Fahreen Walji - Thesis submitted in partial fulfilment of the degree of Doctor of Clinical Psychology (DClinPsych)

Systematic Review of the Literature:
The risks associated with living in hoarded spaces; a systematic review
Background and review question: This review addresses the question “What is the extent of the risks (for humans) associated with the physical conditions of the living spaces of adults with hoarding difficulties?”
Method: Embase, PsycINFO, MEDLINE and Social Services Abstracts databases were searched for English-language articles dated from 2013 onward. The review criteria included that studies focus on adults, contain quantitative data and meet pre-defined requirements around hoarding and risk identification. For all included studies, citation-tracking was conducted, reference lists were reviewed, and authors were contacted for unpublished work. Pre-defined data were extracted, and papers quality assessed using an amended version of the Kmet et al. (2004) tool. A narrative synthesis of the findings was conducted.
Findings: Nineteen studies (totalling 3,986 hoarders, including overlap across studies) were included. Quality assessment scores spanned 14 to 20, out of 28. Evidence of elevated risks relating to fire, squalor, falling, impaired utilities, landslip, and properties’ structure/composition was found. Within this, some of the relative risks regarding hoarded environments were extremely high: data on fire-related deaths provide a key illustration of this.
Discussion: Limitations of the available literature are identified. The findings’ implications, and related recommendations for research and practice, are discussed.
Funding: None.
Study registration number: CRD42022293840 (PROSPERO).

Service Improvement Project:
Improving the Autism Spectrum Disorder diagnostic process in the Oxford Health NHS Foundation Trust Child and Adolescent Mental Health Service Neurodevelopmental Conditions Service
Background: This study’s overall aim was to investigate parent/carer experiences of the feedback session and assessment report forming part of the target service’s Autism Spectrum Disorder (ASD) assessment process, consider how these reflect adherence to the National Institute for Health and Care Excellence (NICE) guidelines, and identify potential improvements.
Method: A mixed-methods, cross-sectional design was used, consisting of: semi-structured interviews (analysed using thematic analysis) with parents/carers; and collecting service data (analysed using descriptive statistics) on referrals and assessments to provide context to the interviews.
Results: Four themes were developed from the interview data (finally – a diagnosis; the varied influence of wider factors; variable gains made; competent and caring professionals), which indicated variation in experiences and variable accordance with the NICE guidelines. The service data revealed a high ASD diagnostic rate.
Discussion: Key clinical implications of the results are: parent/carer needs appear to be variably met, the incremental validity of the diagnostic process is called into question; and the possibility of false negatives at triage and false positives at assessment is raised. Improvement recommendations (including future research), dissemination of the results and study limitations (including the potential impact of the Covid-19 pandemic) are discussed.

Theoretically Driven Research Project:
Hoarding Disorder – investigating the development of beliefs about possessions
Background and aims: Hoarding Disorder (HD) presents in individuals with varied background experiences, suggesting there are multiple avenues to hoarding. One suggested pathway is that early material deprivation leads to hoarding primarily driven by a fear of further material deprivation: this study aimed to investigate this.
Method: A cross-sectional design dividing participants into three groups was used: hoarders with early material deprivation experience (HWD); hoarders without early material deprivation experience (HND); and community controls (CC). All groups completed quantitative measures assessing descriptives, demographics, psychopathology, and three hoarding-related beliefs (fear of material deprivation, harm avoidance, attachment disturbance).
Results: There was no significant difference between the HWD and HND groups in terms of fear of material deprivation beliefs, nor for the other two hoarding-related beliefs. All three beliefs were raised in the HND and HWD groups relative to the CC group.
Discussion: Fear of material deprivation beliefs can motivate hoarding irrespective of any perceived experience of early material deprivation, and future research should investigate what might contribute to the development of these beliefs.

Advisor: Salkovskis, P
Hotton, M
Stacey, J
Chapman, J
Halldorsson, B