Applying attachment theory to indecisiveness in hoarding disorder

Cluttered spaces, strained bonds: Examining the correlation between hoarding symptoms and social functioning among long-term care facilities older adult residents

BACKGROUND

Symptoms of hoarding, such as the inability to part with possessions, leading to significant clutter, are commonly observed among residents in long-term care facilities in Egypt. This behavior significantly impacts their social interactions and functioning. Therefore, this study examined the relationship between hoarding symptoms and social functioning among older adult residents in long-term care facilities.

METHODS

The study employed a cross-sectional survey on a purposive sample of 300 older adults.

TOOLS

Saving Inventory-Revised and Functional Idiographic Assessment Template-Questionnaire-Short Form were used.

RESULTS

The findings revealed a significant positive correlation between hoarding symptoms and social functioning (r = 0.682, p < 0.000). A linear regression analysis supported this correlation, establishing hoarding symptoms as a significant predictor of social functioning (adjusted R2 = 0.32).

CONCLUSION

The current study highlighted that a significant proportion of long-term care older adult residents displayed moderate hoarding symptoms and compromised social functioning. A noticeable positive association was observed between hoarding symptoms and social functioning. These results underscore the potential impact of hoarding symptoms on various aspects of social functioning. Given these findings, long-term care nurses should comprehend the various facets of compulsive hoarding behavior and devise effective strategies for assessment and intervention. Establishing support groups within these facilities could provide a platform for these residents to share their experiences and coping strategies. This could reduce interpersonal conflicts and argumentativeness and foster emotional expression and intimacy.

Neural correlates of overvaluation and the effort to save possessions in a novel decision task: An exploratory fMRI study

Introduction

People exhibit a strong attachment to possessions, observed in behavioral economics through loss aversion using new items in the Endowment or IKEA effects and in clinical psychology through pathological trouble discarding domestic items in Hoarding Disorder. These fields rarely intersect, but both document a reticence to relinquish a possessed item, even at a cost, which is associated with feelings of loss but can include enhanced positive states as well.

Methods

To demonstrate the shared properties of these loss-related ownership effects, we developed the Pretzel Decorating Task (PDT), which concurrently measures overvaluation of one's own over others' items and feelings of loss associated with losing a possession, alongside enhanced positive appraisals of one's items and an effort to save them. The PDT was piloted with 31 participants who decorated pretzels and responded to their own or others' items during functional neuroimaging (fMRI). Participants observed one item per trial (self or other) and could work to save it (high or low probability loss) before learning the fate of the item (trashed or saved). Finally, participants rated items and completed hoarding tendency scales.

Results

The hypotheses were supported, as even non-clinical participants overvalued, viewed as nicer, feared losing, and worked harder to save their items over others'-a response that correlated with hoarding tendencies and motor-motivational brain activation. Our region of interest in the nucleus accumbens (NAcc) was engaged when viewing one's own items to the extent that people worked harder to save them and was more active when their items were saved when they felt emotionally attached to possessions in real life. When their items were trashed, NAcc activity negatively correlated with trouble discarding and emotional attachments to possessions. Right anterior insula was more active when working to save one's own over others' items. Extensive motor-motivational areas were engaged when working to save one's own over others' items, including cerebellum, primary motor and somatosensory regions, and retrosplenial/parahippocampal regions-even after controlling for tapping.

Discussion

Our attachments to items are emotional, continuous across typical and pathological populations, and drive us to save possessions that we value.

Interpersonal attachment, early family environment, and trauma in hoarding: A systematic review

The formation of intense emotional attachments to objects, difficulty parting with possessions, and the extreme accumulation of clutter are key features of Hoarding Disorder (HD). Although substantial literature implicates processes such as dysfunctional beliefs and maladaptive emotional cycles in HD, little is known about the vulnerability factors that lead to their development and hoarding symptomatology. The current review sought to systematically collate and integrate findings from studies investigating the relationship between hoarding symptoms and three proposed vulnerability factors: i) interpersonal attachment, ii) early family environment, and iii) traumatic or adverse life events. A comprehensive search of the databases PsycInfo, PubMed, and Scopus identified a total of 39 studies for inclusion. The results presented a complex pattern that supported the presence of relationships between insecure attachment, cold and controlling family experiences, and exposure to adverse life events with increased hoarding severity. However, the specificity of these factors to HD over other clinical groups remains unclear and findings are limited by the heterogenous and small number of studies. We conclude by discussing the clinical implications and limitations of these findings and propose new directions for future research.

Excessive Object Attachment in Hoarding Disorder: Examining the Role of Interpersonal Functioning

Excessive attachment towards possessions can be maladaptive because it can lead individuals to excessively acquire and save objects. Little is known about how attachment to objects develops and changes over time; however, interpersonal factors have been theorized to play a role. The current study examined whether interpersonal factors, specifically interpersonal attachment style and empathy, moderate changes in object attachment over time. A total of 145 participants with excessive acquiring and discarding difficulties rated their level of attachment to a novel object just after receiving it, and 1 week later. Participants also completed measures of interpersonal anxious attachment and interpersonal functioning. We found that changes in object attachment over time were moderated by interpersonal anxious attachment. Also, our findings suggested that individuals with hoarding problems are likely not impaired in their ability to empathize with others, but rather have difficulty displaying empathy in tense social situations and also have more empathy for fictional characters. Further, greater discomfort in tense social situations and greater empathy for fictional characters interacted to predict greater object attachment. Taken together, these findings indicate that individuals with an interpersonal anxious attachment style may be those at risk of forming greater attachments to objects over time. A learning history that includes inconsistent support from caregivers may result in individuals experiencing more empathy for fictional characters and discomfort in tense social situations, which may produce a vulnerability for becoming excessively attached to objects. Our results are in line with theories of hoarding which propose that individuals use objects to compensate for unmet interpersonal needs and suggest that treatment may need to target interpersonal functioning to reduce hoarding symptoms.

A critical review of cognitive behavioural therapy for hoarding disorder: How can we improve outcomes?

Psychological treatment for hoarding problems has historically been associated with poor outcomes. When treated as a subgroup of obsessive-compulsive disorder, individuals with hoarding beliefs were less likely to respond to treatment than individuals exhibiting other obsessive-compulsive beliefs and behaviours. When treated as its own disorder using cognitive behavioural therapy, individuals report approximately 25% improvement in symptoms on average. However, less than a third of people experience clinically meaningful change. Further, changes in functioning and quality of life are not routinely assessed. In this paper, we review the current conceptualization and treatment of hoarding problems to shed light on how treatment for hoarding disorder may be improved. Utilizing a harm reduction approach before administering treatment may be important to ensure the safety of individuals. Research should test whether treatment outcomes improve by including strategies that enhance a client's interpersonal functioning and ability to regulate emotions (i.e., based on dialectal behaviour therapy and mentalization-based treatments), especially while discarding and organizing belongings. We should also use modern learning theory to improve the delivery of exposure activities.

A systematic review and realist synthesis on toilet paper hoarding: COVID or not COVID, that is the question

OBJECTIVE

To explore whether the coronavirus disease 2019 (COVID-19) pandemic is associated with toilet paper hoarding and to assess which risk factors are associated with the risk of toilet paper hoarding.

DESIGN

A systematic review and realist review were conducted.

DATA SOURCES

PubMed, Web of Science, Scopus and PsycINFO were searched (systematic review). PubMed, pre-prints and grey literature were also searched (realist review). The databases were searched from inception until October 2020.

STUDY SELECTION

There were no restrictions on the study design.

OUTCOMES AND MEASURES

For the systematic review, toilet paper hoarding was the main outcome, and pathological use of toilet paper was the secondary outcome. For the realist review, the context-mechanisms-outcome (CMO) scheme included the COVID-19 pandemic (context), four proposed mechanisms, and one outcome (toilet paper hoarding). The four potential mechanisms were (1) gastrointestinal mechanisms of COVID-19 (e.g. diarrhoea), (2) social cognitive biases, (3) stress-related factors (mental illnesses, personality traits) and (4) cultural aspects (e.g. differences between countries).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

All studies of human populations were considered (including general population studies and clinical studies of patients suffering from mental health problems).

RESULTS

The systematic review identified 14 studies (eight studies for the main outcome, six studies for the secondary outcome). Three surveys identified the role of the COVID-19 threat in toilet paper hoarding in the general population. One study pointed to an association between a personality trait (conscientiousness) and toilet paper buying and stockpiling as well as an additional significant indirect effect of emotionality through the perceived threat of COVID-19 on toilet paper buying and stockpiling. Six case reports of pathological use of toilet paper were also identified, although none of them were associated with the COVID-19 pandemic. The realist review suggested that of all the mechanisms, social cognitive biases and a bandwagon effect were potential contributors to toilet paper hoarding in the general population. The stressful situation (COVID-19 pandemic) and some personality traits (conscientiousness) were found to be associated with toilet paper hoarding. Cultural differences were also identified, with relatively substantial effects of toilet paper hoarding in several Asian regions (Australia, Japan, Taiwan and Singapore).

CONCLUSIONS

The COVID-19 pandemic has been associated with a worldwide increase in toilet paper hoarding. Social media and social cognitive biases are major contributors and might explain some differences in toilet paper hoarding between countries. Other mental health-related factors, such as the stressful situation of the COVID-19 pandemic, fear of contagion, or particular personality traits (conscientiousness), are likely to be involved.

REGISTRATION

PROSPERO CRD42020182308.

Recent Advances in Research on Hoarding

PURPOSE OF REVIEW

The purpose of the following paper is to review recent literature trends and findings in hoarding disorder (HD). Our goal is to highlight recent research on etiology, associated features, and empirically based treatments.

RECENT FINDINGS

Recent literature has added support for cognitive differences as a risk factor for HD; however, there is evidence that individuals with HD may overestimate their level of cognitive impairment. Several associated features have been highlighted in recent studies, including emotion regulation, intolerance of uncertainty and distress intolerance, and attachment. Finally, several psychotherapeutic treatments for hoarding have been recently validated, including group-based therapy and treatments using the cognitive-behavioral model. Although recent research demonstrates that hoarding can be effectively treated with available psychotherapeutic modalities, the effectiveness of current treatments is not as robust as that for other psychiatric disorders and more work is needed in treatment precision.