An exploration of economic reasoning in hoarding disorder patients

doi:10.1016/j.brat.2011.09.005

Behaviour Research and Therapy

Volume 49, Issue 12, December 2011, Pages 914-919

https://doi.org/10.1016/j.brat.2011.09.005 Get rights and content

Abstract

Current models of hoarding disorder (HD) emphasize problems of decision-making. Evidence for neuropsychological impairment in HD, however, has been mixed. The present study examined whether HD patients show problems of economic reasoning that could be associated with decision-making problems. Forty-two HD patients, 29 obsessive-compulsive disorder (OCD) patients, and 36 healthy control participants completed the Iowa gambling task (IGT), a computerized card playing game that assesses participants’ ability to learn and utilize a rule of sacrificing short-term gain for long-term gain, and a cognitive dissonance reduction task that measured changes in preference for items (art prints) after selecting or rejecting them. Results showed no deficits on the IGT for HD participants, and no difference in dissonance reduction results after selecting or rejecting items on the dissonance reduction task. Furthermore, performance on these two tasks was unrelated to hoarding symptom severity or self-reported indecisiveness. It is suggested that the problems of cognitive processing in HD patients may be largely related to as-yet understudied processes, including idiosyncratic categorization problems for personally-owned items as well as other aspects of economic reasoning.

Highlights

► Explored economic reasoning in hoarding patients, OCD patients, and healthy controls. ► Iowa gambling task and a dissonance reduction task were used. ► No evidence was found for problems of economic reasoning in hoarding patients.

Section snippets

Participants

One hundred seven adult participants met inclusion criteria of age 18–65; fluent in English; absence of lifetime bipolar, psychotic, developmental, or substance use disorders; absence of medical conditions known to impact brain function; and (for the clinical groups) symptom duration of 1 year or more and Clinician’s Global Impressions (CGI; Guy, 1976) rating of 4 (moderately ill) or higher. Furthermore, participants were included if they could be classified into one of three diagnostic groups:

Sample description

Table 1 shows that the OCD group was younger on average than were the hoarding and healthy control groups. Subsequent analyses therefore corrected for age. As expected, the hoarding group exhibited higher SI-R scores than did the other two groups (the OCD group also showed some elevation, but were well within the nonclinical range on the SI-R). The OCD and healthy control groups’ SI-R scores were somewhat lower than those found in previous research (Frost et al., 2004). The two clinical groups

Discussion

The HD patients in the present study reported higher fear of decision-making and lower positive feelings about decision-making than did OCD patients or healthy controls, replicating and extending the findings of previous research (Frost and Gross, 1993, Frost and Shows, 1993, Samuels et al., 2002, Steketee et al., 2003). However, they did not exhibit abnormalities of economic reasoning on the behavioral tasks used. HD patients performed adequately on the IGT, a finding that contrasts with

Acknowledgments

This study was funded by NIMH grant #R01MH074934 to Dr. Tolin.

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Clients with hoarding disorder (HD) report problems suggesting neurocognitive underpinnings of some of their symptoms. However, previous investigations have failed to identify replicable patterns of neurocognitive deficits related to these symptoms. These inconsistent findings may be due to task impurity inherent in assessment of higher-order cognitive functions. To address this problem, this study examined multiple overlapping measures with both categorical and dimensional analytic methods to test whether key symptoms of HD are related to neurocognitive deficits. A total of 178 adults completed neuropsychological tests, a diagnostic interview, and questionnaires. Comparisons between participants meeting criteria for the HD (N = 61) and healthy control (N = 55) groups revealed few differences among 53 neurocognitive indicators across all domains of performance, and those few differences were not consistent with other findings from this or previous studies. Dimensional analyses using the full sample found no cognitive functioning factor that was a significant negative predictor of hoarding symptoms. We conclude that in standard clinical administration of tests of attention, memory, and executive function, individuals with HD do not show reliable deficits relative to controls. Given these findings, we suggest that future research should examine clients’ subjective appraisal of cognitive abilities and emotionally-laden cognition.
Information processing in hoarding disorder: A systematic review of the evidence
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Whilst Morein-Zamir et al. (2014) reported poorer performance for HD participants on the SST and TOL, Sumner et al. (2016) found no significant group differences on any of the neuropsychological measures used, indicating that state anxiety is not always associated with impaired performance. Similarly, there were no significant group differences on EF tasks with an affective element, such as the affective go/no-go (Grisham et al., 2010), or gambling tasks thought to assess emotion-based decision-making (Grisham et al., 2007, Grisham et al., 2010, Mackin et al., 2016, Morein-Zamir et al., 2014, Tolin and Villavicencio, 2011). For studies with greater ecological validity, Raines et al. (2014) found no group differences in information processing for participants who completed EF tasks under clutter vs. non-clutter conditions.
Hoarding Disorder (HD), conceptualised as difficulties with discarding possessions resulting in distress, the accumulation of items creating a cluttered, unusable environment, and significant impairment in functioning, is reported to affect 1.5% of adults. In addition, evidence suggests that those with HD experience further difficulties in executive functioning, including inhibition, attention, and decision-making. Deficits in executive function and other areas of information processing are hypothesised to play a key role in maintaining HD. This review aimed to systematically review the evidence for impaired information processing in this population when compared to community controls, focusing specifically on studies using clinician-delivered interviews to diagnose HD, and those using primary assessments of neuropsychological function. 12 studies were included in this review. Results suggest consistent evidence for some difficulties in sustained attention, motor inhibition and organisation, however literature on deficits in other areas of executive function is wide ranging, limiting the extent to which firm conclusions can be drawn. Further research is needed to investigate deficits in other areas of information processing in HD, with a focus on consistent methods to diagnose HD and measure neuropsychological function, as these design issues place restrictions on a full understanding of the true deficits associated with HD. Consideration should be given to whether recorded deficits are ‘true’ or are difficulties associated with the emotional context of hoarding. It is hypothesized that future research will reveal more distinct subgroups of people with hoarding difficulties, only some of whom will show true neuropsychological deficits.
Perceived decision-making styles among individuals with obsessive-compulsive and hoarding disorders
2019, Journal of Obsessive-Compulsive and Related Disorders
Individuals with obsessive-compulsive disorder (OCD) and hoarding disorder (HD) struggle with decision-making. 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 decision-making 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 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 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.
A model-based analysis of decision making under risk in obsessive-compulsive and hoarding disorders
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Lawrence et al. (2006) found evidence of a “link between hoarding and [increased] risky behavior on the IGT,” while the OCD group did not differ from controls. In contrast, neither Grisham et al. (2007), nor Tolin and Villavicencio (2011) found that hoarding participants differed from controls on the IGT (Grisham et al., 2007; Tolin and Villavicencio, 2011). A large study by Mackin and colleagues found no differences between HD, OCD, or age matched controls on the IGT (Mackin et al., 2015).
Attitudes towards risk are highly consequential in clinical disorders thought to be prone to “risky behavior”, such as substance dependence, as well as those commonly associated with excessive risk aversion, such as obsessive-compulsive disorder (OCD) and hoarding disorder (HD). Moreover, it has recently been suggested that attitudes towards risk may serve as a behavioral biomarker for OCD. We investigated the risk preferences of participants with OCD and HD using a novel adaptive task and a quantitative model from behavioral economics that decomposes risk preferences into outcome sensitivity and probability sensitivity. Contrary to expectation, compared to healthy controls, participants with OCD and HD exhibited less outcome sensitivity, implying less risk aversion in the standard economic framework. In addition, risk attitudes were strongly correlated with depression, hoarding, and compulsion scores, while compulsion (hoarding) scores were associated with more (less) “rational” risk preferences. These results demonstrate how fundamental attitudes towards risk relate to specific psychopathology and thereby contribute to our understanding of the cognitive manifestations of mental disorders. In addition, our findings indicate that the conclusion made in recent work that decision making under risk is unaltered in OCD is premature.
Review of cognitive performance in hoarding disorder
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This scale shows moderately high correlations with hoarding symptom severity (Frost & Gross, 1993; Frost & Shows, 1993; Steketee, Frost, & Kyrios, 2003; Wincze, Steketee, & Frost, 2007). Hoarding clients complain more of indecisiveness than do healthy controls, with an average effect size of d = 1.6 across four studies (Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Steketee et al., 2003; Tolin & Villavicencio, 2011a; Wincze et al., 2007). Notably, the only study that matched groups on age showed the smallest effect size (d = 0.8) in this comparison (Grisham et al., 2010).
Hoarding disorder is characterized by extreme difficulty letting go of objects other people would routinely discard or give away, such that the home becomes dysfunctionally cluttered with possessions. Specific cognitive processes, such as decision-making, categorization, and attention, have been hypothesized to contribute to the overvaluing of objects. This review synthesizes the evidence related to those propositions and other executive functioning processes that have received research attention. In this paper, we are primarily interested in cognitive processes that can be, but are not always, studied using performance tasks. Compared to both healthy controls and clinical controls, participants with clinical levels of compulsive hoarding show replicable performance deficits in several areas: planning/problem-solving decisions, visuospatial learning and memory, sustained attention/working memory, and organization. Categorization/concept formation, visuospatial processing, and inhibitory control require further investigation and more detailed testing methods to address inconsistencies in reported findings. Many studies fail to account for potential confounds presented by comorbid depression and between-group differences in age, a problem that should be rectified in future research on this topic. The article concludes with recommendations for a research agenda to better understand contributors to abnormal valuing of objects in hoarding disorder.
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Difficulties were found in spatial planning, and spatial memory and organizational strategies (Grisham et al., 2010; Hartl et al., 2004). However, recent studies testing hoarders with no OCD did not find evidence for executive function difficulties, including spatial planning (Tolin et al., 2011) or on the IGT (Tolin and Villavicencio, 2011). Individuals with hoarding symptoms have also been found to have unimpaired cognitive flexibility, inhibitory control for emotional stimuli, decision-making and verbal organization strategies (Grisham et al., 2010).
Hoarding disorder is a new mental disorder in DSM-5. It is classified alongside OCD and other presumably related disorders in the Obsessive-Compulsive and Related Disorders chapter. We examined cognitive performance in two distinct groups comprising individuals with both OCD and severe hoarding, and individuals with hoarding disorder without comorbid OCD. Participants completed executive function tasks assessing inhibitory control, cognitive flexibility, spatial planning, probabilistic learning and reversal and decision making. Compared to a matched healthy control group, OCD hoarders showed significantly worse performance on measures of response inhibition, set shifting, spatial planning, probabilistic learning and reversal, with intact decision making. Despite having a strikingly different clinical presentation, individuals with only hoarding disorder did not differ significantly from OCD hoarders on any cognitive measure suggesting the two hoarding groups have a similar pattern of cognitive difficulties. Tests of cognitive flexibility were least similar across the groups, but differences were small and potentially reflected subtle variation in underlying brain pathology together with psychometric limitations. These results highlight both commonalities and potential differences between OCD and hoarding disorder, and together with other lines of evidence, support the inclusion of the new disorder within the new Obsessive-Compulsive and Related Disorders chapter in DSM-5.

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Shorter communicationAn exploration of economic reasoning in hoarding disorder patients

Abstract

Highlights

Section snippets

Participants

Sample description

Discussion

Acknowledgments

Neuropsychologia

Cognition

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Anxiety Disorders

American Journal of Geriatric Psychiatry

Psychiatry Research

Behaviour Research and Therapy

American Journal of Geriatric Psychiatry

Clinical Psychology Review

Brain and Cognition

Behaviour Research and Therapy

Journal of Consumer Psychology

Clinical Psychology Review

Journal of Economic Behavior and Organization

Psychiatry Research

Behaviour Research and Therapy

Journal of Consumer Psychology

To discard or not to discard: the neural basis of hoarding symptoms in obsessive-compulsive disorder

Molecular Psychiatry

A neural basis for collecting behaviour in humans

Brain

Dissociation of working memory from decision making within the human prefrontal cortex

Journal of Neuroscience

Deciding advantageously before knowing the advantageous strategy

Science

Postdecision changes in the desirability of alternatives

Journal of Abnormal Psychology

Anxiety disorders interview schedule for DSM-IV

Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders

Journal of Abnormal Psychology

The influence of sad mood on cognition

Emotion

The challenge of obsessive-compulsive disorder hoarding

Primary Psychiatry

Reliability and clinical concepts underlying global judgments in dementia: implications for clinical research

Psychopharmacology Bulletin

Shorter communication
An exploration of economic reasoning in hoarding disorder patients