The implications of psychological inflexibility on difficulty discarding in hoarding disorder: A structural equation modelling approach
Creators: name: Malcolm, Jan
Publisher: name: RMIT University
Year: 2024
Subjects: classificationCode: 520304
subject: Health psychology

description: Hoarding Disorder (HD) is defined as the persistent difficulty discarding or parting with belongings regardless of their monetary value due to an overwhelming need to avoid the presupposed intolerable emotional and physiological distress of discarding (American Psychiatric Association, 2013). The result of this pathological saving behaviour is congestive disorganised clutter which renders living spaces unusable or, if the spaces are uncluttered, are so only due to a third party’s intervention (APA, 2013). For a clinical diagnosis, the hoarding must cause significant distress or impairment in social, occupational, or other important areas of functioning including the health and safety of the sufferer and others (APA, 2013).<br><br>Australian prevalence rates for hoarding are unknown currently; however, research indicates a lower-bound prevalence of 1.5% (Nordsletten, Reichenberg, et al., 2013) and an upper-bound prevalence of 4.6% (Mueller, Mitchell, Crosby, Glaesmer, &amp; de Zwaan, 2009) in British and German samples.<br><br>Unfortunately, hoarding is considered difficult to treat (Abramowitz, Franklin, Schwartz, &amp; Furr, 2003; Mataix-Cols, Marks, Greist, Kobak, &amp; Baer, 2002). Indeed, a recent meta-analysis of treatment evaluations indicated that HD-specific gold standard cognitive behavioural therapy (CBT) is ineffective in approximately 65% of cases (Tolin, Frost, Steketee, &amp; Muroff, 2015). Evidence suggests the treatment- resistant nature of HD could be due to factors inherent in the disorder itself that make it incompatible with particular CBT techniques such as cognitive reappraisal. In fact, cognitive reappraisal (Frost, Ong, Steketee, &amp; Tolin, 2016) may be rendered ineffectual in the presence of comorbidity (Hall, Tolin, Frost, &amp; Steketee, 2013), cognitive impairment (Woody, Kellman-McFarlane, &amp; Welsted, 2014), lack of insight (Frost, Tolin, &amp; Maltby, 2010), and emotion dysregulation (Tolin, Levy, Wootton, Hallion, &amp; Stevens, 2018) commonly found in HD.<br><br>Recent research has looked towards potential treatment alternatives to the key CBT technique of cognitive reappraisal currently used in CBT for HD (Frost et al., 2016; Tolin et al., 2018). In fact, preliminary evidence suggests that a cognitive distancing method used in acceptance-based treatment programs known as thought listing may be more effective in reducing both saving, a behavioural symptom of HD, and emotional attachment to possessions that leads to saving(Frost et al., 2016).<br><br>In order to develop more efficacious treatments for HD, the exploration of alternate theoretical approaches, particularly those based on acceptance and mindfulness practices, is necessary to augment the current CBT protocol. Like CBT, the efficacy of Acceptance and Commitment Therapy (ACT) is empirically supported by randomised-controlled trials (A-Tjak et al., 2015) and emerging evidence suggests it is an effective treatment for a broad range of psychopathologies. ACT offers a theoretical approach suited to explicate the avoidance behaviours of saving and acquiring that are used as a method of emotion regulation by hoarding sufferers. ACT has therefore been chosen in this thesis as a theoretical lens through which to view the development and maintenance of HD.<br><br>The aim of the current research project was to reconceptualise the Frost and Hartl (1996) cognitive-behavioural theoretical model of HD through the lens of ACT and test the impact of ACT components on the difficulty discarding phase of the proposed model in a community sample. Difficulty discarding is the primary maladaptive process in HD and it is the key pattern of behaviour responsible for disorganised clutter reaching clinical levels in HD. Significantly improving the rate of discarding through effective intervention appears central to achieving clinically significant change for more individuals who hoard. Consequently, techniques that target emotional aspects that contribute to the distress experienced by hoarding sufferers and that offer an alternative emotion regulation strategy to habitual avoidance of discarding possessions could be key to improved treatment outcomes. The current project is the first attempt, at the time of writing, to develop a novel acceptance-based emotion regulation model for HD and to test the psychological inflexibility difficulty discarding phase in a community sample, with oversampled clinical-level HD participants, using structural equation modelling path analyses.<br><br>Findings<br><br>The preliminary investigation of the six core processes of psychological inflexibility and HD in Study 1 found that overall, hoarding sufferers tend to be more psychologically inflexible than non-hoarding sufferers even when controlling for general distress. Specifically, hoarding sufferers were less flexible, over and above negative affect, in the areas of general cognitive defusion and acceptance, acting with awareness and reacting to inner experiences, and taking committed action towards freely chosen values.<br><br>Based on the findings from Study 1, the psychological inflexibility difficulty discarding model was hypothesised. Study 2 results indicated that the variables and relationships were a good fit for the data. Overall, the psychological inflexibility model accounted for 69% of the variance in the dependent variable, clutter. Psychological inflexibility and anxiety contributed significantly to the variance in hoarding-specific cognitive fusion, which in turn significantly impacted hoarding- specific experiential avoidance, leading to the outcome variable, clutter as hypothesised. Furthermore, results indicated that psychological inflexibility contributed significantly more to the variance in cognitive fusion than anxiety. Conversely, depression did not significantly impact hoarding specific cognitive fusion as hypothesised. Instead, a path from depression to clutter directly and indirectly via hoarding specific experiential avoidance was significant. <br><br>The theoretical and practical implications of the novel acceptance-based emotion regulation model of HD and the findings from the multivariate analyses and path analyses are discussed in Chapter 8. Finally, a discussion of the limitations of the project, suggestions for future research, and a detailed discussion of the ways the novel treatment protocol, developed as part of this project, can assist clinicians treating hoarding suffers will be included.<br>