Elsevier

Comprehensive Psychiatry

Volume 57, February 2015, Pages 36-45
Comprehensive Psychiatry

A consideration of hoarding disorder symptoms in China

https://doi.org/10.1016/j.comppsych.2014.11.006Get rights and content

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.

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 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 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], [8], [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].

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], [22], [23], [24], [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 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.

Section snippets

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

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 (χ2 [227, 887] = 1107.16, p < .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 >0.3, indicative of an acceptable validity of

Participants

The Chinese sample consisted of 303 student volunteers from Weifang Medical University, Shanxi Normal University, 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%

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 (χ2 [181, 303] = 522.39, p < .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

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,

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