Behaviour Research and Therapy 125 (2020) 103549

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Behaviour Research and Therapy

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Attachment theory and hoarding disorder: A review and theoretical T

integration
Brittany M. Mathesa, Kiara R. Timpanob, Amanda M. Rainesc,d, Norman B. Schmidta,∗
a
Department of Psychology, Florida State University, 1107 West Call St, Tallahassee, FL, USA
b
Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL, USA
c
Southeast Louisiana Veterans Health Care System, 2400 Canal St, New Orleans, LA, USA
d
Department of Psychiatry, Louisiana State University, 1542 Tulane Ave, New Orleans, LA, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Hoarding disorder (HD) is a severe and persistent mental illness characterized by extreme difficulty parting with
Hoarding disorder possessions and considerable clutter that can result in dangerous living conditions. HD poses a considerable
Attachment public health burden; however, treatment for HD remains relatively limited, as many individuals do not respond
Interpersonal processes to treatment and/or do not maintain treatment gains, suggesting there are important factors not being ade-
Saving behaviors
quately addressed. In particular, one area that is not well-understood nor well-integrated into cognitive beha-
vioral models is the pathological attachment individuals with HD hold to their possessions. The current review
delineates existing work regarding attachment in HD and integrates findings regarding attachment into existing
cognitive behavioral models of HD. We use attachment theory as a foundation by which to examine HD and
better understand the dysfunctional relationships seen in those who hoard. We propose that both maladaptive
cognitions and dysfunctional attachments to people and possessions jointly underlie saving behaviors char-
acteristic of the disorder. The hypotheses put forth in this theory may help to advance our knowledge of HD,
identify potential factors that can be targeted in intervention and prevention efforts, and provide important
future directions for empirical work.

Hoarding behaviors have long been a part of human nature.
Archaeologists uncovered evidence of hoarding since as early as the
prehistoric era, in which hunter-gatherers collected necessary supplies
in order to ensure protection from potential danger. Historic literary
pieces depict characters who hoard, from Beowulf, published around
1000 AD, to Sherlock Holmes in 1893. In contemporary history, one of
the most commonly cited cases of compulsive hoarding is the Collyer
brothers, two brothers who died in 1947 surrounded by 140 tons of
collected goods in their Manhattan home (Lidz, 2003). Despite these
examples of hoarding throughout history, it was not until the 1990s
that hoarding was systematically examined through an empirical lens.
Frost and Gross (1993) published the first scientific article defining and
characterizing pathological hoarding, and since then, over 200 pub-
lished manuscripts have further investigated the nature of such beha-
vior (Google Scholar, PsycInfo, 3/31/2019). Despite the significant
increase in empirical work regarding hoarding over the last two dec-
ades, treatment for such behaviors remains limited in efficacy (Tolin,
Frost, Steketee, & Muroff, 2015) and the pathogenesis of the disorder
remains poorly understood. In particular, one component of hoarding
that is not adequately explained in existing cognitive behavioral models
is the pathological attachment to possessions. Therefore, the purpose of
the current review is to delineate existing work regarding the etiology
and maintenance of hoarding, and to highlight the extent to which
components of attachment theory may help to fill important gaps in the
current understanding of hoarding behaviors.
Hoarding disorder (HD) is a psychiatric condition in which in-
dividuals have significant difficulty discarding possessions, which re-
sults in excessive clutter that interferes with their ability to use their
homes (Frost & Gross, 1993). Individuals may also report excessive
acquisition of items, though this has been established as a specifier for
the diagnosis, rather than a core criteria (American Psychiatric
Association, 2013). Epidemiological studies estimate that HD affects
approximately 1.5% of the population (Nordsletten et al., 2013), and
clinically significant hoarding symptoms may impact up to 5.8% of the
population (Timpano, Keough, Traeger, & Schmidt, 2011). Though
symptoms of HD typically develop in adolescence and young adulthood
(Tolin, Meunier, Frost, & Steketee, 2010), clinically significant symp-
toms, particularly in regards to impairing clutter, typically do not

∗
Corresponding author. Department of Psychology, Florida State University, 1107 W. Call St, Tallahassee, FL, 32306-4301, USA.
E-mail address: schmidt@psy.fsu.edu (N.B. Schmidt).

https://doi.org/10.1016/j.brat.2019.103549
Received 13 June 2019; Received in revised form 19 December 2019; Accepted 29 December 2019
Available online 30 December 2019
0005-7967/ © 2020 Elsevier Ltd. All rights reserved.
B.M. Mathes, et al.
present until middle to late adulthood (Dozier, Porter, & Ayers, 2016;
Grisham, Frost, Steketee, Kim, & Hood, 2006).
Hoarding symptoms are notably dimensional in that they occur
along a continuum, rather than as a dichotomy (Timpano et al., 2013).
While general saving tendencies can be normative, at the severe end of
the continuum, symptoms of HD can have an enormous impact on
public health outcomes. HD is associated with high rates of un-
employment and work impairment, as well as greater financial diffi-
culties and impairment in activities of daily living (e.g., cooking; Tolin,
Frost, Steketee, Gray, & Fitch, 2008). Hoarding is also associated with
greater prevalence of comorbid medical health conditions (e.g., obesity,
diabetes) and greater utilization of public aid programs and healthcare
services (Tolin et al., 2008). Moreover, individuals who hoard often
report having never married and/or alienating themselves from family
members who try to help clear their homes, thereby leading to social
isolation (Kim, Steketee, & Frost, 2001; Tolin et al., 2008). Extreme
clutter often results in fire hazards, unsanitary living conditions, high
rates of evictions and associated legal fees, and in some cases, death
(Tolin et al., 2008). Little research has investigated specific economic
costs associated with HD. Nonetheless, it has been estimated that re-
moval of clutter in Florida cost up to $8 million per year (McGuire,
Kaercher, Park, & Storch, 2013), direct and indirect costs of hoarding in
San Francisco were over $6 million (San Francisco Task Force on
Compulsive Hoarding, 2009), and the societal cost per individual is
greater than that of most other psychiatric disorders, including anxiety
and depression (Tolin et al., 2008).
Taken together, HD is a severe and debilitating illness that poses a
tremendous burden on the individual, as well as his/her family and
community. Though research regarding HD has significantly pro-
gressed, many gaps in the literature remain, which may help to explain
why treatment is only moderately effective (Tolin et al., 2015). Evi-
dence-based treatment for HD consists of cognitive behavioral therapy
(CBT), which focuses on challenging maladaptive beliefs about pos-
sessions, developing skills for organization, practicing resisting urges to
acquire and/or save, and using behavioral experiments to test as-
sumptions about feared negative outcomes associated with discarding
and/or not acquiring valued possessions (Steketee & Frost, 2013).
Though CBT results in symptom reduction, treatment response remains
low and most individuals continue to exhibit clinically significant
symptoms at post-treatment (Tolin et al., 2015). As such, given the
enormous impact of HD on the community coupled with poor treatment
response, it is imperative to identify and investigate underlying factors
of HD that may not currently be accounted for in order to improve our
understanding of the disorder and optimize treatment.
1. Cognitive behavioral conceptualizations of hoarding disorder
Cognitive behavioral models of HD posit that several core vulner-
abilities contribute to hoarding symptoms (Frost & Hartl, 1996; see
Fig. 1). These core vulnerabilities include genetic, environmental,
personality, and neurobiological factors, which may include family
history, trauma, stress, impulsivity, and neurobiological dysfunction
(Frost & Hartl, 1996). In regard to biologically-based factors, HD has a
strong genetic factor, as it is more common among first-degree relatives
and genetics account for approximately 50% of the variance in symp-
toms (Iervolino et al., 2009). Additionally, dysfunction in the ven-
tromedial prefrontal cortex and dorsal anterior cingulate cortex are
thought to underlie hoarding symptoms (An et al., 2009; Mataix-Cols
et al., 2004). Regarding environmental and personality factors, trauma
and impulsivity are proposed to be particularly salient risk factors for
HD (Cromer, Schmidt, & Murphy, 2007; Timpano et al., 2013). Overall,
these core vulnerabilities are thought to contribute to information
processing deficits, erroneous beliefs about oneself, other people, and
possessions, and maladaptive reinforcement cycles that then interact in
their influence on the development of HD.
Information processing deficits implicated in HD include attention,
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Behaviour Research and Therapy 125 (2020) 103549
categorization, decision-making, planning, and memory difficulties,
which are hypothesized to interfere with one's ability to efficiently
organize and make decisions about one's belongings, thereby con-
tributing to a tendency to save, rather than discard, possessions
(Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Wincze,
Steketee, & Frost, 2007). Though it is clear that HD is characterized by
overall cognitive dysfunction, research regarding specific deficits has
been somewhat mixed. For example, some research suggests individuals
who hoard do not exhibit memory deficits, but rather decreased con-
fidence in their memory that contributes to their perceived need to save
items to aid memory (Fitch & Cougle, 2013; Hallion, Diefenbach, &
Tolin, 2015; Hartl et al., 2004). Additionally, trait-level indecisiveness
is thought to underlie difficulties making decisions about possessions
(Frost & Gross, 1993; Preston, Muroff, & Wengrovitz, 2009). None-
theless, hoarding is characterized by information processing deficits
that interfere with one's ability to organize and make decisions about
possessions.
Maladaptive cognitions in HD surround beliefs about oneself, other
people, and possessions. Individuals with HD describe core beliefs
about being unlovable, helpless, and unworthy (Moulding, Mancuso,
Rehm, & Nedeljkovic, 2016, pp. 123–133), and endorse negative views
of other people, such as believing that other people cannot be trusted
and relied upon (Hartl, Duffany, Allen, Steketee, & Frost, 2005;
Moulding et al., 2016, pp. 123–133). Hoarding symptoms are also po-
sitively associated with negatively perceived emotional coping, such
that individuals who hoard hold negative beliefs about their ability to
tolerate negative emotions (Ayers, Castriotta, Dozier, Espejo, & Porter,
2014; Fernández de la Cruz et al., 2013; Shaw, Timpano, Steketee,
Tolin, & Frost, 2015; Timpano, Shaw, Cougle, & Fitch, 2014). Finally,
beliefs about possessions include the perception that possessions are
unique and cannot be replaced, aid in one's memory, and must be
protected and not wasted (Frost, Hartl, Christian, & Williams, 1995;
Steketee, Frost, & Kyrios, 2003). Frost and Hartl (1996) also highlight
the importance of beliefs about emotional attachment to possessions,
which they define as encompassing three related beliefs: possessions
provide comfort and security, have human-like qualities, and represent
a piece of one's self-image. It has further been suggested that insecure
attachment style and negative early developmental experiences may
facilitate the development of hoarding behaviors aimed to compensate
for perceived threat or uncertainty from oneself and others (Kyrios,
2014, pp. 206–220; Kyrios et al., 2018). Overall, HD is characterized by
a myriad of cognitions, and existing treatments largely focus on chan-
ging maladaptive beliefs about possessions as the primary mechanism
of change (Levy et al., 2017).
According to cognitive behavioral models, the presence of both in-
formation processing deficits and maladaptive beliefs contributes to
positive and negative emotional reactions, including pleasure and pride
regarding the importance of a possession, as well as sadness, anxiety,
and guilt regarding the prospect of losing or having to discard a valued
possession (Frost & Hartl, 1996). These emotional responses are re-
inforced through the act of saving and/or acquiring, such that they
confirm the individual's beliefs regarding the perceived value of their
possessions. Consequently, saving and acquiring behaviors are devel-
oped and maintained, which, coupled with executive functioning defi-
cits that interfere with organization, lead to excessive clutter in one's
home.
2. Gaps in the literature
Overall, cognitive behavioral models have provided an important
foundation by which to examine the etiology and maintenance of HD.
However, an important question that has been left unanswered is: why
is it that some individuals, but not others, develop intense attachments
to possessions that results in them being unable to discard those items?
Existing cognitive behavioral models of HD conceptualize emotional
attachment to possessions as part of a myriad of cognitive distortions
B.M. Mathes, et al.
Fig. 1. Integration of attachment disturbances in cognitive behavioral models of HD.
that occur on a continuum from non-clinical to clinical levels of severity
(Frost & Hartl, 1996; Steketee et al., 2003; Timpano, Broman-Fulks
et al., 2013). However, such models fail to explain how or why those
distortions reach a clinical level of severity. Indeed, feeling attached to
possessions to some degree is not unique to HD (Grisham et al., 2009),
and Grisham et al. (2009) found that beliefs about the importance of
possessions were strongly associated with attachment to a novel object,
regardless of the presence of hoarding symptoms. Therefore, even those
without clinical levels of psychopathology may hold inflated beliefs
about possessions that can result in increased attachment to objects.
However, there is a lack of understanding about why only some in-
dividuals develop such a significant emotional attachment that causes
them to be unable to part with possessions. We suggest that attachment
theory, described below, may provide a foundation by which to eluci-
date the nature of hoarding symptoms.
3. Attachment theory
Attachment theory provides a basis for understanding the complex
nature of human relationships. The foundation of this theory is that
humans have a basic need for social connection, such that they must
form and maintain interpersonal relationships, and derive a sense of
security, acceptance, and belongingness from those relationships
(Baumeister & Leary, 1995). Attachment theory has historically focused
on the importance of the relationship between an infant and his/her
primary caregiver, suggesting that infants have an innate need to seek
safety and security in their caregivers when stressed or threatened
(Ainsworth, 1991; Bowlby, 1982). According to Bowlby (1982), when a
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Behaviour Research and Therapy 125 (2020) 103549
caregiver provides sufficient physical and emotional security, the infant
is thought to develop a secure attachment with the caregiver. However,
when the caregiver fails to do so, the infant develops an insecure at-
tachment. Importantly, an infant's attachment style (i.e., secure or in-
secure) is thought to provide the foundation for social and emotional
development. Over time, securely-attached infants go on to develop
adaptive emotional coping skills, portray others as trustworthy, and
cultivate self-efficacy and confidence. In contrast, insecurely-attach-
ment infants may have difficulty managing negative emotions, expect
others to be unreliable or hurtful, and view themselves negatively.
Though attachment theory has its roots in the study of infants, it has
been extended and applied to the study of adult relationships. Hazan
and Shaver (2004) suggest that adults, like children, are securely or
insecurely attached, and are characterized by similar features as in-
fants. Securely attached individuals are able to effectively express and
cope with negative emotions, and appropriately seek support from
others in times of distress (Mikulincer & Shaver, 2012). In contrast,
insecurely attached individuals may seek attention due to their per-
ceived inability to independently cope and/or socially isolate and try to
suppress negative emotions (Mikulincer & Shaver, 2012). Further, in-
secure attachment is associated with maladaptive coping strategies,
such as self-blame, avoidance of negative emotion, poor impulse con-
trol, and perceived inability to regulate emotions (Mikulincer, Shaver,
& Pereg, 2003). Finally, individuals who are insecurely attached also
report increased self-doubt and unstable self-esteem, which can then
exacerbate interpersonal difficulties by increasing sensitivity to per-
ceived attacks on one's self-image, thereby contributing to avoidance of
or increased hostility toward others (Dickinson & Pincus, 2003; Jones,
B.M. Mathes, et al.
Freemon, & Goswick, 1981; Mikulincer & Shaver, 2012; Park, Crocker,
& Mickelson, 2004).
Attachment in adults is further conceptualized as falling along two
continua: anxiety and avoidance (Brennan, Clark, & Shaver, 1998).
High attachment anxiety is characterized by negative self-evaluation
and fears of abandonment that typically result in efforts to seek re-
assurance regarding these fears. High attachment avoidance is char-
acterized by negative views of others and a subsequent desire to avoid
social connection and intimacy. Whereas individuals high on attach-
ment anxiety can become overly reliant on attachment figures, thereby
resulting in interpersonal difficulties, individuals high on attachment
avoidance generally become overly reliant on themselves, thereby
leading to social isolation. Further, individuals high on both attachment
anxiety and avoidance are likely to desire close relationships yet fear
rejection, thereby resulting in both interpersonal difficulties and social
isolation. In general, individuals low on both attachment anxiety and
avoidance are characterized as being securely attached, whereas in-
dividuals high on one or both are considered to be insecurely attached.
It should be noted that there is significant debate regarding the extent
to which attachment should be conceptualized as a categorical or di-
mensional construct (Ravitz, Maunder, Hunter, Sthankiya, & Lancee,
2010; Simpson & Rholes, 1998). However, existing work largely sup-
ports the dimensional nature of attachment (Fraley, Hudson, Heffernan,
& Segal, 2015), and as such, we focus on delineating correlates of in-
secure attachment more broadly across a continuum.
Overall, attachment is thought to be a relationship or bond between
two entities that largely manifests through a behavioral system aimed
to increase or decrease physical or emotional proximity to the other
being (Ainsworth, 1991; Ainsworth, Blehar, Waters, & Wall, 2015;
Bowlby, 1979, 1982; Hazan & Shaver, 2004). It is theorized that at-
tachment figures across the lifespan serve three main functions: they
should be someone to whom the individual seeks proximity and avoids
separation, a safe haven in times of need, and a secure base in which the
individual can develop his or her unique identity (Ainsworth et al.,
2015; Hazan & Shaver, 2004). Importantly, attachment needs are
thought to be an integral part of human development, such that when
interpersonal attachment needs are not met, individuals may attempt to
compensate through other means, such as food and objects (Norris,
Lambert, Nathan DeWall, & Fincham, 2012).
4. The current review
The primary aims of this review are to a) refine cognitive behavioral
models in order to highlight the role of interpersonal factors in the
development of HD, b) consolidate findings regarding attachment and
HD, and c) provide avenues for future research to further clarify the
role of attachment in HD. As shown in Fig. 1, we propose that both
maladaptive cognitions and dysfunctional attachments to both people
and possessions jointly contribute to the phenomenological features of
HD. In the next sections, we provide further background regarding our
rationale for the integration of attachment in conceptualizations of
hoarding, and then review the extant literature regarding attachment
and hoarding.
5. Attachment theory and hoarding
How might attachment theory help to explain HD? We hypothesize
that individuals with HD have thwarted interpersonal needs, and
therefore compensate by attempting to form secure attachments with
possessions. However, because possessions cannot provide reciprocal
care in the way that a human can, they do not actually fulfill one's
interpersonal needs, and in fact, only further thwart them by interfering
with the formation and maintenance of interpersonal relationships.
Importantly, our theoretical conceptualization of attachment to
possessions is closely related to the existing definition of emotional
attachment within the cognitive behavioral model, which focuses on
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Behaviour Research and Therapy 125 (2020) 103549
beliefs regarding the extent to which possessions provide comfort and
safety, possess human-like attributes, and represent one's identity (Frost
& Hartl, 1996; Frost et al., 1995). However, we suggest that rather than
attachment being conceptualized solely as a cognitive distortion, it
should represent the relationship between the individual and his/her
possessions from a cognitive, emotional, and behavioral perspective,
which is in line with attachment theory (Grossmann & Grossmann,
2006). Further, we propose that attachment should encompass attach-
ment to both possessions and people in order to account for the function
of one's relationship with their belongings, which we hypothesize is to
compensate for unsatisfying interpersonal relationships. Therefore, the
proposed model focuses on the extent to which individuals who hoard
form and maintain relationships with their possessions and other
people, as well as the ways in which those relationships interact to not
only reinforce existing dysfunctional beliefs, but to then contribute to
emotional responses to possessions and people that result in saving
behaviors.
It should be noted that in a recent review of psychological factors in
HD, Kyrios (2014, pp. 206–220) included poor attachments, attachment
style, self-ambivalence, self-construal, and possessions as extension of
self as factors that may be implicated in the etiology of HD. However,
this review did not delineate a specific theoretical model, nor clearly
define these terms and the ways in which they may contribute to
hoarding symptoms. Therefore, this work provides an important outline
of potential risk factors, but a clear theoretical model that can be em-
pirically tested is needed in order to advance our understanding of the
disorder.
As with many theoretical models of psychopathology, we suggest
that the proposed model comprises both specific and non-specific risk
factors for the development of HD. Insecure attachment and beliefs
about oneself and others are risk factors for a myriad of psychological
disorders (Ehring & Watkins, 2008; Ein-Dor & Doron, 2015, pp.
346–373), whereas beliefs about possessions and object attachment
appear to be more specific to HD. Indeed, several studies have found
that individuals with HD report higher dysfunctional beliefs about
possessions, including those related to sentimentality, than do in-
dividuals with related disorders (e.g., OCD, anxiety disorder;
ds = 1.3–1.4) and healthy controls (ds = 1.2–2.4; Frost, Steketee,
Tolin, Sinopoli, & Ruby, 2015; Grisham et al., 2009; Grisham, Steketee,
& Frost, 2008; Nedelisky & Steele, 2009; Pertusa, Fullana, Singh,
Alonso, Menchon, & Mataix-Cols, 2008; Steketee et al., 2003).
Taken together, we suggest that integrating interpersonal attach-
ment in models of HD may help to explain the extreme attachment to
possessions often seen in individuals with hoard. We hypothesize that
individuals who hoard experience an insecure attachment style, which
likely manifests through interpersonal difficulties, as well as dysfunc-
tional relationships with possessions that serve as efforts to fulfill unmet
interpersonal needs. Indeed, as noted, insecure attachment is strongly
associated with interpersonal difficulties, including social isolation,
conflict, and/or hostility towards others (Dickinson & Pincus, 2003;
Jones, Freemon, & Goswick, 1981; Mikulincer & Shaver, 2012; Park
et al., 2004). However, because possessions cannot actually provide
reciprocal care, those needs remain unmet, thereby exacerbating in-
terpersonal dysfunction. Overall, we hypothesize that individuals with
HD view their possessions, rather than people, as primary attachment
figures.
6. Review of literature regarding hoarding and attachment
In order to evaluate the state of the current literature regarding
associations between hoarding and attachment, a literature search was
conducted using Google Scholar, PsychINFO, and PubMed through
March 2019 (Fig. 2). Search terms related to attachment processes
consisted of: “attachment,” “interpersonal,” “loneliness,” and “iden-
tity.” Search terms related to hoarding disorder consisted of:
“hoarding,” “buying,” “possessions,” and “anthropomorphism.” Of
B.M. Mathes, et al.
Fig. 2. PRISMA flow diagram.
note, anthropomorphism was included as a search term given that
cognitive behavioral models indicate that individuals who hoard hold
beliefs that possessions have human-like qualities, which is consistent
with definitions of anthropomorphism (Epley, Waytz, & Cacioppo,
2007). Search terms from the hoarding and attachment categories were
used in all possible combinations to generate the initial literature se-
lection (n = 223). Titles and abstracts were then reviewed.
Both quantitative and qualitative studies, but not review nor theo-
retical papers, were included if they described or investigated associa-
tions between object attachment, interpersonal attachment, or inter-
personal processes and hoarding, buying, or saving objects.
Additionally, studies were included if they were available in English,
used adult samples, and focused on object hoarding, as empirical work
suggests other forms of hoarding (e.g., animals, food) are characterized
by different clinical characteristics (Frost, Patronek, & Rosenfield,
2011). Using the aforementioned criteria, 52 articles were fully re-
viewed and included below and in Tables 1–3. The following data were
extracted: 1) author and publication year, 2) sample type, 3) mean age
of sample, 4) sample size, 5) study design, 6) measures of saving be-
haviors, object attachment, and/or interpersonal attachment, and 7)
main findings. Results are described qualitatively. Notably, for the re-
mainder of this manuscript, we use “object attachment” to refer to at-
tachment to possessions and “interpersonal attachment” to refer to at-
tachment to other people. Consistent with attachment theory
(Grossmann & Grossmann, 2006), we use “attachment” in both defini-
tions to refer to the relationship and behavioral system between an
individual and an attachment figure that serves to facilitate physical
and emotional proximity between both entities.
7. Interpersonal dysfunction and hoarding symptoms
Empirical work shows that insecure attachment is moderately cor-
related with saving behaviors and hoarding symptoms across non-
clinical and clinical samples (rs = .24 - 0.42, ßs = 0.22 - 0.38; Danet &
Secouet, 2018; Keefer, Landau, Rothschild, & Sullivan, 2012; Kehoe &
Egan, 2019; Neave, Tyson, McInnes, & Hamilton, 2016). In addition to
5
Behaviour Research and Therapy 125 (2020) 103549
correlational findings, when compared to healthy controls, individuals
who hoard report greater insecure interpersonal attachment (Grisham,
Martyn, Kerin, Baldwin, & Norberg, 2018; Medard & Kellett, 2014),
though there have been no reported differences in interpersonal at-
tachment when compared to other clinical groups (e.g., OCD, anxiety;
Grisham et al., 2018; Nedelisky & Steele, 2009). Two recent studies
found somewhat contradictory evidence regarding the association be-
tween hoarding and attachment. One study utilized a sample of un-
dergraduates who had elevated scores on the acquiring subscale of a
measure of hoarding symptoms and the second study recruited under-
graduates with elevated scores on the difficulty discarding subscale
(Crone, Kwok, Chau, & Norberg, 2019; Norberg, Crone, Kwok, &
Grisham, 2018). Across both studies, hoarding symptoms were not
significantly associated with interpersonal attachment. The authors
noted one reason for these findings may be range restriction as the
measure used to recruit participants in both studies was also used as the
outcome of interest. Another possible explanation is study differences in
the measure used to assess interpersonal attachment. Crone et al.
(2019) and Norberg et al. (2018) used the Experiences of Close Re-
lationships-Relationship Structures scale (Fraley, Heffernan, Vicary, &
Brumbaugh, 2011), whereas other studies examining associations be-
tween hoarding and interpersonal attachment (Danet & Secouet, 2018;
Keefer et al., 2012; Kehoe & Egan, 2019; Neave et al., 2016) used the
Revised Adult Attachment Scale (Collins & Read, 1990), Adult Attach-
ment Scale (Simpson, Rholes, & Phillips, 1996), and Experiences of
Close Relationships-Revised Scale (Fraley, Waller, & Brennan, 2000).
Though the aforementioned questionnaires were all designed to mea-
sure interpersonal attachment, researchers have noted that many in-
terpersonal attachment questionnaires show inconsistent validity and
reliability across studies and/or may be assessing different aspects of
interpersonal attachment that are differentially associated with per-
sonality traits and psychopathological symptoms (Mikulincer & Shaver,
2007; Scharfe, 2016). In support of this hypothesis within the hoarding
literature, Neave et al. (2016) used both the RAAS and the ECR-RS and
reported significant associations between hoarding symptoms and the
RAAS subscales, whereas associations with ECR-RS subscales were ei-
ther non-significant or the effect was small (rs = 0.17). Therefore, it
may be that the ECR-RS has psychometric limitations and/or is mea-
suring some aspect of interpersonal attachment that is less relevant to
the study of hoarding. In sum, though most work has indicated positive
associations between insecure attachment and hoarding symptoms,
more work is needed in light of these mixed findings.
In addition to work directly assessing the connection between
hoarding and attachment processes, there is also indirect evidence for
this relationship. Individuals with HD report poorer social support and
greater interpersonal difficulties than do healthy controls (Grisham
et al., 2008; Medard & Kellett, 2014), and often live alone and do not
have romantic partners (Kim et al., 2001). Hoarding symptoms are
associated with significant burden on one's family and social network
(Tolin, Frost, Steketee, & Fitch, 2008), as well as increased cognitive
beliefs about being a burden on others (Raines et al., 2016). Hoarding is
negatively associated with maternal care (Chen et al., 2017), which is
posited to be an indicator of insecure attachment in childhood (Bowlby,
1979). Moreover, recent work has indicated that hoarding symptoms
may be associated with increased reactivity to and recovery from in-
terpersonal stress, suggesting that sensitivity to social threat may un-
derlie one's tendency to save (Grisham et al., 2018; Mathes, Kennedy,
Cougle, & Schmidt, 2019). In one study, individuals with HD, as com-
pared to healthy controls, exhibited a slower reduction in negative
emotions due a task in which they recalled a conflict with an individual
important to the participant (Grisham et al., 2018). Similarly, a sepa-
rate study found that hoarding symptoms were associated with greater
hostile feelings in response to a social exclusion lab paradigm (Mathes
et al., 2019).
A growing body of research also indicates that interpersonal trauma
and stress are significantly associated with greater hoarding symptoms
 Table 1
Interpersonal dysfunction and hoarding symptoms.
Author/year Sample type
Burgess et al. Undergraduate students
(2018) and community adults
Chen, Bienvenu, Individuals with OCD with
et al. (2017) and without hoarding
Claes et al. (2016) Community adults
Crone et al. (2019) Undergraduate students
and community adults
Danet and Secouet Community adults
(2018)
Frost et al. (2007) Community adults
Grisham et al. Individuals with
6
(2008) compulsive hoarding,
individuals with anxiety
or depression, community
controls
Grisham et al. Individuals with hoarding
(2018) disorder, clinical controls,
healthy controls
Hartl et al. (2005) Individuals with hoarding
and healthy controls
Keefer et al. (2012) Community adults
(studies 1 and 2) and
undergraduate students
(study 3)
Mean age Sample size Study design Measures of hoarding behaviors Measures of interpersonal Main findings
attachment processes
B.M. Mathes, et al.
20.00 224 Correlational Anthropomorphism Questionnaire; UCLA Loneliness Scale Loneliness was significantly associated
Graves Anthropomorphism Task with hoarding symptoms and
Scale; Saving Inventory Revised; cognitions, and was a moderator of
Saving Cognitions Inventory anthropomorphism of objects
40.3 OCD with hoarding: Comparative None Parental Bonding Instrument Women with hoarding reported lower
334; OCD without maternal care and higher maternal
hoarding: 560 protection and control than did women
without hoarding.
39.37 254 Correlational Compulsive Buying Scale; Saving Erikson Psychosocial Stage The association between identity
Inventory Revised Inventory confusion and compulsive buying was
mediated by materialistic values
21.96 156 Correlational Saving Inventory Revised; Frost Experiences in Close There was an indirect effect of anxious,
Indecisiveness Scale Relationships-Relationship but not avoidant, attachment on
Structures Questionnaire indecisiveness via emotional reactivity
30.58 197 Correlational Saving Inventory Revised Relationship Scale Questionnaire When accounting for age and education,
anxious attachment, but not fearful,
avoidant, nor secure, was a significant
predictor of hoarding symptoms
Not reported, age 127 Correlational Saving Inventory Revised; Self-Ambivalence Measure; Early Self-ambivalence and uncertainty were
range = 18-22 Compulsive Acquisition Scale Developmental Influences significantly and positively associated
Inventory with hoarding symptoms, even when
accounting for indecisiveness and
depression.
Hoarding group: 55.0; 30 in each group Comparative Saving Inventory Revised; Saving Inventory of Interpersonal Individuals with hoarding reported
Anxiety or depression Cognitions Inventory Problems-Circumplex Version greater interpersonal problems than did
group: 51.5; Control community controls, but not individuals
group: 52.1 with anxiety or depression. Across both
clinical groups, beliefs about
possessions was a marginally significant
predictor of interpersonal problems,
when accounting for depression and
anxiety.
Clinical group: 40.38; Clinical group: 24; Comparative Saving Inventory Revised Modified experiences in close Individuals with HD reported
Clinical controls: 41.00; Clinical controls: 22; relationships-Relationship significantly greater attachment anxiety
Community controls: Community controls: Structures Questionnaire; self- and avoidance than did clinical, but not
48.31 26 reported and physiological healthy, controls. Additionally,
reactivity to recollections of individuals with HD reported more
interpersonal conflict intense negative emotions and slower
recovery during the stressor task than
did clinical and health controls.
Clinical group: 54.27; Clinical group: 36; Comparative Saving Inventory Revised Traumatic Events Scale-Lifetime Individuals with hoarding reported
Control group: 50.17 Control group: 26 significantly greater interpersonal
traumas than did healthy controls.
Not reported Study 1: 99; Study 2: Experimental Reciprocal Attachment Experiences in Close In studies 1 and 2, participants
47; Study 3: 51 Questionnaire-Adapted Relationships-Revised scale instructed to write about times in which
a close friend or family member was
unreliable reported greater attachment
to possessions than did individuals
instructed to write about strangers' or
self unreliability. Additionally, there
was an indirect effect of condition on
object attachment through attachment
anxiety, but not avoidance. In study 3,
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Behaviour Research and Therapy 125 (2020) 103549
 Table 1 (continued)

Author/year Sample type Mean age Sample size Study design Measures of hoarding behaviors Measures of interpersonal Main findings
attachment processes
B.M. Mathes, et al.

participants instructed to write about

uncertainty about their relationships
reported greater separation anxiety
from mobile phones than did those
instructed to write about self-
uncertainty.
Kehoe and Egan Community adults Not reported; age 463 Correlational Saving Inventory Revised; Saving Adult Attachment Questionnaire Attachment anxiety and avoidance were
(2019) range = 18-75 Cognitions Inventory significantly and positively correlated
with hoarding symptoms and
attachment to possessions. A chained
mediation model indicated there was an
indirect effect of childhood trauma on
hoarding symptoms via attachment
insecurity and attachment to
possessions.
Kim et al. (2001) Older adults with 76.9 62 Correlational Semi-structured interview created Semi-structured interview Of the sample, 55% were unmarried and
compulsive hoarding and qualitative for the study created for the study 82% lived alone. Having never been
married was associated with greater
hoarding symptoms and impairment
due to symptoms.
Kyrios et al. (2018) Individuals with hoarding 47.4 Clinical group: 89; Comparative Saving Inventory Revised; Saving Hoarding-Related Early As compared to healthy controls and
disorder, OCD, social Control group: 20 Cognitions Inventory Developmental Influences individuals without HD, individuals
anxiety and/or panic Inventory with HD reported significantly greater
disorder, and healthy uncertainty about self and others and
controls significantly less emotional warmth in

7
one's family. However, there were no
differences in uncertainty and warmth
between individuals with HD with OCD
and without OCD.
Mathes et al. Community adults 37.30 258 Correlational Saving Inventory Revised Buss-Perry Aggression There was an indirect effect of
(2017) Questionnaire; Posttraumatic interpersonal trauma, but not other
Diagnostic Scale types of trauma, on hoarding symptoms
via aggression, even when accounting
for negative affect.
Mathes et al. Undergraduate students Study 1: 19.14; Study 2: Study 1: 195; Study 2: Correlational Saving Inventory Revised Word Sentence Association Hoarding symptoms were significantly
(2019) 18.70 117 and Paradigm-Hostility and self- and positively associated with perceived
experimental reported state-based hostility hostility. Additionally, hoarding
symptoms moderated hostile reactivity
to a social exclusion manipulation.
Medard and Kellett Individuals with hoarding Clinical group: 36.66; Clinical group: 380; Comparative Saving Inventory Revised Relationship Questionnaire; Individuals with hoarding symptoms
(2014) symptoms, undergraduate Student group: 22.93; Student group: 670; Social Provisions Questionnaire reported significantly greater
students, and community Community group: 40.18 Community group: 379 attachment anxiety and avoidance and
controls lower social support than did students
and controls. Across the entire sample,
was a significant interaction between
attachment anxiety, but not avoidance,
and social support in the effect of
hoarding symptoms.
Neave et al. (2016) Community adults Females: 22.41; Males: 283 (210 females, 73 Correlational Saving Inventory Revised; Saving Revised Adult Attachment Scale; Hoarding behaviors and cognitions were
27.86 males) Cognitions Inventory; Reciprocal Experiences of Close significantly and positively correlated
Attachment Questionnaire- Relationships-Relationship with attachment anxiety, attachment
Adapted; Anthropomorphism Structures avoidance, object attachment, and
Questionnaire anthropomorphism. When accounting
for age, sex, and other variables of
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Behaviour Research and Therapy 125 (2020) 103549
 Table 1 (continued)

Author/year Sample type Mean age Sample size Study design Measures of hoarding behaviors Measures of interpersonal Main findings
attachment processes
B.M. Mathes, et al.

interest, only attachment anxiety and

object attachment remained
significantly associated with hoarding
behaviors, and only object attachment
remained associated with hoarding
cognitions.
Nedelisky and Individuals with OCD with 46.09 Hoarding group: 14; Comparative Saving Inventory Revised Reciprocal Attachment Individuals with hoarding reported
Steele (2009) and without hoarding Non-hoarding group: Questionnaire; Five Minute significantly less emotional
16 Speech Statement overinvolvement with family members
or friends than did individuals without
hoarding.
Norberg et al. Individuals with acquiring 22.79 361 Correlational Saving Inventory Revised; Experiences of Close There was an indirect effect of anxious
(2018) behaviors Compulsive Acquisition Scale; Relationships-Relationship attachment on acquiring behaviors
Graves Anthropomorphic Task Structures through distress intolerance and
Scale-Comfort anthropomorphism of comforting items.
Raines et al. (2016) Community adults with 31.77 125 Correlational Saving Inventory Revised Interpersonal Needs Hoarding symptoms were significantly
elevated hoarding Questionnaire and positively associated with the
symptoms perception that one is a burden on
others.
Roster (2015) Professional organizers Not reported 28 Qualitative Narrative case descriptions of Narrative case descriptions of Individuals with hoarding described
who work with hoarding behavior attachment styles attachment to possessions that provide
individuals with hoarding both affiliative and self-identity
motivations.
Timpano et al. Undergraduate students 18.97 465 Correlational Saving Inventory Revised Negative Life Events Stress related to friends, school, and
(2011) Questionnaire family was uniquely and positively

8
associated with hoarding symptoms.
Tolin et al. (2010) Adults with self-identified 49.16 751 Correlational Hoarding Rating Scale Self-reported distress, Periods of symptom onset and increases
hoarding symptoms and descriptive impairment, and history of were more likely to be associated with
traumatic life events periods of relationship changes and/or
interpersonal violence.
Tolin, Frost, Friends or family Family of individuals Family of individuals Correlational Hoarding Rating Scale; Clutter Patient Rejection Scale and self- Living with an individual who hoards
Steketee, and members of individuals with hoarding: 45.36; with hoarding: 571; and descriptive Image Rating reported distress regarding was associated with significant familial
Fitch (2008) with hoarding or family of individuals with family of individuals family member's hoarding stress, and increased family frustration
subthreshold hoarding subthreshold hoarding: with subthreshold symptoms and hostility.
53.23 hoarding: 94
Behaviour Research and Therapy 125 (2020) 103549
 Table 2
Interpersonal attachment and object attachment.
Author/year Sample type Mean age Sample size Study design Measures of saving behaviors Measures of object attachment Main findings
B.M. Mathes, et al.

Bartz, Tchalova, & Community adults 39.50 178 Experimental Self-report measure of Experiences in Close Reminding people of a close relationship reduces
Fenerci, 2016 anthropomorphism Relationships Scale; UCLA anthropomorphism of gadgets and pets
Loneliness Scale; Need to Belong
Scale
Chen, Wan, and Undergraduate students and Not reported Study 1: 118; Experimental Self-reported attitudes towards Self-reported need for social Socially excluded participants demonstrated a
Levy (2017) community adults Study 2: 342; products affiliation greater preference for products with human
Study 3: 378 characteristics, in part, due to an increased need
for social affiliation
Ferraro et al. (2011) Study 1: undergraduate Not reported Study 1: 137; Experimental Self-reported rating of the importance Self-reported rating of the The extent to which an individual views a
students; Study 2: Study 2: 361 of possessions and reactions to the loss perceived link between self and possession as part of their self-worth, but not
community adults of possessions possessions, and the importance monetary value of a possession, is significantly
of domains of self-worth associated with increased object attachment,
which in turn, is associated with increased
negative emotions when asked to consider losing
possessions
Keefer et al. (2012) Community adults (studies Not reported Study 1: 99; Study Experimental Reciprocal Attachment Questionnaire- Experiences in Close In studies 1 and 2, participants instructed to
1 and 2) and undergraduate 2: 47; Study 3: 51 Adapted Relationships-Revised scale write about times in which a close friend or
students (study 3) family member was unreliable reported greater
attachment to possessions than did individuals
instructed to write about strangers' or self
unreliability. Additionally, there was an indirect
effect of condition on object attachment through
attachment anxiety, but not avoidance. In study
3, participants instructed to write about
uncertainty about their relationships reported

9
greater separation anxiety from mobile phones
than did those instructed to write about self-
uncertainty.
Kwok et al. (2018) Community adults and 22.88 331 Experimental Saving Inventory Revised; Social exclusion manipulation Individuals who were socially excluded did not
undergraduate students Anthropomorphic Mental State ratings; (Cyberball) report greater anthropomorphism than did
with elevated acquiring self-reported object attachment and socially included individuals. However,
behaviors perceived value of an object regardless of condition, there was an indirect
effect of anthropomorphism on object
attachment via perceived sentimental value.
Lastovicka and Community adults Not reported Study 1: 11; Study Correlational Measure created for the study that UCLA Loneliness Scale Loneliness significantly mediated the association
Sirianni (2011) 2: 127; Study 3: assesses possession love between interpersonal deficits and possession
110; Study 4: 142; love.
Study 5: 41
Loveland et al. Studies 1,2,3,4: Study 1: 21.7; Study 1: 136; Experimental Decisions regarding nostalgic and non- Need to Belong Scale; self- Individuals who were socially excluded, but not
(2010) undergraduate students; Study 1b: 42.6; Study 1b: 63; nostalgic products reported social support; implicit included, demonstrated greater preference for
Study 1b: community adults Study 2: 24.1; Study 2: 43; Study word task comprising words nostalgic products, and this effect was
Study 3: 21.6; 3: 94; Study 4: 72 related to belongingness particularly pronounced for individuals with a
Study 4: 21.2 high need to belong. Additionally, the
consumption, but not selection, of a nostalgic
product subsequently reduced the need to
belong.
Mead et al. (2011) Undergraduate students Not reported Study 1: 30; Study Experimental Preference for and decision to buy Experimental manipulation of As compared to control participants, individuals
2: 149; Study 3: products social exclusion and subsequent who were socially excluded were more likely to
151; Study 4: 116 ratings of affect spend money on products that represented group
membership, report product preferences
consistent with those of peers, and be willing to
try foods and substances they did not like to
increase social connection.
Undergraduate students Not reported Experimental
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Behaviour Research and Therapy 125 (2020) 103549
B.M. Mathes, et al. Behaviour Research and Therapy 125 (2020) 103549

(Hartl et al., 2005; Mathes et al., 2017; Timpano et al., 2011; Tolin

Participants who were randomized to conditions

are present when individuals are reminded that

Specifically, they reported a decreased need to
engaged with products that contained human

behaviors. However, compensatory behaviors

et al., 2010). Individuals with clinically significant hoarding symptoms

characteristics exhibited fewer compensatory

engage with close others and/or in prosocial

behaviors than did individuals who engaged
possessions as more self-expressive than did

Individuals who were socially excluded and

connections, as well as a decreased need to

inducing self-uncertainty reported viewing
endorse a greater lifetime incidence of interpersonal trauma, including

inflate the number of one's social media

with non-anthropomorphized products.
sexual and physical assault, than do healthy controls (Hartl et al.,
those who received a self-certainty 2005), and describe interpersonal violence and/or a significant change

products are not actually human.

in a relationship preceding the worsening of symptoms (Tolin et al.,
2010). Further, many individuals who hoard report experiencing a
significant interpersonal loss that precipitated the onset or exacerbation
of their symptoms (Landau et al., 2011; Tolin et al., 2010). Interest-
ingly, a recent study indicated that insecure interpersonal attachment
manipulation.
Main findings

and increased attachment to objects partially mediated the association

between childhood trauma and hoarding symptoms among a commu-
nity samples of adults (Kehoe & Egan, 2019). The authors suggested
that adverse life experiences result in negative relationships with self
and others that then interact with or contribute to maladaptive re-
Self-reported number of friends

spend on the phone with close

Measures of object attachment

and self-reported sense of self-

others; Social Assurance Scale

Experimental manipulation of

lationships with possessions, which, in turn, results in hoarding symp-

on Facebook, desired time to

toms.
There is also evidence that anthropomorphism may play a role in
the connection between processes related to interpersonal attachment
and hoarding symptoms. Recently, Burgess, Graves, and Frost (2018)
found that loneliness moderated the association between anthro-
certainty

pomorphism and hoarding symptoms in a large sample of under-

graduate students, and the authors suggested that saving and anthro-
pomorphizing possessions may serve to compensate for a lack of social
Experimental manipulation of products
with or without human characteristics

connection. Additionally, in a study of individuals with increased ac-

and subsequent questions regarding
Self-reported view of possessions as

quiring behavior, Norberg et al. (2018) found that anthropomorphism

and distress intolerance partially mediated the associated between an-
Measures of saving behaviors

xious attachment and compulsive buying. The authors concluded that

individuals with maladaptive interpersonal styles may engage in ex-
being self-expressive

cessive acquisition partially due to their difficulties with emotion reg-

ulation and tendency to humanize objects. Therefore, the tendency to
desire to save

imbue human characteristics on non-human beings may be an im-

portant indicator of attachment difficulties in individuals who hoard.
Finally, insecure attachment styles are associated with negative or
uncertain self-evaluation, and hoarding symptoms are significantly as-
sociated with self-ambivalence (Frost, Kyrios, McCarthy, & Matthews,
Experimental
Study design

2007) and identity confusion (Claes, Müller, & Luyckx, 2016). Further,
a recent study found that individuals with HD reported greater un-
certainty about self and others as compared to healthy controls (Kyrios
et al., 2018). Qualitative work has also indicated that individuals who
Study 1: 96; Study

hoard often describe saving possessions to feel connected to others and

2: 51; Study 3:

118;
327;
162;
184

to maintain a sense of identity (Roster, 2015).

Sample size

Taken together, research regarding interpersonal attachment pro-

1:
2:
3:
4:
Study
Study
Study
Study

cesses and hoarding symptoms is relatively nascent, and most, though

124

not all, of the extant literature indicates a positive association between

hoarding symptoms, attachment difficulties, and maladaptive inter-
personal functioning.
20.3;
33.0;
29.5;
36.0
Mean age

8. Interpersonal dysfunction and object attachment

1:
2:
3:
4:
Study
Study
Study
Study

Connections between interpersonal processes and object attach-

ment, more broadly, can largely be found in social psychology and
Undergraduate students and

consumer marketing research. Empirical work indicates that percep-

tions of other people as being unreliable is associated with increased
community adults

object attachment (Keefer et al., 2012). Additionally, loneliness is as-

sociated with increased liking of possessions (Lastovicka & Sirianni,
Sample type

2011) and preference for products that are associated with nostalgia or
affiliation with a group (Loveland, Smeesters, & Mandel, 2010; Mead,
Baumeister, Stillman, Rawn, & Vohs, 2011). In a separate, but related,
line of research, the study of anthropomorphism may also be relevant to
Johnson (2011)
Table 2 (continued)

understanding the link between interpersonal relationships and object

attachment. Anthropomorphism is thought to be a reaction to real or
Morrison and

Mourey et al.
Author/year

perceived social isolation (Chen, Wan, & Levy, 2017), and one study
(2017)

found that reminding people of close relationships reduces anthro-

pomorphism of both pets and objects (Bartz, Tchalova, & Fenerci,
2016). Anthropomorphism may also mitigate the impact of social

10
 Table 3
Object attachment and hoarding symptoms.
Author/year Sample type Mean age Sample size Study design Measures of saving behaviors Measures of object attachment Main findings
B.M. Mathes, et al.

Burgess et al. Undergraduate students and 20.00 224 Correlational Anthropomorphism Saving Questionnaire; Graves Anthropomorphism was significantly
(2018) community adults Inventory Revised; Saving Anthropomorphism Task Scale and positively associated with
Cognitions Inventory hoarding behaviors and cognitions.
Cherrier and Individuals who classify Not reported; age 8 Qualitative Discussion of hoarding symptoms Discussion of attachment to Participants described saving
Ponnor themselves as “hoarders” range = 35-57 in a documentary video of each possessions in a documentary possessions to maintain emotional
(2010) participant video of each participant connection to the past, feel safe and
prepared for the future, and maintain
joy in the present
Dozier et al. Individuals with hoarding Clinical group: 61.83; Clinical group: 77; control Correlational Saving Inventory Revised; Clutter Relationship Between Self and Object interconnectedness was
(2017) disorder and community control group: 42.80 group: 30 Inventory Revised; Saving Items Measure significantly and positively associated
controls Cognitions Inventory with overall hoarding symptoms and
difficulty discarding possessions, but
not acquiring behaviors, clutter in one's
home, saving cognitions, nor
depression and anxiety symptoms
Frost et al. Undergraduate students and Control group: not Control group: 101; Comparative and Hoarding Scale Control Over Possessions Scale; Emotional attachment to possessions
(1995) individuals with self- reported; Clinical group: Clinical group: 52 correlational Attachment to Possessions Scale; and perceived need to protect
identified hoarding 43 Environmental Consciousness possessions was significantly correlated
Scale; Responsibility for Harm with hoarding symptoms in both the
control group and clinical group.
Frost et al. Individuals with HD and HD group: 52.72; Control HD group: 103; Control Experimental Hoarding Rating Scale; Saving Possessions List-Discarding; Compared to community controls,
(2016) community controls group: 53.85 group: 66 Inventory Revised Saving Cognitions Inventory individuals with HD reported stronger
beliefs related to emotional
attachment, responsibility, memory,
utility, and aesthetic appeal about a

11
Frost et al. Individuals with hoarding
(2015) disorder, individuals with
OCD, and community controls
Gordon et al. Individuals with hoarding
(2013) without OCD, individuals
with hoarding with OCD,
individuals with OCD without
hoarding, and clinical
controls
Grisham et al. Individuals with OCD
(2009)
personal item and a lab item.
HD group: 52.63; OCD HD group: 217; OCD Comparative Hoarding Rating Scale; Saving Hoarding Interview Individuals with HD reported
group: 34.54; Control group: 96; Control group: Inventory Revised significantly higher motives (aesthetic,
group: 52.63 130 avoid waste, emotion, information) for
saving and acquiring than did clinical
and healthy controls. Among
individuals with HD, avoiding waste
and aesthetic reasons were the
strongest predictors of acquiring
behaviors, whereas avoiding waste and
saving information were the strongest
predictors of saving behaviors.
Emotional attachment to possessions
was not a significant predictor of
behaviors in the HD group.
Hoarding - OCD: 59; Hoarding - OCD: 24; Correlational Saving Inventory Revised; Clutter Beliefs about Hoarding Individuals with hoarding without
Hoarding + OCD: 50.6; Hoarding + OCD: 21; Inventory Revised; Compulsive Questionnaire OCD reported greater object
OCD – Hoarding: 32.5; OCD – Hoarding: 22; Acquisition Scale attachment disturbances than
Control: 51.4 Control: 21 individuals with OCD without hoarding
and clinical controls; however, there
were no differences in attachment as
compared to individuals with hoarding
with OCD
43.42 62 Correlational Saving Inventory Revised; Saving Object Attachment Hoarding behaviors and cognitions
Cognitions Inventory Questionnaire were significant predictors of
attachment to a novel item at baseline.
Attachment at baseline was a
significant predictor of attachment to
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Behaviour Research and Therapy 125 (2020) 103549
 Table 3 (continued)

Author/year Sample type Mean age Sample size Study design Measures of saving behaviors Measures of object attachment Main findings

the item one week later, regardless of

B.M. Mathes, et al.

hoarding symptom severity.

Hartl et al. Individuals with hoarding and Clinical group: 54.27; Clinical group: 36; Comparative Saving Inventory Revised Possessions Comfort Scale Individuals with hoarding reported
(2005) healthy controls Control group: 50.17 Control group: 26 significantly greater comfort derived
from possessions than did healthy
controls.
Haws et al. Study 1: Community adults; Study 1: 39.00; Study 2: Study 1: 313; Study 2: Correlational Product Retention Tendency Attachment to Possessions Scale; Product retention tendency is
(2012) Studies 2,3,4,5: 21.00; Study 3: 21.00; 186; Study 3: 167; Study and Scale; Saving Inventory Revised; Self-reported attachment to significantly and positively associated
undergraduate students Study 4: 21.00; Study 5: 4: 211; Study 5: 278 experimental Self-reported likelihood of specific possessions with attachment to possessions.
21.00 discarding possessions However, compulsive hoarding
symptoms are more strongly associated
with attachment than is product
retention tendency.
Kellett et al. Individual with hoarding 55 1 Case study Self-reported number of objects Self-reported attachment to Cognitive behavioral therapy with a
(2010) disorder discarded each day and perceived possessions focus on object-affect fusion was
ease of ability to discard associated with significant reductions
in hoarding symptoms.
Kellett et al. Individuals with compulsive 38.41 11 Descriptive Semi-structured interview Semi-structured interview Participants described four common
(2010) hoarding themes that underlie their hoarding
behaviors: childhood factors,
relationship with possessions,
avoidance, and relationship with self
and others.
Kwok et al. Community adults and 22.88 331 Experimental Saving Inventory Revised; Social exclusion manipulation Individuals who were socially excluded
(2018) undergraduate students with Anthropomorphic Mental State (Cyberball) did not report greater
elevated acquiring behaviors ratings; self-reported object anthropomorphism than did socially

12
attachment and perceived value included individuals. However,
of an object regardless of condition, there was an
indirect effect of anthropomorphism on
object attachment via perceived
sentimental value.
Levy et al. Individuals with hoarding 56.55 62 Naturalistic Saving Inventory Revised Saving Cognitions Inventory Changes in saving cognitions, including
(2017) disorder treatment emotional attachment to possessions,
significantly mediated reductions in
hoarding behaviors following
individual or group cognitive
behavioral therapy for hoarding.
Moulding et al. Individuals with hoarding Treatment completers: Treatment completers: 41; Naturalistic Saving Inventory Revised Saving Cognitions Inventory There were large reductions in
(2017) disorder 53.5; treatment non- treatment non- treatment hoarding symptoms and moderate
completers: 55.1 completers: 36 reductions in beliefs about emotional
attachment to possessions.
Neave et al. Community adults 31.3 93 Correlational Saving Inventory Revised; Saving Anthropomorphism Anthropomorphism was a significant
(2015) Cognitions Inventory Questionnaire predictor of hoarding behaviors and
cognitions, and women showed
significantly higher levels of
anthropomorphism than did men.
Nedelisky and Individuals with OCD with 46.09 Hoarding group: 14; Non- Comparative Saving Inventory Revised Reciprocal Attachment Individuals with hoarding reported
Steele and without hoarding hoarding group: 16 Questionnaire-Adapted significantly greater emotional
(2009) overinvolvement with possessions than
did individuals without hoarding.
Attachment to possessions was a
significant predictor of hoarding
symptoms.
Norberg et al. Individuals with acquiring 22.79 361 Correlational Saving Inventory Revised; Graves Anthropomorphic Task
(2018) behaviors Compulsive Acquisition Scale Scale-Comfort
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Behaviour Research and Therapy 125 (2020) 103549
 Table 3 (continued)

Author/year Sample type Mean age Sample size Study design Measures of saving behaviors Measures of object attachment Main findings

Anthropomorphism was significantly

B.M. Mathes, et al.

and moderately associated with

Pertusa et al. Individuals with compulsive
(2008) hoarding with OCD and
individuals with compulsive
hoarding without OCD
Phung et al. Community adults
(2015)
Roster (2015) Professional organizers who
work with individuals with
hoarding
Shafran and Individuals with hoarding
Tallis
(1996)
Steketee et al. Individuals with hoarding,
(2003) individuals with OCD,
community controls
hoarding symptoms.
Hoarding with OCD Hoarding with OCD Comparative Saving Inventory Revised Self-reported descriptions of Individuals with hoarding reported
group:; Hoarding without group: 25; Hoarding items saved saving items primarily due to
OCD group: without OCD group: 27 emotional or intrinsic value.
29.11 150 Correlational Saving Inventory Revised Saving Cognitions Inventory There was an indirect effect of
measures of emotion regulation
(anxiety sensitivity and negative
urgency) on hoarding symptoms via
beliefs about attachment to
possessions, when accounting for
anxiety and depression.
Not reported 28 Qualitative Narrative case descriptions of Narrative case descriptions of Individuals with hoarding described
hoarding behavior attachment styles attachment to possessions that provide
both affiliative and self-identity
motivations.
Not reported 3 Qualitative Narrative case descriptions of Narrative case descriptions of Participants described significant loss
hoarding behavior hoarding behavior and fear of criticism that they
attributed to early childhood
experiences.
Hoarding group: 52.0; Hoarding group: 95; OCD Comparative Saving Inventory Saving Cognitions Inventory Individuals with hoarding reported
OCD group: 36.7; Control group: 21; Control group: significantly greater cognitions,
group: 42.0 40 including beliefs about attachment to
possessions, than did individuals

13
without hoarding.
Steketee et al. Individuals with and without Hoarding group: 71.7; Hoarding group: 25; Non- Comparative Saving Inventory Revised Saving Cognitions Inventory Individuals with hoarding reported
(2012) hoarding Non-hoarding group: 77.2 hoarding group: 28 significantly greater beliefs about
attachment to possessions and
responsibility for possessions than did
individuals without hoarding.
Timpano and Undergraduate students 19.23 72 Correlational Saving Inventory Revised; Saving Individual Differences in Hoarding symptoms were significantly
Shaw Cognitions Inventory; Anthropomorphism and positively associated with
(2013) Compulsive Acquisition Scale Questionnaire anthropomorphism, and
anthropomorphism moderated the
impact of saving cognitions on
acquiring behaviors and attachment to
a novel item.
Behaviour Research and Therapy 125 (2020) 103549
B.M. Mathes, et al.
exclusion (Mourey, Olson, & Yoon, 2017), though a recent study found
that individuals who were socially included and excluded did not differ
in their self-reported anthropomorphism of objects after the social ex-
clusion manipulation (Kwok, Grisham, & Norberg, 2018). The authors
of this recent study noted this may be due to the nature of the lab
manipulation used (Cyberball), but more work is needed to assess the
impact of acute versus chronic social stress on the tendency to imbue
human characteristics on non-human beings. Finally, possessions may
be used an attempt to compensate for one's uncertain sense of self by
creating a sense of connection to others (Ferraro, Escalas, & Bettman,
2011; Morrison & Johnson, 2011), providing further evidence for the
connection between interpersonal factors and object attachment.
Nonetheless, there is evidence that objects, in general, may be used to
compensate for negative beliefs about oneself and others.
9. Object attachment and hoarding symptoms
It is well-established that individuals who hoard hold an extreme
attachment to possessions. The behaviors characteristic of HD largely
serve to maintain proximity to and avoid separation from possessions,
which consistent with attachment theory conceptualizations of a secure
base. Indeed, a core symptom of HD is the inability to part with pos-
sessions due to the perceived distress that would arise from discarding
(APA, 2013). Further, when compared to healthy and clinical controls,
individuals who hoard report greater attachment to possessions and
tendency to seek comfort in possessions (Frost et al., 2015; Frost, Ong,
Steketee, & Tolin, 2016; Gordon, Salkovskis, & Oldfield, 2013; Hartl
et al., 2005; Nedelisky & Steele, 2009; Pertusa et al., 2008; Steketee
et al., 2003; Steketee, Schmalisch, Dierberger, DeNobel, & Frost, 2012).
Hoarding symptoms are also correlated with increased emotional
comfort derived from possessions and greater beliefs related to one's
attachment to possessions (Frost et al., 1995; Grisham et al., 2009;
Haws, Naylor, Coulter, & Bearden, 2012; Phung, Moulding, Taylor, &
Nedeljkovic, 2015). Moreover, individuals who hoard report viewing
their possessions as extensions of themselves and their individuality
(Dozier, Taylor, Castriotta, Mayes, & Ayers, 2017; Roster, 2015), and
feel as though parting with possessions is like losing a part of who they
are (Steketee et al., 2003). In treatment, there are moderate reductions
in beliefs about emotional attachment to possessions (Moulding,
Nedeljkovic, Kyrios, Osborne, & Mogan, 2017), changes in beliefs about
attachment to possessions are a significant mediator of treatment out-
come (Levy et al., 2017), and a case study indicated that a focus on
object-affect fusion was associated with reductions in hoarding symp-
toms (Kellett et al., 2010). Finally, qualitative studies have further
described dysfunctional attachments to possessions characterized by
use of possessions for comfort in those who hoard (Cherrier & Ponnor,
2010; Kellett, Greenhalgh, Beail, & Ridgway, 2010; Shafran & Tallis,
1996). For example, Frost and Hartl (1996) described a client who
explained that after a stressful day, he/she wanted to “go home and
gather my treasures (things) around me.
Additionally, anthropomorphism is thought to be a component of
one's attachment to possessions (Frost & Hartl, 1996) and is moderately
associated with hoarding symptoms (Burgess et al., 2018; Neave,
Jackson, Saxton, & Hönekopp, 2015; Norberg et al., 2018; Timpano &
Shaw, 2013). A recent study also found an indirect effect of anthro-
pomorphism on object attachment via perceived sentimental value,
indicating an association between imbuing human characteristics on
items and attachment to those items (Kwok et al., 2018). Further, many
individuals with HD report believing that discarding a possession would
be like losing a friend or a part of themselves, and often describe grief
reactions when discarding (Frost et al., 1995; Steketee et al., 2003).
It should be noted that a recent study found that beliefs about at-
tachment to possessions was not a significant predictor of saving be-
haviors when considered with other hoarding-related beliefs, such as
saving for aesthetic reasons or to retain information (Frost et al., 2015).
However, this study was importantly focused on motivations for saving
14
Behaviour Research and Therapy 125 (2020) 103549
and acquiring, not object attachment, and the measure used to assess
reasons for saving was not validated and included only one item as-
sessing emotional attachment. Therefore, consistent with con-
ceptualizations of hoarding, it may be that individuals who hoard save
belongings for a variety of reasons, but those reasons for saving may
nonetheless contribute to increased attachment to possessions. Overall,
individuals who hoard describe extreme attachment to their possessions
that is consistent with conceptualizations of interpersonal attachment
figures.
10. Discussion and future directions
Taken together, existing work largely supports our hypothesis that
HD is characterized by dysfunctional relationships with both people
and possessions, thereby supporting our theoretical model. However,
considerable research is needed to elucidate the nature of the re-
lationship between hoarding and interpersonal factors. To start, future
research should further examine the relationship between object at-
tachment and interpersonal attachment in HD. Though some studies
suggest that individuals who hoard hold an insecure attachment with
people (Grisham et al., 2018; Medard & Kellett, 2014), there is limited
empirical support for the connection between object and interpersonal
attachment within the area of HD. There is also a dearth of work ex-
amining the extent to which insecure attachment is associated with
interpersonal dysfunction specifically among individuals with HD. As
such, more work is needed to delineate the specific interpersonal dif-
ficulties that may arise as a result of insecure attachment within HD.
Additionally, research regarding object attachment has focused on at-
tachments to objects that are owned; however, future work should
explore the extent to which attachments might generalize to objects
regardless of ownership status. Finally, given that HD is commonly
comorbid with disorders characterized by social difficulties (e.g., social
anxiety, depression; Frost et al., 2011), future work should examine the
extent to which attachment disturbances are unique to HD or represent
overlap with comorbid conditions.
Future research should also further explore potential subgroups
within HD to which attachment disturbances most apply. There is
evidence to suggest that sentimental beliefs about possessions may not
be a primary reason for saving, which may suggest object attachment is
not an integral piece of the disorder for all individuals. Indeed, in-
dividuals who hoard often report saving objects for many reasons, in-
cluding sentimentality, avoidance of waste, aesthetic reasons, feelings
of responsibility for the item, remembering information, and main-
taining control of their environment (Frost et al., 2015; Gordon et al.,
2013; Steketee et al., 2003). Additionally, in one study comparing
hoarding beliefs and symptoms in undergraduates in China and the
United States, concerns about usefulness and wastefulness, but not
memory, attachment, control, responsibility, and aesthetics, were sig-
nificantly associated with hoarding symptoms in China, whereas all
seven beliefs about possessions were associated with hoarding symp-
toms in the U.S. (Timpano et al., 2015). Overall, the aforementioned
findings regarding reasons for saving may suggest the presence of
subgroups that may be differentially associated with attachment dis-
turbances. However, it may also be that, consistent with the proposed
model, reasons for saving interact with attachment disturbances. For
example, an individual might save their belongings due to their per-
ceived use, but then be unable to part with those items due to the be-
havioral attachment related to unmet interpersonal needs. Indeed, in-
itial support for this hypothesis can be found in a recent study that
found an indirect effect of anthropomorphism on object attachment via
both instrumental and sentimental value (Kwok et al., 2018), indicating
that both sentimental and non-sentimental beliefs likely underlie saving
behavior. Nonetheless, further empirical work is needed to assess this
hypothesis.
There is also a dearth of work regarding the underlying mechanisms
of attachment relevant to HD. Bowlby (1982) suggested that
B.M. Mathes, et al.
attachment represents a broader construct characterized by cognitive
biases about oneself and others. In particular, individuals may view
other people as being unreliable, threatening, and/or harmful, thereby
contributing to their decreased attachment to others. Initial work sug-
gests that hoarding symptoms are associated with greater aggression
and hostility (Mathes et al., 2019, 2017) and greater emotional reac-
tions in response to interpersonal stress (Grisham et al., 2018; Mathes
et al., 2019), though further work is needed to identify and elucidate
specific mechanisms. Moreover, exploration of genetic and biological
mechanisms implicated in attachment is sorely needed. For example,
oxytocin and vasopressin have been implicated as integral in the de-
velopment of interpersonal attachment (e.g., Carter, 1998; Feldman,
2012), though no study to date has explored these mechanisms in HD.
Additionally, given that approximately 50% of variance in HD is ac-
counted for genetics (Iervolino et al., 2009), an investigation of po-
tential genetic traits that may confer risk for attachment disturbances
may prove promising.
Additionally, longitudinal studies are needed to examine the tem-
poral precedence of attachment processes and hoarding symptoms.
Importantly, though our proposed model posits that attachment dis-
turbances lead to hoarding symptoms, it is quite possible that hoarding
symptoms actually contribute to attachment disturbances. As noted,
individuals with HD experience considerable interpersonal difficulties,
often due to conflict with loved ones and community members re-
garding belongings and clutter (Kim et al., 2001; Tolin et al., 2008).
Further, individuals with HD are prone to self-criticism and shame
(Chou et al., 2018), all of which may arise in response to the symptoms
and associated consequences. Therefore, it may be that HD is actually a
risk factor for attachment disturbances and interpersonal difficulties,
such as interpersonal conflict, social isolation, and loneliness. As such,
future work is needed to identify the direction of the relationship be-
tween attachment and hoarding in order to enhance our understanding
of these phenomena and inform the development of prevention and
treatment efforts.
Similarly, it would be interesting to examine the longitudinal re-
lationship between object and interpersonal attachment in hoarding.
We suggest that these factors concurrently interact, but there may be
temporal precedence. Further, investigations of associations between
hoarding symptoms, cognitive beliefs, and attachment disturbances
over the lifespan are needed to determine temporal precedence. It may
be that attachment disturbances are present in childhood and worsen
over time, or alternatively, life stressors, such as trauma, may result in
the development of attachment disturbances, which, in turn, contribute
to hoarding symptoms. Similarly, more work is needed to determine the
factors that contribute to the development of object attachment, and to
the tendency to use possessions to attempt to compensate for unmet
interpersonal needs. Though the core vulnerabilities identified in the
model (e.g., genetics, family history), likely play an important role,
research is needed to determine the ways in which patterns of attach-
ment to possessions develop.
Another line of related research that may prove promising is that of
prolonged grief. As noted, many individuals who hoard report experi-
encing a significant interpersonal loss prior to the onset or exacerbation
of their symptoms (Landau et al., 2011; Tolin et al., 2010). Therefore, it
may be that the loss of an attachment figure results in a need to replace
that void, but instead of replacing it with other people, it becomes re-
placed with possessions. As such, it may not necessarily be that in-
dividuals who hoard have had insecure attachments with all people, but
rather they have lost their primary source of attachment and do not feel
they can turn to others, which exacerbates their biological predisposi-
tion to HD.
Research should also explore potential moderators of the relation-
ship between attachment and hoarding symptoms. Some research has
suggested that emotional attachment to possessions may be most re-
levant in Euro-American culture (Kings, Moulding, & Knight, 2017), as
beliefs about the perceived usefulness of possessions and/or a desire to
15
Behaviour Research and Therapy 125 (2020) 103549
avoid waste were the strongest cross-cultural predictors of hoarding
symptoms (Timpano et al., 2015). Therefore, culture may be an im-
portant consideration when assessing this relationship. Additionally,
future work should further assess the impact of information processing
deficits on attachment and hoarding symptoms. Though research is
mixed (see Woody, Kellman-McFarlane, & Welsted, 2014 for a review),
individuals with HD are thought to have memory deficits that con-
tribute to or exacerbate their tendency to save as they keep items as an
attempt to aid memory. Therefore, a further exploration regarding the
extent to which these deficits may relate to attachment processes is
warranted.
Finally, and perhaps most importantly, there is a need for standar-
dization of measurement as there is significant variation in the mea-
sures used to assess hoarding and attachment across studies. To start,
the hoarding literature continues to be clouded by historical overlap
with OCD, as many studies of hoarding utilize samples of individuals
with OCD. Additionally, the attachment literature, in general, is hin-
dered by inconsistency across measures (Fraley et al., 2015), and this is
further exacerbated in HD research by the lack of standardized measure
of attachment to possessions. Indeed, many studies use the Saving
Cognitions Inventory, which assess emotional attachment to posses-
sions as part of a myriad of distorted cognitions (Steketee et al., 2003).
More recently, some researchers have started using an adapted version
of the Reciprocal Attachment Questionnaire, which is a measure of
interpersonal attachment based on attachment theory (Nedelisky &
Steele, 2009). However, the adapted RAQ lacks validity, thereby lim-
iting the meaningfulness of its use. Further, behavioral assessments of
attachment in HD would likely be fruitful for exploring in vivo re-
sponses to objects. Though there are a handful of behavioral tasks often
used in research regarding hoarding (Shaw & Timpano, 2016; Tolin,
Kiehl, Worhunsky, Book, & Maltby, 2009), such tasks are not con-
ceptualized as measuring attachment per say. The development of a
task that assesses behavioral components of attachment, such as
showing preference for an attachment figure, would elucidate the
nature of hoarding behaviors.
11. Clinical implications
Our model may have implications for the assessment and treatment
of HD, as the evaluation of interpersonal factors may provide im-
portant, yet previously overlooked, information about the nature of the
disorder. Though it is standard practice to assess attachment to pos-
sessions in the evaluation of HD, the assessment of interpersonal at-
tachment and biases are not always included. Therefore, understanding
one's views of others may help to clarify the nature and severity of one's
attachment to possessions. Moreover, interpersonal factors may need to
be more directly addressed in treatment. In particular, it may be that
interpersonal treatments or a combination of CBT for HD and inter-
personal treatments may prove promising. Several evidence-based
treatments directly target interpersonal difficulties and interpretation
biases, including Cognitive Behavioral Analysis System of
Psychotherapy (McCullough, 2003) and Interpersonal Psychotherapy
(IPT; Klerman & Weissman, 1994). Support for the hypothesis that
targeting interpersonal problems may prove promising can be found in
the depression and eating disorder literature, in which IPT has been
shown to be as effective as or more effective than CBT (Ekeblad,
Falkenström, Andersson, Vestberg, & Holmqvist, 2016; Fairburn et al.,
2015). As stated above, HD is commonly comorbid with depression
(Frost, Steketee, & Tolin, 2011). Moreover, HD and binge eating dis-
order are both driven by similar processes, including compulsive be-
haviors, emotion regulation, and insecure attachment (Grisham et al.,
2018; Raines, Boffa, Allan, Short, & Schmidt, 2014; Tasca & Balfour,
2014). Importantly, evidence-based treatments for depression and
binge eating disorder directly addresses negative views of oneself and
have shown to be effective in reducing symptoms (Cuijpers et al., 2013;
Rieger et al., 2010). In addition, given the integral role of both emotion
B.M. Mathes, et al.
regulation and interpersonal difficulties in HD, dialectical behavior
therapy (DBT) may prove promising. DBT is an evidence-based treat-
ment that improves mindfulness, distress tolerance, emotion regulation,
and interpersonal effectiveness (Linehan, 1993) and has been shown to
be effective for a variety of conditions (Neacsiu, Eberle, Kramer,
Wiesmann, & Linehan, 2014; Robins & Chapman, 2004) Therefore, DBT
may be a promising treatment strategy that targets all aspects of the
proposed model.
Should future work support our hypotheses regarding the integral
role of interpersonal attachment in the development and maintenance
of HD, it may help to explain why treatment to date has been shown to
be only moderately effective. Specifically, given that the need for se-
curity is a basic human need, it may be that until interpersonal at-
tachment difficulties are resolved, possessions will continue to remain
the “secure base” for the individual. As such, even if cognitive beha-
vioral strategies focused on reducing the importance of possessions is
effective, the strong emotional attachment will remain until the inter-
personal difficulties are addressed.
12. Conclusions
HD is a severe and persistent mental illness characterized by ex-
treme difficulty parting with possessions and considerable clutter that
can result in dangerous living conditions. HD poses a considerable
public burden, as clean-up costs are substantial and it is estimated the
cost per individual may be greater than that of related disorders, in-
cluding depression and anxiety. Though research regarding HD has
advanced in recent years, there remain important gaps in the literature,
particularly regarding the pathological attachment individuals with HD
hold to their possessions. Moreover, treatment for HD remains rela-
tively limited, as many individuals do not respond to treatment and/or
do not maintain treatment gains, suggesting there are important factors
not being adequately addressed.
Therefore, we propose that attachment theory may provide an im-
portant foundation by which to examine HD. Specifically, we propose
that individuals who hoard view possessions as their primary attach-
ment figure in order to compensate for an insecure attachment with
people. The hypotheses put forth in this theory may help to advance our
knowledge of HD and to identify potential factors that can be targeted
in intervention and prevention efforts. Indeed, underlying interpersonal
factors may play a larger role in the etiology and maintenance of the
disorder than previously thought. Nonetheless, future research should
test the hypotheses put forth in this manuscript, and should further
explore potential mechanisms that may help to explain the relationship
between hoarding and attachment.
Author disclosure
The authors of this manuscript declare no conflict of interest. The
authors did not receive funding from an external source for this work.
CRediT authorship contribution statement
Brittany M. Mathes: Conceptualization, Methodology,
Investigation, Writing - original draft. Kiara R. Timpano:
Conceptualization, Methodology, Writing - review & editing. Amanda
M. Raines: Conceptualization, Writing - review & editing. Norman B.
Schmidt: Conceptualization, Writing - review & editing.
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