Contributions of self-criticism and shame to hoarding
Introduction
Hoarding disorder (HD) is defined by the American Psychiatric Association (APA, 2013) as pathological difficulty in discarding seemingly valueless possessions, resulting in clutter, and is often accompanied by excessive acquisition of unneeded items. For individuals with HD, the accumulation of large amounts of possessions can interfere with the functionality of their living spaces, their interpersonal relationships, and emotional well-being (APA, 2013).
Pathological beliefs related to saving, acquiring, and discarding are thought to contribute to the development and maintenance of hoarding behaviors (Steketee et al., 2003). For example, the cognitive-behavioral model for HD (Frost and Hartl, 1996) outlines four domains of pathological hoarding-related beliefs: 1) heightened emotional attachment, e.g., “losing this item is like losing a part of me”; 2) desire to rely on possessions as memory aids due to reduced confidence in one's memory, e.g., “I need to leave it in sight, or I will forget about it”; 3) need to control possessions, e.g., “I like to maintain sole control over my things”; 4) inflated sense of responsibility, e.g., “I am responsible for the well-being of my possessions.” The associations between these pathological beliefs and hoarding symptom severity have been established by empirical investigations (e.g., Frost et al., 2004; Steketee and Frost, 2003; Steketee et al., 2003) and may explain why people hoard (Steketee et al., 2003, Wheaton et al., 2011).
One of the focuses of the current standard treatment for HD, cognitive behavioral therapy (CBT; e.g., Steketee and Frost, 2013), is on addressing pathological hoarding beliefs, including the four domains described above (Frost and Hartl, 1996). Although HD-specific CBT has documented efficacy, nearly half of individuals still have symptom severity levels exceeding the cutoff point for clinically significant HD (i.e., ≥ 40 points on the Saving Inventory-Revised; Frost et al., 2004; Tolin et al., 2015) after completing the treatment. This finding indicates that there is still substantial room for improvement in the current treatment approaches. Moreover, while the cognitive-behavioral model for HD (Frost and Hartl, 1996) can be used to explain the development of hoarding symptoms to some degree, it is important to examine other constructs that may be linked to the pathology of HD and therefore lead to more efficacious treatment approaches (Wheaton et al., 2011).
The current study aimed to build on existing findings regarding the relationship of compromised self-identity with HD, since compromised self-identity has been suggested to underlie the development of obsessive-compulsive and related disorders, including HD (Frost et al., 2007). Among the various aspects of compromised self-identity, the inability to sustain the well-being and cohesion of one's self-identity has been hypothesized to be associated with animal hoarding (Brown, 2011), while self-ambivalence (i.e., presence of incompatible beliefs about oneself, and uncertainty and preoccupation about one's self-worth) has been associated with compulsive hoarding, buying, hoarding beliefs, and materialism among college students in non-clinical samples (Frost et al., 2007). In two studies by García-Soriano and colleagues, the severity of hoarding symptoms was associated with the extent to which self-worth was tied with hoarding beliefs among individuals with obsessive-compulsive disorder (García-Soriano and Belloch, 2012, García-Soriano et al., 2012). In other words, individuals with strong beliefs that they might discard something they would later need, combined with the belief that such a “mistake” would harm their self-worth, tended to report more severe hoarding symptoms. This finding suggests that it is not hoarding beliefs alone, but the coupling of hoarding-related beliefs and compromised self-identity, that predicts hoarding symptom severity most strongly.
However, studies investigating self-identity in clinical HD samples are sparse. The goal of this study, therefore, was to examine the relationship between compromised self-identity and HD-related pathology among individuals with HD. Of the components of compromised self-identity discussed above (e.g., Campbell, 1990; Higgins et al., 1985; Linville, 1985), we were primarily interested in the relationship between self-criticism and HD. Self-criticism is closely related to perfectionism (Gilbert et al., 2006, Sherry et al., 2016), which is associated with HD symptoms and worse treatment response to CBT among individuals with HD (Frost and Gross, 1993, Muroff et al., 2014). Self-criticism has multiple definitions, including perceived failure to meet personal standards, drawing attention to one's inadequate qualities or behaviors (e.g., Thompson and Zuroff, 2004), as well as self-hatred and self-attacking rooted in aggression and disgust toward oneself as a global entity (Gilbert et al., 2004). For this study, we chose to examine a global measure of self-criticism defined by Gilbert et al. (2004) because of its close tie with self-identity as a global self-view, as opposed to a measure with specific qualities.
Another cognitive-affective construct closely related to self-identity is shame. Shame is a deeply painful self-conscious emotion experienced when one judges oneself as wholly negative (i.e., shame about oneself as a person), or when one judges one's mental health conditions as extremely undesirable and unacceptable (i.e., shame about mental health conditions) (Lewis, 1971, Tangney and Dearing, 2002). It has been suggested that shame is the underlying trigger of self-criticism. In order to avoid shame-based feelings, an individual may develop a self-critical style as a defensive strategy, despite this style being shaming itself (Shahar et al., 2015). Shame has been associated with obsessive-compulsive and related disorders (Weingarden and Renshaw, 2015), but empirical examination of its association with HD is sparse.
The primary aim of the current study was to investigate the relationship between self-criticism, the four domains of hoarding beliefs (i.e., emotional attachment, memory, control, responsibility), and severity of HD symptoms. We hypothesized that self-criticism would be associated with more severe HD symptoms, and that this relationship would be mediated through these hoarding beliefs. We also explored the relationships between shame, hoarding beliefs, and HD symptoms, as well as the hypothesis that the relationship between shame and HD symptom would be mediated through hoarding beliefs. As the measure used to assess shame was developed for this study, and its psychometric properties have not yet been established, these analyses are exploratory.
Section snippets
Procedures
This study was part of a randomized controlled trial (RCT) comparing two types of group therapy for HD (Uhm et al., 2016). The study took place at the University of California, San Francisco (UCSF), and was approved by the UCSF Institutional Review Board. All participants provided informed consent to participate in all study procedures. Participants who screened positive for significant HD symptoms (see criteria below) subsequently participated in a clinical interview aimed at assessing HD
Results
Of the 632 individuals who were screened for inclusion into the study, 413 met screening criteria and participated in the clinical interview. Of these, 323 were deemed eligible for and were interested in participating in the RCT. Of the 323 participants in the RCT, 104 completed the measures assessing self-criticism and shame and were included in this study. Of the total final sample of 104 participants, 23.1% (n = 24) were male, and the age range was 41–85 (see Table 1 for other descriptive
Discussion
The significance of compromised self-identity in affecting HD symptoms through the mediation of hoarding beliefs has been previously shown in non-clinical samples (García-Soriano and Belloch, 2012, García-Soriano et al., 2012). This study is among the first to investigate, in a clinical sample of individuals with HD, the roles of self-criticism and shame in hoarding pathology, specifically hoarding beliefs and overall symptom severity. Our data show that both self-criticism and shame are
Acknowledgement
This study was funded by the Patient-Centered Outcomes Research Institute (PCORI 1304-6000).
References (42)
- et al.
Hoarding behaviors in a large college sample
Behav. Res. Ther.
(2003) - et al.
The hoarding of possessions
Behav. Res. Ther.
(1993) - et al.
A cognitive-behavioral model of compulsive hoarding
Behav. Res. Ther.
(1996) - et al.
Measurement of compulsive hoarding: saving Inventory-Revised
Behav. Res. Ther.
(2004) - et al.
Exploring the role of obsessive–compulsive relevant self-worth contingencies in obsessive–compulsive disorder patients
Psychiatry Res.
(2012) - et al.
Self-worth contingencies and obsessionality: a promising approach to vulnerability?J. obsessive Compuls
Relat. Disord.
(2012) - et al.
Investigating relationships between perfectionism, forms and functions of self-criticism, and sesitivity to put-down
Pers. Individ. Dif.
(2006) - et al.
Intrusive thoughts, obsessions, and appraisals in obsessive–compulsive disorder: a critical review
Clin. Psychol. Rev.
(2007) - et al.
The structured Interview for hoarding disorder (SIHD): development, usage and futher validation
J. Obsessive Compuls. Relat. Disord.
(2013) - et al.
The UCLA hoarding severity scale: development and validation
J. Affect. Disord.
(2015)
Perfectionism explains variance in self-defeating behaviors beyond self-criticism: evidence from a cross-national sample
Pers. Individ. Dif.
Compulsive hoarding: current status of the research
Clin. Psychol. Rev.
The levels of self-criticism scale: comparative self-criticism and internalized self-criticism
Personal. Individ. Diff.
Comparison of a peer facilitated support group to cognitive behavior therapy: study protocol for a randomized controlled trial for hoarding disorder
Contemp. Clin. Trials
Shame in the obsessive compulsive related disorders: a conceptual review
J. Affect. Disord.
The menace within: obsessions and the self
J. Cogn. Psychother.
Predicting depressive symptoms with a new measure of shame: the experience of Shame scale.
Br. J. Clin. Psychology
Psychometric evaluation of the Saving Inventory-Revised in older adults
Clin. Gerontol.
Forms of self-Criticising/Attacking & self-reassuring scale: psychometric properties and normative study
Psychol. Psychother.-T.
Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients
J. Pers. Assess.
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