Nicholas Maltby

An exploratory study of the neural mechanisms of decision making in compulsive hoarding

BACKGROUND 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. METHOD 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. RESULTS 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. CONCLUSIONS 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.

A Brief Motivational Intervention for Treatment‐Refusing OCD Patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive‐compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self‐identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4‐session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait‐list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4‐week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop‐out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop‐out as well as directions for future research are discussed.

Stepped care for obsessive-compulsive disorder: A pilot study

Cognitive-behavioral therapy incorporating exposure and ritual prevention (EX/RP) is the first-line psychosocial treatment of choice for obsessive-compulsive disorder (OCD). However, several barriers to care prevent many OCD patients from receiving this treatment. Previous research has indicated that some OCD patients may benefit from less intensive treatment options, such as bibliotherapy; however, it is not clear how to assign patients to their appropriate level of treatment. We suggest that an optimal approach may be to use a stepped care protocol, in which patients begin with a low-intensity treatment and then progress to more costly (but perhaps more efficacious) treatments as needed. In this pilot study, 11 adults with OCD initially received bibliotherapy EX/RP treatment; 20% of patients completing this treatment met stringent responder criteria. The remaining patients were then assigned to a therapist who provided brief education and EX/RP advice but did not actually assist patients with exposure exercises. Twenty-nine percent of patients who completed this treatment were classified as responders. The remaining patients then received the more traditional therapist-administered EX/RP; 67% of patients completing this treatment were responders. Across the entire protocol, 86% of treatment completers and 80% of the intent-to-treat sample were rated as “much improved” or “very much improved.” Cost-effectiveness analyses, in which the total cost of treatment was divided by the degree of symptom reduction, showed that stepped care compared favorably to other forms of EX/RP delivery. We provide a detailed case discussion that illustrates the clinical decision-making process and one patients response to different levels of treatment.

The Relationship between Obsessive Beliefs and Thought-Control Strategies in a Clinical Sample

Previous research has linked obsessive-compulsive disorder (OCD) to maladaptive strategies of thought control, which in turn may elicit a paradoxical increase in the unwanted thought. One explanation for OCD patients’ use of maladaptive thought control strategies is that they tend to overestimate the importance of their thoughts, or perceive a greater need to control them. The aim of the present study was to examine the relationship between obsessive beliefs and use of maladaptive thought control strategies in a sample of 77 OCD patients and 35 anxious control patients. Patients completed the Obsessive Beliefs Questionnaire-44 (OBQ-44) and the Thought Control Questionnaire (TCQ), as well as measures of trait anxiety and depression. Across the entire sample and for OCD patients only, when controlling for depression and trait anxiety, the TCQ Punishment scale correlated significantly with the OBQ-44 Importance/Control of Thoughts scale. Regression analyses indicated that beliefs about the Importance/Control of Thoughts accounted for the relationship between OCD and the use of Punishment as a thought control strategy. In addition to providing additional construct validation for the OBQ-44, the present data add to a growing body of research suggesting that OCD patients, believing their intrusive thoughts to be particularly important and perceiving a need to control them, overuse maladaptive thought control strategies; these strategies tend to “backfire” and trigger additional intrusive thoughts.

The Use of the MMPI-2 Infrequency–Psychopathology Scale in the Assessment of Posttraumatic Stress Disorder in Male Veterans

This study evaluated the use of the FP (Infrequency–Psychopathology) scale of the Minnesota Multiphasic Personality Inventory—2 (MMPI-2) as a measure of symptom overreporting among 423 service-seeking male veterans with and without PTSD. Results were consistent with several predictions based on the logic of the FP scale. FP produced lower scores for PTSD and non-PTSD patients than the other two MMPI-2 measures of infrequent responding; F and FB. FP also resulted in fewer invalid protocols than did F or FB. Finally, FP yielded lower correlations with MMPI-2 and other measures of psychopathology than did F or FB. Consistent with previous studies, compensation-seeking status was associated with extreme elevations across clinical and validity scales. Contrary to previous findings, however, compensation-seeking veterans were also more likely to receive a PTSD diagnosis. Implications for the relationship between compensation seeking and symptom overreporting are discussed.