Overview of Generalized Anxiety

Disorder AssessmentsRobert, Sarah & Ashley

Overview Of Generalized Anxiety Disorder

Definition: Generalized anxiety disorder (GAD) is a common anxiety disorder that

involves chronic worrying, nervousness, and tension.

Unlike a phobia, where your fear is connected to a specific thing or situation, the

anxiety of generalized anxiety disorder is widespread—a general feeling of dread or

unease that colors your whole life. This anxiety is less intense than a panic attack, but

much longer lasting, making normal life difficult and relaxation impossible.

Generalized anxiety disorder (GAD) is a chronic, impairing and highly comorbid

psychiatric condition afflicting an estimated 2.1% to 3.1% of the U.S. population during

any given 12-month period (Grant et al., 2005; Kessler et al., 2005).

DSM V Criteria1. excessive anxiety and worry occurring more days than not for at least 6 mo, about

a number of events or activities2. the individual finds it difficult to control the worry3. the anxiety and worry are associated with 3 or more of the following symptoms

a. restlessness or feeling keyed up or on edgeb. being easily fatiguedc. difficulty concentrating or mind going blankd. irritabilitye. muscle tensionf. sleep disturbance

4. the anxiety worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

5. the disturbance is not attributable to the physiological effects of a substance or other medical condition

6. the disturbance is not better explained by another mental disorder

Overview Continued… Symptoms: trouble falling asleep or staying asleep, sweating or hot flashes, irritability, muscle tension, trembling and or twitching, trouble concentrating, inability to relax and headaches.

Understanding the development and maintenance of GAD as a cognitive model:

4 Main Components of Experience and development Intolerance of uncertaintyPositive beliefs about worry Poor problem solvingCognitive avoidance

Five Common Assessments

● Beck Anxiety inventory (BAI) ● Hamilton Anxiety Rating Scale (HAM-A)

o Structured Interview Guide for Ham-A (SIGH-A)● State-Trait Anxiety Inventory (STAI)

o State- Trait Inventory for Cognitive and Somatic Anxiety (STICS)

● Generalized Anxiety Disorder Questionnaire (GAD-Q-IV) ● Anxiety Disorders Interview Schedule for the DSM-IV

(ADIS)

Beck Anxiety Inventory (BAI)

● created in 1988 by Beck, Epstein, Brown, and Steer

● created to discriminate between anxiety and depression

● 21 question self-report questionnaire that assess the frequency of anxiety symptomatology over 1 week

● created with a 2 factor system:o cognitive symptoms- measure of fearful thoughts and

impaired cognitive functioning 7 items

o somatic symptoms- symptoms of physiological arousal 14 items

BAIhttps://dih.wiki.otago.ac.nz/images/8/80/Beck.pdf● not a measure of trait or state anxiety,

measure of prolonged state anxiety

BAI Psychometrics ● Cronbach alpha= .90-.92

o high level of internal consistencyo for cognitive component, =.86-.87o for somatic component, =.85-.89

● one week test-retest reliability, r=.83

● shown to have larger correlations to other anxiety measures than measures of depressiono good discriminant validity when compared to BDI and Hamilton

Depression Rating Scaleo good convergent validity with other anxiety measures such as STAI,

Hamilton Anxiety Rating Scale (HAMA), Cognition Checklist- anxiety subscale, and Brief Symptom Inventory- anxiety and somatization subscales (range from .35 to .69) more closely correlated with A-State scale than A-Trait scale

BAI multicultural● congruence between factor structures

o .95 between Factor 1 in men and womeno .98 between Factor 2 in men and women

suggests factor structure is very similar for men and women

● women tend to endorse higher levels of anxietyo mean BAI score is higher in womeno women scored higher than men on both the cognitive factor and

somatic factor

● people with Intellectual Disabilitieso BAI is able to be used reliably and consistently in people with mild

IDo factors that emerge are similar to the factors that emerge in the

mainstream population

BAI Multicultural (cont.)● Older Adults with GAD

o older adults may not experience the same degree of autonomic arousal associated with anxiety as younger people do

o showed discriminant validity with measures of pathological worry (the GAD severity rating and PSWQ)

o no evidence of discriminant validity with measures of depression (Hamilton Depression Rating Scale and BDI) investigators believe that the discrimination between anxiety

and depression may become even harder in older adults due to a “de-differentiation” of anxiety symptoms with aging

o indicates limitations of using BAI with older adults and suggests the use of an instrument focusing on cognitive aspects of anxiety

o in non-clinical older adults the somatic items from the BAI may tap into symptoms of medical illness rather than anxiety, leading to an overdiagnosis

BAI Multicultural Psychometrics

Portugese BAI● The BAI showed adequate internal consistency (0.88–0.92) and discriminant

validity, with 0.74 sensitivity and 0.71 specificity for a cut-off score of 10. The factorial analysis suggested a three-factor solution to be the most adequate. Conclusions. The version of the BAI studied is quite adequate to be used in the context of Brazilian university students, identifying the presence of anxiety indicators. However, its usefulness to screen for SAD seems limited

Hindi BAI● The statistical analyses shows that the internal consistency (Cronbach alpha) is

0.882 for Hindi BAI and all the items of inventory are highly reliable as well as valid for the students of higher education.

BAI Multicultural Psychometrics

Spanish BAI● The BAI demonstrated a high level of internal consistency (α= 0,88), and the factor analyses

revealed a general anxiety dimension composed of two highly interrelated factors, corresponding to somatic and affective- cognitive symptoms. Taking the DSM-IV as standard the content validity of the BAI was adequate since, its items covered 45% of the specific symptomatic criteria of anxiety disorders and 78% of the symptoms of panic attacks. The BAI was correlated 0.58 with the Beck Depression Inventory-II, but a combined factor analysis of their items revealed two distinct factors, suggesting that the correlation between the BAI and BAI-II is a reflection of the relationship between anxiety and depression constructs rather than a problem of discriminant validity. Criterion validity analyses concerning the Quick DIS-III-R structured interview pointed out that the BAI had a good discriminative ability to identify clinical anxiety in university student samples. Finally, norms scores for university students were provided from the total sample and from the male and female subsamples, since females scored higher than males.

BAI Multicultural PsychometricsMexican BAI

● Factor structure, internal consistency, reliability, and convergent validity were determined. Four factors consistent with those reported for the English version of the instrument were identified. The results indicate that the Mexican version of the Beck Anxiety Inventory is highly useful in the Mexican population.

Chinese BAI● The results show that the BAI-C had excellent internal consistency; and that both

exploratory and confirmatory factor analyses indicated that the 2-factor model was the best fit for the data set. The study concludes that the BAI-C had good reliability; and that the 2 factors of the BAI-C, "physiological response" and "anxious cognition" were similar to the factors extracted from Beck's original scale and consistent with the cognitive-behavior model of anxiety.

French BAI● satisfactory internal consistency, convergent and discriminant validity, reliability, item

characteristics, and factorial structure. The BAI is recommended as a valid and reliable instrument for use in clinical and research settings.

BAI Multicultural Psychometrics

Turkish BAI● The BAI showed a high internal consistency. The exploratory factor analysis using

the principal components procedure yielded 2 factors. The results favor the use of the BAI as a reliable and valid measure of anxiety with Turkish psychiatric populations.

Icelandic BAI● Both internal consistency reliability and test-retest reliability were excellent.

Convergent and divergent validity were supported. The BAI showed discriminant validity both with regard to discriminating anxiety disorder patients from other patients and panic disorder patients from other anxiety disorder patients. Confirmatory factor analyses revealed excellent support for a one-factor model in the student population, which was superior to the alternative two- and four-factor models. The four-factor model was, however, supported in the patient population whereas the one- and two-factor models were not. It is concluded that the psychometric properties of the Icelandic version of the BAI are satisfactory.

BAI Limitations● With 14/21 of the items measuring physiological

symptoms, the cognitive, affective, and behavioral components of anxiety may be underrated o may have sacrificed some construct validity for

discriminant validity● GAD severity may include features such as impairment or

distress that are not captured by scales measuring cognitive or somatic symptoms of anxiety. o Assessment of functional impairment is missing from

symptom scales such as the BAI

BAI Limitations (cont.)● Because many individuals with GAD do not experience the

range or severity of autonomic symptoms associated with panic attacks, the BAI may be less appropriate as a measure of anxiety symptomatology in individuals with GAD, as the 14/21 items assess somatic symptoms of anxiety that overlap with panic attacks

● BAI may function best in anxiety disorders with a high physiological component such as Panic Disorder and less well with disorders with a stronger cognitive or behavioral component such as Social Phobia or OCD

Hamilton Anxiety Rating Scale (HAM-A)

● Developed in 1959 ● most widely used and accepted assessment globally● most common treatment outcome measure● inter rater reliability as a intra class coefficient (ICC) of .74-.96● lacks severity assessment ● proceded DSM III● considered poor at differentiating between GAD & MDD due to

changes in DSM diagnostic criteria● Currently a supplemental assessment is recommended● The Structured Interview Guide for the Hamilton Anxiety Rating

Scale (SIGH-A)

The Structured Interview Guide for the Hamilton Anxiety Rating scale (SIGH-A)

● Allows for severity ratings and cut off points● Allows for clarification of frequency of items● test -retest reliability

o HAM A ICC= .86, SIGH-A ICC= .89● Inter rater reliability

o HAM A ICC= .98, SIGH-A ICC= .99● validity of the SIGH A as a HAM A score

o r= .77

HAM A vs SIGH A1. Anxious mood

a. Worriesb. Anticipates worst

2. tensiona. startlesb. Cries easilyc. Restlessnessd. Trembling

3. Fearsa. fear of the darkb. fear of strangersc. fear of being aloned. fear of animals

4. Insomniaa. Difficulty falling asleepb. Difficulty with nightmares

RATE EACH ITEM 0= NOT PRESENT TO 4=SEVERE

1. what’s your mood been like this week ?a. have you been anxious or nervousb. have you been worryingc. Feeling that something bad might

happend. Feeling irritable

RATING: 0 = no anxious mood1 = mild worry or anxiety ( no change in functioning2 = preoccupation with minor events, anxiety on as many days as not3 = Near daily episodes of anxiety/worry with disruption of daily activities: daily preoccupation4 = Nearly constant anxiety: significant disruption

State Trait Anxiety Inventory (STAI-T) ● The distinction between state and trait anxiety was introduced

by Cattell (1966). Using this model Spielberger, Gorsuch and

Lushene (1993) created that State-Trait Anxiety Inventory (STAI)

in order to differentiate between different types of anxiety. State

anxiety is described as existing in a transitory emotional state

that varies in intensity and fluctuates over time. On the other

hand, trait anxiety refers to a stable susceptibility or a

proneness to experience state anxiety frequently.

● The STAI has appeared in over 3,000 studies

● The STIA continues to be widely used in psychological research

Description of the Assessment

● The STAI consists of two 20-item self-report measures. Respondents are asked to rate themselves on each item on the basis of a 4-point Likert scale, ranging from not at all to very much so for the STAI State form and from almost never to almost always for the STAI Trait form.

● The “State” portion of the inventory assesses how respondents feel “right now, at this moment” (e.g., “I feel at ease”; “I feel upset”).

● The “Trait” targets how respondents “generally feel” (e.g., “I am a steady person”; “I lack self-confidence”)

● http://yogabharati.org/public_download/Yoga_SN_2014/State_Trait_Anxiety_Inventory_for_adults.pdf

● The STAI State and Trait each have been found to contain two factors, labeled anxiety-present and anxiety-absent.

Psychometric Properties● A metanalysis by Barnes, Harp and Jung (2002) examines the

reliability and generalization of scores on the STAI, the measures demonstrated excellent internal consistency. o State: (average α = .91) o Trait: (average α = .89)

● Test retest reliability o State: (average r = .70) *Given the nature of this construct,

lower stability is expected for the State version of the STAIo Trait: (average r = .88)

Convergent and Discriminant Validity ● The measures have evidenced adequate convergent and

discriminant validity with other measures of state and trait anxiety (Spielberger, 1993).

● HOWEVER, The STAI State and Trait measures have been criticized for their inability to adequately discriminate between the symptoms of anxiety and depression.

● In particular, it is argued that the STAI Trait does not assess pure anxiety; rather, it assesses Negative Affect, including: Anxiety, characterized by rumination, worry, and distressing thoughts items, and Depression, characterized by dysphoric mood and negative self-appraisal items (e.g. I lack self-confidence) Bieling et al. (1998).

● This suggest that a new measure of state and trait anxiety may be needed.

State-Trait Inventory for Cognitive and Somatic Anxiety

● Ree, MacLeod, French, and Locke (2000) developed a new

measure, entitled the State–Trait Inventory for Cognitive and

Somatic Anxiety (STICSA), to assess state and trait anxiety.

● The primary improvement of the STICSA was the design of its

structure. Rather than making the distinction between anxiety-

present and anxiety-absent the STICSA separates anxiety into

cognitive (e.g., “I think the worst will happen”) and somatic

symptoms (e.g.,“My heart beats fast”)(Gros, Anthony, Simms,

McCabe 2007).

Psychometric Properties

● STICSA demonstrated excellent internal consistency, with

Cronbach's alpha coefficients of .88 for the Cognitive and

Somatic subscales of the STICSA State and .87 for both

subscales of the STICSA Trait.

● Compared with the Depression Anxiety Stress Scale (DASS-A)

the STICSA Trait was significantly more correlated with the

DASS–A scale than was the STAI Trait ( z = 7.9, p < .01, two-

tailed) and the STAI Trait was significantly more correlated with

the DASS–D scale than was the STICSA Trait ( z = 4.2, p < .01,

two-tailed) (Gros, Anthony, Simms, McCabe 2007).

Multi-cultural Implications

● State–Trait Anxiety Inventory (STAI) is the most researched of

anxiety measures from a cross-cultural basis.

● It has been translated into more than 30 different languages

● The State-Trait Inventory for Children is an adaption of the STAI

that has been normed for use with children. This assessment has

demonstrated good validity and reliability, however, its

discriminant validity has been called into questions.

● Research suggests the instrument lacks the ability to

differentiate youth with anxiety disorders from youth with

affective disorders (Seligman, Ollendick & Langley, 2004).

Multicultural Implications Cont...

● Hishinuma et al. (2000) conducted a study on the use of the

STAI with with adolescent Asian/Pacific Islanders. Participants

included 7000 White, Filipino, Hawaiian, Japanese and

Mixed/non Hawaiian students.

o Cronbach's alpha < .93

● Internal consistency supported the reliability of the factors.

● The study suggested to be cautious of its use and interpretation

of 1 particular item (Trait item 14 “I try to avoid facing a crisis

or difficulty’) and cautious application of the STAI to Filipino

adolescents (particularly males).

Multicultural Implications Cont...

● Baloğlu, Abbasi, and Masten (2007) conducted a cross-cultural

comparison of anxiety among college students using the STAI.

The sample consisted of 1709 American, Turkish, Mexican and

Filipino college students.

● Significant differences were found in terms of levels of state and

trait anxiety. Philippines scored highest followed by Turkish,

Mexican and American students. Interestingly, these findings

also indicated that younger participants have lower levels of

anxiety.

Multi- Cultural Implications ● Iwata and Higuchi (2000) Used the STAI to assess the level of

Anxiety in Japanese and American university students.

Participants included 149 Japanese students (99 living in Japan

and 50 Studying in the U.S) and 76 American students.

● Japanese students demonstrated significantly higher levels of

anxiety than American students.

● Japanese students presented lower scores on the anxiety- absent

items, that correspond to a lack of positive feelings.

Generalized Anxiety Disorder Questionnaire (GAD-Q-IV)

● a 9 item assessment based on the DSM IV● assesses the occurrence of excessive and

uncontrollable worry ● asks to list topics of worry● includes a checklist of DSM IV physical

symptoms● 2 likert scales 0-8 about interference and

severity of worry

Generalized Anxiety Disorder Questionnaire (GAD-Q-IV)

● SCORINGo yes = 1, no = 0o each topic of worry = 1 pt then total /3o each DSM IV symptom endorsed = 1 then

total /3o linkert scale scores and /4 then addedo a max total of 12o 5.7 best cutoff for diagnosis

Generalized Anxiety Disorder Questionnaire (GAD-Q-IV)

● PSYCHOMETRICSo inter rater reliability 94% overall

concordance rateo discriminant validity 93% chance an

individual with another anxiety disorder will score lower

o sensitivity = 83%o specificity = 89%o construct validity K = .67 with ADIS and GAD

Q IVo test retest reliability K =.64o concurrent validity r= .55 when compared to

PSWQ

Generalized Anxiety Disorder Questionnaire (GAD-Q-IV)

cross cultural assessment● African American,Caucasian, hispanic/latino, and Asian

o no sig. diffs on mean scoreso chi square analysis no sig. diff in gendero convergent validity no sig diffs found across race correlating

PSWQ, BAI, IUS, and ADISo incremental validity GAD Q IV predicted PSWQ scores sig

better than BDI and BAI with no sig diffs found between racial categories

o divergent reliability no racial differences found

The Anxiety disorders Interview Schedule IV

● Considered the “gold standard for assessing GAD”

● Assesses for onset, remission, temporal sequence, and comorbidity

● An all inclusive diagnostic tool for all anxiety disorders

● Inquires about excessive and/or uncontrollable worry in multiple life domains

● addressed DSM IV physical symptoms● includes a clinical severity rating (CSR) a rating

of 4 or higher= GAD

The Anxiety disorders Interview Schedule IV

PSYCHOMETRICS● construct reliability

o k=.67 for primary diagnosis● inter rater reliability

o r=.73 excessiveness of worryo r=.78 uncontrollability of worryo r= .83 DSM IV physical symptomso r= .72 clinical severity rating

Overview of Multicultural Assessments

● Anxiety disorders are said to be universal across all cultures.

● Based on a review of 16 international studies of children (ages 6-

17 years) prevalence rates of anxiety disorders ranging from

5.7% to 17.7%

● However the context in which anxiety is experienced the

interpretations of it’s meaning, and the responses to it are, like

those of other emotions, strongly influenced by cultural beliefs

and practices (Hishinuma et al., 2000).

● Woman report higher levels of cognitive and somatic symptoms

of anxiety than men.

Overview of Multicultural Assessment ● African Americans

o have lifetime prevalence rates of anxiety disorders equal to or up to 3x higher than that of European Americans

o report more somatic symptoms surrounding their experiences with anxiety than do European Americans

o makes the BAI a good tool to use with them

● Due to reports of increased experience of anxiety in women and African Americans, is it possible that anxiety could be induced/exasperated by power differentials within society?

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