Distress tolerance and experiential avoidance in compulsive acquisition behaviours

Early maladaptive schemas, distress tolerance and self-injury in Iranian adolescents: serial mediation model of transdiagnostic factors

BACKGROUND

Non-suicidal self-injury (NSSI) is prevalent behaviour among adolescents. Although there are different etiological models of NSSI, there is a general lack of evidence-based, comprehensive and transdiagnostic models of NSSI in adolescents.

AIMS

The aim of this study was to investigate a model of transdiagnostic factors of NSSI in adolescents, testing a serial mediation model of the relationship between early maladaptive schemas (EMS), distress tolerance and NSSI through experiential avoidance and rumination.

METHOD

A community sample was identified of 1014 adolescents aged 13-17, of whom 425 had a history of NSSI. A serial mediation path analytic method was utilised to examine the relationships between NSSI and its associated functions as criterion variables, EMS and distress tolerance as predictors, experiential avoidance as the first mediator and rumination as the second mediator.

RESULTS

The path analytic model fit indices were good (X2/d.f. = 2.25, goodness of fit index = 0.98, normed fit index = 0.97, comparative fit index = 0.98, root mean square error of approximation = 0.054, standardised root mean squared residual = 0.028). Rumination significantly mediated the relationship between schemas of 'vulnerability to harm', 'emotional deprivation', 'social isolation', 'insufficient self-control', and NSSI frequency and intrapersonal functions. In serial fashion, experiential avoidance mediated the role of rumination in the relationship between social isolation, and insufficient self-control and NSSI frequency and intrapersonal functions. All indirect effects were significant.

CONCLUSIONS

Key indirect effects were found linking maladaptive schemas and distress tolerance to NSSI frequency, and NSSI intrapersonal functions via experiential avoidance and rumination. Thus, it is important to address these transdiagnostic factors with particular emphasis on the sequential mediating role of experiential avoidance and rumination in conceptualisation and therapeutic interventions for NSSI.

The experience of leaving a valuable object: An investigation of emotional processes related to Hoarding disorder features

One of the core features of hoarding is a significant resistance to discarding objects, which is fueled by dysfunctional beliefs and unwarranted negative emotions that hoarders tend to feel when disposing of their possessions. To our knowledge, longitudinal studies investigating the psychological effects that people who hoard experience after separating from their valuable possessions have yet to be conducted. Our study's principal aim was to explore psychological processes that individuals with high hoarding features (n = 53; 49.1%) and individuals with low hoarding features (n = 55; 50.9%) experienced when they had to separate from a valuable possession. To do this, we evaluated participants' thoughts and feelings at several time points after they had to leave a valuable object at the University laboratory (evaluations were specifically conducted at baseline, during the week, and at the end of the week). To investigate hoarding and anxiety, as well as depressive, obsessive-compulsive, and emotional processes-related features, a mixed-method approach was employed involving self-report questionnaires, ad hoc surveys, and a daily self-monitoring schedule. Our findings showed that compared to participants with low hoarding features, participants with high hoarding traits: 1) scored higher for anxiety sensitivity, distress tolerance, and emotional dysregulation; 2) reported having more negative emotions when leaving their object; 3) had more intrusive object-related beliefs; and 4) experienced a higher frequency of negative emotions as well as a higher level of distress during the week. Both groups experienced more negative emotions in the first part of the week, which decreased as the time at which participants could receive their object back drew closer. Finally, dysfunctional beliefs about leaving a personal object (Saving Cognitions Inventory), sensitivity to anxiety (Anxiety Sensitivity Index-3), and distress tolerance (Distress Tolerance Scale) contributed to the level of discomfort that participants with higher hoarding scores reported when they had to leave their possession. These results highlight the relevance of emotional processes in the hoarding disorder framework as well as underscore the importance of assessing and treating them in clinical settings.

The investigation of mechanisms underlying addictive behaviors: a case-control study

Background: The contradictory nature of behavioral addictions has sustained a nondefinitive debate regarding their construct validity. Objective(s): The current study aims at exploring mechanisms underlying two distinct classes of behaviors-behavioral addictions characterized by core alterations in reward processing systems (ARPS) and behaviors with a main function of maladaptive coping. Methods: This case-control study included 99 treatment-seeking individuals with a primary diagnosis of alcohol use disorder (male: N = 68; female: N = 31) and 74 healthy control (HC) subjects (male: N = 38; female: N = 36). The severity of maladaptive behaviors was measured through the Shorter PROMIS Questionnaire (SPQ). Latent mechanisms were assessed by the Disinhibition Domain of the Personality Inventory for DSM-5 (PID-5-DI) and the Acceptance and Action Questionnaire-II (AAQ-II). Results: The clinical group showed higher severity of behavioral addictions than HC. This difference was not replicated for the other class of maladaptive behaviors, except for compulsive buying. Ordinal regression analysis showed that the clinical group significantly predicted SPQ scores reflecting ARPS, SPQ shopping and starving subscales. This was not replicated for the overall SPQ score capturing maladaptive coping and binge eating behaviors. Controlling for PID-5-DI and AAQ-II scores, which were significantly associated to SPQ subscales, effects of the aforementioned clinical group were not significant. Conclusions: The study highlighted distinct and common mechanisms underlying different classes of maladaptive behaviors. Results supported future neuroscience research for clarifying the role of ARPS in compulsive sex and buying in order to consider them as addictive disorders.

The Role of Emotional Distress Tolerance on Fear Responding in a Heights-Fearful Sample: Perceived Versus Actual Behavior

Emotional distress tolerance (EDT)-or the ability to withstand negative emotional states-is considered a transdiagnostic risk factor for psychopathology. Although EDT is theorized to play a role in anxiety development and maintenance, research aiming to delineate the relationship between anxiety and EDT is lacking. The current study tested whether self-reported EDT predicted self-reported and actual avoidance in the presence of feared stimuli using a heights-fearful sample. Moreover, the study tested whether EDT predicted other in-the-moment fear responses, such as peak anxiety, anxious cognitions, and bodily sensations. Participants (N = 128) completed questionnaires assessing fear of heights, negative affect, anxious cognitions, and bodily sensations, as well as two heights behavioral avoidance tasks (BATs). Results demonstrated that EDT did not predict actual avoidance or other in-the-moment fear responses, except for peak anxiety in one BAT. However, EDT predicted self-reported avoidance of heights beyond fear of heights and negative affect. Taken together, results suggest that perception of ability to tolerate emotional distress predicts perception of avoidance of heights, but not actual avoidance of heights or reactions to heights (with the exception of peak anxiety in one BAT). Given these findings, self-reported EDT may not adequately predict how individuals react in anxiety-provoking situations.

Coping associated with compulsive buying tendency

Research on general coping is limited within compulsive buying (CB) literature. Nevertheless, other behavioural addictions and hoarding might provide insights into coping in CB. One-hundred and ninety-nine participants (M age = 52.72, SD = 16.06; 50.3% female, 1% unknown sex) completed online questionnaires. Mental and behavioural disengagements were hypothesized to predict greater self-reported CB tendency. Whilst these relationships were found in the correlations, a regression analysis indicated that only mental disengagement significantly predicted CB tendency. Additionally, the exploration of denial and substance use identified that denial was an important predictor of CB tendency coping. The relationship between CB tendency and substance use could not be explored given the large degree of participants reporting minimal scores. CB tendency is associated with maladaptive mental disengagement, denial and lack of acceptance coping strategies, which could be useful to consider in therapy.

Brief psychological intervention for distress tolerance in an adult secondary care community mental health service: an evaluation

Distress intolerance has been suggested to be a maintaining factor in several mental health conditions. Distress tolerance skills training has been found to be beneficial in emotionally unstable personality disorder (EUPD) and post-traumatic stress disorder (PTSD). Short-term targeted interventions are increasingly being implemented in response to demand. This study investigates the efficacy of a distress tolerance brief psychological intervention (DT BPI) delivered by non-psychologists within an adult secondary care mental health service. Questionnaire data (pre and post) are reported from 43 participants who completed the intervention. Results suggest that the intervention was associated with significant improvements in distress tolerance, mood, anxiety and wellbeing. This indicates that a DT BPI can be effective when delivered by non-psychologists to real-world adult secondary care clients. The findings offer promising evidence that DT BPI could be a beneficial, cost-effective intervention and warrants further large-scale investigation.

Key learning aims

(1)

The role of Experiential Avoidance in transdiagnostic compulsive behavior: A structural model analysis

Compulsivity is recognized as a transdiagnostic phenotype, underlying a variety of addictive and obsessive-compulsive behaviors. However, current understanding of how it should be operationalized and the processes contributing to its development and maintenance is limited. The present study investigated if there was a relationship between the affective process Experiential Avoidance (EA), an unwillingness to tolerate negative internal experiences, and the frequency and severity of transdiagnostic compulsive behaviors. A large sample of adults (N = 469) completed online questionnaires measuring EA, psychological distress and the severity of seven obsessive-compulsive and addiction-related behaviors. Using structural equation modelling, results indicated a one-factor model of compulsivity was superior to the two-factor model (addictive- vs OCD-related behaviors). The effect of EA on compulsivity was fully mediated by psychological distress, which in turn had a strong direct effect on compulsivity. This suggests distress is a key mechanism in explaining why people with high EA are more prone to compulsive behaviors. The final model explained 41% of the variance in compulsivity, underscoring the importance of these constructs as likely risk and maintenance factors for compulsive behavior. Implications for designing effective psychological interventions for compulsivity are discussed.

Determinants of object choice and object attachment: Compensatory consumption in compulsive buying-shopping disorder and hoarding disorder

BACKGROUND AND AIMS

Individuals who meet criteria for compulsive buying-shopping disorder (i.e., acquiring problems only) or hoarding disorder (i.e., acquiring and discarding problems) may acquire possessions to compensate for unmet belonging needs, but may do so in different ways. Those with compulsive buying-shopping disorder may acquire objects that they believe will relieve the distress associated with unmet belonging needs (e.g., objects that distract or comfort), whereas those with hoarding disorder may acquire objects that they believe achieve belonging needs (e.g., objects that have interpersonal connotations). Accordingly, this study examined whether a belongingness threat would drive individuals who excessively acquire possessions to choose a human-like object (person-shaped tea holder) or a comfort item (box of chamomile tea).

METHODS

One hundred seventy-five participants (57 self-reported excessive acquiring only; 118 self-reported excessive acquiring and difficulty discarding) recalled a time when they either felt supported or unsupported by a significant other before choosing an object to take home with them. Participants rated how anthropomorphic and comforting the objects were as well as how attached they became to their chosen object.

RESULTS

Unsupported individuals were more likely to acquire the comfort item than supported individuals; however, individuals with both acquiring and discarding problems were more likely to acquire the human-like item than those with an acquiring problem only. Comfort and anthropomorphism ratings predicted object choice and attachment.

DISCUSSIONS AND CONCLUSION

The current findings extend the Compensatory Consumer Behavior Model to include what factors determine strategy choice and object attachment.

Treating hoarding disorder with compassion-focused therapy: A pilot study examining treatment feasibility, acceptability, and exploring treatment effects

OBJECTIVES

Hoarding disorder (HD) was recognized as a psychiatric disorder in 2013. Existing literature suggests room for improvement in its treatment. The current pilot study aimed to provide an initial evaluation on the potential of compassion-focused therapy (CFT) as an intervention for HD, with the primary aim being assessing its feasibility and acceptability, and the secondary being evaluating its effects.

DESIGN

Both CFT and a second round of the current standard of treatment and cognitive behavioural therapy (CBT) were investigated in the current study as follow-up treatment options for individuals who had completed CBT but were still significantly symptomatic.

METHODS

Forty eligible individuals were enrolled (20 in each treatment). Treatment feasibility and acceptability were assessed by quantitative and qualitative measures. To explore treatment effects, HD symptom severity, HD-related dysfunctions, and their underlying mechanisms were assessed pre-treatment and post-treatment.

RESULTS

Retention rates were 72% for CFT and 37% for CBT. All participants and 79% of the participants rated CFT and CBT, respectively, as good or excellent. After receiving CFT as a follow-up treatment, HD symptom severity dropped below the cut-off point for clinically significant HD for 77% of the treatment completers, and 62% achieved clinically significant reduction in symptom severity. In contrast, after completing a second course of CBT, 23% had HD symptom severity dropped below the cut-off threshold, and 29% achieved clinically significant symptom reduction.

CONCLUSIONS

The current study showed satisfactory feasibility and acceptability of CFT. Moreover, it also found promising effects of CFT in addressing hoarding-related mechanisms that may not have been sufficiently addressed by CBT. The results suggest promising potential of CFT as a treatment for HD. Further investigation on this intervention is needed.

PRACTITIONER POINTS

CFT may be a promising treatment option, particularly for those who do not respond well to CBT. Improving emotion regulation and negative self-perception by applying CFT interventions may help relieve hoarding symptoms. Generalization of the findings should be applied with caution given the small convenience sample of the current study. Statistical comparison on treatment effect measures between CFT and CBT as follow-up treatments was not available due to small sample size. Therefore, the comparative conclusions based on this pilot study should be made with caution.

Applying attachment theory to indecisiveness in hoarding disorder

Research shows that individuals who experience distress when discarding their possessions are more indecisive than individuals who do not experience such difficulty. These individuals report more intense emotional responses and greater intolerance to distress when faced with a discarding task. The aim of this study was to determine whether an insecure attachment style contributes to indecisiveness among individuals with discarding difficulties and whether this association is mediated by emotional reactivity and distress intolerance. This study used a within-group cross-sectional design. One hundred fifty-six participants with clinically significant discarding problems (82.7% female; Mean age = 21.96, SD = 7.38) from a population of university students and community members completed self-report questionnaires that assessed severity of hoarding behaviours, insecure attachment styles, emotional reactivity, distress intolerance, and indecisiveness. Analyses revealed that an anxious attachment style was associated with greater indecisiveness, and this relationship was mediated by emotional reactivity, but not distress intolerance. Furthermore, avoidant attachment was not related to indecisiveness. Clinical interventions should consider the role of attachment styles in hoarding disorder and address emotional reactivity difficulties in treatment through the use of discarding exposures, as emotion plays an important role in these decision-making processes.

A qualitative analysis of emotion and emotion regulation in hoarding disorder

OBJECTIVE

The role of emotion regulation (ER) has been receiving increased attention in relation to various forms of psychopathology including hoarding disorder (HD). However, questionnaire designs are limited to finding associations of ER with symptoms or symptom groups, without finding out how such constructs might be involved in the disorder.

METHODS

This study was a qualitative investigation of ER in a clinical HD sample (N = 11).

RESULTS

Prominent themes provided support for ER difficulties in hoarding. In particular, difficulties with identifying and describing feelings, unhelpful attitudes toward the emotional experience, the use of avoidance-based strategies, and a perceived lack of effective ER strategies were prominent themes. Furthermore, emotional factors were identified as being associated with the onset and/or exacerbation of hoarding behavior, and possessions and acquiring behavior appeared to serve an ER function.

CONCLUSION

The current paper provides a nuanced account of the role of ER in hoarding difficulties.

An examination of the role of intolerance of distress and uncertainty in hoarding symptoms

BACKGROUND

Hoarding disorder (HD) is a common and debilitating disorder characterized by an accumulation of and failure to discard one's possessions. The identification and examination of underlying factors that may contribute to hoarding symptoms are needed to elucidate the nature of the disorder and refine existing treatments. Two transdiagnostic vulnerability factors that have been associated with hoarding symptoms are distress intolerance (DI) and intolerance of uncertainty (IU).

OBJECTIVES

This study examined the relationships between DI, IU, and symptoms of hoarding in two samples consisting of outpatients and individuals recruited from Amazon's Mechanical Turk. We hypothesized that DI and IU would show unique and interactive associations with hoarding symptoms.

RESULTS

Across both samples, DI and IU were significantly associated with hoarding symptoms. However, DI and IU did not interact in their prediction of symptoms, and only IU remained a significant predictor, when accounting for relevant covariates.

CONCLUSIONS

Results suggest that IU is a robust predictor of hoarding symptoms and may be a promising and novel treatment target for HD.

Gender Differences in Pathways to Compulsive Buying in Chinese College Students in Hong Kong and Macau

Background and aims The addictive nature of compulsive buying implies that mood disturbances, stress, and cognitive biases that underlie compulsive buying might operate in ways similar in both genders. In the current study, we aimed to test hypothetical pathways of mood compensation and irrational cognitions, which may explain compulsive buying tendencies. We also examined potential gender differences in these pathways. Methods Two-hundred and thirty-two male (age: M = 20.30, SD = 1.74) and 373 female Chinese college students (age: M = 19.97, SD = 1.74) in Hong Kong and Macau completed measures assessing compulsive buying, psychological distress, avoidance coping, materialism, and buying-related cognitions. Mediation analyses via a structural equation modeling approach explained by Cheung (2007, 2009) were conducted, with gender as a grouping variable. Results There was a gender difference in the mood compensation pathway; avoidance coping partially mediated the link between psychological distress and compulsive buying severity in females only. On the other hand, the irrational cognitive pathway, in which irrational buying-related cognitions fully mediated the link between materialism and compulsive buying severity, was supported for both genders. There was no gender difference in the extent of mediation within the irrational cognitive pathway, and the mediation effect within the irrational cognitive pathway was larger than that within the mood compensation pathway for both genders. Conclusions Mood compensation processes in compulsive buying might be female specific, and secondary to irrational cognitions, which were gender invariant. Gender-dependent mechanisms and irrational cognitions should be emphasized in compulsive buying treatment.

An investigation of the role of intolerance of uncertainty in hoarding symptoms

BACKGROUND

Hoarding disorder (HD) is a common, debilitating mental illness and public health burden. Understanding the factors that contribute to hoarding is critical for identifying treatment targets. As a relatively new diagnostic entity, this research remains in its initial stages. Intolerance of uncertainty (IU) is thought to be a vulnerability factor for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD), and may also be relevant to HD. We investigated the possible association between IU and hoarding in two sets of analyses.

METHOD

First, we administered self-report measures of IU and hoarding symptoms to unscreened undergraduate students (N=456) and used regressions to probe their association controlling for relevant covariates. Second, in a clinical sample, we compared IU across groups of patients with HD (N=26), GAD (N=26), OCD (N=51), other anxiety disorders (N=91) and healthy controls (N=29).

RESULTS

In the student sample, IU predicted hoarding symptoms above and beyond relevant covariates, including hoarding-related beliefs. In the clinical sample, HD patients evidenced greater IU relative to healthy individuals and the mixed anxiety group, and comparable levels of IU to the GAD and OCD groups.

LIMITATIONS

This study relied exclusively on self-report questionnaires and a cross-sectional design.

CONCLUSIONS

IU is associated with hoarding behavior and, as we discuss, conceptual models might benefit from the study of IU as a potentially contributing factor. Directions for future research are discussed.

Hoarding and emotional reactivity: the link between negative emotional reactions and hoarding symptomatology

Hoarding disorder (HD) is characterized by difficulty discarding, clutter, and frequently excessive acquiring. Theories have pointed to intense negative emotional reactions (e.g., sadness) as one factor that may play a critical role in HD's etiology. Preliminary work with an analogue sample indicated that more intense negative emotions following emotional films were linked with greater hoarding symptoms. Symptom provocation imaging studies with HD patients have also found evidence for excessive activation in brain regions implicated in processing emotions. The current study utilized a sample with self-reported serious hoarding difficulties to examine how hoarding symptoms related to both general and hoarding-related emotional reactivity, taking into account the specificity of these relationships. We also examined how two cognitive factors, fear of decision-making and confidence in memory, modified this relationship. 628 participants with self-identified hoarding difficulties completed questionnaires about general emotional reactivity, depression, anxiety, decision-making, and confidence in memory. To assess hoarding-related emotional reactivity, participants reported their emotional reactions when imagining discarding various items. Heightened general emotional reactivity and more intense emotional reactions to imagined discarding were associated with both difficulty discarding and acquisition, but not clutter, controlling for age, gender, and co-occurring mood and anxiety symptoms. Fear of decision-making and confidence in memory interacted with general emotional reactivity to predict hoarding symptoms. These findings provide support for cognitive-behavioral models of hoarding. Experimental research should be conducted to discover whether emotional reactivity increases vulnerability for HD. Future work should also examine whether emotional reactivity should be targeted in interventions for hoarding.

A multifaceted assessment of emotional tolerance and intensity in hoarding

Hoarding is characterized by emotionally reinforced saving behaviors, which often combine with excessive acquisition to give rise to clutter, distress, and impairment. Despite the central role emotional processes are thought to play in hoarding, very little research has directly examined this topic. There is suggestive evidence linking hoarding with several facets of emotional intolerance and avoidance, though one key limitation of this past research has been the exclusive reliance on self-report questionnaires. The aim of the current study was to conduct a multimethod investigation of the relationship between hoarding and perceptions of, and cognitions about, negative emotional states. A large unselected sample of nonclinical young adults (N=213) completed questionnaires, behavioral tasks, and a series of negative mood inductions to assess distress tolerance (DT), appraisals of negative emotions, and emotional intensity and tolerance. Hoarding symptoms were associated with lowered tolerance of negative emotions, as well as perceiving negative emotions as more threatening. Individuals high in hoarding symptoms also experienced more intense emotions during the mood inductions than individuals low in hoarding symptoms, though there was no association with poorer performance on a behavioral index of DT. Across measures, hoarding was consistently associated with experiencing negative emotions more intensely and reporting lower tolerance of them. This relationship was particularly pronounced for the difficulty discarding and acquiring facets of hoarding. Our results offer initial support for the important role of emotional processes in the cognitive-behavioral model of hoarding. A better understanding of emotional dysfunction may play a crucial role in developing more effective treatments for hoarding.

Distress intolerance in substance dependent patients

This study seeks to extend the literature by examining distress tolerance (DT) levels for a substance dependent group of individuals. Next, it considers the potential relationship of DT levels with substance dependence features and finally, it compares those factors with a healthy control group. This study included 93 individuals (49 substance dependent and 44 healthy controls). Participants were evaluated using the Structured Clinical Interview for DSM-IV Axis I Diagnosis (SCID-I) and given the Distress Tolerance Scale (DTS), Beck Depression Inventory (BDI), and State & Trait Anxiety Inventory (STAI). Consistent with our expectations, the substance dependent group showed higher scores on the BDI and STAI, and lower scores on the DTS. There was no difference between the single drug dependent group and multiple substance-dependent groups, and their DT levels were not correlated with the duration of substance use, nor with the age of first substance use. Instead, DT was strongly correlated with trait anxiety, state anxiety, and depressive symptoms. The DT levels of this group of substance dependent individuals were very low in comparison to controls and to other groups reported in the literature. Our results suggest that distress tolerance may represent a therapeutic target factor in substance dependency treatment. Limitations and future research directions are also discussed.

Experiential avoidance and emotion regulation difficulties in hoarding disorder

Experiential avoidance can be defined as the tendency to avoid contact with unwanted internal experiences. Current conceptualizations of pathological hoarding appear broadly consistent with an experiential avoidant model. Eighty participants in four groups, namely hoarding disorder (HD) without comorbid obsessive-compulsive disorder (OCD), HD with comorbid OCD, non-hoarding OCD, and healthy controls, were administered measures of experiential avoidance and emotion regulation difficulties. Hoarding individuals reported higher levels of experiential avoidance and difficulties in emotion regulation compared to healthy but not to OCD participants. Both experiential avoidance and emotion regulation difficulties were significantly more prominent when HD was comorbid with OCD than when HD occurred without comorbid OCD. Correlation analyses further showed that both experiential avoidance and emotion regulation were moderately but significantly associated with obsessive-compulsive but not hoarding symptoms. Thus, experiential avoidance and emotion regulation difficulties are not specifically relevant to HD but to a broad range of psychopathologies. However, despite the lack of specificity, the findings raise some potentially useful clinical implications for the treatment of HD.