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Cognitive processes in hoarding: The role of rumination
Personality and Individual Differences 86 (2015) 277–281
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Cognitive processes in hoarding: The role of rumination Amberly K. Portero, Daphne A. Durmaz, Amanda M. Raines, Nicole A. Short, Norman B. Schmidt ⁎ Department of Psychology, Florida State University, 1107 W. Call St., Tallahassee, FL 32306-4301, USA
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Article history: Received 1 March 2015 Received in revised form 11 June 2015 Accepted 12 June 2015 Available online 27 June 2015 Keywords: Rumination Hoarding Cognitions Anxiety
a b s t r a c t Rumination, defined as an individual's repetitive negative cognitions of upsetting symptoms in response to distress, has been established as an important cognitive vulnerability factor within various forms of psychopathology. Despite compelling data to suggest that rumination is associated with a number of mood and anxiety-related conditions, no research to date has examined the relationship between rumination and hoarding. Participants consisted of 275 undergraduate students as well as 106 individuals recruited from the community to participate in a larger randomized clinical trial investigating the effects of a computerized treatment targeting specific risk factors associated with anxiety and suicide. Consistent with initial prediction, results indicated that rumination was a significant predictor of hoarding severity, even after controlling for overall general levels of depression. These findings add to a growing body of literature identifying various cognitive vulnerability factors important for the development and maintenance of hoarding. Increasing our knowledge of cognitive vulnerability factors has import implications for the prevention and treatment of anxiety disorders. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Maladaptive thoughts have been implicated as an important transdiagnostic risk factor for the development and maintenance of numerous psychiatric disorders (Ehring & Watkins, 2008; Harvey, Watkins, Mansell, & Shafran, 2004). Whereas thought content varies by disorder, Ehring and Watkins (2008) suggest that negative content and uncontrollability are common elements of this ideation. Rumination is one type of negative thinking that has been frequently implicated in the development of various forms of psychopathology (McLaughlin & Nolen-Hoeksema, 2011). Rumination is defined as the tendency to repetitively analyze one's problems, concerns, and feelings of distress without taking action to make positive changes (Nolen-Hoeksema, 1991; Watkins, 2008). In recent years, there has been increased interest in the relationship between rumination and various mood and anxiety-related disorders. For instance, rumination has been found to predict the development of depressive symptoms, as well as the onset and number of major depressive episodes (Nolen-Hoeksema, 1991). Rumination is also associated with symptoms of generalized anxiety disorder (GAD; Fresco, Frankel, Mennin, Turk, & Heimberg, 2002), posttraumatic stress disorder (PTSD; Ehlers & Clark, 2000), and social anxiety disorder (SAD; Abbott & Rapee, 2004). Furthermore, researchers have found a ruminative thinking style to be significantly associated with increased obsessive–compulsive (OC) symptoms, in particular obsessions, above and beyond the effects of depression (Wahl, Ertle, Bohne, Zurowski, & ⁎ Corresponding author. Tel.: +1 850 645 1766; fax: +1 850 644 7739. E-mail address: [email protected] (N.B. Schmidt).
http://dx.doi.org/10.1016/j.paid.2015.06.024 0191-8869/© 2015 Elsevier Ltd. All rights reserved.
Kordon, 2011). Within these conditions, rumination is thought to exacerbate disorder specific symptoms by increasing negative maladaptive thoughts, lowering problem solving abilities, and decreasing the likelihood that individuals will engage in more adaptive emotion regulation strategies, such as behavioral activation to improve one's mood (Lyubomirsky, Kasri, Chang, & Chung, 2006; Lyubomirsky & Nolen-Hoeksema, 1993). Despite evidence showing associations between rumination in various anxiety and mood-related conditions, potential relationships between rumination and hoarding disorder have yet to be examined. Hoarding is a complex clinical phenomenon involving the acquisition of and failure to discard large quantities of possessions resulting in incapacitating clutter (Frost & Hartl, 1996). Hoarding disorder affects approximately 2% to 6% of the population (American Psychiatric Association, 2013). Previous research suggests that hoarding is associated with marked role impairment in social, occupational, and family domains (Frost, Steketee, Williams, & Warren, 2000; Tolin, Frost, Steketee, Gray, & Fitch, 2008). At its most severe states, hoarding may also lead to significant health problems due to unsanitary living conditions, work disability, and even death (Frost, Steketee, & Williams, 2000). Hoarding was once thought to be a symptom or subtype of obsessive compulsive disorder (OCD). As such, the majority of hoarding research to date has primarily relied on patients presenting with OCD who also have co-occurring hoarding symptoms. However, recent research suggests that there may be more differences than similarities between the two disorders. Specifically, there is an increasing body of evidence suggesting distinct diagnostic features (Pertusa et al., 2010) and patterns of comorbidity (Pertusa et al., 2008) between OCD and hoarding. Moreover, hoarding has been observed in a number of other psychiatric
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conditions including major depressive disorder (MDD), GAD, and social phobia (Frost, Steketee, & Tolin, 2011). Therefore, hoarding disorder has been included as a discrete diagnostic entity within the 5th revision of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). In light of these nosological changes, research identifying potential risk factors for hoarding outside the context of OCD seems warranted. Despite the lack of research examining the associations between rumination and hoarding, it is theoretically plausible that rumination may play a role in hoarding behaviors. According to the cognitive model of hoarding, manifestations of hoarding (e.g., acquiring and saving) result from various avoidance behaviors aimed at circumventing the distress associated with making a wrong decision regarding a possession (Frost & Hartl, 1996). Repetitive negative thoughts such as those associated with making a mistake while discarding may lead to increased avoidance of discarding and increased saving behaviors. Indeed, research has shown that decision making of any kind is particularly difficult for hoarders because of the high degree of concern over making a mistake while discarding and the need for certainty (Frost & Hartl, 1996; Frost & Shows, 1993). Increased rumination about such tasks may lead to more maladaptive thoughts (e.g., regarding harmful consequences of throwing out a needed possession), less effective problem solving skills (e.g., I could find a suitable replacement if needed), and an inability to engage in constructive mood-lifting activities (e.g., behavioral activation) and instead engaging in maladaptive hoarding behaviors (e.g., increased saving as a means of comfort) resulting in gross disorganization and clutter. The primary aim of the current study was to examine the relationship between rumination and hoarding in large non-selected undergraduate sample (study 1) as well as a large non-selected community sample (study 2). Based on the extant literature establishing an association between rumination and various forms of psychopathology (Nolen-Hoeksema, 2000), we hypothesized that repetitive negative thinking would be associated with increased hoarding severity, even after controlling for symptoms of depression which have been found to be highly associated with rumination and hoarding behaviors (Frost et al., 2011; Just & Alloy, 1997).
2.3. Measures 2.3.1. Self-report 2.3.1.1. Depression. Depression symptoms were assessed using the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Carbin, 1988). The BDI-II is a 21-item self-report measure assessing various symptoms of depression. Respondents were asked to read a group of statements and select the statement that best described how they have felt over the past 2 weeks. The BDI-II is scored using a 4-point Likert scale ranging from 0 to 3, with higher scores reflecting more severe depressive symptoms. The BDI-II has demonstrated strong internal consistency and good test–retest reliability (Beck et al., 1988). Internal consistency in the present sample was excellent (α = .91). 2.3.1.2. Rumination. The Ruminative Responses Scale (RRS; NolenHoeksema & Morrow, 1991) is a 22-item measure administered to assess participants' tendencies to ruminate in response to distress. Respondents indicate how often they typically engage in each of the 22 ruminative thoughts or behaviors when feeling depressed, down, or sad using a 4-point Likert scale ranging from 1 (almost never) to 4 (almost always). The responses are self-focused, symptom-focused, and focused on possible consequences and causes of one's mood. The RRS has demonstrated strong internal consistency (Nolen-Hoeksema & Morrow, 1991), acceptable convergent validity (Butler & NolenHoeksema, 1994), and good test–retest reliability (Nolen-Hoeksema, Parker, & Larson, 1994). Additionally, the RRS demonstrated (α = .96) internal consistency in the present investigation. 2.3.1.3. Hoarding. Hoarding behaviors were assessed using the Saving Inventory-Revised (SIR; Frost, Steketee, & Grisham, 2004). The SIR is a 23-item self-report questionnaire assessing hoarding behaviors including acquiring, clutter, and difficulty discarding (Frost et al., 2004). Participants were asked to respond to each statement using a 5-point Likert scale ranging from 0 (none) to 4 (almost all/complete), with higher scores indicating increased frequency and severity of hoarding behaviors (Frost et al., 2004). The SIR has demonstrated strong internal consistency as well as good test–retest reliability (Coles, Frost, Heimberg, & Steketee, 2003; Frost et al., 2004). The SIR demonstrated excellent internal consistency in the present investigation (α = .93). 3. Results — study 1
2. Methods — study 1 3.1. Sample descriptives 2.1. Participants The sample consisted of 275 undergraduate individuals recruited from a large southern university. Participants were primarily female (65.8% female), with ages ranging from 17 to 24 (M = 18.87, SD = 1.7). Eighty-five percent of the individuals were Caucasian, 6.3% African American, 1.1% Hispanic, 2.6% Asian, and 5% Other (e.g., bi-racial).
2.2. Procedures Undergraduate students from the psychology research pool signed up for a computerized study titled “Behavior and Personality Study”. Upon arrival to the laboratory, participants gave informed consent and then completed a battery of self-report questionnaires administered on a computer. The entire study took approximately 60 to complete, after which participants were debriefed and dismissed. As compensation for their participation, each participant was given course credit. All procedures were approved by the university's institutional review board.
Table 1 contains the means, standard deviations, and zero-order correlations for all variables used in the current analyses. The mean SIR total score was comparable to those found in other reports utilizing non-clinical populations (Oglesby et al., 2013; Timpano, Buckner, Richey, Murphy, & Schmidt, 2009). However, the mean RRS total score was slightly lower than those found in other reports utilizing nonclinical undergraduate populations suggesting that the current sample
Table 1 Zero-order correlations, means, and standard deviations. 1 1. BDI-II 2. RRS 3. SIR
– .67⁎⁎⁎ .48⁎⁎⁎
2 – 46⁎⁎⁎
3
Mean
SD
–
8.23 35.64 21.56
7.65 12.72 9.88
BDI-II, Beck Depression Inventory-II — total score; RRS, Ruminative Response Scale — total score; SIR, Saving Inventory Revised — total score. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.
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was slightly below average with regard to ruminative responses (Roelofs et al., 2007). The mean general levels of depression total score (as measured by the BDI-II) were also comparable to those found in other reports utilizing non-clinical populations (Mitchell & Schmidt, 2014). Consistent with initial predictions, all correlations between the SIR total score, BDI-II, and RRS total scores were significant. 3.2. Primary analyses A hierarchical regression analysis was performed to assess the relationship between rumination (as measured by the RRS) and hoarding (as measured by the SIR), after controlling for general levels of depression (as measured by the BDI-II). Preliminary analyses indicated no threats or violations of normality, multicollinearity, or homoscedasticity. In the first step of the model, BDI-II scores were entered accounting for 23% of the variance in hoarding severity (F (1, 273) = 81.73, p b .001). In the second step of the model, RRS scores were added accounting for an additional 3.3% of the variance in hoarding severity (F Change = 12.30, p = .001). Consistent with initial predictions, findings revealed that after controlling for general levels of depression rumination significantly predicted hoarding severity (β = .24, t = 3.51, p = .001, sr2 = .03). 4. Methods — study 2 4.1. Participants The sample consisted of 106 individuals recruited from the community to participate in a randomized clinical trial investigating the effects of a computerized treatment targeting specific risk factors associated with PTSD, substance use, anxiety, and suicide. Participants were required to be 18 years of age or older, English speakers, and report elevated anxiety sensitivity cognitive concerns. Participants were excluded from the study if they were not stabilized on medication, posed an imminent threat to themselves or others, or if there was evidence of a current psychotic and/or bipolar-spectrum disorder. Gender was somewhat evenly distributed (55.5% female) with ages ranging from 18 to 87 (M = 41.03, SD = 17.71). The marital status of participants was as follows: 51.5% single, 16.8% married, 4% separated, 1% cohabitating, and 26.7% were divorced or widowed. Sixty-seven percent of the individuals were Caucasian, 20.8% African American, 4% Hispanic, 1% Asian, and 6.9% Other (e.g., bi-racial). The sample had primary diagnoses of the following: 34.7% anxiety, 16.8% trauma and stress-related, 15.9% mood, 4% obsessive–compulsive and related disorder, 3% substance-related, 5% other (e.g., Anorexia Nervosa), and 20.6% did not have a diagnosis. 4.2. Procedures Participants from the general community who expressed interest in treatment and/or research studies were considered for eligibility in the screening process. Those deemed eligible based on a brief phone screen were then brought into a university psychology clinic to complete a baseline appointment in which they signed an informed consent and completed a battery of self-report questionnaires. In addition, participants completed a semi-structured clinical interview for the DSM-IV-TR (SCID; First, Spitzer, Gibbon, & Williams, 1996). Upon completion of the baseline appointment, individuals were randomized to either a cognitive anxiety sensitivity treatment condition or a health information control condition (Schmidt, Capron, Raines, & Allan, 2014). Following the treatment session, participants also completed a one-month follow-up session in which they completed a battery of self-report questionnaires. The current report utilizes data collected at the baseline appointment only and has not been reported elsewhere. All study procedures were approved by the university's institutional review board.
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4.3. Measures 4.3.1. Self-report 4.3.1.1. Depression. Symptoms of depressed mood were assessed using all 21 items of the Beck Depression Inventory-II (BDI-II; Beck et al., 1988). See Study 1 for full description of the BDI-II. The BDI-II demonstrated excellent internal consistency in the present investigation (α = .92). 4.3.1.2. Rumination. Participants' tendency to ruminate during depressed mood was assessed using all 22 items from the Ruminative Response Scale (RRS; Nolen-Hoeksema & Morrow, 1991). See Study 1 for full description of the RRS. The RRS demonstrated excellent internal consistency in the present investigation (α = .94). 4.3.1.3. Hoarding. Hoarding behaviors were assessed using the Hoarding Rating Scale-Self-Report Version (HRS; Tolin, Frost, & Steketee, 2010). The HRS is a brief five-item questionnaire assessing for features of hoarding, including: clutter, difficulty discarding, acquisition, distress, and impairment. Participants were asked to respond to each item using a Likert-type rating scale from 0 (Not at All) to 8 (Extremely) indicating the extent to which these features were experienced. The HRS has demonstrated high internal consistency and reliability across time and context (Tolin et al., 2010). The HRS demonstrated excellent internal consistency in the present investigation (α = 90). 5. Results — study 2 5.1. Sample descriptives Table 2 contains the means, standard deviations, and zero-order correlations for all variables used in the current analyses. The mean BDI-II total score was somewhat higher than that found in other reports utilizing community samples (Medley, Capron, Korte, & Schmidt, 2013). However, the mean RRS total score is comparable to those found in other community samples (Joormann, Dkane, & Gotlib, 2006). In addition, the mean HRS total score was slightly higher than those found in other reports utilizing community populations (Tolin, Frost, Steketee, & Fitch, 2008) suggesting that the current sample was above average with regard to hoarding symptoms. Consistent with initial predictions all correlations between the HRS, BDI-II, and RRS total scores were significant. 5.2. Primary analyses A hierarchical regression analysis was performed to assess the relationship between rumination (as measured by the RRS) and hoarding (as measured by the HRS), after controlling for general levels of depression (as measured by the BDI-II). Preliminary analyses indicated no threats or violations of normality, multicollinearity, or homoscedasticity. In the first step of the model, BDI-II scores were entered accounting for 5.5% of the variance in hoarding severity (F (1, 99) = 5.73, p = .02). In the second step of the model, RRS scores were added accounting Table 2 Zero-order correlations, means, and standard deviations. 1 1. BDI-II 2. RRS 3. HRS
– .65⁎⁎⁎ .23⁎
2 – .32⁎⁎
3
Mean
SD
–
22.23 53.89 9.07
11.45 13.97 8.38
BDI-II, Beck Depression Inventory-II — total score; RRS, Ruminative Response Scale — total score; HRS, Hoarding Rating Scale — total score. ⁎⁎⁎ p b .001. ⁎⁎ p b .01. ⁎ p b .05.
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for an additional 10% of the variance in hoarding severity (F Change = 5.27, p = .02). Consistent with initial predictions, results revealed that after controlling for general levels of depression rumination significantly predicted hoarding severity (β = .29, t = 2.30, p = .02, sr2 = .05).
6. Discussion In line with initial hypotheses, we found that rumination was significantly associated with elevated levels of hoarding severity above and beyond the effects of depression, which are highly comorbid with both rumination and hoarding (Frost et al., 2011; Just & Alloy, 1997). These findings were consistent across both studies, which utilized two separate and reliable measures of hoarding behaviors as well as two independent samples (e.g., community and undergraduate student sample). The current investigation extended previous research on the relationships between rumination and various mood and anxiety related disorders (Edwards, Rapee, & Franklin, 2003; Nolen-Hoeksema, 2000) by establishing an association between repetitive negative thoughts and hoarding behaviors. Consistent with these findings, as well as contemporary theories of rumination, it appears that rumination may indeed act as a transdiagnostic risk factor across a wide range of psychopathology (Ehring & Watkins, 2008; McLaughlin & Nolen-Hoeksema, 2011). These findings add to a growing body of literature identifying risk factors important for the development and maintenance of hoarding behaviors (Timpano et al., 2009). For example, extant literature has found associations between various individual difference variables such as perceived control and intolerance of uncertainty and increased hoarding severity (Oglesby et al., 2013; Raines, Oglesby, Unruh, Capron, & Schmidt, 2014). In addition, several studies have found fairly robust associations between elevated levels of anxiety sensitivity and increased hoarding severity (Medley et al., 2013; Timpano et al., 2009). Similar to the way these cognitive risk factors operate, excessive rumination may be another factor contributing to increased hoarding symptoms. In particular, repetitive negative thoughts such as those associated with making a mistake while discarding may lead to increased avoidance of discarding and subsequent saving behaviors. The results of this study also fit within the larger framework of Frost and Hartl's (1996) cognitive behavioral model of hoarding. Within this framework, behavioral avoidance is conceptualized as a core component of hoarding that is closely linked to increased saving behaviors. In particular, it has been suggested that the act of saving is an avoidance behavior aimed at reducing feelings of anxiety and distress brought on by potentially losing a cherished possession (Steketee & Frost, 2003). Similar to the way rumination operates within other emotional distress disorders, increased negative cognitions about such tasks may be another factor leading to increased avoidance. That is, increased rumination regarding potentially making a mistake while discarding or being unable to find an item again in the future may lead one to avoid making a decision all together in an effort to circumvent the distress brought on by these maladaptive thoughts (Steketee & Frost, 2003). The present study's findings may have clinical implications for the treatment of hoarding disorder. Specifically, pending replication and extension of the current study, it may be beneficial for clinicians to assess and intervene on rumination as a way to augment cognitive behavioral treatment for hoarding disorder (Tolin, Frost, & Steketee, 2007). This may be particularly important as some researchers have suggested that excessive rumination interferes with traditional cognitive therapies (Haeffel, 2010). As such, clinicians may consider utilizing functional analytic techniques to assist clients in differentiating between thoughts that are helpful (e.g., concrete, specific problem solving) and unhelpful (e.g., abstract, evaluative repetitive negative thoughts), as well as to encourage clients to engage in adaptive behaviors (e.g., behavioral activation, relaxation, effective engagement in tasks) rather than maladaptive, rumination-associated behaviors (e.g., procrastination, avoidance; Watkins et al., 2007). These techniques could potentially be beneficial
for those with hoarding disorder and clinically significant rumination, and may help to increase the efficacy of hoarding disorder treatment. Results from the current study should be considered in the context of limitations and opportunities for future research. First, the current study relied on self-reported assessments of both rumination and symptoms of hoarding disorder. Although we used well-validated and widely used measures of these constructs, future research would benefit from incorporating other methods of assessment, such as clinical interview (e.g., Structured Interview for Hoarding Disorder; Nordsletten et al., 2013). Second, our measure of rumination was somewhat specific to rumination in response to a sad/low mood. Whereas we controlled for symptoms of depression to demonstrate an association between rumination and hoarding above and beyond depressive symptoms, future research should examine these associations using more general measures of rumination that may allow one to tap hoarding specificcognitive processes. In addition, future research should examine the contribution of rumination above and beyond other hoarding relevant cognitive risk factors such as perceived control and intolerance of uncertainty. Third, due to the cross-sectional nature of the study's design, we cannot make causal inferences regarding these findings. Future research should consider the use of prospective designs to further examine these findings and determine whether rumination is a risk factor for the development of hoarding disorder. Finally, the current sample was not composed of individuals with hoarding disorder. Symptoms of hoarding disorder are considered to be dimensional, and previous research has often utilized non-clinical samples to study correlates of hoarding disorder (Coles et al., 2003; Damecour & Charron, 1998; Timpano et al., 2009). Future research may use clinical samples of individuals with hoarding disorder to ensure these results generalize to that population. In summary, findings from the current investigation add to a growing body of literature identifying risk factors associated with hoarding behaviors (Oglesby et al., 2013; Raines et al., 2014). In addition, these findings add to the emerging research supporting rumination as a transdiagnostic risk factor across various anxiety and related disorders (Ehring & Watkins, 2008). Future research should attempt to replicate these results within clinical populations. Moreover, given the somewhat poor treatment outcomes associated with hoarding (Black et al., 1998), it will be important to determine if directly targeting rumination will increase treatment efficacy. Acknowledgments This work was supported by the Military Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award W81XWH-10-2-0181. Opinions, assertions, and recommendations are those of the authors and are not to be construed as official or as reflecting the views of the Department of Veterans Affairs or the Department of Defense. References Abbott, M. J., & Rapee, R. M. (2004). Post-event rumination and negative self-appraisal in social phobia before and after treatment. Journal of Abnormal Psychology, 113(1), 136. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the beck depression inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77–100 http://dx.doi.org/10.1016/0272-7358(88)90050-5. Black, D., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessive–compulsive disorder. Journal of Clinical Psychiatry, 59, 420–425. Butler, L. D., & Nolen-Hoeksema, S. (1994). Gender differences in responses to depressed mood in a college sample. Sex Roles, 30(5–6), 331–346. Coles, M. E., Frost, R., Heimberg, R. G., & Steketee, G. (2003). Hoarding behaviors in a large college sample. Behaviour Research and Therapy, 41(2), 179–194 http://dx.doi.org/10. 1016/s0005-7967(01)00136-x. Damecour, C., & Charron, M. (1998). Hoarding: a symptom, not a syndrome. The Journal of Clinical Psychiatry, 59(5), 267–272 (quiz 273). Edwards, S. L., Rapee, R. M., & Franklin, J. (2003). Postevent rumination and recall bias for a social performance event in high and low socially anxious individuals. Cognitive Therapy and Research, 27(6), 603–617.
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Cognitive processes in hoarding: The role of rumination Amberly K. Portero, Daphne A. Durmaz, Amanda M. Raines, Nicole A. Short, Norman B. Schmidt ⁎ Department of Psychology, Florida State University, 1107 W. Call St., Tallahassee, FL 32306-4301, USA
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Article history: Received 1 March 2015 Received in revised form 11 June 2015 Accepted 12 June 2015 Available online 27 June 2015 Keywords: Rumination Hoarding Cognitions Anxiety
a b s t r a c t Rumination, defined as an individual's repetitive negative cognitions of upsetting symptoms in response to distress, has been established as an important cognitive vulnerability factor within various forms of psychopathology. Despite compelling data to suggest that rumination is associated with a number of mood and anxiety-related conditions, no research to date has examined the relationship between rumination and hoarding. Participants consisted of 275 undergraduate students as well as 106 individuals recruited from the community to participate in a larger randomized clinical trial investigating the effects of a computerized treatment targeting specific risk factors associated with anxiety and suicide. Consistent with initial prediction, results indicated that rumination was a significant predictor of hoarding severity, even after controlling for overall general levels of depression. These findings add to a growing body of literature identifying various cognitive vulnerability factors important for the development and maintenance of hoarding. Increasing our knowledge of cognitive vulnerability factors has import implications for the prevention and treatment of anxiety disorders. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Maladaptive thoughts have been implicated as an important transdiagnostic risk factor for the development and maintenance of numerous psychiatric disorders (Ehring & Watkins, 2008; Harvey, Watkins, Mansell, & Shafran, 2004). Whereas thought content varies by disorder, Ehring and Watkins (2008) suggest that negative content and uncontrollability are common elements of this ideation. Rumination is one type of negative thinking that has been frequently implicated in the development of various forms of psychopathology (McLaughlin & Nolen-Hoeksema, 2011). Rumination is defined as the tendency to repetitively analyze one's problems, concerns, and feelings of distress without taking action to make positive changes (Nolen-Hoeksema, 1991; Watkins, 2008). In recent years, there has been increased interest in the relationship between rumination and various mood and anxiety-related disorders. For instance, rumination has been found to predict the development of depressive symptoms, as well as the onset and number of major depressive episodes (Nolen-Hoeksema, 1991). Rumination is also associated with symptoms of generalized anxiety disorder (GAD; Fresco, Frankel, Mennin, Turk, & Heimberg, 2002), posttraumatic stress disorder (PTSD; Ehlers & Clark, 2000), and social anxiety disorder (SAD; Abbott & Rapee, 2004). Furthermore, researchers have found a ruminative thinking style to be significantly associated with increased obsessive–compulsive (OC) symptoms, in particular obsessions, above and beyond the effects of depression (Wahl, Ertle, Bohne, Zurowski, & ⁎ Corresponding author. Tel.: +1 850 645 1766; fax: +1 850 644 7739. E-mail address: [email protected] (N.B. Schmidt).
http://dx.doi.org/10.1016/j.paid.2015.06.024 0191-8869/© 2015 Elsevier Ltd. All rights reserved.
Kordon, 2011). Within these conditions, rumination is thought to exacerbate disorder specific symptoms by increasing negative maladaptive thoughts, lowering problem solving abilities, and decreasing the likelihood that individuals will engage in more adaptive emotion regulation strategies, such as behavioral activation to improve one's mood (Lyubomirsky, Kasri, Chang, & Chung, 2006; Lyubomirsky & Nolen-Hoeksema, 1993). Despite evidence showing associations between rumination in various anxiety and mood-related conditions, potential relationships between rumination and hoarding disorder have yet to be examined. Hoarding is a complex clinical phenomenon involving the acquisition of and failure to discard large quantities of possessions resulting in incapacitating clutter (Frost & Hartl, 1996). Hoarding disorder affects approximately 2% to 6% of the population (American Psychiatric Association, 2013). Previous research suggests that hoarding is associated with marked role impairment in social, occupational, and family domains (Frost, Steketee, Williams, & Warren, 2000; Tolin, Frost, Steketee, Gray, & Fitch, 2008). At its most severe states, hoarding may also lead to significant health problems due to unsanitary living conditions, work disability, and even death (Frost, Steketee, & Williams, 2000). Hoarding was once thought to be a symptom or subtype of obsessive compulsive disorder (OCD). As such, the majority of hoarding research to date has primarily relied on patients presenting with OCD who also have co-occurring hoarding symptoms. However, recent research suggests that there may be more differences than similarities between the two disorders. Specifically, there is an increasing body of evidence suggesting distinct diagnostic features (Pertusa et al., 2010) and patterns of comorbidity (Pertusa et al., 2008) between OCD and hoarding. Moreover, hoarding has been observed in a number of other psychiatric
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conditions including major depressive disorder (MDD), GAD, and social phobia (Frost, Steketee, & Tolin, 2011). Therefore, hoarding disorder has been included as a discrete diagnostic entity within the 5th revision of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). In light of these nosological changes, research identifying potential risk factors for hoarding outside the context of OCD seems warranted. Despite the lack of research examining the associations between rumination and hoarding, it is theoretically plausible that rumination may play a role in hoarding behaviors. According to the cognitive model of hoarding, manifestations of hoarding (e.g., acquiring and saving) result from various avoidance behaviors aimed at circumventing the distress associated with making a wrong decision regarding a possession (Frost & Hartl, 1996). Repetitive negative thoughts such as those associated with making a mistake while discarding may lead to increased avoidance of discarding and increased saving behaviors. Indeed, research has shown that decision making of any kind is particularly difficult for hoarders because of the high degree of concern over making a mistake while discarding and the need for certainty (Frost & Hartl, 1996; Frost & Shows, 1993). Increased rumination about such tasks may lead to more maladaptive thoughts (e.g., regarding harmful consequences of throwing out a needed possession), less effective problem solving skills (e.g., I could find a suitable replacement if needed), and an inability to engage in constructive mood-lifting activities (e.g., behavioral activation) and instead engaging in maladaptive hoarding behaviors (e.g., increased saving as a means of comfort) resulting in gross disorganization and clutter. The primary aim of the current study was to examine the relationship between rumination and hoarding in large non-selected undergraduate sample (study 1) as well as a large non-selected community sample (study 2). Based on the extant literature establishing an association between rumination and various forms of psychopathology (Nolen-Hoeksema, 2000), we hypothesized that repetitive negative thinking would be associated with increased hoarding severity, even after controlling for symptoms of depression which have been found to be highly associated with rumination and hoarding behaviors (Frost et al., 2011; Just & Alloy, 1997).
2.3. Measures 2.3.1. Self-report 2.3.1.1. Depression. Depression symptoms were assessed using the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Carbin, 1988). The BDI-II is a 21-item self-report measure assessing various symptoms of depression. Respondents were asked to read a group of statements and select the statement that best described how they have felt over the past 2 weeks. The BDI-II is scored using a 4-point Likert scale ranging from 0 to 3, with higher scores reflecting more severe depressive symptoms. The BDI-II has demonstrated strong internal consistency and good test–retest reliability (Beck et al., 1988). Internal consistency in the present sample was excellent (α = .91). 2.3.1.2. Rumination. The Ruminative Responses Scale (RRS; NolenHoeksema & Morrow, 1991) is a 22-item measure administered to assess participants' tendencies to ruminate in response to distress. Respondents indicate how often they typically engage in each of the 22 ruminative thoughts or behaviors when feeling depressed, down, or sad using a 4-point Likert scale ranging from 1 (almost never) to 4 (almost always). The responses are self-focused, symptom-focused, and focused on possible consequences and causes of one's mood. The RRS has demonstrated strong internal consistency (Nolen-Hoeksema & Morrow, 1991), acceptable convergent validity (Butler & NolenHoeksema, 1994), and good test–retest reliability (Nolen-Hoeksema, Parker, & Larson, 1994). Additionally, the RRS demonstrated (α = .96) internal consistency in the present investigation. 2.3.1.3. Hoarding. Hoarding behaviors were assessed using the Saving Inventory-Revised (SIR; Frost, Steketee, & Grisham, 2004). The SIR is a 23-item self-report questionnaire assessing hoarding behaviors including acquiring, clutter, and difficulty discarding (Frost et al., 2004). Participants were asked to respond to each statement using a 5-point Likert scale ranging from 0 (none) to 4 (almost all/complete), with higher scores indicating increased frequency and severity of hoarding behaviors (Frost et al., 2004). The SIR has demonstrated strong internal consistency as well as good test–retest reliability (Coles, Frost, Heimberg, & Steketee, 2003; Frost et al., 2004). The SIR demonstrated excellent internal consistency in the present investigation (α = .93). 3. Results — study 1
2. Methods — study 1 3.1. Sample descriptives 2.1. Participants The sample consisted of 275 undergraduate individuals recruited from a large southern university. Participants were primarily female (65.8% female), with ages ranging from 17 to 24 (M = 18.87, SD = 1.7). Eighty-five percent of the individuals were Caucasian, 6.3% African American, 1.1% Hispanic, 2.6% Asian, and 5% Other (e.g., bi-racial).
2.2. Procedures Undergraduate students from the psychology research pool signed up for a computerized study titled “Behavior and Personality Study”. Upon arrival to the laboratory, participants gave informed consent and then completed a battery of self-report questionnaires administered on a computer. The entire study took approximately 60 to complete, after which participants were debriefed and dismissed. As compensation for their participation, each participant was given course credit. All procedures were approved by the university's institutional review board.
Table 1 contains the means, standard deviations, and zero-order correlations for all variables used in the current analyses. The mean SIR total score was comparable to those found in other reports utilizing non-clinical populations (Oglesby et al., 2013; Timpano, Buckner, Richey, Murphy, & Schmidt, 2009). However, the mean RRS total score was slightly lower than those found in other reports utilizing nonclinical undergraduate populations suggesting that the current sample
Table 1 Zero-order correlations, means, and standard deviations. 1 1. BDI-II 2. RRS 3. SIR
– .67⁎⁎⁎ .48⁎⁎⁎
2 – 46⁎⁎⁎
3
Mean
SD
–
8.23 35.64 21.56
7.65 12.72 9.88
BDI-II, Beck Depression Inventory-II — total score; RRS, Ruminative Response Scale — total score; SIR, Saving Inventory Revised — total score. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.
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was slightly below average with regard to ruminative responses (Roelofs et al., 2007). The mean general levels of depression total score (as measured by the BDI-II) were also comparable to those found in other reports utilizing non-clinical populations (Mitchell & Schmidt, 2014). Consistent with initial predictions, all correlations between the SIR total score, BDI-II, and RRS total scores were significant. 3.2. Primary analyses A hierarchical regression analysis was performed to assess the relationship between rumination (as measured by the RRS) and hoarding (as measured by the SIR), after controlling for general levels of depression (as measured by the BDI-II). Preliminary analyses indicated no threats or violations of normality, multicollinearity, or homoscedasticity. In the first step of the model, BDI-II scores were entered accounting for 23% of the variance in hoarding severity (F (1, 273) = 81.73, p b .001). In the second step of the model, RRS scores were added accounting for an additional 3.3% of the variance in hoarding severity (F Change = 12.30, p = .001). Consistent with initial predictions, findings revealed that after controlling for general levels of depression rumination significantly predicted hoarding severity (β = .24, t = 3.51, p = .001, sr2 = .03). 4. Methods — study 2 4.1. Participants The sample consisted of 106 individuals recruited from the community to participate in a randomized clinical trial investigating the effects of a computerized treatment targeting specific risk factors associated with PTSD, substance use, anxiety, and suicide. Participants were required to be 18 years of age or older, English speakers, and report elevated anxiety sensitivity cognitive concerns. Participants were excluded from the study if they were not stabilized on medication, posed an imminent threat to themselves or others, or if there was evidence of a current psychotic and/or bipolar-spectrum disorder. Gender was somewhat evenly distributed (55.5% female) with ages ranging from 18 to 87 (M = 41.03, SD = 17.71). The marital status of participants was as follows: 51.5% single, 16.8% married, 4% separated, 1% cohabitating, and 26.7% were divorced or widowed. Sixty-seven percent of the individuals were Caucasian, 20.8% African American, 4% Hispanic, 1% Asian, and 6.9% Other (e.g., bi-racial). The sample had primary diagnoses of the following: 34.7% anxiety, 16.8% trauma and stress-related, 15.9% mood, 4% obsessive–compulsive and related disorder, 3% substance-related, 5% other (e.g., Anorexia Nervosa), and 20.6% did not have a diagnosis. 4.2. Procedures Participants from the general community who expressed interest in treatment and/or research studies were considered for eligibility in the screening process. Those deemed eligible based on a brief phone screen were then brought into a university psychology clinic to complete a baseline appointment in which they signed an informed consent and completed a battery of self-report questionnaires. In addition, participants completed a semi-structured clinical interview for the DSM-IV-TR (SCID; First, Spitzer, Gibbon, & Williams, 1996). Upon completion of the baseline appointment, individuals were randomized to either a cognitive anxiety sensitivity treatment condition or a health information control condition (Schmidt, Capron, Raines, & Allan, 2014). Following the treatment session, participants also completed a one-month follow-up session in which they completed a battery of self-report questionnaires. The current report utilizes data collected at the baseline appointment only and has not been reported elsewhere. All study procedures were approved by the university's institutional review board.
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4.3. Measures 4.3.1. Self-report 4.3.1.1. Depression. Symptoms of depressed mood were assessed using all 21 items of the Beck Depression Inventory-II (BDI-II; Beck et al., 1988). See Study 1 for full description of the BDI-II. The BDI-II demonstrated excellent internal consistency in the present investigation (α = .92). 4.3.1.2. Rumination. Participants' tendency to ruminate during depressed mood was assessed using all 22 items from the Ruminative Response Scale (RRS; Nolen-Hoeksema & Morrow, 1991). See Study 1 for full description of the RRS. The RRS demonstrated excellent internal consistency in the present investigation (α = .94). 4.3.1.3. Hoarding. Hoarding behaviors were assessed using the Hoarding Rating Scale-Self-Report Version (HRS; Tolin, Frost, & Steketee, 2010). The HRS is a brief five-item questionnaire assessing for features of hoarding, including: clutter, difficulty discarding, acquisition, distress, and impairment. Participants were asked to respond to each item using a Likert-type rating scale from 0 (Not at All) to 8 (Extremely) indicating the extent to which these features were experienced. The HRS has demonstrated high internal consistency and reliability across time and context (Tolin et al., 2010). The HRS demonstrated excellent internal consistency in the present investigation (α = 90). 5. Results — study 2 5.1. Sample descriptives Table 2 contains the means, standard deviations, and zero-order correlations for all variables used in the current analyses. The mean BDI-II total score was somewhat higher than that found in other reports utilizing community samples (Medley, Capron, Korte, & Schmidt, 2013). However, the mean RRS total score is comparable to those found in other community samples (Joormann, Dkane, & Gotlib, 2006). In addition, the mean HRS total score was slightly higher than those found in other reports utilizing community populations (Tolin, Frost, Steketee, & Fitch, 2008) suggesting that the current sample was above average with regard to hoarding symptoms. Consistent with initial predictions all correlations between the HRS, BDI-II, and RRS total scores were significant. 5.2. Primary analyses A hierarchical regression analysis was performed to assess the relationship between rumination (as measured by the RRS) and hoarding (as measured by the HRS), after controlling for general levels of depression (as measured by the BDI-II). Preliminary analyses indicated no threats or violations of normality, multicollinearity, or homoscedasticity. In the first step of the model, BDI-II scores were entered accounting for 5.5% of the variance in hoarding severity (F (1, 99) = 5.73, p = .02). In the second step of the model, RRS scores were added accounting Table 2 Zero-order correlations, means, and standard deviations. 1 1. BDI-II 2. RRS 3. HRS
– .65⁎⁎⁎ .23⁎
2 – .32⁎⁎
3
Mean
SD
–
22.23 53.89 9.07
11.45 13.97 8.38
BDI-II, Beck Depression Inventory-II — total score; RRS, Ruminative Response Scale — total score; HRS, Hoarding Rating Scale — total score. ⁎⁎⁎ p b .001. ⁎⁎ p b .01. ⁎ p b .05.
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for an additional 10% of the variance in hoarding severity (F Change = 5.27, p = .02). Consistent with initial predictions, results revealed that after controlling for general levels of depression rumination significantly predicted hoarding severity (β = .29, t = 2.30, p = .02, sr2 = .05).
6. Discussion In line with initial hypotheses, we found that rumination was significantly associated with elevated levels of hoarding severity above and beyond the effects of depression, which are highly comorbid with both rumination and hoarding (Frost et al., 2011; Just & Alloy, 1997). These findings were consistent across both studies, which utilized two separate and reliable measures of hoarding behaviors as well as two independent samples (e.g., community and undergraduate student sample). The current investigation extended previous research on the relationships between rumination and various mood and anxiety related disorders (Edwards, Rapee, & Franklin, 2003; Nolen-Hoeksema, 2000) by establishing an association between repetitive negative thoughts and hoarding behaviors. Consistent with these findings, as well as contemporary theories of rumination, it appears that rumination may indeed act as a transdiagnostic risk factor across a wide range of psychopathology (Ehring & Watkins, 2008; McLaughlin & Nolen-Hoeksema, 2011). These findings add to a growing body of literature identifying risk factors important for the development and maintenance of hoarding behaviors (Timpano et al., 2009). For example, extant literature has found associations between various individual difference variables such as perceived control and intolerance of uncertainty and increased hoarding severity (Oglesby et al., 2013; Raines, Oglesby, Unruh, Capron, & Schmidt, 2014). In addition, several studies have found fairly robust associations between elevated levels of anxiety sensitivity and increased hoarding severity (Medley et al., 2013; Timpano et al., 2009). Similar to the way these cognitive risk factors operate, excessive rumination may be another factor contributing to increased hoarding symptoms. In particular, repetitive negative thoughts such as those associated with making a mistake while discarding may lead to increased avoidance of discarding and subsequent saving behaviors. The results of this study also fit within the larger framework of Frost and Hartl's (1996) cognitive behavioral model of hoarding. Within this framework, behavioral avoidance is conceptualized as a core component of hoarding that is closely linked to increased saving behaviors. In particular, it has been suggested that the act of saving is an avoidance behavior aimed at reducing feelings of anxiety and distress brought on by potentially losing a cherished possession (Steketee & Frost, 2003). Similar to the way rumination operates within other emotional distress disorders, increased negative cognitions about such tasks may be another factor leading to increased avoidance. That is, increased rumination regarding potentially making a mistake while discarding or being unable to find an item again in the future may lead one to avoid making a decision all together in an effort to circumvent the distress brought on by these maladaptive thoughts (Steketee & Frost, 2003). The present study's findings may have clinical implications for the treatment of hoarding disorder. Specifically, pending replication and extension of the current study, it may be beneficial for clinicians to assess and intervene on rumination as a way to augment cognitive behavioral treatment for hoarding disorder (Tolin, Frost, & Steketee, 2007). This may be particularly important as some researchers have suggested that excessive rumination interferes with traditional cognitive therapies (Haeffel, 2010). As such, clinicians may consider utilizing functional analytic techniques to assist clients in differentiating between thoughts that are helpful (e.g., concrete, specific problem solving) and unhelpful (e.g., abstract, evaluative repetitive negative thoughts), as well as to encourage clients to engage in adaptive behaviors (e.g., behavioral activation, relaxation, effective engagement in tasks) rather than maladaptive, rumination-associated behaviors (e.g., procrastination, avoidance; Watkins et al., 2007). These techniques could potentially be beneficial
for those with hoarding disorder and clinically significant rumination, and may help to increase the efficacy of hoarding disorder treatment. Results from the current study should be considered in the context of limitations and opportunities for future research. First, the current study relied on self-reported assessments of both rumination and symptoms of hoarding disorder. Although we used well-validated and widely used measures of these constructs, future research would benefit from incorporating other methods of assessment, such as clinical interview (e.g., Structured Interview for Hoarding Disorder; Nordsletten et al., 2013). Second, our measure of rumination was somewhat specific to rumination in response to a sad/low mood. Whereas we controlled for symptoms of depression to demonstrate an association between rumination and hoarding above and beyond depressive symptoms, future research should examine these associations using more general measures of rumination that may allow one to tap hoarding specificcognitive processes. In addition, future research should examine the contribution of rumination above and beyond other hoarding relevant cognitive risk factors such as perceived control and intolerance of uncertainty. Third, due to the cross-sectional nature of the study's design, we cannot make causal inferences regarding these findings. Future research should consider the use of prospective designs to further examine these findings and determine whether rumination is a risk factor for the development of hoarding disorder. Finally, the current sample was not composed of individuals with hoarding disorder. Symptoms of hoarding disorder are considered to be dimensional, and previous research has often utilized non-clinical samples to study correlates of hoarding disorder (Coles et al., 2003; Damecour & Charron, 1998; Timpano et al., 2009). Future research may use clinical samples of individuals with hoarding disorder to ensure these results generalize to that population. In summary, findings from the current investigation add to a growing body of literature identifying risk factors associated with hoarding behaviors (Oglesby et al., 2013; Raines et al., 2014). In addition, these findings add to the emerging research supporting rumination as a transdiagnostic risk factor across various anxiety and related disorders (Ehring & Watkins, 2008). Future research should attempt to replicate these results within clinical populations. Moreover, given the somewhat poor treatment outcomes associated with hoarding (Black et al., 1998), it will be important to determine if directly targeting rumination will increase treatment efficacy. Acknowledgments This work was supported by the Military Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award W81XWH-10-2-0181. Opinions, assertions, and recommendations are those of the authors and are not to be construed as official or as reflecting the views of the Department of Veterans Affairs or the Department of Defense. References Abbott, M. J., & Rapee, R. M. (2004). Post-event rumination and negative self-appraisal in social phobia before and after treatment. Journal of Abnormal Psychology, 113(1), 136. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the beck depression inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77–100 http://dx.doi.org/10.1016/0272-7358(88)90050-5. Black, D., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessive–compulsive disorder. Journal of Clinical Psychiatry, 59, 420–425. Butler, L. D., & Nolen-Hoeksema, S. (1994). Gender differences in responses to depressed mood in a college sample. Sex Roles, 30(5–6), 331–346. Coles, M. E., Frost, R., Heimberg, R. G., & Steketee, G. (2003). Hoarding behaviors in a large college sample. Behaviour Research and Therapy, 41(2), 179–194 http://dx.doi.org/10. 1016/s0005-7967(01)00136-x. Damecour, C., & Charron, M. (1998). Hoarding: a symptom, not a syndrome. The Journal of Clinical Psychiatry, 59(5), 267–272 (quiz 273). Edwards, S. L., Rapee, R. M., & Franklin, J. (2003). Postevent rumination and recall bias for a social performance event in high and low socially anxious individuals. Cognitive Therapy and Research, 27(6), 603–617.
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