Journal of Anxiety Disorders 27 (2013) 328339

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Journal of Anxiety Disorders

Beliefs and experiences in hoarding

Olivia M. Gordon a, , Paul M. Salkovskis b , Victoria B. Oldeld c,d
a
Royal Holloway, University of London, UK
b
University of Bath, UK
c
Institute of Psychiatry, Kings College London, UK
d
Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Trust, UK

a r t i c l e i n f o a b s t r a c t

Article history: Recent research suggests that hoarding problems may be relatively heterogeneous, with the sugges-
Received 10 March 2012 tion that three belief dimensions may underpin hoarding experiences, namely harm avoidance, fear
Received in revised form of material deprivation, and heightened sentimentality in relation to possessions. The role of these
14 December 2012
hypothesised belief dimensions in hoarding was evaluated in this study, together with the association
Accepted 9 February 2013
between compulsive hoarding and OCD on several clinically relevant variables. As hypothesised, individ-
uals with hoarding and co-existing OCD reported greater harm avoidance beliefs in relation to possessions
Keywords:
compared with a group of hoarders without OCD. Contrary to expectation, however, the hoarding group
Hoarding
Obsessivecompulsive disorder without OCD did not report signicantly stronger beliefs associated with material deprivation and attach-
Co-morbidity ment disturbance relative to the hoarding with OCD group. The comparison of the clinical presentation
Beliefs of participants across groups lends further support to the notion that hoarding should be considered a
Experiences distinct clinical syndrome from OCD.
Motivations for hoarding 2013 Elsevier Ltd. All rights reserved.

1. Introduction comparable to work impairment reported by people with psychotic

The acquisition and retention of material possessions is a
widespread human behaviour, and is largely considered an accept-
able aspect of modern life. Like many such behaviours, however,
the saving of possessions can range from what is viewed as nor-
mal to that which is deemed excessive and problematic. Population
prevalence rates of pathological hoarding have been estimated at
between 2% and 5% (Iervolino et al., 2009; Mueller, Mitchell, Crosby,
Glaesmer, & de Zwaan, 2009; Samuels et al., 2008), with interfer-
ence in daily functioning by mid-30s (Grisham, Frost, Steketee, Kim,
& Hood, 2006; Pertusa et al., 2008). In severe cases, accumulation
of clutter can be a dangerous problem which puts people at risk
for re, falling and even death, due to interference with the nor-
mal use of space for basic household activities (Frost, Steketee,
& Williams, 2000; Steketee, Frost, & Kim, 2001). Further possible
consequences of hoarding include vermin infestation, food contam-
ination and social isolation (e.g. Frost & Gross, 1993; Kim, Steketee,
& Frost, 2001). A recent study found a high level of family conict
and distress in a large-scale survey of participants reporting hoard-
ing symptoms, along with signicant impairment in employment,
exceeding that found in most anxiety or depressive disorders, and
Corresponding author at: Centre for Anxiety Disorders and Trauma, 99 Denmark
Hill, London SE5 8AZ, UK. Tel.: +44 20 3228 2101.
E-mail address: Olivia.Gordon@kcl.ac.uk (O.M. Gordon).
disorders (Tolin, Brady, & Hannan, 2008).
Frost and Hartls (1996) operational denition of hoarding sug-
gests that hoarding is characterised by (a) excessive acquisition
of objects, (b) failure to discard excessive amounts of possessions
which appear to be useless or of limited value, (c) the cluttering
of living space which precludes activities for which those spaces
were designed, and (d) signicant distress or impairment in func-
tioning as a result of hoarding. The nosological status of hoarding
has been the subject of much debate. While hoarding is currently
listed as one of the eight diagnostic criteria of obsessive compulsive
personality disorder (American Psychiatric Association, 1994), it is
also considered a manifestation of obsessive compulsive disorder
(OCD). Indeed, DSM-IV-TR (APA, 2000) states that a diagnosis of
OCD should be considered when hoarding is extreme.
Increasingly, researchers have questioned whether hoarding is
best conceptualised as an OCD symptom with many suggesting that
hoarding be regarded as a distinct disorder (e.g. Rachman, Elliott,
Shafran, & Radomsky, 2009). Hoarding behaviour on a clinical scale
clearly occurs in individuals without a diagnosis of OCD (e.g. Pertusa
et al., 2008). In one study of 70 participants with severe hoarding
behaviour, 33% did not have any signicant OCD symptoms (Frost
et al., 2000). Wu and Watson (2005) found that patients with OCD
did not endorse hoarding symptoms more than did other popula-
tions, such as psychiatric out-patients without an OCD diagnosis,
and non-patients. Hoarding symptoms correlated more weakly
with other OCD symptoms, such as washing and checking, relative

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 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
to how the other OCD symptoms correlated with each other. While
much of the research investigating the relationship between com-
pulsive hoarding and OCD has compared hoarding with co-existing
OCD to non-hoarding OCD (e.g. Frost et al., 2000; Samuels et al.,
2007), very few studies have compared compulsive hoarding with
co-morbid OCD to compulsive hoarding without co-existing OCD.
Theoretical models and effective psychological treatments for
this complex problem are in the early stages of development.
According to one cognitivebehavioural model of compulsive
hoarding, symptoms such as acquisition, saving and clutter, arise
from an interaction between decits in information processing
and maladaptive beliefs about, and emotional attachments to pos-
sessions with emotional distress and avoidance developing as a
result (Frost & Hartl, 1996; Steketee & Frost, 2003). Information-
processing decits associated with hoarding are thought to include
attention (Hartl, Duffany, Allen, Steketee, & Frost, 2005), categori-
sation (Wincze, Steketee, & Frost, 2006), memory and the use of
information in making decisions and drawing conclusions (Tolin,
Frost, & Steketee, 2007), although the evidence is for this is not
compelling.
Seaman, Oldeld, Gordon, Forrester, and Salkovskis (2010) sug-
gest that hoarding may be driven by (i) harm avoidance, where
objects are acquired and not discarded in order to prevent harm
to the person or others, (ii) fear of material deprivation, where
the individuals earlier experiences of being signicantly deprived
of belongings may be linked to a concern that this may recur, so
that objects are hoarded to protect against such an eventuality, and
(iii) attachment disturbance, resulting in the fear that being sepa-
rated from an object will result in severe personal loss, because the
item is regarded as emotionally signicant to the person. While the
rst dimension may be psychologically indistinguishable to OCD,
the second and third dimensions are notably different. They argue
that this may explain the better treatment outcomes for patients
with primary OCD, relative to those with primary hoarding (e.g.
Abramowitz, Franklin, Schwartz, & Furr, 2003) because the psycho-
logical models guiding treatment, and the cognitive or behavioural
mechanisms involved, differ.
Unsurprisingly, there is clear support for the link between
hoarding symptoms and beliefs about possessions (Frost & Hartl,
1996), such as beliefs about emotional attachment (Steketee &
Frost, 2003). Research and clinical evidence appear to suggest that
individuals who hoard report greater levels of emotional attach-
ment, or hypersentimentality (Frost & Hartl, 1996), to their
possessions relative to those who do not hoard (Frost & Hartl, 1996;
Frost, Hartl, Christian, & Williams, 1995). An early study consis-
tently found the theme of attachment disturbance in a number
of case studies of hoarding (Shafran & Tallis, 1996). It has been
hypothesised that early material deprivation may also be asso-
ciated with the development of beliefs which lead to hoarding
behaviour (Seaman et al., 2010). The persons early experience of
massive loss of possessions is linked to a sense of dread that this
may happen again, so objects are acquired and saved to safeguard
against such an eventuality. Compulsive hoarding has been found
to be disproportionately associated with low socioeconomic status
and low household income (Samuels et al., 2008; Tolin et al., 2008).
Several self-reported childhood adversities have been associated
with hoarding, including lack of security from home break-ins,
and parental psychopathology, which may contribute to material
deprivation (Samuels et al., 2008). Such adversities may lead indi-
viduals to seek security in acquiring and saving large amounts of
possessions. It seems therefore that the perceived usefulness of an
item in the future and beliefs about the anticipated anxiety associ-
ated with not having a possession when needed in the future play
an important role in hoarding behaviour. Finally, hoarding can be
motivated by beliefs about harm, where items are collected and
saved because to not do so might result in harm coming to the
329
hoarding individual or to others; this dimension of hoarding may
be indistinguishable from OCD (Seaman et al., 2010). Pertusa et al.
(2008) found that while abnormal attachment or attribution of high
intrinsic value to possessions was reported by individuals in the
pure hoarding group, many participants in the hoarding with OCD
group reported obsessional ideas associated with their hoarding,
which were related to more conventional OCD themes, such as
magical thinking about something bad happening and checking rit-
uals related to fear of losing possessions (Pertusa et al., 2008). It is
possible, therefore, that greater harm avoidance beliefs are found
in hoarding individuals who also meet criteria for OCD relative to
people with primary hoarding who do not meet diagnostic criteria
for OCD. This suggests the possibility that when hoarding co-occurs
with OCD, a common cognitive mechanism (i.e. the perception of
threat and safety-seeking to avoid harm coming to self or others)
drives and motivates both hoarding and OCD difculties.
It is clear that further investigation of cognitive mechanisms
underlying hoarding (both when it occurs with OCD and when it
does not) is warranted. The present study aimed to clarify the rela-
tionship between compulsive hoarding and OCD in terms of the
psychopathology and cognitive features involved in hoarding when
it occurs with OCD and when it does not, and to compare with
a group with OCD without hoarding symptoms and non-clinical
controls. The study included the following hypotheses:
1. Participants with hoarding and co-existing OCD would report
greater harm avoidance beliefs related to their possessions, as
measured by the Belief about Hoarding Questionnaire, relative to
the pure hoarding group, while participants with pure hoarding
would present with greater material deprivation and attachment
disturbance beliefs relative to the hoarding with OCD group.
2. Participants in the hoarding with co-existing OCD group would
attach greater importance to the harm avoidance construct
relative to the pure hoarding group when taking part in a semi-
structured interview, and that individuals in the pure hoarding
group would attach greater importance to the fear of material
deprivation and emotional disturbance constructs relative to the
hoarding with OCD group.
2. Method
2.1. Participants
The sample consisted of 88 individuals, made up of four groups:
compulsive hoarding without co-morbid OCD (pure hoarders;
n = 24), compulsive hoarding with co-existing OCD (n = 21), OCD
without hoarding symptoms (n = 22) and non-clinical controls
(n = 21). Participants in the clinical groups were recruited through
an anxiety disorders clinic, via advertisements in patient organi-
sation websites (e.g. OCD UK, OCD Action), from hoarding support
groups and from an OCD conference. Non-clinical controls were
recruited from the local community and via emails sent to col-
leagues to circulate to family, friends or colleagues.
All participants were interviewed either face-to-face or via tele-
phone using structured diagnostic interviews in order to conrm
diagnoses and suitability for the study. Participants were excluded
if they were <18 years of age, met DSM-IV criteria for psychosis,
bipolar disorder or substance abuse/dependence, or where there
was evidence of organic brain injury. Written informed consent was
obtained and participants were compensated for their time. Ethical
approval was granted by the local NHS Research Ethics Committee
and University Ethics Committee.
The Frost and Hartl (1996) denition of hoarding was applied
to identify primary hoarding cases. In addition, individuals were
deemed to have signicant hoarding symptoms if they had a
330 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
score of >30 on the Savings Inventory-Revised (Frost, Steketee, &
Grisham, 2004). This method ensured that only participants with
signicant hoarding symptoms were included in the study. Partic-
ipants who met these inclusion criteria for hoarding were divided
into two groups (hoarding with OCD or hoarding without OCD/pure
hoarding) based on whether or not they met DSM-IV diagnostic
criteria for prototypical symptoms of OCD. Individuals in the pure
hoarding group were excluded if they scored above the mean total
score of a clinical OCD group on the Obsessive Compulsive Inven-
tory (>66 on OCI, as reported by Foa, Kozak, Salkovskis, Coles, &
Amir, 1998) when the score obtained on the hoarding subscale
had been subtracted. Participants were assigned to the OCD with-
out hoarding group if they met DSM-IV criteria for OCD, and did
not meet criteria for hoarding, while individuals were included in
the non-clinical control group did not meet diagnostic criteria for
any mental health disorder.
All participants completed the questionnaire pack. Participants
in both hoarding groups were also interviewed using the semi-
structured interview schedule to gather ratings for each construct.
The semi-structured interviews were recorded and transcribed,
and ratings for each subscale were noted.
2.2. Measures
2.2.1. Beliefs about Hoarding Questionnaire (BAH)
The BAH is a new self-report measure developed during the
initial phase of the study to assess beliefs and experiences char-
acteristic of hoarding including: hoarding motivated by harm
avoidance/responsibility for harm, hoarding motivated by previous
experience of material deprivation and hoarding related to attach-
ment disturbance. The nal version of the BAH (Appendix A) is
comprised of 28 items with three subscales. Participants are asked
to rate the degree of belief for each item on a scale from 0 to 100,
where 0 indicates I did not believe this at all and 100 indicates
I was completely convinced this idea was true. Belief ratings are
totaled to give an overall score. Items for each of the three subscales
representing patterns of hoarding are added and then divided by
the number of items in each subscale to provide average belief rat-
ings for each subscale. There are six items in the harm avoidance
subscale (items 6, 12, 21, 24, 25, 28), nine items in the material
deprivation subscale (items 1, 5, 7, 10, 13, 15, 18, 23, 27), twelve
items in the attachment disturbance subscale (items 3, 4, 8, 11, 14,
16, 17, 19, 20, 22, 26) and one item representing the positive emo-
tion associated with acquiring (item 9: It feels exhilarating and
very exciting to get new items to add to my things).
Reliability was good in the present sample, indicating high inter-
nal consistency for the measure as a whole ( = .96) and for each
subscale on the measure, including harm avoidance ( = .79), mate-
rial deprivation ( = .93) and attachment disturbance ( = .93). On
the basis of re-administration of the measure to a sub-sample of
10 individuals with compulsive hoarding difculties (7 females, 3
males, mean age: 59.7, range: 4173), the 28-item measure was
found to have good testretest reliability (r = .83) as has each of the
subscales, including harm avoidance (r = .85), material deprivation
(r = .89) and attachment disturbance (r = .69).
2.2.2. Semi-structured interview to identify type of hoarding
The semi-structured interview consisted of a number of open
and closed questions, attempting to assess the individuals expe-
riences and beliefs about hoarding. Individuals were asked about
their experiences of acquisition, saving and difculty discarding.
At the end of the interview, participants were asked to rate, on a
scale from 0 to 100, how much they believed their hoarding was
motivated by the three proposed patterns of hoarding, (i.e. harm
avoidance, material deprivation and emotional attachment).
2.2.3. Diagnostic measures
Psychiatric Diagnostic Screening Questionnaire (PDSQ;
Zimmerman, 2003). The PDSQ is a brief self-report instrument that
screens for DSM-IV Axis I disorders most commonly encountered
in clinical settings.
Screener for Structured Clinical Interview for DSM Axis II Per-
sonality Disorders. This is a self-report screener to determine
four Axis II diagnoses, including avoidant personality disorder,
obsessivecompulsive personality disorder, paranoid personality
disorder and borderline personality disorder. Where indicated, the
full module of the relevant Structured Clinical Interview for DSM-
IV Axis II Personality Disorders (SCID-II; First, Spitzer, Gibbon,
Williams, & Benjamin, 1997) was administered.
Structured Clinical Interview for DSM-IV (SCID) for Axis I disor-
ders Version 2.0 (First, Spitzer, Gibbon, & Williams, 1996). This
semi-structured interview was used to establish DSM-IV diagno-
sis of OCD and any other diagnosis indicated by the Axis I disorder
screener (APA, 1994).
2.2.4. Measures of psychopathology
Savings Inventory Revised (SI-R; Frost et al., 2004). The SI-R is
a self-report measure designed to assess the severity of the main
symptoms of hoarding (clutter, difculty discarding and excessive
acquisition) and the distress and interference associated with each.
Composed of 23 items, each item is rated on a 5-point Likert scale.
The measure is made up of three subscales: compulsive acquisition,
difculty discarding, and cluttered living spaces. A sum of all items
yields a total score for the measure, which ranges from 0 to 92. Reli-
ability and validity have been established for the SI-R (Frost et al.,
2004). Internal consistency, testretest reliability, convergent and
divergent validity have been established for the SI-R and the mea-
sure has also demonstrated specicity in terms of distinguishing
individuals with hoarding behaviour from those without hoarding
behaviour (Frost et al., 2004). Previous studies have reported overall
mean scores of between 53 and 62 for individuals with compulsive
hoarding and a mean total score of 23.8 for those without hoard-
ing difculties (Frost et al., 2004; Frost, Steketee, Tolin, & Renaud,
2008; Hartl et al., 2005). Mean scores (and standard deviations) on
each of the subscales for individuals with hoarding difculties have
been found as follows (Frost et al., 2004): clutter = 26.9 (6.6), dis-
carding = 19.8 (5.0) and acquisition = 15.2 (5.4). Mean scores (and
standard deviations) on each of the subscales for individuals with-
out hoarding difculties have been found as follows (Frost et al.,
2004): clutter = 8.2 (7.1), discarding = 9.2 (5.0) and acquisition = 6.4
(3.6).
Clutter Images Rating Scale (CIR; Frost et al., 2008). The CIR is a
visual rating scale which was developed in order to assess sever-
ity of clutter associated with compulsive hoarding. This pictorial
scale contains nine photographs representing increasing severity
of clutter for each of three main rooms of most peoples homes: liv-
ing room, kitchen, and bedroom. Participants are asked to choose
which of the nine images most represents the different areas of
their home (1 = least cluttered; 9 = most cluttered). A mean compos-
ite score is calculated for each participant, where the range is 19.
The scale has good internal consistency ( = .84), high testretest
reliability (r = 0.82), high inter-rater reliability (r = 0.94), and good
convergent and discriminant validity (Frost et al., 2008). An over-
all mean of 4.01 (SD = 1.80) has been reported among individuals
with signicant difculties with compulsive hoarding (Frost et al.,
2008).
Compulsive Acquisitions Scale (CAS; Frost et al., 1998). The CAS
is an 18-item Likert-type scale that measures the extent to which
individuals acquire and feel compelled to acquire possessions. Each
item is rated from 1 (not at all or rarely) to 7 (very much or very
often). The CAS contains two subscales: CAS-Buy and CAS-Free.
The CAS-Buy is a 12-item subscale which is a broad measure of
 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
compulsive buying and its consequences. The CAS-Free is a 6-item
subscale which is a measure of the excessive acquisition of free
objects. Both the CAS-Buy and CAS-Free demonstrated satisfac-
tory reliability (alphas = .94 and .87 respectively; Frost et al., 2000;
Kyrios, Frost, & Steketee, 2004).
Obsessive Compulsive Inventory (OCI; Foa et al., 1998). The OCI
is 42-item self-report measure of the frequency and distress asso-
ciated with a range of obsessions and compulsions. Each item is
scored for distress on a scale of 04 (0 = Never, and 4 = Almost
always) and the measure has seven subscales relevant to vari-
ous manifestations of obsessional behaviour: washing, checking,
doubting, ordering, obsessions, hoarding and mental neutralising.
The maximum total score across the subscales is 168. The max-
imum score for the hoarding subscale is 12. The OCI has high
internal consistency for both total frequency (0.93) and total dis-
tress (0.92) scores, and high testretest reliability in an OCD sample
and non-clinical controls (Foa et al., 1998). Distress and frequency
total scores are highly correlated on the OCI (above 0.9), in both
OCD and non-OCD groups, which led Foa et al. (2002) to con-
clude that the frequency scale was redundant. On this basis, the
version of the OCI used in this study requested only distress
ratings.
Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996).
The BDI is a widely used 21-item self-report scale used to mea-
sure symptoms and severity of depression over the previous
week, including cognitive, affective, motivational, and physiolog-
ical symptoms. Each item has four alternative answers scored 0
to 3 and total scores range from 0 to 63. Internal consistency and
testretest validity have been established for the BDI. Although not
designed as a diagnostic instrument, BDI scoring gives categories
of non-depressed (09) mildly depressed (1019), and clinical
depression (score of 16 or over), with scores of between 20 and
30 an indication of moderate depression, and a score of 30 or over
an indication of severe depression (Kendall, Hollon, Beck, Hammen,
& Ingram, 1987).
Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, &
Williams, 2001). The PHQ-9 is an instrument for screening, diag-
nosing, monitoring and measuring the severity of depression. With
nine items, the measure rates the frequency of symptoms, where
0 indicates not at all, 1 indicates several days, 2 = more than half
the days, and 3 = nearly every day. PHQ-9 scores of 59 indicate
minimal symptoms, scores of between 10 and 14 suggests mild
depression, 1519 indicates moderately severe and scores of more
than 20 suggests severe depression.
Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988).
The BAI is a 21-item self-report questionnaire designed to assess
distress associated with symptoms of anxiety over the previous
week. Each item enquires about how much the respondent has
been bothered by each symptom on a 03 scale of severity from
not at all to severely. Scores are added to give a single score ran-
ging from 0 to 63. A total score of 07 is interpreted as minimal
level of anxiety; 815 as mild, 1625 as moderate, and 2663
as severe. Reliability and validity have been established for this
measure. The internal consistency of the BAI has been found to be
in the range 0.850.94 (Beck & Steer, 1991).
Generalised Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke,
Williams, & Lowe, 2006). Consisting of seven items, the GAD-7 is
a measure of generalised anxiety. Each item is rated from zero to
three, where zero indicates not at all, one indicates several days,
two indicates half the days and three indicates nearly every day.
Total scores of ve, ten, and fteen are taken as the cut off points
for mild, moderate and severe anxiety respectively. The GAD -7 has
been found to be a valid tool to screen for anxiety and to assess its
severity in clinical practice and research.
Work and Social Adjustment Scale (WSAS; Mundt, Marks, Shear,
& Greist, 2002). The WSAS is a self-report scale of functional
331
impairment. Containing ve items, each with nine points, ranging
from zero to eight, the WSAS has been found to be a simple, reliable
and valid measure of impaired functioning.
2.2.5. Measures of cognition
Responsibility Attitudes Scale (RAS; Salkovskis et al., 2000). The
RAS is a 26-item self-report questionnaire designed to assess gen-
eral beliefs about responsibility. Each item is measured on a 7-point
Likert scale, with responses ranging from 1 = totally agree to
7 = totally disagree. The scale has high testretest reliability and
internal consistency (r = 0.94; = 0.92; Salkovskis et al., 2000). The
RAS correlates signicantly with measures of obsessionality, there-
fore demonstrating concurrent validity (Salkovskis et al., 2000).
Responsibility Interpretations Questionnaire (RIQ; Salkovskis
et al., 2000). The RIQ is a 22-item self-report questionnaire designed
to assess the frequency and extent of belief in specic interpreta-
tions of intrusive thoughts about potential harm. In order to prime
negative interpretations specic to intrusive thoughts, the ques-
tionnaire asks responders to make a note of the intrusions they
have had in the previous two weeks. Participants are then asked
to rate the extent to which they believed the interpretation at the
time on 16 questions, on a scale from 0 to 100, where 0 indicates
that I did not believe this idea at all and 100 indicates I was com-
pletely convinced this idea was true. The total score is divided by
16 to provide an average score for the questionnaire. The RIQ has
demonstrated good testretest reliability as well as good internal
consistency and criterion validities (Salkovskis et al., 2000).
Saving Cognitions Inventory (SCI; Steketee, Frost, & Kyrios, 2003).
The SCI is a 24-item questionnaire designed to measure hoarding
beliefs and emotional reactions. Participants are asked to rate the
extent to which a thought inuenced their decision about whether
to discard a possession on a 7-point Likert scale, where 1 represents
not at all and 7 indicates very much. Factor analysis of this scale
yielded four dimensions labelled emotional attachment, memory
concerns, desire for control and responsibility for possessions.
The SCI total score was found to have good internal consistency
and good convergent and discriminant validity. Alpha coefcients
and inter-item correlations suggest very good to excellent internal
consistency for each of the four subscales (.95 for Emotional com-
fort, .89 for Memory, .86 for Control and .90 for Responsibility) as
well as for the 24-item score (.96).
Buying Cognitions Inventory (BCI; Kyrios et al., 2004). The BCI is
a 36-item scale devised to measure cognitive domains associated
with compulsive buying, such as i) compensation or neutralising
negative feelings, ii) emotional reasons for buying objects, includ-
ing emotional attachment to and emotional security from objects,
iii) perceptions about the uniqueness of objects and concerns about
loss of opportunity and an inated sense of personal responsibility
for objects, and iv) concerns about maintaining control over ones
buying behaviour and choices. On a 7-point Likert scale, where 1
indicates not at all, and 7 indicates very much, participants are
asked to rate the extent to which a thought inuenced their deci-
sion to buy. Alpha coefcients for the BCI scores indicate highly
satisfactory internal consistency: compensation (.94), reasons to
buy (.96), uniqueness/loss of opportunity (.92), and control (.88).
2.3. Design
The study employed a cross-sectional between-subjects design
with four groups the index groups (pure hoarding, hoarding with
comorbid OCD) and control groups (OCD without hoarding, non-
clinical control). The main focus of the study was between group
differences in participants responses on the three subscales (harm
avoidance, fear of future material deprivation, attachment disturb-
ance) of the Beliefs about Hoarding measure and semi-structured
interview, and between group differences on measures of
332 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
phenomenology, psychopathology and cognition. Therefore, the
group to which the participant belonged (hoarding plus OCD,
hoarding minus OCD, OCD minus hoarding, non-clinical control),
was the between subjects factor, with the various measures being
tested, (e.g. Beliefs about Hoarding Harm Avoidance), as the
within subjects factor. Where appropriate, non-clinical control data
was used for benchmarking purposes.
2.4. Data analyses
Categorical data were compared using chi square or Fishers
exact tests; Chi square analyses were partitioned when larger
tables showed signicant associations. Continuous independent
data were compared using t-tests or one way analysis of variance
(ANOVA). Where the results of ANOVAs indicated a statistically
signicant main effect of group, post hoc comparisons were
made using Tukey LSD (in cases of equal variances) or Dunnetts
T3 (in cases of unequal variances) post hoc tests. For within
subject variables where the Epsilon coefcient was signicant,
GreenhouseGeisser corrections were applied.
3. Results
The demographic characteristics of the four groups are shown in
Table 1. A one-way analysis of variance (ANOVA) revealed a signi-
cant difference in age between the four study groups (F[3,87] = 23.28,
p < .001). Post-hoc tests revealed that individuals in the pure hoard-
ing group and the hoarding with OCD group were signicantly older
than individuals in the OCD without hoarding group (p < .001). Indi-
viduals in the pure hoarding group were signicantly older than
those participants in the hoarding with OCD group (p < .05). The
association between relationship status and group was signicant
(2 (3) = 19.74, p < .001) with portioned Chi square tests indicating
a greater number of people in relationships in the OCD without
hoarding group relative to both the hoarding with OCD group
(2 (1) = 5.2, p < .05) and the pure hoarding group (2 (1) = 8.7, p < .05).
There were also more individuals in relationships in the non-
clinical group relative to both the pure hoarding group (2 (1) = 14.5,
p < .001) and the hoarding with OCD group (2 (1) = 10.1, p < .05).
The difference between both hoarding groups was not signicant
(2 (1) = 0.40, p > .5).
There was no association between gender and group
(2 (3) = 0.609, p > .5). The main effect of diagnostic group was
not signicant in terms of number of years spent in education,
(F[3,87] = .578, p > .5). For the purposes of statistical analysis the
ethnic group category was divided into Caucasian and Non-
Caucasian. The association between ethnicity and group was not
signicant (2 (3) = 1.18, p > .5). Employment status was divided into
two groups (employed/unemployed). The association between
employment status and group was signicant, (2 (3) = 14.67,
p < .05). This was accounted for by the signicantly higher levels
of employment in the OCD without hoarding group relative to
the pure hoarding group (2 (1) = 5.5, p < .05) and greater rate of
employment in the non-clinical control group relative to both the
pure hoarding group (2 (1) = 14.0, p < .001) and the hoarding with
OCD group (2 (1) = 5.1, p < .05). The difference between the two
hoarding groups was not signicant, (2 (1) = 2.5, p > .05).
3.1. Mood and social functioning
Table 2 presents the results of general psychopathology in the
four groups. There was no signicant difference in reported depres-
sion (BDI and PHQ-9) across clinical groups, which was signicantly
greater than that found in the non-clinical control group. Levels of
reported anxiety (BAI, GAD-7) was also signicantly greater in the
clinical groups relative to the non-clinical group. While there was
no signicant difference across clinical groups on one measure of
reported anxiety (BAI), the pure hoarding group scored signicantly
lower on the GAD-7 measure of anxiety relative to both the hoard-
ing with OCD group and the OCD without hoarding group. In terms
of social functioning, participants in the pure hoarding group rated
themselves as signicantly less impaired relative to both the hoard-
ing with OCD group (p < .05) and the OCD without hoarding group
(p < .05). Social impairment was signicantly greater in all clinical
groups relative to the non-clinical group.
3.2. Axis I and II co-morbidity
Table 3 presents number of participants in each group meet-
ing diagnostic criteria for Axis I and II disorders. The signicant
main effect of group with regard to diagnosis of major depres-
sion was accounted for by the difference between the non-clinical
control group and the clinical groups, including the pure hoarding
group (2 (1) = 3.8, p < .05), the hoarding with OCD group (2 (1) = 8.4,
p < .05), and the OCD without hoarding group (2 (1) = 5.4, p < .05).
The signicant main effect of group for diagnosis of GAD was
accounted for by the greater frequency of GAD in the hoarding with
OCD group relative to both the pure hoarding group (2 (1) = 12.8,
p < .001), and the OCD without hoarding group (2 (1) = 4.6, p < .05)
as well as the non-clinical control group (2 (1) = 11.5, p < .001). The
signicant main effect of group with regard to OCPD was accounted
for by the signicantly greater number of individuals meeting diag-
nostic criteria for OCPD in the hoarding with OCD group relative to
both the OCD without hoarding group (2 (1) = 4.1, p < .05) and the
non-clinical control group (2 (1) = 15.9, p < .0001). There were also
signicantly fewer cases of OCPD in the non-clinical control group
relative to the pure hoarding group (2 (1) = 8.0, p < .05) and the OCD
without hoarding group (2 (1) = 5.2, p < .05). The signicant differ-
ence between groups on diagnosis of Avoidant PD was accounted
for by the absence of this diagnosis in the non-clinical control group
relative to the pure hoarding group (2 (1) = 6.1, p < .05) and the OCD
without hoarding group (2 (1) = 7.9, p < .05).
3.3. Severity of hoarding symptoms
Table 4 presents the means and standard deviations for the
OCD and hoarding measures of the clinical and non-clinical groups.
Overall, the results indicate that both hoarding groups had sim-
ilar hoarding symptom severity while both groups with OCD
reported similar OCD symptom severity. Scores on the hoarding
measures (SI-R, CIR, CAS, BCI, SCI) indicated substantial symp-
tom severity with no signicant differences in hoarding symptom
severity between the two hoarding groups. However, individ-
uals with hoarding and co-morbid OCD reported signicantly
higher scores on the control subscale of the SCI, compared to
hoarders without OCD. As expected, the two hoarding groups
had signicantly higher scores on these measures relative to
the OCD without hoarding group and the non-clinical control
group.
Savings Inventory-Revised (SI-R). A mixed model analysis of
variance using one grouping factor (the four groups) and one
within-subjects factor (subscale) was carried out for this measure of
severity of hoarding symptoms. There was a signicant main effect
of subscale (F[2,168] = 34.3, p < .001), with a main effect of group
(F[3,84] = 59.8, p < .001). These effects were modied by a signicant
group subscale interaction F[6,168] = 10.3, p < .001). Post hoc tests
revealed signicant differences between the pure hoarding group
and the OCD without hoarding group (p < .001) and between the
hoarding with OCD group and the OCD without hoarding group
(p < .001). The difference between the two hoarding groups on total
SI-R score was not signicant (p > .5). The non-clinical control group
scored signicantly lower than both hoarding groups (p < .001),
 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339 333

Table 1
Sociodemographic characteristics of the four groups.

Group

Hoarding/OCD (n = 24) Hoarding/OCD+ (n = 21) OCD/Hoarding (n = 22) Non-clinical (n = 21)

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Age (years) 59 (13.8) 50.6 (11.7) 32.5 (8.1) 51.4 (9.4)

Education (years) 16.4 (3.7) 15.4 (3.3) 15.5 (3.5) 16.7 (5.0)

N (%) N (%) N (%) N (%)

Female 17 (70.8) 13 (61.9) 15 (68.2) 13 (61.9)

Caucasian 21 (87.5) 18 (85.7) 20 (90.9) 20 (95.2)
Married/In 7 (29.2) 8 (38.1) 16 (72.7%) 18 (85.7)
Relationship
Employed 7 (29.2) 10 (47.6) 12 (54.5) 17 (81)

Table 2
Measures of general psychopathology.

Group

Hoarding/OCD (n = 24) Hoarding/OCD+ (n = 21) OCD/Hoarding (n = 22) Non-clinical (n = 21) Statistics

Mean (SD) Mean (SD) Mean (SD) Mean (SD) F df p

BDI 16.8a (13.4) 22.5a (14.9) 20.3a (12.0) 6.4b (4.7) 7.48 3,87 <.001
PHQ-9 8.2a (7.5) 13.9a (8.2) 13.6a (8.6) 2.6b (2.0) 11.96 3,87 <.001
BAI 13.9a (10.0) 20.4a (13.4) 21.9a (13.4) 6.0b (5.3) 9.12 3,87 <.001
GAD-7 7.5a (6.1) 12.8b (6.2) 14.1b (5.2) 2.3c (1.9) 22.8 3,87 <.001
WSAS 14.9a (10.2) 22.4b (8.1) 20.2b (8.1) 3.0c (3.4) 25.2 3,87 <.001

Note. Means with differing letters differ signicantly; BDI = Beck Depression Inventory; PHQ-9 = Patient Health Questionnaire 9; BAI = Beck Anxiety Inventory;
GAD-7 = Generalised Anxiety Disorder 7; WSAS = Work and Social Adjustment Scale.

however the difference between the OCD without hoarding group
and the non-clinical control group was not signicant (p > .05). The
mean total scores on the SI-R for both hoarding groups were consis-
tent with previous studies which reported overall mean scores of
between 53 and 62 for individuals with compulsive hoarding (Frost
et al., 2004, 2008; Hartl et al., 2005).
Saving Cognitions Inventory (SCI). A mixed model analysis of
variance using one grouping factor (the four groups) and one
within-subjects factor (subscale) was carried out on this measure
of hoarding beliefs and emotional reactions related to possessions.
There was a signicant main effect of subscale (F[1.9 ,161.6] = 153.9,
p < .001), with a main effect of group (F[3,84] = 31.8, p < .001). How-
ever, these effects were modied by a signicant group subscale
interaction, F[5.8,161.6] = 8.4, p < .001). In order to analyse the
interaction further, simple main effects ANOVAs with multiple
comparisons were carried out for each subscale. Post-hoc tests
(Dunnetts T3) revealed signicant differences between the pure
hoarding group and the OCD without hoarding group (p < .001)
and between the hoarding with OCD group and the OCD without
hoarding group (p < .001). The difference between the two hoarding
groups on total SCI score was not signicant (p > .05). The non-
clinical control group scored signicantly lower than both hoarding
groups (p < .001), however the difference between the OCD with-
out hoarding group and the non-clinical control group was not
signicant (p > .5).
Compulsive Acquisitions Scale (CAS). Analysis of the Compulsive
Acquisitions Scale (CAS) showed a signicant main effect of group
on this measure of acquiring possessions (F[3,87] = 16.3 p < .001).
Buying Cognitions Inventory (BCI). Analysis of the Buying
Cognitions Inventory (BCI) showed a main effect of group on
this measure of cognitive domains associated with hoarding
(F[3,87] = 7.5, p < .001).
Clutter Images Rating Scale (CIR). Analysis of the Clutter Images
Rating Scale (CIR) showed a main effect of group on this measure of

Table 3
Axis I and II co-morbidity according to group.

Group

Hoarding/OCD (n = 24) Hoarding/OCD+ (n = 21) OCD/Hoarding (n = 22) Non-clinical (n = 21) Statistics

N (%) N (%) N (%) N (%) 2 df p

Depression 4 (16.7) 7 (33.3) 5 (22.7) 0 (0) 8.2 3 .04

Panic disorder 1 (4.2) 1 (4.8) 4 (18.1) 0 (0) 6.4 3 .09
PTSD 1 (4.2) 3 (14.3) 2 (9.1) 0 (0) 3.8 3 .28
Agoraphobia 1 (4.2) 0 (0) 4 (18.1) 0 (0) 9.0 3 .03
Social phobia 1 (4.2) 2 (9.5) 1 (4.5) 0 (0) 2.2 3 .53
GAD 0 (0) 9 (42.9) 3 (13.6) 0 (0) 22.3 3 <.001
Health anxiety 0 (0) 1 (4.8) 1 (4.5) 0 (0) 2.1 3 .54
BDD 3 (12.5) 2 (9.5) 1 (4.5) 0 (0) 3.2 3 .36
Specic phobia 0 (0) 4 (19.0) 2 (9.1) 2 (9.5) 4.9 3 .18
OCPD 12 (50) 15 (71.4) 9 (40.9) 2 (9.5) 16.2 3 <.001
Avoidant PD 6 (25%) 2 (9.5) 7 (31.8) 0 (0) 9.6 3 .02
Paranoid PD 4 (16.7) 4 (19) 4 (18.2) 0 (0) 4.4 3 .22
Borderline PD 4 (16.7) 4 (19) 5 (22.7) 0 (0) 5.1 3 .16

Note. PTSD = posttraumatic stress disorder; GAD = generalised anxiety disorder; BDD = body dysmorphic disorder; OCPD = obsessive compulsive personality disorder.
334 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339

Table 4
Mean scores (SD) for OCD and hoarding measures according to group.

Hoarding/OCD (n = 24) Hoarding/OCD+ (n = 21) OCD/hoarding (n = 22) Non-clinical (n = 21) Simple main effects

Mean (SD) Mean (SD) Mean (SD) Mean (SD) F df p

OCI distress
Washing 4.4a (5.0) 12.8b (10.3) 15.9b (10.8) 1.0a,c (1.8) 17.2 3,87 <.001
Checking 5.2a (4.0) 17.1b (7.3) 14.7b (9.2) 2.3a,c (2.7) 28.0 3,87 <.001
Doubting 2.3a (2.7) 6.4b (3.3) 5.0b (3.4) 0.7a,c (1.0) 18.6 3,87 <.001
Ordering 4.1a (3.4) 8.2b (4.9) 10.1b (6.0) 1.8a,c (2.6) 16.0 3,87 <.001
Obsessions 5.7a (6.4) 12.5b (8.7) 18.1c (7.5) 1.9a,d (2.6) 25.1 3,87 <.001
Hoarding 7.6a (2.5) 8.9a (3.1) 3.0b (3.3) 0.9c (1.2) 43.6 3,87 <.001
Neutralising 2.5a (3.3) 8.5b (5.3) 8.6b (6.5) 0.9a,c (0.9) 16.8 3,87 <.001
Total 31.7a (19.7) 74.5b (28.7) 75.5b (31.8) 9.5c (8.7)

RAS
Total score 96.4a (29.2) 126.8b (24.8) 125.3b (25.7) 83.7a (27.6)

RIQ
Mean rating 20.6a (25.3) 50.3b (25.0) 47.2b (20.5) 4.9c (7.9)

SI-R
Excessive acquisition 14.3a (6.3) 14.9a (8.7) 5.9b (5.1) 3.6b (2.1) 19.7 3,87 <.001
Difculty discarding 19.5a (4.1) 20.0a (6.0) 8.3b (6.3) 5.1b (2.9) 50.5 3,87 <.001
Clutter 22.7a (7.8) 25.9a (8.0) 5.5b (5.9) 4.8b (4.6) 59.2 3,87 <.001
Total 56.1a (15.6) 61.1a (18.5) 19.8b (15.1) 13.6b (7.3)

SCI
Emotional attachment 38.1a (10.6) 44.8a (17.2) 22.1 (13.4) 17.0b (7.4) 23.1 3,87 <.001
Control 15.1a (4.6) 18.3b (3.9) 9.7 (5.5) 9.2c (4.2) 19.6 3,87 <.001
Responsibility 18.9a (6.6) 24.8a (9.7) 11.2 (6.5) 10.2b (4.5) 20.5 3,87 <.001
Memory 18.5a (7.6) 22.0a (7.5) 9.3 (5.1) 8.3b (5.4) 22.9 3,87 <.001
Total 90.1a (20.1) 109.8a (33.8) 52.3 (27.6) 44.7b (17.6)

CAS
Total score 64.9a (21.2) 70.4a (33.4) 39.8b (18.3) 31.1b (8.4)

BCI
Total score 89.5a (36.8) 107.5a (52.6) 69.7a,b (35.4) 57.2b (14.5)

CIR
Average 3 main rooms 4.1a (1.8) 4.0a (2.0) 1.4b (0.5) 1.2b (0.3)

Note. Means with differing letters differ signicantly. OCI = obsessive compulsive inventory; RAS = Responsibility Attitudes Scale; RIQ = Responsibility Interpretations Ques-
tionnaire; SI-R = Savings Inventory Revised; SCI = Saving Cognitions Inventory; CAS = Compulsive Acquisitions Scale; BCI = Buying Cognitions Inventory; CIR = Clutter Images
Rating Scale.

average severity of clutter for the three main rooms (F[3,87] = 28.3,
p < .001).
3.4. Severity of OCD symptoms
As expected, the pure hoarding group had signicantly lower
OCD symptom severity and beliefs about responsibility relative to
the two groups with OCD (OCD with hoarding, OCD without hoard-
ing). However, there was no signicant difference between the
hoarding groups on the hoarding subscale of the OCI. The OCD with-
out hoarding group scored signicantly higher on the obsessions
subscale of the OCI compared to the hoarding with OCD group.
ObsessiveCompulsive Inventory (OCI). A mixed model analy-
sis of variance using one grouping factor (the four groups) and
one within-subjects factor (subscale) was carried out on this mea-
sure of distress associated with obsessions and compulsions. There
was a signicant main effect of subscale (F[3.6,304] = 26.6, p < .001),
with a main effect of group (F[3,84] = 38.9, p < .001). However, these
effects were modied by a signicant group subscale interaction
(F[10.9,304.5] = 9.5, p < .001).
Responsibility Attitudes Scale (RAS). Analysis of the Responsibility
Attitudes Scale (RAS) showed a main effect of group on this measure
of generalised beliefs about responsibility (F[3,87] = 13.6, p < .001).
Responsibility Interpretations Questionnaire (RIQ). Analysis of the
Responsibility Interpretations Questionnaire (RIQ) showed a main
effect of group on this measure of interpretations of intrusive
thoughts about harm, for average RIQ score (F[3,86] = 22.7, p < .001).
3.5. Beliefs about hoarding
Using the original a priori subscales, harm avoidance, material
deprivation and attachment disturbance, a mixed model anal-
ysis of variance using one grouping factor (the four groups)
and one within-subjects factor (subscale) was carried out. There
was a signicant main effect of subscale (F[2,166] = 38.0, p < .001),
with a main effect of group (F[3,83] = 18.2, p < .001; see Table 5

Table 5
Mean scores (SD) on each of the BAH subscales according to group.

Subscale Hoarding/OCD Hoarding/OCD+ OCD/Hoarding Non-clinical (n = 21) Statistics

(n = 24) (n = 21) (n = 22)

Mean (SD) Mean (SD) Mean (SD) Mean (SD) F df p

Harm avoidance 20.8a (13.5) 31.2b (20.1) 19.5a (23.3) 7.5c (7.5) 6.7 3,87 <.001
Material deprivation 47.1a (19.6) 55.6a (25.6) 19.6b (18.1) 11.1b (12.1) 25.9 3,87 <.001
Attachment disturbance 39.4a (17.1) 48.4a (24.0) 21.2b (22.2) 12.9b (14.4) 14.5 3,87 <.001

Note. Means with differing letters differ signicantly.

 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
Fig. 1. Mean scores on each BAH subscale according to group.
and Fig. 1). However, these effects were modied by a sig-
nicant group subscale interaction (F[6,166] = 8.7, p < .001). In
order to analyse the interaction further, simple main effects
ANOVAs with multiple comparisons were carried out for each
subscale. The hoarding with OCD group had signicantly greater
harm avoidance beliefs related to possessions compared to the
pure hoarding group, while there was no signicant difference
between the two hoarding groups on beliefs about fear of future
material deprivation. There was also no signicant difference
between the two hoarding groups on beliefs about attachment to
possessions.
3.6. Group differences in construct ratings (0100) in
semi-structured interview
Independent t-tests were used to compare the ratings of both
hoarding groups on each subscale. Separate variance estimates
were used since homogeneity of variance assumptions were not
met (Harm avoidance: F = 10.2, p < .05; material deprivation: F = 5.6,
p < .05; attachment disturbance: F = 5.4, p < .05). As expected, the
hoarding with OCD group scored signicantly higher than the
pure hoarding group on the harm avoidance rating (t(26) = 2.8,
p < .05). In terms of the other two subscale ratings, the hoard-
ing with OCD group scored signicantly higher than the pure
hoarding only group on the material deprivation subscale rating
(t(32) = 3.0, p < .05). There was no signicant difference between
groups on the attachment disturbance subscale rating (t(30) = .08,
p > .5).
3.7. Identifying distinct categories of hoarding from the
semi-structured interview
Of the 45 participants with hoarding who took part in the study,
40 individuals with hoarding symptoms took part in the semi-
structured interview to identify type of hoarding. Of those, 21
experienced hoarding but did not meet criteria for OCD, while 19
participants experienced hoarding and also had a diagnosis of OCD.
In total, when asked to judge which of the three subscales was
most relevant to them, 17 participants identied beliefs related to
material deprivation to be most relevant to them, while 23 individ-
uals identied beliefs related to attachment to be most relevant.
Contrary to expectation no participants identied harm avoidance
as their primary reason for hoarding. Chi-square tests revealed
that the difference between groups was not signicant, (2 (1) = 1.5,
p > .05).
335
4. Discussion
As anticipated, individuals with compulsive hoarding who also
met DSM-IV criteria for OCD reported signicantly greater harm
avoidance beliefs associated with possessions relative to individ-
uals with hoarding who did not meet criteria for OCD. However,
the group with pure hoarding (hoarding without OCD) did not
report signicantly greater fear of future material deprivation
and attachment disturbance beliefs relative to the hoarding with
OCD group. When interviewed, the hoarding with OCD group
reported attaching signicantly greater importance to the harm
avoidance construct in terms of their hoarding difculties rela-
tive to the pure hoarding group. The hoarding with OCD group
also assigned signicantly greater importance to the fear of future
material deprivation construct. There was no signicant differ-
ence between hoarding groups on the attachment disturbance
construct.
When asked to describe their experiences and beliefs about
possessions in terms of three distinctive responses (i.e. harm avoid-
ance, fear of material deprivation, attachment disturbance) the
harm avoidance category was not endorsed by any participant in
any of the hoarding groups as the most important category (fear
of future material deprivation, attachment disturbance) between
hoarding groups (with and without OCD). There were no differ-
ences between groups in the extent to which they endorsed fear
of material deprivation versus emotional attachment constructs as
primary reason for hoarding.
The results of this study are consistent with previous research,
such as that of Pertusa et al. (2008), which indicated that indi-
viduals with hoarding who also met diagnostic criteria for OCD
were more likely to report obsessional themes related to their
hoarding (e.g. something bad may happen if a possession is dis-
carded) relative to a hoarding group without OCD. Pertusa et al.
found that all participants in a hoarding without OCD sample
reported hoarding due to the emotional or intrinsic value of pos-
sessions.
The clinical groups did not differ in terms of depression and
anxiety ratings, but diagnostic data suggests a greater prevalence
of GAD and OCPD in hoarding difculties, with a signicantly
greater prevalence of these disorders in the hoarding with OCD
group relative to the OCD without hoarding group. It has previ-
ously been suggested that both GAD and hoarding may share some
degree of negative problem orientation (Tolin, Meunier, Frost, &
Steketee, 2011). Individuals with a diagnosis of GAD exhibit poor
condence in problem-solving skills, low sense of control over
the problem-solving process (Ladouceur, Blais, Freeston, & Dugas,
1998), and difculty tolerating uncertainty (Dugas, Freeston, &
Ladouceur, 1997), which have also been reported among patients
with hoarding (Tolin et al., 2008). GAD and hoarding may also
share a degree of indecisiveness which in hoarding interferes with
organisation and discarding (Steketee et al., 2003; Timpano, Exner,
Rief, Brhler, & Wilhelm, 2010; Tolin et al., 2011). This does not
explain why it was found that individuals with hoarding symp-
toms and OCD had a greater prevalence of GAD than the pure
hoarding group. It is possible that indecision may be a risk fac-
tor for hoarding behaviour in some cases of OCD (Samuels et al.,
2007) given that indecision is a suggested fundamental decit in
OCD (Sachdev & Malhi, 2005). The greater prevalence of GAD in
the hoarding with OCD sample may also be somewhat accounted
for by an increased co-morbidity generally in the hoarding with
OCD group. It is interesting to note that the majority of the Axis I
co-morbidity was found within the nine individuals who, in addi-
tion to diagnoses of OCD and hoarding, met diagnostic criteria for
GAD. It is possible that the presence of two or more problems (e.g.
OCD, hoarding, GAD) increases the likelihood for further Axis I dis-
orders.
336 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
The greater prevalence of OCPD in the hoarding with OCD
group relative to the pure hoarding group and the OCD without
hoarding group may be explained by the combination of a greater
prevalence of OCPD in OCD and hoarding constituting one of the
eight criteria for OCPD. Previous research has found that the asso-
ciation between hoarding and OCPD was primarily mediated by
the overlapping item content (Pertusa et al., 2008), which indi-
cates that people with compulsive hoarding are not more likely
to endorse OCPD relative to individuals with other psychiatric dis-
orders.
Data from previous research suggests that 1545% of people
with compulsive hoarding also meet criteria for OCPD (Winsberg,
Cassic, & Korran, 1999). Prevalence of OCPD in the hoard-
ing sample in the present study far exceeds that (50% and
71%) with prevalence of OCPD being greater in the group with
both hoarding and OCD. The ndings of this study were not
consistent with previous research which found an increased preva-
lence of social anxiety and paranoid and avoidant personality
disorders in hoarding (e.g. Frost et al., 2000; Samuels et al.,
2002).
Participants with compulsive hoarding without OCD were
objectively more impaired in terms of relationship and employ-
ment status relative to individuals meeting diagnostic criteria
for OCD without hoarding symptoms and non-clinical controls;
however, the pure hoarding group showed less self-reported
impairment (as measured by the WSAS) relative to the other two
clinical groups. The ndings of the current study are consistent with
previous research (e.g. Samuels et al., 2008) which suggests that
hoarding is associated with greater impairment in social function-
ing. Participants in both hoarding groups were less likely to be in
a relationship and in employment than the OCD without hoard-
ing group and the non-clinical control group. Previous research has
found a low rate of marriage among people who hoard, a nding
which indicates the possibility of greater social role impairment
(Samuels et al., 2002; Steketee & Frost, 2003). Hoarding may dis-
rupt social functioning, possibly due to embarrassment about the
clutter in the homes resulting in social isolation. Excessive clut-
ter in the home may also become a stressor in itself and thus
interfere with relationships. The pure hoarding group self reported
less impairment in social functioning relative to the hoarding with
OCD group and the OCD without hoarding group raising the issue
of insight in hoarding. It is often noted that hoarding tends
to be ego-syntonic, in that hoarders often do not see it as a
problem, with referral frequently triggered by a relative or pub-
lic health/re services. Recent research lends empirical support to
clinical reports of limited insight in hoarding. In one study, friends
and family members of individuals with hoarding difculties pro-
vided ratings of the hoarders level of insight and severity of the
persons hoarding behaviour (Tolin, Fitch, Frost, & Steketee, 2010).
Results indicated that informants described the individual with
hoarding problems on average as having fair to poor insight, with
more than half described as showing either poor insight or no
insight into the severity of their hoarding condition. Individuals
with hoarding difculties described as showing less distress about
the hoarding were described by their friends/family as showing
poorer insight. The authors suggested that individuals who hoard
may be two to three times more likely than are patients with OCD
to be described as having poor insight (Tolin et al., 2010). Another
study found that substantial recognition of the symptoms of hoard-
ing as problematic typically began a decade or more following
the onset of symptoms (Grisham et al., 2006). These studies con-
tribute to accumulating evidence that limited insight is common in
hoarding.
The nding that the group with OCD without hoarding
reported greater distress related to obsessions relative to
the hoarding without OCD group suggests the possibility that
hoarding may be linked to the tendency to engage in overt rituals.
Hoarding may therefore be more strongly associated with the
tendency to react to distress behaviourally (both by hoarding and
ritualising).
4.1. Theoretical implications
The relatively high ratings in each of the three theoreti-
cally derived subscales by individuals with hoarding difculties
indicates that beliefs relating to harm avoidance, fear of future
material deprivation and emotional attachment to possessions
are all prevalent in hoarding to varying degrees with the excep-
tion of harm avoidance beliefs in the pure hoarding group. The
greater levels of harm avoidance beliefs, as measured by the
BAH measure, in the hoarding with OCD sample, relative to
the pure hoarding group suggests that harm avoidance beliefs
commonly seen in individuals with OCD may also generalise to
their possessions. However, the ndings in the present study
are not entirely consistent with the hypotheses suggested by
Seaman et al. (2010), which propose that one type of hoarding
may be psychologically identical to OCD (i.e. harm avoidance)
which is typically seen in hoarding with OCD, while another
is more related to fear of material deprivation and emotional
attachment, typically seen in pure hoarding. While greater harm
avoidance was found in the hoarding with OCD group, this group
also reported elevated beliefs in all three proposed domains.
As expected, the pure hoarding group did not report inated
harm avoidance beliefs relative to the hoarding with OCD group,
but neither did they report increased levels of beliefs associated
with fear of future material deprivation and emotional attach-
ment, as hypothesised. While none of the participants in the
pure hoarding group reported harm avoidance as the primary
reason for hoarding, neither did the hoarding with OCD group,
contrary to expectation. It seems therefore, that when hoarding
co-occurs with OCD, it may not be the case that a common cog-
nitive mechanism (i.e. the avoidance of harm coming to self or
others) drives both hoarding and OCD difculties in all cases,
and the relationship between hoarding and OCD may be more
complex.
However, before such a conclusion is reached, it would be
appropriate to reconsider the denition of harm avoidance in
relation to hoarding. For example, it is possible that harm avoid-
ance in the context of hoarding may relate to the need to save
possessions in order to prevent harm coming to the memory
of the person who gave possessions to the individual. To dis-
card the possession therefore would cause harm to the memory
of that person resulting in the possession being saved. Similar
considerations could be applied to the fear of material depriva-
tion (i.e. avoiding any possibility of future destitution, poverty,
hunger).
A very high degree of emotional attachment to possessions
was found in both hoarding groups. It has been suggested that
the excessive emotional attachment to possessions which is asso-
ciated with hoarding (Steketee et al., 2003) may reect a lack
of emotional connection with other people (Grisham, Steketee,
& Frost, 2008). Relative to non-hoarding OCD and non-clinical
controls hoarders in this study and in other studies (e.g. Frost
& Gross, 1993; Samuels et al., 2002) were less likely to be in
a relationship. Further, evidence suggests that individuals who
hoard have difculty forming and/or maintaining relationships
with other people (Frost et al., 2000). Excessive emotional attach-
ments to possessions may be similar to attachments formed
with other people (Frost & Hartl, 1996) and may be a replace-
ment for, or a way of avoiding interpersonal contact (Tolin et al.,
2011). Hoarding typically begins in childhood or early adoles-
cence (Grisham et al., 2006) and is associated with adverse
 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339
and traumatic events in childhood, which may disrupt crucial
attachment relationships. Given the ndings that individuals who
hoard report a signicantly greater number of traumatic expe-
riences (Hartl et al., 2005), it may be the case that possessions
represent safer attachment gures than humans. From this per-
spective, beliefs about emotional attachments to possessions may
develop to compensate for a problematic social environment. Of
course, conversely, beliefs and behaviour relating to hoarding,
as well as clutter itself, may negatively impact on interper-
sonal functioning, and may result in social isolation (Grisham
et al., 2008).
While no signicant difference between the hoarding groups
was found on the fear of future material deprivation subscale,
individuals with hoarding and OCD rated the fear of future mate-
rial deprivation construct as signicantly more relevant to their
hoarding problems relative to the pure hoarding group when
interviewed. This construct regarding the perceived usefulness
of a possession in the future therefore appeared to be particu-
larly relevant in hoarding with OCD. It is possible that the higher
general responsibility beliefs found in this group relative to the
pure hoarding group may play a role in this. Hoarders with OCD
may have a more elaborate sense of responsibility, whereby they
must be prepared to meet a future need (Frost & Hartl, 1996), so
it important to retain items just in case (Frost & Gross, 1993)
and may be more likely to have obsessional ideas related to
fear of discarding an important item which they believe may
be needed in the future. In addition, the higher prevalence of
GAD in the hoarding with OCD group may be associated with
greater indecision about what to discard and difculty tolerat-
ing uncertainty (Dugas et al., 1997) about whether the possession
may be needed in the future, resulting in the item being saved.
In this way, saving allows hoarding individuals to avoid mak-
ing difcult decisions about what to keep or discard in order to
avoid making potentially important mistakes (Warren & Ostrom,
1988).
4.2. Clinical implications
Previous research (Seaman et al., 2010) found that the pres-
ence of secondary hoarding symptoms in primary OCD did not
adversely impact on the treatment of OCD, and that such treatment
resulted in improvement of the hoarding symptoms themselves.
This is probably because in such cases the treatment of OCD
using standard CBT targets the primary cognitive factors involved
in the maintenance of the obsessional symptoms (particularly
responsibility for preventing harm) regardless of hoarding symp-
toms. However, it has also been suggested that primary hoarding
is associated with relatively poor outcome. The present study
(where patients had primary hoarding with and without co-
existing OCD) allows us to consider the possibility that hoarding
patients may be inuenced by a range of quite different cogni-
tive factors, with harm avoidance being relatively less important.
If this is so, then standard CBT would need to be adapted
to take account of these cognitions as part of the alternative
explanation/shared understanding which forms the key driver of
therapy.
Assessing the extent to which particular beliefs are present at
assessment in individuals with hoarding difculties will contribute
towards developing a formulation in collaboration with the client
and tailoring the treatment approach effectively and appropriately.
From the ndings in this study, it seems that when pure hoarding
is encountered in clinical settings, harm avoidance beliefs are less
likely to be important relative to those with compulsive hoarding
with co-existing OCD. Stronger beliefs regarding fear of material
deprivation and emotional attachment to possessions, appear more
337
likely to be present in hoarding whether it co-occurs with OCD or
whether it does not.
4.3. Limitations of the study
Unlike the OCD groups, the majority of individuals with com-
pulsive hoarding, (who rarely seek help), were recruited from
non-clinical settings. As in the study by Pertusa et al. (2008), how-
ever, the primary comparisons between hoarding groups may have
been minimally affected due to this potential limitation because
the majority of participants in these groups were recruited through
support groups.
Another limitation of this study is the signicantly younger age
of the pure OCD group relative to the hoarding and non-clinical
control groups. The inuence of younger age on employment status,
marital status, and other aspects of social functioning in this study
must be considered. In addition, it is worth noting that severity of
hoarding symptoms increases with age, therefore in a younger pure
OCD sample, hoarding symptom severity may have been articially
reduced.
Finally, the analysis of comorbidity includes a large num-
ber of comparisons, and no corrections for multiple comparisons
have been done. This is because we did not wish to be
over-conservative as such comparisons are seldom carried
out.
4.4. Conclusion
This research suggests that pure hoarding in the absence of
other OCD symptoms may constitute a somewhat different prob-
lem to primary hoarding with co-occurring OCD and OCD itself. We
suggest a synergistic relationship, resulting in a malignant interac-
tion between hoarding and OCD when they co-occur. The result
of this interaction may lead not only to increased co-morbidity,
but also elevated harm avoidance beliefs in this group relative to
pure hoarding. It is clear that beliefs about emotional attachment
to possessions and fear of future material deprivation are impor-
tant constructs in hoarding separate from OCD without hoarding.
However, further elaboration of the concept of harm avoidance in
relation to hoarding is needed to better understand the hypothe-
sised interaction between OCD and hoarding. Further investigation
and development of cognitive models of hoarding are needed in
order to improve treatment for this chronic and complex prob-
lem.
Acknowledgements
The authors wish to thank the participants who took part
in this study. We acknowledge with thanks the contribution of
Dr. Gary Brown to this research. We are also grateful to Oliver
Schauman, Rebekah Chadwick, Shona McKenna, Satwant Singh,
as well as research staff and clinicians at the Centre for Anxi-
ety Disorders and Trauma. This research was conducted, in part,
at the Centre for Anxiety Disorders and Trauma which receives
infrastructure funding from National Institute for Health Research
(NIHR) Mental Health Biomedical Research Centre at South Lon-
don and Maudsley NHS Foundation Trust and Kings College
London. The views expressed are those of the authors and not
necessarily those of the NHS, the NIHR or the Department of
Health.
 338 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339

Appendix A. BAH Questionnaire

Name................................................. Date........................ BAH

The following list includes various beliefs which people some-
times hold about their possessions. Over the last two weeks, when
you were thinking about your ordinary possessions or items, how
much did you believe each of the ideas below to be true? applies to your belief. Do this by thinking of where it might lie
Please read each statement and rate how much you believed between the ends of the scale shown below, from I did not believe
these ideas at the time you were thinking about your possessions by this idea at all at one end through to I was completely convinced
placing a circle around the number on the line that most accurately this idea was true.

Over the past two weeks when I was thinking about my ordinary possessions:
I did not I was completely
believe this convinced this
idea at all idea was true

I have to have this if there is even a very slight chance I will need it 0 10 20 30 40 50 60 70 80 90 100
It would be disloyal to this item if I dont take care of it 0 10 20 30 40 50 60 70 80 90 100
Many of my possessions are linked to someone I care about, so it would be 0 10 20 30 40 50 60 70 80 90 100
very distressing to lose them
If I throw this away, it would be like losing part of myself 0 10 20 30 40 50 60 70 80 90 100
If I throw this away, Im throwing away an opportunity which could change 0 10 20 30 40 50 60 70 80 90 100
my life
It is important to keep this to make sure that nothing bad happens 0 10 20 30 40 50 60 70 80 90 100
If something is free then it would be very upsetting not to have it 0 10 20 30 40 50 60 70 80 90 100
This reminds me of someone I know so I cant let it come to harm 0 10 20 30 40 50 60 70 80 90 100
It feels exhilarating and very exciting to get new items to add to my things 0 10 20 30 40 50 60 70 80 90 100
I am responsible for nding a use for this item 0 10 20 30 40 50 60 70 80 90 100
To throw this away would be cruel to the object 0 10 20 30 40 50 60 70 80 90 100
This will cause someone harm unless I keep it 0 10 20 30 40 50 60 70 80 90 100
If I throw this out, I might be crippled by regret if I ever need it in the future 0 10 20 30 40 50 60 70 80 90 100
This possession is my friend so I must keep it 0 10 20 30 40 50 60 70 80 90 100
I have to have this item because I would have been grateful for it in the past 0 10 20 30 40 50 60 70 80 90 100
I see an importance in my possessions that others cant see 0 10 20 30 40 50 60 70 80 90 100
If I throw this possession away, it will be upsetting because its like throwing 0 10 20 30 40 50 60 70 80 90 100
away a memory of my past
I would feel terrible if I got rid of this item because it would be wasteful to do 0 10 20 30 40 50 60 70 80 90 100
so
If I get rid of this item it is like abandoning someone I love 0 10 20 30 40 50 60 70 80 90 100
I can see how valuable my possessions are although others cant 0 10 20 30 40 50 60 70 80 90 100
If harm comes to this possession, that means that harm will come to the 0 10 20 30 40 50 60 70 80 90 100
person connected to it
I will be rejecting someone connected to this possession if I dont look after it 0 10 20 30 40 50 60 70 80 90 100
properly
I would be very upset if I didnt keep something which might come in handy 0 10 20 30 40 50 60 70 80 90 100
someday
I will throw this item out only when it feels completely right to throw it out 0 10 20 30 40 50 60 70 80 90 100
I cannot stand the idea that I would be blamed for not having something 0 10 20 30 40 50 60 70 80 90 100
important even if it seemed ordinary at the time I got rid of it
This possession will be hurt if I dont take care of it 0 10 20 30 40 50 60 70 80 90 100
It will be upsetting if I throw this item out without being sure it will be put to 0 10 20 30 40 50 60 70 80 90 100
good use
I cant throw things like this away because it might cause harm to come to 0 10 20 30 40 50 60 70 80 90 100
someone I care for
BAH Scoring. Harm avoidance subscale: Items 6, 12, 21, 24, 25, 28. Fear of material deprivation subscale: Items 1, 5, 7, 10, 13, 15, 18, 23, 27. Attachment disturbance subscale:
Items 2, 3, 4, 8, 11, 14, 16, 17, 19, 20, 22, 26. Positive emotion associated with acquiring: Item 9.
 O.M. Gordon et al. / Journal of Anxiety Disorders 27 (2013) 328339 339

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