DEPRESSION AND ANXIETY 20:59–69 (2004)

Research Article
ACTUAL AND PERCEIVED MEMORY DEFICITS IN
INDIVIDUALS WITH COMPULSIVE HOARDING
Tamara L. Hartl, Ph.D.,1 Randy O. Frost, Ph.D.,2 George J. Allen, Ph.D.,1 Thilo Deckersbach, Ph.D.,2
Gail Steketee, Ph.D.,3 Shannon R. Duffany,1 and Cary R. Savage, Ph.D.4

Memory problems have been hypothesized to underlie compulsive hoarding

behavior [Frost and Hartl, 1996: Behav Res Ther 34:341–350]. This study
examined memory performance, memory confidence, and memory beliefs in 22
individuals with severe hoarding symptoms and 24 matched normal control
subjects. Participants were administered two measures of learning and memory
that required strategic planning and organization for successful performance:
the Rey-Osterrieth Complex Figure Test (RCFT) and California Verbal
Learning Test (CVLT). Self-reports of memory confidence, perceived con-
sequences of forgetting, importance of remembering, and need to keep
possessions in sight also were assessed. In comparison to controls, participants
with compulsive hoarding recalled less information on delayed recall of the
RCFT and CVLT and used less effective organizational strategies on the RCFT
but not the CVLT. Hoarders also reported significantly less confidence in
their memory, more catastrophic assessments of the consequences of forgetting,
and a stronger desire to keep possessions in sight. Results provide initial
evidence of learning and memory impairment and poor memory confidence in
subjects with compulsive hoarding. Depression and Anxiety 20:59–69, 2004.
& 2004 Wiley-Liss, Inc.

Key words: hoarding; obsessive-compulsive disorder; memory; neuropsychology;

organizational strategies

INTRODUCTION
Clinical investigators have become increasingly inter-
ested in the phenomenon of compulsive hoarding.
Although not clearly delineated in the Diagnostic and
Statistical Manual of Mental Disorders-IV [American
Psychiatric Association, 1994], Frost and Hartl [1996]
proposed the following definition for compulsive
hoarding: 1) the acquisition of, and failure to discard,
a large number of possessions that seem to be useless or
of limited value, 2) living spaces sufficiently cluttered
so as to preclude activities for which those spaces were
designed, and 3) significant distress or impairment in
functioning caused by the hoarding. Hoarding beha-
vior has been described in a number of clinical
disorders including anorexia nervosa [Frankenburg,
1984], schizophrenia [Greenberg et al., 1990], and
dementia [Hwang et al., 1998]; however, it is most
often associated with obsessive-compulsive disorder
(OCD). Hoarding symptoms are present in approxi-
mately 18–30% of cases with OCD [Frost et al., 1996;
1
Department of Psychology, University of Connecticut, Storrs,
Connecticut
2
Department of Psychology, Smith College, Northampton,
Massachusetts
3
Boston University School of Social Work, Boston University,
Boston, Massachusetts
4
Hoglund Brain Imaging Center, Kansas University Medical
Center, Kansas City, Kansas
This research was presented at the Association for the Advance-
ment of Behavior Therapy, November 1999, Toronto, Canada.
Contract grant sponsor: Obsessive–Compulsive Foundation;
Contract grant sponsor: David Judah Research Fund.
*Correspondence to: Cary R. Savage, Ph.D., Hoglund Brain
Imaging Center, Mail Stop 1052, Kansas University Medical
Center, 3901 Rainbow Blvd., Kansas City, KS 66160.
E-mail: csavage@kumc.edu
Received for publication 15 August 2003; Accepted 25 January
2004
DOI: 10.1002/da.20010
Published online 9 June 2004 in Wiley InterScience (www.
interscience.wiley.com).

& 2004 WILEY-LISS, INC.

60 Hartl et al.
Rasmussen and Eisen, 1992] and share several of its
defining clinical features, including indecisiveness
[Frost and Gross, 1993], perceptions of responsibility
[Frost et al., 1995], and perfectionism [Frost and Gross,
1993].
Despite these similarities with OCD, hoarding has
consistently emerged in factor analytic investigations as
a separate symptom factor, distinct from other ob-
sessive–compulsive characteristics such as checking,
symmetry, and cleanliness concerns [Baer, 1994; Leck-
man et al., 1997; Summerfeldt et al., 1999]. Similarly, a
cluster analysis of OCD symptoms by Calamari et al.
[1999] indicated that hoarding symptoms comprise an
independent subgroup. There also is evidence that
hoarding symptoms predict poorer prognosis in treat-
ment outcome studies of OCD, including treatments
with paroxetine or cognitive behavioral treatment
[Black et al., 1998], and other selective serotonin
reuptake inhibitors (SSRI) [Mataix-Cols et al., 1999;
Winsberg et al., 1999]. These findings have led
researchers to suggest that the neurobiological features
underlying hoarding may be distinct from those of
other subgroups of individuals with OCD [Black et al.,
1998; Winsberg et al., 1999].
ORGANIZATION DEFICITS AND MEMORY
BELIEFS AMONG HOARDERS
Frost and Hartl [1996] proposed a cognitive-
behavioral model of hoarding, defining it as a multi-
faceted behavior involving information processing
deficits and behavioral avoidance, as well as a tendency
to form strong emotional attachments to objects and
have erroneous beliefs about the nature of possessions.
In this model, memory disturbance is believed to be an
essential deficit underlying hoarding behavior. Indivi-
duals with hoarding report certain beliefs about their
memory ability, including poor memory confidence,
over-estimating the importance of remembering pos-
sessions, exaggerating the consequences of forgetting,
and preferring to keep possessions in sight to serve as
visual cues [Frost and Hartl, 1996]. Whether these
beliefs are actually more salient for hoarders compared
to nonhoarders has not yet been investigated.
The relevance of hoarders’ poor memory confidence
is reflected in four classes of difficulty observed in
association with their patterns of saving [Frost and
Hartl, 1996]. First, hoarders often have dif ficulty
selecting individual categories when organizing posses-
sions, fearing that they will forget assigned file head-
ings. Second, hoarders seem to over-emphasize the
importance of remembering information and posses-
sions, often reporting that seemingly insignificant
phone numbers or newspaper articles are ‘‘crucial to
remember.’’ Third, hoarders reportedly believe that
serious negative consequences may result from forget-
ting information. Fourth, hoarders often report a
preference to keep possessions in sight so as not to
forget their existence. Many hoarders report that their
capacity to remember is so poor that they cannot recall
information or personal events without retaining some
hard copy or visual reminder of the event. Despite
these perceived memory deficits among hoarders, there
have been no neuropsychological studies of memory
performance in this group. The question remains
whether hoarders suffer from actual memory deficits.
LEARNING AND MEMORY DEFICITS IN
INDIVIDUALS WITH OCD
An extensive literature has examined memory
deficits in individuals with OCD. Several studies failed
to find evidence of memory deficits associated with
OCD on measures of verbal memory [e.g., Abbruzzese
et al., 1993; Dirson et al., 1995], word recognition [Foa
et al., 1997], word recall [MacDonald et al., 1997;
Zielinski et al., 1991], working memory [Martin et al.,
1995], and recall of ‘‘safe’’ versus neutral objects [Tolin
et al., 1999]. OCD washers and checkers have also
shown some indication of having a positive memory
bias toward remembering threat-relevant information
[Radomsky et al., 2001; Radomsky and Rachman,
1999].
Other research does provide evidence for learning
and memory problems in clinical and subclinical OC
groups [Christensen et al., 1992], in particular deficits
related to spatial working memory and spatial recogni-
tion [Purcell et al., 1998a,b], and memory for actions
[Sher et al., 1984, 1989]. In response to these mixed
outcomes, Savage [1998] suggested that memory
measures stressing organizational planning skills may
be most sensitive to memory dif ferences in individuals
with OCD. Such problems would be similar to findings
in neurologic groups with frontal-striatal neural system
dysfunction [Savage, 1997] and, therefore, consistent
with neurobiological models of OCD [Rauch and
Baxter, 1998].
Several studies have now shown learning and
memory deficits among OCD patients when memory
assessments include an organizational component
[Deckersbach et al., 2000a; Martinot et al., 1990;
Savage et al., 1999, 2000]. Evidence suggests that
memory impairment among OCD patients is statisti-
cally mediated by poor organizational strategies during
encoding [Savage et al., 1999, 2000]. This seems to be
true for both verbal and nonverbal tests, provided they
adequately stress organizational capacities. Secondary
to strategic impairments, OCD patients may have poor
representations of episodes during encoding, yet
correctly recognize items that had been presented.
Savage et al. [1996, 2000] have demonstrated that
OCD patients tend to perform as well as controls on
recognition measures of verbal and visual memory, but
fare less well on tasks of free recall.
There is evidence that patients with OCD show
abnormal learning and memory, particularly in condi-
tions that are ambiguous or complex and require
organizational planning. These problems may also be
 Research Article: Hoarding and Memory Deficits
present in individuals with compulsive hoarding.
Although there have been several recent investigations
into the phenomenology of hoarding behavior, none
have examined memory functioning. To our knowl-
edge, this is the first neuropsychological investigation
of a sample of individuals with hoarding symptoms as
their primary concern. It was hypothesized that
hoarders, relative to controls, would perform more
poorly on measures of verbal and visual memory that
include an organizational component and report
significantly poorer confidence in their memory. In
addition, based on Frost and Hartl’s [1996] model,
hoarders are predicted to 1) over-emphasize the
importance of remembering possessions and informa-
tion, 2) report keeping possessions in sight to serve as
visual cues significantly more, and 3) associate more
severe negative consequences with forgetting informa-
tion relative to controls.
PARTICIPANTS AND METHODS
PARTICIPANTS
Hoarding participants were solicited from self-help
groups in Connecticut or referred by clinicians at the
OCD Clinic and Research Unit at the Massachusetts
General Hospital. Control participants were solicited
by advertisements in a state university and in the
surrounding community. This study was approved by
the Subcommittee for Human Studies at MGH and the
University of Connecticut. All participants gave written
consent after a full explanation of procedures. Three
criteria were used to dif ferentiate hoarders from non-
hoarders. First, participants were screened with the
Saving Behavior Scale (SBS) [Frost et al., 1999] to
ensure that the two groups were statistically differ-
entiated on this index of hoarding behavior. SBS total
scores ranged from 3–31 in the control group and from
38–100 in the hoarding sample. Second, participants
were included in the hoarding sample, and excluded
from the control sample, if they reported severe distress
or interference in quality of life as a function of saving
or cluttering behaviors. Third, all participants con-
sented to a home visit to verify self-reported saving and
cluttering behaviors among hoarding participants and
normal clutter among control participants. Three
hoarding participants were retained whose SBS scores
were extremely high and who did not allow a home visit
because of reported embarrassment over the conditions
of their homes.
To reduce the possibility of influences on memory
performance other than group status, potential parti-
cipants were excluded if they 1) reported any psychotic
symptoms during the Structured Clinical Interview for
DSM-IV Disorders (SCID) [First et al., 1995], 2)
reported ever having been diagnosed with bipolar
disorder, or 3) had a history of epilepsy or any other
seizure disorder. In addition, participants for the
hoarding sample were excluded if they indicated that
61
clutter was not a defining feature of their saving
behavior or if they met criteria for substance abuse or
dependence. Control participants were excluded if they
met SCID criteria for an Axis I disorder or if they were
taking any psychoactive medication. The final sample
consisted of 22 people with compulsive hoarding
symptoms and 24 healthy control participants.
Despite the fact that the hoarding sample on average
manifested clinically dysfunctional obsessive-compul-
sive features, only four of the participants met SCID
criteria for OCD. Twelve participants in the hoarding
sample had at least one current Axis I diagnosis and six
had more than one Axis I condition, broken down as
follows: major depressive episode (n ¼ 3), obsessive-
compulsive disorder (n ¼ 4), post-traumatic stress
disorder (n ¼ 4), dysthymia (n ¼ 2), panic disorder
(n ¼ 3), agoraphobia (n ¼ 1), social phobia (n ¼ 1),
specific phobia (n ¼ 5), and generalized anxiety dis-
order (n ¼ 5). Six had more than one Axis I condition.
SAMPLE CHARACTERISTICS
The SCID was conducted by trained interviewers to
determine the diagnoses of hoarding participants and
to verify the absence of Axis I disorders in the control
sample. Participants were matched according to
gender, handedness (as verified with the Edinburgh
Handedness Inventory; Oldfield, 1971), age, education,
and estimated verbal IQ (VIQ; estimated using short
forms of the Information, Vocabulary, and Similarities
subtests of the Wechsler Adult Intelligence Scale-
Revised; WAIS-R). Independent sample t-tests and w2
analyses showed no significant dif ferences between
groups on these variables (Table 1).
Participants also completed the Yale-Brown Obses-
sive-Compulsive Scale (Y-BOCS) [Goodman et al.,
1989], the revised Beck Depression Inventory (BDI-II)
[Beck and Steer, 1987] and the Beck Anxiety Inventory
(BAI) [Beck et al., 1988]. Hoarders scored significantly
higher on these measures, indicating greater psycho-
pathology than in the control sample. Demographic
and clinical characteristics for the sample are summar-
ized in Table 1.
PROCEDURE
Participants were first administered the SCID,
followed by the neuropsychological measures and the
WAIS subscales in counterbalanced order across
participants. Self-reports were completed either before
or immediately after the assessment session.
NEUROPSYCHOLOGICAL MEASURES
Rey-Osterrieth Complex Figure Test (RCFT)
[Osterrieth, 1944]. Participants were given the RCFT
figure and a blank piece of paper and asked to copy the
figure as accurately as possible (copy condition). After
completing the copy condition, the figure was removed
and participants were instructed to redraw the figure
62
TABLE 1. Demographic and clinical characteristics of hoarding and control samples
Hoarders (n ¼ 22)a
Female (%) 81.8
Right-handed (%) 95.0
Age (yr) 52.73
Education (yr) 16.73
Estimated VIQ 125.23
Y-BOCS 9.59
Beck Depression Inventory II 13.06
Beck Anxiety Inventory 9.05
a
Values are expressed as meand (sd), unless otherwise indicated.
*Po.001.
**Po.01.
from memory, without intervening distraction (im-
mediate recall condition). After a 20-min delay,
participants were again asked to redraw the figure
from memory (delayed recall condition). During each
of the three conditions, the examiner gave the
participant a predetermined sequence of differently
colored pencils every 10–15 s to assess organization of
the drawing. After completing the delayed recall
condition, participants were given a recognition task
[Meyers and Meyers, 1995] in which they were asked to
discern which smaller pieces on several sheets of paper
were part of the larger Rey figure. Scoring for
recognition was based on the total number of correctly
identified elements.
The RCFT drawings were scored for both accuracy
and organization. To score copy accuracy, 24 individual
segments of the figure were identified, each having
three criteria. It was possible to earn 0–3 points for
each segment to achieve a total possible accuracy score
of 72 [Denman, 1984]. Scoring for organization
involved a quantitative analysis of the construction of
five configural elements (base rectangle, two diagonals,
vertical midline, horizontal midline, and the right-side
triangle vertex) [Deckersbach et al., 2000c; Savage et
al., 1999]. Participants received points for constructing
each element as an unfragmented unit. The order of
construction did not af fect the organization score. The
largest configural element, the base rectangle, was
assigned two points, and each of the other components
was assigned one point. Participants could therefore
score between 0–6 points on organization. Reliability
for half of the sample’s organizational scores was
verified via three independent scorers. Correlations
between raters ranged from .93–.98.
California Verbal Learning Test (CVLT) [Delis et
al., 1987]. The CVLT is a well-established measure of
verbal learning and memory consisting of a list of 16
shopping items that can be grouped into four
categories (spices, tools, clothing, and fruits). The list
is presented so that no two words from the same
category occur in sequence and participants are not
informed of the semantic structure. The list is
Hartl et al.
Controls (n ¼ 24)a t
83.3

96.0

(8.76) 50.38 (6.11) 1.06
(2.75) 17.21 (2.64) 0.61
(14.90) 124.71 (17.12) 0.11
(9.52) 1.08 (1.79) 4.30*
(13.08) 2.08 (2.64) 4.03**
(10.75) 1.33 (2.08) 3.45**
presented for 5 trials, with a recall score assessed after
each trial, and a learning score assessed by adding trials
1–5. After a 20-min delay, participants are asked to
recall as many words as possible and then discriminate
between items on the original list and a set of
distracters, for which recognition discriminability
scores were calculated.
Verbal strategy scores were based on a semantic
clustering index that measured the extent to which
participants grouped words into semantic categories
during recall over the 5 learning trials. Participants
received points toward the semantic clustering score
when they recalled words from the same category in
succession. Scoring followed standard protocols [Delis
et al., 1987], and corrections were made to account for
an increase in semantic clustering points by chance
with an increase in the number of words recalled.
We were interested in the following CVLT mea-
sures: Trial 1 and Trial 5 free recall, learning over Trials
1–5, short- and long-delay free recall, semantic
clustering (averaged over Trials 1–5), and long-delay
recognition discriminability [1
((False PositivesþFalse
Negatives)/32)]. In addition, two contrast measures
were calculated to evaluate retention rates: 1) percen-
tage recall, Trial 5 to short-delay ¼ short-delay/trial
5  100), and 2) percentage recall, short-delay to long-
delay ¼ long-delay/short-delay  100.
SELF-REPORT CLINICAL MEASURES
Saving Behavior Scale. The Saving Behavior Scale
(SBS) [Frost et al., 1999] is a 28-item self-report
measure of various aspects of hoarding behavior,
including clutter, distress, avoidance, and saving.
Responses are made on a scale of 0–4 with 4 indicating
maximum distress or severity. Earlier versions of the
SBS have been found to be both reliable and valid
[Frost and Gross, 1993; Frost et al., 1995]; the internal
consistency in this sample for the SBS was extremely
high (Cronbach coefficient a ¼ .98). Four exploratory
measures were developed to assess beliefs in memory
hypothesized by Frost and Hartl [1996].
 Research Article: Hoarding and Memory Deficits 63

Memory Reliability Questionnaire. The Memory Importance of Remembering. The Importance of

Reliability Questionnaire (MRQ) [Frost and Longo,
1996] is a 22-item scale designed to assess self-reported
confidence in memory and the reliance on memory aids
to compensate for perceived deficits. The MRQ has a
Likert-type response format with responses ranging
from 1–5. Items included ‘‘I am confident that I will
remember really important things’’ and ‘‘I get fru-
strated with my memory.’’ The scale demonstrated
good internal consistency in this sample (a ¼ .86).
Possessions in View Scale. The Possessions in
View Scale (PIVS) is an 11-item scale assessing the
extent to which individuals keep their belongings in
sight to serve as visual retrieval cues. Items included ‘‘I
cannot remember something unless I keep a possession
in sight to remind me of it’’ and ‘‘If I put something in
storage I will forget I own it (1 ¼ strongly disagree,
5 ¼ strongly agree).’’ The scale had good internal
consistency in this sample (a ¼ .88).
Consequences of Forgetting Scale. The Conse-
quences of Forgetting Scale (COFS) contains 10-items
assessing the perceived consequences and severity of
forgetting information. Items included ‘‘Other people
will think I am a failure if I forget something’’ and ‘‘If I
forget some information, I will never have access to it
again.’’ Participants were asked to indicate their level of
agreement with each item, from 1, ‘‘strongly disagree,’’
to 5, ‘‘strongly agree.’’ In this sample, the COFS also
had good internal consistency (a ¼ .89).
Remembering (IOR) is a 20-item scale assessing the
importance placed on remembering possessions and
information. For example, participants were asked to
indicate how important it is to remember ‘‘what you
read in the newspaper,’’ ‘‘what books you own,’’ ‘‘where
you filed something,’’ and ‘‘what you did yesterday.’’
Items were scored from 1, ‘‘not at all important,’’ to 5,
‘‘extremely important.’’ Internal consistency for this
measure also was good (a ¼ .89). Three subsets of
items from the IOR were considered separately,
including six items pertaining to the importance of
remembering information (IOR-info., a ¼ .75), four
items that specifically pertained to remembering what
possessions are kept (IOR-poss., a ¼ .74), and two
items that pertained to the importance of remembering
where possessions are kept (IOR-location, a ¼ .60).
RESULTS
ASSESSMENT OF VISUAL AND VERBAL
MEMORY
Scores for mean RCFT accuracy and organization
are presented in Table 2. RCFT accuracy scores were
evaluated via a mixed-model 2 (Group)  3 (Condition)
ANOVA with Condition (copy, immediate recall,
delayed recall) as the within-subjects factor. Although
there was no main effect for Group, there was a

TABLE 2. Descriptive statistics and significance tests comparing hoarders and control respondents on indices of visual
and verbal memory functioningw

Hoarders mean (sd) Controls mean (sd) t

RCFT measures
Accuracy in copying 67.00 (4.29) 67.29 (3.95) 0.24
Accuracy in immediate recall 33.59 (12.46) 38.79 (14.24) 1.31
Accuracy in delayed recall 32.05 (12.52) 40.58 (12.64) 2.30*
% Recall –immediate to delayed 98.18 (23.31) 110.64 (31.55) 1.51
Copy organization 3.14 (1.58) 4.58 (1.64) 3.04**
CVLT measures
General learning and memory
Trial 1 7.91 (2.29) 8.70 (2.38) 1.13
Trial 5 12.59 (2.15) 14.04 (1.69) 2.52*
Trials 1–5 55.00 (9.25) 59.39 (8.85) 1.63
SD free recall 10.86 (3.59) 12.74 (2.22) 2.12*
LD free recall 11.64 (2.70) 13.17 (2.21) 2.10*
Retention over a delay
% Recall: Trial 5 to SD 84.97 (21.88) 90.75 (11.59) 1.12
% Recall: SD to LD 117.61 (51.27) 104.44 (14.91) 1.18
Encoding strategies
Semantic clustering 2.36 (0.98) 2.67 (0.81) 1.13
Serial clustering 2.32 (1.84) 1.95 (1.45) 0.76
Response to retrieval aids
LD recognition discriminability 95.55 (4.46) 96.91 (3.42) 1.16
w
LD, long duration; SD, short duration.
n
Po.05.
nn
Po.01.
64 Hartl et al.
significant Group  Condition interaction (F[1,44] ¼
4.24, P ¼ .02). Post hoc t-tests indicated that hoarders
did not differ from controls in copy performance
(t[44] ¼ .24, P ¼ .81) or in performance during the
immediate recall condition (t[44] ¼ 1.31, P ¼ .20, effect
size ¼ .39). Hoarders recalled significantly less infor-
mation from the figure during the delayed recall
condition 20 min later (t[44] ¼ 2.30, P ¼ .03). Figure
1 depicts mean RCFT copy and recall scores for both
groups.
Mean percent recall from immediate to delayed
recall, defined as: [(delayed recall/immediate recall) *
100] (Table 2) showed no significant difference
between groups regarding how much information was
retained between immediate and delayed recall
(t[44] ¼ 1.51, P ¼ .14, effect size ¼ .45). This suggests
that the significant dif ference in accuracy at delayed
recall may be due to improvement shown by controls,
rather than substantial forgetting in the hoarding
group. There was no group dif ference on the recogni-
tion test (t[44] ¼ .48, P ¼ .64). During the copy
condition, hoarders’ drawings of the figure were
significantly less organized than nonhoarders
(t[44] ¼ 3.04, P ¼ .001), which is similar to previous
Fig. 1. Summary of the primary Rey Complex Figure Test
(RCFT) [Osterrieth, 1944] scores. Error bars ¼ SEM. Hoarders
recalled significantly less than control participants on delayed
recall, but the difference does not reflect an abnormal rate of
forgetting in the hoarding group. Delayed recognition accuracy
was also normal.
findings in OCD [Deckersbach et al., 2000a; Savage
et al., 1999, 2000].
Based on Savage et al. [1999, 2000] findings in OCD
that memory deficits were mediated by poor organiza-
tion during encoding, the long-delay free recall
measure on the RCFT was selected as the dependent
variable in a test of the same mediation hypothesis.
Structural model analyses for the RCFT follow the
procedure outlined in Baron and Kenny [1986] and by
Savage et al. [1999, 2000] with OCD patients. Group
(controls ¼ 1, hoarders ¼ 2) had a direct effect on long-
delay recall (b ¼
.33, P ¼ .03; control M ¼ 40.58,
hoarder M ¼ 32.05) and on the hypothesized mediator,
copy organization (b ¼
.42, P ¼.00; control M ¼
4.58, hoarder M ¼ 3.14). In the multiple regression
analysis, both copy organization (b ¼ .23, P ¼.15) and
the direct effect of group (b ¼
.23, P ¼ .14) reduced in
size and were no longer predictive for long-delay recall.
Thus, group and encoding strategy both predicted
delayed recall independent of one another, but their
effects weakened when considered together. Change in
R2 from the direct to the mediated model increased
only .04, indicating that the mediated model did not
better explain group dif ferences in recall. This out-
come is different from previous findings in OCD
patients [Savage et al., 1999, 2000] in which organiza-
tional strategies during encoding were found to
statistically mediate recall.
Figure 2 depicts the CVLT recall means for Trials
1–5, short and long-delay free recall, and recognition.
For the general learning and memory measures (Table
2), a mixed-model 2 (Group)  4 (Condition; Trial 1,
Trial 5, short-delay free recall, long-delay free recall)
ANOVA, with Condition as the within-subjects factor,
showed a significant main effect for Group
(F[1,43] ¼ 4.98, P ¼ .03) with no Group  Condition
interaction (F[1,129] ¼ 1.16, P ¼ .33). Hoarding parti-
cipants recalled less information overall. Results are
summarized in Table 2.
There were no group differences for percent recall
from Trial 5 to short-delay (t[43] ¼ 1.12, P ¼ .27) or
from short-delay to long-delay recall (t[43] ¼ .74,
P ¼ .46), suggesting that although hoarders did not
recall as much verbal information as controls, this was
not the result of abnormal forgetting rates. In addition,
there were no significant group differences in semantic
clustering during encoding. Therefore, hoarders were
as likely as controls to use semantic clustering to
organize items on the shopping list into categories
(t[43] ¼ 1.13, P ¼ .27, effect size ¼ .35). This finding is
also different from previous studies in participants with
OCD. Finally, there were no group dif ferences
on recognition discriminability, t(43) ¼ 1.16, P ¼
.25. Hoarders and controls performed similarly when
asked to discriminate previously learned words from
distracters.
In summary, results indicate that hoarders are
impaired relative to their matched controls on organi-
zation and delayed recall of visual information (RCFT),
 Research Article: Hoarding and Memory Deficits
Fig. 2. Summary of the primary California Verbal Learning Test (CVLT) [Delis et al., 1987] scores. Error bars ¼ SEM. Hoarders recalled
significantly less than controls on free recall measures, including Trial 5, short-delay, and long-delay free recall. Long delay recognition
accuracy was normal in the hoarding group.
and on short and long-delayed recall measures of verbal
information (CVLT). Hoarders did not show evidence
of difficulty with semantic organization during encod-
ing of verbal information, as evidenced by their normal
semantic clustering scores on the CVLT.
SUBJECTIVE SELF-ASSESSMENTS OF
HOARDING BEHAVIOR AND MEMORY
BELIEFS
Table 3 presents descriptive statistics pertaining to
hoarding severity scores and memory beliefs for
hoarders and control participants. Relative to non-
hoarders, the hoarding sample reported significantly
(Po.01) poorer confidence in their memories, stronger
inclinations to keep possessions in sight, and more
concerns about serious and detrimental consequences
for forgetting information. Hoarders also placed great-
er importance on remembering where possessions are
kept (IOR-location) (t[44] ¼ 2.15, P ¼ .04). The IOR
total score and two of its subscales (remembering
information and possessions) were the only self-report
measures that did not significantly differentiate hoar-
ders from controls (Table 1). These three measures
were excluded from subsequent analyses.
Given that hoarders reported significantly poorer
confidence in their memory than controls and also
displayed visual and verbal memory deficits, we sought
to determine whether their poor memory confidence
65
might be an accurate appraisal of their actual memory
functioning. Three ANCOVA were run with the MRQ
as the dependent variable, and measures of actual
memory on which hoarders showed deficits as the
covariates (long-delay recall on the RCFT, and short
and long-delay free recall on the CVLT). After
covarying out actual memory deficits, all three analyses
remained statistically significant (F[1,43] ¼ 14.55, and
F[1,42] ¼ 12.87, and 13.71, respectively, Po.001) in
each case. Poor memory confidence endorsed by
hoarders was not explained by actual memory deficits.
Conversely, when the MRQ was used as the covariate
and each recall variable that was significantly lower for
hoarders (long-delay recall on the RCFT, and short-
and long-delay recall on the CVLT) was evaluated as
the dependent variable, the F-test remained significant
only for delayed recall on the RCFT (F[1,43] ¼ 4.45,
P ¼ .04). For the two CVLT analyses, results were no
longer statistically significant (short delay: F[1,43] ¼
1.30, P ¼ .26; long delay: F[1,43] ¼ 1.82, P ¼ .18).
These results suggest that nonverbal recall deficits
are not explicable by group dif ferences in memory
confidence, but that poor memory confidence may
indeed contribute to verbal recall deficits.
To explore whether the phenomenon of keeping
things in sight could be largely accounted for by having
poor memory confidence, an ANCOVA was run with
PIVS as the dependent variable and the MRQ as
the covariate (F[1,43] ¼ 6.88, P ¼ .01). With memory
66 Hartl et al.

TABLE 3. Self-reported memory beliefs of hoarders and control respondents

Hoarders Controls
mean (sd) mean (sd) t
Saving behavior (SBS) 67.52 (16.06) 14.54 (8.40) 14.19***
Memory reliability (MRQ) 69.03 (11.02) 56.84 (9.80) 3.97**
Possessions in view (PIVS) 27.31 (8.83) 16.75 (5.18) 5.00***
Importance of remembering (IOR) 53.41 (10.10) 49.52 (11.43) 1.22
IOR-Information 16.64 (3.92) 14.67 (3.55) 1.79
IOR-Possessions 9.00 (3.24) 8.63 (2.75) 0.43
IOR-Location 7.64 (1.43) 6.58 (1.84) 2.15*
Consequences of forgetting (COFS) 26.95 (8.97) 18.29 (6.40) 4.30**
n
Po.05.
nn
Po.01.
nnn
Po.001.

confidence controlled for, there was still a group
dif ference on the PIVS. Therefore, hoarders’ tenden-
cies to keep possessions in sight cannot be fully
explained by lack of confidence in memory.
RELATIONSHIPS AMONG SELF-REPORT
MEASURES AND NEUROPSYCHOLOGICAL
PERFORMANCE
A matrix of 32 correlations was computed between
the four exploratory self-report measures (MRQ, PIVS,
COFS, and IOR), four RCFT performance indices,
and four CVLT performance criteria. Only two of
these correlations were significant, suggesting that
memory performance could not be consistently pre-
dicted by various indices of memory confidence. We
carried out additional analyses examining the relation-
ships between strategy measures and memory scores.
For the entire sample, better organization predicted
better RCFT immediate recall (r ¼ .36, Po.05) and
delayed recall (r ¼ .33, Po.05) but not copy perfor-
mance (r ¼ .26). When broken down by group,
organization was not significantly correlated with any
of these three performance measures in the non-
hoarding sample (r ¼ .11, .03, and .18), but was so in
the hoarding sample (r ¼ .57, .46, and .43 for short-
delay, long-delay, and copy conditions, respectively).
Interestingly, semantic clustering was also relatively
more predictive of better performance on the CVLT by
hoarders, but not control participants, for recall at trial
5 (r ¼ .68 vs. .28), at short-delay (r ¼ .39 vs. .06), and at
long-delay (r ¼ .65 vs. .19).
ANALYSES BASED ON DEMOGRAPHIC
CHARACTERISTICS, DIAGNOSIS, AND
MEDICATIONS
With the exception of verbal IQ, none of the
demographic variables in Table 1, including age, the
YBOCS, the BDI-II, and the BAI were correlated
significantly with any of the neuropsychological or
subjective memory measures. As noted, four hoarding
participants met full DSM-IV criteria for OCD. To
verify that findings did not primarily reflect effects
from these four subjects, we repeated the analyses
excluding them. All significant dif ferences remained
significant and all nonsignificant differences remained
nonsignificant. Similarly, five hoarders on psychotropic
medications were removed from the analysis to assess
whether medication ef fects influenced the results. This
also caused no changes in significance on the neurop-
sychological measures that discriminated between
hoarders and controls.
DISCUSSION
Participants with compulsive hoarding were im-
paired on specific verbal and nonverbal learning and
free recall measures compared to matched control
participants. Hoarders also showed significant plan-
ning and organization problems when copying a
complex figure, drawing disjointed elements of the
stimulus rather than its major organizational features.
The ability to use a verbal learning strategy, measured
in semantic clustering, was not impaired in hoarding
participants. Hoarders, therefore, had dif ficulties
utilizing spatial, but not verbal, encoding strategies.
Both verbal and nonverbal strategy measures were
correlated with subsequent recall in the hoarding
group.
Results of this study also indicate that hoarders
believe that they have general and specific memory
problems. In validation of Frost and Hartl’s [1996]
cognitive-behavioral model of hoarding, hoarders in
this study reported significantly less confidence in their
memory, stronger needs to keep possessions in sight
(even when poor memory confidence was controlled
for), and more concerns about catastrophic conse-
quences of forgetting where objects were placed. In
addition, covariance analyses indicated that memory
confidence measures statistically explained verbal
memory problems in the hoarding group. Thus,
 Research Article: Hoarding and Memory Deficits
confidence in memory seemed to be disproportionately
af fected in comparison to objective verbal memory
performance on the CVLT in this hoarding sample.
This was not the case for nonverbal memory. Delayed
recall deficits on the RCFT remained statistically
significant in the covariance analyses. It is possible
that individuals with compulsive hoarding primarily
have neuropsychological problems affecting nonverbal
or spatial memory. These real problems might then
lead to more generalized concerns about the adequacy
of memory that negatively impact other (e.g., verbal)
modalities.
These findings provide some empirical validation for
treatment approaches that combine organization train-
ing with cognitive modification interventions [Frost et
al., 1999; Hartl and Frost, 1999; Steketee et al., 2000].
Although these treatments have included help with
devising organizational techniques such as filing
systems, their ef ficacy might well be improved by
providing rigorous organizational training at the outset
of treatment and ensuring that such training remains a
central focus. This focus may help prevent newly
acquired organizational systems from quickly becom-
ing nonfunctional. It may also help improve confidence
in memory, which could have beneficial effects in other
areas. In addition, embedding specific exposure and
response prevention exercises within a larger frame-
work of teaching organizational strategies may help
hoarders better habituate to having possessions out of
sight.
Anxiety about not being able to remember where
possessions are kept might also contribute to a vicious
self-perpetuating cycle that fosters reluctance by
hoarders to relegate possessions to out-of-view storage
areas (Frost and Hartl, 1996). Cognitive interventions
for poor memory confidence and over-estimations of
negative consequences of forgetting may, therefore, be
a second crucial treatment element. In particular,
cognitive restructuring techniques should be aimed at
challenging hoarders’ pervasive beliefs about the
importance of leaving every possession in sight and
the catastrophic consequences of not being able to
remember everything.
Our findings also speak to the questions regarding
the relationship between OCD and compulsive hoard-
ing. Similar to Winsberg et al. [1999], we found that
the majority of individuals in our hoarding sample did
not meet SCID criteria for OCD. In both studies,
o20% of hoarders met SCID diagnostic criteria for
OCD. This may be a function of the SCID and the
DSM-IV, as the appropriate location for compulsive
hoarding within the current classification system is as
yet unclear. Alternatively, as several studies have
suggested that hoarders are less responsive to tradi-
tional medications and CBT for OCD [e.g., Mataix-
Cols et al., 1999], it is possible that hoarding represents
a fundamentally distinct disorder [Black et al., 1998].
Results from this study share similarities and discre-
pancies with previous findings regarding memory
67
functioning in individuals with OCD. Hoarders in this
sample, like OCD patients in previous studies [Deck-
ersbach et al., 2000a; Savage et al., 1999, 2000] recalled
less verbal information at short and long-delays, as well
as less visual information after a long-delay. Hoarders
used semantic clustering strategies to a similar degree
as controls. Unlike previous studies with OCD patients
[Savage et al., 1999, 2000], regression analyses in this
study did not support mediation models in which
encoding strategies mediate group differences in
subsequent recall. It is notable that these mediation
models were recently extended to a group with body
dysmorphic disorder [Deckersbach et al., 2000b]. Our
findings indicate that there may be important qualita-
tive differences in the nature of memory impairment in
these various ‘‘OC-spectrum’’ groups.
Some caution is needed when interpreting results
from this initial study. One limitation is the relatively
small size of our patient and control samples. Other
limitations of this study include the fact that many of
our clinical hoarding measures were designed specifi-
cally for this study and, therefore, have not been
validated. The initial development of these instruments
was guided by a coherent theoretical model of hoarding
[Frost and Hartl, 1996] and our findings are generally
in accord with predictions from that model and
expected relationships to more established clinical
measures. The most significant limitation may pertain
to the diagnostic quandaries surrounding compulsive
hoarding. There is little consensus regarding the
diagnosis of compulsive hoarding, or even whether it
is best characterized in Axis I or Axis II of the DSM-IV.
However, we verified saving and cluttering behaviors
with a home visit in all but three participants diagnosed
with compulsive hoarding. Participants in the hoarding
group showed a clear pattern of extreme saving and
cluttering.
In summary, results from this study suggest that
hoarders have selected visual and verbal learning and
memory problems and impaired use of organizational
strategies during nonverbal encoding. They also have
reduced confidence in their memory, along with
increased catastrophic assessments of the consequences
of forgetting and a stronger desire to keep possessions
in sight. There are both similarities and differences
between these results and findings from previous work
in OCD. Both groups show reduced use of nonverbal
organizational strategies and impaired free recall for
verbal and nonverbal information. Participants in this
compulsive hoarding sample used semantic clustering
strategies during verbal learning as effectively as
control subjects. Furthermore, statistical models docu-
mented in OCD studies were not supported in this
group of participants with hoarding. We view this
investigation as a first step toward better understanding
the complex relationships between subjective confi-
dence and objective memory functioning in compulsive
hoarders. Future studies should further explore these
relationships in OCD and hoarding patient groups.
68
Acknowledgments. We thank D. Kenny for statis-
tical consultation.
REFERENCES
Abbruzzese M, Bellodi L, Ferri S, Scarone S. 1993. Memory
functioning in obsessive compulsive disorder. Behav Neurol
6:119–122.
American Psychiatric Association. 1994. Diagnostic and statistical
manual of mental disorders. 4th Ed. Washington, DC: American
Psychiatric Association.
Baer L. 1994. Factor analysis of symptom subtypes of obsessive
compulsive disorder and their relation to personality and tic
disorders. J Clin Psychiatry 55:18–23.
Baron RM, Kenny DA. 1986. The moderator-mediator variable
distinction in social psychological research: Conceptual, strategic,
and statistical considerations. J Pers Soc Psychol 51:1173–1182.
Beck AT, Epstein N, Brown G, Steer RA. 1988. An inventory for
measuring anxiety: Psychometric properties. J Consult Clin
Psychol 56:893–897.
Black DW, Monahan P, Gable J, Blum N, Clancy G, Baker P. 1998.
Hoarding and treatment response in 38 nondepressed subjects with
obsessive-compulsive disorder. J Clin Psychiatry 59:420–425.
Calamari JE, Wiegartz PS, Janeck, AS. 1999. Obsessive-compulsive
disorder subgroups: A symptom-based clustering approach. Behav
Res Ther 37:113–125.
Christensen KJ, Kim SW, Dysken MW, Hoover KM. 1992.
Neuropsychological performance in obsessive-compulsive disor-
der. Biol Psychiatry 31:4–18.
Deckersbach T, Otto MW, Savage CR, Baer L, Jenike MA. 2000a.
The relationship between semantic organization and memory in
obsessive-compulsive disorder. Psychother Psychosom 69:101–107.
Deckersbach T, Savage CR, Henin A, Mataix-Cols D, Otto MW,
Wilhelm S, Rauch SL, Baer L, Jenike MA. 2000b. Reliability and
validity of a scoring system for measuring organizational approach
in the complex figure test. J Clin Exp Psychol 22:640–648.
Deckersbach T, Savage CR, Wilhelm S, Buhlman U, Rauch SL, Baer
L, Jenike MA, Phillips KA. 2000c. Characteristics of memory
dysfunction in body dysmorphic disorder. J Int Neuropsychol Soc
6:673–681.
Delis DC, Kramer JH, Kaplan E, Ober BA. 1987. California verbal
learning test: manual. San Antonio, TX: Psychological Corpora-
tion.
Denman SB. 1984. Denman Neuropsychology Memory Scale.
Charlestown, SC: S.B. Denman.
Dirson S, Bouvard M, Cottraux J, Martin R. 1995. Visual memory
impairment in patients with obsessive-compulsive disorder: a
controlled study. Psychother Psychosom 63:22–31.
First MB, Spitzer RL, Gibbon M, Williams JBW. 1995. Structured
Clinical Interview for DSM-IV Axis I Disorders-Patient Edition
(SCID-I/D, Version 2.0). New York: Biometrics Research Depart-
ment, New York Psychiatric Institute.
Frankenburg F. 1984. Hoarding in anorexia nervosa. Br J Med
Psychol 57:57–60.
Frost RO, Gross RC. 1993. The hoarding of possessions. Behav Res
Ther 31:367–381.
Frost RO, Hartl TL. 1996. A cognitive behavioral model of
compulsive hoarding. Behav Res Ther 34:341–350.
Frost RO, Hartl TL, Christian R, Williams N. 1995. The value of
possessions in compulsive hoarding: Patterns of use and attach-
ment. Behav Res Ther 33:897–902.
Frost RO, Krause M, Steketee G. 1996. Hoarding and obsessive
compulsive symptoms. Behav Modif 20:116–132.
Hartl et al.
Frost RO, Longo C. 1996. The Memory Reliability Questionnaire.
Unpublished scale.
Frost RO, Steketee G, Kyrios M. 1999. The Saving Behavior Scale.
Unpublished scale.
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann
RL, Hill CL, Heninger GR, Charney DS. 1989. The Yale-Brown
Obsessive Compulsive Scale: I: Development, use, and reliability.
Arch Gen Psychiatry 46:1006–1011.
Greenberg D, Witzum E, Levy A. 1990. Hoarding as a psychiatric
symptom. J Clin Psychiatry 51:417–421.
Hwang J, Tsai S, Yang C, Liu K, Lirng J. 1998. Hoarding behavior in
dementia. Am J Geriatr Psychiatry 6:285–289.
Leckman JF, Grice DE, Boardman J, Zhang H, Vitale A, Bondi C,
Alsobrook J, Peterson BS, Cohen DJ, Rasmussen SA, Goodman
WK, McDougle CJ, Pauls DL. 1997. Symptoms of obsessive-
compulsive disorder. Am J Psychiatry 154:911–917.
MacDonald PA, Antony MM, MacLeod CM, Richter MA. 1997.
Memory and confidence in memory judgments among individuals
with obsessive compulsive disorder and non-clinical controls.
Behav Res Ther 35:497–505.
Martin A, Wiggs CL, Altemus M, Rubenstein C, Murphy DL. 1995.
Working memory as assessed by subject-ordered tasks in patients
with obsessive-compulsive disorder. J Clin Exp Neuropsychol
17:786–792.
Martinot JL, Allilaire JF, Mazoyer BM, Hantouche E, Huret JD,
Legaut-Demare F, Deslauriers AG, Hardy P, Pappata S, Baron JC.
1990. Obsessive-compulsive disorder: A clinical, neuropsychologi-
cal and positron emission tomography study. Acta Psychiatr Scand
82:233–242.
Mataix-Cols D, Rauch SL, Manzo PA, Jenike MA, Baer L. 1999.
Use of factor-analyzed symptom dimensions to predict
outcome with serotonin reuptake inhibitors and placebo in the
treatment of obsessive-compulsive disorder. Am J Psychiatry
156:1409–1416.
McNally RJ, Kohlbeck PA. 1993. Reality monitoring in obsessive-
compulsive disorder. Behav Res Ther 31:249–253.
Meyers JE, Meyers KR. 1995. Rey complex figure test and
recognition trial: Professional manual. Odessa: Psychological
Assessment Resources.
Oldfield RC. 1971. The assessment and analysis of handedness: The
Edinburgh Inventory. Neuropsychologia 9:97–113.
Osterrieth PA. 1944. Le test de copie d’une figure complex:
Contribution à létude de la perception et de la memoire
[The test of copying a complex figure: A contribution to the
study of perception and memory]. Archives de Psychologie 30:
286–350.
Purcell R, Maruff P, Kyrios M, Pantelis C. 1998a. Cognitive deficits
in obsessive-compulsive disorder on tests of frontal-striatal
function. Biol Psychiatry 43:348–357.
Purcell R, Maruff P, Kyrios M, Pantelis C. 1998b. Neuropsycholo-
gical deficits in obsessive-compulsive disorder: A comparison with
unipolar depression, panic disorder, and normal controls. Arch
Gen Psychiatry 55:415–423.
Radomsky AS, Rachman S. 1999. Memory bias in obsessive-
compulsive disorder. Behav Res Ther 37:605–618.
Radomsky AS, Rachman S, Hammond D. 2001. Memory bias,
confidence and responsibility in compulsive checking. Behav Res
Ther 39:813–822.
Rasmussen S, Eisen L. 1992. The epidemiology and clinical features
of obsessive compulsive disorder. Psychiatr Clin North Am 15:
743–758.
Rauch SL, Baxter LR. 1998. Neuroimaging in obsessive-compulsive
disorder and related disorders. In: Jenike MA, Baer L, Minichiello
 Research Article: Hoarding and Memory Deficits
WE, editors. Obsessive-compulsive disorders: Practical manage-
ment. 3rd Ed. St. Louis: Mosby. p 289–317.
Savage CR. 1997. Neuropsychology of subcortical dementias.
Psychiatr Clin North Am 20:911–931.
Savage CR. 1998. Neuropsychology of OCD: Research findings and
treatment implications. In: Jenike MA, Baer L, Minichiello WE,
editors. Obsessive-compulsive disorders: Practical management.
3rd Ed. St. Louis: Mosby. p 254–275.
Savage CR, Baer L, Keuthen NJ, Brown HD, Rauch SL, Jenike MA.
1999. Organizational strategies mediate nonverbal memory
impairment in obsessive-compulsive disorder. Biol Psychiatry
45:905–916.
Savage CR, Deckersbach T, Wilhelm S, Rauch SL, Baer L, Reid T,
Jenike MA. 2000. Strategic processing and episodic memory
impairment in obsessive-compulsive disorder. Neuropsychology
14:141–151.
Savage CR, Keuthen NJ, Jenike MA, Brown HD, Baer L, Kendrick
AD, Miguel EC, Rauch SL, Albert MS. 1996. Recall and
recognition memory in obsessive-compulsive disorder. J Neurop-
sychiatr 8:99–103.
69
Sher KJ, Mann B, Frost RO. 1984. Cognitive dysfunction in
compulsive checkers: Further explorations. Behav Res Ther
22:493–502.
Sher KJ, Frost RO, Kushner M, Crews TM, Alexander JE. 1989.
Memory deficits in compulsive checkers: Replication and extension
in a clinical sample. Behav Res Ther 27:65–69.
Summerfeldt LJ, Richter MA, Antony MM, Swinson RP. 1999.
Symptom structure in obsessive-compulsive disorder: A confirma-
tory factor-analytic study. Behav Res Ther 37:297–311.
Tolin DF, Brigidi BD, Abramowitz JS, Amir N, Street GP,
Foa EB. 1999. Memory and confidence biases in obsessive-
compulsive disorder. Paper presented at the meeting of the
Association for Advancement of Behavior Therapy, Toronto,
Canada.
Winsberg ME, Cassic KS, Koran LM. 1999. Hoarding in obsessive
compulsive disorder: A report of 20 cases. J Clin Psychiatry 60:
591–597.
Zielinski CM, Taylor MA, Juzwin KR. 1991. Neuropsychological
deficits in obsessive-compulsive disorder. Neuropsychiatr Neu-
ropsychol Behav Neurol 4:110–126.