The Beck Anxiety Inventory: Psychometric Properties with Older Adults

The assessment of anxiety disorders in late life is often hindered by the lack of measures specifically validated with older adults. Because anxiety manifestations may vary across age groups, it is important to design new instruments or validate existing measures with older adults. This study examined the psychometric properties of the Beck Anxiety Inventory (BAI) in a sample of 281 older adults who were community-dwelling (82.6%) or living in residential care facilities (17.4%). The mean total BAI score was 6.5 (SD = 7.2), indicating minimal anxiety symptomatology in this older sample. There was a trend for older subjects to score higher. Females scored higher than males, and subjects living in a residential facility scored higher than did community dwellers. Item-total correlations were in the moderate range and the internal consistency of the BAI was adequate (alpha = 0.89). A factor analysis yielded a six-factor structure accounting for 64.6% of the variance, with a somatic factor accounting for the largest portion of the variance (32.2%). Because somatic symptoms are more prevalent with aging, such symptoms should not be weighed as heavily in the total BAI score as cognitive or behavioral symptoms. The findings indicate that the BAI is a useful self-report scale for assessing anxiety symptomatology among older adults.     

Effectiveness of the Hamilton Anxiety Rating Scale with Older Generalized Anxiety Disorder Patients

To expand the collection of instruments available for assessment of anxiety in the elderly, this report examined the original and revised Hamilton anxiety scales in a sample of 50 older adults diagnosed with Generalized Anxiety Disorder (GAD) and 93 normal community participants (ages 55–82). Although the revised anxiety scale had better discriminant validity (lower correlation with the revised Hamilton depression scale) than the original anxiety and depression scales, a considerable amount of shared variance still existed (41% shared variance, GAD sample alone; 17% control sample alone; 74% shared variance, both samples combined). Near-perfect group classification was possible using 7 items from the original anxiety scale and 10 items from the revised anxiety scale. Results are discussed in light of their implications for use of the Hamilton anxiety rating scale with older anxiety-disordered patients.     

Integrating Religion and Spirituality Into Treatment for Late-Life Anxiety: Three Case Studies

Generalized anxiety disorder (GAD) is common in older adults and, although cognitive behavioral therapy (CBT) is an efficacious treatment for late-life GAD, effect sizes are only moderate and attrition rates are high. One way to increase treatment acceptability and enhance current cognitive behavioral treatments for GAD in older adults might be to incorporate religion/spirituality (R/S). The cases presented here illustrate the use of a 12-week modular CBT intervention for late-life anxiety, designed to allow incorporation of R/S elements in accordance with patient preferences. The three women treated using this protocol chose different levels and methods of R/S integration into therapy. All three women showed substantial improvement in worry symptoms, as well as a variety of secondary outcomes following treatment; these gains were maintained at 6-month follow-up. These preliminary results suggest that the incorporation of R/S into CBT might be beneficial for older adults with GAD. Strengths, limitations, and future directions are discussed.     

Psychometric properties of a Spanish version of the Beck Anxiety Inventory (BAI) in general population

This is the first study that provides normative, reliability, factor validity and discriminant validity data of the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) in the Spanish general population, Sanz and Navarro's (2003) Spanish version of the BAI was administered to 249 adults. Factor analyses suggested that the BAI taps a general anxiety dimension comprising two related factors (somatic and affective-cognitive symptoms), but these factors hardly explained any additional variance and, therefore, little information is lost in considering only full-scale scores. Internal consistency estimate for the BAI was high (alpha = .93). The BAI was correlated .63 with the BDI-II and .32 with the Trait-Anger scale of the STAXI 2, but a factor analysis of their items revealed three factors, suggesting that the correlations between the instruments may be better accounted for by relationships between anxiety, depression, and anger, than by problems of discriminant validity. The mean BAI total score and the distribution of BAI scores were similar to those found in other countries. BAI norm scores for the community sample were provided from the total sample and from the male and female subsamples, as females scored higher than males. The utility of these scores for assessing clinical significance of treatment outcomes for anxiety is discussed.     

Generalized Anxiety Disorder in Older Medical Patients: Diagnostic Recognition, Mental Health Management and Service Utilization

Background Primary care physicians often treat older adults with Generalized Anxiety Disorder. Objective To estimate physician diagnosis and recognition of anxiety and compare health service use among older adults with GAD with two comparison samples with and without other DSM diagnoses. Methods Participants were 60+ patients of a multi-specialty medical organization. Administrative database and medical records were reviewed for a year. Differences in frequency of health service use were analyzed with logistic regression and between-subjects analysis of covariance. Results Physician diagnosis of GAD was 1.5% and any anxiety was 9%, and recognition of anxiety symptoms was 34% in older adults with GAD. After controlling for medical comorbidity, radiology appointments were increased in the GAD group relative to those with and without other psychiatric diagnoses, χ² (2, N = 225) = 4.75, p < .05. Conclusions Most patients with anxiety do not have anxiety or symptoms documented in their medical records.     

A Comparison of the Factorial Structure of DSM-IV Criteria for Generalized Anxiety Disorder Between Younger and Older Adults

The controversy concerning the validity and reliability of generalized anxiety disorder (GAD) appears to be particularly relevant in the elderly, since physical symptoms associated with GAD can readily be considered as the consequences of normal aging. This study aims to analyze the structure invariance of a questionnaire assessing the DSM-IV diagnostic criteria across samples of older adults and college students. Ninety-seven adults aged 65 or over and 130 college students completed the Worry and Anxiety Questionnaire (WAQ). The results revealed that factorial invariance could be assumed and, in addition, that scores for severity of GAD symptoms were higher in younger subjects than in older ones. The results support the applicability of DSM-IV criteria for GAD in elderly people, as the factorial structure of the WAQ was the same for this age group as for younger adults. A higher degree of GAD severity was found in the younger sample.

DSM-IV criteria for generalized anxiety disorder in older adults: distinguishing the worried from the well

This study compared 36 older adults with generalized anxiety disorder (GAD), 22 older adults with subsyndromal anxiety symptoms, and 32 normal controls on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) for GAD. GAD patients reported more frequent and uncontrollable worry, somewhat different worry content, higher prevalence of most associated symptoms, and more distress or impairment than the subsyndromal group or normal controls. Individuals with subsyndromal anxiety reported more excessive, frequent, and uncontrollable worry than asymptomatic individuals, along with more sleep disturbance, fatigue, and distress or impairment. Results indicate that the key features of late-life GAD are distress and impairment, frequency and uncontrollability of worry, muscle tension, and sleep disturbance and that clinicians treating older adults with GAD should monitor and treat residual symptoms.     

Anxiety sensitivity within the anxiety disorders: disorder-specific sensitivities and depression comorbidity

The tendency to perceive anxious states as aversive and harmful is hypothesized to confer vulnerability to the development of anxiety disorders. The most commonly used measure of anxiety sensitivity, the Anxiety Sensitivity Index [ASI; Reiss, S., Peterson, R.A., Gursky, D.M., & McNally R.J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behavior Research and Therapy, 24, 1-8], is composed of multiple lower-order factors, assessing fear of physical symptoms, fear of publicly observable anxious symptoms, and fear of cognitive dyscontrol. This study examined the convergent validity of the lower-order anxiety sensitivity dimensions in DSM-IV diagnosed anxiety disorders. Participants with primary diagnoses of panic disorder with agoraphobia, social phobia, and generalized anxiety disorder (GAD) completed the ASI and measures of anxiety and depression severity. Support was found for the convergent validity of all ASI dimensions in reference to thematically related anxiety disorders and in the identification of patients presenting with and without secondary major depressive disorder (MDD). The ASI-fear of cognitive dyscontrol dimension displayed strong and nonredundant associations with GAD, dimensional depression scores, and secondary diagnoses of MDD. The conceptual implications of the shared importance of fear of cognitive dyscontrol in GAD and MDD are discussed.     

'Minor GAD': characteristics of subsyndromal GAD in older adults

Subsyndromal emotional symptoms are common in older adults and are associated with increased disability, health care utilization, and risk for developing psychiatric disorders. The purpose of this study was to examine subsyndromal generalized anxiety disorder (GAD) in older adults. Participants included 30 older adults with diagnosable GAD, 19 with subsyndromal anxiety symptoms [minor GAD; (MGAD)], and 21 normal control volunteers (NC). Participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV and completed self-report measures of anxiety, worry, depression, and life satisfaction. Excessive worry on more days than not, difficulty controlling worry, and clinically significant distress or impairment were the diagnostic criteria endorsed by MGAD participants least often. Therefore, these criteria may be useful in distinguishing between GAD and subsyndromal GAD. Self-reported anxiety and worry also systematically differed across groups in the expected directions, with a discriminant analysis yielding good classification of the GAD and NC groups based on these measures. Categorization of MGAD participants generally was poor, with most misclassified as GAD patients. Clinical implications of these findings are discussed.     

Generalized anxiety and panic disorders: Response to Cox, Cohen, Direnfeld, and Swinson (1996)

Contrary to the contention of Cox, Cohen, Direnfeld and Swinson (1996, Behaviour Research and Therapy, 34, 949–954) that the Beck Anxiety Inventory (BAI; Beck & Steer, 1993, Manual for the Beck Anxiety Inventory) measures primarily symptoms associated with panic attacks rather than anxiety in general, we propose that the higher level of anxiety found in patients with panic disorders not only is not an artifact of the BAI's symptom content, but patients with panic disorders truly have more anxiety than patients with other types of anxiety disorders. Furthermore, the BAI contains symptoms present in other anxiety disorders, besides panic disorder, and specifically includes 11 symptoms of generalized anxiety disorder (GAD). The BAI and revised Hamilton Anxiety Rating Scale (HARS-R; Riskind, Beck, Brown & Steer, 1987, Journal of Nervous and Mental Disease, 175, 474–479) scores of 274 (69%) outpatients with panic disorders and 123 (31%) outpatients with GAD were found to differentiate these two diagnostic groups equally and significantly. The panic disorder outpatients had higher scores on both the BAI and the HARS-R than did the GAD patients. Thus, Cox et al.'s (1996) speculation about the BAI's yielding spuriously high levels of anxiety in patients with panic disorders revives an important issue relevant to the relation of panic disorder to GAD.     

Cognitive Behavior Therapy for Women With Generalized Anxiety Disorder in the Perinatal Period: Impact on Problematic Behaviors

Generalized anxiety disorder (GAD) is the most frequently diagnosed anxiety disorder among women in the perinatal period (pregnancy to one year postpartum). Recent studies have examined the relationship between problematic behaviors and GAD symptoms. Studies in nonperinatal samples indicate that adults with GAD engage in avoidance and safety behaviors and these behaviors are associated with greater symptom severity. Little research has examined the use of problematic behaviors among pregnant or postpartum women. However, preliminary research suggests that these behaviors may have a negative impact on both anxious women and their children. Our aim was to examine the extent to which women with GAD in pregnancy or the postpartum engage in problematic behaviors and whether cognitive behavioral therapy is effective in reducing these behaviors. Fifty-eight women with GAD in pregnancy or postpartum were recruited from a larger clinical trial (Clinicaltrials.gov ID NCT02850523) evaluating the effectiveness of group-based cognitive behavioral therapy (CBGT) for perinatal anxiety disorders. The results indicated that women with perinatal GAD reported high levels of avoidance and safety behaviors and greater engagement in these behaviors was associated with higher levels of worry and related symptoms. CBGT was effective in reducing GAD symptoms and problematic behaviors and a bidirectional relationship was found between changes in worry and problematic behaviors during treatment. Limitations and future directions are discussed.     

Examination of the Hamilton Scales in Assessment of Anxious Older Adults: A Replication and Extension

This study examined the original and reconstructed Hamilton scales in the assessment of anxiety and depression in a sample of older adults diagnosed with GAD (n = 82). Internal consistency of all scales appeared adequate. Results indicated improved construct validity with the reconstructed scales, which demonstrated reduced shared variance. However, construct validity examined through intercorrelations of the Hamilton scales with self-report measures of anxiety and depression was generally poor. Discriminant function analysis indicated that the reconstructed scales might have some clinical utility in differentiation of patients with and without coexistent depressive diagnosis (67% correct classification). In addition, two items from the Hamilton rating scale for depression (Work and Activities; Hopelessness) correctly classified patients with and without depression at a similar level as the Hamilton scale total scores (64–65% correct classification). These results suggest that the Work and Activities, and Hopelessness items may provide clinicians with useful screening questions for depression in anxious older adults.     

Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n = 46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.     

Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.     

The Conceptualization of Anxiety: An Exploratory Study of Japanese American Older Adults

Few empirical studies exist on the mental health of Japanese American older adults. This study focused on how Japanese American older adults conceptualize anxiety. Participants were presented with a checklist, which included anxiety and depression symptoms identified in a previous qualitative study conducted by the authors, as well as symptoms from Generalized Anxiety Disorder in the Statistical Manual of Mental Disorders, Fourth Edition (DSM-IVrpar;. They were asked to imagine a Japanese American older adult who was experiencing anxiety and check off the symptoms he/she would be experiencing. Results indicated that these Japanese American participants conceptualized anxiety by using more depressive symptoms than anxiety symptoms. In addition, contrary to previous research and speculation about how Asian Americans experience psychological distress, participants also checked a larger number of cognitive symptoms as opposed to somatic symptoms. The present data suggest that Japanese American older adults conceptualize anxiety differently from the traditional psychiatric conceptualization of anxiety. Thus, clinicians and researchers should not generalize symptoms of psychological distress developed and researched on nonminority older adults to ethnic minority adults, and should consider such ethnic group differences in their assessment and treatment methods for ethnic minority adults.     

Evidence-based psychological treatments for late-life anxiety

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.     

“Cold” Cognitive Control and Attentional Symptoms in Anxiety: Perceptions Versus Performance

Clinically significant anxiety is associated with an array of attentional symptoms (e.g., difficulty concentrating; unwanted thought) that are subjectively experienced as severe. However, neuropsychological findings are mixed with respect to the presence of cognitive deficits that can account for these symptoms. Contextualizing predictions from established clinical theories (e.g., Attentional Control Theory) within contemporary, neurobiologically derived models of cognitive control (Dual Mechanisms of Control Theory), the present study investigated the relationship between “cold” proactive and reactive cognitive control, task effort, and subjective attentional symptoms (difficulty concentrating; unwanted thought) in a mixed clinical sample of individuals with generalized anxiety disorder (GAD) and/or obsessive-compulsive disorder (OCD) and a comparison sample of healthy controls. Clinical status moderated the relationship between attentional symptoms (attentional focusing and trait worry) and proactive cognitive control response time. Clinical status also moderated the relationship between trait worry and task effort. Higher trait worry was associated with slower proactive control and lower effort in healthy participants, but faster proactive control in clinical participants. Self-reported attentional focusing showed differential validity vis-à-vis proactive control response time in clinical versus healthy participants. Post-hoc conditional effects analysis suggested more accurate self-appraisals in healthy controls, but was not significant after correction for multiple comparisons. Preliminary evidence suggested that differences in task effort in anxious versus healthy adults may relate to subjective attentional symptoms in GAD and OCD.     

Individually tailored internet-based cognitive behaviour therapy for older adults with anxiety and depression: a randomised controlled trial

Mixed anxiety and depression is common among older adults. The aim of the study was to compare the effects of an eight-week-long tailored internet-supported cognitive behaviour therapy (ICBT) programme and to compare against the provision of weekly general support. A second aim was to investigate if pre-treatment cognitive flexibility and self-reported cognitive problems would predict outcome. We included 66 older adults (aged over 60 years) with mixed anxiety/depression following media recruitment and randomised them into treatment and control groups. We also included a one-year follow-up. As a measure of executive function, we used the Wisconsin Card Sorting Test (perseverative errors) and the Cognitive Failures Questionnaire during the pre-treatment phase. Results showed a moderate between-group effect on the main outcome measure, the Beck Anxiety Inventory (BAI) (d= .50), favouring the treatment group. Nearly half (45.5%) of that group were classified as responders. One person (3%) in the treatment group deteriorated. There were significant correlations between perseverative errors and outcome (on the BAI r = ?.45), but not among self-reported cognitive function. We conclude that guided, tailored ICBT may be effective for some older adults and that the role of cognitive function needs to be investigated further.     

Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample.

With the advent of DSM-III-R, the diagnostic criteria for generalized anxiety disorder (GAD) shifted in emphasis from the autonomic arousal to the cognitive component of the disorder, namely worry. The Penn State Worry Questionnaire was developed to assess the trait of worry and has proven to be a reliable and valid measure in a series of studies largely based on college student samples. The purpose of the present study was to assess the psychometric properties and utility of the PSWQ in a clinical sample of 436 anxiety disorder patients and 32 normal controls. Factor analysis indicated that the PSWQ assesses a unidimensional construct. Furthermore, the PSWQ evidenced quite favorable internal consistency using GAD patients and each of the other anxiety disorder groups and normal controls. The validity of the PSWQ was supported by an analysis indicating that the measure distinguished. GADs from each of the other anxiety disorder groups including those with obsessive-compulsive disorder. Moreover, correlations between the PSWQ and measures of anxiety, depression, and emotional control supported the convergent and discriminant validity of the measure. Collectively, the findings speak favorably to the use of the PSWQ in research examining the nature and treatment of GAD and the processes of normal and pathological worry.