ORDERING AND ARRANGING COMPULSIONS 1 Symmetry, Ordering and Arranging Compulsive Behaviour

Compulsive ordering and arranging, and a preoccupation with symmetry are features of obsessive-compulsive disorder (OCD) that have not been examined experimentally. Three connected studies were conducted to examine this phenomenon: a self-report measure of this behaviour was developed and validated, participants were asked to engage in tasks designed to assess preferences for order, and to assess the interference of disorder in the completion of a stressful activity. The self-report measure has sound psychometric properties and validity. Participants with a strong preference for order were made more anxious by having to complete a difficult task in a disorganized environment. Participants without this preference did not show this effect. The results are discussed in terms of the phenomenology of compulsive ordering and arranging, and its relationship to both OCD and normal human behaviour. It is suggested that compulsive ordering and a drive for symmetry are extreme manifestations of the common preference for order and symmetry. ORDERING AND ARRANGING COMPULSIONS 3 Symmetry, Ordering and Arranging Compulsions A feature of obsessive-compulsive disorder (OCD) that has received little attention is a compulsion to order and arrange one’s surroundings, to avoid disorderly surroundings, and to ensure that objects are arranged in “exactly the right way”. This may often include an increased preference for symmetry, either generally, or with respect to a few select possessions. Patients will often report that they need to ensure that their belongings are “just right” before they can proceed with their day, often spending several hours in front of a shelf or table, repositioning objects until their anxiety decreases to a tolerable level. While our knowledge of different types of OCD has been expanding (Rachman, 1997, 1998, 2002), little attention has been given to this set of symptoms. Given the results of epidemiological data indicating that ordering and arranging is one of the more common presentations of OCD (e.g., Rasmussen & Eisen, 1992; Sasson et al., 1997), in adults (e.g., Leckman et al., 1997; Summerfeldt et al., 1999), and in children (e.g., Flament et al., 1988; Valleni-Bassile et al., 1994), the neglect is surprising. There is an absence of experimental analyses of ordering and arranging, and of theoretical explanations of this behaviour. Little is known about the specific phenomenology of ordering and arranging other than the experiences of those who encounter the problem clinically. Compulsive ordering and arranging are often seen in children with OCD. In a study of the development of OCD, it was found that nearly half of a sample of children with OCD were engaged in ordering and arranging behaviour and/or were preoccupied with a need for symmetry (Shafran, Rachman, & Teachman, 2001). For many parents, compulsive ordering and arranging is the first sign that their child is encountering problems. The prominence of ordering and arranging in childhood OCD is not matched by a comparable prominence in adult OCD, ORDERING AND ARRANGING COMPULSIONS 4 suggesting that the problem gradually wanes in intensity or is perhaps overshadowed by the emergence of more intrusive problems. Of course, not all ordering and arranging behaviour is abnormal and the dividing line between normal and abnormal aspects of this compulsive activity remains to be determined. It is an important feature of socially meaningful ritualistic behaviour in many cultures (Dulaney & Fiske, 1994; Fiske & Haslam, 1997). Given the wide range of data about obsessional and compulsive phenomena in the normal population (see review by Gibbs, 1996), it is quite likely that ordering and arranging behaviour occur, and can be investigated in both normal and clinical samples. Indeed, it has been reported as one of many types of behaviour engaged in by normal participants in a study of normal rituals (Rassin, Merckelbach, Muris & Stapert, 1999). It is possible that this compulsion serves the same purpose as many other compulsions to reduce anxiety (Rachman & Hodgson, 1980). People with ordering and arranging compulsions may feel that by obtaining control over a small part of their external environment (which may also include an internal sense of being “just right”), they can feel safe and/or more in control of the rest of their environment. This is similar to some conceptualizations of eating disorders, in which it is hypothesized that some of these patients restrict their diets because they feel that weight is one of the few things that they can control and this limited control provides some relief from a perceived chaotic world (Fairburn, Shafran & Cooper, 1999; Rodin, 1977). This similar formulation may account for the strong overlap between eating disorders and the specific subtype of ordering and arranging within OCD found by Matsunaga and colleagues (1999). Theoretical and established areas of overlap between eating disorders and compulsive disorders are common. These include Thought-Action Fusion in OCD (Shafran, Thordarson & ORDERING AND ARRANGING COMPULSIONS 5 Rachman, 1996) and Thought-Shape Fusion in eating disorders (Radomsky, et al., 2002; Shafran, Teachman, Kerry & Rachman, 1999). There is also an obvious overlap between OCD and obsessive-compulsive personality disorder (OCPD). This personality disorder is characterized by a “preoccupation with orderliness, perfectionism, and mental and interpersonal control” (American Psychiatric Association, 1994, p.669), and there is no reason to assume that ordering and arranging behaviour in OCD is different from the behaviour in OCPD. The conceptualization of this behaviour as an attempt at gaining more control is applicable to both disorders. OCD ordering and arranging may serve a different function as anxiety reducing behaviour; whereas OCPD ordering and arranging may be done because of a simple preference for orderly environments. Much like other symptoms of OCD, we would expect that ordering and arranging behaviour lies on a continuum from normal, adaptive, everyday ordering and arranging behaviour to more significant, clinically impairing compulsive ordering and arranging. Certainly, we all need some degree of order in our lives. We tend to sort and arrange things naturally for convenience (e.g., plates, glasses, pots, are kept in groups/piles in the kitchen), for aesthetics (e.g., pictures tend to hang on our walls level with the floor/ceiling, organized rooms are more appealing, etc.), and for cultural reasons (Dulaney & Fiske, 1994; Fiske & Haslam, 1997). In the absence of any ordering and arranging, it would be more difficult to find the things we need, to manoeuvre safely through our homes, and to live in our complicated physical and social environments. Some of us tend to prefer more order than others and many people feel as if the objects in their home (e.g., trophies, prized possessions, etc.) have an exact and proper place. Obsessions and compulsions occur in non-clinical populations (Gibbs, 1996); for example, virtually all ORDERING AND ARRANGING COMPULSIONS 6 people experience the same types of thoughts as patients with obsessions (Rachman & de Silva, 1978; Salkovskis & Harrison, 1984). We also know that behaviour almost identical to compulsions occurs in non-clinical groups (Muris, Merkelbach & Clavan, 1997; Rassin et al., 1999). It is reasonable to expect then, that a preference for order and some amount of arranging behaviour is prevalent in a majority of people. This hypothesis needs to be tested however, and evidence from other studies of normal undergraduates and community adults suggests that, if it is present, it can be easily detected (Gibbs, 1996). In order to assess the degree to which this behaviour occurs in non-clinical populations, there is a need for a tool that measures ordering and arranging behaviour. One of the most popular pencil and paper measures of OCD symptomatology has been the Maudsley Obsessional Compulsive Scale (MOCI Rachman & Hodgson, 1980). Regrettably, none of the 30 items in this scale assesses ordering or arranging behaviour or a desire for symmetry. The revision of the MOCI, the Vancouver Obsessive Compulsive Scale (VOCI Thordarson, Radomsky, Rachman, Sawchuk, Shafran & Hakstian, 2003), contains only one relevant item, “I feel upset if my furniture or other possessions are not always in exactly the same position”, and it does not adequately assess the full range of ordering and arranging behaviour hypothesized to occur among compulsive orderers and arrangers. While other self-report measures of ordering and arranging behaviour do exist (e.g., the Ordering Scale of the Obsessive-Compulsive Inventory, OCI, Foa et al., 1998; and the Dressing and Grooming Subscale of the revised Padua Inventory, Burns et al., 1996), problems have been suggested regarding the ease of use of the OCI (Thordarson et al., 2003) and both the specificity (Taylor, 1998) and comprehensiveness (Thordarson et al., 2003) of the Padua. ORDERING AND ARRANGING COMPULSIONS 7 The development of a new psychometric assessment tool provides an opportunity to gather information about the singularity of the construct. Unlike claustrophobia, which is comprised of both a fear of restriction and a fear of suffocation (Rachman & Taylor, 1993; Radomsky et al., 2001), it is unlikely that ordering and arranging behaviour is made up of highly separable elements. Compulsive ordering and arranging seem to be related to a simple distress or discomfort in the presence of disorderliness and a contrasting calmness in the presence of orderliness. While there are occasional cases that present with concerns about only symmetry, for example, the majority appear to have more general preferences for orderliness. Idiosyncratic cognitions can underlie this behaviour (e.g., “if my belongings are not properly arranged, my husband will be in an accident” or “if my belongings are not just right, I will have bad luck”) as with other compulsive behaviour. However, clinicians indicate that ordering and arranging compulsions often occur in the absence of these types of fear-related cognitions. The demonstration of a unitary factor structure within a self-report measure of ordering and arranging behaviour would lend support to this hypothesis, indicating consistency across this behaviour rather than a collection of idiosyncratic manifestations. Additionally, an experiment in which participants are asked to indicate their preference for both orderly and disorderly environments would provide a more ecologically valid method for assessing the degree to which ordering and arranging preferences are prevalent. Also, provoking participants who express a strong preference for orderly surroundings, by having them complete a difficult task in a disorderly and disorganized environment, should provide an opportunity to examine the beliefs and cognitions operating in these people in vivo, as well as to test the hypothesis that these people are more anxious when they are placed in disorderly surroundings. Should we find elevated anxiety among participants who have a ORDERING AND ARRANGING COMPULSIONS 8 preference for order, who are placed in disorderly surroundings, it may provide some indication of how these preferences lead to distress and interference in daily functioning. In order to evaluate the present conceptualization of normal and abnormal ordering, arranging and symmetry compulsions, a set of psychometric, experimental, and ecologically valid studies was conducted. Study 1 Aim: The aim of this first study was to develop a psychometric scale (The Symmetry, Ordering and Arranging Questionnaire – SOAQ) to assess beliefs and behaviour associated with compulsive ordering and arranging. The scale was developed to serve as an optional module, to supplement the VOCI (Thordarson, et al., 2003) in cases where a more comprehensive assessment of ordering and arranging behaviour is desired. Method – Phase I Thirty-four items pertaining to compulsive ordering, arranging and a desire for symmetry were formulated by the UBC Fear and Anxiety Disorders Laboratory from both theoretical conceptualizations and clinical presentations of ordering and arranging in OCD. Items were based on clinical reports, on logical extensions of items developed for the Vancouver Obsessional Compulsive Inventory (VOCI – Thordarson et al., 2003), and on extensions of current cognitive behavioural conceptions of OCD. This scale was distributed to 250 undergraduate psychology students, who were asked to rate each item on a 0 to 4 scale to indicate how strongly they agree with each statement. Participants were also asked to complete scales that assess both highly and moderately related constructs – e.g., the Maudsley Obsessional-Compulsive Inventory – MOCI (Rachman & ORDERING AND ARRANGING COMPULSIONS 9 Hodgson, 1980), the Vancouver Obsessive Compulsive Inventory – VOCI (Thordarson, et al., 2003), the Beck Anxiety Inventory – BAI (Beck & Steer, 1990), and the Beck Depression Inventory II – BDI (Beck, Steer, & Garbin, 1996). Participants were offered course credit upon the return of the completed questionnaires to the lab. Participants We received 211 completed questionnaire packages (a return rate of 84.4%). 74.3% of participants who completed the questionnaires were female. Other participant characteristics are displayed in Table 1. Results – Phase 1 Inter-item reliability The inter-item reliability of the 34 items was high, Cronbach’s α=0.98. Factor Structure Items were subjected to a principal components analysis (without rotation). The best solution (both statistically and conceptually) was a one-factor solution that accounted for 56.7% of the variance. Factor loadings, item means and standard deviations are displayed in Table 2. Items from the original pool with factor loadings of less than 0.7 (items 9, 10, 17, 23, 29, 31, 33 and 34) were removed. Additionally, items with means at or less than 0.6 (items 5, 7, 14, 16, 24 and 25) were deleted in order to produce a scale that will better discriminate between normal and excessive orderers/arrangers. ORDERING AND ARRANGING COMPULSIONS 10 Method – Phase 2 The revised 20-item SOAQ was distributed to an additional 250 undergraduate psychology students, along with related questionnaires (MOCI, VOCI). Questionnaires which assess problems that are NOT hypothesized to be closely related to compulsive ordering and arranging, such as the BDI, the BAI, the Claustrophobia Questionnaire – CLQ (Radomsky et al., 2001), the Agoraphobic Cognitions Questionnaire – ACQ (Chambless et al., 1984), and the Body Sensations Questionnaire – BSQ (Chambless et al., 1984) were also included. Participants received course credit for completing the questionnaires if/when they returned them to the lab. Participants There were 190 questionnaire packages returned by psychology undergraduate students (a return rate of 76.0%). 72.3% of the participants who completed the questionnaire packages were female. Other participant characteristics are displayed in Table 1. Results – Phase 2 Inter-item reliability The inter-item reliability of the SOAQ was high, Cronbach’s α=0.96.