Neural Mechanisms of Decision Making in Hoarding Disorder
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CONTEXT: Hoarding disorder (HD), previously considered a subtype of obsessive-compulsive disorder (OCD), has been proposed as a unique diagnostic entity in DSM-5. Current models of HD emphasize problems of decision-making, attachment to possessions, and poor insight, whereas previous neuroimaging studies have suggested abnormalities in frontal brain regions. OBJECTIVE: To examine the neural mechanisms of impaired decision making in HD in patients with well-defined primary HD compared with patients with OCD and healthy control subjects (HCs). DESIGN: We compared neural activity among patients with HD, patients with OCD, and HCs during decisions to keep or discard personal possessions and control possessions from November 9, 2006, to August 13, 2010. SETTING: Private, not-for-profit hospital. PARTICIPANTS: A total of 107 adults (43 with HD, 31 with OCD, and 33 HCs). MAIN OUTCOME MEASURES: Neural activity as measured by functional magnetic resonance imaging in which actual real-time and binding decisions had to be made about whether to keep or discard possessions. RESULTS: Compared with participants with OCD and HC, participants with HD exhibited abnormal activity in the anterior cingulate cortex and insula that was stimulus dependent. Specifically, when deciding about items that did not belong to them, patients with HD showed relatively lower activity in these brain regions. However, when deciding about items that belonged to them, these regions showed excessive functional magnetic resonance imaging signals compared with the other 2 groups. These differences in neural function correlated significantly with hoarding severity and self-ratings of indecisiveness and "not just right" feelings among patients with HD and were unattributable to OCD or depressive symptoms. CONCLUSIONS: Findings suggest a biphasic abnormality in anterior cingulate cortex and insula function in patients with HD related to problems in identifying the emotional significance of a stimulus, generating appropriate emotional response, or regulating affective state during decision making.
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Because many individuals with hoarding disorder experience intense distress and negative emotions during decision-making, refusal to discard or make decisions about items may represent avoidance of negative emotions that are difficult to manage.
“Because many individuals with HD experience intense distress and negative emotions during decision-making (Frost et al., 2016;Tolin et al., 2012), refusal to discard or make decisions about items may represent avoidance of negative emotions that are difficult to manage.”
From A naturalistic study of emotion regulation-enhanced cognitive-behavioral group therapy for hoarding disorder in a community setting (2022) · cites this paper as Tolin et al., 2012
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Imperfection, Indecision, and Hoarding
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Self-citationValidation of a Behavioral Measure of Acquiring and Discarding in Hoarding Disorder
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A narrative synthesis of possible causes and risk factors of hoarding behaviours
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“Because many individuals with HD experience intense distress and negative emotions during decision-making (Frost et al., 2016; Tolin et al., 2012), refusal to discard or make decisions about items may represent avoidance of negative emotions that are difficult to manage.”
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- Authors
- Tolin, D. F., Stevens, M. C., Villavicencio, A. L., Norberg, M. M., Calhoun, V. D., Frost, R. O., Steketee, G., Rauch, S. L., & Pearlson, G. D.
- Affiliations
- Boston University (US)
- ORCID
- Venue
- Archives of General Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2012-08-01
- Volume
- 69
- Issue
- 8
- Pages
- 832
- ISSN
- 0003-990X (ISSN-L)
- PMC
- PMC3506167
- OpenAlex
- W2099281977
- Cited by
- 174
- References
- 64
- Citations by year
- 2026: 7 · 2025: 11 · 2024: 7 · 2023: 15 · 2022: 9 · 2021: 18 · 2020: 11 · 2019: 17 · 2018: 21 · 2017: 11 · 2016: 13 · 2015: 15 · 2014: 11 · 2013: 5 · 2012: 3
- FWCI
- 12.37
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Archives of General Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Smith ScholarWorks (Smith College) (submittedVersion)
- Funders
- National Institute of Mental Health (R01MH074934)
- National Institute of Biomedical Imaging and Bioengineering (R01EB000840, R01EB020407, R01EB006841)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Clinical Psychology › Perfectionism, Procrastination, Anxiety Studies
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- hoarding disorder, decision-making, anterior cingulate cortex, insula, obsessive-compulsive disorder, indecision, emotion regulation, hoarding severity
- MeSH terms
- Hoarding Disorder, Adult, Brain Mapping, Cerebral Cortex, Decision Making, Evoked Potentials, Female, Gyrus Cinguli, Hospitals, Voluntary, Humans, Magnetic Resonance Imaging, Male, Middle Aged, Neural Pathways, Obsessive Behavior, Sickness Impact Profile, Expressed Emotion, Diagnostic and Statistical Manual of Mental Disorders
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