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Panic attacks and hoarding disorder: An initial investigation Amanda M. Raines, Mary E. Oglesby, Nicole A. Short, Brian J. Albanese, Norman B. Schmidt⁎ Department of Psychology, Florida State University, 1107 W. Call St., Tallahassee, FL 32306-4301, USA

Abstract Panic attacks (PAs) defined as a discrete period of intense fear or discomfort, occur in the context of numerous anxiety and mood related disorders. Research has suggested that PAs serve as a significant indicator and prognostic factor for overall symptom severity, course, and comorbidity within various conditions. Consequently, a PA specifier is now applicable to all DSM-5 disorders. Despite these clinical and nosological implications, no research to date has examined associations between PAs and hoarding disorder. The current investigation evaluated relationships between PA endorsement and hoarding severity within a sample of 32 patients with hoarding disorder. Findings suggested a high rate of panic history among those with hoarding disorder (56%). Hoarders with co-occurring PAs, compared to those without PAs, evidenced significantly higher symptom severity. Moreover, PAs continued to significantly predict hoarding severity even after controlling for relevant covariates. When examining the specific relationships among PAs and hoarding symptoms (i.e., acquiring, difficulty discarding, and clutter), the endorsement of PAs was associated with increased acquiring and difficulty discarding symptoms. These findings add considerably to a growing body of literature on hoarding disorder. Implications for the assessment and treatment of PAs that co-occur with hoarding disorder are discussed. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Panic attacks (PAs), characterized by an abrupt surge of discomfort or fear that peaks within minutes, are among the most prevalent psychiatric symptoms [1]. A seminal epidemiological assessment of panic revealed that 28% of the general population report having suffered at least one PA in their lifetime and 11% report having had a PA in the last year [2]. Individuals with a history of panic are likely to report substantial role impairment [2] and greater disability in one or more areas of functioning including social, occupational, and family domains [3]. These data highlight the high prevalence as well as the adverse influence of PAs [2]. Whereas PAs themselves are not considered to be a psychiatric condition, they frequently occur in the context of anxiety- and nonanxiety-related disorders [4,5]. For example, utilizing a large epidemiological sample, Goodwin and Hamilton [6] found that approximately 9 of 10 individuals with a history of PAs met the criteria for at least one mental disorder. Similarly, Kessler and colleagues [2] reported that 71.9% of their PA group (i.e., PAs without a history of panic

⁎ Corresponding author. Tel.: +1 850 645 1766: fax: +1 850 644 7739. E-mail address: [email protected] (N.B. Schmidt). http://dx.doi.org/10.1016/j.comppsych.2014.04.004 0010-440X/© 2014 Elsevier Inc. All rights reserved.

disorder or agoraphobia) had one or more comorbid conditions. In the large majority of cases, these PAs preceded the onset of various mood and anxiety-related disorders suggesting that PAs may serve as a risk factor for a wide range of psychopathology. In addition to high rates of comorbidity, a growing body of literature further suggests that PAs are associated with a poorer prognosis and treatment response. Data from a 5-year prospective longitudinal study among 3021 German adolescents and young adults indicated that individuals reporting experiencing a PA at baseline, compared to those with no history of panic, were nearly four times more likely to meet the criteria for three or more psychiatric diagnoses at 5-year follow-up [7]. Cougle and colleagues [3] compared the symptom severity and course of PTSD among individuals with and without a history of PAs. PTSD with comorbid PAs was associated with a greater prevalence of comorbid depression, substance abuse/dependence, number of anxiety disorders and lifetime traumatic events. Moreover, individuals with comorbid PTSD and PAs reported significantly more re-experiencing and avoidance/numbing PTSD symptoms as well as treatment-seeking behaviors compared to those without PAs. Taken together, these and other findings have led to the inclusion of a PA specifier across all diagnoses within DSM-5 [1].

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Despite evidence suggesting significant sequelae associated with PAs, there is a dearth of research investigating the role of PAs in the context of many disorders, including hoarding disorder. Hoarding disorder is defined as the accumulation of and failure to discard a large number of possessions to the extent that one's living spaces are significantly cluttered [8]. Once thought to be a rare disorder, hoarding is now estimated to affect between 2% and 6% of the population [1]. In recent years, hoarding has emerged as a considerable public health burden leading to significant impairment in social, occupational, and family domains [9,10]. Hoarding was traditionally viewed as a symptom or subtype of obsessive–compulsive disorder (OCD). As such, the majority of research to date has relied on samples drawn from patients seeking treatment at OCD specialty clinics. Recent advances in our understanding of the development and course [11], diagnostic features [12], and associated comorbidity [13] however, have led to the inclusion of hoarding disorder as a separate diagnostic entity within DSM-5 [1]. In light of these nosological changes, research examining associations among PAs and hoarding disorder seems warranted. A number of lines of prior research attest to the plausibility of a PA association with hoarding disorder as well as with increased hoarding severity. For example, previous research has demonstrated associations among known panic-related vulnerability factors such as anxiety sensitivity (AS) [14,15] and increased hoarding severity. AS, otherwise known as a “fear of fear,” is a well-established individual difference variable reflecting a tendency to fear bodily sensations associated with anxious arousal [16]. For example, individuals high in AS may misinterpret benign bodily sensations such as heart palpitations as being indicative of a heart attack, whereas those low in AS will simply regard the sensations as uncomfortable. A growing body of literature suggests a strong relationship between AS and hoarding. Coles et al. [17] found that AS was strongly associated with hoarding symptoms (r = 0.54) in a large unselected, non-clinical sample. Similarly, Timpano et al. [18] found that AS and hoarding were robustly associated with one another even after accounting for relevant covariates. More recently, Medley et al. [19] found AS to be highly related to hoarding symptoms in a large non-selected clinical sample. Results indicated that hoarding behaviors were associated with overall AS. Moreover, hoarding behaviors were specifically associated with the physical concerns subfactor of AS. The physical concerns subfactor, which reflects fears of physical catastrophe such as heart attacks (i.e., “It scares me when my heart beats rapidly”) is most strongly related to panic [20,21]. Despite these suggested associations, no research to date has examined the presence of PAs in the context of hoarding disorder. Thus, the current study sought to expand upon existing literature by addressing the question of whether PAs may be a valuable specifier for patients with hoarding disorder. Based on the extant literature demonstrating increased rates of

comorbidity and higher symptom severity among various psychiatric populations with comorbid PAs compared to those without, as well as associations between known panic vulnerability factors and hoarding, we hypothesized that hoarding disorder patients with co-occurring PAs would exhibit greater hoarding severity compared to those without. Additionally, we examined the associations among PAs and specific hoarding symptoms (i.e., acquiring, difficulty discarding, and clutter). Previous research has suggested that the act of discarding is associated with increased distress, whereas acquiring and clutter are not [17]. Consistent with this hypothesis, previous research has found an association between the difficulty discarding component of hoarding and elevated levels of AS [19]. Based on these findings, we hypothesized that the discarding dimension of hoarding would be most closely associated with panic.

2. Methods 2.1. Participants Participants included 32 individuals from the local community with hoarding disorder. The majority of participants were interested in research with 19% seeking treatment for hoarding disorder. To be eligible for inclusion participants had to have a current diagnosis of hoarding, as determined by the Structured Interview for Hoarding Disorder (SIHD; [22]). Seventy-eight percent of the sample were women, with ages ranging from 18 to 77 (M = 44.13, SD = 16.04). The majority of the sample selfidentified as Caucasian (59.4%), followed by African American (37.5%), and other (3.1%). In terms of relationship status, 56.3% of participants were single, 15.6% married, 12.5% divorced or separated, 9.4% cohabitating, and 6.2% widowed. Finally, with regard to additional diagnoses, 46.9.% of the sample met the criteria for a current anxiety diagnosis, 43.7% met the criteria for a current mood diagnosis, 18.8% met the criteria for current PTSD, 9.4% met the criteria for current OCD, 21.9% met the criteria for a current substance use disorder, and 3.1% met the criteria for an eating disorder. 2.2. Procedure Participants were recruited from the community, as well as an outpatient anxiety disorders clinic. Upon arrival to the lab, participants provided informed consent and completed a battery of self-report questionnaires, including measures of hoarding behaviors and negative affect, as well as additional questionnaires related to the project. Next, participants completed the Mini International Neuropsychiatric Interview (MINI), a brief structured diagnostic interview for the Diagnostic and Statistical Manual 4th edition (DSM-IV). Finally, participants were debriefed and compensated $20 cash for their participation. The full appointment lasted approximately 2 hours, and all procedures were approved by the university's institutional review board.

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2.3. Measures 2.3.1. Clinician administered 2.3.1.1. Hoarding disorder. The Structured Interview for Hoarding Disorder (SIHD) is a brief structured interview based on the DSM-5 diagnostic criteria for Hoarding Disorder [12]. It consists of detailed questions and specifiers regarding each of the six DSM-5 criteria. The SIHD was used to assess for Hoarding Disorder in the current study. Each interview was administered by a highly trained and advanced doctoral student and confirmed by a licensed psychologist. 2.3.1.2. Panic attacks. All participants were interviewed using a brief structured diagnostic interview (MINI). The MINI consists of standardized close-ended questions that were administered to assess for the presence of any Axis I condition. Previous research has demonstrated that the MINI is both a reliable and valid diagnostic tool [23]. All MINIs were administered by a highly trained, advanced doctoral student. The panic disorder screener was used to assess for the presence of PAs. Specifically individuals were asked “Have you, on more than one occasion had spells or attacks when you suddenly felt frightened, uncomfortable or uneasy, even in situations where most people would not feel that way?” Based on their responses, individuals were either coded as “1” (having a history of panic attacks) or “0” (no history of panic attacks). 2.3.2. Self-report 2.3.2.1. Anxiety sensitivity. AS was assessed using the Anxiety Sensitivity Index (ASI; [24]). The ASI is a 16-item self-report measure of an individual's level of fear and concern regarding the negative effects of anxious arousal. The ASI consists of three empirically supported subscales: (1) physical concerns (e.g., “It scares me when my heart beats rapidly”), (2) cognitive concerns (e.g., “When I cannot keep my mind on a task, I worry that I might be going crazy”), and (3) social concerns (e.g., “It is important for me not to appear nervous”). Participants were asked to rate how much they agreed with

each item on a 5-point scale ranging from 0 (very little) to 4 (very much). Within the current investigation, the ASI was used as a covariate in analyses. The ASI has previously demonstrated good psychometric properties [25], and internal consistency was excellent in the present sample (α = .94). 2.3.2.2. Hoarding behaviors. The Saving Inventory Revised (SIR) is a 23-item self-report measure used to index hoarding behaviors. It features three subscales designed to reflect the three facets of hoarding: acquiring, difficulty discarding, and clutter. Respondents indicated their answers using a 5-point Likert scale ranging from 0 to 4 (0 = none; 4 = almost all/complete), with higher scores on the SIR indicating greater levels of hoarding behaviors. The SIR has demonstrated excellent internal consistency and reliability [26]. In the current investigation, the SIR showed good internal consistency (α = .90). Additionally, the acquisition, difficulty discarding, and clutter subscales demonstrated adequate to excellent internal consistency (α = .80, .80, and .92, respectively). 2.3.2.3. Negative affect. The Positive and Negative Affect Schedule (PANAS) is a 20-item self-report measure assessing two global dimensions of affect: negative and positive. Participants were instructed to read various words describing different feelings and emotions and indicate how they felt currently on a scale of 1 (very slightly or not at all) to 5 (extremely). Previous research has indicated the PANAS is a valid and reliable measure of both positive and negative affect [27]. In the current investigation only the 10-item negative affect subscale was utilized. Internal reliability was excellent for this subscale (α = .89). 3. Results 3.1. Preliminary analyses First, we examined the means, standard deviations, and zero-order correlations for all variables included in the

Table 1 Zero-order correlations, means, and standard deviations. 1 1. NA 2. ASI 3. SIR-A 4. SIR-D 5. SIR-C 6. SIR 7. PA

– .68⁎⁎⁎ .32 .23 .17 .30 .21

2 − .39⁎ .35⁎ .12 .33 .24

3

– .60⁎⁎⁎ .42⁎ .83⁎⁎⁎ .48⁎⁎

4

– .30 .72⁎⁎⁎ .44⁎

5

– .81⁎⁎⁎ .34

6

– .52⁎⁎

7

Mean

SD



23.25 26.47 15.38 18.88 21.59 55.84 .56

8.10 15.30 5.61 4.01 7.16 13.26 .51

NA, Positive and Negative Affect Schedule–Negative Affect Subscale; ASI, Anxiety Sensitivity Index–Total Score; SIR-A, Saving Inventory Revised– Acquiring Subscale; SIR-D, Saving Inventory Revised–Discarding Subscale; SIR-C, Saving Inventory Revised–Clutter Subscale; SIR, Saving Inventory Revised–Total Score; PA, Panic Attacks. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

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current analyses (Table 1). The mean ASI total score was similar to that found in other reports utilizing clinical samples [28]. In addition, the mean SIR total score and subscale scores were similar to those found in reports using hoarding samples [26]. With regard to the endorsement of PAs, 56% of the sample reported experiencing more than one panic attack (expected and unexpected) in their lifetime. Consistent with initial prediction, PAs were significantly correlated with overall hoarding severity and the difficulty discarding subfactor of the SIR. PAs were also associated with the acquiring subfactor of the SIR. Next, we wished to examine demographic and psychiatric differences between individuals with and without PAs. An independent-samples t-test was conducted to compare differences in age for those with and without PAs. Results revealed that there were no significant differences for those with cooccurring panic (M = 44.61, SD = 16.86) compared to those without (M = 43.50, SD =15.53) t(30) = −.19, p = .85 (two-tailed). Additionally, chi-square test for independence indicated no significant associations between gender χ 2(1, N = 32) = 1.54, p =0.22, phi = 0.30 or race χ 2(1, N = 31) = 0.46, p = 0.50, phi = −.19 and PA status. However, an independent-samples t-test indicated that there was a significant difference across groups with respect to number of comorbid diagnoses. Specifically, individuals with a history of PAs (M = 2.12, SD, 1.62) had significantly more comorbid diagnoses than those individuals without a history of (M = .57, SD =.65; t(29) = −3.36, p = .002) and the magnitude of this difference (mean difference = −1.55, 95% CI: −2.49 to −.60) was very large (eta square = 0.28). 3.2. Primary analyses Prior to conducting any of the primary analyses, data screening was performed. Preliminary analyses for all regression equations revealed no threats or violations of normality, multicollinearity, or homoscedasticity. To assess the robustness of the association between PAs and hoarding severity (as measured by the SIR), a hierarchical regression equation was computed. In the first step of the model, overall levels of negative affect (as measured by the PANAS) were entered accounting for 9% of the variance in hoarding severity (F(1, 30) = 2.89, p = .10). In the second step of the model, PAs were added accounting for an additional 22% of the variance in hoarding severity (F Change = 9.19, p = .01). Consistent with initial predictions, PAs were associated with increased hoarding severity (β = .48, t = 3.03, p = .01, sr 2 = .22), above and beyond overall negative affect. Next, we constructed a similar regression equation covarying for AS (as measured by the ASI). In the first step of the model, ASI scores were entered accounting for 11.2% of the variance in hoarding severity (F(1, 30) = 3.78, p = .06). In the second step of the model, PAs were added accounting for an additional 21% of the variance in hoarding severity (F Change = 8.76, p = .01). Results indicated that PAs were associated with increased hoarding severity, even after covarying for AS (β = .47, t =

2.96, p = .01, sr 2 =.21). A third and final regression equation was computed to assess the robustness of the association between PAs and hoarding severity after controlling for overall levels of negative affect and AS. Step one of the model, which included both covariates, accounted for 12.1% of the variance in hoarding severity (F(2, 29) = 1.99, p = .16). In the second step of the model PAs were added accounting for an additional 20% of the variance in hoarding severity (F Change = 8.31, p = .01). Results revealed that PAs were significantly associated with increased hoarding severity (β = .46, t = 2.88, p = .01, sr 2 = .20) above and beyond overall levels of negative affect and AS. Specifically, hoarding disorder patients with co-occurring PAs, compared to those without, evidenced significantly higher symptom severity (EMMs = 61 and 49, respectively). 1 Next a series of hierarchical regression analyses were performed to examine the relationships among PAs and specific hoarding symptoms (i.e., acquiring, difficulty discarding, and clutter) after controlling for overall levels of negative affect and AS. For each regression equation, the PANAS-NA and ASI total scores were entered into the first step of the model. In the second step, PAs were added. Results revealed that the acquiring (β = .41, t = 2.54, p = .02, sr 2 = .16) and difficulty discarding (β = .38, t = 2.24, p = .03, sr 2 = .13) subscales of the SIR were significantly associated with PAs, whereas the clutter subscale was not (β = .33, t = 1.80, p = .08, sr 2 = .10).

4. Discussion As expected, we found that PAs were associated with increased hoarding severity even after controlling for overall levels of negative affect and AS. This finding is consistent with prior research demonstrating that PAs often co-occur in the context of anxiety- and nonanxiety-related disorders [4,5]. In addition, these findings support a growing body of literature demonstrating increased rates of symptom severity among individuals with various psychiatric conditions and co-occurring PAs. For example, Roy-Byrne and colleagues [29] examined the severity of depressive symptoms among individuals with and without co-occurring PAs and found increased depressive symptomatology (including increased suicide attempts) among those individuals with PAs compared to those without. Similarly, Jack et al. [30] found that cued PAs were associated with increased distress and impairment among a sample of social phobic patients. Consistent with these reports, findings indicate that PAs are associated with increased hoarding severity and thus are a valuable and clinically relevant specifier for individuals with hoarding disorder.

1 To ensure that the relationship between PAs and hoarding severity was not due to differences in psychiatric comorbidity, a separate regression equation was computed controlling for both AS and number of diagnoses. Results remained significant.

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Consistent with initial prediction, results also indicated that PAs were significantly associated with the difficulty discarding subscale of the SIR. These findings remained significant even after accounting for the contribution of overall levels of negative affect and AS. Previous research has suggested that the act of discarding is associated with increased levels of distress [17]. In particular, it has been suggested that individuals who hoard may delay or avoid decisions to discard in an effort to circumvent the unpleasant physiological arousal brought on by thoughts of potentially losing a cherished possession [31]. Consistent with this conceptualization, the experience of PAs during such tasks may be another factor leading to fearful responding and increased saving behaviors. Results also indicated that PAs were associated with increased acquiring behaviors after controlling for overall levels of negative affect and AS. Excessive acquiring behaviors are often viewed as an avoidance behavior in which one acquires items as a way to avoid the potential distress associated with not collecting an item of future worth or value [31]. Because PAs, by definition, involve an abrupt surge of intense fear and/or discomfort that subsequently leads to increased behavioral avoidance [32], PAs are likely a contributor to increased acquiring behaviors. Taken together, the findings of this investigation fit within the larger framework of Frost and Hartl's [8] cognitive behavioral model of hoarding. According to this model, behavioral avoidance is a key feature of hoarding observed in a substantial proportion of patients. For example, excessive acquiring behaviors are conceptualized as an avoidance behavior aimed at preventing feelings of anxiety and grief/loss that often accompany not collecting an item deemed potentially useful or valuable [31]. Similarly, difficulty discarding behaviors are viewed as an avoidance strategy aimed at circumventing the distress associated with losing a cherished possession [31]. Given that PAs have been found to lead to substantial behavioral avoidance [32], it is reasonable to assume that PAs could contribute to the increased avoidance behaviors seen among hoarding patients. Results of the present investigation highlight the importance of assessing for co-occurring PAs as part of a comprehensive diagnostic assessment for hoarding disorder. Specifically, clinicians should inquire about the presence of PAs and determine the context in which they occur. Considering that PAs led to increased hoarding severity, it is reasonable to assume that targeting PAs within the context of cognitive–behavioral therapy for hoarding disorder could be beneficial for lowering overall symptom severity. In particular, given the strong associations between PAs, AS, and hoarding behaviors [18–20], interventions designed to lower an individual's sensitivity to panic-related sensations could be an innovative way to treat hoarding symptoms. Indeed, previous research has demonstrated that brief AS interventions can significantly reduce overall AS and disorderspecific symptoms [33,34]. Given the poor treatment outcomes associated with hoarding disorder [35] as well as the

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malleable nature of AS [34], targeting these factors in the treatment of hoarding disorder could prove to be beneficial. The findings from the current study should be considered in the context of its limitations. First, due to the crosssectional design of the study, definitive causal inferences cannot be made. It is unclear if PAs result in increased hoarding symptoms, or if elevated hoarding symptoms result in PAs. Regardless, co-occurring PAs in the context of hoarding disorder appear to provide clinically relevant information regarding the increased severity of hoarding symptoms. Future studies should utilize prospective designs to investigate the causal nature of this relationship. Second, although a clear strength of the present study includes our use of a clinical sample of individuals with hoarding disorder, the sample size is somewhat small. Further research should seek to replicate these findings in larger, diverse samples to ensure this pattern of findings applies to the general population of those with hoarding disorder. Third, although we used the MINI, a valid and reliable diagnostic interview, to assess for PAs, this interview does not consider the context in which PAs occurred [36]. Thus, we are unable to determine whether PAs were cued by symptoms of hoarding disorder or symptoms of another comorbid disorder. Future research should extend these findings by investigating the context in which PAs occurred and whether they were directly related to symptoms of hoarding disorder. Finally, panic attacks were classified using the screener question for the panic disorder module of the MINI. This may have resulted in an over-endorsement of panic attacks in the current sample. Thus, future work should attempt to replicate these findings in clinical samples where full diagnostic information is available. Despite these limitations, the current findings add to a growing body of literature suggesting that PAs are associated with increased symptom severity and impairment in a number of mood and anxiety disorders [2,3]. To our knowledge, this study is the first to demonstrate that PAs are associated with overall increased hoarding severity, as well as increased severity of the specific symptoms of acquiring and difficulty discarding. In addition, these findings add to the literature on hoarding disorder, and indicate that clinicians should assess for the presence of PAs in those with hoarding disorder and, pending future research, target the experience of PAs during treatment to improve treatment outcomes for hoarding disorder.

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[4] Baillie AJ, Rapee RM. Panic attacks as risk markers for mental disorders. Soc Psychiatry Psychiatr Epidemiol 2005;40:240-4. [5] Goodwin RD, Gotlib I. Panic attacks and psychopathology among youth. Acta Psychiatr Scand 2004;109:216-21. [6] Goodwin RD, Hamilton SP. Panic attack as a marker of core psychopathological processes. Psychopathology 2002;34:278-88. [7] Goodwin RD, Lieb R, Hoefler M, Pfister H, Bittner A, Beesdo K, et al. Panic attack as a risk factor for severe psychopathology. Am J Psychiatry 2004;161:2207-14. [8] Frost R, Hartl T. A cognitive–behavioral model of compulsive hoarding. Behav Res Ther 1996;34:341-50. [9] Tolin DF, Frost R, Steketee G, Fitch KE. Family burden of compulsive hoarding: results of an Internet survey. Behav Res Ther 2008;46:334-44. [10] Tolin DF, Frost R, Steketee G, Gray KD, Fitch KE. The economic and social burden of compulsive hoarding. Psychiatry Res 2008;160:200-11. [11] Samuels J, Bienvenu O, Riddle M, Cullen B, Grados M, Liang K, et al. Hoarding in obsessive compulsive disorder: results from a case-control study. Behav Res Ther 2002;40:517-28. [12] Pertusa A, Frost R, Fullana M, Samuels J, Steketee G, Tolin DF, et al. Refining the diagnostic boundaries of compulsive hoarding: a critical review. Clin Psychol Rev 2010;30:371-86. [13] Pertusa A, Fullana MA, Singh S, Alonso P, Menchon JM, Mataix-Cols D. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? Am J Psychiatry 2008;165:1289-98. [14] Schmidt NB, Lerew DR, Jackson RJ. The role of anxiety sensitivity in the pathogenesis of panic: prospective evaluation of spontaneous panic attacks during acute stress. J Abnorm Psychol 1997;106:355-64. [15] Schmidt NB, Zvolensky MJ, Maner JK. Anxiety sensitivity: prospective prediction of panic attacks and Axis I pathology. J Psychiatr Res 2006;40:691-9. [16] Reiss S, McNally R. Expectancy model of fear. In: Reiss S, & Bootzin R, editors. Theoretical issues in behavior therapy. San Diego, CA: Academic Press; 1985. [17] Coles ME, Frost R, Heimberg RG, Steketee G. Hoarding behaviors in a large college sample. Behav Res Ther 2003;41:179-94. [18] Timpano KR, Buckner JD, Richey JA, Murphy DL, Schmidt NB. Exploration of anxiety sensitivity and distress tolerance as vulnerability factors for hoarding behaviors. Depress Anxiety 2009;26:343-53. [19] Medley A, Capron DW, Korte KJ, Schmidt NB. Anxiety sensitivity: a potential vulnerability factor for compulsive hoarding. Cogn Behav Ther 2013;42:45-55. [20] Deacon BJ, Abramowitz JS. Anxiety sensitivity and its dimensions across the anxiety disorders. J Anxiety Disord 2006;20:837-57. [21] Rector NA, Szacun-Shimizu K, Leybman M. Anxiety sensitivity within the anxiety disorders: disorder-specific sensitivities and depression comorbidity. Behav Res Ther 2007;45:1967-75.

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Panic attacks and hoarding disorder: an initial investigation.

Panic attacks (PAs) defined as a discrete period of intense fear or discomfort, occur in the context of numerous anxiety and mood related disorders. R...
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