Gail Steketee

Perfectionism in Obsessive-Compulsive Disorder patients

Considerable theory and anecdotal evidence has suggested that patients with Obsessive-Compulsive Disorder (OCD) are more perfectionistic. Evidence with non-clinical populations supports this hypothesis. However, no data are available on levels of perfectionism among patients diagnosed with OCD. The present study extends findings on perfectionism and OCD by comparing perfectionism levels of OCD-diagnosed patients with those of non-patients and a group of patients diagnosed with panic disorder with agoraphobia (PDA). As predicted, patients with OCD had significantly elevated scores on Total Perfectionism, Concern Over Mistakes, and Doubts About Actions compared to non-patients controls. However, they did not differ from patients with PDA on Total Perfectionism or Concern Over Mistakes. Patients with OCD did have higher Doubts Actions scores than those with PDA. The implications for role of perfectionism in OCD and other anxiety disorders are discussed.

The economic and social burden of compulsive hoarding

The aim of the present study was to determine the economic and social burden of compulsive hoarding in a large sample of individuals with self-identified hoarding, as well as a separate sample of family members of individuals who hoard. Self-identified hoarding participants (N=864, 94% female, 65% met research criteria for clinically relevant compulsive hoarding) and family informants (N=655, 58% described a relative who appeared to meet research criteria for compulsive hoarding), completed an internet survey. Questions were derived in part from those used in the National Comorbidity Survey (NCS), and when possible, hoarding participants were compared to NCS participants. Compulsive hoarding was associated with an average 7.0 work impairment days in the past month, equivalent to that reported by individuals with psychotic disorders and significantly greater than that reported by female NCS participants with all other anxiety, mood, and substance use disorders. Severity of hoarding predicted the degree of work impairment after controlling for age, sex, and non-psychiatric medical conditions. Hoarding participants were nearly three times as likely to be overweight or obese as were family members. Compared to female NCS participants, hoarding participants were significantly more likely to report a broad range of chronic and severe medical concerns and had a five-fold higher rate of mental health service utilization. Eight to 12% had been evicted or threatened with eviction due to hoarding, and 0.1-3.0% had a child or elder removed from the home. These results suggest that compulsive hoarding represents a profound public health burden in terms of occupational impairment, poor physical health, and social service involvement.

Refining the diagnostic boundaries of compulsive hoarding: a critical review.

Like most human behaviors, saving and collecting possessions can range from totally normal and adaptive to excessive or pathological. Hoarding, or compulsive hoarding, are some of the more commonly used terms to refer to this excessive form of collectionism. Hoarding is highly prevalent and, when severe, it is associated with substantial functional disability and represents a great burden for the sufferers, their families, and society in general. It is generally considered difficult to treat. Hoarding can occur in the context of a variety of neurological and psychiatric conditions. Although it has frequently been considered a symptom (or symptom dimension) of obsessive-compulsive disorder, and is listed as one of the diagnostic criteria for obsessive-compulsive personality disorder, its diagnostic boundaries are still a matter of debate. Recent data suggest that compulsive hoarding can also be a standalone problem. Growing evidence from epidemiological, phenomenological, neurobiological, and treatment studies suggests that compulsive hoarding may be best classified as a discrete disorder with its own diagnostic criteria.

Cognitive Aspects of Compulsive Hoarding

Hoarding of possessions is thought to be influenced by deficits in information processing, emotional attachments, and erroneous beliefs about possessions. This study examined hypothesized beliefs about possessions using an instrument developed for this purpose, the Saving Cognitions Inventory (SCI). Participants were individuals with compulsive hoarding (n = 95), obsessive compulsive disorder without hoarding (n = 21), and community controls (n = 40). An exploratory factor analysis yielded 4 factors similar to those hypothesized, representing emotional attachment, concerns about memory, control over possessions, and responsibility toward possessions. Subscales created based on these factors were internally consistent, and showed known groups, convergent and discriminant validity. Regression analyses indicated that 3 of the 4 subscales (memory, control, and responsibility) significantly predicted hoarding severity after age, moodstate, OCD symptoms and other OCD-related cognitive variables were entered. Interestingly, difficulty with decision-making also proved to be an important predictor of hoarding behavior. Implications for understanding and treating hoarding are discussed and study limitations are noted.

Comorbidity in hoarding disorder

Background: Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM‐5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large‐scale study of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures. Methods: We compared psychiatric comorbidity in a large HD sample (n = 217) to 96 participants meeting criteria for OCD without HD. Results: High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition‐related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition‐related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%). Conclusions: These findings form important base rates for developing research and treatments for hoarding disorder. Depression and Anxiety, 2011.

A brief interview for assessing compulsive hoarding: The Hoarding Rating Scale-Interview

This article describes the development and validation of the Hoarding Rating Scale-Interview (HRS-I), a brief (5-10 min) five-item semi-structured interview that assesses the features of compulsive hoarding (clutter, difficulty discarding, acquisition, distress and impairment). Trained interviewers administered the HRS-I to 136 adults (73 compulsive hoarding, 19 OCD, 44 non-clinical controls) along with a battery of self-report measures. An initial assessment was conducted in the clinic, and a second assessment was conducted in participants homes. The HRS-I showed high internal consistency and reliability across time and context. The HRS-I clearly differentiated hoarding and non-hoarding participants, and was strongly associated with other measures of hoarding. It is concluded that the HRS-I is a promising measure for determining the presence and severity of compulsive hoarding.

Hoarding and Obsessive-Compulsive Symptoms.

The present study attempts to extend recent research on the relation between hoarding and obsessive-compulsive experiences. In both college student and community samples, hoarding was associated with higher scores on the Yale-Brown Obsessive-Compulsive Scale (YBOCS). The relationship was stronger among the community sample, in which there was a greater range of compulsive symptoms and hoarding behavior. Hoarding was also associated with higher levels of general psychopathology as measured by the Brief Symptom Inventory but not by the Obsessive-Compulsive Personality Disorder subscale from the Millon Clinical Multiaxial Inventory-II or by a measure of ordinary risk taking. Among a sample of patients with obsessive-compulsive disorder (OCD), 31% reported hoarding obsessions and 26% reported hoarding compulsions on the YBOCS symptom checklist. These frequencies are similar to those found elsewhere and suggest that, although not as frequent as the classical symptoms of OCD, hoarding is a common symptom among OCD patients.

Deliberate exposure and blocking of obsessive-compulsive rituals: Immediate and long-term effects

The present experiment was designed to examine the separate and combined effects of exposure and blocking of ritualistic behavior on obsessive-compulsive symptoms. Thirty-two patients with a primary diagnosis of obsessive-compulsive disorder were assigned to one of three treatment groups: exposure in vivo only, response prevention only and the combination of these two procedures. Assessments were conducted before treatment, three days after completion of treatment, and at follow-ups 3, 6, and 12 months later. All three groups were significantly improved on most measures of symptomatology, with some tendency for partial loss of gains at follow-up, particularly for the single-component treatments. Overall, combined treatment produced greater changes in anxiety and rituals than did the single component treatments. There was some evidence for the specificity of the treatment effects: exposure affected anxiety to contaminants significantly more than did response prevention; a tendency for the latter procedure to impact more on ritualistic behavior was also observed. Possible mechanisms which may be operative during these procedures are discussed in light of conceptualizations of processing of fear-associated information.

THE ETIOLOGY AND MAINTENANCE OF SEVERE ANIMAL PHOBIAS

Abstract Twenty-two outpatients who sought behavioral treatment for a severe animal phobia were questioned via structured interview to obtain information on the mode of onset and course of development of their fear. Information was also obtained regarding feared consequences and distressing stimulus characteristics of their feared animal. In each case, the phobia began in early childhood and remained stable or worsened with age. Mode of onset was unclassifiable in 15 cases (68%) because of patient inability to remember precipitants. Of the remaining 7 patients, 5 ascribed their fear to a frightening encounter with the animal (‘conditioning’); indirect (‘instructional’ and ‘vicarious’) causes were cited in the remaining cases. Virtually all patients feared panic and its consequences following an unavoidable encounter with the phobic animal, whereas less than half reported fear that the animal would attack. Stimulus features, especially movement, were found to be salient fear-eliciting cues.

Disability and family burden in obsessive-compulsive disorder.

This paper reviews 2 aspects of obsessive–compulsive disorder (OCD): impairment in functioning and family burden associated with OCD. Impairment is evident from epidemiological and clinical studies in several areas, particularly in occupational and social maladjustment. Clinic outpatients show a range of impairment associated with OCD, while hospitalized patients exhibit consistently severe disabilities that rival those of patients with schizophrenia. Although behaviourally and medication-treated patients improve in adjustment levels, there is some evidence of persistent impairment, particularly in social and work functioning. Several studies support extensive family involvement and accommodation of OCD symptoms, as well as the considerable burden placed on families who reduce their social activities and increase their isolation and distress. Findings are equivocal regarding OCD and marital distress. Predictors of treatment outcome do not include marital dissatisfaction, but may include expressed anger and criticism. With regard to treatment, family support groups are popular but untested interventions, and family-assisted individual and group behaviour therapy have demonstrated good outcomes in limited trials.