title: Neural mechanisms of decision making in hoarding disorder.
abstract: BACKGROUND
  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).
  
  
  METHODS
  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.
  
  
  METHODS
  Private, not-for-profit hospital.
  
  
  METHODS
  A total of 107 adults (43 with HD, 31 with OCD, and 33 HCs).
  
  
  METHODS
  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.
authors.affiliation: The Institute of Living, Hartford, Connecticut 06106, USA. dtolin@harthosp.org
authors.forename: David F
authors.initials: DF
authors.lastname: Tolin
authors.forename: Michael C
authors.initials: MC
authors.lastname: Stevens
authors.forename: Anna L
authors.initials: AL
authors.lastname: Villavicencio
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Norberg
authors.forename: Vince D
authors.initials: VD
authors.lastname: Calhoun
authors.forename: Randy O
authors.initials: RO
authors.lastname: Frost
authors.forename: Gail
authors.initials: G
authors.lastname: Steketee
authors.forename: Scott L
authors.initials: SL
authors.lastname: Rauch
authors.forename: Godfrey D
authors.initials: GD
authors.lastname: Pearlson
mesh_terms: D000328:Adult; D001931:Brain Mapping / Q000379:methods; D002540:Cerebral Cortex / Q000503:physiopathology; D003657:Decision Making / Q000502:physiology*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005071:Evoked Potentials / Q000502:physiology; D019260:Expressed Emotion / Q000502:physiology*; D005260:Female; D006179:Gyrus Cinguli / Q000503:physiopathology*; D000067836:Hoarding Disorder / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology; D006788:Hospitals, Voluntary; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009434:Neural Pathways / Q000503:physiopathology; D009770:Obsessive Behavior / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology; D018434:Sickness Impact Profile