Psychiatric Comorbidity and Hoarding Symptoms in African Americans With Obsessive-Compulsive Disorder

Abstract

This study investigated comorbidity and hoarding symptoms in a sample of African American adults with obsessive-compulsive disorder (N = 75). For lifetime disorders, 87.9% of participants had at least one other comorbid condition. The most prevalent comorbidities were mood disorders (67.1%), anxiety disorders (51.4%), and substance abuse disorders (38.0%). There was low comorbidity with eating disorders, as only 4.1% had binge-eating disorder and none met criteria for anorexia or bulimia nervosa. In terms of gender differences, females were more likely to have posttraumatic stress disorder and males were more likely to have a comorbid alcohol use disorder. Over half of the participants had hoarding compulsions (56.0%) as indicated by the Yale-Brown Obsessive-Compulsive Scale. Individuals with hoarding compulsions were more likely to have comorbid anxiety-related disorders than those without, and experienced greater indecisiveness, pathological slowness, and doubting; they also had less education and earning power than those without these behaviors. African Americans with obsessive-compulsive disorder tend to have high rates of comorbid disorders, with patterns that resemble findings in non-Hispanic White populations.

Keywords

African Americans comorbidity obsessive-compulsive disorder ethnic differences hoarding

Introduction

African Americans and Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a highly disabling disorder and is one of the leading causes of disability worldwide (Lopez & Murray, 1998). OCD afflicts an estimated 1.6% of the American population, is equally common among men and women, and causes significant impairment in multiple domains, including home life, work, and relationships (Karno, Golding, Sorenson, & Burnam, 1988; Kessler et al., 2005; Ruscio, Stein, Chiu, & Kessler, 2010). OCD-related costs have previously been estimated at $8 billion dollars annually in the United States (DuPont, Rice, Shiraki, & Rowland, 1995), and this amount may be substantially higher today. Furthermore, OCD is often unrecognized in primary care, leaving many afflicted individuals untreated (Sussman, 2003).

African Americans have equivalent prevalence rates of OCD in comparison with the general population (Himle et al., 2008; Ruscio et al., 2010; Zhang & Snowden, 1999), but are underrepresented in OCD research studies and treatment clinics (Foa et al., 1995; M. Williams, Powers, Yun, & Foa, 2010). Previous research has suggested that this lack of African American inclusion could be due to a failure to identify OCD because of its heterogeneous presentation and potential cultural differences in symptom manifestation (Friedman et al., 2003). Furthermore, factors related to OCD in African Americans may be different from those in non-Hispanic Whites (i.e., M. T. Williams, Chapman, Simms, & Tellawi, in press; M. T. Williams, Domanico, Marques, Leblanc, & Turkheimer, 2012).

Comorbidity and Obsessive-Compulsive Disorder

OCD is a highly comorbid disorder, with a substantial number of sufferers also meeting criteria for another anxiety, mood, or substance use disorder (Ruscio et al., 2010). Prior investigators have not studied these comorbidity patterns in African Americans diagnosed with OCD by a clinician, limiting our knowledge to predominately non-Hispanic Whites. Recently, it has been demonstrated that among those with OCD, comorbid disorders can increase the severity of OCD and its resistance to treatment, increase impairment in daily functioning, and reduce quality of life (e.g., Huppert, Simpson, Nissensen, Liebowitz, & Foa, 2009). The National Survey of American Life (NSAL; Himle et al., 2008) found that a majority of Black Americans with a probable OCD diagnosis also met the criteria for at least one other psychiatric disorder; 93.2% in African Americans and 95.6% in Caribbean Blacks.

Disorders that are commonly comorbid with OCD include anxiety disorders, mood disorders, social phobia, posttraumatic stress disorder (PTSD), and panic disorder (Himle et al., 2008; Ruscio et al., 2010). Ruscio et al. (2010) found that OCD comorbidity included anxiety disorders (75.8%), followed by mood disorders (63.3%), impulse-control disorders (55.9%), and substance use disorders (38.6%) among a predominately non-Hispanic White sample. Furthermore, 90% of subjects who reported having lifetime OCD also met diagnostic criteria for another lifetime disorder. When considering racial differences, Himle et al. (2008) found that among African Americans comorbidities were somewhat different for anxiety disorders (83.9%), major depressive disorder (MDD; 45.5%), and substance use disorders (25.8%). The understanding of comorbidity in OCD is essential, as it is a significant factor in overall psychopathology severity and treatment outcome (Pallanti, Grassi, Sarrecchia, Cantisani, & Pellegrini, 2011).

Obsessive-Compulsive Disorder and Hoarding

Hoarding disorder is characterized by excessive saving behaviors and refusal to discard items, causing significant distress and impairment in social and work life domains (Frost & Hartl, 1996). Severe impairment in social and occupational functioning may occur, as living space can become so cluttered that it hinders activities for which they were designed (Frost, Steketee, Williams, & Warren, 2000; Saxena et al., 2002). In more severe cases, hoarders can risk fires, falling, poor sanitation, an inability to eat in the home, and other health risks from infestations (Damecour & Charron, 1998). Previous research demonstrates that OCD clients with significant hoarding symptoms had significantly greater disability in their family relationships, romantic relationships, and friendship domains in comparison to nonhoarding OCD patients and other patients with other anxiety disorders (Frost, Steketee, & Williams, 2000; Lochner et al., 2005). Furthermore, Saxena et al. (2002) found that those with hoarding symptoms had significantly lower global functioning and greater symptom severity compared to nonhoarding OCD patients.

Increasing data have led to the reclassification of problematic hoarding as a disorder of its own, or as an OCD-related disorder in the recent DSM-5 (American Psychiatric Association [APA], 2013; Mataix-Cols et al., 2010; Wheaton, Abramowitz, Fabricant, Berman, & Franklin, 2011). Hoarding as a symptom has been most often associated with OCD, although it is also seen in additional disorders including depression, schizophrenia, and other anxiety disorders (Damecour & Charron, 1998; Tolin, Meunier, Frost, & Steketee, 2011; Wheaton, Timpano, Lasalle-Ricci, & Murphy, 2008). Though hoarding is included in several OCD measures and interviews, the Diagnostic and Statistical Manual for Mental Disorders, fourth edition, Text Revision (DSM-IV-TR; APA, 2000) never directly states its function as a symptom of OCD. Hoarding disorder is different from OCD in that hoarders do not generally have intrusive thoughts about their behaviors (obsessions) or associated rituals that must be followed in a prescribed manner (Mataix-Cols et al., 2010). Nonetheless, in the National Comorbidity Survey Replication (NCS-R), 62.3% of people with OCD had hoarding symptoms as well (Ruscio et al., 2010), implying some link between these symptoms. To date, there are no epidemiological studies that have included hoarding disorder, as described by the DSM-5, as a separate diagnostic entity. However, it is estimated that hoarding disorder is found in 2% to 5% of the population, and estimates of comorbidity with OCD range from 16% to 30% (M. Williams & Viscusi, 2016).

Purpose of the Current Study

The lack of empirical research on African Americans with anxiety-related disorders, is a significant problem for the field of psychology (Hunter & Schmidt, 2010), as findings associated with OCD severity and diagnosis cannot be generalized to populations underrepresented in clinical research (i.e., M. Williams et al., 2010). The NSAL data set is the largest study of African and Caribbean Americans, however only a small number of subjects were diagnosed with OCD (N = 54 for African Americans). Further, since the NSAL data set was the result of an epidemiological study, subjects were screened using a computerized system, which was not administered by clinicians. The OCD assessment was incomplete due to the use of short-form diagnostic measures, resulting in “probable diagnoses,” and hoarding symptoms were not assessed. Furthermore, we could locate no studies of hoarding in African Americans, either as a symptom in OCD or as a stand-alone disorder.

In light of the dearth of literature on African Americans with OCD, the current study investigated clinical comorbidity and hoarding symptoms in a sample of clinician-diagnosed African Americans with OCD. We also examined differences in comorbidity between men and women with OCD, as prior research suggests that different clinically relevant patterns may be present, such as elevated eating disorders in females and greater substance abuse in males (de Mathis et al., 2011).

Method

Participants

Seventy-five African Americans diagnosed with lifetime OCD were recruited via clinical referral, advertisement, and community outreach at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania in Philadelphia. The study was approved by the institution’s institutional review board and all participants were provided with informed consent by study personnel. OCD diagnosis was determined based on a combination of clinical interviews, the Yale-Brown Obsessive-Compulsive Checklist and Severity Scale (Y-BOCS; Goodman et al., 1989), and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002) findings. Further details about the recruitment and evaluation process are detailed elsewhere (M. T. Williams, Proetto, Casiano, & Franklin, 2012).

Of these subjects, 71 had current OCD and 4 had subclinical symptoms, which at one time met criteria for an OCD diagnosis. The mean age of the sample was 41.4 (SD = 12.3) years, and 56.8% of the sample was female. Median household income was $10,000 to 39,000. At least 70.4% of the sample reported education levels up to and including some college, and 51.4% of participants reported themselves as the sole primary source of income. None were currently receiving treatment for OCD symptoms. Table 1 includes demographic information.

Table 1.

Sociodemographic Characteristics of Participants With and Without Hoarding Compulsions.

Demographic characteristics	Full sample	OCD with hoarding	OCD without hoarding
Sample size, n	74	32	42
Age, years, M ± SD	41.4 ± 12.3	42.3 ± 14.6	40.7 ± 10.4
Gender, % female)	56.8	56.3	57.1
Insurance, % yes)	70.5	65.4	74.3
Education level, %)
Some high school	12.2	12.5	11.9
High school diploma/equivalent	17.6	25.0	11.9
Some college	31.1	31.3	31.0
Graduated college	27.1	25.0	28.6
Some graduate/professional school	2.7	3.1	2.4
Completed graduate/professional school	9.5	3.1	14.3
Income, $, %
<9,000	27.3	36.7	19.4
10,000-39,000	45.4	36.7	52.8
40,000-79,000	15.1	16.6	13.9
80,000-99,000	4.5	3.3	5.6
>100,000	7.6	6.7	8.3
Primary source income, %
Public assistance	8.1	6.3	11.9
Self	51.4	53.1	50.0
Spouse/partner	6.8	9.4	4.8
Parents	4.1	3.1	4.8
Disability	9.5	9.4	9.5
Other	9.5	12.5	7.1
Employment, %
Full-time for pay	29.7	31.3	28.6
Part-time for pay	9.5	6.3	11.9
Homemaker	1.4	6.3	2.4
Student	12.2	18.8	7.2
Unemployed	31.1	25.1	35.7
Retired	1.4	3.1	0.0
Public assistance	1.4	0.0	2.4
Other	13.5	15.6	11.9
Marital status, %
Married/living with partner	18.9	21.9	16.7
Unmarried/living alone	23.0	25.1	21.5
Single (never married)	58.1	53.1	61.9

Note: OCD = obsessive-compulsive disorder.

Evaluators

African American clients generally prefer to be ethnically matched to their therapist (Ibaraki & Nagayama Hall, 2014); thus, whenever possible African American evaluators were used to create a familiar environment where participants could feel comfortable (Hatchett, Holmes, Duran, & Davis, 2000; M. T. Williams, Beckmann-Mendez, & Turkheimer, 2013). Previous research has demonstrated that participants may be uncomfortable in a university setting (K. E. Williams, Chambless, & Steketee, 1997), so evaluators were clinicians who were practicing in the community. All community evaluators received extensive training prior to assessing participants, observing at least two OCD evaluations conducted by the principal investigator (PI) and conducting two study evaluations with the PI present (M. T. Williams, Domanico, et al., 2012; M. T. Williams, Proetto, et al., 2012). Evaluators attended reliability meetings, a training workshop about assessment and treatment of OCD, and met regularly with the PI for supervision.

Although five African American evaluators were hired for this study over the recruitment period, there were also two university-affiliated European Americans who were trained as evaluators to assess participants when the community evaluators were unavailable. Of the 75 participants with lifetime OCD, five assessments were conducted by the European American evaluators and one was conducted by a team consisting of one European American and one African American evaluator. The remaining assessments were conducted by African American master’s or doctoral-level evaluators. For additional details about the methodology of the study, see M. T. Williams, Proetto, et al. (2012).

Measures

The following measures were utilized for this study as part of a larger battery.

Structured Clinical Interview for DSM-IV Axis I Disorders (SCID)

The SCID (First et al., 2002) is a widely used semistructured clinical interview used to make reliable DSM-IV psychiatric diagnoses. Participants were assessed for mood disorders, anxiety disorders, psychotic disorders, eating disorders, substance abuse and dependence, somatoform disorders, and adjustment disorder.

Yale-Brown Obsessive-Compulsive Checklist and Severity Scale (Y-BOCS)

The Y-BOCS (Goodman et al., 1989) is a semistructured interview that includes a checklist and severity scale. The severity scale contains 16 items designed to assess the severity of obsessive-compulsive symptoms, with scores on a 0-to-4 ranking scale where higher scores indicate greater disturbance. There are five obsessive-compulsive aspects (duration, distress, interference, resistance, and control) that are reported by the patient. The first 10 items are summed for a total score, and the remaining 6 supplementary items assess insight, avoidance, indecisiveness, overvalued responsibility, slowness, and doubting. Prior to receiving the severity scale, all participants were administered the Y-BOCS checklist to identify specific obsessions and compulsions. The Y-BOCS checklist is not scored, but all affirmative responses were probed by evaluators to ensure that they were consistent with OCD. The Y-BOCS severity scale was administered to assess the severity of symptoms in OCD patients. Cronbach’s alpha for our sample was .83 (M. T. Williams, Wetterneck, Thibodeau, & Duque, 2013).

Hoarding Rating Scale–Self-Report (HRS-SR)

The HRS-SR (Tolin, Frost, Steketee, Gray, & Fitch, 2008) consists of five items rated from 0 (none) to 8 (extreme) for the assessment of clutter, difficulty discarding, excessive acquisition, distress, and impairment. The items are summed and averaged for a total score. Among primarily White, female subjects, the mean HRS-SR score is 6.32 (SD = 1.0) among those meeting full criteria for hoarding disorder, and 3.85 (SD = 1.3) for those with problematic hoarding that does not meet full criteria for hoarding disorder (Tolin et al., 2008). The HRS-SR was administered after the main assessment was completed; thus, not all participants were available. The HRS-SR in this sample (N = 46) had good internal consistency (α = .89).

Data Analytic Procedures

Thirty-two subjects were classified as having hoarding symptoms and 42 were classified as without hoarding symptoms for the purposes of this study. Because hoarders do not generally have obsessions about possessions (Mataix-Cols et al., 2010), we believed that hoarding compulsions were a better indication of pathological behaviors than obsessions alone. Thus, participants were considered to have hoarding symptoms if they disclosed hoarding compulsions on the Y-BOCS checklist as a current symptom. Those with hoarding symptoms were not diagnosed with hoarding disorder, per se, because at the time data were collected hoarding disorder was not a separate diagnostic entity, thus no separate interview to assess for hoarding disorder was administered. However, hoarders have been identified in similar studies using the Y-BOCS (e.g., Saxena et al., 2002). Among those with hoarding symptoms, all had other current symptoms of OCD.

Pearson and point biserial correlations were used to measure the association between OCD scales in participants with and without hoarding symptoms. Cronbach’s alpha was computed for each scale to assess reliability. Two-tailed t tests were then used to compare groups on Y-BOCS scales. Fisher’s exact test was used to compare rates of comorbid disorders by gender and between those with and without hoarding symptoms. These analyses were conducted using SPSS, Version 22.

Results

Comorbidity Findings

Fully 87.9% of participants with lifetime OCD also met criteria for another lifetime disorder (Table 2). Of these, the most prevalent were mood disorders (67.1%), anxiety-related disorders (51.4%), and substance use disorders (38.0%). Mood disorders included MDD, bipolar disorder I or II, dysthymic disorder (current only), mood disorder caused by a drug or medical condition, and mood disorder NOS (not otherwise specified). Anxiety-related disorders included panic, agoraphobia without history of panic disorder, social phobia, specific phobia, PTSD, general anxiety disorder (current only), anxiety caused by a drug or medical condition, and anxiety disorder NOS. Substance use disorders included abuse or dependence of alcohol, cannabis, sedatives, opioids, cocaine, stimulants, hallucinogens, or multiple substances. Psychotic disorders assessed included schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, psychosis caused by a drug or medical condition, and psychosis NOS. Eating disorders assessed included anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED). No participants reported symptoms of either anorexia or bulimia; thus, Table 1 represents only those with BED. The presence of a current somatoform disorder was assessed (somatization disorder, pain disorder, hypochondriasis, and body dysmorphic disorder), but no participants in the sample met criteria for any of these, thus, it does not appear in the table.

Table 2.

Comorbidity of Sample With Lifetime OCD.

	Lifetime		Current
	n	Percent	n	Percent
Any anxiety-related disorder (other than OCD)	38/74	51.4	31/73	42.5
Panic disorder	16/74	21.6	10/74	13.5
Agoraphobia without history of panic	1/74	1.4	0/74	0.0
Social phobia	8/74	10.8	6/73	8.2
Specific phobia	9/74	12.2	9/74	12.2
Posttraumatic stress disorder	16/74	21.6	13/74	17.6
Generalized anxiety disorder	NA	NA	6/74	8.1
Any mood disorder	49/73	67.1	37/71	52.1
Major depressive disorder	44/74	59.5	30/74	40.5
Bipolar disorder I/II	7/73	9.6	4/73	5.5
Dysthymic disorder	NA	NA	6/73	8.2
Any substance use disorder	27/71	38.0	4/72	5.6
Alcohol abuse/dependence	24/73	32.9	2/73	2.7
Cannabis abuse/dependence	15/74	20.3	3/73	4.1
Adjustment disorder	NA	NA	1/71	1.4
Any psychotic disorder	5/68	7.4	4/69	5.8
Any eating disorder (BED)	3/73	4.1	2/73	2.7
Any disorder (in addition to OCD)	58/66	87.9	44/61	72.1

Note: OCD = obsessive-compulsive disorder. BED = binge-eating disorder, as no participants had lifetime anorexia nervosa or bulimia nervosa. N ranged from 67 to 74 because of missing data from the SCID.

Hoarding Symptoms in Obsessive-Compulsive Disorder

As shown in Table 1, those with and without hoarding symptoms were similar in many respects (e.g., age, gender, marital status, religion), but there are a few notable differences. For example, more participants without hoarding symptoms had completed graduate/professional school (14.3%) than those with hoarding symptoms (3.1%), and those without hoarding symptoms had higher earning power than did those with hoarding symptoms. As shown in Table 1, 36.7% of those hoarding symptoms were in the less than $9,000 category (compared with 19.4% of those without), whereas 52.8% of those without were in the $10,000 to $39,000 income category (compared to 36.7% of those with hoarding symptoms). Additionally, compared with those without hoarding symptoms, those with hoarding symptoms tended to rely more on spouses/partners as a primary income source (9.4% vs. 4.8%) and were more likely to be students (18.8% vs. 7.2%).

We also examined differences between those with and without hoarding symptoms in terms of the prevalence of other comorbid disorders. Specifically, we created comorbidity indices across five diagnostic categories by determining if there was a lifetime diagnosis for each participant in each category. The mood disorder category included MDD and bipolar disorders. The anxiety-related disorder category included anxiety disorders and PTSD but not OCD. The substance use category included any diagnosis of alcohol or drug abuse or dependence (see Table 3). Those with hoarding symptoms were significantly more likely to have comorbid anxiety-related disorder.

Table 3.

Comparisons of OCD With and Without Hoarding Compulsions on Lifetime Comorbidity.

	OCD with hoarding; n (%)	OCD without hoarding; n (%)	z
Any mood disorder	25/32 (78.1)	25/42 (59.5)	1.7
Any substance use disorder	12/29 (41.4)	15/42 (35.7)	0.5
Any anxiety-related disorder (including PTSD but not OCD)	21/32 (65.6)	17/42 (40.5)	2.1*
Any eating disorder (BED)	2/32 (6.3)	1/41 (2.4)	0.8
Any psychotic disorder	3/28 (10.7)	2/40 (5.0)	0.9
Any disorder	26/27 (96.3)	32/39 (82.1)	1.7

Note: OCD = obsessive-compulsive disorder; PTSD = posttraumatic stress disorder.

p < .05.

We compared those with and without hoarding symptoms on the Y-BOCS severity scale and its supplementary items (Table 4), and those with hoarding symptoms had significantly higher levels of slowness, indecisiveness, and pathological doubting. Correlational analyses showed that the HRS-SR was significantly correlated to the presence of hoarding compulsions as indicated by the Y-BOCS checklist (r = .40, p < .01). The mean HRS-SR score for those with hoarding symptoms was 5.2 (SD = 2.0), which indicates a severity level right between the range of those with a diagnosis of hoarding disorder (M = 6.3, SD = 1.0, N = 645) and those with clinically significant hoarding symptoms but not meeting full diagnostic criteria (M = 3.85, SD = 1.33, N = 216) based on data from the original validation sample (Tolin et al., 2008).

Table 4.

Comparisons of Y-BOCS Means and Ancillary Items in Subjects With and Without Hoarding Compulsions.

	OCD with hoarding; M (SD)	OCD without hoarding; M (SD)	t
Y-BOCS total	23.41 (6.74)	22.26 (6.98)	0.71
Y-BOCS obsessions	11.00 (4.13)	10.26 (4.10)	0.77
Y-BOCS compulsions	12.41 (3.74)	12.00 (3.71)	0.47
Insight	1.52 (1.21)	1.56 (1.23)	0.16
Avoidance	1.63 (1.07)	1.51 (1.19)	0.44
Indecisiveness***	1.73 (1.05)	0.61 (0.92)	4.80***
Pathologic responsibility	1.23 (0.94)	0.85 (1.01)	1.61
Slowness**	1.67 (1.12)	0.88 (0.87)	3.30**
Doubting*	1.43 (1.22)	0.83 (0.96)	2.34*

Note: Y-BOCS = Yale-Brown Obsessive-Compulsive Checklist and Severity Scale; OCD = obsessive-compulsive disorder.

p < .05. **p < .01. ***p < .001.

Gender-Segregated Analyses

We then divided the sample by gender and focused on the most common lifetime diagnoses. As shown in Table 5, male participants were more likely to have an alcohol use disorder whereas female participants were more likely to have PTSD.

Table 5.

Data From Gender-Segregated Analyses.

	Females, n (%)	Males, n (%)	Statistic
1. Age of onset, years, M (SD)	21.4 (10.0)	22.76 (9.72)	t = −0.51
2. Y-BOCS total (SD)	22.48 (7.48)	23.13 (6.03)	t = 0.40
3. Bipolar I disorder	2/41 (4.9%)	4/32 (12.5)	z = 1.2
4. Major depression	26/42 (61.9)	18/32 (56.3)	z = 0.5
5. Dysthymia	2/39 (4.8%)	4/32 (12.5)	z = 1.2
6. Alcohol use	8/41 (19.5)	16/32 (50)	z = 2.8*
7. Cannabis use	6/42 (14.3)	9/32 (28.1)	z = 1.5
5. Posttraumatic stress disorder	13/42 (31.0)	3/32 (9.4)	z = 2.2*
6. Panic disorder	12/42 (28.6)	4/32 (12.5)	z = 1.7
7. Social phobia	5/42 (11.9)	3/32 (9.4)	z = 0.3
8. Generalized anxiety	3/42 (7.1)	3/32 (9.4)	z = 0.4
9. Binge-eating disorder	1/42 (2.4)	0/32 (0)	z = 0.9

Note: Y-BOCS = Yale-Brown Obsessive-Compulsive Checklist and Severity Scale. Data for dysthymic disorder and generalized anxiety disorder are for current rather than lifetime diagnosis.

p < .05.

Discussion

Comorbidity Findings

This is the first study to focus on comorbidity in African Americans diagnosed with OCD by a clinician, as opposed to the limited OCD assessments conducted in epidemiological studies. The vast majority (88%) of participants had at least one other disorder comorbid with lifetime OCD, which is similar to the rates of comorbidity found in epidemiological studies (i.e., Himle et al., 2008; Ruscio et al., 2010). Epidemiological studies have found lower rates of mood disorders in African Americans compared to European Americans (Breslau et al., 2006), but this was not the case in our OCD sample. MDD was the most prevalent mood disorder observed, with 60% of the sample experiencing lifetime symptoms. Conversely, a much smaller percentage of the sample suffered from lifetime bipolar disorder (10%), and no participants experienced current dysthymic disorder (lifetime dysthymic disorder was not assessed). Recent epidemiological studies have found high comorbidity with mood disorders in people with OCD, but the prevalence of these differs, with lifetime MDD found in 41% for the NCS-R and 46% for the NSAL. However, rates of lifetime bipolar disorder (23%) and current dysthymic disorder (13%) in the NCS-R were higher (Ruscio et al., 2010). In their clinical sample, McElroy et al. (2001) also reported higher comorbidity rates with bipolar disorder than our sample (22% vs. 10%, respectively). Additionally, our sample had a higher rate of current MDD than found in a clinical study by Tukel, Polat, Ozdemir, Aksut, and Turksoy (2002; 60% vs. 40%). More research is needed to investigate the cause of these differences. The therapeutic implications of comorbid depressive disorders in OCD are still not completely understood; however, severe MDD has been negatively correlated with successful outpatient cognitive behavioral therapy and concomitant bipolar disorder complicates the use of SRI medications (Pallanti et al., 2011). Thus, MDD in African Americans with OCD should be carefully assessed.

Over half (51%) of our sample had a comorbid anxiety disorder. Epidemiological studies also find high rates of comorbid anxiety disorders in OCD samples, with the NCS-R reporting 76% and NSAL at 84% (Himle et al., 2008; Ruscio et al., 2010). Among these, panic disorder was reported at near identical levels to prior studies (22% Penn, 20% NCS-R, 22% NSAL). However, Crino and Andrews (1996) reported panic disorder in their clinical sample at a rate of 48%. The most interesting difference found in this subgroup was the significant difference in the experience of social phobia between groups. NCS-R and NSAL report social anxiety at a frequency of 44%, while only 11% of our participants had this disorder. In another clinical study, social anxiety was reported in 46% of the participants (Crino & Andrews, 1996). This difference could be due to methodological issues that required study participants to venture into a university medical center, which could be difficult for those who are socially fearful or who experience cultural mistrust (K. E. Williams et al., 1997). However, the same trend can be seen in the presentation of a specific phobia between groups. Our sample reported a specific phobia in only 11% of participants, while the same subgroup comprised 44% of the NCS-R sample.

Substance use disorders were reported at near identical frequencies in the NCS-R and our own sample (38.6% and 38.0%, respectively), and somewhat higher than NSAL (26%). Eating disorders such as bulimia nervosa, anorexia nervosa, and binge eating were uncommon in our sample, as has been the case in other studies of African Americans (Taylor, Caldwell, Baser, Faison, & Jackson, 2007). In a primarily European American clinical sample, Sallet et al. (2010) found OCD to be comorbid with 11% of their eating disordered sample. Conversely, our sample reported a comorbid eating disorder at a rate of only 4%. Moreover, the reported disorder in our study was neither bulimia nervosa nor anorexia nervosa, but binge eating. Although the NSAL study reported a comorbidity rate of 27% for eating disorders, anorexia nervosa was extremely rare in that sample (Himle et al., 2008; Taylor et al., 2007). This is likely due to a more positive body image among African American women, which is thought to be protective against anorexia nervosa (Abrams, Allen, & Gray, 1993).

No participants reported symptoms of hypochondriasis or body dysmorphic disorder, which is particularly noteworthy because both disorders have been hypothesized to have some relationship to OCD. Hypochondriasis (now divided into illness anxiety and somatic symptom disorder in DSM-5) is often indistinguishable from OCD (Abramowitz & Braddock, 2006). Body dysmorphic disorder has been classified as an OCD-related disorder in the DSM-5 due to phenomenological similarities, which include obsessive concerns about appearance and repetitive behaviors or acts in response to these concerns (APA, 2013). Both disorders are thought to have high comorbidity with OCD (APA, 2013), but our study does not support such a relationship. Further research will be needed to determine the cause of these differences.

Findings for Those With Hoarding Symptoms

Over half of participants had hoarding compulsions (56%) as indicated by the Yale-Brown Obsessive-Compulsive Scale, at a severity level comparable to those with clinically relevant hoarding symptoms. There were several significant differences between those with and without hoarding symptoms in our African American sample, for example those with hoarding symptoms were more likely to be diagnosed with an anxiety disorder. It is also interesting to note that more participants reporting a BED also reported hoarding symptoms, which is consistent with literature finding a relationship between hoarding, obesity, and binge eating (Raines, Boffa, Allan, Short, & Schmidt, 2015).

In our study, those with hoarding compulsions had significantly higher levels of indecisiveness. This is not the first study to find a link between hoarding and indecisiveness (Abramowitz, Wheaton, & Storch, 2008; Frost, Tolin, Steketee, & Oh, 2011; Samuels et al., 2007), and our findings further demonstrate that these individuals suffer from serious decision-making problems, which could be a factor in trying to decide which items to retain or discard. We also found that those with hoarding symptoms were more likely to endorse pathological doubting which is in line with previous studies (Norman, Davies, Nicholson, & Malla, 1998; Tolin, Abramowitz, Brigidi, & Foa, 2003; Wade, Kyrios, & Jackson, 1988). Someone who has pathological doubting would continue questioning whether an activity was performed correctly after completing it, or whether he or she completed the task at all.

Additionally, our results showed that participants with hoarding symptoms had significantly higher levels of pathological slowness, which is consistent with previous studies (Grisham, Brown, Savage, Steketee, & Barlow, 2007; Wincze, Steketee, & Frost, 2007). Those with pervasive slowness tend to struggle with routine activities by taking longer than they should. Pathological slowness in those with hoarding symptoms may be caused by neuropsychological weaknesses in sustained attention and spatial ability, which in turn may contribute to the inability to stay focused on particular tasks and cause difficulty categorizing and organizing possessions (Frost & Hartl, 1996; Grisham et al., 2007). These basic tasks then take much longer and start to get backlogged until the individual starts to have problematic clutter. Additionally, slowness could be a result of greater doubt due to concerns about having completed a behavior or task correctly, resulting in slowness to ensure that tasks are complete and accurate.

Many people with OCD have hoarding symptoms, although it has been suggested that less than 5% of patients with OCD have hoarding as a truly clinically significant problem (Foa et al., 1995; Mataix-Cols et al., 2010). However, we found several significant differences between those with hoarding symptoms and those without, with hoarding compulsions as a marker of increased overall psychopathology. Collectively, this study along with previous research suggests distinct clinical and sociodemographic differences between OCD sufferers with hoarding symptoms and those without (e.g., Fontenelle, Mendlowicz, Soares, & Versiani, 2004).

Gender Differences

Age of onset did not significantly differ by gender, although other studies find an earlier age of onset in males (Ruscio et al., 2010). Females in the current sample experienced higher rates of PTSD, which is consistent with epidemiological studies that find greater PTSD in African American females in general (Himle, Baser, Taylor, Campbell, & Jackson, 2009). However, the large difference noted in this study points to the need for further examination of this finding, especially with respect to the temporal onset of OCD versus PTSD symptoms, to determine if trauma is a contributing factor to the development and maintenance of the disorder in this demographic. In the NCS-R, 21% of those with OCD and PTSD developed both disorders in the same year (Ruscio et al., 2010). There has been some research aimed at describing a posttraumatic subtype of OCD (Fontenelle et al., 2012), which may be particularly relevant to African American women due to their greater risk of traumatic victimization. The ongoing stress of racism and discrimination have been conceptualized as a form of trauma (Carter, 2007; Helms, Nicholas, & Green, 2012), which may increase vulnerability to certain forms of psychopathology.

Clinical Implications

African Americans with OCD experience high rates of comorbidity, therefore a thorough assessment is essential to identify other co-occurring disorders. Women with OCD should be thoroughly assessed for comorbid PTSD, men should be assessed for alcohol use disorder, and all should be assessed for MDD.

The co-occurrence of hoarding symptoms should also be investigated. Women with hoarding symptoms should be carefully assessed for BED. Due to the ego-syntonic nature of hoarding behaviors, patients with OCD may not volunteer hoarding symptoms as an area of concern. Those with hoarding symptoms are likely to be more impaired, have more difficulty making decisions, and struggle with pathological slowness and doubt. African Americans with OCD are typically unsure about where to go for help (76.1%) or whether help is even needed (M. T. Williams, Domanico, et al., 2012). Thus, clients with OCD and hoarding symptoms may be particularly difficult to engage in treatment due to doubts about the nature of their disorder or whether they have a disorder at all.

Study Limitations

The Y-BOCS is considered the gold standard for assessing OCD symptoms, but unfortunately it only includes two questions that investigate hoarding behaviors and thoughts. The HRS-SR measure is limited because the data are based on self-report to distinguish hoarding symptoms. Furthermore, these individuals with hoarding difficulties may have insufficient insight into their condition and therefore may not be able to immediately report these symptoms accurately (Christensen & Greist, 2001; Matsunaga et al., 2002; Tolin, Fitch, Frost, & Steketee, 2010). Finally, those with hoarding symptoms in this study may or may not meet full DSM-5 criteria for hoarding disorder. Future research should include the administration of a hoarding disorder diagnostic interview and clinician assessment of clutter in participants’ homes, to allow for a more objective interpretation of living conditions as compared to self-report. Additionally, there is limited research validating the use of measures like the Y-BOCS and HRS-SR in African Americans (M. T. Williams, Wetterneck, & Sawyer, 2015), although it is intended that this study will be an important early step in realizing that goal.

Future Directions

Studying psychopathology in ethnic minorities continues to be necessitated by a prominent dearth of data, thus more research is needed to further investigate and understand the differences between cultural groups to advance our collective knowledge and determine empirically supported ways to assess this demographic.

Future research should be directed at exploring potential psychological or biological factors, which may provide a better understanding of the relationship between OCD and hoarding symptoms in African Americans. In addition, future research should endeavor to address correlates of OCD in other demographics, such as African American youth and the elderly.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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