Amanda N. Medley a, Daniel W. Capron a, Kristina J. Korte a & Norman B. Schmidt a a Department of Psychology, Florida State University,

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1 This article was downloaded by: [Florida State University] On: 15 March 2014, At: 08:05 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Cognitive Behaviour Therapy Publication details, including instructions for authors and subscription information: Anxiety Sensitivity: A Potential Vulnerability Factor For Compulsive Hoarding Amanda N. Medley a, Daniel W. Capron a, Kristina J. Korte a & Norman B. Schmidt a a Department of Psychology, Florida State University, Tallahassee, FL, USA Published online: 19 Mar To cite this article: Amanda N. Medley, Daniel W. Capron, Kristina J. Korte & Norman B. Schmidt (2013) Anxiety Sensitivity: A Potential Vulnerability Factor For Compulsive Hoarding, Cognitive Behaviour Therapy, 42:1, 45-55, DOI: / To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content ) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at

2 Cognitive Behaviour Therapy, 2013 Vol. 42, No. 1, 45 55, Anxiety Sensitivity: A Potential Vulnerability Factor For Compulsive Hoarding Amanda N. Medley, Daniel W. Capron, Kristina J. Korte and Norman B. Schmidt Department of Psychology, Florida State University, Tallahassee, FL, USA Abstract. Compulsive hoarding is defined as the accumulation of and failure to discard a large number of possessions that appear to be useless or limited in value. Severe hoarding can result in illnesses due to unsanitary conditions, social isolation, work disability, and even death. Despite the severity of impairment associated with this clinical syndrome, research examining potential vulnerability factors is limited. Two independent studies have demonstrated that hoarding behaviors are significantly associated with anxiety sensitivity (AS), a well-known risk factor for anxiety pathology. However, the relationship between AS subfactors and hoarding behaviors is somewhat unclear. The primary aim of this investigation was to examine the relationships between hoarding and AS subfactors utilizing the anxiety sensitivity index-3, a measure designed to more accurately assess AS subfactors. Participants consisted of 279 college students, as well as 210 nonselected clinical participants. Consistent with initial predictions, hoarding behaviors were significantly associated with overall AS. Moreover, when looking at the relationships among hoarding behaviors and specific AS subfactors, hoarding was significantly associated with the physical concerns subscale. Finally, when examining the relationships among overall AS and specific hoarding facets, results indicated that the difficulty discarding subfactor of hoarding was associated with overall AS. Implications for future research and treatment are discussed. Key words: compulsive hoarding; anxiety sensitivity; anxiety sensitivity subfactors; risk factor; behavioral avoidance Received 20 July, 2012; Accepted 25 September, 2012 Correspondence address: Norman B. Schmidt, Department of Psychology, Florida State University, 1107 W Call Street, Tallahassee, FL, USA. Tel: Fax: schmidt@psy.fsu.edu Introduction Compulsive hoarding is defined as the acquisition of and inability to discard large quantities of possessions that appear to be of limited value, to the extent that one s living spaces are significantly cluttered (Frost & Hartl 1996). Compulsive hoarding is thought to affect somewhere between 4% and 5% of the population (Samuels et al., 2008) and is associated with high levels of disability and impairment (Tolin, Frost, Steketee, Gray, & Fitch, 2008). This impairment includes but is not limited to illnesses due to unsanitary conditions, social isolation, work disability, and even death (Frost, Steketee, & Williams, 2000; Frost, Steketee, Williams, & Warren, 2000; Kim, Steketee, & Frost, 2001). Compulsive hoarding has been observed in a number of psychiatric conditions including social phobia, schizophrenia, and anorexia (Frankenburg 1984; Greenberg, Witztum, & Levy, 1990; Samuels et al., 2002). Although hoarding was commonly assumed to be a manifestation of obsessive-compulsive disorder (OCD), current research suggests that hoarding may be a distinct clinical syndrome. Specifically, research has demonstrated that a large percentage of individuals who hoard display no other OCD symptoms (Pertusa q 2013 Swedish Association for Behaviour Therapy

3 46 Medley, Capron, Korte and Schmidt COGNITIVE BEHAVIOUR THERAPY et al., 2010; Samuels et al., 2008). In addition, when looking at the psychiatric comorbidity among hoarding patients, hoarding is more commonly correlated with symptoms of depression, rather than OCD (Wu & Watson 2005). For example, Frost, Steketee, and Tolin (2011) found that major depressive disorder was the most frequently comorbid condition occurring in more than half of hoarding patients, compared to,20% being diagnosed with comorbid OCD. Frost and Hartl (1996) were the first to propose a cognitive behavioral model of hoarding. Within this framework, compulsive hoarding is viewed as a multifaceted problem resulting from information processing deficits, extreme emotional attachments to possessions, erroneous beliefs about the nature of possessions, and behavioral avoidance (Frost & Hartl 1996). Numerous studies have demonstrated that individuals who hoard experience cognitive processing problems in the areas of decision-making, categorization, and attention (Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Hartl, Duffany, Allen, Steketee, & Frost, 2005; Wincze, Steketee, & Frost, 2007). These difficulties are posited to directly contribute to the organizational problems and extreme clutter associated with hoarding. Faulty beliefs about the nature of one s possessions are also associated with hoarding behaviors. For example, many patients have mistaken beliefs regarding the future utility of their possessions leading them to save worthless or worn out objects just in case they are needed in the future (Frost, Hartl, Christian, & Williams, 1995). In addition to these beliefs, individuals who hoard also experience extreme emotional attachments to their possessions (Frost & Gross 1993). Beliefs such as throwing this item away means losing a part of my life or without this possession I will be vulnerable undoubtedly lead to saving behaviors. The final component of Frost and Hartl s cognitive behavioral model of hoarding involves behavioral avoidance. Behavioral avoidance refers to the act of saving possessions in order to postpone making decisions (Frost & Hartl 1996). It has been suggested that this type of avoidance directly leads to difficulty discarding and subsequent debilitating clutter (Frost & Gross 1993). Patterns of behavioral avoidance are thought to play an integral role in the development and maintenance of numerous anxiety-related conditions (Craske & Barlow 1988; Heuer, Rinck, & Becker, 2007). Specifically, avoidance negatively reinforces maladaptive behaviors (in this case hoarding) by preventing one from fully experiencing the fear-related extinction process (Bouton, Mineka, & Barlow, 2001). One factor that is possibly related to the behavioral avoidance observed in compulsive hoarding is anxiety sensitivity (AS). AS refers to a fear of fear or fear of anxiety-related sensations (Reiss, Peterson, Gursky, & McNally, 1986). For example, individuals with high levels of AS may misinterpret bodily sensations such as heart palpitations as being indicative of a heart attack, whereas those with lower levels of AS will regard the sensations as merely uncomfortable. AS is composed of three subfactors including physical, cognitive, and social concerns (Zinbarg, Barlow, & Brown, 1997). Research has demonstrated that AS is associated with a number of psychiatric conditions including panic disorder (Schmidt, Lerew, & Jackson, 1997), anxiety and mood disorders (Schmidt, Zvolensky, & Maner, 2006), substance use disorders (Schmidt, Buckner, & Keough, 2007; Zvolensky et al., 2009), and elevated suicidality (Capron, Cougle, Ribeiro, Joiner, & Schmidt, 2012; Capron et al., 2012). Among these conditions, higher levels of AS are thought to amplify anxious reactions and fear-related responding which subsequently leads to greater levels of avoidance (Reiss 1991; Taylor, Koch, & McNally, 1992). That is, heightened levels of AS contribute to the catastrophic misinterpretations of benign anxiety-related sensations, which in turn increases the severity of these sensations leading to increased avoidance behaviors. There are a number of indications that individuals who hoard are at risk for elevated AS. Primarily, clinical observations suggest that when discarding, individuals who hoard experience grief-like physical reactions that produce strong and unpleasant anxiety responses (Coles, Frost, Heimberg, & Steketee, 2003). It is plausible that they avoid decisions to discard in an effort to prevent experiencing these unpleasant emotional states. Indeed, Frost and Hartl s (1996)

4 VOL 42, NO 1, 2013 Anxiety Sensitivity and Compulsive Hoarding 47 cognitive behavioral model of hoarding suggests that individuals who hoard may avoid decisions to discard in an effort to circumvent the unpleasant emotional states associated with loss. This allows them to avoid the fear associated with making a mistake, while discarding and thereby negatively reinforces saving behaviors. Because heightened levels of AS produce the avoidance of unpleasant emotional states, AS is a likely contributor to saving behaviors. The limited empirical work available also suggests a strong relationship between AS and hoarding. For example, Coles et al. (2003) examined the nature of hoarding behaviors in a large, unselected, non-clinical sample and found that the relationship between AS and hoarding was identical in strength to the relationship between obsessive-compulsive (OC) symptoms and hoarding (r ¼ 0.54). They also found that AS contributed unique variance in predicting hoarding behaviors. Timpano, Buckner, Richey, Murphy, and Schmidt (2009) conducted a multi-study investigation assessing the relationship between AS and hoarding behaviors, within a large college sample. One study in this report indicated that AS and hoarding were associated above and beyond general depressive, anxiety, and non-hoarding OC symptoms. Furthermore, the cognitive subfactor of AS, which is associated with fears of losing control or going mentally ill, was significantly associated with hoarding as measured by the obsessive-compulsive inventory-revised (OCI-R) hoarding subscale. Relatedly, the cognitive subfactor of AS is elevated in post-traumatic stress disorder (PTSD) patients (Marshall, Miles, & Stewart, 2010) and experiencing a trauma is a known risk factor for compulsive hoarding (Cromer, Schmidt, & Murphy, 2007). In the next study, Timpano et al. (2009) found that AS physical concerns (i.e. the exaggerated fear of the physical symptoms of anxiety such as rapid heartbeat, hyperventilation, and sweating) were associated with hoarding as measured by the saving inventory revised (SIR). Finally, within a more exploratory framework, Timpano et al. (2009) examined the relationships among overall AS and hoarding subfactors (i.e. acquiring, discarding, and clutter). Results indicated that after controlling for relevant covariates only the acquisitioning component of the SIR was associated with anxiety sensitivity index (ASI) total scores, which is inconsistent with previous research suggesting that the act of acquiring produces positive emotional states (Grisham & Barlow 2005; Steketee & Frost 2003). Given the debilitating nature of hoarding and the potential relationship between AS and hoarding, there are still a number of limitations in the extant literature. Only one empirical study has evaluated the role of hoarding and AS subfactor relationships and this study utilized a non-clinical undergraduate sample (Timpano et al., 2009). Although previous research has suggested a dimensional view of hoarding symptoms (Preston, Muroff, & Wengrovitz, 2009), it is possible that the relationship between AS and hoarding is unique to non-clinical samples. Second, findings within this multi-study investigation were inconsistent. In study 1, Timpano et al. (2009) found that the ASI cognitive subfactor was associated with hoarding behaviors, whereas in another study they found that the ASI physical concerns subfactor was associated with hoarding behaviors. One possibility for these mixed findings is that the previous investigation used the original ASI, which was designed as a unidimensionsal measure of AS. Some have argued that measurement of AS subfactors using the original ASI is not ideal due to low reliability (Taylor et al., 2007). More specifically, the physical concerns subscale of the ASI is composed of eight items, whereas the cognitive and social concerns subscales are composed of only four items. This inconsistency reduces the chances that a specific factor would be reliability obtained across different samples. In addition to problems with reliability, the latter two subscales also show compromised content validity. For example, some ASI items seem to target more than one AS dimension (Taylor et al., 2007). It scares me when I am nauseous could be measuring physical concerns related to the symptom of nausea or social concerns related to the fear of vomiting in front of others. For all these reasons, using the original ASI to measure AS subfactors is not ideal. This study sought to address these limitations in the literature by examining the relationship between AS and hoarding in both a large non-selected undergraduate sample

5 48 Medley, Capron, Korte and Schmidt COGNITIVE BEHAVIOUR THERAPY (study 1) and a large non-selected clinical sample (study 2). Study 1 sets out to replicate the previous work establishing a link between AS and hoarding behaviors. In an effort to clarify the inconsistent findings presented in the Timpano et al. report regarding the relationships among AS subfactors and hoarding behaviors, AS was assessed using the anxiety sensitivity index-3 (ASI-3) which was designed to more reliably measure the AS subfactors (Taylor et al., 2007). Based on the limited empirical work available, we expected to find a relationship between overall AS and hoarding severity, even after covarying for general levels of depression which have been found to be highly comorbid with hoarding behaviors (Frost et al., 2011). Furthermore, based on clinical observations of hoarding patients and the limited research examining the role of AS subfactors in hoarding, we also hypothesized that both the cognitive concerns and physical concerns subfactors would be significantly associated with hoarding severity above and beyond general levels of depression. Finally, we also examined the role of overall AS in predicting more specific hoarding dimensions (i.e. acquiring, discarding, and clutter). Consistent with clinical observations revealing that hoarding patients often experience physical distress during discarding tasks (Coles et al., 2003), we expected to find a relationship between overall AS and the difficulty discarding subfactor of hoarding (as measured by the discarding subfactor of the SIR). Study 2 was designed to investigate the unexplored relationship between AS and hoarding within a large non-selected clinical sample, once again, we expected to find a relationship between overall AS and hoarding severity (as measured by the OCI-R hoarding subscale), even after controlling for general levels of depression [(as measured by Beck depression inventory-ii (BDI-II)]. Furthermore, we expected that both the cognitive concerns and physical concerns subscales would be significantly associated with hoarding severity, above and beyond general levels of depression. Study 1: methods Participants Participants consisted of 279 college students from the southern USA. Participants were primarily female (65.2% female and 34.8% male) with ages ranging from 17 to 24 (M ¼ and SD ¼ 1.26). Eighty-five percent of the participants were Caucasian, 6% African American, 3% Asian, 1% American Indian, and 5% other (e.g. biracial). Measures Hoarding. Hoarding was measured using SIR (Frost, Steketee, & Grisham, 2004). The SIR is a 23-item self-report measure that is used to assess hoarding behaviors. The measure consists of three subscales representing the three factors of hoarding: acquiring, difficulty discarding, and clutter. Participants were instructed to answer the questions using a five-point Likert scale ranging from 0 to 4 (0 ¼ none and 4 ¼ almost all/complete). Higher scores on the SIR reflect greater levels of hoarding behaviors. Previous research has shown good internal consistency and reliability in both clinical and non-clinical samples (Frost et al., 2004). The SIR demonstrated excellent internal consistency within the current investigation (a ¼ 0.93). Anxiety sensitivity. AS was measured using ASI-3 (Taylor et al., 2007). The ASI-3 is an 18-item self-report questionnaire designed to measure the physiological, cognitive, and social subfactors of AS. Respondents were asked to indicate the degree to which they agree with each item on a five-point Likert scale (0 ¼ very little and 4 ¼ very much). The ASI-3 is composed of three subscales corresponding to the three subfactors of AS. The physical concerns subscale is composed of six items asking about fear of arousal (i.e. It scares me when my heart beats rapidly ). In addition, the cognitive concerns subscale contains six items related to fear of the cognitive component of anxiety (i.e. When my thoughts seem to speed up, I worry that I might be going crazy ). Finally, the social concerns subscale is composed of six items related to the potential social consequences associated with anxiety (i.e. I worry that other people will notice my anxiety ). The ASI-3 has been found to be a psychometrically sound and valid measure of AS (Taylor et al., 2007). The ASI-3 demonstrated excellent internal consistency within the current sample (a ¼ 0.91). Depression. Depression was measured using BDI-II (Beck, Steer, & Carbin, 1988). The

6 VOL 42, NO 1, 2013 Anxiety Sensitivity and Compulsive Hoarding 49 Table 1. Means, standard deviations, and intercorrelations for all variables Measure M SD 1. ASI-3 Tot ASI-3 Phy 0.85* ASI-3 Cog 0.83* 0.58* ASI-3 Soc 0.85* 0.57* 0.53* SIR Tot 0.40* 0.32* 0.36* 0.32* SIR Acq 0.29* 0.25* 0.24* 0.25* 0.73* SIR Dis 0.37* 0.31* 0.28* 0.34* 0.87* 0.56* SIR Clu 0.32* 0.24* 0.35* 0.21* 0.86* 0.39* 0.59* BDI-II Tot 0.46* 0.27* 0.48* 0.41* 0.48* 0.33* 0.40* 0.43* Notes: ASI-3 Tot, anxiety sensitivity index-3 total; ASI-3 Phy, anxiety sensitivity index-3 physical concerns subscale; ASI-3 Cog, anxiety sensitivity index-3 cognitive dysregulation subscale; ASI-3 Soc, anxiety sensitivity index-3 social concerns subscale; SIR Tot, saving inventory revised total; SIR Acq, saving inventory revised acquiring subscale; SIR Dis, saving inventory revised discarding subscale; SIR Clu, saving inventory revised clutter subscale; BDI-II Tot, Beck depression inventory-ii total; M, mean; SD, standard deviation. *p, BDI-II is a self-report questionnaire composed of 21-item measuring symptoms associated with depression. Each item is composed of a group of statements in which the respondents are asked to select the statement that best describes how they have felt over the past 2 weeks. The BDI-II utilizes a four-point Likert scale, ranging from 0 to 3, with higher scores reflecting greater levels of depression. The BDI-II has been demonstrated to be a reliable and valid measure of depressive symptoms, particularly in college samples (Steer & Clark 1997). Because depression has been shown to be highly comorbid with hoarding (Frost et al., 2011), the BDI-II was used to control for depressive symptoms in the current analyses. In this study, the BDI-II demonstrated excellent internal consistency (a ¼ 0.90). Procedure Participants were recruited from the undergraduate psychology research pool. Participants signed up for a study titled Behavior and Personality Study through an online experiment database. Upon arrival, participants were consented and instructed to complete a battery of self-report questionnaires. The questionnaire battery included those used in this study and additional questionnaires used for other ongoing projects. The study took approximately 60 min to complete. Upon completion, participants were debriefed and dismissed. Participants received course credit as compensation for their participation. Study 1: results Sample descriptives Table 1 contains the means, standard deviations (SDs), and intercorrelations for all variables included in the current analyses. The mean SIR total score in the present sample was comparable to the mean SIR scores found in other reports utilizing non-clinical populations (Coles et al., 2003). The mean ASI-3 total score was above that found in other nonclinical samples (M total ¼ 12.8; Taylor et al., 2007), suggesting that the current sample was slightly above average in AS. Both the ASI-3 physical and ASI-3 cognitive concerns subscale means were similar to those reported by Taylor et al. (2007). However, the ASI-3 social concerns subscale was somewhat higher than that reported by Taylor et al. (2007; M ¼ 5.9). All AS subfactors were significantly correlated with hoarding, with the AS cognitive subfactor having the highest correlation. Primary analyses A hierarchical regression was performed to assess the relationship between ASI-3 total scores and hoarding severity (as measured by SIR) after controlling for general levels of depression (as measured by BDI-II). Preliminary analyses indicated that there were no violations of normality, multicollinearity, or homoscedasticity. BDI-II scores were entered in the first step of the model, explaining 23% of the variance in hoarding severity (F(1,277) ¼ 82.92, p, 0.001). In the second step of the model, ASI-3 total scores were added. The inclusion of

7 50 Medley, Capron, Korte and Schmidt COGNITIVE BEHAVIOUR THERAPY ASI-3 total scores accounted for an additional 3.8% of the variance in hoarding severity (F change ¼ 14.53, p, 0.001). As anticipated, results indicated that after controlling for general levels of depression, AS significantly predicted hoarding severity (b ¼ 0.22, t ¼ 3.81, p,0.001, sr 2 ¼ 0.05). A second hierarchical regression equation was computed to assess the specific relationship between ASI-3 subscales and hoarding symptoms, in which hoarding severity (as measured by SIR) was regressed onto all three ASI-3 subscales simultaneously, after controlling for general levels of depression (as measured by BDI-II). Preliminary analyses revealed no threats or violations of normality, multicollinearity, or homoscedasticity. Once again, BDI-II scores were entered into step 1 of the model accounting for 23% of the variance in hoarding severity (F(1,277) ¼ 82.92, p, 0.001). The inclusion of the ASI-3 subscales accounted for an additional 4.2% of the variance in hoarding severity (F change ¼ 5.32, p ¼ 0.001). As predicted, results revealed that after controlling for general levels of depression, the physical concerns subscale significantly predicted hoarding severity (b ¼ 0.16, t ¼ 2.33, p ¼ 0.021, sr 2 ¼ 0.02) and the social concerns subscale did not (b ¼ 0.03, t ¼ 0.51, p ¼ 0.61, sr 2 ¼ 0.00). Inconsistent with prediction however, the cognitive concerns subscale was not significantly associated with hoarding severity (b ¼ 0.06, t ¼ 8.51, p ¼ 0.395, sr 2 ¼ 0.00). We also examined the potential relationships among specific hoarding symptoms (i.e. acquisition, discarding, and clutter) and AS. Thus, a final hierarchical regression equation was computed. BDI-II scores were entered into the first step of the model accounting for 21.1% of the variance in AS (F(1,277) ¼ 74.04, p, 0.001). In the second step of the model, all three hoarding dimensions were added, accounting for an additional 4.4% of the variance in AS (F change ¼ 5.40, p ¼ 0.001). Consistent with prediction, results indicated that the discarding dimension of the SIR was significantly associated with AS (b ¼ 0.17, t ¼ 2.29, p ¼ 0.022, sr 2 ¼ 0.02), whereas the acquisitioning and clutter dimensions were not. Study 2: methods Participants Participants consisted of 210 individuals from the community. Participants were primarily female (53.8% female and 45.8% male) with ages ranging from 18 to 87 (M ¼ 38.17, SD ¼ 16.69). Sixty-nine percent of the participants were Caucasian, 20% African American, 3.8% Hispanic, 1.4% Asian, 1.4% American Indian, and 3.4% other (e.g. biracial). Measures Hoarding. The OCI-R (Foa et al., 2002) is an 18-item self-report questionnaire measuring the six OC symptom dimensions. Respondents were asked to indicate the degree to which they have been bothered by each symptom on a five-point Likert scale ranging from 0 (not at all) to 4 (very much). For this study, the three hoarding items were summed to create a measure of hoarding. Anxiety sensitivity. AS was measured by ASI-3 (Taylor et al., 2007). See study 1 for a full description of ASI-3. The ASI-3 was shown to have excellent internal consistency in the present sample (a ¼ 0.92). Depression. Depression was measured using BDI-II (Beck et al., 1988). See study 1 for a full description of BDI-II. BDI-II demonstrated excellent internal consistency in the present sample (a ¼ 0.94). Procedure Participants were individuals from the general community who presented to an anxiety clinic to participate in various research and or treatment studies. Upon arrival, individuals were consented and instructed to complete a battery of self-report questionnaires. The questionnaire battery included those used in this study and additional questionnaires used for other ongoing projects. The questionnaires took approximately 30 min to complete. Upon completion, participants were debriefed and dismissed. Study 2: results Sample descriptives Table 2 contains the means, SDs, and intercorrelations for all variables included in the current analyses. The mean OCI-R

8 VOL 42, NO 1, 2013 Anxiety Sensitivity and Compulsive Hoarding 51 Table 2. Study 2 means, standard deviations, and intercorrelations for all variables. Measure M SD 1. ASI-3 Tot ASI-3 Phy 0.81* ASI-3 Cog 0.84* 0.52* ASI-3 Soc 0.84* 0.54* 0.54* BDI-II Tot 0.66* 0.47* 0.64* 0.53* OCI-R Hoard 0.35* 0.35* 0.33* 0.21* 0.36* Notes: ASI-3 Tot, anxiety sensitivity index-3 total; ASI-3 Phy, anxiety sensitivity index-3 physical concerns subscale; ASI-3 Cog, anxiety sensitivity index-3 cognitive dysregulation subscale; ASI-3 Soc, anxiety sensitivity index-3 social concerns subscale; BDI-II Tot, Beck depression inventory-ii total. OCI-R Hoard, obsessivecompulsive index-revised hoarding subscale; M, mean; SD, standard deviation. *p, hoarding score in the present sample was comparable to scores found in other reports utilizing clinical populations (Grisham, Brown, Savage, Steketee, & Barlow, 2007). The mean ASI-3 total and subscale scores were comparable to those in other clinical samples (Taylor et al., 2007), suggesting that the current sample was average in AS. All AS subfactors were significantly correlated with hoarding, with the AS physical subfactor having the highest correlation. Primary analyses A hierarchical regression was performed to assess the relationship between ASI-3 total scores and hoarding severity (as measured by the OCI-R hoarding subscale) after controlling for general levels of depression (as measured by BDI-II). Preliminary analyses indicated that there were no violations of normality, multicollinearity, or homoscedasticity. BDI-II scores were entered in the first step of the model, explaining 13% of the variance in hoarding severity (F(1,188) ¼ 28.72, p, 0.001). In the second step of the model, ASI-3 total scores were added. The inclusion of ASI-3 total scores accounted for an additional 2.1% of the variance in hoarding severity (F change ¼ 4.53, p ¼ 0.035). As anticipated, results indicated that after controlling for general levels of depression, AS was significantly associated with hoarding severity (b ¼ 0.19, t ¼ 2.13, p ¼ 0.035, sr 2 ¼ 0.02). A second hierarchical regression equation was computed to assess the specific relationship between ASI-3 subscales and hoarding symptoms, in which hoarding severity (again measured by the OCI-R hoarding subscale) was regressed onto the three ASI-3 subscales after controlling for general levels of depression (as measured by BDI-II). Preliminary analyses revealed no threats or violations of normality, multicollinearity, or homoscedasticity. Once again, BDI-II scores were entered into step 1 of the model accounting for 13% of the variance in hoarding severity (F(1,277) ¼ 29.18, p,0.001). The inclusion of the ASI-3 subscales accounted for an additional 4.8% of the variance in hoarding severity (F Change ¼ 3.65, p ¼ 0.014). As predicted, results indicated that after controlling for general levels of depression, the physical concerns subscale was significantly associated with hoarding severity (b ¼ 0.23, t ¼ 2.74, p ¼ 0.007, sr 2 ¼ 0.04), while social concerns subscale was not (b ¼ 20.09, t ¼ 21.05, p ¼ 0.293, sr 2 ¼ 0.01). However, inconsistent with initial predictions, the cognitive concerns subscale was not associated with hoarding severity (b ¼ 0.10, t ¼ 1.10, p ¼ 0.271, sr 2 ¼ 0.01). Discussion Consistent with initial predictions, we found that AS was significantly associated with hoarding severity, even after covarying for general levels of depression which have been shown to be highly comorbid with hoarding behaviors (Frost et al., 2011). These findings were consistent across both a non-selected undergraduate sample and a non-selected clinical sample. Moreover, these findings were consistent across both studies which utilized two different measures of hoarding behaviors. These findings support previous

9 52 Medley, Capron, Korte and Schmidt COGNITIVE BEHAVIOUR THERAPY research suggesting that AS may act as a vulnerability factor for compulsive hoarding (Timpano et al., 2009). In addition, these findings add to the extant literature establishing AS as a key risk factor among various psychiatric conditions including anxiety and mood disorders (Schmidt et al., 1997, 2006). As predicted, we found that the physical concerns aspect of AS appeared to be the dimension of AS most significantly associated with hoarding severity (study 1 and study 2). This relationship remained significant even after controlling for general levels of depression. These findings were consistent across both samples and support previous research by Timpano et al. (2009), demonstrating that the physical concerns subfactor of AS is significantly associated with hoarding severity. The physical concerns subscale of AS represents fears of physiological arousal (i.e. It scares me when my heart beats rapidly ). Previous research has demonstrated that individuals who hoard often experience physiological arousal during task such as discarding and thus may avoid decisions to discard in an effort to circumvent these unpleasant physiological states (Frost & Hartl 1996; Steketee & Frost 2003). Given the extant empirical work demonstrating that AS physical concerns are associated with anxious or fearful responding (Zinbarg, Brown, Barlow, & Rapee, 2001), it stands to reason that the physical concerns subscale of AS may be one factor contributing to the fearful responding seen among hoarding patients. We also examined the relationships among specific hoarding facets and AS (study 1). Results indicate that even after controlling for general levels of depression, the difficulty discarding subscale of the SIR was associated with overall AS whereas the acquisitioning and clutter subscales were not. This finding is consistent with previous work among hoarding patients suggesting that the act of discarding is associated with distress, whereas acquiring and clutter are not (Coles et al., 2003). That is, individuals who hoard may avoid decisions to discard in an effort to avoid the unpleasant arousal associated with potentially discarding a cherished possession (Steketee & Frost 2003). Unexpectedly, the cognitive concerns subfactor of AS was not associated with hoarding severity. Although these findings were consistent across both studies, they are inconsistent with previous investigations by Timpano et al. (2009), demonstrating that AS cognitive concerns are associated with hoarding behaviors. One potential explanation for these mixed findings is that previous investigation used the original ASI. The original ASI was not designed as a multidimensional construct, and measurement of AS subfactors using the original ASI is not ideal due to low reliability (Taylor et al., 2007). More specifically, the original ASI cognitive concerns subfactor is composed of only four items, whereas the ASI-3 cognitive concerns subscale is composed of six items. In addition, the ASI and ASI-3 cognitive concerns subscales only contain two items in common. Thus, the possibility exists that the two subscales are measuring different constructs. The current findings fit within the broader framework of Frost and Hartl s cognitive behavioral model of hoarding. Within this model, behavioral avoidance is viewed as a central component of hoarding that is closely tied to saving behaviors (Frost & Hartl 1996). Specifically, it has been suggested that the act of saving is an avoidance behavior aimed at reducing the distress associated with potentially making a wrong decision regarding a cherished possession (Coles et al., 2003). Similar to the way AS is believed to act among other anxiety conditions, heightened levels of AS may be one factor contributing to the avoidance of discarding. That is, heightened levels of AS are likely to contribute to avoidance of tasks, such as discarding, that trigger strong, unpleasant emotions. The results of this investigation are encouraging when considering treatment implications for compulsive hoarding. Previous research has demonstrated that AS is a highly malleable construct (Feldner, Zvolensky, Babson, Leen-Feldner, & Schmidt, 2008; Keough & Schmidt 2012). Single session interventions involving psychoeducation and exposure exercises have shown to be effective at reducing AS and AS subfactors over a 2-year period (Schmidt et al., 2007). Given the poor treatment outcomes associated with compulsive hoarding (Abramowitz, Franklin, Schwartz, & Furr, 2003; Black et al., 1998) and the malleability of AS (Schmidt et al., 2007), current cognitive behavioral treatments could

10 VOL 42, NO 1, 2013 Anxiety Sensitivity and Compulsive Hoarding 53 benefit from targeting this key vulnerability factor. Limitations of this study should be considered in light of future directions. For example, due to the cross-sectional nature of the current investigation, we cannot speak of the causal nature of the relationship between AS and hoarding. Prospective studies are needed to more clearly determine the temporal relationship between these two constructs. However, given the extant theoretical and empirical work on behavioral avoidance and other anxiety disorders, we believe it is far more likely that AS leads to hoarding behaviors than vice versa. It is also possible that AS scores are a proxy for more central emotional vulnerability factors that were not measured in this study. Although we controlled for general levels of depression, which have been found to be highly comorbid with compulsive hoarding (Frost et al., 2011), it is possible that other emotional vulnerability factors such as grief may be accounting for the proposed relationships among AS and hoarding. Finally, given the malleability of AS (Schmidt et al., 2007), and the poor treatment outcomes associated with compulsive hoarding (Abramowitz et al., 2003), research should assess whether reducing AS via AS amelioration protocols results in a reduction of hoarding behaviors. In summary, this study adds to a growing body of literature on the relationship between AS and compulsive hoarding. To our knowledge, this study is the first to examine the relationships between AS and hoarding utilizing a more reliable measure of AS. Moreover, this study is the first to examine the relationships between hoarding and AS in a non-selected clinical sample. It appears that AS is significantly associated with hoarding behaviors even after controlling for general levels of depression. Considering the lack of information regarding risk factors for compulsive hoarding and the poor treatment outcomes associated with hoarding, these findings add considerably to a growing body of literature on hoarding behaviors. It will be particularly important for future research to not only determine the temporal nature of the relationship between these two variables but also determine if a reduction in AS is associated with a subsequent reduction in hoarding behaviors. References Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 71(6), doi: / x Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck depression inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), doi: / (88) Black, D., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108(1), doi: / x Capron, D. W., Cougle, J. R., Ribeiro, J. D., Joiner, T. E., & Schmidt, N. B. (2012). An interactive model of anxiety sensitivity relevant to suicide attempt history and future suicidal ideation. Journal of Psychiatric Research, 46(2), doi: /j.jpsychires Capron, D. W., Fitch, K., Medley, A., Blagg, C., Mallott, M., & Joiner, T. (2012). Role of anxiety sensitivity subfactors in suicidal ideation and suicide attempt history. Depression and Anxiety, 29(3), doi: /da Coles, M. E., Frost, R. O., Heimberg, R. G., & Steketee, G. (2003). Hoarding behaviors in a large college sample. Behaviour Research and Therapy, 41(2), doi: /s (01)00136-x Craske, M. G., & Barlow, D. H. (1988). A review of the relationship between panic and avoidance. Clinical Psychology Review, 8(6), doi: / (88) Cromer, K. R., Schmidt, N. B., & Murphy, D. L. (2007). Do traumatic events influence the clinical expression of compulsive hoarding? Behaviour Research and Therapy, 45(11), doi: /j.brat Feldner, M. T., Zvolensky, M. J., Babson, K., Leen-Feldner, E. W., & Schmidt, N. B. (2008). An integrated approach to panic prevention targeting the empirically supported risk factors of smoking and anxiety sensitivity: Theoretical basis and evidence from a pilot project evaluating feasibility and short-term efficacy. Journal of Anxiety Disorders, 22(7), doi: /j.janxdis Foa, E., Huppert, J., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. (2002). The obsessive-compulsive inventory: Development and validation of a short version. Psychol Assess, 14(4), Frankenburg, F. R. (1984). Hoarding in anorexia nervosa. British Journal of Medical Psychology, 57(1), doi: /j tb01581.x

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