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Perceived decision-making styles among individuals with obsessive-compulsive and hoarding disorders
Journal of Obsessive-Compulsive and Related Disorders 23 (2019) 100472
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Perceived decision-making styles among individuals with obsessivecompulsive and hoarding disorders
T
Jedidiah Sieva,∗, Keith Litb, Yan Leykinc a
Swarthmore College, Department of Psychology, 500 College Ave, Swarthmore, PA, 19081, USA Jackson Health System, 1695 NW 9th Ave, Miami, FL, 33136, USA c Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Obsessive-compulsive disorder Hoarding disorder Decision-making Indecisiveness
Individuals with obsessive-compulsive disorder (OCD) and hoarding disorder (HD) struggle with decisionmaking. One potentially important aspect of decision-making that has yet to be studied in relation to OCD and HD is decision-making style, a trait-like pattern of responding that is relatively stable across a variety of decisionmaking situations. The aim of the present study was to investigate the extent to which people with OCD and/or HD report specific decision-making styles and low levels of decisional self-esteem. Participants who self-identified as having OCD (n = 30), HD (n = 19), both OCD and HD (n = 33), or neither (n = 78) completed a measure of how they make important decisions, as well as symptom measures. Compared to controls, individuals with OCD and/or HD perceived themselves to be less confident and respected decision-makers, avoid decisionmaking and brood about making bad decisions more, and rely less on intuition when making decisions. Compared to those with HD, individuals with OCD reported being more anxious and dependent on others and less spontaneous when making decisions. Future research should examine whether these decision-making styles lead to maladaptive decision-making outcomes, their role vis-à-vis the maintenance of symptoms, and the mechanisms for these tendencies.
1. Introduction Obsessive-compulsive (OC) spectrum disorders are characterized by repetitive, ritualistic behaviors and obsessional or recurrent thoughts, urges, and sensations. Obsessive-compulsive disorder (OCD) and hoarding disorder (HD) are two OC spectrum disorders that have a number of shared and unique features. For example, both compulsions in OCD and saving in HD are maintained by reductions in distress, but the pleasurable feelings generated by acquisition behaviors in HD generally have no corollary in OCD (Mataix-Cols et al., 2010). Similarly, recurrent thoughts feature prominently in both disorders, but whereas these thoughts are experienced as intrusive or unwanted in OCD, they are mostly experienced as part of the normal flow of thoughts in HD (Mataix-Cols et al., 2010). Identifying these types of shared and distinct features helps to increase understanding of these specific disorders and of the OC spectrum in general, and may ultimately contribute to efforts to develop treatment approaches that can be tailored for specific clinical presentations. Abnormal decision-making is one particular area of overlap between OCD and HD. In clinical settings, patients with OCD struggle with
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indecisiveness, slow decision-making, excessive doubt and distress when faced with decisions, and maladaptive decisions that result in high costs for minimal benefits (e.g., Dunne & Llamas, 1998; Volans, 1976). For example, a person with contamination fears might spend several minutes anxiously trying to decide whether or not to touch a doorknob, closely inspecting it to estimate potential dangers, and ultimately choosing not to touch it because of some imagined harm, thereby sacrificing likely rewards on the other side of the door. HD is similarly characterized clinically by excessive indecisiveness, avoidance of decisions about discarding and organizing, and decisions to save possessions despite negative consequences (e.g., Timpano, Shaw, Yang, & Çek, 2014). A person with HD might spend a long time anxiously mulling over a decision to throw away a bag of trash, ruminating about the possibility of needing some discarded item in the future, and eventually deciding to save the entire bag of trash even though it contributes to clutter. Empirical evidence of decision-making deficits in OCD and HD has been found in clinical, experimental, neuropsychological, and neurobiological research. Investigations using self-report measures show that both OCD and HD are associated with decisional procrastination or
Corresponding author. E-mail addresses: [email protected] (J. Siev), [email protected] (K. Lit), [email protected] (Y. Leykin).
https://doi.org/10.1016/j.jocrd.2019.100472 Received 1 April 2019; Received in revised form 16 August 2019; Accepted 20 August 2019 Available online 21 August 2019 2211-3649/ © 2019 Elsevier Inc. All rights reserved.
Journal of Obsessive-Compulsive and Related Disorders 23 (2019) 100472
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making style, leading to both overlapping and competing conceptualizations of specific styles. For example, whereas the Decision Making Style Inventory (DMI; Nygren, 2000) includes three styles (analytical, intuitive, and regret-avoidant), the General DecisionMaking Style (GDMS; Scott & Bruce, 1995) includes five styles (rational, avoidant, dependent, intuitive, and spontaneous). In order to consolidate and refine these various constructs, Leykin and DeRubeis (2010) performed a factor analysis on 50 items taken from three existing measures (Mann, 1982; Schwartz et al., 2002; Scott & Bruce, 1995), as well as thirty-four new items developed specifically for their study. Their data best fit a 9-factor solution, including seven decisional styles (spontaneous, dependent, vigilant, avoidant, brooding, intuitive, and anxious) and two decisional self-esteem factors (confident and respected). Leykin and DeRubeis (2010) then assessed the relationships between these nine factors and depressive symptoms, and found that depression related significantly with six of the seven decision-making styles. Specifically, more depressed people were more likely to display dependent, avoidant, brooding, and anxious decision-making styles, and less likely to display vigilant and intuitive styles (Leykin & DeRubeis, 2010). Additionally, they found that more depressed people perceived themselves as less confident and less respected decisionmakers. To date, these decision-making styles have not been investigated in individuals with specific clinical disorders other than mood disorders. However, given the evidence of abnormal decision-making in OCD and HD, it seems likely that decision-making style plays a role in these conditions. Furthermore, because of the overlap and distinction between these two disorders, some styles are likely to characterize both OCD and HD while others may be evident in one disorder but not the other. For example, one might expect that both OCD and HD would be associated with avoidant, vigilant, and less intuitive decision-making, as well as poor decisional self-esteem. Similarly, considering that OCD is characterized by obsessing and HD is associated with ruminating (Portero, Durmaz, Raines, Short, & Schmidt, 2015), individuals with OCD and HD may both brood when making important decisions. In contrast, OCD more closely resembles anxiety disorders than most OC spectrum disorders (Abramowitz, 2018), and one would specifically expect individuals with OCD to endorse anxious decision-making. Notwithstanding their tendency to be indecisive, individuals with HD are also impulsive – e.g., in response to negative affect (Timpano et al., 2013) – and might therefore report spontaneous decision-making, although there is evidence individuals with OCD can also be impulsive (e.g., Grassi et al., 2015). Finally, we had competing hypotheses about dependent decision-making. On the one hand, HD is more strongly related to dependent personality symptoms than is OCD (e.g. Frost, Steketee, Williams, & Warren, 2000), although individuals with OCD also have elevations in dependent personality traits (Torres et al., 2006). On the other hand, individuals with OCD rely more on feedback from others when making decisions (Sarig et al., 2012), and this may reflect a broader tendency to use proxies because those with OCD cannot access, or do not trust, their internal states (e.g., Lazarov, Dar, Oded, & Liberman, 2010; Liberman & Dar, 2018). In fact, recent research in non-clinical samples demonstrates that this reliance on external proxies may partially explain the relationship between OC symptoms and use of a maximizing decision-making strategy (Oren, Dar, & Liberman, 2018). Although decision-making patterns may be evident especially for disorder-related decisions, they are likely well-practiced and may function as default or automated decision styles that could influence life – and even treatment – decisions without an individual's awareness. Understanding how people with OCD and HD make important decisions may allow clinicians to help them become aware of these patterns and make better choices. With the aforementioned predictions in mind, the aim of the present study was to investigate the extent to which people with OCD and/or HD report specific decision-making styles and aspects of decisional self-esteem, and to compare the decisional styles of
indecisiveness (e.g. Ferrari & McCown, 1994; Fitch & Cougle, 2013; Frost & Gross, 1993; Frost & Shows, 1993; Grisham, Norberg, Williams, Certoma, & Kadib, 2010). Additionally, self-reports show that people with OCD are less confident in their decision-making abilities (Nedeljkovic & Kyrios, 2007), and that people who hoard tend to delay decisions, feel regret after making decisions, and report more fears about – and less positive attitudes toward – decision-making (Fitch & Cougle, 2013; Frost, Tolin, Steketee, & Oh, 2011; Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Kyrios et al., 2018; Steketee, Frost, & Kyrios, 2003; Tolin & Villavicencio, 2011; Wincze, Steketee, & Frost, 2007). In studies employing laboratory decision-making tasks, people with OCD and people with HD are slower to make decisions and report greater distress about decisions when compared to clinical and healthy controls (Foa et al., 2003; Grisham et al., 2010; Luchian, McNally, & Hooley, 2007; Tolin, Kiehl, Worhunsky, Book, & Maltby, 2009; Wincze et al., 2007). Individuals with OCD also require more information, use poorer quality information when making decisions, and make more errors in probabilistic judgments than controls in laboratory tasks (Banca et al., 2015; Fear & Healy, 1997; Foa et al., 2003; Pélissier & O'Connor, 2002; Sarig, Dar, & Liberman, 2012). During laboratory discarding tasks, hoarding participants decide to keep more items than OCD participants and healthy controls, though this effect may be specific to their own possessions (Grisham et al., 2010; Luchian et al., 2007; Tolin et al., 2009; Wincze et al., 2007). These self-report and performance-based measures of decision-making deficits are consistent with the findings of functional neuroimaging studies, which show that activation levels in brain regions that are implicated in affective decision-making differ between people with OCD and HD compared to healthy controls, and compared to each other (Sachdev & Malhi, 2005; Tolin et al., 2009, 2012). That some of these effects may be specific to personal possessions also suggests the possibility that personally relevant decision-making may be different from laboratory decisions. In addition, several recent studies have investigated performance of individuals with OCD or HD on behavioral economics decision-making tasks that are not specific to OCD or HD concerns and symptom domains (e.g., Aranovich, Cavagnaro, Pitt, Myung, & Mathews, 2017; Pushkarskaya, Tolin, Henick, Levy, & Pittenger, 2018; Pushkarskaya et al., 2017; Pushkarskaya et al., 2015). There are inconsistencies in the results of these studies (cf. Aranovich et al., 2017; Pushkarskaya et al., 2015), which are difficult to interpret considering differences in specific tasks used. Furthermore, these behavioral economics tasks test particular decisions such as when making (theoretical) gambles to win money; not only might they not be relevant to OCD or HD concerns, but they do not necessarily reflect styles of making important decisions in life more broadly, even outside the realm of psychopathology. Therefore, one potentially important aspect of decision-making that has yet to be studied in relation to OCD and HD is overall decision-making style. Decision-making styles are conceptualized as stable, trait-like approaches to decision-making, which may include ways an individual gathers and processes information, considers alternatives, and ultimately makes choices (Driver, 1979; Harren, 1979; Scott & Bruce, 1995). Early research on decision styles originated outside of clinical psychology. More recently, however, researchers began to study decision styles in the context of psychopathology (Alexander, Oliver, Burdine, Tang, & Dunlop, 2017; Bavolar & Bacikova-Sleskova, 2018; Bavolar & Orosova, 2015; Di Schiena, Luminet, Chang, & Philippot, 2013; Leykin & DeRubeis, 2010), finding relationships between decision styles and mental health. Although decision styles are conceptualized as traits, or cognitive styles (Hunt, Krzystofiak, Meindl, & Yousry, 1989; Janis & Mann, 1977), which make them more akin to personality characteristics rather than symptoms of disorders, it is possible that certain disorders increase the likelihood of an individual using a particular style of set of styles or that decision styles increase vulnerability to certain disorders. Several researchers have developed measures to assess decision2
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sample, internal consistency for DOCS total score was α = .96 and αs = .93–.96 for subscale scores. Obsessive-Compulsive Inventory – Revised (OCI-R; Foa, Huppert, Leiberg, Langner, Kichic, Hajcak, et al., 2002). The OCI-R is an 18-item self-report measure of distress associated with OCD symptoms. Six domains of common symptomatology are assessed: (a) washing, (b) checking/doubting, (c) obsessing, (d) mental neutralizing, (e) ordering, and (f) hoarding (Foa et al., 2002). Participants use a five-point scale ranging from 0 (not at all) to 4 (extremely) to rate how much they have been distressed or bothered by each symptom, yielding six subscale scores and a total score. The OCI-R has consistently demonstrated a stable factor structure, adequate indices of reliability and convergent validity, and good sensitivity and specificity in identifying individuals with OCD (Abramowitz & Deacon, 2006; Foa et al., 2002; Hajcak, Huppert, Simons, & Foa, 2004; Huppert et al., 2007). In the present sample, we scored the OCI-R without the three hoarding items, and internal consistency was α = .92. Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is a 9-item self-report measure of depression symptom severity. Participants use a 4-point scale ranging from 0 (not at all) to 3 (nearly every day) to rate the frequency of each symptom of a major depressive episode. The PHQ-9 has been validated in medical, psychiatric, and general populations and has demonstrated adequate to good internal consistency, good convergent and discriminant validity, and good sensitivity and specificity (Beard, Hsu, Rifkin, Busch, & Björgvinsson, 2016; Kroenke, Spitzer, Williams, & Löwe, 2010). Internal consistency for the present sample was α = .90.
individuals with the two disorders to each other, as well as to the decisional styles of healthy controls. 2. Method 2.1. Participants Clinical participants (n = 82) were recruited through listservs for individuals who hoard and through the International OCD Foundation website. These participants reported diagnoses of OCD (n = 30), HD (n = 19), or both OCD and HD (n = 33). Control participants (n = 78) without OCD or HD diagnoses were recruited from a university campus and via social media. For the entire sample, ages ranged from 18 to 78 (M = 35.40, SD = 16.74). Participants were mostly women (74%), White (89%), non-Hispanic (85%), and had at least some college education (92%). Demographic characteristics by group are provided in Table 1. 2.2. Measures Decision Styles Questionnaire (DSQ; Leykin & DeRubeis, 2010). The DSQ is a 43-item self-report measure of decision-making style. Participants use a five-point scale ranging from 1 (never) to 5 (always) to rate the extent to which items match their style of making important decisions. Seven subscales correspond to decision-making styles (a representative item is included in parentheses): 1. Intuitive (e.g., “When I make a decision, I trust my inner feelings and reactions”) 2. Spontaneous (e.g., “I make impulsive decisions”) 3. Vigilant (e.g., I like to consider all the alternatives”) 4. Dependent (e.g., “I need the assistance of other people when making important decisions”) 5. Anxious (e.g., “I feel very anxious when I need to make a decision”) 6. Brooding (e.g., “I think about all the bad decisions I have made in my life”) 7. Avoidant (e.g., “I postpone decision-making whenever possible”)
2.3. Data analytic strategy Missing data were imputed by calculating the scale (OCI-R, PHQ-9) or subscale (DSQ, SI-R, DOCS) average score provided no more than 20% of items were missing. The threshold of 20% was chosen to allow for computation of 5-item scales with 1 missing item; however, there were no participants with less than 20% and more than 1 item missing on any (sub)scales. Therefore, no data were imputed for any scale or subscale with more than one item missing. We first examined whether the OCD and HD groups differed on each DSQ scale without controlling for any other variable. For DSQ scales on which the OCD and HD groups differed, that group comparison was treated as the primary analysis of interest. When the OCD and HD groups did not differ on a DSQ scale, they were combined with the comorbid OCD/HD group into a single clinical OCD and/or HD group and compared with the control group on that scale. Because depression symptoms are associated with most DSQ scales (Leykin & DeRubeis, 2010), all analyses were conducted controlling for depression symptoms (PHQ-9) except for those initially identifying whether to combine the OCD and HD groups. Miller and Chapman (2001) note that it is improper to covary a baseline factor that differs between groups and is correlated with an independent variable of interest because doing so removes variance associated with the independent variable of interest (e.g., diagnostic group and symptoms) as well as the covariate (e.g., demographic variable). Consistent with their recommendations, we did not covary demographic characteristics.1
Two additional subscales correspond to decisional self-esteem: 1. Confident (e.g., “I think I am a good decision maker”) 2. Respected (e.g., “Others seek my help in making their decisions”). Internal consistency of these subscales ranged from αs = .72–93 in the present sample. Saving Inventory – Revised (SI-R; Frost, Steketee, & Grisham, 2004). The SI-R is 23-item self-report measure of hoarding symptoms. Subscales include (a) clutter, (b) difficulty discarding, and (c) acquisition. The SI-R has demonstrated good internal consistency and testretest reliability, as well as convergent and discriminant validity in clinical samples (Frost et al., 2004). Internal consistency in the current sample was α = .97 for the total score and αs = .81–.98 for the subscales. Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz et al., 2010). The DOCS is a 20-item self-report measure that assesses multiple parameters of OCD symptom severity including the frequency and duration of obsessions and compulsions, distress, avoidance, and functional interference (Abramowitz et al., 2010). Using a five-point scale ranging from 0 (none/not at all) to 4 (extreme/severe), participants rate symptoms of the four most common OCD dimensions including (a) contamination and washing, (b) responsibility and checking, (c) unacceptable thoughts, and (d) symmetry. Psychometric analyses of the DOCS have found a consistent factor structure, good to excellent internal consistency, moderate test-retest reliability, and good convergent and discriminant validity (Abramowitz et al., 2010; Thibodeau, Leonard, Abramowitz, & Riemann, 2015). In the present
1 The groups differed in age, F (3, 147) = 61.10, p < .001, and post-hoc LSD analyses indicated that each group differed significantly from every other group. To elucidate this potential confound, we examined the relationships between age and each DSQ scale separately within each group. Age was not correlated with any DSQ scale within the hoarding, combined hoarding/OCD, and control groups, and was associated with only one of nine scales within the OCD group. Considering that age predicted only 1/36 of outcomes of interest and there is no theoretical reason to expect otherwise, we conclude that it is unlikely that differences in age account for differences in perceived decisionmaking between clinical groups. Gender, ethnicity, and race all differed between the groups, as well, X2s (3) > 13, p ≤ .005. In all three cases, the control
3
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Table 1 Clinical measures and demographic characteristics by group (M [SD] and percentages).
SI-R DOCS OCI-R PHQ-9 Age Gender (% women) Ethnicity (% Hispanic/Latino) Race (% White/Caucasian) Education (% with at least some college)
OCD (n = 30)
Hoarding (n = 19)
Hoarding & OCD (n = 33)
Control (n = 78)
p-value
22.98 (15.11)a 27.58 (11.36)a 24.97 (10.47)a 9.74 (5.55)a 33.76 (11.50) 83% 4% 93% 93%
58.51 (15.50)b 6.81 (6.59)b 9.31 (5.66)b 8.06 (4.28)a 58.03 (5.87) 95% 0% 100% 100%
64.94 26.81 20.26 13.33 48.01 88% 3% 100% 94%
12.82 (12.49)c 7.04 (7.29)b 6.66 (7.20)b 3.99 (4.13)c 24.72 (9.85) 59% 28% 80% 88%
< .001 < .001 < .001 < .001
(17.16)b (17.61)a (12.21)c (6.99)b (15.76)
Note. SI-R = Saving Inventory – Revised; DOCS = Dimensional Obsessive-Compulsive Scale; OCI-R = Obsessive-Compulsive Inventory – Revised (without the hoarding items); PHQ = Patient Health Questionnaire – 9. Values with different subscript letters differ significantly per LSD post-hoc or X2 tests.
3. Results
Table 2 Decision Styles Questionnaire scores by group (M [SD]).
3.1. Preliminary analyses
DSQ Scale
Means and standard deviations on symptom measures by group are presented in Table 1 and are consistent with self-reported diagnostic status. The means for all clinical groups on the SI-R, DOCS, and OCI-R, were similar to the normative data for those clinical groups (Abramowitz et al., 2010; Foa et al., 2002; Frost et al., 2004). Means and standard deviations for all DSQ scales for each group are presented in Table 2.
OCD (n = 30)
Decision-making style: Intuitive 3.08 (0.48) Spontaneous 2.43 (0.67) Vigilant 4.07 (0.63) Dependent 3.85 (0.62) Anxious 3.93 (0.58) Brooding 3.42 (0.71) Avoidant 3.41 (0.90) Decisional self-esteem: Confident 2.99 (0.61) Respected 3.10 (0.69)
3.2. OCD versus HD The OCD and HD groups differed significantly from each other on three DSQ scales: Dependent, Anxious, and Spontaneous. Specifically, compared to the HD group, the OCD group reported being more dependent (F [1, 44] = 18.36, p < .001, ηp2 = .29) and more anxious (F [1, 44] = 4.98, p = .03, ηp2 = .10) when making important decisions. In contrast, the OCD group reported being less spontaneous than the HD group, although this difference was a trend after controlling for depression (F [1, 41] = 3.62, p = .06, ηp2 = .08). Although there was a trend to suggest that the OCD group was more vigilant than the HD group (p = .07), this was no longer the case when controlling for depression (F [1, 44] = 2.56, p = .12, ηp2 = .06). See Fig. 1.
Hoarding (n = 19)
Hoarding & OCD (n = 33)
Control (n = 78)
3.27 2.82 3.74 3.14 3.48 3.20 3.62
3.17 2.74 3.70 3.42 4.00 3.49 3.85
3.38 2.75 3.97 3.34 2.67 2.65 2.43
(0.46) (0.52) (0.57) (0.60) (0.57) (0.71) (0.51)
2.98 (0.75) 2.82 (0.58)
(0.66) (0.81) (0.67) (0.71) (0.60) (0.70) (0.81)
2.75 (0.69) 3.17 (0.88)
(0.63) (0.70) (0.53) (0.54) (0.68) (0.57) (0.67)
3.99 (0.51) 3.60 (0.65)
Note. DSQ = Decision Styles Questionnaire.
ηp2 = .23) and brooding (F [1, 153] = 12.41, p = .001, ηp2 = .08) when making important decisions. In terms of decisional self-esteem, they were also less confident (F [1, 152] = 63.30, p < .001, ηp2 = .29) and perceived themselves to be less respected (F [1, 150] = 7.61, p = .007, ηp2 = .05). Although the clinical group was less intuitive than the control group (p = .02), this was no longer significant when controlling for depression (F [1, 153] = 2.45, p = .12, ηp2 = .02). See Fig. 2. 4. Discussion
3.3. OCD/HD versus control
The purpose of this study was to understand the common and disorder-specific decision-making styles of individuals with self-identified OCD and HD, as well as to compare those to styles of individuals who do not have either disorder. Using a measure assessing seven distinct decisional styles and two aspects of decisional self-esteem, we found both differences between disorders as well as differences between clinical and healthy participants. Compared to healthy controls, clinical groups reported their style of decision-making as more avoidant, and they tended to brood over their decisions. They further reported having low opinions of their decisionmaking abilities, and believed that this opinion was shared by others. Perhaps not surprisingly, given their low decisional self-esteem, clinical groups tended to rely less on their intuition than did healthy controls when making choices. In many ways, these findings suggest considerable insight for individuals with OCD and/or HD. Indeed, past research identified indecisiveness and decisional procrastination as features of the overall cognitive processes of both disorders (e.g., Ferrari & McCown, 1994; Fitch & Cougle, 2013; Frost & Gross, 1993; Frost & Shows, 1993; Grisham et al., 2010), and it appears that individuals readily acknowledge their decision-making difficulties. There is evidence that decisions of individuals with OCD and HD are poorer both in terms of information processing as well as the outcomes of decisions (e.g., Fear & Healy, 1997; Foa et al., 2003; Pélissier & O'Connor, 2002),
The OCD and HD groups did not differ significantly from each other on the other five DSQ scales, ps > .14, and were combined with the comorbid OCD/HD group. After controlling for depression, the combined OCD/HD group differed significantly from controls on four of these five scales: Avoidant, Brooding, Confident, and Respected. Specifically, compared to controls, participants with OCD and/or HD reported being more avoidant (F [1, 153] = 45.82, p < .001,
(footnote continued) group was more diverse than the clinical groups, which did not differ from each other. Specifically, the control group was more balanced in terms of gender, and had a higher percentage of Hispanic and non-White participants than did the clinical groups. The groups did not differ in level of education, X2 (3) = 3.09, p = .38. Because the clinical groups did not differ from each other on gender, ethnicity, or race, these potential demographic confounds are relevant only to the comparisons between the combined clinical groups and controls. Moreover, gender, ethnicity, and race were not associated with any DSQ scale across the clinical groups, and both gender and ethnicity (but not race) were associated with only one DSQ scale each in the control group. Considering that these variables predicted only 2/54 of outcomes of interest and there is no theoretical reason to expect otherwise, we again conclude that it is unlikely that differences in gender, ethnicity, or race might account for possible differences in perceived decision-making between clinical and control groups. 4
Journal of Obsessive-Compulsive and Related Disorders 23 (2019) 100472
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Fig. 1. Perceived decision-making styles (DSQ scores) that differ between hoarding and OCD. Error bars represent 1 SE. P-values are for comparisons between the hoarding and OCD groups without any covariate.
styles were not measured specifically for the domains in which affected individuals struggle; that is, individuals with HD were not asked, for instance, to describe their decisional styles when they are deciding to discard an item. Rather, participants were asked to describe the way they make important decisions, with examples such as career decisions, financial decisions, etc. Furthermore, considering that all analyses controlled for level of depression, it is unlikely that differences in decision styles were due entirely to the greater levels of distress and perhaps lower self-esteem that might be present in individuals struggling with a debilitating and stigmatized mental illness (Chasson, Guy, Bates, & Corrigan, 2018; Stengler-Wenzke, Beck, Holzinger, & Angermeyer, 2004). Instead, it appears that these differences in selfreported decisional styles are reflective of underlying cognitive mechanisms, some of which might be broad (i.e., encompassing a substantial portion of the OC spectrum), and others more specific (i.e., relevant for one disorder on the OC spectrum but not others). One such broad mechanism might be the general fear of making a wrong choice, which may lead to avoidance of decisions, though perhaps the underlying causes of that fear might be different between the two disorders. A wrong choice for individuals with OCD may lead to anxiety about a harm that was not prevented appropriately – and indeed, individuals with OCD reported greater anxiety about decisions. A wrong choice for individuals with HD may lead to regret about discarding a potentially useful item. Observing the scores on the avoidance subscale, it seems that individuals with comorbid HD and OCD are more avoidant than either of the single disorder groups, which might suggest that the causes of avoidance are compounded for these individuals. The present study does not elucidate two other important questions with respect to the decision-making styles characteristic of OCD and HD. First, are these perceived decision-making styles associated with maladaptive decision-making strategies during in vivo, real-life decision-making? Second, what are the mechanisms and reasons for these decisional styles, and are they the same for individuals with OCD and HD? For example, one might speculate that perfectionism or an inflated sense of responsibility or guilt for potential harm could lead to
which once again suggests insight considering the comparatively lower ratings of decisional self-esteem. In addition to the differences between clinical groups and healthy controls, several differences were noted between individuals with selfidentified OCD and HD. Thus, individuals with OCD reported more decisional anxiety and preferred to rely on others for their decisions. Individuals with HD, on the other hand, reported making more impulsive and spontaneous choices, which is consistent with their report that they are less likely to be systematic and deliberate in their decisionmaking. Abramowitz (2018) reported that in contrast to other disorders on the OC spectrum, OCD has the strongest anxiety profile; indeed, the desire to reduce anxiety might underlie the majority of compulsive behaviors. Similarly, the nature of their disorder requires individuals with OCD to be quite deliberative and thorough in regards to their behavior, which may also translate into their style of decision-making. Similar outcomes have been found in laboratory tasks, where individuals with OCD were found to require more information before a choice is made (Pélissier & O'Connor, 2002). This is in contrast to HD, where the sufferers are more likely to make impulsive decisions (Timpano et al., 2013). Individuals with HD also reported relying less on others when making decisions than those with OCD. On one hand, this difference may be in part due to the comparatively high “dependent” scores of individuals with OCD, and indeed, OC symptoms were found to be related to greater reliance on feedback from others in a laboratory task (Sarig et al., 2012). On the other hand, however, observing the scores of individuals with HD, it appears that they are less dependent on others than even healthy individuals. It is possible that the considerable interpersonal conflict individuals with HD may experience with their families and loved ones (Büscher, Dyson, & Cowdell, 2014) may weaken their social support system (e.g., Medard & Kellett, 2014); this, along with the likely conflicts with family members regarding saving/discarding decisions, may prompt individuals with HD to eschew others in their decision-making. It may be tempting to ascribe the decisional styles of the clinical groups solely to the nature of their disorder(s). However, the decisional
Fig. 2. Perceived decision-making styles and decisional self-esteem scales (DSQ scores) that do not differ between hoarding and OCD. Error bars represent 1 SE. Pvalues are for comparisons without any covariate. 5
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avoidance, and indeed these are related to indecisiveness (e.g., Burgess, Frost, Marani, & Gabrielson, 2018; Chiang & Purdon, 2019; Frost & Shows, 1993). However, individuals with OCD and HD could be avoidant of making important decisions for different reasons. Further research is necessary to address these questions. There are several limitations that ought to be acknowledged. First, because this was a sample collected online, diagnoses of HD and OCD could not be independently verified; however, scores on the symptom measures are comparable to those seen in diagnosed samples. Second, the clinical sample consisted of mainly fairly highly educated Caucasian women; whether the results of this study would generalize to other populations is not yet known. Third, though the questionnaire offered ample instructions about the nature of decisions about which questions were asked, it is possible that some individuals, especially from the clinical sample, mainly considered decisions that are consistent with their diagnoses. Fourth, the groups differed from each other in terms of age, and the healthy control group appeared to be somewhat more diverse than were the other groups. Within groups, however, there was scant evidence that demographic variables predicted any decisionmaking style. It is therefore implausible that group demographic differences account for differences in perceived decision-making styles between groups. In sum, compared to healthy controls, individuals with OCD and/or HD see themselves as less confident and respected decision-makers, avoid decision-making and brood about making bad decisions more, and rely less on intuition when making decisions. Compared to those with HD, individuals with OCD are more anxious and dependent on others and less spontaneous when making decisions, and may try to gather more information and consider more alternatives, as well. Future research is warranted to determine the mechanisms that account for these perceived styles, as well as the extent to which they match in vivo behavioral choices.
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Declarations of interest None. Contributors Jedidiah Siev conceived the study, collected and analyzed data, and prepared the manuscript. Keith Lit and Yan Leykin contributed to decisions about data analysis, interpretation of the data, and manuscript preparation. All authors approve the final manuscript. Conflicts of interest The authors declare no conflicts of interest related to this work. Acknowledgments The authors thank Lori Merling and Joseph Slimowicz for their assistance with conducting this study. References Abramowitz, J. S. (2018). Presidential address: Are the obsessive-compulsive related disorders related to obsessive-compulsive disorder? A critical look at DSM-5's new category. Behavior Therapy, 49, 1–11. https://doi.org/10.1016/j.beth.2017.06.002. Abramowitz, J. S., & Deacon, B. J. (2006). Psychometric properties and construct validity of the Obsessive-Compulsive Inventory–Revised: Replication and extension with a clinical sample. Journal of Anxiety Disorders, 20, 1016–1035. https://doi.org/10. 1016/j.janxdis.2006.03.001. Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., ... Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the dimensional obsessive-compulsive scale. Psychological Assessment, 22, 180–198. https://doi.org/10.1037/a0018260. Alexander, L., Oliver, A., Burdine, L., Tang, Y., & Dunlop, B. (2017). Reported maladaptive decision-making in unipolar and bipolar depression and its change with treatment. Psychiatry Research, 257, 386–392.
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Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Perceived decision-making styles among individuals with obsessivecompulsive and hoarding disorders
T
Jedidiah Sieva,∗, Keith Litb, Yan Leykinc a
Swarthmore College, Department of Psychology, 500 College Ave, Swarthmore, PA, 19081, USA Jackson Health System, 1695 NW 9th Ave, Miami, FL, 33136, USA c Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Obsessive-compulsive disorder Hoarding disorder Decision-making Indecisiveness
Individuals with obsessive-compulsive disorder (OCD) and hoarding disorder (HD) struggle with decisionmaking. One potentially important aspect of decision-making that has yet to be studied in relation to OCD and HD is decision-making style, a trait-like pattern of responding that is relatively stable across a variety of decisionmaking situations. The aim of the present study was to investigate the extent to which people with OCD and/or HD report specific decision-making styles and low levels of decisional self-esteem. Participants who self-identified as having OCD (n = 30), HD (n = 19), both OCD and HD (n = 33), or neither (n = 78) completed a measure of how they make important decisions, as well as symptom measures. Compared to controls, individuals with OCD and/or HD perceived themselves to be less confident and respected decision-makers, avoid decisionmaking and brood about making bad decisions more, and rely less on intuition when making decisions. Compared to those with HD, individuals with OCD reported being more anxious and dependent on others and less spontaneous when making decisions. Future research should examine whether these decision-making styles lead to maladaptive decision-making outcomes, their role vis-à-vis the maintenance of symptoms, and the mechanisms for these tendencies.
1. Introduction Obsessive-compulsive (OC) spectrum disorders are characterized by repetitive, ritualistic behaviors and obsessional or recurrent thoughts, urges, and sensations. Obsessive-compulsive disorder (OCD) and hoarding disorder (HD) are two OC spectrum disorders that have a number of shared and unique features. For example, both compulsions in OCD and saving in HD are maintained by reductions in distress, but the pleasurable feelings generated by acquisition behaviors in HD generally have no corollary in OCD (Mataix-Cols et al., 2010). Similarly, recurrent thoughts feature prominently in both disorders, but whereas these thoughts are experienced as intrusive or unwanted in OCD, they are mostly experienced as part of the normal flow of thoughts in HD (Mataix-Cols et al., 2010). Identifying these types of shared and distinct features helps to increase understanding of these specific disorders and of the OC spectrum in general, and may ultimately contribute to efforts to develop treatment approaches that can be tailored for specific clinical presentations. Abnormal decision-making is one particular area of overlap between OCD and HD. In clinical settings, patients with OCD struggle with
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indecisiveness, slow decision-making, excessive doubt and distress when faced with decisions, and maladaptive decisions that result in high costs for minimal benefits (e.g., Dunne & Llamas, 1998; Volans, 1976). For example, a person with contamination fears might spend several minutes anxiously trying to decide whether or not to touch a doorknob, closely inspecting it to estimate potential dangers, and ultimately choosing not to touch it because of some imagined harm, thereby sacrificing likely rewards on the other side of the door. HD is similarly characterized clinically by excessive indecisiveness, avoidance of decisions about discarding and organizing, and decisions to save possessions despite negative consequences (e.g., Timpano, Shaw, Yang, & Çek, 2014). A person with HD might spend a long time anxiously mulling over a decision to throw away a bag of trash, ruminating about the possibility of needing some discarded item in the future, and eventually deciding to save the entire bag of trash even though it contributes to clutter. Empirical evidence of decision-making deficits in OCD and HD has been found in clinical, experimental, neuropsychological, and neurobiological research. Investigations using self-report measures show that both OCD and HD are associated with decisional procrastination or
Corresponding author. E-mail addresses: [email protected] (J. Siev), [email protected] (K. Lit), [email protected] (Y. Leykin).
https://doi.org/10.1016/j.jocrd.2019.100472 Received 1 April 2019; Received in revised form 16 August 2019; Accepted 20 August 2019 Available online 21 August 2019 2211-3649/ © 2019 Elsevier Inc. All rights reserved.
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making style, leading to both overlapping and competing conceptualizations of specific styles. For example, whereas the Decision Making Style Inventory (DMI; Nygren, 2000) includes three styles (analytical, intuitive, and regret-avoidant), the General DecisionMaking Style (GDMS; Scott & Bruce, 1995) includes five styles (rational, avoidant, dependent, intuitive, and spontaneous). In order to consolidate and refine these various constructs, Leykin and DeRubeis (2010) performed a factor analysis on 50 items taken from three existing measures (Mann, 1982; Schwartz et al., 2002; Scott & Bruce, 1995), as well as thirty-four new items developed specifically for their study. Their data best fit a 9-factor solution, including seven decisional styles (spontaneous, dependent, vigilant, avoidant, brooding, intuitive, and anxious) and two decisional self-esteem factors (confident and respected). Leykin and DeRubeis (2010) then assessed the relationships between these nine factors and depressive symptoms, and found that depression related significantly with six of the seven decision-making styles. Specifically, more depressed people were more likely to display dependent, avoidant, brooding, and anxious decision-making styles, and less likely to display vigilant and intuitive styles (Leykin & DeRubeis, 2010). Additionally, they found that more depressed people perceived themselves as less confident and less respected decisionmakers. To date, these decision-making styles have not been investigated in individuals with specific clinical disorders other than mood disorders. However, given the evidence of abnormal decision-making in OCD and HD, it seems likely that decision-making style plays a role in these conditions. Furthermore, because of the overlap and distinction between these two disorders, some styles are likely to characterize both OCD and HD while others may be evident in one disorder but not the other. For example, one might expect that both OCD and HD would be associated with avoidant, vigilant, and less intuitive decision-making, as well as poor decisional self-esteem. Similarly, considering that OCD is characterized by obsessing and HD is associated with ruminating (Portero, Durmaz, Raines, Short, & Schmidt, 2015), individuals with OCD and HD may both brood when making important decisions. In contrast, OCD more closely resembles anxiety disorders than most OC spectrum disorders (Abramowitz, 2018), and one would specifically expect individuals with OCD to endorse anxious decision-making. Notwithstanding their tendency to be indecisive, individuals with HD are also impulsive – e.g., in response to negative affect (Timpano et al., 2013) – and might therefore report spontaneous decision-making, although there is evidence individuals with OCD can also be impulsive (e.g., Grassi et al., 2015). Finally, we had competing hypotheses about dependent decision-making. On the one hand, HD is more strongly related to dependent personality symptoms than is OCD (e.g. Frost, Steketee, Williams, & Warren, 2000), although individuals with OCD also have elevations in dependent personality traits (Torres et al., 2006). On the other hand, individuals with OCD rely more on feedback from others when making decisions (Sarig et al., 2012), and this may reflect a broader tendency to use proxies because those with OCD cannot access, or do not trust, their internal states (e.g., Lazarov, Dar, Oded, & Liberman, 2010; Liberman & Dar, 2018). In fact, recent research in non-clinical samples demonstrates that this reliance on external proxies may partially explain the relationship between OC symptoms and use of a maximizing decision-making strategy (Oren, Dar, & Liberman, 2018). Although decision-making patterns may be evident especially for disorder-related decisions, they are likely well-practiced and may function as default or automated decision styles that could influence life – and even treatment – decisions without an individual's awareness. Understanding how people with OCD and HD make important decisions may allow clinicians to help them become aware of these patterns and make better choices. With the aforementioned predictions in mind, the aim of the present study was to investigate the extent to which people with OCD and/or HD report specific decision-making styles and aspects of decisional self-esteem, and to compare the decisional styles of
indecisiveness (e.g. Ferrari & McCown, 1994; Fitch & Cougle, 2013; Frost & Gross, 1993; Frost & Shows, 1993; Grisham, Norberg, Williams, Certoma, & Kadib, 2010). Additionally, self-reports show that people with OCD are less confident in their decision-making abilities (Nedeljkovic & Kyrios, 2007), and that people who hoard tend to delay decisions, feel regret after making decisions, and report more fears about – and less positive attitudes toward – decision-making (Fitch & Cougle, 2013; Frost, Tolin, Steketee, & Oh, 2011; Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Kyrios et al., 2018; Steketee, Frost, & Kyrios, 2003; Tolin & Villavicencio, 2011; Wincze, Steketee, & Frost, 2007). In studies employing laboratory decision-making tasks, people with OCD and people with HD are slower to make decisions and report greater distress about decisions when compared to clinical and healthy controls (Foa et al., 2003; Grisham et al., 2010; Luchian, McNally, & Hooley, 2007; Tolin, Kiehl, Worhunsky, Book, & Maltby, 2009; Wincze et al., 2007). Individuals with OCD also require more information, use poorer quality information when making decisions, and make more errors in probabilistic judgments than controls in laboratory tasks (Banca et al., 2015; Fear & Healy, 1997; Foa et al., 2003; Pélissier & O'Connor, 2002; Sarig, Dar, & Liberman, 2012). During laboratory discarding tasks, hoarding participants decide to keep more items than OCD participants and healthy controls, though this effect may be specific to their own possessions (Grisham et al., 2010; Luchian et al., 2007; Tolin et al., 2009; Wincze et al., 2007). These self-report and performance-based measures of decision-making deficits are consistent with the findings of functional neuroimaging studies, which show that activation levels in brain regions that are implicated in affective decision-making differ between people with OCD and HD compared to healthy controls, and compared to each other (Sachdev & Malhi, 2005; Tolin et al., 2009, 2012). That some of these effects may be specific to personal possessions also suggests the possibility that personally relevant decision-making may be different from laboratory decisions. In addition, several recent studies have investigated performance of individuals with OCD or HD on behavioral economics decision-making tasks that are not specific to OCD or HD concerns and symptom domains (e.g., Aranovich, Cavagnaro, Pitt, Myung, & Mathews, 2017; Pushkarskaya, Tolin, Henick, Levy, & Pittenger, 2018; Pushkarskaya et al., 2017; Pushkarskaya et al., 2015). There are inconsistencies in the results of these studies (cf. Aranovich et al., 2017; Pushkarskaya et al., 2015), which are difficult to interpret considering differences in specific tasks used. Furthermore, these behavioral economics tasks test particular decisions such as when making (theoretical) gambles to win money; not only might they not be relevant to OCD or HD concerns, but they do not necessarily reflect styles of making important decisions in life more broadly, even outside the realm of psychopathology. Therefore, one potentially important aspect of decision-making that has yet to be studied in relation to OCD and HD is overall decision-making style. Decision-making styles are conceptualized as stable, trait-like approaches to decision-making, which may include ways an individual gathers and processes information, considers alternatives, and ultimately makes choices (Driver, 1979; Harren, 1979; Scott & Bruce, 1995). Early research on decision styles originated outside of clinical psychology. More recently, however, researchers began to study decision styles in the context of psychopathology (Alexander, Oliver, Burdine, Tang, & Dunlop, 2017; Bavolar & Bacikova-Sleskova, 2018; Bavolar & Orosova, 2015; Di Schiena, Luminet, Chang, & Philippot, 2013; Leykin & DeRubeis, 2010), finding relationships between decision styles and mental health. Although decision styles are conceptualized as traits, or cognitive styles (Hunt, Krzystofiak, Meindl, & Yousry, 1989; Janis & Mann, 1977), which make them more akin to personality characteristics rather than symptoms of disorders, it is possible that certain disorders increase the likelihood of an individual using a particular style of set of styles or that decision styles increase vulnerability to certain disorders. Several researchers have developed measures to assess decision2
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sample, internal consistency for DOCS total score was α = .96 and αs = .93–.96 for subscale scores. Obsessive-Compulsive Inventory – Revised (OCI-R; Foa, Huppert, Leiberg, Langner, Kichic, Hajcak, et al., 2002). The OCI-R is an 18-item self-report measure of distress associated with OCD symptoms. Six domains of common symptomatology are assessed: (a) washing, (b) checking/doubting, (c) obsessing, (d) mental neutralizing, (e) ordering, and (f) hoarding (Foa et al., 2002). Participants use a five-point scale ranging from 0 (not at all) to 4 (extremely) to rate how much they have been distressed or bothered by each symptom, yielding six subscale scores and a total score. The OCI-R has consistently demonstrated a stable factor structure, adequate indices of reliability and convergent validity, and good sensitivity and specificity in identifying individuals with OCD (Abramowitz & Deacon, 2006; Foa et al., 2002; Hajcak, Huppert, Simons, & Foa, 2004; Huppert et al., 2007). In the present sample, we scored the OCI-R without the three hoarding items, and internal consistency was α = .92. Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is a 9-item self-report measure of depression symptom severity. Participants use a 4-point scale ranging from 0 (not at all) to 3 (nearly every day) to rate the frequency of each symptom of a major depressive episode. The PHQ-9 has been validated in medical, psychiatric, and general populations and has demonstrated adequate to good internal consistency, good convergent and discriminant validity, and good sensitivity and specificity (Beard, Hsu, Rifkin, Busch, & Björgvinsson, 2016; Kroenke, Spitzer, Williams, & Löwe, 2010). Internal consistency for the present sample was α = .90.
individuals with the two disorders to each other, as well as to the decisional styles of healthy controls. 2. Method 2.1. Participants Clinical participants (n = 82) were recruited through listservs for individuals who hoard and through the International OCD Foundation website. These participants reported diagnoses of OCD (n = 30), HD (n = 19), or both OCD and HD (n = 33). Control participants (n = 78) without OCD or HD diagnoses were recruited from a university campus and via social media. For the entire sample, ages ranged from 18 to 78 (M = 35.40, SD = 16.74). Participants were mostly women (74%), White (89%), non-Hispanic (85%), and had at least some college education (92%). Demographic characteristics by group are provided in Table 1. 2.2. Measures Decision Styles Questionnaire (DSQ; Leykin & DeRubeis, 2010). The DSQ is a 43-item self-report measure of decision-making style. Participants use a five-point scale ranging from 1 (never) to 5 (always) to rate the extent to which items match their style of making important decisions. Seven subscales correspond to decision-making styles (a representative item is included in parentheses): 1. Intuitive (e.g., “When I make a decision, I trust my inner feelings and reactions”) 2. Spontaneous (e.g., “I make impulsive decisions”) 3. Vigilant (e.g., I like to consider all the alternatives”) 4. Dependent (e.g., “I need the assistance of other people when making important decisions”) 5. Anxious (e.g., “I feel very anxious when I need to make a decision”) 6. Brooding (e.g., “I think about all the bad decisions I have made in my life”) 7. Avoidant (e.g., “I postpone decision-making whenever possible”)
2.3. Data analytic strategy Missing data were imputed by calculating the scale (OCI-R, PHQ-9) or subscale (DSQ, SI-R, DOCS) average score provided no more than 20% of items were missing. The threshold of 20% was chosen to allow for computation of 5-item scales with 1 missing item; however, there were no participants with less than 20% and more than 1 item missing on any (sub)scales. Therefore, no data were imputed for any scale or subscale with more than one item missing. We first examined whether the OCD and HD groups differed on each DSQ scale without controlling for any other variable. For DSQ scales on which the OCD and HD groups differed, that group comparison was treated as the primary analysis of interest. When the OCD and HD groups did not differ on a DSQ scale, they were combined with the comorbid OCD/HD group into a single clinical OCD and/or HD group and compared with the control group on that scale. Because depression symptoms are associated with most DSQ scales (Leykin & DeRubeis, 2010), all analyses were conducted controlling for depression symptoms (PHQ-9) except for those initially identifying whether to combine the OCD and HD groups. Miller and Chapman (2001) note that it is improper to covary a baseline factor that differs between groups and is correlated with an independent variable of interest because doing so removes variance associated with the independent variable of interest (e.g., diagnostic group and symptoms) as well as the covariate (e.g., demographic variable). Consistent with their recommendations, we did not covary demographic characteristics.1
Two additional subscales correspond to decisional self-esteem: 1. Confident (e.g., “I think I am a good decision maker”) 2. Respected (e.g., “Others seek my help in making their decisions”). Internal consistency of these subscales ranged from αs = .72–93 in the present sample. Saving Inventory – Revised (SI-R; Frost, Steketee, & Grisham, 2004). The SI-R is 23-item self-report measure of hoarding symptoms. Subscales include (a) clutter, (b) difficulty discarding, and (c) acquisition. The SI-R has demonstrated good internal consistency and testretest reliability, as well as convergent and discriminant validity in clinical samples (Frost et al., 2004). Internal consistency in the current sample was α = .97 for the total score and αs = .81–.98 for the subscales. Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz et al., 2010). The DOCS is a 20-item self-report measure that assesses multiple parameters of OCD symptom severity including the frequency and duration of obsessions and compulsions, distress, avoidance, and functional interference (Abramowitz et al., 2010). Using a five-point scale ranging from 0 (none/not at all) to 4 (extreme/severe), participants rate symptoms of the four most common OCD dimensions including (a) contamination and washing, (b) responsibility and checking, (c) unacceptable thoughts, and (d) symmetry. Psychometric analyses of the DOCS have found a consistent factor structure, good to excellent internal consistency, moderate test-retest reliability, and good convergent and discriminant validity (Abramowitz et al., 2010; Thibodeau, Leonard, Abramowitz, & Riemann, 2015). In the present
1 The groups differed in age, F (3, 147) = 61.10, p < .001, and post-hoc LSD analyses indicated that each group differed significantly from every other group. To elucidate this potential confound, we examined the relationships between age and each DSQ scale separately within each group. Age was not correlated with any DSQ scale within the hoarding, combined hoarding/OCD, and control groups, and was associated with only one of nine scales within the OCD group. Considering that age predicted only 1/36 of outcomes of interest and there is no theoretical reason to expect otherwise, we conclude that it is unlikely that differences in age account for differences in perceived decisionmaking between clinical groups. Gender, ethnicity, and race all differed between the groups, as well, X2s (3) > 13, p ≤ .005. In all three cases, the control
3
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Table 1 Clinical measures and demographic characteristics by group (M [SD] and percentages).
SI-R DOCS OCI-R PHQ-9 Age Gender (% women) Ethnicity (% Hispanic/Latino) Race (% White/Caucasian) Education (% with at least some college)
OCD (n = 30)
Hoarding (n = 19)
Hoarding & OCD (n = 33)
Control (n = 78)
p-value
22.98 (15.11)a 27.58 (11.36)a 24.97 (10.47)a 9.74 (5.55)a 33.76 (11.50) 83% 4% 93% 93%
58.51 (15.50)b 6.81 (6.59)b 9.31 (5.66)b 8.06 (4.28)a 58.03 (5.87) 95% 0% 100% 100%
64.94 26.81 20.26 13.33 48.01 88% 3% 100% 94%
12.82 (12.49)c 7.04 (7.29)b 6.66 (7.20)b 3.99 (4.13)c 24.72 (9.85) 59% 28% 80% 88%
< .001 < .001 < .001 < .001
(17.16)b (17.61)a (12.21)c (6.99)b (15.76)
Note. SI-R = Saving Inventory – Revised; DOCS = Dimensional Obsessive-Compulsive Scale; OCI-R = Obsessive-Compulsive Inventory – Revised (without the hoarding items); PHQ = Patient Health Questionnaire – 9. Values with different subscript letters differ significantly per LSD post-hoc or X2 tests.
3. Results
Table 2 Decision Styles Questionnaire scores by group (M [SD]).
3.1. Preliminary analyses
DSQ Scale
Means and standard deviations on symptom measures by group are presented in Table 1 and are consistent with self-reported diagnostic status. The means for all clinical groups on the SI-R, DOCS, and OCI-R, were similar to the normative data for those clinical groups (Abramowitz et al., 2010; Foa et al., 2002; Frost et al., 2004). Means and standard deviations for all DSQ scales for each group are presented in Table 2.
OCD (n = 30)
Decision-making style: Intuitive 3.08 (0.48) Spontaneous 2.43 (0.67) Vigilant 4.07 (0.63) Dependent 3.85 (0.62) Anxious 3.93 (0.58) Brooding 3.42 (0.71) Avoidant 3.41 (0.90) Decisional self-esteem: Confident 2.99 (0.61) Respected 3.10 (0.69)
3.2. OCD versus HD The OCD and HD groups differed significantly from each other on three DSQ scales: Dependent, Anxious, and Spontaneous. Specifically, compared to the HD group, the OCD group reported being more dependent (F [1, 44] = 18.36, p < .001, ηp2 = .29) and more anxious (F [1, 44] = 4.98, p = .03, ηp2 = .10) when making important decisions. In contrast, the OCD group reported being less spontaneous than the HD group, although this difference was a trend after controlling for depression (F [1, 41] = 3.62, p = .06, ηp2 = .08). Although there was a trend to suggest that the OCD group was more vigilant than the HD group (p = .07), this was no longer the case when controlling for depression (F [1, 44] = 2.56, p = .12, ηp2 = .06). See Fig. 1.
Hoarding (n = 19)
Hoarding & OCD (n = 33)
Control (n = 78)
3.27 2.82 3.74 3.14 3.48 3.20 3.62
3.17 2.74 3.70 3.42 4.00 3.49 3.85
3.38 2.75 3.97 3.34 2.67 2.65 2.43
(0.46) (0.52) (0.57) (0.60) (0.57) (0.71) (0.51)
2.98 (0.75) 2.82 (0.58)
(0.66) (0.81) (0.67) (0.71) (0.60) (0.70) (0.81)
2.75 (0.69) 3.17 (0.88)
(0.63) (0.70) (0.53) (0.54) (0.68) (0.57) (0.67)
3.99 (0.51) 3.60 (0.65)
Note. DSQ = Decision Styles Questionnaire.
ηp2 = .23) and brooding (F [1, 153] = 12.41, p = .001, ηp2 = .08) when making important decisions. In terms of decisional self-esteem, they were also less confident (F [1, 152] = 63.30, p < .001, ηp2 = .29) and perceived themselves to be less respected (F [1, 150] = 7.61, p = .007, ηp2 = .05). Although the clinical group was less intuitive than the control group (p = .02), this was no longer significant when controlling for depression (F [1, 153] = 2.45, p = .12, ηp2 = .02). See Fig. 2. 4. Discussion
3.3. OCD/HD versus control
The purpose of this study was to understand the common and disorder-specific decision-making styles of individuals with self-identified OCD and HD, as well as to compare those to styles of individuals who do not have either disorder. Using a measure assessing seven distinct decisional styles and two aspects of decisional self-esteem, we found both differences between disorders as well as differences between clinical and healthy participants. Compared to healthy controls, clinical groups reported their style of decision-making as more avoidant, and they tended to brood over their decisions. They further reported having low opinions of their decisionmaking abilities, and believed that this opinion was shared by others. Perhaps not surprisingly, given their low decisional self-esteem, clinical groups tended to rely less on their intuition than did healthy controls when making choices. In many ways, these findings suggest considerable insight for individuals with OCD and/or HD. Indeed, past research identified indecisiveness and decisional procrastination as features of the overall cognitive processes of both disorders (e.g., Ferrari & McCown, 1994; Fitch & Cougle, 2013; Frost & Gross, 1993; Frost & Shows, 1993; Grisham et al., 2010), and it appears that individuals readily acknowledge their decision-making difficulties. There is evidence that decisions of individuals with OCD and HD are poorer both in terms of information processing as well as the outcomes of decisions (e.g., Fear & Healy, 1997; Foa et al., 2003; Pélissier & O'Connor, 2002),
The OCD and HD groups did not differ significantly from each other on the other five DSQ scales, ps > .14, and were combined with the comorbid OCD/HD group. After controlling for depression, the combined OCD/HD group differed significantly from controls on four of these five scales: Avoidant, Brooding, Confident, and Respected. Specifically, compared to controls, participants with OCD and/or HD reported being more avoidant (F [1, 153] = 45.82, p < .001,
(footnote continued) group was more diverse than the clinical groups, which did not differ from each other. Specifically, the control group was more balanced in terms of gender, and had a higher percentage of Hispanic and non-White participants than did the clinical groups. The groups did not differ in level of education, X2 (3) = 3.09, p = .38. Because the clinical groups did not differ from each other on gender, ethnicity, or race, these potential demographic confounds are relevant only to the comparisons between the combined clinical groups and controls. Moreover, gender, ethnicity, and race were not associated with any DSQ scale across the clinical groups, and both gender and ethnicity (but not race) were associated with only one DSQ scale each in the control group. Considering that these variables predicted only 2/54 of outcomes of interest and there is no theoretical reason to expect otherwise, we again conclude that it is unlikely that differences in gender, ethnicity, or race might account for possible differences in perceived decision-making between clinical and control groups. 4
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Fig. 1. Perceived decision-making styles (DSQ scores) that differ between hoarding and OCD. Error bars represent 1 SE. P-values are for comparisons between the hoarding and OCD groups without any covariate.
styles were not measured specifically for the domains in which affected individuals struggle; that is, individuals with HD were not asked, for instance, to describe their decisional styles when they are deciding to discard an item. Rather, participants were asked to describe the way they make important decisions, with examples such as career decisions, financial decisions, etc. Furthermore, considering that all analyses controlled for level of depression, it is unlikely that differences in decision styles were due entirely to the greater levels of distress and perhaps lower self-esteem that might be present in individuals struggling with a debilitating and stigmatized mental illness (Chasson, Guy, Bates, & Corrigan, 2018; Stengler-Wenzke, Beck, Holzinger, & Angermeyer, 2004). Instead, it appears that these differences in selfreported decisional styles are reflective of underlying cognitive mechanisms, some of which might be broad (i.e., encompassing a substantial portion of the OC spectrum), and others more specific (i.e., relevant for one disorder on the OC spectrum but not others). One such broad mechanism might be the general fear of making a wrong choice, which may lead to avoidance of decisions, though perhaps the underlying causes of that fear might be different between the two disorders. A wrong choice for individuals with OCD may lead to anxiety about a harm that was not prevented appropriately – and indeed, individuals with OCD reported greater anxiety about decisions. A wrong choice for individuals with HD may lead to regret about discarding a potentially useful item. Observing the scores on the avoidance subscale, it seems that individuals with comorbid HD and OCD are more avoidant than either of the single disorder groups, which might suggest that the causes of avoidance are compounded for these individuals. The present study does not elucidate two other important questions with respect to the decision-making styles characteristic of OCD and HD. First, are these perceived decision-making styles associated with maladaptive decision-making strategies during in vivo, real-life decision-making? Second, what are the mechanisms and reasons for these decisional styles, and are they the same for individuals with OCD and HD? For example, one might speculate that perfectionism or an inflated sense of responsibility or guilt for potential harm could lead to
which once again suggests insight considering the comparatively lower ratings of decisional self-esteem. In addition to the differences between clinical groups and healthy controls, several differences were noted between individuals with selfidentified OCD and HD. Thus, individuals with OCD reported more decisional anxiety and preferred to rely on others for their decisions. Individuals with HD, on the other hand, reported making more impulsive and spontaneous choices, which is consistent with their report that they are less likely to be systematic and deliberate in their decisionmaking. Abramowitz (2018) reported that in contrast to other disorders on the OC spectrum, OCD has the strongest anxiety profile; indeed, the desire to reduce anxiety might underlie the majority of compulsive behaviors. Similarly, the nature of their disorder requires individuals with OCD to be quite deliberative and thorough in regards to their behavior, which may also translate into their style of decision-making. Similar outcomes have been found in laboratory tasks, where individuals with OCD were found to require more information before a choice is made (Pélissier & O'Connor, 2002). This is in contrast to HD, where the sufferers are more likely to make impulsive decisions (Timpano et al., 2013). Individuals with HD also reported relying less on others when making decisions than those with OCD. On one hand, this difference may be in part due to the comparatively high “dependent” scores of individuals with OCD, and indeed, OC symptoms were found to be related to greater reliance on feedback from others in a laboratory task (Sarig et al., 2012). On the other hand, however, observing the scores of individuals with HD, it appears that they are less dependent on others than even healthy individuals. It is possible that the considerable interpersonal conflict individuals with HD may experience with their families and loved ones (Büscher, Dyson, & Cowdell, 2014) may weaken their social support system (e.g., Medard & Kellett, 2014); this, along with the likely conflicts with family members regarding saving/discarding decisions, may prompt individuals with HD to eschew others in their decision-making. It may be tempting to ascribe the decisional styles of the clinical groups solely to the nature of their disorder(s). However, the decisional
Fig. 2. Perceived decision-making styles and decisional self-esteem scales (DSQ scores) that do not differ between hoarding and OCD. Error bars represent 1 SE. Pvalues are for comparisons without any covariate. 5
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avoidance, and indeed these are related to indecisiveness (e.g., Burgess, Frost, Marani, & Gabrielson, 2018; Chiang & Purdon, 2019; Frost & Shows, 1993). However, individuals with OCD and HD could be avoidant of making important decisions for different reasons. Further research is necessary to address these questions. There are several limitations that ought to be acknowledged. First, because this was a sample collected online, diagnoses of HD and OCD could not be independently verified; however, scores on the symptom measures are comparable to those seen in diagnosed samples. Second, the clinical sample consisted of mainly fairly highly educated Caucasian women; whether the results of this study would generalize to other populations is not yet known. Third, though the questionnaire offered ample instructions about the nature of decisions about which questions were asked, it is possible that some individuals, especially from the clinical sample, mainly considered decisions that are consistent with their diagnoses. Fourth, the groups differed from each other in terms of age, and the healthy control group appeared to be somewhat more diverse than were the other groups. Within groups, however, there was scant evidence that demographic variables predicted any decisionmaking style. It is therefore implausible that group demographic differences account for differences in perceived decision-making styles between groups. In sum, compared to healthy controls, individuals with OCD and/or HD see themselves as less confident and respected decision-makers, avoid decision-making and brood about making bad decisions more, and rely less on intuition when making decisions. Compared to those with HD, individuals with OCD are more anxious and dependent on others and less spontaneous when making decisions, and may try to gather more information and consider more alternatives, as well. Future research is warranted to determine the mechanisms that account for these perceived styles, as well as the extent to which they match in vivo behavioral choices.
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Declarations of interest None. Contributors Jedidiah Siev conceived the study, collected and analyzed data, and prepared the manuscript. Keith Lit and Yan Leykin contributed to decisions about data analysis, interpretation of the data, and manuscript preparation. All authors approve the final manuscript. Conflicts of interest The authors declare no conflicts of interest related to this work. Acknowledgments The authors thank Lori Merling and Joseph Slimowicz for their assistance with conducting this study. References Abramowitz, J. S. (2018). Presidential address: Are the obsessive-compulsive related disorders related to obsessive-compulsive disorder? A critical look at DSM-5's new category. Behavior Therapy, 49, 1–11. https://doi.org/10.1016/j.beth.2017.06.002. Abramowitz, J. S., & Deacon, B. J. (2006). Psychometric properties and construct validity of the Obsessive-Compulsive Inventory–Revised: Replication and extension with a clinical sample. Journal of Anxiety Disorders, 20, 1016–1035. https://doi.org/10. 1016/j.janxdis.2006.03.001. Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., ... Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the dimensional obsessive-compulsive scale. Psychological Assessment, 22, 180–198. https://doi.org/10.1037/a0018260. Alexander, L., Oliver, A., Burdine, L., Tang, Y., & Dunlop, B. (2017). Reported maladaptive decision-making in unipolar and bipolar depression and its change with treatment. Psychiatry Research, 257, 386–392.
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