<jats:sec id="S0033291708003371_sec_a001"><jats:title>Background</jats:title><jats:p>Prior studies have suggested unique patterns of neural activity associated with compulsive hoarding. However, to date no studies have examined the process of making actual decisions about whether to keep or discard possessions in patients with hoarding symptoms. An increasing body of clinical data and experimental psychopathology research suggests that hoarding is associated with impaired decision making; therefore, it is important to understand the neural underpinnings of decision-making abnormalities in hoarding patients.</jats:p></jats:sec><jats:sec id="S0033291708003371_sec_a002"><jats:title>Method</jats:title><jats:p>Twelve adult patients diagnosed with compulsive hoarding, 17% of whom also met criteria for obsessive–compulsive disorder (OCD), and 12 matched healthy controls underwent functional magnetic resonance imaging (fMRI) while making decisions about whether or not to discard personal paper items (e.g. junk mail) brought to the laboratory as well as control items that did not belong to them. Items were either saved or destroyed following each decision.</jats:p></jats:sec><jats:sec id="S0033291708003371_sec_a003" sec-type="results"><jats:title>Results</jats:title><jats:p>When deciding about whether to keep or discard personal possessions, compulsive hoarding participants displayed excessive hemodynamic activity in lateral orbitofrontal cortex and parahippocampal gyrus. Among hoarding participants, decisions to keep personal possessions were associated with greater activity in superior temporal gyrus, middle temporal gyrus, medial frontal gyrus, anterior cingulate cortex, precentral gyrus, and cerebellum than were decisions to discard personal possessions.</jats:p></jats:sec><jats:sec id="S0033291708003371_sec_a004" sec-type="conclusion"><jats:title>Conclusions</jats:title><jats:p>These results provide partial support for an emerging model of compulsive hoarding based on complications of the decision-making process. They also suggest that compulsive hoarding may be characterized by focal deficits in the processing of reward and changes in reward contingencies, particularly when these are perceived to be punishing.</jats:p></jats:sec>