harm, collecting/hoarding, symmetry/ordering, sexual/religious, and miscellaneous obsession and compulsions” (Pertusa, et al, 2008), it is used to assess the degree of severity. Using an assessment developed for this study, participants were asked the following questions:
1) Specific items that were hoarded
2) The extent of the clutter
3) Reasons for hoarding
4) What is the degree and impairment caused by their hoarding
5) At what age did their hoarding start
6) If there is a family history
7) What are their living conditions
8) Martial status

Data Analyses:
Data was compared by using the “chi square of Fisher’s exact tests” (Pertusa, et al, 2008). Independent data was compared using two –tailed t tests, and/or (ANOVA). The following post hoc tests were used: for cases of equal variance: Turkey B or the Tamhane’s T2, for unequal variance.
Results showed that both hoarding groups collected the same type of items, although individuals diagnosed with OCD and hoarding also kept letters, receipts, old medications and bills. Individuals with OCD and hoarding were prone to collecting bizarre items (N=4) as compared to hoarders without OCD (N=0). It was found that 12% of OCD with hoarding and none in hoarding without OCD reported that their hoarding behavior was extremely pervasive (the need to keep every thing). There was no difference in the degree of clutter between the two groups: 74.1% of hoarders without OCD, and 70.1% of hoarders with OCD.
Both groups noted that hoarding started at a similar age (19.6 years [SD = 9.4]), although it was reported that the homes of OCD with hoarding participants versus hoarding without OCD had become cluttered at an earlier age: (25.1 years [SD-8.2]) versus (31.3 years [SD-12.0]). Hoarders with OCD reported that they only kept items due to “intrinsic, and/or emotional value of the hoarded items” (Pertusa, et al, 2008). However, 25% of OCD with hoarding reported compulsions or obsessions as a reason to hold on to items (See appendix 1).
The two hoarding groups had significantly higher scores relative to the three comparison groups on clinician and self-rated measures regarding hoarding severity. The OCD with hoarding group tended to have significantly higher hoarding severity relative to the hoarding without OCD group on all measures. Individuals in the OCD without hoarding comparison group had hoarding scores that were comparable with scores of individuals in the anxiety disorder and community comparison groups (Pertusa, et al, 2008).
The hoarding without OCD group had significantly lower scores relative to the two OCD groups (OCD plus hoarding and OCD minus hoarding) on all other OCD symptom dimensions, both clinician and self-rated. Individuals in the hoarding minus OCD group and anxiety disorder along with the community comparison groups had comparable scores on all symptom dimensions. The OCD plus hoarding group scored higher on the symmetry dimension of the Dimensional Yale-Brown Obsessive Compulsive Scale relative to the OCD minus hoarding comparison group, but not on the Obsessive Compulsive Inventory (Pertusa, et al, 2008). See appendix 2

Researchers relied on participant’s use of a self report; without doing a visual inspection of their homes. Even though the participants told the truth (as they believed it), their standard of clutter and another person’s standard might not be the same. This leaves the question: is their hoarding more severe than they reported? Another area of concern is the fact that most of the compulsive hoarding group were recruited through advertisements which stated that they would be compensated for their time, again having made no visual inspection of their house, researchers can only assume that the participants have hoarding problems. Though researchers had a good sample size of participants, they did not state how many participants were female or male.

In “Cognitive Aspects of Compulsive Hoarding” (Steketee, Frost, & Kyrios, 2003) researchers Frost and Hartl (1996) proposed that hoarding was the result of “three types of problems or deficits (information processing, emotional attachment to possessions, and erroneous beliefs about possessions)” which influenced hoarders’ keeping and discarding behavior (Steketee, Frost, and Kyrios, 2003). In 1988, Frost and Gross, speculated that keeping items allows hoarders to avoid making decisions about what to keep and throw away in order to prevent making mistakes. “This, in turn increases hoarders’ perceptions of control” (Steketee, Frost, & Kyrios, 2003).
Researchers wanted to examine the role of these beliefs using a newly developed self-report instrument. Items represented the following constructs: emotional comfort from items, identifications with items, value of possessions, control over possession, responsibility towards possessions, and beliefs about memory. This study was done to answer whether these beliefs are specific to hoarders compared to non-hoarders and “whether they are linked to mood, OCD symptoms, and decision making (Stekette, Frost, & Kyrios, 2003).

A total of 156 people participated in the study of which 111 (>71%) were female,
46 (<30%) male, 146 (>90%) white, 11 (<10%) were considered other. From this sample researchers divided the participants into the following groups: Compulsive hoarding (95), OCD without hoarding (21) and a control group (40). Participants were recruited from “clinics, self-help or support groups, and from Obsessive Compulsive Foundation newsletter, website, or their annual conference” (Steketee, Frost and Kyrios, 2003). The control group was recruited through newspapers advertisement or by other participants. Each person signed a consent form and received money after completing and returning their packet of questionnaires; which included the following: The “Saving Cognition Inventory” (SCI) which was used to measure hypothesized beliefs and attitudes among compulsive hoarders. It consisted of thirty-five questions which participants answered by checking the “extent to which a thought influenced their decision on whether or not to discard an item on a 7-point Likert scale. It was broken into six categories: memory, value of possessions, emotional comfort, loss, control over items and responsibility. The Saving Inventory (SI) is a revised version of the Hoarding Scale used in earlier research (Steketee, Frost, and Kyrios, 2003)). It contained 28 items generated to reflect other aspects of hoarding that was not included in the Hoarding Scale. The self-report version of the Yale–Brown Obsessive Compulsive Scale contained 10 items that gauge the severity of OCD symptoms. The Obsessional Beliefs Questionnaire is an 87-item scale designed to assess the degree of belief in six domains characteristic of clinical samples with OCD. Subscales cover “Over importance of Thoughts, Control of Thoughts, Threat Estimation, Tolerance for Uncertainty, Responsibility, and Perfectionism. The Frost Indecisiveness Scale is a 15-item scale designed to measure fears and difficulties associated with making decisions. Nine were worded negatively: “I become anxious when making a decision”; “I do not get my work done on time because I cannot decide what to do first”) and six positively (e.g., “I find it easy to make decisions” (Steketee, Frost and Kyrios, 2003). ANOVAs were used to compare groups regarding decision making and OCD beliefs. Data Analysis: Compulsive hoarders showed more difficulty making decisions than OCD participants; OCD participants’ scores were not different from the control group. OCD beliefs assessed through the OBQ, showed that hoarders and OCD patients scored the same in regard to those beliefs as in comparison to the control group. It was also found that when OCD or mood was controlled, it had no effect on hoarder’s behavior (.00 - .27), showing that hoarding tendencies were independent of OCD. To further substantiate these findings several analyses were used by FIS. These posthoc tests showed that hoarders again had more difficulty making decisions than the other groups. Further findings showed that hoarding behaviors correlated highly with their beliefs (rs=.60-.80). Limitations: Most of the participants were from the same demographic area and the majority was white females, this can create a bias. Again, the sample size was small; yet given the year it was done and with it being a newly developed test/questionnaire; it is understandable. Another concern is the fact that researchers did not confirm the diagnoses of the participants. This could have been done by a home visit, or having it confirmed by a Psychologist (with the participants consent). Conclusion: Though hoarding has been considered a symptom of OCD, it was not until about 15 years ago that Psychologists started noticing differences among people diagnosed with OCD, OCD with hoarding and compulsive hoarders with or without OCD. They noticed that people who hoard without OCD had problems in four areas: “information processing, emotional attachments to possessions, unhelpful beliefs about possessions, and avoidance behaviors” (Tompkins & Hartl, 2009). In noticing these differences researchers hypothesized that hoarding many not be a symptom of OCD, but a syndrome of its own (Tolin, Frost, & Steketee, 2007). In order to prove whether or not this assumption was correct; they used questionnaires and self-reports (revised to pertain to hoarding, as they had noted), along with brain imaging to confirm their ideas. Results from all these reports/studies have shown differences; yet because research in this area is considered “new” more research needs to be done on a larger scale. Hoarding is a bafflingly disorder, one that is often hidden behind closed doors. As stated by Frost: “many people with compulsive hoarding are intensely bothered by the problem. They recognize that their clutter is excessive, they feel ashamed of it, and wish they could do something about it” (2007). This is why research is so important; researchers/doctors need to find the causes of this problem in order to treat it. Though studies are in their infancy, researchers are on the right path. Literature that was read stated that the previous studies will be done using a larger population, adding home inspections/interviews that will be done in order to confirm that they are hoarders. Another area that needs to be taking inconsideration is genetics. Could this be due to genetics? Is it heredity? Could it be due to a defect in a chromosome? As a researcher, there are many possibilities that need to be looked into. This makes this such an interesting subject. Bibliography: Pertusa, A, Fullana, M, Singh, S, Alonso, P, et al. (2008, May). Compulsive Hoarding: OCD Symptom, Distinct Clinical Syndrome, or Both? The American Journal of Psychiatry, 165(10), 1289 – 1298. Retrieved from Proquest. Pertusa, Fullana, Singh, Alonso and other researchers wanted to do a study to find out if compulsive hoarding is associated with obsessive-compulsive disorder (OCD), or if it is a syndrome of its own. Specialists in this field have notice differences between patients diagnosed with hoarding and those diagnosed with hoarding and OCD. All patients reported that they kept items because of “emotional and/or intrinsic value of their possessions”, whereas patients who were also diagnosed with OCD “reported other obsessional ideas related to their hoarding, such as fear of catastrophic events (e.g., something bad may happen if possessions are discarded)...the need to perform excessive checking rituals in relation to the hoarding” (Pertusa. et al., 2008). Researchers recruited 163 individuals to participate in the study: 27 were diagnosed with hoarding, 25 were diagnosed with OCD and hoarding, 71 diagnosed with OCD, 19 with anxiety disorder and 21 people with no disorder to be used as a comparison group. “90% of participants in both hoarding groups were recruited by advertisement and support groups, whereas 60% of the OCD without hoarding were recruited through clinical settings (Pertusa, et al., 2008). All participants were interviewed either face-to-face interviews or by telephone, and then given a “Saving Inventory” and Obsessive- Compulsive Inventory (both revised), and asked to rate their hoarding. The two hoarding groups had significantly higher scores relating to hoarding then the three comparison groups. Participants, who had OCD along with hoarding, had a higher degree of severe hoarding tendencies compared to participants diagnosed as hoarders without OCD. Individuals with OCD only, had hoarding scales that were comparable to scores on individuals with anxiety disorder and the comparison group (Pertusa, 2008). Both hoarding groups scored high on social-phobia Participant with Hoarding did not differ in the number of personality traits, although patients who also had hoarding and OCD endorsed more personality traits than the OCD group; which is consistent with previous studies (Pertusa, et al, 2008). Steketee, G, Frost, R, and Kyrios, M. (2003, August). Cognitive Aspects of Compulsive Hoarding. Cognitive Therapy and Research. 27(4), pp. 463-479. Retrieved from: Proquest. Steketee, Frost, and Kyios wanted to explore the possible link to the cognitive aspects of hoarding; they believe that hoarding could be caused by problems with decision-making; along with beliefs about the items/possessions of “hoarders”, and not related to OCD. Frost and Steketee recruited 95 people with compulsive hoarding, 21 with OCD and 40 participants as a control group. The hoarding and OCD group were recruited from area “clinics, self-help groups, support groups, and from the Obsessive Compulsive Foundation newsletter, website and from the Obsessive Compulsive Foundation annual conference” (Steketeet, Frost and Kyrios, 2003). Each participant was given a copy of “Saving Cognition Inventory” questionnaire, which is used to measured attitudes and beliefs of compulsive hoarder. There were six categories: beliefs: memory, value of possession, emotional comfort, loss, control over possessions, and responsibility. Participants were ask to rate themselves on a 7 point Likert scale (Steketee, Frost and Kyrios, 2003). Their research showed that hoarders beliefs correlated highly with the severity of hoarding “(rs ranging from .60 to .80) and moderately strongly with OCD (rs = .42 - .58) and anxiety and depression (rs = .39 - .55)” (Steketee, Frost and Kyrios, 2003). This study shows the importance of beliefs about possessions that plays a major role in acquiring and saving behavior. Researchers think that hoarding is associated with certain types of beliefs and with problems in information processing (memory, organization, and categorizations) that may produce fear when trying to make decisions. Researchers believe that further research is needed to find the exact cause of hoarding, and which areas should be focused on in order to help people overcome this problem. Tolin,D, Kiel,P, Worthunsky, Book,G and Maltby,N. (February, 2009). An Exploratory Study of the Neural Mechanisms of Decision Making in Compulsive Hoarding. Psychological Medicine. 39 (2) pp. 325 – 337. Previous studies have suggested that hoarders had a different pattern of neural activity, though at the time no studies had done on brain imagining; which could possible show any abnormalities in the brain that would affect their decision making. Researchers took two groups: 12 people diagnosed with hoarding and a 12 person control group. Both groups had fMRI while deciding to discard items (which were in their visual field). The results showed that hoarders had increased hemodynamic activity in the lateral cortex and parahippocampal gyrus. Increased activity was shown in the superior temporal, middle temporal , medial frontal, and percental gyrus while hoarders were making decisions regarding whether to keep an item. Scans of the control group did not show an increase in these areas. Which supports their hypothesis that hoarding can be contributed to a defect in these regions. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington D.C. American Psychiatric Association. Tolin, D., Frost, R., and Steketee (2007). Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding. New York: Oxford University Press. Tompkin, M. & Hartl, T. (2009). Digging Out: Helping your Love One Manage Clutter, Hoarding & Compulsive Acquiring. CA: New harbinger Publications, Inc. Appendix I and II: Pertusa, A, Fullana, M, Singh, S, Alonso, P, et al. (2008, May). Compulsive Hoarding: OCD Symptom, Distinct Clinical Syndrome, or Both? The American Journal of Psychiatry, 165(10), 1289 – 1298. Retrieved from: Proquest.