Recent Advances in
Sanjaya Saxena, MD
Sanjaya Saxena, MD
Department of Psychiatry, University of California at San Diego,
8950 Villa La Jolla Village Drive, Suite C-207, San Diego,
CA 92037, USA.
Current Psychiatry Reports 2008, 10: 297– 303
Current Medicine Group LLC ISSN 1523-3812
Copyright © 2008 by Current Medicine Group LLC
Compulsive hoarding is a common and often disabling
neuropsychiatric disorder. This article reviews the con-
ceptualization, phenomenology, diagnosis, etiology,
neurobiology, and treatment of compulsive hoard-
ing. Compulsive hoarding is part of a discrete clinical
syndrome that includes diffi culty discarding, urges to
save, excessive acquisition, indecisiveness, perfection-
ism, procrastination, disorganization, and avoidance. It
was thought to be part of obsessive-compulsive disor-
der or obsessive-compulsive personality disorder, but
recent evidence indicates that it should be classifi ed
as a separate disorder with its own diagnostic criteria.
Compulsive hoarding is a genetically discrete, strongly
heritable phenotype. Neuroimaging and neuropsy-
chological studies are elucidating its neurobiology,
implicating dysfunction of ventral and medial prefrontal
cortical areas that mediate decision-making, attention,
and emotional regulation. Effective treatments include
pharmacotherapy and cognitive-behavioral therapy.
More research will be required to determine the preva-
lence, etiology, and pathophysiology of compulsive
hoarding and to develop better treatments.
Hoarding is defi ned as the acquisition of and inability to
discard items even though they appear (to others) to have
no value [ 1 ]. Hoarding behavior has been observed in
several neuropsychiatric disorders, including schizophre-
nia, dementia, autism, and mental retardation, as well as
in nonclinical populations [ 2 ], but it is most commonly
associated with obsessive-compulsive disorder (OCD).
Approximately 18% to 42% of patients with OCD have
hoarding and saving symptoms [ 2 , 3 , 4• ].
Although standard diagnostic classifi cations consider
OCD to be a single diagnostic entity, factor analyses of
OCD symptoms have consistently identifi ed at least four
principal symptom factors: 1) aggressive, harm-related,
sexual, and religious obsessions with checking compul-
sions; 2) symmetry and order obsessions with arranging,
repeating, and counting compulsions; 3) contamination
obsessions with washing and cleaning compulsions; and
4) compulsive hoarding and saving symptoms [ 5 , 6 ]. These
symptom factors appear to be relatively stable over time
and show different patterns of genetic inheritance, comor-
bidity, and treatment response [ 6 ]. Cluster analyses,
which identify mutually exclusive, categorical subgroups,
indicate that some of these symptom factors, including
hoarding, may constitute discrete subtypes of OCD [ 7 ].
The hoarding symptom factor has been identifi ed in
phenomenologic and epidemiologic studies of OCD in
the United States, Brazil, Canada, Costa Rica, France,
Germany, Italy, Japan, the Netherlands, Poland, Turkey,
Egypt, Singapore, and South Africa, where it is found in
both blacks and whites [ 6 , 8 ]. Thus, compulsive hoarding
is not a culture-bound syndrome.
The Compulsive Hoarding Syndrome
Frost and Hartl [ 9 ] developed the fi rst systematic defi nition
and diagnostic criteria for clinically signifi cant compulsive
hoarding: 1) the acquisition of and failure to discard a large
number of possessions that appear (to others) to be useless
or of limited value, 2) living or work spaces suffi ciently
cluttered so as to preclude activities for which those spaces
were designed, and 3) signifi cant distress or impairment
in functioning caused by the hoarding behavior or clutter.
They found that hoarding and saving symptoms are part
of a discrete clinical syndrome that includes the core symp-
toms of urges to save, diffi culty discarding, and excessive
acquisition but also indecisiveness, perfectionism, procras-
tination, disorganization, and avoidance [ 2 ]. In addition,
many compulsive hoarders are slow to complete tasks, are
frequently late for appointments, and display circumstan-
tial and overinclusive language. Patients with prominent
hoarding and saving symptoms who display these other
associated symptoms thus are considered to have the com-
pulsive hoarding syndrome [ 2 , 10 ].
Recent Advances in Compulsive Hoarding Saxena 303
25.•• Samuels J, Shugart YY, Grados MA, et al. : Signifi cant linkage
to compulsive hoarding on chromosome 14 in families with
obsessive-compulsive disorder: results from the OCD Collab-
orative Genetics Study. Am J Psychiatry 2007, 164: 493– 499.
This genome-wide linkage study of 219 multiplex OCD families,
collected as part of the OCD Collaborative Genetics Study,
assessed genetic linkage with a phenotype defi ned by the presence
of clinically signifi cant compulsive hoarding symptoms in patients
with early-onset OCD (before age 18 years). It found “suggestive”
linkage of compulsive hoarding to a region on chromosome 14 and
signifi cant linkage to another region on chromosome 14 in families
with two or more hoarding relatives. This suggests that compulsive
hoarding may be a genetically discrete phenotype with an etiology
at least partially distinct from that of OCD in general.
26. Cohen L, Angladette L, Benoit N, Pierrot-Deseilligny C: A
man who borrowed cars. Lancet 1999, 353: 34.
27. Hahm DS, Kang Y, Cheong SS, Na DL: A compulsive col-
lecting behavior following an A-com aneurysmal rupture.
Neurology 2001, 56: 398– 400.
28. Volle E, Beato R, Levy R, Dubois B: Forced collectionism
after orbitofrontal damage. Neurology 2002, 58: 488– 490.
29. Nakaaki S, Murata Y, Sato J, et al. : Impairment of decision-mak-
ing cognition in a case of frontotemporal lobar degeneration
(FTLD) presenting with pathologic gambling and hoarding as the
initial symptoms. Cogn Behav Neurol 2007, 20: 121– 125.
30.• Anderson SW, Damasio H, Damasio AR: A neural basis for
collecting behaviour in humans. Brain 2005, 128: 201– 212.
This study compared 13 patients with compulsive hoarding
symptoms that began after they suffered brain damage with 54
brain-damaged patients who did not develop hoarding behaviors. All
hoarding patients had damage to the mesial prefrontal cortex. The
brain regions with greatest overlap in hoarders and least overlap with
nonhoarders were the right orbitofrontal pole, right rostral ACC,
and adjacent white matter. The authors suggested that damage to
these areas, which are involved in decision-making and planning,
disrupts the ability to inhibit urges to acquire and save items.
31.• Lawrence NS, Wooderson S, Mataix-Cols D, et al. : Deci-
sion making and set shifting impairments are associated
with distinct symptom dimensions in obsessive-compulsive
disorder. Neuropsychology 2006, 20: 409– 419.
This study was the fi rst to show specifi c neurocognitive defi cits
in compulsive hoarders. OCD patients with prominent hoarding
symptoms were found to have signifi cantly worse performance
on the Iowa Gambling Task than nonhoarding OCD patients and
controls, as well as lower skin conductance responses.
32. Saxena S, Brody A, Maidment KM, et al. : Cerebral glucose
metabolism in obsessive-compulsive hoarding. Am J
Psychiatry 2004, 161: 1038– 1048.
33. Saxena S, Bota RG, Brody AL: Brain-behavior relationships
in obsessive-compulsive disorder. Semin Clin Neuropsy-
chiatry 2001, 6: 82– 101.
34. Hartl TL, Frost RO, Allen GJ, et al. : Actual and perceived
memory defi cits in individuals with compulsive hoarding.
Depress Anxiety 2004, 20: 59– 69.
35. Mataix-Cols D, Wooderson S, Lawrence N, et al. : Distinct
neural correlates of washing, checking, and hoarding symp-
tom dimensions in obsessive-compulsive disorder. Arch Gen
Psychiatry 2004, 61: 564– 576.
36.• An SK, Mataix-Cols D, Lawrence NS, et al. : To discard or
not to discard: the neural basis of hoarding symptoms in
obsessive-compulsive disorder. Mol Psychiatry 2008 Jan 8
(Epub ahead of print).
This study used functional MRI to examine brain activation during
provocation of compulsive hoarding symptoms and found that hoarding
OCD patients had signifi cantly greater activation of the ventromedial
prefrontal cortex than nonhoarding OCD patients or normal controls.
Hoarding-related anxiety correlated with greater activation of the
ventromedial prefrontal cortex, mesial temporal lobe, sensorimotor
cortex, and thalamus but with less activation of the dorsal prefrontal,
parietal, and temporal cortical regions and basal ganglia. These results
elucidated the neural mediation of compulsive hoarding symptoms and
showed that it is quite different from that of “typical” OCD.
37.• Grisham JR, Brown TA, Savage CR, et al. : Neuropsycho-
logical impairment associated with compulsive hoarding.
Behav Res Ther 2007, 45: 1471– 1483.
This study found that compulsive hoarders had signifi cantly slower
and more variable reaction time, greater impulsivity, and worse
spatial attention than controls and a mixed clinical patient group.
These results indicate that compulsive hoarding is associated with
specifi c neurocognitive defi cits.
38. Black DW, Monahan P, Gable J, et al. : Hoarding and
treatment response in non-depressed subjects with obsessive-
compulsive disorder. J Clin Psychiatry 1998, 59: 420– 425.
39. Mataix-Cols D, Rauch SL, Manzo PA, et al. : Use of factor-ana-
lyzed symptom dimensions to predict outcome with serotonin
reuptake inhibitors and placebo in the treatment of obsessive-
compulsive disorder. Am J Psychiatry 1999, 156: 1409– 1416.
40. Stein DJ, Andersen EW, Overo KF: Response of symptom
dimensions in obsessive-compulsive disorder to treatment with
citalopram or placebo. Rev Bras Psiquiatr 2007, 29: 303– 307.
41. Alonso P, Menchon JM, Pifarre J, et al. : Long-term follow-up
and predictors of clinical outcome in obsessive-compulsive
patients treated with serotonin reuptake inhibitors and
behavioral therapy. J Clin Psychiatry 2001, 62: 535– 540.
42. Ferrao YA, Shavitt RG, Bedin NR, et al. : Clinical features
associated to refractory obsessive-compulsive disorder. J
Affect Disord 2006, 94: 199– 209.
43. Erzegovesi S, Cavallini MC, Cavedini P, et al. : Clinical pre-
dictors of drug response in obsessive-compulsive disorder. J
Clin Psychopharmacol 2001, 21: 488– 492.
44. Shetti CN, Reddy YC, Kandavel T, et al. : Clinical predic-
tors of drug nonresponse in obsessive-compulsive disorder.
J Clin Psychiatry 2005, 66: 1517– 1523.
45.•• Saxena S, Brody AL, Maidment KM, Baxter LR: Paroxetine
treatment of compulsive hoarding. J Psychiatr Res 2007,
41: 481– 487.
This was the fi rst prospective, quantitative study of pharmaco-
therapy for compulsive hoarding. Thirty-two compulsive hoarders
were found to respond equally well to paroxetine as 47 nonhoard-
ing OCD patients, with nearly identical improvements in OCD
symptoms, depression, anxiety, and overall functioning. Hoarding
symptoms responded as well as nonhoarding symptoms. These
results suggested that SRIs are just as effective for treatment of
compulsive hoarding as they are for nonhoarding OCD.
46. Mataix-Cols D, Marks IM, Greist JH, et al. : Obsessive-
compulsive symptom dimensions as predictors of compliance
with and response to behaviour therapy: results from a
controlled trial. Psychother Psychosom 2002, 71: 255– 262.
47. Abramowitz JS, Franklin ME, Schwartz SA, Furr JM:
Symptom presentation and outcome of cognitive-behavioral
therapy for obsessive-compulsive disorder. J Consult Clin
Psychol 2003, 71: 1049– 1057.
48. Rufer M, Fricke S, Moritz S, et al. : Symptom dimensions in
obsessive-compulsive disorder: prediction of cognitive-behavior
therapy outcome. Acta Psychiatr Scand 2006, 113: 440– 446.
49.• Tolin DF, Frost RO, Steketee G: An open trial of cognitive-
behavioral therapy for compulsive hoarding. Behav Res
Ther 2007, 45: 1461– 1470.
This study presented the methods and outcome of a CBT developed
specifi cally for compulsive hoarding. Ten of 14 patients completed
26 sessions of treatment, and fi ve improved greatly.