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ScienceDirect Comprehensive Psychiatry 57 (2015) 36 – 45 www.elsevier.com/locate/comppsych

A consideration of hoarding disorder symptoms in China Kiara R. Timpano a , Demet Çek a , Zhong-Fang Fu b , Tan Tang b , Jian-Ping Wang b, c,⁎, Gregory S. Chasson d a

University of Miami, Coral Gables, FL, USA Beijing Normal University, Beijing, People's Republic of China c Capital Medical University, Beijing, People's Republic of China d Towson University, Towson, MD, USA b

Abstract Background: Hoarding disorder is rarely examined in populations of non-European and/or non-Euro-American descent, especially in East Asian nations like China. Across two studies, the current investigation sets out to examine the psychometric properties of a Chinese version of a widely used measure of hoarding symptoms—the Savings Inventory Revised (SIR)—and to explore the nature of hoarding beliefs compared to a separate US sample. Procedures: For the first study, 1828 college students in China completed a Mandarin translation of the SIR and measures of anxiety, depression, and obsessive-compulsive disorder. For the second study, 303 students from China and 87 students from the US completed the SIR and a novel hoarding beliefs questionnaire. Findings: In the first study, the Chinese-version of the SIR demonstrated convergent and discriminant validity, as well as internal reliability and preliminary construct validity. However, evidence of temporal stability was modest and requires further investigation. In the second study, the Chinese sample endorsed greater hoarding symptoms and hoarding beliefs compared to the US sample, although only themes of usefulness and wastefulness were associated with hoarding in the Chinese samples, whereas a wider range of beliefs was linked with hoarding in the US sample. In addition, the factor structure of the SIR from the first study did not replicate in second study, suggesting that construct validity of the Chinese SIR may require further corroboration. Conclusions: The current study established preliminary evidence for the reliability and validity of the Chinese SIR, although future research is needed to confirm its temporal stability and factor structure. Hoarding beliefs in China may be centered on themes of usefulness and wastefulness compared to more heterogeneous themes in the West, suggesting differential manifestations of hoarding tendencies in cultures of non-European and/or non-Euro-American descent. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Hoarding disorder represents one of the few new diagnoses included in the recent DSM-5 [1] and is characterized by extreme difficulties discarding possessions and accompanying clutter [2]. Many patients also excessively acquire objects, which contributes significantly to the distress and impairment linked with hoarding [3]. Once considered a rare phenomenon, current research indicates that symptoms are dimensionally

⁎ Corresponding author at: School of Psychology, Beijing Normal University, No. 19 Xinjiekouwai Street, Haidian District, Beijing 100875, People's Republic of China. E-mail address: [email protected] (J.-P. Wang). http://dx.doi.org/10.1016/j.comppsych.2014.11.006 0010-440X/© 2014 Elsevier Inc. All rights reserved.

distributed [4] ranging from normative collecting behaviors to extremely debilitating levels that affect between 3% and 5% of the population [5]. It has also become clear that at the clinical end of the spectrum this syndrome represents a severe public health concern with potentially serious ramifications for the individual and his or her community. Over the last decade the field has made tremendous strides in expanding our knowledge regarding the phenomenology, underlying vulnerability, and associated features of hoarding [2]. The cognitive behavioral model of hoarding developed by Frost and colleagues [6] outlines a complex relationship between core risk factors, information processing deficits, and hoarding specific beliefs that jointly give rise to saving behaviors, clutter, and acquiring. A definitive limitation of this body of research is that it has almost

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exclusively relied on samples primarily of European and/or Euro-American descent collected in the developed nations of Italy, Spain, Germany, the United States, and England [e.g., 7–9]. The only notable exceptions are two hoarding questionnaire validation studies conducted in Iran [10], a developing nation, and Brazil [11], a newly industrialized country. This culturally myopic perspective of hoarding is limiting for a number of reasons. First, there is now an increasing awareness that the phenomenology of disorders can vary across cultures and that the language with which different cultures describe syndromes and symptoms can differ in important ways [12,13]. Second, culture-specific characteristics can act as risk or protective factors, meaning that vulnerability in one culture may not translate to vulnerability in another culture [13]. Third, culture-specific factors may influence treatment utilization and effectiveness [14]. These multicultural perspectives have important implications for phenomenological investigations, as well as subsequent etiologically focused research, treatment development, and assessment practices for any given syndrome. Therefore, as we continue to expand our investigations of hoarding within a global perspective, a necessary first step will be to better understand the nature of hoarding in non-European/American based populations. Another direct implication of these considerations is that hoarding measures developed in one cultural context should not be assumed to be valid and reliable instruments in other cultural contexts [15]. China is the most populated nation in the world and Mandarin represents the most widely spoken language, making Chinese populations a particularly important culture in which to further investigate hoarding. In 2005 the Beijing Tokyo Art Projects mounted an art installation titled Waste Not by the Chinese artist Song Dong, which presents an interesting case-study of hoarding in contemporary China [16]. The exhibit consisted of thousands of everyday, domestic objects that were grouped and arranged by type (e.g., buttons, shoes, newspaper clippings, crockery, etc.). The objects were items that Dong's mother, Zhao Xiang Yuan, collected throughout her lifetime under the mantra of wu jin qi yong (物尽其用, translated as “waste not” in English), which refuses to abandon “anything that might prove useful one day” [17]. Following the death of her husband in 2002, Xiang Yuan's collecting grew to extremes, resulting in an unmanageable and unsafe home. In an effort to help his mother, Dong proposed an artistic collaboration in which they would take her collected and cluttered belongings and display them in an organized fashion in a replica of her former home. Although the term “hoarding” was never mentioned in the exhibition catalog [17], the types of objects exhibited, the artist's description of his mother's clutter and saving behaviors, and the sentiment of wu jin qi yong, are all very reminiscent of elements highlighted in the DSM-5 description of hoarding disorder [16]. Of note, the type of objects collected by Dong's mother are almost identical in nature to items commonly collected by US hoarding patients [18], and not wanting to be wasteful is a frequently endorsed belief linked with clinical saving behaviors [19].

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From an empirical perspective, our current knowledge of hoarding in Asian samples has been limited to studies investigating the phenomenology of obsessive compulsive disorder (OCD). Historically, hoarding was classified as a variant of OCD [20], and studies in China, Korea, and Japan that relied on OCD symptom measures (e.g., Obsessive Compulsive Inventory Revised, Yale Brown Obsessive Compulsive Scale) consistently indicated that hoarding represented one of the core symptom dimensions [21–25]. These findings largely mirrored outcomes from similar studies that used European or primarily Euro-American samples [26]. However, one recent study of OCD in China [25] reported some measurement difficulties with the hoarding subscale of the Chinese version of the Obsessive Compulsive Inventory Revised: poor internal reliability, low test–retest reliability, and poor criterion-related validity. These findings may be partially explained by a recent paradigm shift, specifically that hoarding should be considered a separate phenomenon from OCD [2]. From a measurement perspective this reconceptualization indicates that questionnaires designed to assess symptoms of OCD do not fully reflect hoarding as it is now described in the DSM-5 [2,4]. Research on hoarding in Asian samples has therefore failed to accurately capture the core psychopathological features, namely the three dimensions of difficulty discarding, acquiring, and clutter. In addition, no research to-date has examined risk factors or associated features (e.g., hoarding beliefs) linked with hoarding disorder, to determine if similar relationships as noted in non-Asian samples also exist in Asian samples. The current investigation sought to examine hoarding disorder symptomatology in two separate samples of Chinese students and a comparative US student sample. Our first aim was to translate and validate a Mandarin version of the Saving Inventory Revised (SIR [7]), a gold standard, self-report instrument that captures the three core features of hoarding disorder. In addition to investigating the construct validity of the Chinese version (C-SIR) in Study 1, we also considered the internal and test–retest reliability of the translation. We hypothesized that the factor structure of the C-SIR would mirror the three factor solution of the English SIR, and that it would altogether reflect a reliable and valid measure of hoarding in China. Our second aim was to examine common reasons for saving, in order to consider whether non-Asian and Chinese samples would endorse similar beliefs. Certain saving cognitions have been found to be significant and specific predictors of hoarding severity in US samples [27], including emotional attachment (emotional comfort derived from objects), memory (utility of objects as memory aids), control (the need to control possessions), and responsibility (perceived proprietary obligation toward possessions). Additional beliefs that may be relevant include wastefulness (not wanting to be wasteful), usefulness (perceived usefulness of saving objects) and aesthetics (saving possessions because they are visually pleasing) [16,19,28,29]. To date, no study has examined these beliefs within a cross-cultural perspective, and we therefore measured both hoarding symptoms and hoarding beliefs in a Chinese student sample and a US

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counterpart in Study 2. Although largely exploratory, we hypothesized that hoarding symptoms would be associated with hoarding beliefs in a similar manner across both samples. 2. Study 1 – methods 2.1. Participants The sample consisted of 1828 student volunteers from Weifang Medical University, Shanxi Normal University, and Xinzhou Normal University. Ages ranged from 17 to 30 (M = 20.6, SD = 1.2) and 64.4% were female. The ethnic composition of the sample was 95% Han Chinese, and 63% of participants reported originating from rural areas, compared to 37% from suburban or urban areas. The total sample was randomly split into two halves, which allowed us to first test the U.S. derived factor structure of the C-SIR and explore model-fit indices (n = 887, 64.9% female), followed by cross-validation of the final modified model in a separate sub-sample (n = 941, 63.9% female). 2.2. Measures 2.2.1. Chinese Saving Inventory Revised (C-SIR) The Saving Inventory Revised (SIR [7]) is a 23-item self-report questionnaire assessing a range of hoarding behaviors in both clinical and non-clinical samples. Participants are required to answer items using a 5-point Likert scale from none (0) to almost all/extreme/very often (4). The measure includes three factor analytically derived subscales, including acquisition (7 items), clutter (9 items), and difficulty discarding (7 items). SIR scores have been shown to have good psychometric indices in American samples, including strong internal consistency coefficients (α = .97–.87), as well as convergent and discriminant validity in both clinical [7] and student samples [30]. The C-SIR is a direct translation of the English instrument; recommended and standardized procedures for the crosslingual adaptation of measures were used for the translation [31,32]. Specifically, the process of translation and evaluation of the Mandarin version involved (1) translating the English SIR items into Mandarin by a native speaker (JW), (2) examining the translated version for clarity and surface-level relevance to the construct of interest by a bilingual team of researchers and clinicians, and (3) back-translating the C-SIR into English. The back-translated version was then compared to the original instrument (KT and GC), with only a few additional clarification changes necessary. 2.2.2. Chinese Obsessive Compulsive Inventory Revised (COCIR) The OCIR is a widely used measure of the severity of six OCD symptom dimensions, including washing, checking, ordering, obsessing, neutralizing, and hoarding [33]. The total score from the Chinese version of the instrument has demonstrated adequate internal consistency (α = .84) and test–retest reliability (r = .63). The total score also evidenced sufficient construct validity based on confirmatory factor

analysis of a six-factor structure, as well as patterns of convergent and discriminant validity [25,34]. For the current investigation we calculated a modified total score by excluding the hoarding items, which allowed us to examine a non-hoarding COCIR total score (COCIR-NH). 2.2.3. Chinese Center for Epidemiologic Studies Depression Scale (CES-D) The Chinese version of the CES-D [35] is a 20-item questionnaire assessing depressive symptoms. It is derived from the English version [36]. Responses are rated on a scale ranging from 1 (less than 1 day) to 4 (5 to 7 days). The total score ranges from 20 to 80. The CES-D has been shown to demonstrate high internal consistency, good validity, and acceptable test–retest reliability [35,37]. The CES-D was included in this study to investigate discriminant validity. 2.2.4. Zung Self-Rating Anxiety Scale (SAS) Based on the English version of the SAS [38], the Chinese version [39] is a 20-item questionnaire used to assess symptoms of anxiety. Responses are rated on a scale of 1 (less than 1 day) to 4 (5 to 7 days), with a total score ranging between 20 and 80. The SAS has been shown to have good reliability and represent a valid measure [39]. The scale was included to examine discriminant validity. 2.3. Procedure Data were collected at the three aforementioned universities with approval from an ethics committee. In groups participants completed a voluntary informed consent form, followed by an anonymous questionnaire packet, which took approximately 30–40 minutes to complete. Four weeks later, 219 completed a re-administration for evaluating test–retest reliability.

2.4. Data analyses Analyses were conducted using the SPSS 16.0 and AMOS 6.0 statistical software programs (SPSS Inc, Chicago, IL). Confirmatory factor analysis (CFA) in a structural equation modeling (SEM) framework was used to test the SIR/C-SIR factor model derived from US samples. Parameters were estimated using the maximum likelihood approach. Several indices were used to identify good model fit, including the chi-square statistic (χ 2 N .05), comparative fit index (CFI N .9) root mean square error of approximation (RMSEA ≤ .05), and standardized root mean square residual (SRMR b .1) [40]. Minimum acceptable factor loadings were set to N0.3, in line with standard practices. Convergent and discriminant validity were examined with Pearson correlation coefficients using C-SIR total score and subscales, the COCIR-NH, CES-D, and SAS. Reliability of the C-SIR was evaluated with the internal consistency (Cronbach's alpha) and test–retest reliability coefficients.

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3. Study 1 – results 3.1. Factor structure Using the first randomly selected subsample (n = 887), a measurement model was tested in which the three latent variables (difficulties discarding, clutter, and acquiring) were allowed to covary (see Fig. 1). This model fit the data poorly (χ 2 [227, 887] = 1107.16, p b .001, CFI = .86, RMSEA = .07, SRMR = .06). We then examined the modification indices and altered the model accordingly. First we considered the level of factor loadings to determine if all were N0.3, indicative of an acceptable validity of the directly measured variables. The two control items (items 2 and 4) were identified as having factor loadings that were too low (item 2 on acquiring = .15 and item 4 on difficulties discarding = .19). These items were subsequently

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removed from the model. Next we examined the modification indices for covariances. Results suggested that several residual error terms should be allowed to covary in order to improve fit (item 9 with item 7, item 1 with item 3, item 3 with item 5, item 10 with item 12, and item 20 with item 22). We then examined this modified model in the second randomly selected subsample (n = 941). This model fit the data (χ 2 [181, 941] = 662.83, p b .001, CFI = .92, RMSEA = .05, SRMR = .05); see Table 1 for factor loadings and squared multiple correlations (SMC). In addition, the acquiring latent variable was significantly correlated with both the clutter (/ = .68) and the difficulty discarding (/ = .85) latent variables; the clutter and difficulty discarding latent variables were also significantly correlated (/ = .77) with one another.

SIR 2: control SIR 9: distress SIR 11: urge SIR 14: distress

A

SIR 16: impairment SIR 18: urge SIR 21: frequency

SIR 1: level SIR 3: level SIR 5: level SIR 8: level

C

SIR 10: interference SIR 12: distress SIR 15: control SIR 20: level SIR 22: level

SIR 4: control SIR 6: severity SIR 7: distress

DD

SIR 13: urge SIR 17: avoid SIR 19: frequency SIR 23: severity

Fig. 1. The factor model of the English Saving Inventory Revised, including the three latent factors difficulty discarding (DD), acquiring (A), and clutter (C). To achieve good fit with a Chinese sample, several modifications were made: two items (dotted lines) were removed from the final model, and several error terms were allowed to covary (double headed arrows joining items).

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3.2. Correlations, internal reliability, and test–retest reliability Means, standard deviations and ranges for the C-SIR and non-hoarding measures are included in Table 2. Table 3 captures the correlations between each of the C-SIR subscales and the total score, as well as correlations with the other symptom measures, including non-hoarding OCD (COCIR-NH), general anxiety (SAS), and depression (CESD). Results revealed that each of the C-SIR subscales correlated strongly with the C-SIR total score (r‘s between .83 and .84), yet the intercorrelations between the subscales were characterized as more moderate (r‘s between .54 and .64). Similarly, the strength of the correlations between the C-SIR and the COCIR-NH, SAS, and CES-D was moderate. These results support patterns of convergent and discriminant validity. Also reflected in Table 3 are the test–retest correlations and the internal reliability coefficients for the C-SIR total and subscale scores. All alphas were deemed to be acceptable (α N .7). 4. Study 2 – methods 4.1. Participants The Chinese sample consisted of 303 student volunteers from Weifang Medical University, Shanxi Normal University, Table 1 Chinese Saving Inventory Revised confirmatory factor analysis data for modified model, including factor loadings and squared multiple correlations. Latent factor C-SIR item: summarized description Acquiring Item 9: distress if not able to acquire Item 11: strength of urge to acquire free things Item 14: distress about acquiring habits Item 16: financial difficulties due to compulsive buying Item 18: frequency of urge to acquire Item 21: frequency of acquiring Clutter Item 1: level of clutter in living area Item 3: amount of home clutter prevents use of Item 5: amount of home made impassable by clutter Item 8: extent that belongings result in clutter Item 10: interference caused by clutter Item 12: distress caused by clutter Item 15: degree of inability to control clutter Item 20: frequency of clutter preventing social encounters Item 22: degree to which clutter prevents use of home Difficulties discarding Item 6: degree of difficulties discarding Item 7: distress caused by discarding Item 13: urge to save Item 17: frequency of avoiding discarding Item 19: frequency of decisions to save objections Item 23: severity of inability to discard

Loading SMC .48 .63 .48 .55 .64 .70

.23 .39 .23 .30 .41 .49

.47 .46 .54 .65 .65 .68 .66 .61 .66

.22 .24 .29 .43 .42 .46 .43 .37 .43

.54 .50 .52 .51 .70 .68

.29 .25 .27 .26 .49 .46

C-SIR = Chinese Saving Inventory Revised; Loading = factor loading; SMC = squared multiple correlations; Acquiring = acquiring latent factor; Clutter = clutter latent factor; Difficulties discarding = difficulties discarding latent factor.

and Xinzhou Normal University. Ages ranged from 17 to 30 (M = 22.1, SD = 2.1) and 72.6% were female. The ethnic composition of the sample was 94.4% Han Chinese, and 46% of participants reported originating from rural areas, compared to 54% from suburban or urban areas. The US sample consisted of 87 young adults at a large university. Ages ranged from 18 to 29 (M = 19.18, SD = 2.4), and 68% were female. The racial/ethnic composition of the sample was as follows: African American (8.9%), Asian American (3.0%), Caucasian (72.6%), Hispanic/Latino (10.8%), and other (4.8%). 4.2. Measures 4.2.1. Saving Inventory Revised (SIR) See Study 1 for a full description. The Chinese sample completed the C-SIR. The US sample completed the English version of the SIR [7]. Given that Study 1 demonstrated that items 2 and 4 should not be included for acceptable model fit with a Chinese sample, a modified total score (removing items 2 and 4) was calculated for the English version of the SIR. This allowed for easier comparisons between the two samples. 4.2.2. Saving Beliefs Questionnaire (SBQ) For the purposes of the current investigation, we created a short, 14-item exploratory measure examining a range of attitudes and beliefs associated with hoarding disorder. We first examined the Saving Cognitions Inventory (SCI [27]), a validated and established measure of hoarding beliefs. The SCI includes four belief categories, including emotional attachment, memory, control, and responsibility. We also included three additional categories that are not captured by the SCI. Notions of wastefulness and potential usefulness were included to reflect the Chinese phrase wu jin qi yong (i.e., waste not) [16,17], and beliefs about aesthetic qualities were included because hoarding patients often discuss their attachment to objects because they are beautiful and/or pleasing [28,29]. Each of the final seven categories included two items, and all items were designed to be answered on a 7-point Likert scale from not at all (1) to very much (7). The representative items for each of the four SCI subscales were selected based on high factor loadings in a US sample [27] and cross-cultural considerations. Following the initial selection of questions for each category, the items were translated from English into Mandarin by a native speaker (JW), evaluated for clarity by lay Mandarin-speakers, and then back-translated into English [31,32]. Modifications were subsequently made to several of the items to better match and clarify wording in both versions. The specific items included in each category were the following: • Emotional attachment: My possessions give me tremendous emotional comfort. My possessions represent an important part of who I am. • Memory: I keep my possessions because they help me remember things. Possessions should be saved because of their informational content.

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• Control: I like to maintain sole control over my things. No one has the right to touch my possessions. • Responsibility: I am responsible for the well-being of this possession. I am responsible for finding a use for this possession. • Wastefulness: I find it difficult to discard my possessions because it is extremely wasteful to throw things away. I believe everything should be used fully or completely, and nothing should be wasted. • Usefulness: Having many of a particular possession is helpful because you'll never run out. Saving objects is useful for the future, because you may need them down the road. • Aesthetic qualities: I value my possessions because I find them pleasing to look at. My home is more visually pleasing with my possessions. 4.3. Procedure Participants completed the questionnaires at their respective Chinese and US universities in exchange for partial course credit and after having completed an informed consent form. The study took approximately 30–40 minutes to complete. All experimental guidelines were in accordance with American Psychological Association standard ethical guidelines. Both studies were approved by their respective ethics committees (e.g., institutional review board) prior to data collection. 4.4. Data analyses Analyses were conducted using the SPSS 16.0 and AMOS 6.0 statistical software programs (SPSS Inc, Chicago, IL). Confirmatory factor analysis (CFA) in a structural equation modeling (SEM) framework was used to test the modified factor model of the C-SIR identified in Study 1. Please see Study 1 for a more detailed description of the CFA methods. Independent-samples t-tests, adjusted for violations of homogeneity of variance as needed, were carried out to compare the US and Chinese samples on rates of endorsement for hoarding symptoms and saving beliefs. The relationship between hoarding symptoms and beliefs was examined with Pearson correlations between the SBQ categories and the C-SIR total score.

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Table 3 Correlations between C-SIR total and subscale scores and measures of anxiety, depression, and obsessive compulsive disorder symptoms, along with C-SIR internal reliability coefficients and test-retest reliability in Study 1. Correlations with C-SIR scores Total Difficulty Clutter Acquisitioning α discarding C-SIR: total C-SIR: difficulty discarding C-SIR: clutter C-SIR: acquisitioning COCIR-NH SAS CESD Test–retest reliability (r)

.84 .86 .83 .45 .38 .35 .54

.55 .64 .39 .31 .31 .41

.54 .36 .32 .30 .53

.89 .76 .85 .75 .89 .75 .87

.38 .32 .29 .46

All Pearson correlation coefficients had p‘s b .001. C-SIR = Chinese Saving Inventory Revised; COCIR-NH = Chinese ObsessiveCompulsive Inventory-Revised, Non-Hoarding total score; SAS = Zung Self-Rating Anxiety Scale; CESD = Chinese Center for Epidemiologic Studies Depression Scale.

5. Study 2 – results 5.1. Factor structure In an effort to replicate the CFA findings from Study 1, we first examined the stability of the modified factor structure in the Study 2 Chinese sample. Results demonstrated that the model fit the data poorly (χ 2 [181, 303] = 522.39, p b .001, CFI = .83, RMSEA = .08, SRMR = .08). We next considered whether any additional modifications would render a better fitting model. All factor loadings were greater than .03, indicating acceptable validity, and the modification indices suggested that only modest improvements in fit would be possible with additional adjustments. 5.2. Comparison of hoarding symptoms in the US and Chinese samples Means, standard deviations and ranges for the C-SIR are included in Table 2. Across the total and subscale scores, the Chinese participants reported greater hoarding symptoms than the US participants. Statistical comparisons revealed

Table 2 Means, standard deviations (SD), and ranges for measures of interest. Study 1

Study 2

Chinese sample (N = 1828)

C-SIR: total C-SIR: difficulty discarding C-SIR: clutter C-SIR: acquisitioning COCIR-NH SAS CESD

M (SD)

Range

24.94 (10.12) 8.30 (3.59) 8.66 (4.83) 7.97 (3.54) 8.06 (7.5) 32.45 (6.48) 12.00 (8.67)

0–72 0–24 0–29 0–20 0–54 20–60 0–54

Chinese sample (N = 303) M (SD) 25.31 (10.70) 7.94 (3.87) 9.09 (5.06) 8.28 (3.76) -

Range 0-55 0-19 0-25 0-23 -

US sample (N = 87) M (SD) 15.64 (11.56) 4.94 (3.87) 5.40 (5.26) 5.30 (3.84) -

Range 0–46 0–15 0–18 0–14 -

C-SIR = Chinese Saving Inventory Revised; COCIR-NH = Chinese Obsessive-Compulsive Inventory-Revised, Non-Hoarding total score; SAS = Zung Self-Rating Anxiety Scale; CESD = Chinese Center for Epidemiologic Studies Depression Scale.

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that these differences were significant (total: t(388) = 7.29, p b .001; clutter: t(388) = 5.94, p b .001; difficulties discarding: t(388) = 6.35, p b .001; acquiring: t(388) = 6.50, p b .001), and represented a large effect size for the total score (Cohen's d = .87) and medium-large effect size for the subscale scores (Cohen's d = .71–.78). 5.3. Comparison of reasons for saving in the US and Chinese samples Next we examined the different saving beliefs captured by the SBQ. In the present sample the SBQ total demonstrated acceptable internal reliability (ɑ = .92 for combined sample; ɑ = .95 for US sample; ɑ = .78 for Chinese sample). Similar to the C-SIR comparisons, the Chinese sample endorsed all saving beliefs to a greater degree than the US sample. The differences across the SBQ total and subscale scores were found to be significant (Table 4) and represented large effect sizes. We next considered correlations between the SBQ and the C-SIR across each of the samples separately (Table 4). In line with our hypotheses and previous research, every category of saving beliefs was significantly correlated with hoarding symptoms in the US sample. In stark contrast, only the total score and the usefulness and wastefulness categories were significantly correlated with hoarding symptoms in the Chinese sample. 6. Discussion The current study represents the first examination of DSM-5 defined hoarding disorder symptoms [1] within a Chinese population, using the Mandarin version of the SIR. Given the emerging research that hoarding embodies a stand-alone

syndrome [20], newer measures that validly assess the core hoarding features are required. The SIR represents a self-report instrument that reliably captures the full spectrum of saving behaviors [4,41] across the three domains of difficulties discarding, acquiring, and clutter. The SIR is also the most widely used hoarding measure, and as such it will be necessary and informative for future research on hoarding to establish this questionnaire as a cross-cultural instrument. Although it has been suggested that hoarding disorder is restricted to developed-nations, there are reasons to surmise that clinically significant saving and acquiring behaviors are a cross-cultural phenomenon. Support comes largely from the convergence of findings using Iranian, Brazilian, US/European, and Australian samples to investigate hoarding. The case-study of the artist Song Dong's mother presented in the introduction, along with the results from the present empirical study, provides further credence to the notion that hoarding symptoms are present across the globe and reflect the same general construct. The current study demonstrated that the Mandarin version of the SIR met certain conventional psychometric criteria. Results supported the convergent and discriminant validity with measures of OCD, depression, and anxiety symptoms. The internal consistency for the total and subscale scores was found to be acceptable (ɑ N .70). However, the modest strength of the correlations for test–retest reliability suggests that temporal stability of the C-SIR may require further examination in future research. Our consideration of the factor structure revealed several issues that should be examined further in subsequent research. The first issue is that the two ‘control’ items, which ask about one's perceived self-control over saving and acquiring behaviors, did not demonstrate strong enough loadings on

Table 4 Comparison of mean scores on the Saving Beliefs Questionnaire and correlations with hoarding symptoms across the two samples in Study 2.

Comparison of means (SD) across samples SBQ: Total SBQ: Memory SBQ: Attachment SBQ: Control SBQ: Responsibility SBQ: Usefulness SBQ: Wastefulness SBQ: Aesthetic Correlations with the C-SIR total score across samples SBQ: Total SBQ: Memory SBQ: Attachment SBQ: Control SBQ: Responsibility SBQ: Usefulness SBQ: Wastefulness SBQ: Aesthetic C-SIR = ⁎ ⁎⁎ ⁎⁎⁎

Chinese sample (N = 303)

US sample (N = 87)

t statistic

df

d

63.67 (10.67) 10.25 (2.37) 9.25 (2.40) 7.34 (2.47) 8.99 (2.53) 8.98 (2.39) 9.74 (2.51) 9.13 (2.33)

32.29 (16.97) 4.89 (3.14) 4.24 (2.75) 5.16 (3.11) 4.18 (2.79) 4.60 (2.79) 4.24 (2.59) 4.98 (2.91)

16.00⁎⁎⁎ 14.46⁎⁎⁎ 16.27⁎⁎⁎ 5.91⁎⁎⁎ 14.98⁎⁎⁎ 13.05⁎⁎⁎ 17.55⁎⁎⁎ 11.98⁎⁎⁎

100.39 108.96 384 112.02 384 117.27 384 112.21

2.21 1.93 1.94 .78 1.81 1.69 2.16 1.57

.16⁎⁎ .07 .08 .01 .07 .18⁎⁎ .20⁎⁎ .07

Chinese Saving Inventory Revised; SBQ = Saving Beliefs Questionnaire. p b .05. p b .01. p b .001.

.52⁎⁎⁎ .51⁎⁎⁎ .50⁎⁎⁎ .23⁎ .49⁎⁎⁎ .45⁎⁎⁎ .41⁎⁎⁎ .47⁎⁎⁎

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their respective factors and were therefore removed from the final model. Although it is difficult to make any firm conclusions about why these items in particular had to be removed, it may be that there are differences in the cultural interpretation of the phrasing regarding control, or that the construct of control plays less of a (perceived or actual) role in Chinese hoarding symptomatology. Relevant to these considerations is a small body of research that has suggested that greater importance is placed on self-control in more collectivistic societies, such as China, compared to more individualistic societies, such as the U.S. [42]. For example, the Chinese terms “kè jǐ” and “kè zhi”, referring respectively to “control of self” and “to restrain,” are regarded as desirable virtues within Confucianism [43]. Future research in China, including qualitative and ethnographic accounts of control, may be needed to parse out these details further, particularly as they relate to hoarding. The second issue to consider in future studies is that the modified model identified in Study 1 did not result in good fit with the sample from Study 2. Given that the smaller sample size in Study 2 may have resulted in decreased power compared to Study 1, replication in both similar and different samples will be necessary to definitively identify the factor structure of the C-SIR in Chinese populations. Although the two student samples were drawn from the same general population, it is possible that slight demographic differences resulted in the non-replication of fit. Another plausible explanation is that the three factor model would be better captured in clinical samples of individuals with hoarding disorder. Although research with US and European samples has demonstrated that hoarding symptoms are dimensionally distributed [4], and we would have no reason to believe this to be any different across cultures, it could be that the taxometric and factor structure of hoarding is variant in China. The direct comparison between the US and Chinese student samples in Study 2 revealed several interesting differences. Foremost was the greater endorsement of hoarding symptoms in the Chinese sample. This difference was particularly striking for the C-SIR total score, where the US sample endorsed rates almost one standard deviation lower than the Chinese sample. Without a Chinese epidemiological study on hoarding disorder, it is impossible to draw any conclusions regarding the meaning of this greater endorsement of symptoms. An initial step would be to examine whether similar differences would emerge when using alternative assessment instruments, such as the interview based Hoarding Rating Scale [44] or the pictorial Clutter Image Rating [45]. Should the over endorsement of symptoms replicate in other samples and using different measures, it will be important to investigate the reasons underlying the higher endorsement of symptoms. In addition, clinical cut-offs derived using US/European clinical samples may need to be adjusted when considering a Chinese population. Previous research has demonstrated that depression scores on the CES-D also tend to be higher in Chinese versus US samples [46]. One theory put forth is that differences may result from higher levels of concomitant

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health problems and the experience of greater general life stress in Chinese populations. It is possible that similar factors are at play in relation to hoarding, as symptoms have been linked with greater rates of physical and psychiatric comorbidity [47], as well as greater endorsement of general life [48] and traumatic stressors [49]. Similar to the findings for the C-SIR, we also found evidence for greater endorsement in the Chinese sample across each of the seven saving belief categories we assessed. This finding could speak to a cultural phenomenon, wherein Chinese populations simply feel more strongly about beliefs about saving compared to US samples. When we examined the relationship between saving beliefs and hoarding symptoms, only wastefulness and usefulness beliefs were significantly linked with hoarding symptoms in a Chinese sample, whereas all seven belief categories were strongly associated with hoarding in the US sample. Conclusions about what this may mean should be made very cautiously without further research. One possibility is that hoarding in China is associated with different vulnerabilities than hoarding in US/European cultures. Alternatively, hoarding beliefs may represent a post-hoc explanation for why an item was acquired or saved, and is plausible that culture could enact a strong influence on shaping these rationalizations [12,13]. Another hypothesized explanation for the stronger endorsement of hoarding symptoms and beliefs in the Chinese sample is a potentially culture-specific response tendency to rate items at the extremes. Considering the general research literature, there are a number of studies that reveal inclinations toward extreme styles of answering items [50,51], although others highlight the opposite pattern [52,53]. This suggests that subtle moderators may play a role in influencing the type of response style (i.e., extreme versus under-endorsement of items). Theorized moderators include the focus of questions, the nature of the reference group [54], the presence of participant anonymity [55], and culture. No study has directly evaluated response tendencies on Likert measures of hoarding or OCD in China, but certainly it is plausible that cultural differences may have resulted in extreme responding on the C-SIR and SBQ Likert scales in the Chinese samples. Findings overall should be interpreted with caution, as the present student samples may not be representative of the Chinese people or Chinese immigrant populations more generally. As highlighted above, future research should examine hoarding disorder symptomatology in different samples, including the general population and clinical samples. Given the rapid urbanization currently taking place in China, research may also wish to examine differences between rural and urban populations. An additional limitation is that the measure we used to examine hoarding disorder symptoms was a self-report instrument. It will therefore be important to supplement our consideration of the C-SIR with translations of other measures developed for the assessment of hoarding disorder (e.g., the interview form of the Hoarding Rating Scale). Using a multimethod approach to assess hoarding

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symptoms would furthermore help alleviate potential concerns about Chinese response styles with Likert scales. In summary, the Mandarin version of the SIR demonstrated acceptable internal consistency and satisfactory convergent and discriminant validity. The factor structure and temporal stability of the C-SIR will need to be considered more closely in future research. Our findings regarding the over-endorsement of symptoms and the differences in saving beliefs linked with hoarding symptoms, generally point to the importance of conducting more research on hoarding disorder in China and other cultures that have yet to be investigated, such as Indo-Asian and African populations. As we continue to establish and define the construct of hoarding disorder, these types of globallyfocused studies will be invaluable, particularly with regard to the investigation of etiological factors and maintenance factors, as well as the development of more efficacious treatments [12,14]. References [1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington: American Psychiatric Association; 2013. [2] Mataix-Cols D, Frost RO, Pertusa A, Clark LA, Saxena S, Leckman JF, et al. Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety 2010;27:556-72. [3] Frost RO, Tolin DF, Steketee G, Fitch KE, Selbo-Bruns A. Excessive acquisition in hoarding. J Anxiety Disord 2009;23:632-9. [4] Timpano KR, Broman-Fulks JJ, Glaesmer H, Exner C, Rief W, Olatunji BO, et al. A taxometric exploration of the latent structure of hoarding. Psychol Assess 2013;25:194-203. [5] Timpano KR, Exner C, Keshaviah A, Rief W, Brähler E, Wilhelm S. The epidemiology of the proposed hoarding disorder: exploration of the acquiring specifier, associated features, and distress. J Clin Psychiatry 2011;72:780-6. [6] Frost RO, Hartl TL. A cognitive-behavioral model of compulsive hoarding. Behav Res Ther 1996;34:341-50. [7] Frost RO, Steketee G, Grisham JR. Measurement of compulsive hoarding: Saving Inventory-Revised. Behav Res Ther 2004;42:1163-82. [8] Mueller A, Crosby RD, Frost RO, Leidel B, Bleich S, Glaesmer H, et al. Fragebogen zum zwanghaften Horten (FZH) – Validierung der deutschen Version des Saving Inventory-Revised (German Compulsive Hoarding Inventory (FZH) – evaluation of the German version of the Saving Inventory-Revised). Verhaltenstherapie 2009;19:243-50. [9] Tortella-Feliu M, Fullana MA, Caseras X, Andion O, Torrubia R, Mataix-Cols D. Spanish version of the savings inventory-revised: adaptation, psychometric properties, and relationship to personality variables. Behav Modif 2006;30:693-712. [10] Mohammadzadeh A. Validation of Saving Inventory-Revised (SI-R): compulsive hoarding measure. Iran J Psychiatry Clin Psychol 2009;15 (1):33-41. [11] Fontenelle IS, Prazeres AM, Borges MC, Range BP, Versiani M, Fontenelle LF. The Brazilian Portuguese version of the Saving InventoryRevised: internal consistency, test-retest reliability, and validity of a questionnaire to assess hoarding. Psychol Rep 2010;106:279-96. [12] Draguns JG. Abnormal behavior patterns across cultures: implications for counseling and psychotherapy. Int J Intercult Relat 1997;21:213-48. [13] Draguns JG, Tanaka-Matsumi J. Assessment of psychopathology across and within cultures: issues and findings. Behav Res Ther 2003;41:755-76. [14] Bernal G. Intervention development and cultural adaptation research with diverse families. Fam Process 2006;45:143-51.

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