Assessment of anxiety in older adults: a review of self-report measures

With increasing numbers of older adults in the general population, anxiety will become a widespread problem in late life and one of the major causes of health care access contributing to high societal and individual costs. Unfortunately, the detection of anxiety disorders in late life is complicated by a series of factors that make it different from assessment in younger cohorts, such as differential symptom presentation, high comorbidity with medical and mental disorders, the aging process, and newly emergent changes in life circumstances. This review covers commonly and currently used self-report inventories for assessing anxiety in older adults. For each tool, psychometric data is investigated in depth. In particular, information about reliability, validity evidence based on data from clinical and nonclinical samples of older adults, and availability of age-appropriate norms are provided. Finally, guidance for clinical evaluation and future research are proposed in an effort to highlight the importance of clinical assessment in the promotion of clinically relevant therapeutic choices.

Related papers:

title: Health anxiety disorders in older adults: conceptualizing complex conditions in late life.
abstract: Health anxiety disorders (e.g., hypochondriasis) are prevalent but understudied in older adults. Existing research suggests that severe health anxiety has a late age of onset, perhaps because of comorbidity with physical health conditions that are more likely to occur with aging. Despite being under diagnosed in later life due to a lack of age-appropriate diagnostic criteria, significant positive associations with age suggest that health anxiety disorders are more prevalent in older than younger adults. Preliminary research also highlights the complexity of these disorders in older adults and the potential importance of medical morbidity as a risk factor. This review explores the complexities of health anxiety disorders in later life with a focus on understanding defining features, prevalence rates, correlates, assessment, diagnosis, and treatment. We offer a theoretical model of the development of severe health anxiety among older adults to encourage further research on this important and under-studied topic.

title: Global prevalence of anxiety disorders: a systematic review and meta-regression
abstract: The literature describing the global prevalence of anxiety disorders is highly variable. A systematic review and meta-regression were undertaken to estimate the prevalence of anxiety disorders and to identify factors that may influence these estimates. The findings will inform the new Global Burden of Disease study.  A systematic review identified prevalence studies of anxiety disorders published between 1980 and 2009. Electronic databases, reference lists, review articles and monographs were searched and experts then contacted to identify missing studies. Substantive and methodological factors associated with inter-study variability were identified through meta-regression analyses and the global prevalence of anxiety disorders was calculated adjusting for study methodology.  The prevalence of anxiety disorders was obtained from 87 studies across 44 countries. Estimates of current prevalence ranged between 0.9% and 28.3% and past-year prevalence between 2.4% and 29.8%. Substantive factors including gender, age, culture, conflict and economic status, and urbanicity accounted for the greatest proportion of variability. Methodological factors in the final multivariate model (prevalence period, number of disorders and diagnostic instrument) explained an additional 13% of variance between studies. The global current prevalence of anxiety disorders adjusted for methodological differences was 7.3% (4.8–10.9%) and ranged from 5.3% (3.5–8.1%) in African cultures to 10.4% (7.0–15.5%) in Euro/Anglo cultures.  Anxiety disorders are common and the substantive and methodological factors identified here explain much of the variability in prevalence estimates. Specific attention should be paid to cultural differences in responses to survey instruments for anxiety disorders.

title: Anxiety disorders in older adults: a comprehensive review
abstract: This review aims to address issues unique to older adults with anxiety disorders in order to inform potential changes in the DSM‐V. Prevalence and symptom expression of anxiety disorders in late life, as well as risk factors, comorbidity, cognitive decline, age of onset, and treatment efficacy for older adults are reviewed. Overall, the current literature suggests: (a) anxiety disorders are common among older age individuals, but less common than in younger adults; (b) overlap exists between anxiety symptoms of younger and older adults, although there are some differences as well as limitations to the assessment of symptoms among older adults; (c) anxiety disorders are highly comorbid with depression in older adults; (d) anxiety disorders are highly comorbid with a number of medical illnesses; (e) associations between cognitive decline and anxiety have been observed; (f) late age of onset is infrequent; and (g) both pharmacotherapy and CBT have demonstrated efficacy for older adults with anxiety. The implications of these findings are discussed and recommendations for the DSM‐V are provided, including extending the text section on age‐specific features of anxiety disorders in late life and providing information about the complexities of diagnosing anxiety disorders in older adults. Depression and Anxiety, 2010.

title: Anxiety symptoms and disorder predict activity limitations in the elderly.
abstract: In the elderly, little attention has been paid to anxiety both on a symptom dimension and as a disorder, as an independent risk factor for the incidence of activity limitations.



In a community-dwelling cohort of 1581 persons aged 65+, the association between trait anxiety symptoms (Spielberger Trait, third highest tertile) and baseline DSM-IV anxiety disorder, and 7-year incident activity limitations was determined using mixed logistic regression models. Repeated measures of activity limitations included, by increased severity level: social restriction (neighbourhood and house confined), mobility (Rosow and Breslau scale) and limitations in instrumental activities of daily living (IADL).



Of the sample, 14.2% had an anxiety disorder at baseline. Adjusting for baseline socio-demographic and health variables, depression (past and current), antidepressant and anxiolytic drugs, baseline anxiety disorder was associated with an increased risk of incident IADL limitation (OR (95% CI): 1.84 (1.01-3.39), p=0.048) and trait anxiety with increased incidence of social restriction (OR (95% CI): 2.41 (1.42-4.09), p=0.001). Associations remained significant in participants free of depressive symptoms at baseline (OR (95% CI): 2.92 (1.41-6.05), p=0.004; OR (95% CI): 3.21 (1.31-7.89), p=0.011, respectively).



Activity limitations were self-reported and may have been over-reported in participants with anxiety.



Both trait anxiety symptomatology and anxiety disorder were independently associated with increased incidence of activity limitations with a gradient of severity: trait anxiety associated with incident social restriction and anxiety disorder with more severe IADL limitations, suggesting that anxiety is a predictor of activity limitations in the elderly independently of depression comorbidity.

title: Measuring anxiety in late life: a psychometric examination of the geriatric anxiety inventory and geriatric anxiety scale.
abstract: We examined the psychometric properties, internal scale reliability and validity, of two geriatric anxiety measures: the Geriatric Anxiety Inventory (GAI) and Geriatric Anxiety Scale (GAS). We also determined the extent to which memory ability influenced the psychometric properties of these measures. Older adult participants (N=110; M age=75 years) completed self-report, clinician-rated and diagnostic psychiatric measures and a neuropsychiatric battery. GAI and GAS scores had good internal consistency, adequate reliability, and strong convergent validity. GAI scores had better discriminant validity than GAS scores relative to a health rating. Both measures had strong associations with depression scores. Psychometric properties were decreased in participants with average delayed memory recall compared with those with superior recall. Both measures had good psychometric support, particularly in those with strong memory abilities. Psychometric performance characteristics indicate that the GAI and GAS may be good alternatives to anxiety measures not designed specifically for older adults.

title: Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group
abstract: Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late‐life anxiety disorders.

title: Prevalence of social phobia in non-demented elderly from a swedish population study.
abstract: To examine the prevalence of social phobia, and how the different Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic components of social phobia influence prevalence rates, among a population sample aged 70 years and older.



A general population sample was investigated in 2000-2001 with semistructured psychiatric examinations, including the Comprehensive Psychopathological Rating Scale, the Mini International Neuropsychiatric Interview, the Global Assessment of Functioning (GAF) scale, and the Mini Mental State Examination.



General population  Randomized sample of 914 nondemented elderly, response rate 68%. The sample was stratified into two age groups: 70-year olds (N = 338 women and 224 men) and aged 78 and above (N = 352 women).



Social phobia according to DSM-IV requiring: a) fearing social situations, b) experiencing the fear as unreasonable or excessive, c) avoiding feared social situations or enduring them with intense anxiety or distress, and d) that this causes social consequences.



The 1-month prevalence of social phobia was 1.9% (N = 17), an additional 1.6% (N = 15) fulfilled criteria a, c, and d, but not b. Thus, 3.5% had "social phobia" that caused social consequences. This was related to lower GAF-score and concurrent depression,panic attacks, and agoraphobia. Almost one fourth (N = 220) of the total sample feared social situations. This was more common in 70-year-old women compared with 70-year-old men (29.9% versus 20.5%), and to women aged 78-92 years (21.0%).



Our results indicate that DSM-IV criteria exclude a large group of individuals with social phobia. It could be discussed whether DSM-IV criteria should be revised to also encompass these individuals.

title: Assessment of anxiety in older adults: current status.
abstract: In 1994 there were 33.2 million older adults (65 years of age and older) in the United States, and approximately one quarter of these older adults meet diagnostic criteria for some mental disorder. Anxiety is among the most prevalent psychiatric disorder in older adults. However, insufficient research has been conducted on the assessment of anxiety in older adults. The purpose of this article was to provide an overview of issues to consider in assessing anxiety in older adults. First, a discussion of factors that may influence current prevalence and incidence figures is provided. Second, age-related differences in factors that can influence the experience and presentation of anxiety symptoms are considered. Third, age-related factors that can influence the assessment process or outcome are presented. Fourth, a discussion on the important role of multimethod assessment and the psychometric adequacy of available anxiety assessment instruments is presented. Finally, recommendations for clinical assessment and future research are provided.

title: Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression.
abstract: The authors examined 179 veterans with chronic obstructive pulmonary disease (COPD) to determine the relative contribution of clinical depression and/or anxiety (Beck Depression and Beck Anxiety Inventories) to their quality of life (Chronic Respiratory Questionnaire and Medical Outcomes Survey Short Form). Multiple-regression procedures found that both depression and anxiety were significantly related to negative quality-of-life outcomes (anxiety with both mental and physical health quality-of-life outcomes, and depression primarily with mental health). When comorbid with COPD, mental health symptoms of depression and anxiety are some of the most salient factors associated with quality-of-life outcomes.

title: Behavioral Assessment of Anxiety in Older Adults
abstract: The behavioral assessment of anxiety in older adults is reviewed in this article. Despite the high rate of anxiety symptoms uncovered during the course of large-scale epidemiological studies, the comprehensive evaluation of anxiety in this age group (55 and over) is not highly sophisticated at this juncture. In this review, diagnostic issues, psychometric evaluation, motoric assessment, and psychophysiological assessment are considered. Throughout the articles, gaps in the extant research are identified, and a research agenda for the future is developed.

title: A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy.
abstract: Interventions to promote prescribing of preventive therapies in patients with cardiovascular disease (CVD) or diabetes have reported variable success.



(i) To evaluate the effect of prescribing feedback on GP practice using academic detailing compared to postal bulletin on prescribing of CVD preventive therapies in patients with CVD or diabetes at 3 and 6 months post intervention and (ii) to evaluate the intervention from a GP's perspective.



Volunteer GP practices (n = 98) were randomized to receive individualized prescribing feedback via academic detailing (postal bulletin plus outreach visit) (n = 48) or postal bulletin (n = 50). The proportion of CVD or diabetic patients on statins and antiplatelet agents/warfarin pre- and post-intervention was calculated for each GP practice. Multivariate regression with a random effects model was used to compare differences between the groups adjusting for GP clustering and confounding factors. beta-Coefficients and 95% confidence intervals (CIs) are presented.



There was a 3% increase in statin prescribing in CVD patients at 6 months post-intervention for both randomized groups, but there was no statistical difference between the groups (beta = 0.004; 95% CI = -0.01 to 0.02). Statin and antiplatelet/warfarin prescribing also increased in the diabetic population; there was no significant differences between the groups. GPs participating in the project expressed a high level of satisfaction with both interventions.



Prescribing of preventive therapies increased in both randomized groups over the study period. But academic detailing did not have an additional effect on changing prescribing over the postal bulletin alone.

title: Assessment of Anxiety in Older Adults: Translation and Psychometric Evaluation of the German Version of the Geriatric Anxiety Scale (GAS)
abstract: Anxiety occurs frequently among older adults, and can have deleterious impacts on the quality of daily life. Due to the dearth of well-validated elder-specific anxiety screening instruments available in the German language, this study aimed to translate the Geriatric Anxiety Scale (GAS), a reliable and valid 30-item self-report screening instrument for assessing anxiety based on DSM-IV-TR diagnostic criteria (Segal et al. Journal of Anxiety Disorders, 24(7), 709–714, 2010a), into German, and to validate the new measure. The German version of the GAS was developed through a translation and back translation process, with careful attention paid to culturally-sensitive expressions of anxiety in the German older adult population. The final version of the German GAS was tested in a sample of 242 community-dwelling older adults (Mage = 72.0 years, SD = 6.9 years; 59 % women) who completed either an online (26 %) or a paper-pencil (74 %) version of the questionnaire. The findings confirmed the successful translation of the GAS into German and provided psychometric support for the new measure. The validation of the factor structure based on confirmatory factor analyses was in support of a unidimensional structure of the GAS-G. Correlational analyses with inventories measuring anxiety related and non-anxiety related personality traits additionally confirmed the convergent and discriminant validity of the GAS for use as an assessment measure for anxiety among German older adults.

title: Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey.
abstract: To assess the association between sleep problems and chronic disease in older adults.



Self-reported standardized questionnaire data from 1506 community-dwelling men and women aged 55-84 years in the continental United States who completed a 20-min telephone interview when contacted from lists of randomly selected telephone numbers.



A majority of the participants (83%) reported one or more of 11 medical conditions and nearly one in four elderly respondents (age 65-84 years) had major comorbidity (i.e. four or more conditions). Depression, heart disease, bodily pain and memory problems were associated with more prevalent symptoms of insomnia. Other conditions such as obesity, arthritis, diabetes, lung diseases, stroke and osteoporosis were associated with other sleep-related problems such as breathing pauses, snoring, daytime sleepiness, restless legs or insufficient sleep (<6 h nightly).



Poll findings are consistent with epidemiological studies of sleep, aging and chronic disease. These results suggest that the sleep complaints common in older adults are often secondary to their comorbidities and not to aging per se. These types of studies may be useful in promoting sleep awareness among health professionals and among older adults, especially those with heart disease, depression, chronic bodily pain or major comorbidity.

title: Assessment of anxiety in older adults: A systematic review of commonly used measures
abstract: The authors set out to systematically review the research literature in order to identify the anxiety measures most commonly used in the assessment of older adults. Once identified, the literature was reviewed to determine the extent to which these instruments had age-relevant norms and psychometric data supporting their use with older adults.  Literature searches were conducted in PsycINFO and PubMed to identify research articles in which anxiety measures were completed by older adults. After screening for suitability, a total of 213 articles were reviewed to determine the most commonly used anxiety measures with older adults to examine the psychometric properties of these instruments and to evaluate whether the instruments are appropriate for use with older adults.  A total of 91 different anxiety measures were used in the 213 included articles. Twelve anxiety measures were most commonly used in the literature and of those three were specifically developed for older adults.  Of the most commonly used measures, the majority lacked sufficient evidence to warrant their use with older adults. Based on psychometric evidence, three measures (Beck Anxiety Inventory, Penn State Worry Questionnaire, and Geriatric Mental Status Examination) showed psychometric properties sufficient to justify the use of these instruments when assessing anxiety in older adults. In addition, two measures developed specifically for older adults (Worry Scale and Geriatric Anxiety Inventory) were also found to be appropriate for use with older adults.

title: Comorbidity of anxiety and unipolar mood disorders.
abstract: Research on relationships between anxiety and depression has proceeded at a rapid pace since the 1980s. The similarities and differences between these two conditions, as well as many of the important features of the comorbidity of these disorders, are well understood. The genotypic structure of anxiety and depression is also fairly well documented. Generalized anxiety and major depression share a common genetic diathesis, but the anxiety disorders themselves are genetically hetergeneous. Sophisticated phenotypic models have also emerged, with data converging on an integrative hierarchical model of mood and anxiety disorders in which each individual syndrome contains both a common and a unique component. Finally, considerable progress has been made in understanding cognitive aspects of these disorders. This work has focused on both the cognitive content of anxiety and depression and on the effects that anxiety and depression have on information processing for mood-congruent material.

title: Structural differentiation of self-reported depression and anxiety in late life.
abstract: Research has shown impressive support for tripartite models of anxiety and depression that include a common factor of negative affect, and the unique factors positive affect and arousal. It is not clear whether this structure extends into later life. The current study used confirmatory factor analysis to model the structural relationship of anxiety and depression in two samples of older adults: a large probability sample (N = 1429) and a smaller convenience sample (N = 210). Across all analyses, a correlated, two-factor, psychometric model was most parsimonious. The tripartite model could be fit to the data, but added no explanatory power; in some cases a one-factor model also fit. The results suggest that there is a unitary factor of "distress" that incorporates anxiety and depression, but that the structure is not consistent with factor structures found in younger samples. Instead, the broad constructs may be represented in a more complex manner among older adults, and are less easily differentiated.

title: Assessing older adults with generalized anxiety: a replication and extension.
abstract: Anxiety is a major health problem for older adults. The cornerstone for further work in this area is research that establishes the psychometric utility of standardized measurement strategies to characterize anxiety in older adults. The goals of the current study were to replicate and extend prior research addressing the psychometric properties of five self-report measures of anxiety in a sample of 57 older adults with generalized anxiety disorder (GAD). Data addressed the descriptive characteristics, internal consistency, test-retest reliability, interrelation of subscales, and convergent and divergent validity of the Penn state worry questionnaire (PSWQ), worry scale (WS), Spielberger state-trait anxiety inventory - Form Y (STAI), and two versions of the fear questionnaire (FQ). Descriptive data generally replicated prior findings, with some increased state and trait anxiety in the current sample. Measures were internally consistent, with evidence that a revised version of the FQ that focuses on severity of fear irrespective of associated avoidance demonstrated greater internal consistency than the original version. Measures of content-specific fears and worries (WS, FQ) were stable over time and demonstrated convergent validity. Evidence of convergent validity also was evident for measures of worry and general anxiety (WS, PSWQ, STAI-Trait), but two of these measures (PSWQ, STAI) were not reliable over time. Only the PSWQ showed evidence of divergent validity with respect to self-report measures of depression.

title: Anxiety Disorders in Adults: An Evidence-Based Approach to Psychological Treatment
abstract: This is the second book in Oxford's Guidebooks in Clinical Psychology series. This book provides practical guidelines on the treatment of anxiety disorders (the second most frequent clinical diagnosis), linking guidelines to empirical evidence. The authors review the several classifications of anxiety disorders using the latest DSM-IV categories, covering specific phobias, social phobia, panic disorder and agoraphobia, obsessive-compulsive disorder, and post-traumatic stress disorder, among others. The chapters assess the efficacy of various treatments, and the authors conclude with a discussion of how treatment standards can be implemented in clinical training and practice.

title: Anxiety: a hidden element in dementia
abstract: Anxiety has reported prevalence rates between 38 and 72% among people with dementia. It has a negative impact on cognitive impairment and is associated with agitation and poor quality of life. The presence of excessive anxiety can be difficult to establish in people with dementia, especially when expressive or receptive speech is impaired. Unfortunately, there is a lack of research on the treatment of anxiety in dementia, and also on the wider issue of the management of anxiety disorders in old age. We explore the prevalence, presentation and diagnosis of anxiety in dementia and discuss the therapeutic options available.

title: Association between cognitive impairments and anxiety disorders following traumatic brain injury
abstract: This study examined the association between cognitive impairment and anxiety disorders following traumatic brain injury (TBI). Sixty-six participants recruited from a rehabilitation hospital completed the Structured Clinical Interview for the DSM–IV (Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition) and cognitive tests at one year post injury. Prevalence of anxiety disorder was 27.3%. Logistic regression analyses revealed that the attention/working memory, information processing, and executive functions models were significantly associated with anxiety disorder. The memory model was not significant. Processing speed emerged as the strongest model associated with anxiety disorder. The role of cognitive impairment in the etiology of anxiety disorders after TBI is discussed, and treatment implications are explored.

title: Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication.
abstract: Current information on the prevalence of psychiatric disorders among older adults in the United States is lacking. Prevalence of anxiety, mood, and substance disorders was examined by age (18-44, 45-64, 65-74, and 75 years and older) and sex. Covariates of disorders for older adults (65 years and older) were explored.



Cross-sectional epidemiologic study, using data from the National Comorbidity Survey-Replication.



Community-based epidemiologic survey.



Representative national sample of community-dwelling adults in the United States.



The World Health Organization Composite International Diagnostic Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders.



Prevalence of 12-month and lifetime mood, anxiety, and substance-use disorders was lower for older adults (65 years and older) than younger age groups: 2.6% for mood disorder, 7.0% for anxiety disorder, 0 for any substance-use disorder, and 8.5% for any of these disorders (for any disorder, 18-44 years = 27.6%, 45-64 years = 22.4%). Among older adults, presence of a 12-month anxiety disorder was associated with female sex, lower education, being unmarried, and three or more chronic conditions. Presence of a 12-month mood disorder was associated with disability. Similar patterns were noted for lifetime disorders (any disorder: 18-44 years = 46.4%, 45-64 years = 43.7%, and 65 years and older = 20.9%).



This study documents the continued pattern of lower rates of formal diagnoses for elders. These rates likely underestimate the burden of late-life psychiatric disorders, given the potential for underdiagnosis, clinical significance of subthreshold symptoms, and lack of representation from high-risk older adults (e.g., medically ill, long-term care residents).

title: The burden of late-life generalized anxiety disorder: effects on disability, health-related quality of life, and healthcare utilization.
abstract: To describe the burden of Generalized Anxiety Disorder (GAD), a common anxiety disorder in older adults.



Cross-sectional.



Late-life depression and anxiety research clinic in Pittsburgh, PA.



One hundred sixty-four older adults with GAD and 42 healthy comparison participants with no lifetime history of psychiatric disorder were recruited from primary care and mental health settings as well as advertisements.



Participants were evaluated with the Late Life Function and Disability Index to assess disability, the MOS 36-Item Short Form Survey Instrument to assess health-related quality of life (HRQOL), and the Cornell Service Index to assess healthcare utilization.



Older adults with GAD were more disabled, had worse HRQOL, and had greater healthcare utilization, than nonanxious comparison participants, even in the absence of psychiatric comorbidity. After controlling for medical burden and depressive symptoms, higher severity of anxiety symptoms was associated with greater disability and poorer HRQOL in several domains. The greatest decrements in HRQOL and function were observed in measures assessing role functioning, including social function.



This study, the largest ever of GAD in older adults, provides evidence of the significant burden of this disorder in late life. Given the high prevalence and chronicity of GAD in the elderly, these data provide a public health imperative for finding and implementing effective management strategies for this typically undiagnosed and untreated disorder.

title: Acceptance and Commitment Therapy for generalized anxiety disorder in older adults: a preliminary report.
abstract: Some evidence suggests that acceptance-based approaches such as Acceptance and Commitment Therapy (ACT) may be well-suited to geriatric generalized anxiety disorder (GAD). The primary goal of this project was to determine whether ACT was feasible for this population. Seven older primary-care patients with GAD received 12 individual sessions of ACT; another 9 were treated with cognitive-behavioral therapy. No patients dropped out of ACT, and worry and depression improved. Findings suggest that ACT may warrant a large-scale investigation with anxious older adults.

title: Anxiety symptoms and generalized anxiety disorder in the elderly: a review.
abstract: Anxiety is a common but underestimated, undertreated, and poorly studied problem in the elderly. Generalized anxiety disorder (GAD) and nonspecific anxiety symptoms that do not fall under a specific anxiety disorder are good examples. The current literature on the epidemiology, consequences, phenomenology, assessment, and treatment implications of these challenging problems is reviewed. A variety of limitations are observed. They include limited understanding of the expression of GAD in this age group, variable definitions of "elderly" (specifically with regard to the minimum age), limited ability of currently available diagnostic instruments to identify GAD in the elderly, and the availability of only a few trials addressing treatment of GAD specifically in this group. Despite these limitations there is enough evidence suggesting GAD in the elderly has a potential for negative consequences independent of the common comorbidity with major depressive disorder. The treatments reviewed are promising but need further research in order to document their safety and efficacy. The limitations of our current knowledge are discussed, with recommendations for future research.

title: Self-report measures of anxiety: Are they suitable for older adults?
abstract: To assess the performance of four self-report measures of anxiety in an older adult population.  Forty older adults with current or previous anxiety symptoms completed four self-report measures of anxiety (Beck Anxiety Inventory, State Trait Anxiety Inventory, Hospital Anxiety and Depression Scale and Visual Analogue Scale) and received an independent diagnostic assessment and rating of anxiety severity. After a minimum of four months, participants were re-assessed on all measures.  The self-report measures most suited for anxiety screening and assessing severity when compared to the independent assessment were the Beck Anxiety Inventory (BAI), the anxiety scale from the Hospital Anxiety and Depression Scale (HADS-A) and State Trait Anxiety Inventory-Trait form (STAI-T). However, participants made an unacceptably high number of errors using the STAI-T, making the BAI and HADS-A the most suitable measures for older adults. The Visual Analogue Scale (VAS) performed poorly in both screening and measuring severity. All self-report measures were poor at detecting change as evaluated by the independent assessment.  There was no single measure that performed adequately in screening, measuring severity and monitoring changes, suggesting that measures may need to be adapted if they are to be used in an older adult population. The lack of appropriately designed self-report measures with adequate normative data for older people presents a barrier to future research.

title: Older Adult Psychological Assessment
abstract: The psychological assessment of older adults is often challenging due to the frequent co-morbidity of mental and physical health problems, multiple medications, interactions among medications, age-related sensory and cognitive deficits, and the paucity of assessment instruments with psychometric support for use with older adults. First, psychological assessment instruments for examining five important clinical areas (suicide ideation, sleep disorders, anxiety, depression, and personality) are discussed in light of the most current research regarding their psychometric properties and suitability for use with older adults. Instruments developed specifically for older adults are distinguished from instruments developed for younger adults that have some psychometric support for their use with older adults. Second, the potential sensory deficits that could compromise assessment, factors to consider in light of these deficits, and accommodations that can be made to minimize their effects are discussed.

title: Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model.
abstract: The assessment of worry among older adults typically has involved measures designed with younger cohorts. Because of special concerns in assessing older adults, modifications to existing instruments may be necessary. Addressing equivocal factor analytic data on the Penn State Worry Questionnaire (PSWQ) among younger adults, the authors conducted confirmatory factor analyses to evaluate the generalizability of previous models to older adults with generalized anxiety disorder. Data fit poorly with established single- and two-factor models. The single-factor model was modified, resulting in the elimination of 8 items, strong fit indices, high internal consistency, adequate test-retest reliability, and good convergent and divergent validity. Further psychometric work is required to assess whether the revised model is a more parsimonious method to assess late-life anxiety.

title: Assessing worry in older and younger adults: Psychometric properties of an abbreviated Penn State Worry Questionnaire (PSWQ-A).
abstract: Among older adults, recent work indicated that Penn State Worry Questionnaire (PSWQ) data fit poorly with previously established models, leading to use of model modification procedures to create an abbreviated worry questionnaire (PSWQ-A; Hopko, D. R., Stanley, M. A., Reas, D. L., Wetherell, J. L., Beck, J. G., Novy, D. M., et al. (2003). Assessing worry in older adults: Confirmatory factor analyses of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychological Assessment, 15, 173-183). Given limitations of this prior study that included the post hoc statistical development of the scale and undefined relevance toward assessing worry in younger cohorts, psychometric properties of the PSWQ-A were explored among independent samples of older (n = 115) and younger adults (n = 183). Exploratory factor analyses supported a unidimensional model (breadth and control of worry) that accounted for substantial variance in older (57%) and younger adult samples (70%) and was associated with high factor loadings (.66-.89). Internal consistency (alpha = .89-.94) and test-retest reliability (r = .87-.95) was strong in both samples. Moderate to strong convergent validity with measures of worry and anxiety was evident (r = .46-.83), as was support for the construct validity of the PSWQ-A via its relation to the PSWQ (r = .65-.83) and similar relations with other anxiety and worry measures. Although further study is required, the PSWQ-A may be a parsimonious method to assess worry in older and younger adults.

title: A test of the measurement invariance of a brief version of the Penn State Worry Questionnaire between American and Spanish older adults.
abstract: Both anxiety disorders and subclinical anxiety symptoms are related to poorer health and functioning in later life. Because worry is an important component of anxiety, the accurate measurement of worry is crucial to studying the etiology, prevention and treatment of anxiety disorders. Assessment of the trait worry has emerged as the most widely used strategy to establish the presence and extent of pathological worry. However, the Penn State Worry Questionnaire (PSWQ), the most widely used measure of the trait worry, has not been validated cross-culturally in groups outside of the U.S.A.



We tested the psychometric properties and measurement invariance of an 8 item abbreviated version of the PSWQ (PSWQ-A) in American (N = 206) and Spanish (N = 137) older adult samples.



Internal consistency was high and analyses supported a unidimensional solution in both samples. Measurement invariance was tested using confirmatory factor analysis (CFA) and Rasch models. Results of the CFA suggest that measurement invariance between the samples can be assumed for women but not for men. Rasch modeling results by gender suggested that three items have different endorsability levels in the two samples, suggesting that certain items may more closely represent the construct of the trait worry in American and Spanish older adults.



Overall, the PSWQ-A appears appropriate for cross-cultural use, although deletion of one item (item 6) may improve the psychometric properties of the scale across different populations.

title: Comparison of the Penn State Worry Questionnaire (PSWQ) and abbreviated version (PSWQ-A) in a clinical and non-clinical population of older adults.
abstract: The Penn State Worry Questionnaire (PSWQ) is a widely used measure of worry severity. An 8-item abbreviated version (PSWQ-A) has been developed as a brief screening measure, although there are limited studies assessing the psychometric properties of this measure in a large geriatric population. The aim of this study was to assess the utility of the PSWQ-A compared to the full PSWQ, to identify pathological worry in an older adult sample (N=108) of clinically anxious and depressed older adults, compared to a non-clinical sample (N=53). The PSWQ and PSWQ-A were found to have similarly adequate reliability and validity. The factor structure of the PSWQ-A was replicated, but not for the PSWQ. Both measures accurately distinguished between clinical and non-clinical status with similar sensitivity and specificity. These findings indicate the PSWQ-A is a useful measure for screening or epidemiological studies assessing worry in geriatric populations.

title: Development and validation of a short form of the Geriatric Anxiety Inventory – the GAI-SF
abstract: Anxiety symptoms and anxiety disorders are highly prevalent among older people and are associated with considerable disability burden. While several instruments now exist to measure anxiety in older people, there is a need for a very brief self-report scale to measure anxiety symptoms in epidemiological surveys, in primary care and in acute geriatric medical settings. Accordingly, we undertook the development of such a scale, based on the Geriatric Anxiety Inventory.  This is a cross-sectional study of randomly selected, community-residing, older women (N = 284; mean age 72.2 years) using receiver operating characteristic (ROC) analyses. DSM-IV diagnostic interviews were undertaken using the Mini International Diagnostic Interview, fifth edition (MINI-V).  We developed a 5-item version of the Geriatric Anxiety Inventory, which we have termed the Geriatric Anxiety Inventory – Short Form (GAI-SF). We found that a score of three or greater was optimal for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in this community sample. At this cut-point, sensitivity was 75%, specificity was 87%, and 86% of participants were correctly classified. GAI-SF score was not related to age, MMSE score, level of education or perceived income adequacy. Internal consistency was high (Cronbach's α = 0.81) and concurrent validity against the State-Trait Anxiety Inventory was good (rs = 0.48, p < 0.001).  The GAI-SF is a short form of the Geriatric Anxiety Inventory, which we recommend for use in epidemiological studies. It may also be useful in primary care and acute geriatric medical settings.

title: Development and validation of the Geriatric Anxiety Inventory.
abstract: Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people.



We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale.



Cronbach's alpha for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test-retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%.



The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

title: Development and initial validation of a self-report assessment tool for anxiety among older adults: the Geriatric Anxiety Scale.
abstract: Anxiety is a common experience among older adults and can be a cause for major clinical concern. Brief and psychometrically sound screening instruments are needed to detect anxiety in later life. The purposes of this study were to develop a brief, self-report measure of anxiety for use with older adults (called the Geriatric Anxiety Scale [GAS]) and to report on its preliminary psychometrics. The GAS includes 30 self-report items of which 25 items represent three common domains of anxiety symptoms among older adults (cognitive, somatic, and affective) and 5 items represent common content areas of worry. The GAS total score and subscale scores demonstrated good internal reliability in community dwelling and in clinical samples. In addition, correlation analyses provided solid evidence of convergent and construct validity for the GAS in both samples. Present results support the preliminary validity of the GAS for clinical and research purposes. We conclude with a discussion of limitations and future research topics.

title: The relationship between self-reported health and mental health problems among older adults in New Zealand: Experiential avoidance as a moderator
abstract: This study sought to examine the influence of experiential avoidance (EA) as a moderating variable between reported physical health problems and anxiety and depression among older adults. Experiential avoidance has been found in previous studies to be strongly associated with a number of psychological disorders in younger adults but has received minimal attention in older populations. Two-hundred-and-eight individuals from New Zealand between the ages of 70 and 92 years old participated in this study. The Geriatric Anxiety Inventory, the Geriatric Depression Scale and the Acceptance and Action Questionnaire were used to measure anxiety, depression and EA, respectively. It was hypothesized that self-reported health (SRH) and EA would be associated with depression and anxiety at the zero order level. We also hypothesized that EA would be a unique predictor of depression and anxiety and would moderate the relationships between SRH and both depression and anxiety. Multiple regression analyses indicated that EA explained 8% of the unique variance in depression, 20% in anxiety and moderated the relationships between SRH and both depression and anxiety. This study also found that the relationships involving EA were more pronounced with anxiety as compared with depression in this elderly sample. The theoretical and practical applications of these findings are discussed.

title: Assessment of anxiety in older home care recipients.
abstract: This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services.



Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD).



Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified).



These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.

title: The influence of cognitive flexibility on treatment outcome and cognitive restructuring skill acquisition during cognitive behavioural treatment for anxiety and depression in older adults: Results of a pilot study.
abstract: There is some evidence that cognitive flexibility negatively impacts cognitive restructuring skill acquisition with brief training; however, there is little understanding of how this relates to learning cognitive restructuring over the course of a therapy program, and how it relates to overall treatment outcome. This study assessed the impact of cognitive flexibility on cognitive restructuring skill acquisition following group CBT, and on treatment outcome, along with changes in cognitive flexibility over treatment. 44 older participants with anxiety and depression completed self-report and neuropsychological tests of cognitive flexibility and a clinical interview at pre and post-treatment. Qualitative and quantitative measures of cognitive restructuring were completed at post-treatment. Pre-treatment cognitive flexibility was not related to the quality of cognitive restructuring at post-treatment or overall treatment outcome. However, it did predict reduction in subjective units of distress from using cognitive restructuring and therapist ratings of cognitive restructuring ability at post-treatment. Few participants showed changes in cognitive flexibility over treatment. Those with poorer cognitive flexibility may not find cognitive restructuring as useful to alleviate emotional distress as those with better cognitive flexibility. However, those with poorer cognitive flexibility can still benefit from standardised CBT, even if their use of cognitive restructuring is less effective.

title: Geriatric Anxiety Scale: item response theory analysis, differential item functioning, and creation of a ten-item short form (GAS-10)
abstract: The Geriatric Anxiety Scale (GAS; Segal et al. (Segal, D. L., June, A., Payne, M., Coolidge, F. L. and Yochim, B. (2010). Journal of Anxiety Disorders, 24, 709–714. doi:10.1016/j.janxdis.2010.05.002) is a self-report measure of anxiety that was designed to address unique issues associated with anxiety assessment in older adults. This study is the first to use item response theory (IRT) to examine the psychometric properties of a measure of anxiety in older adults.  A large sample of older adults (n = 581; mean age = 72.32 years, SD = 7.64 years, range = 60 to 96 years; 64% women; 88% European American) completed the GAS. IRT properties were examined. The presence of differential item functioning (DIF) or measurement bias by age and sex was assessed, and a ten-item short form of the GAS (called the GAS-10) was created.  All GAS items had discrimination parameters of 1.07 or greater. Items from the somatic subscale tended to have lower discrimination parameters than items on the cognitive or affective subscales. Two items were flagged for DIF, but the impact of the DIF was negligible. Women scored significantly higher than men on the GAS and its subscales. Participants in the young-old group (60 to 79 years old) scored significantly higher on the cognitive subscale than participants in the old-old group (80 years old and older).  Results from the IRT analyses indicated that the GAS and GAS-10 have strong psychometric properties among older adults. We conclude by discussing implications and future research directions.

title: Psychometric properties of the French Canadian version of the Geriatric Anxiety Inventory
abstract: The Geriatric Anxiety Inventory (GAI) and a short form of this instrument (GAI-SF) were developed to assess the severity of anxiety symptoms in older adults in order to compensate for the lack of validated screening tools adapted to the elderly population. This study examined the psychometric properties of the French Canadian version of the GAI, in its complete (GAI-FC) and short form (GAI-FC-SF).  A total of 331 community-dwelling seniors between 65 and 92 years old participated in this study.  Both the GAI-FC and the GAI-FC-SF have sound psychometric properties with, respectively, a high internal consistency (α = .94 and .83), an adequate convergent validity (r = .50 to .86 with instruments known to evaluate constructs similar to the GAI or related to anxiety), a good test–retest reliability (r = .89 and .85), in addition to a single-factor structure.  The results support the use of both the GAI-FC and the GAI-FC-SF. The GAI-FC-SF seems to be an interesting alternative to the GAI-FC as a screening tool when time available for assessment is limited.

title: Portuguese version of the Geriatric Anxiety Inventory: Transcultural adaptation and psychometric validation
abstract: The Geriatric Anxiety Inventory (GAI) is a recently developed anxiety instrument designed to assess the severity of anxiety symptoms across a range of presentations in older adults. In this study, the authors examined the validity of the Portuguese version of the GAI and assessed its psychometric properties.  A cross-sectional study was designed using a sample of 152 community-dwelling older adults, and a geriatric psychiatric sample of outpatients with clinical diagnoses of depression (n = 32), anxiety disorders (n = 23), and early Alzheimer's disease (n = 10).  The Portuguese version of the GAI required linguistic and transcultural adaptations, particularly on the somatic expressions of anxiety. It exhibited sound internal consistency and demonstrated good concurrent validity against the state half of the Spielberg State-Trait Anxiety Inventory, the Geriatric Depression Scale (GDS-30), and the General Health Questionnaire (GHQ-12). The optimal cut-off point to detect severe anxiety symptoms was 8/9, but no optimal cut-off point for Generalized Anxiety Disorder could be estimated.  These findings provide initial evidence that the Portuguese version of the GAI is a valid and reliable measure for assessing late-life anxiety and highlights the need for possible modifications of the instrument before being used in other languages and cultural groups.

title: Examination of the Psychometric Properties of the Adult Manifest Anxiety Scale-Elderly Version Scores
abstract: The psychometric properties of the Adult Manifest Anxiety Scale-Elderly Version (AMAS-E) scores were evaluated in two studies. In Study 1, the temporal stability and construct validity of the AMAS-E test scores were examined in a group of 226 older adults, aged 60 years and older. Results indicated adequate to excellent temporal stability (2-week interval) for the AMAS-E test scores. Evidence supporting the construct validity of the AMAS-E scale scores as measures of various aspects of anxiety was found. In Study 2, the factor structure of the AMAS-E was examined across gender for a sample of 863 older adults, 555 women and 308 men, aged 60 to 100 years. Coefficient of congruence and salient variable similarity index values reported suggest that the pairs of matched factors of each of the four factors (i.e., Fear of Aging, Physiological Anxiety, Worry/Oversensitivity, and Lie) and the general anxiety (g anx ) or Total Anxiety factor were invariant across gender. Implications of the findings are discussed.

title: Evaluation of the factor structure of the Adult Manifest Anxiety Scale – Elderly version (AMAS-E) in community dwelling older adult New Zealanders
abstract: Anxiety in older adults is a phenomenon that has gained increasing empirical attention. Early investigators in this field asserted that the measurement of anxiety in older adults using the psychometric measures available was problematic due to (1) a lack of construct validity; the field did not have a clear empirical understanding of the features of anxiety in older adults, (2) a lack of psychometric measures designed specifically for older adults--e.g. the inclusion of items of low relevance for older people and a high potential overlap with measuring medical symptoms, and (3) a lack of normative information for existing psychometric measures when used in older adult populations (Stanley & Beck, 2000). The research community responded in two ways, either by developing new measures of anxiety specifically for older adults (e.g the Geriatric Anxiety Scale (Pachana et al., 2007), or by validating existing anxiety measures in older adult populations (e.g. the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970). As yet, no 'gold standard' anxiety measure has been identified for use with older-adult clients. Given that there has been limited research into the nature of anxiety in older adults, the evaluation of the construct validity of measures is problematic as essential content has not been fully explored. Some authors suggest that measures for older adults should: (a) avoid items with worry content (e.g. topics) as they may be less useful in predicting worry severity when compared to worry content (Diefenbach, Stanley, & Beck, 2001); (b) avoid items which overlap with medical conditions (Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010); (c) formats should be age-appropriate for older people with sensory and or cognitive impairments; (d) include developmentally appropriate themes e.g. avoid topics relating to work which may not be relevant to the retired; (e) be sensitive to functional impairment; (f) include sleep disturbances which are common in older adults with generalised anxiety disorder (Wetherell, Le Roux, & Gatz, 2003). The Adult Manifest Anxiety Scale-Elderly Version (AMAS-E) (Lowe & Reynolds, 2000) is a 44 item measure of chronic manifest anxiety developed for older adults in response to concerns that the nature of anxiety is different in older adults when compared to younger adults. Exploratory factor analysis revealed a three-factor structure: fear of aging --assessing a preoccupation with age-related decline; worry/oversensitivity --reflecting excessive worry; and physiological anxiety--evaluating physical manifestations of anxiety. A 'lie' scale intended to contribute to validity and measure social desirability was added at a later stage, (Lowe & Reynolds, 2006), however the theoretical justification for this was not presented by the authors. The four factors of the AMAS-E all were hypothesized to contribute to a higher order factor of general anxiety/total anxiety (Lowe & Reynolds, 2006). Confirmatory factor analytic (CFA) studies of the AMAS-E have not been published. Psychometric studies of the AMAS-E have shown good reliability for the total anxiety ([alpha] = .90 - .92), worry /oversensitivity (a = .88 - .91), fear of aging ([alpha] = .78 - .85), physiological ([alpha] = .69 - .71), and lie scales ([alpha] = .73 - .79) (Lowe & Reynolds, 2000, 2006; Reynolds, Richmond, & Lowe, 2003). Convergent validity analysis of the AMAS-E has been undertaken using the State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1970) and the Geriatric Anxiety Scale (GAS) (Segal, June, Payne, Coolidge, & Yochim, 2010). Low to moderate correlations were reported between the anxiety subscales of the AMAS-E and the STAI-S (.24 and .39), and between the AMAS-E and STAI-T (.31 and .65) (Lowe & Reynolds, 2006). Because the STAI had a large amount of variance when measuring anxiety in older adults, it was unclear whether the correlation observed between these measures is due to shared variance unrelated to the construct of anxiety. …

title: Exploratory Analyses of the Latent Structure of Anxiety among Older Adults
abstract: Responses to the Adult Manifest Anxiety Scale-Elderly Version (AMAS-E) of 458 older individuals, ranging in age from 60 to 100 years with 5 to 16 years of education, were submitted to an exploratory factor analysis. Using the method of principal axis factoring with promax rotation, a four-factor solution—three anxiety factors and one lie scale factor—was produced. The emergence of a three-factor structure of anxiety (Worry/Stress, Fear of Aging, and Physiological) is consistent with current multidimensional theories of anxiety and lends support to the construct validity of the AMAS-E. Internal consistency data are reported, and implications for interpretation are discussed.

title: Development and validation of a geriatric depression screening scale: a preliminary report.
abstract: A new Geriatric Depression Scale (GDS) designed specifically for rating depression in the elderly was tested for reliability and validity and compared with the Hamilton Rating Scale for Depression (HRS-D) and the Zung Self-Rating Depression Scale (SDS). In constructing the GDS a 100-item questionnaire was administered to normal and severely depressed subjects. The 30 questions most highly correlated with the total scores were then selected and readministered to new groups of elderly subjects. These subjects were classified as normal, mildly depressed or severely depressed on the basis of Research Diagnostic Criteria (RDC) for depression. The GDS, HRS-D and SDS were all found to be internally consistent measures, and each of the scales was correlated with the subject's number of RDC symptoms. However, the GDS and the HRS-D were significantly better correlated with RDC symptoms than was the SDS. The authors suggest that the GDS represents a reliable and valid self-rating depression screening scale for elderly populations.

title: Psychometric properties of the Geriatric Anxiety Inventory (GAI) and its short-form (GAI-SF) in a clinical and non-clinical sample of older adults
abstract: The Geriatric Anxiety Inventory is a 20-item geriatric-specific measure of anxiety severity. While studies suggest good internal consistency and convergent validity, divergent validity from measures of depression are weak. Clinical cutoffs have been developed that vary across studies due to the small clinical samples used. A six-item short form (GAI-SF) has been developed, and while this scale is promising, the research assessing the psychometrics of this scale is limited.  This study examined the psychometric properties of GAI and GAI-SF in a large sample of 197 clinical geriatric participants with a comorbid anxiety and unipolar mood disorder, and a non-clinical control sample (N = 59).  The internal consistency and convergent validity with other measures of anxiety was adequate for GAI and GAI-SF. Divergent validity from depressive symptoms was good in the clinical sample but weak in the total and non-clinical samples. Divergent validity from cognitive functioning was good in all samples. The one-factor structure was replicated for both measures. Receiver Operating Characteristic analyses indicated that the GAI is more accurate at identifying clinical status than the GAI-SF, although the sensitivity and specificity for the recommended cutoffs was adequate for both measures.  Both GAI and GAI-SF show good psychometric properties for identifying geriatric anxiety. The GAI-SF may be a useful alternative screening measure for identifying anxiety in older adults.

title: Psychometric properties and health correlates of the Geriatric Anxiety Inventory in Australian community-residing older women
abstract: To assess the psychometric properties and health correlates of the Geriatric Anxiety Inventory (GAI) in a cohort of Australian community-residing older women.  Cross-sectional study of a population-based cohort of women aged 60 years and over (N = 286).  The GAI exhibited sound internal consistency and demonstrated good concurrent validity against the state half of the Spielberger State Trait Anxiety Inventory and the neuroticism domain of the NEO five-factor inventory. GAI score was significantly associated with self-reported sleep difficulties and perceived memory impairment, but not with age or cognitive function. Women with current DSM-IV Generalized Anxiety Disorder (GAD) had significantly higher GAI scores than women without such a history. In this cohort, the optimal cut-point to detect current GAD was 8/9. Although the GAI was designed to have few somatic items, women with a greater number of general medical problems or who rated their general health as worse had higher GAI scores.  The GAI is a new scale designed specifically to measure anxiety in older people. In this Australian cohort of older women, the instrument had sound psychometric properties.

title: Psychometric properties of the Spanish version of the Geriatric Anxiety Inventory
abstract: The Geriatric Anxiety Inventory (GAI) was developed for assessing anxiety in older adults. The objectives of this work were: (a) to analyze the psychometric properties of the Spanish version of the GAI, and (b) to explore the associations between anxiety and other variables related to emotional distress (depression) and emotion regulation (rumination, experiential avoidance, and emotion suppression).  Three-hundred-and-two people (75.5% female) aged 60 years and over living in the community participated in this study. Anxiety, depression, rumination, suppression and experiential avoidance were measured.  Three factors explaining 50.11% of the variance were obtained. The obtained internal consistency for the total scale was 0.91, with alphas ranging between 0.71 and 0.89 for the factors. Significant associations between all the GAI factors, the GAI total score, and depression, rumination, and experiential avoidance were found (all p < 0.01). Women reported higher scores than men for both the GAI total score and for all of the subscales. However, no significant gender differences were found between people with scores higher than the cut-off score for the GAI.  The results of this study suggest that the Spanish version of the GAI displays good psychometric properties. Further, our data suggest that the scale can be recommended for measuring anxiety in non-clinical older Spanish persons, and may be a useful instrument to be used in research studies aimed at analyzing anxiety and its correlates among older adults.

title: Personality and depression: evidence of a possible mediating role for anger trait in the relationship between cooperativeness and depression.
abstract: An increasingly growing area of empirical research has found consistent links between anger, depression, and temperament and character domains of personality, separately. However, precise nature of these relationships remains still unclear, and little is known about its underlying processes.



The aim of our explorative research was to conduct a more detailed investigation into the relationships among depression, anger trait, and personality characteristics based on Cloninger's 7-factor personality theory in healthy individuals.



In this preliminary study, 230 Italian undergraduates were investigated by using the Temperament and Character Inventory-Revised, the State-Trait Anger Expression Inventory-2, and the Beck Depression Inventory-II. Depression and cooperativeness were expected to have a negative and significant relationship and separate relationships with the trait-anger. Theoretically, a new hypothesis was that the trait-anger would mediate the relationship between depression and cooperativeness.



Zero-order and partial correlations and a path analysis based on Baron and Kenny's method (J Pers Soc Psychol.1986;51:1173-1182) for calculating multiple regression analyses were calculated. Consistent with the hypotheses, cooperativeness and depression were strongly associated; the trait-anger was significantly associated with both cooperativeness and depression, and the mediation model fit the data.



Behaviors related to the trait-anger could help to explain how depression and reduced cooperativeness are related each other.

title: Aging and symptoms of anxiety and depression: structural invariance of the tripartite model.
abstract: Negative affect measures were evaluated in a cross-sectional community sample of adults aged 18-93 (N = 335) to examine the structure of neuroticism, anxiety, and depressive symptoms in young, middle, and older adult cohorts. Structural equation modeling was used to contrast 3 nested models: a 1-factor general distress model; a 2-factor high negative-low positive affect model; and a 3-factor "tripartite model" reflecting a higher order Negative Affect factor that is common to depression and anxiety problems and 2 lower order factors, Low Positive Affect (mostly specific to depression) and Arousal (specific to anxiety/panic). As expected, the tripartite model fit best for all age groups. Further, multigroup analyses indicated age invariance for the tripartite model, suggesting the model can be effectively applied with older populations.

title: Anger and Depression: Evidence of a Possible Mediating Role for Rumination
abstract: Tendency to ruminate may mediate the relationship between anger and depression. In this preliminary study, 353 Italian community participants completed the State-Trait Anger Expression Inventory–2, the Padua Inventory's Tendency to Doubt and to Ruminate subscale, and the Beck Depression Inventory–II. Trait anger and depression were expected to have a positive relationship, and separate relationships with the tendency to ruminate. Theoretically, a new hypothesis was that the tendency to ruminate would mediate the relationship between depression and anger. Zero-order and partial correlations and a path analysis based on Baron and Kenny's method for calculating multiple regression analyses were calculated. Consistent with the hypotheses, anger and depression were strongly associated; the tendency to ruminate was significantly associated with both anger and depression; and the mediation model fit the data. Behaviors related to the tendency to ruminate could help to explain how depression is related to anger.

title: Cognitive Vulnerabilities and Depression in Young Adults: An ROC Curves Analysis
abstract: The aim of the present study was to evaluate, by means of receiver operating characteristic (ROC) curves, whether cognitive vulnerabilities (CV), as measured by three well-known instruments (the Beck Hopelessness Scale, BHS; the Life Orientation Test-Revised, LOT-R; and the Attitudes Toward Self-Revised, ATS-R), independently discriminate between subjects with different severities of depression. Participants were 467 young adults (336 females and 131 males), recruited from the general population. The subjects were also administered the Beck Depression Inventory-II (BDI-II).  Four first-order (BHS Optimism/Low Standard; BHS Pessimism; Generalized Self-Criticism; and LOT Optimism) and two higher-order factors (Pessimism/Negative Attitudes Toward Self, Optimism) were extracted using Principal Axis Factoring analysis. Although all first-order and second-order factors were able to discriminate individuals with different depression severities, the Pessimism factor had the best performance in discriminating individuals with moderate to severe depression from those with lower depression severity.  In the screening of young adults at risk of depression, clinicians have to pay particular attention to the expression of pessimism about the future.

title: Religious Fundamentalism and Psychological Well-Being: An Italian Study
abstract: This study's aims were two-fold: to contribute to an understanding of the relationship between religious fundamentalism and psychological well-being and to test the psychometric properties of the Italian adaptation of the revised Religious Fundamentalism Scale (RFS-12; Altemeyer & Hunsberger, 2004), one of the most important instruments for assessing religious fundamentalism when it is conceptualized as a cognitive process. Confirmative factor analysis and reliability and correlational analyses were conducted on a sample of 319 Catholic undergraduate students. Findings indicate that the Italian adaptation of the Religious Fundamentalism Scale, as a one-dimensional construct, represents a valid and reliable measure of religious fundamentalism. Furthermore, results highlight the positive role that religious fundamentalism plays in promoting life satisfaction and psychological well-being.

title: Psychometric Properties of the Attitudes toward Self-Revised in Italian Young Adults
abstract: Several researchers have provided support for the critical role of cognitive vulnerabilities in the development of depression. The Attitudes toward Self-Revised (ATS-R) was designed to assess three potential self-regulatory vulnerabilities to depression: High Standards (HS), Self-Criticism (SC), and Negative Generalization (NG). The aim of the study was to assess the psychometric properties of the ATS-R in the Italian young adult population. The ATS-R, the Beck Depression Inventory-II (BDI-II), the Beck Hopelessness Scale (BHS), and the Teate Depression Inventory (TDI) were administered to 857 (320 men and 537 women) young adults.  The best-fitting solution for the ATS-R was a 2-factor model, which obtained satisfactory homogeneity of content (HS/SC: Cronbach α = 0.81; mean interitem correlation = 0.46. NG: Cronbach α = 0.75; mean interitem correlation = 0.43) and significant correlation with the BDI-II (NG: Pearson r = 0.29, P < 0.01), the TDI (HS/SC: Pearson r = −0.26, P < 0.01), and the BHS (HS/SC: Pearson r = −0.29, P < 0.01; NG: Pearson r = 0.22, P < 0.01).  The Italian version of the ATS-R seems to be a valid instrument for the study of the role of cognitive tendencies as potential vulnerability for depression.

title: Geriatric anxiety inventory: factor structure and associations with cognitive status.
abstract: The factor structure and clinical correlates of the Geriatric Anxiety Inventory were determined within a sample of patients with cognitive impairment.



Using a cross-sectional design, data were collected within an outpatient Memory Disorders Center. Clinical participants were diagnosed with either mild dementia (N = 45) or cognitive impairment, no dementia (N = 55). A comparison group of participants without subjective memory complaints (N = 50) was also included. The Geriatric Anxiety Inventory was administered and scored as both the 20-item version and 5-item short form. Measures of cognitive status, depressive symptoms, and functioning were also completed.



Clinical participants reported more severe anxiety than did participants in the comparison group; however, the two patient groups did not differ. Principal components analysis revealed a four-factor structure of the Geriatric Anxiety Inventory. Item endorsement on factors characterized by excessive worry and difficulty making decisions were associated with a nearly twofold (odds ratio [OR]: 1.86) and nearly sixfold (OR: 5.70) odds of having cognitive impairment, respectively. The short-form version was composed of a single factor, and item endorsement was associated with a twofold increased odds of having cognitive impairment (OR: 2.02).



Psychometric properties of the Geriatric Anxiety Inventory are acceptable among patients with cognitive impairment. Anxiety symptoms were common, and symptoms characterized by excessive worry and difficulty making decisions demonstrated the strongest associations with cognitive status.

title: Assessment of anxiety in long-term care: examination of the Geriatric Anxiety Inventory (GAI) and its short form
abstract: Accurate assessment of anxiety in later life is critical, as anxiety among older adults is associated with social and functional impairment and poorer quality of life. The Geriatric Anxiety Inventory (GAI) and the GAI–Short Form (GAI-SF) were designed to detect anxiety symptoms among community-dwelling older adults, but the usefulness of the GAI and GAI-SF in long-term care is unknown. The present study examined the psychometric properties of the GAI and GAI-SF among residents at a long-term care facility.  Seventy-five nursing home residents completed the GAI and measures of depression, executive functioning, and adaptive functioning. The mean age of residents was 69.60 years (SD = 10.76). Psychiatric diagnoses included dementia, psychotic disorders, mood disorders, anxiety disorders, substance abuse, sleep disorders, and mental retardation.  Internal consistency of the GAI was good (α = 0.92) and the GAI-SF was adequate (α = 0.73). GAI and GAI-SF scores were moderately correlated with depression scores, and weakly correlated with adaptive functioning scores and executive functioning scores, suggesting discriminant validity. Logistic regression analyses were conducted with GAI and GAI-SF scores predicting an anxiety disorders diagnosis.  provided support for the predictive validity of the GAI and GAI-SF. Sensitivity, specificity, and the percentage of individuals correctly classified at various cut-off scores were also calculated.  Both the GAI and GAI-SF appear to be useful tools for assessing anxiety among nursing home residents with psychological disorders. The GAI-SF may be a viable replacement for the GAI as a screener for anxiety in long-term care.

title: Symptoms of Anxiety in Older Adults with Depression, Dementia, or Psychosis: A Principal Component Analysis of the Geriatric Anxiety Inventory
abstract: The primary aim of this study was to examine anxiety symptoms as measured by the Geriatric Anxiety Inventory (GAI) in older patients with depression, dementia, or psychotic disorders. The secondary aim was to conduct a principal component analysis (PCA) of the GAI and to examine whether its subscales differ between the 3 disorders.  We included data from 428 patients who were admitted to a department of geriatric psychiatry and examined according to a standardized protocol. The GAI was used to measure current anxiety symptoms.  The GAI symptoms occurred more frequently in the group with depression than in the other 2 groups. The PCA of the GAI with oblimin rotation resulted in a 2-component solution, labelled as “worries” (explained variance 46.3%, Cronbach's α 0.92) and “physical symptoms” (explained variance 7.1%, Cronbach's α 0.85).  The results indicate that in old age, anxiety is especially prevalent in depression. The 2-component solution indicates that the GAI measures 2 different aspects of anxiety with different symptomatology.

title: Persian version of the geriatric anxiety scale: Translation and preliminary psychometric properties among Iranian older adults
abstract: The Geriatric Anxiety Scale (GAS) is a new self-report screening measure designed for older adults. Due to the burgeoning Iranian population of older adults and the need for validated, culturally-appropriate screening measures for anxiety in Iran, the purposes of the present study were to translate the GAS into Persian and to explore its preliminary psychometric properties.  Iranian older adults (N = 295; M age = 67.0 years) completed the GAS and the Iranian version of the Geriatric Depression Scale (GDS-15).  Cronbach's alpha for the GAS total score and the GAS subscales were excellent (Total score α = .92; Cognitive α = .81; Somatic α = .84; Affective α = .80). As expected, each subscale was significantly positively correlated (all p's < .01) with the other subscales. The subscales share common variance ranging from 42% to 56%. The GAS total score and GAS subscale scores were significantly positively correlated with the GDS-15, with medium effect sizes (GAS Total r = .55; Cognitive r = .51; Somatic r = .50; Affective r = .48). Finally, exploratory and confirmatory factor analyses were conducted to investigate the factor structure of the Persian version of the GAS. Results support a one factor solution (general anxiety) for this Iranian sample.  This study provides preliminary psychometric support for the Persian version of the GAS as a screening measure for anxiety in Iranian older adults, with a one-dimensional factor structure.

title: Validation of a Chinese Version of the Geriatric Anxiety Scale Among Community-Dwelling Older Adults in Mainland China
abstract: The Geriatric Anxiety Scale (GAS) was developed as an international screening instrument for anxiety in older adults. The aims of the present study were to translate the GAS into Chinese and to subsequently evaluate the preliminary psychometric properties of the Chinese version of the GAS (GAS-C) among community-dwelling Chinese older adults. The translation of the GAS into Chinese was developed through a translation and back translation process. A sample of 206 community-dwelling older adults (51.9 % men, Mean age = 70.70 years, SD = 8.15 years) completed the GAS-C, the Beck Anxiety Inventory (BAI), the Geriatric Depression Scale (GDS) and the Pittsburgh Sleep Quality Index (PSQI). A confirmatory factor analysis was conducted to examine the factor structure of the GAS-C. Internal consistency and convergent validity were used to evaluate the psychometric properties of the translated measure. The factor analyses were in support of a unidimensional factor model of the GAS-C in this Chinese sample, and the item-total correlations for all 25 items ranged from 0.40 to 0.83. The internal consistency for the GAS-C total score was excellent (α = 0.92). The GAS-C total score were significantly and strongly correlated with the BAI (r = 0.86), the GDS (r = 0.78) and the PSQI (r = 0.63), which indicated good convergent validity of the GAS-C. The GAS-C appears to be a reliable and valid screening instrument to assess anxiety symptoms among community-dwelling older adults in mainland China.

title: An investigation of the psychometric properties of the Geriatric Anxiety Scale (GAS) in an Italian sample of community-dwelling older adults
abstract: The Italian older adult population is increasing and psychiatric problems, such as anxiety among older adults, represent major challenges for public welfare. A strong need exists for instruments specifically developed to assess anxiety among Italian older adults. The Geriatric Anxiety Scale (GAS) is a 30-item self-report questionnaire that evaluates anxiety among older adults and has demonstrated strong psychometric properties in several languages.  The present study aimed to validate an Italian version of the GAS (GAS-I) and to preliminarily investigate its psychometric properties.  The translation was performed using a five-stage procedure, following a forward–back process and paying attention to cultural issues. The GAS-I was administered to 231 community-dwelling older adults with other commonly-used questionnaires of anxiety, depression, and quality of life.  Results confirmed good psychometric qualities of the questionnaire. Confirmatory factor analyses evidenced a unidimensional structure of the GAS-I, in accordance with other validated versions. Convergent and discriminant validity were highly satisfactory. The three-factor model also provided an acceptable fit to the data. Receiver operating characteristic curve analyses revealed good discriminatory power of the GAS-I.  These findings demonstrate that the GAS-I is a reliable and valid self-report questionnaire to measure anxiety among Italian older adults.

title: Psychometric properties of four anxiety measures in older adults.
abstract: Despite relatively high prevalence rates of anxiety disorders in older adults, little attention has been paid to the establishment of psychometrically sound measures for this population. The current study addresses this issue by examining the psychometric properties of four self-report anxiety measures: the Spielberger State-Trait Anxiety Inventory (STAI), Worry Scale (WS), Fear Questionnaire (FQ), and Padua Inventory (PI). Two older adult community subsamples were assessed, one with Generalized Anxiety Disorder (GAD; n = 50) and the other with no anxiety complaints (Normal Controls: NC; n = 94). Descriptive data revealed that mean scores in the GAD sample were similar to those reported in studies of younger GAD patients. Mean scores in the NC sample, however, were lower than those reported in studies of younger control samples. Internal consistency for all measures generally was adequate in both the GAD and NC subsamples, although alpha coefficients for two of the FQ subscales were marginal. Test-retest reliability over a 2-4 week interval (assessed in a subgroup of NC subjects) was mixed, with some measures apparently assessing stable, trait-like dimensions of fear and anxiety, and others estimating more state-like clinical features. Intercorrelations among subscales for all four measures in both the GAD and NC groups generally were high and consistent with findings from prior research. Finally, some support for the convergent validity of the four anxiety measures was obtained, particularly in the NC sample. Results are discussed in terms of the utility of these instruments for future investigations of the psychopathology and treatment of anxiety disorders in the elderly.

title: Worry and use of coping strategies among older and younger adults.
abstract: Eighty four adults over age 64 were compared with 110 college students on two measures of worry and on their methods of coping with worry. Results indicated that there were no differences in overall worry between the two groups, as measured by the Worry Scale for Older Adults--Revised, but on the individual subscales of health, family concerns, and world issues older adults expressed significantly more worries than younger adults. On the Penn State Worry Questionnaire, which measures a general, trait-like tendency to worry, younger adults reported significantly more worry than did the older adults. Younger adults also utilized a greater number of coping strategies in an effort to control worry. These results support the notion that older adults report relatively low levels of worrying when compared with the younger population. Explanations for these differences are discussed along with implications for the function of worry across the life span.

title: Culture, Health, and Financial Appraisals: Comparison of Worry in Older Japanese Americans and European Americans
abstract: There is limited understanding of the potential impact of cultural identification and values on the emotional experiences of older adults. This study considered potential differences in worry based on culture and acculturation type. The study also evaluated differences in worry based on self-appraisals of perceived health and financial status. Sixty-six older community-based Japanese Americans (JAs) and 65 older European Americans (EAs) completed the Penn State Worry Questionnaire (PSWQ) and the Worry Scale–Revised (WSR). Cultural differences were not found. Social desirability scores were elevated, particularly among JAs who had been relocated to internment camps during World War II. Irrespective of cultural status, elevated average daily worry frequency scores and WSR–Health scores were found in the group who perceived their health status to be poor/fair. Irrespective of cultural status, elevated average daily worry frequency scores, PSWQ scores, and WSR–Financial scores were found in the group who perceived their financial status to be poor/fair. Recommendations for using the WSR with older populations are discussed.

title: Assessment of anxiety in older adults: a community-based survey and comparison with younger adults.
abstract: The reliability and validity of existing anxiety self-report scales in elderly adults has not been adequately established, and the phenomenology of anxiety in older adults is largely unknown. In the present study, three anxiety scales and measures of depression and somatization were used to compare symptoms between older (n = 84, mean age = 75.3) and younger (n = 48, mean age = 40.3) community-dwelling adults. Results showed that the anxiety scales demonstrated good internal consistency in both age groups, although the reliabilities of the Fear Questionnaire subscales ranged from poor to good. Convergent and divergent validity were found to be variable in the older group, but this may reflect differences in anxiety as it occurs in older persons rather than psychometric problems. Anxiety symptoms did not vary with age, and levels of anxiety also remained constant. However, gender differences were found only within the older age group, with women reporting more anxiety than men. Findings are discussed with respect to current conceptualizations of anxiety in older people, as well as implications for future research.

title: Treatment of generalized anxiety in older adults: A preliminary comparison of cognitive-behavioral and supportive approaches.
abstract: Generalized Anxiety Disorder (GAD) in older adults has received little attention from researchers, despite evidence that anxiety disorders are a significant mental health problem in this population. This study compared the efficacy of cognitive behavior therapy (CBT) and nondirective, supportive psychotherapy (SP) for 48 older adults, ages 55 and up, with well-diagnosed GAD. Treatments were administered in small groups that met for 14 weekly 1 1/2 hour sessions. Treatment effects were assessed at posttreatment and over a 6-month follow-up period. Primary outcome variables targeted anxiety and worry, and transfer effects were assessed with measures of depression and associated fears. Two composite indexes of treatment response were derived to identify treatment responder status and high endstate functioning. Two participants declined participation prior to randomization; 15 others were classified as drop-outs. Results for the remaining 31 participants (CBT: n = 18; SP: n = 13) demonstrated significant improvements on primary outcome and transfer effect variables in both treatment conditions. Effect sizes generally were large, and treatment gains were maintained or improved over the 6-month follow-up phase. Examination of treatment responder status and endstate functioning revealed no significant differences between groups. The data support the potential efficacy of psychosocial group treatment for GAD in older adults, although limitations of the work and suggestions for future research are discussed.

title: Cognitive-behavioral treatment of late-life generalized anxiety disorder.
abstract: This study addressed the efficacy of cognitive-behavioral therapy (CBT), relative to minimal contact control (MCC), in a sample of 85 older adults (age 60 years and over) with generalized anxiety disorder (GAD). All participants completed measures of primary outcome (worry and anxiety), coexistent symptoms (depressive symptoms and specific fears), and quality of life. Results of both completer and intent-to-treat analyses revealed significant improvement in worry, anxiety, depression, and quality of life following CBT relative to MCC. Forty-five percent of patients in CBT were classified as responders, relative to 8% in MCC. Most gains for patients in CBT were maintained or enhanced over 1-year follow-up. However, posttreatment scores for patients in CBT failed to indicate return to normative functioning.

title: Financial worry among older people: who worries and why?
abstract: This study sought to clarify what drives economic worries among older people. Based upon the data from a national sample of adults aged 65 and older in Israel (N=550), we examined associations between financial worry and economic status, lifestyle, social network, concerns about functional health, long term care needs and cognition, and population group. The main financial worry was that pension funds will not suffice for one's entire life. Multivariate analysis revealed that financial worry was negatively related to perceived income adequacy and age, and positively related to concerns about care and to apprehensions regarding one's ability to make decisions. Immigrants from the former Soviet Union were found to worry less. Understanding the different sources of financial worries among older people is essential insofar as older people are increasingly expected to take personal responsibility for their financial futures. Dealing with negative outcomes that stem from financial worries are important programming and policy goals in an era of population aging.

title: Psychometric properties of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA): comparison to the State-Trait Anxiety Inventory (STAI).
abstract: The State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA; M. J. Ree, C. MacLeod, D. French, & V. Locke, 2000) was designed to assess cognitive and somatic symptoms of anxiety as they pertain to one's mood in the moment (state) and in general (trait). This study extended the previous psychometric findings to a clinical sample and validated the STICSA against a well-published measure of anxiety, the State-Trait Anxiety Inventory (STAI; C. D. Spielberger, 1983). Patients (N=567) at an anxiety disorders clinic were administered a battery of questionnaires. The results of confirmatory factor analyses (Bentler-Bonnett nonnormed fit index, comparative fit index, and Bollen fit index>.90; root-mean-square error of approximation<.05); convergent and discriminant validity analyses; and group comparisons supported the reliability and validity of the STICSA as a measure of state and trait cognitive and somatic anxiety. In addition, compared with the STAI (anxiety: rs</=.52; depression: rs>/=.64), the STICSA was more strongly correlated with another measure of anxiety (rs>/=.67) and was less strongly correlated with a measure of depression (rs</=.61). These findings suggest that the STICSA may be a purer measure of anxiety symptomatology than is the STAI.

title: Some norms and reliability data for the State--Trait Anxiety Inventory and the Zung Self-Rating Depression scale.
abstract: Means and standard deviations are reported for the State-Trait Anxiety Inventory and the Zung Self-Rating Depression scale, collected during the course of a general health survey. Data for different age samples and for both sexes are presented for use in the evaluation of the significance of anxiety and depression levels in patients presenting with these symptoms. High estimates of reliability based on internal consistency statistics were found for all scales. Females scored more highly on both the measures and scores were inversely correlated with age, indicating the importance of specific and appropriate norms in assessing affective states.

title: Swedish population norms for the GHRI, HI and STAI-state
abstract: This paper presents reference values for two questionnaires measuring general health, the General Health Rating Index (GHRI) and the Health Index (HI) and one questionnaire measuring anxiety state, the State Trait Anxiety Inventory (STAI-state). The sample used was randomly selected from a Swedish urban population consisting of 180 individuals (90 men, 90 women), divided into three age groups, 26–45, 46–65 and > 65 years. There was a main effect for age on the total GHRI score. The GHRI score was lower for older than for younger people, which is in agreement with earlier studies. For the HI there were main effects both for gender and age and no interaction was found. Although the sample size is small our result was in agreement to earlier studies and to health statistics in Sweden 1989. The health measures significantly correlated with the scores of anxiety inventory used. The total GHRI scores correlated positively and significantly with the HI scale (r=0.7, p<0.001). The GHRI and HI scales correlated negatively and significantly with the STAI scale (r=−0.4, p<0.001, r=−0.4, p<0.001) respectively. Thus, the better the general health the lower the rated anxiety. The value of health status measures in clinical research is reasonably well established, but their values for clinical care are less clear. The use for health index scores for quality assurance purpose is almost unexplored and could possibly be used for outcome measures in evaluating areas of nursing interventions. The short Health index is one possible outcome measure.

title: State and trait anxiety in women affected by allergic and vasomotor rhinitis.
abstract: It is still debatable whether anxiety and depression in patients affected by rhinitis could play a role in the genesis of the disease, whether they are a consequence of the symptoms. The aim of this study was to evaluate anxiety levels in both state and trait forms, and depression, in patients affected by allergic (AR) and vasomotor rhinitis (VMR). A total of 45 women, 24 AR and 21 VMR were compared with 64 healthy nonallergic women matched for age and sociodemographic characteristics. All subjects were administered the State and Trait Anxiety Inventory (STAI) and the Zung self-rating depression scale. The percentage of subjects with high levels of state anxiety was significantly higher in AR (p<0.005) and VMR (p<0.01) with respect to controls. The percentage of subjects with high levels of trait anxiety was significantly higher in AR (p<0.001) and VMR (p<0.05) than controls. There was no significant difference in depression between AR and VMR and controls. No significant difference was found in state anxiety, trait anxiety, or depression between AR and VMR. In conclusion, anxiety in patients with rhinitis is present both as a state and as a trait, at least when measured with the STAI.

title: Assessment of preoperative anxiety: comparison of measures in patients awaiting surgery for breast cancer.
abstract: We have compared three measurements of anxiety to determine their equivalence in assessing anxiety before surgery. Forty-four patients awaiting breast cancer surgery completed the state scale of the state-trait anxiety inventory (STAI), the hospital anxiety and depression scale (HAD) and a 100-mm visual analogue scale (VAS). Analysis restricted to correlations between the scales gave the misleading impression that VAS scores were inconsistent with those of the HAD and STAI. However, when scores were considered in relation to normative cut-off values to categorize anxiety levels, the three scales showed good agreement. We conclude that the scales were equivalent in their assessment of anxiety before surgery, but that reference to normative data was important in establishing such equivalence and in determining the patient's state.

title: The Visual Analog Scale Allows Effective Measurement of Preoperative Anxiety and Detection of Patients’ Anesthetic Concerns
abstract: The advent of managed care, reduction of costs, and advances in medical technology place increasing demands on anesthesiologists. Preoperative anxiety may go unnoticed in an environment that stresses increased productivity. The present study compares different methods for measuring preoperative anxiety, identifies certain patient characteristics that predispose to high anxiety, and describes the quantity and quality of anxiety that patients experience preoperatively. Seven hundred thirty-four patients participated in the study. We assessed aspects of anxiety by means of visual analog scales (VAS) and the State Anxiety Score of the Spielberger State-Trait Anxiety Inventory (STAI). The mean STAI anxiety score was 39 ± 1 (n = 486) and the mean VAS for fear of anesthesia was 29 ± 1 (n = 539). Patients feared surgery significantly more than anesthesia (P < 0.001). The VAS measuring fear of anesthesia correlated well with the STAI score (r = 0.55;P < 0.01). Young patients, female patients, and patients with no previous anesthetic experience or a previous negative anesthetic experience had higher anxiety scores. Patients worried most about the waiting period preceding surgery and were least concerned about possible awareness intraoperatively. Factor analysis of various anxiety items showed three distinct dimensions of fear: 1) the fear of the unknown 2) the fear of feeling ill, and 3) the fear for one’s life. Among these dimensions, fear of the unknown correlated highest with the anxiety measuring techniques STAI and VAS. The simple VAS proved to be a useful and valid measure of preoperative anxiety.  The study of qualitative aspects of anxiety reveals three distinct dimensions of preoperative fear: fear of the unknown, fear of feeling ill, and fear for one’s life. Groups of patients with a higher degree of preoperative anxiety and their specific anesthetic concerns can be identified using the visual analog scale.

title: The prevalence and correlates of anxiety symptoms in older adults.
abstract: An anxiety symptom scale was administered to a community sample of 713 males and 1338 females representative of persons aged 55 and older in Kentucky and quite similar to that of the US population in that age range. On the basis of a cutting point established previously, 17.1% of the males and 21.5% of the females were estimated to experience sufficient anxiety symptoms to place them at risk so as to require some form of intervention. In addition to gender and marital status differences, the study found a systematic but complex relationship between anxiety and age within this age range. Anxiety was inversely associated with socioeconomic status, education, and urban dwelling. Anxiety was inversely and highly correlated with physical health, and related to the presence of nine specific medical conditions and the need for and use of a number of medical services. The implications of the findings regarding the use of medical services for early diagnosis and treatment for mental health needs are discussed.

title: The Spielberger State‐Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients
abstract: In geriatric psychiatry assessment scales are often used in clinical praxis in the diagnostic work‐up of mental disorders.

title: Differentiating Symptoms of Anxiety and Depression in Older Adults: Distinct Cognitive and Affective Profiles?
abstract: Cognitive and affective dimensions of symptomsof anxiety and depression were examined in a sample of283 community-dwelling older adults (ranging in age from65 to 93 years). A principal-axis factor analysis with varimax rotation conducted on theCognition Checklist (CCL) revealed a factor structuredifferent than that found in younger adults. Threefactors emerged (Anxious, Social Loss, and NegativeSelf-Evaluation/Worthlessness Cognitions) and, in general, these cognitionswere not specifically related to anxious and depressivesymptoms. Instead, worthlessness cognitions wererobustly associated with both anxious and depressive symptoms, including variance that was unique toeach. In terms of affective dimensions, factor analysesrevealed that only anxiety-related items loaded on thenegative affectivity subscale. Consequently, negative affectivity was strongly related tovariance that was unique to anxious symptoms, but wasonly weakly related to variance that was unique todepressive symptoms. On the other hand, positiveaffectivity was only weakly associated with both forms ofsymptomatology. Findings are discussed in terms of thecognitive and affective distinctions between older andyounger adulthood.

title: Differentiating anxiety and depression in older adults with generalized anxiety disorder.
abstract: To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.

title: Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory with older adult psychiatric outpatients.
abstract: In order to assess the psychometric properties and diagnostic utility of the Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI) with older adults, these measures were administered to 217 older adult outpatients with mixed psychiatric disorders. Both the BAI and STAI scales demonstrated high internal reliabilities. The BAI demonstrated good factorial validity, with a somatic anxiety and a subjective anxiety factor emerging. In contrast, the STAI did not evidence factorial validity, with analyses failing to support presence of state and trait anxiety factors. Both the BAI and Trait Anxiety scale of the STAI demonstrated discriminant validity in separating patients with a current anxiety disorder from patients without such a disorder. However, the State Anxiety scale of the STAI did not discriminate between these groups. When used to predict presence of an anxiety disorder, no single cutting score for either the BAI or STAI proved optimal, due to tradeoffs between sensitivity and specificity. Results suggest that both the subjective subscale and total score on the BAI can be somewhat useful as a quick screening instrument in detecting presence of a current anxiety disorder for older adult psychiatric outpatients, although results were not as strong as previous findings regarding screening tests for depression in the elderly.

title: Measures of anxiety: State‐Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale‐Anxiety (HADS‐A)
abstract: This review covers commonly used measures of anxiety. For this review, the author included measures that were 1) measures of general measures of anxiety and severity of anxiety symptoms, 2) administered by self-report, 3) used in rheumatologic populations, and 4) has evidence of adequate psychometric data. To maintain brevity, the majority of the measures reviewed here were selected to provide broad coverage of general symptoms of anxiety, and measures were excluded if they are intended to identify or characterize a specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorder (1). Specifically, this author excluded measures typically used to evaluate diagnostic criteria or features of specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and others. In addition, broader measures of psychiatric distress, including the Symptom Checklist-90, the General Health Questionnaire, and the Medical Outcomes Study Short Form 36 are not included in this review since they are included elsewhere in this special issue. 
 
However, subscales that have been used frequently in rheumatology as “stand-alone” measures, such as the anxiety scale of the Hospital Anxiety and Depression Scale, are included in this review. Importantly, the measures included in this review should not be interpreted as diagnostically significant for an anxiety disorder, even generalized anxiety disorder, but should be used to measure the presence of symptoms and to calibrate the severity of general symptoms of anxiety commonly occurring in rheumatic disease. The measures reviewed below include the State Trait Anxiety Index, the Beck Anxiety Inventory, and the anxiety subscale of the Hospital Anxiety and Depression Scale. In this review, the content and structure of each measure is presented (number of items, recall period, response options, presence of translations, and adaptations), the use in rheumatic disease when possible is discussed, and the psychometric properties of each measure, particularly when validated in any of the rheumatic diseases, is detailed. In addition, information regarding responsiveness of each measure to longitudinal change is presented, including responsiveness to change in rheumatology when available. Finally, a summary of the strengths and weaknesses specific to rheumatology is presented.

title: Anxiety in rheumatoid arthritis.
abstract: To examine the level of anxiety experienced by individuals with rheumatoid arthritis (RA).



Data from 2 previous studies were used to compare the level of anxiety (measured by the State-Trait Anxiety Inventory) in the following 4 subgroups: a general RA sample, a general osteoarthritis sample, a sample with both RA and major depression, and a normative sample of age-equivalent, working adults. Canonical correlations were used to examine associations between measures of anxiety and measures of both stress and depression. The relationship between anxiety and duration of RA was also explored.



The general RA sample had state anxiety levels that were comparable to the normative sample, although trait anxiety levels were significantly higher (P < 0.001). In addition, individuals with RA who also met criteria for depression exhibited significantly higher levels of both state anxiety (P < 0.0001) and trait anxiety (P < 0.0001) than was observed in the normative sample. Canonical correlations revealed that measures of anxiety were correlated with both measures of depression (r = 0.83) and measures of stress (r = 0.50). Anxiety was not found to be significantly related to RA disease duration.



These findings demonstrated that individuals with RA, especially if concomitantly depressed, tend to exhibit levels of anxiety that are generally higher than a normative group of age-equivalent, working adults. The substantial canonical correlations between anxiety and both depression and stress revealed that anxiety shares variance with these more frequently studied variables in RA. However, anxiety was not found to be related to RA disease duration.

title: Psychological distress and changes in the activity of systemic lupus erythematosus.
abstract: To determine if changes in depressive symptoms or anxiety lead to changes in the activity of systemic lupus erythematosus (SLE).



Twenty-three patients with SLE were examined prospectively every 2 weeks for up to 40 weeks. At each assessment, patients completed the Centers for Epidemiologic Studies--Depression scale (CES-D), the State subscale of the State-Trait Anxiety Inventory and a global assessment of the activity of their SLE by visual analogue scale. SLE activity was also assessed at each visit by physician global assessment, the Systemic Lupus Activity Measure (SLAM), the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the European Consensus Lupus Activity Measure (ECLAM).



Changes in depression and anxiety were positively correlated with simultaneous changes in the patient global assessment of SLE activity and in the SLAM, but not with changes in the physician global assessment, SLEDAI or ECLAM. Depression and anxiety scores were also correlated with patient global assessments and SLAM scores 2 weeks later, but lagged scores were not significantly associated with the patient global assessment or SLAM after controlling for current depression and anxiety scores. The associations between depression and anxiety scores and the SLAM were not present when SLAM scores were modified to exclude ratings of depression and fatigue. No measure of SLE activity increased in the 2 weeks immediately after a large increase in CES-D or State Anxiety scores.



Depression and anxiety scores parallel changes in patients' assessments of the activity of their SLE. We found no evidence to support the hypothesis that psychological distress causes increased SLE activity.

title: Chronic widespread musculoskeletal pain with or without fibromyalgia: psychological distress in a representative community adult sample.
abstract: To estimate the severity of depression, anxiety, and other symptoms of psychological distress in a representative general population sample of fibromyalgia (FM) cases (FC) compared to pain controls (PC), and to identify strong correlates of depression and anxiety.



We compared the severity of depression, anxiety, and other symptoms of psychological distress between 2 representative community samples: (1) 74 confirmed FC, and (2) 48 adults with chronic widespread pain (PC) who did not meet the 1990 ACR criteria for FM. Psychological distress was measured using the Centre for Epidemiological Studies Depression (CES-D) Scale, the State-Trait Anxiety Inventory (STAI), and other measures of psychological distress from the literature. Using cutoff scores for CES-D and trait anxiety, we compared demographic and clinical characteristics in those above and below each cutoff score. Simple linear regression was performed to identify factors strongly and independently correlated with depression and trait anxiety.



Compared to PC, FC were more symptomatic on virtually all measures of psychological distress. Similarly, individuals who scored above cutoff scores for depression and anxiety had more physical symptoms and had poorer function than those below. Depression and trait anxiety were highly correlated (r = 0.86). In a simple regression model, the best predictors for both depression and trait anxiety were the total number of symptoms and a physical disability score.



Depression and anxiety are common and frequently severe even among community cases of FM.

title: Assessment of State and Trait Anxiety in Subjects with Anxiety and Depressive Disorders
abstract: The State-Trait Anxiety Inventory (STAI) is one of the most widely used scales for the evaluation of anxiety in medical and, to a lesser extent, psychiatric patients. Although there is a relatively large amount of STAI data about anxiety for individuals with a variety of psychiatric disorders, the results of many anxiety studies include only state or trait and many studies have been influenced by comorbidity and by variations in diagnostic criteria used. We studied state and trait anxiety and compared the revised form of the STAI (Form Y) with the original (Form X) to evaluate the anticipated improvement in the measure. In addition, we compared the STAI results with those of another self-report measure (the Symptom Checklist–90 anxiety and depression scales) and also with interviewer-rated measures of anxiety (Hamilton Rating Scale for Anxiety) and depression (Hamilton Rating Scale for Depression). Results indicate that the STAI does not clearly differentiate anxiety disorders from depressive disorders and support the use of multiple tests and of both self-report and interviewer ratings in the evaluation of anxiety and depression in psychiatric patients.

title: The State-Trait Anxiety Inventory, Trait version: structure and content re-examined.
abstract: Although the State-Trait Anxiety Inventory (STAI) is a popular measure of anxiety, some previous research suggests that the trait scale may assess depression, as well as anxiety. The factor structure of the trait items was initially examined using factor analytic procedures. Confirmatory factor analytic methods suggested that a hierarchical solution best fit the data, with one overall factor and two lower order factors. The lower order subscales created from this factor solution were examined in a sample of individuals diagnosed with an anxiety disorder. Overall, the results offered good support for the notion that the trait scale of the STAI assesses depression, as well as anxiety. One set of items appeared to assess anxiety and worry, whereas the other assessed sadness and self-deprecation. The two subscales correlated differentially with other measures of anxiety and depression in a manner that was consistent with their content. Finally, diagnostic groups and controls could be meaningfully distinguished on these subscales. Implications for the use of this measure are discussed.

title: Relationship between the beck anxiety inventory and the Hamilton anxiety rating scale with anxious outpatients
abstract: The Beck Anxiety Inventory (BAI) and Hamilton Anxiety Rating Scale (HARS) were administered to 367 outpatients with DSM-III/DSM-III-R anxiety disorders. Principal components analyses of the 21-item BAI and 14-item HARS found four BAI components reflecting neurophysiological, subjective, panic, and autonomic self-reported symptoms of anxiety and two HARS components indicating psychic and somatic clinical-ratings of anxiety. Subscales derived by summing the ratings for the items with the highest loadings for each instrument's components had coefficient alphas ….70. The positive correlations of the BAI subscales with the HARS subscales supported the concurrent validities of the BAI subscales. Evidence for the BAI subscales' discriminant validities was also found: The mean BAI subjective, neurophysiological, and panic subscale scores of the patients diagnosed with panic disorders were significantly higher than those for the patients diagnosed with generalized anxiety disorder.

title: Normative values for the Beck Anxiety Inventory, Fear Questionnaire, Penn State Worry Questionnaire, and Social Phobia and Anxiety Inventory.
abstract: Community norms are reported for the Beck Anxiety Inventory (BAI ; A. T. Beck, N. Epstein, G. Brown, & R. A. Steer, 1988), Fear Questionnaire (FQ ; I. M. Marks & A. Mathews, 1979), Penn State Worry Questionnaire (PSWQ ; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990), and Social Phobia and Anxiety Inventory (SPAI ; S. M. Turner, D. C. Beidel, C. V. Dancu, & M. A. Stanley, 1989). The demographic profile of the samples closely matched the 1990 U.S. national census. On the SPAI, women scored higher than men on the Agoraphobia subscale, and the lowest income group scored higher than higher income participants on the Difference and Social Phobia subscales. Participants under 45 years of age exceeded those aged 45-65 on the BAI, the PSWQ, and FQ Social Phobia, Blood/Injury, and Total Phobia scores. Percentile scores are provided for all measures, as well as discussion oftheir usefulness for assessing clinical significance of therapy outcomes.

title: Addressing the need for appropriate norms when measuring anxiety in seniors
abstract: In order to address the paucity of research concerning the use of anxiety measures in seniors, we investigated whether commonly used measures of anxiety should be normed separately for this population. One hundred and one participants between the ages of 40 and 93 years, who were living independently in the community, were administered three commonly used measures of anxiety. These were the Beck Anxiety Inventory (BAI), the Anxiety Sensitivity Index (ASI) and the Fear Survey Schedule (FSS). They also completed a brief questionnaire concerning demographic and medical information. The main design involved two (younger versus older persons) × two (males versus females) analyses. ASI scores varied as a function of age and sex (i.e. two main effects) with older and male participants obtaining lower scores. Analysis of the BAI scores revealed a significant age by sex interaction, with older men obtaining significantly lower scores than both younger men and women over 60 years of age. Age did not play a significant role with respect to total FSS scores, although females obtained higher scores than males. The results of this investigation suggest that separate norms should be used when the BAI and the ASI are administered to persons over 60 years of age.

title: Psychometric evaluation of the Beck Anxiety Inventory with older medical patients
abstract: Disadvantaged older medical outpatients (N = 197; ages 55-92) completed the Beck Anxiety Inventory (BAI). The instrument demonstrated high intemal consistency and no significant differences by sex or race, suggesting that it is appropriate to use with diverse populations. Total BAI score correlated negatively with age. Confirmatory factor analysis revealed a good fit to a 4-factor model consisting of cognitive, autonomic, neuromotor, and panic symptoms. Although scores on the BAI and 2 widely used depression scales were significantly correlated, factor analysis distinguished BAI and depression scale items, suggesting that the instruments measure distinct constructs. These findings suggest that the BAI could serve as a valuable screening test for anxiety symptoms among primary care patients who are older and have low income.

title: The Beck Anxiety Inventory in Older Adults With Generalized Anxiety Disorder
abstract: The authors investigated the psychometric properties of the Beck Anxiety Inventory (BAI) in a sample of 75 older generalized anxiety disorder (GAD) patients and a comparison group of 32 older adults without significant psychopathology. Internal consistency was above .80, and the BAI showed evidence of convergent validity in both groups. Evidence for discriminant validity with respect to measures of depression was weaker. Two items, fearing the worst and nervousness, correctly distinguished 86.5% of patients with GAD and 93.8% of the normal controls. Medical comorbidity was associated with somatic but not cognitive anxiety symptoms in the normal older sample. Overall, results indicate the limitations of the BAI in assessing anxiety symptoms in older adults and suggest the need for use of an instrument focusing on cognitive aspects of anxiety.

title: Reliability and validity of the beck anxiety inventory
abstract: Two studies were conducted to further psychometric research on the recently developed Beck Anxiety Inventory (BAI). In Study 1 the test-retest reliability and internal consistency of the scale were examined with a sample of 40 outpatients having anxiety disorders. The BAI proved highly internally consistent (cronbach's alpha = .94) and acceptably reliable over an average time lapse of 11 days (r = .67). Study 2 was conducted to assess the convergent and discriminant validity of the BAI vis a vis anxiety and depression and in comparison to the widely used trait Anxiety measure from the State-Trait Anxiety Inventory. Seventy-one outpatients with anxiety disorders completed the revised State-Trait Anxiety Inventory, the Beck Depression Inventory, and daily diary ratings of anxiety and depression in addition to the BAI. The BAI fared better on tests of convergent and discriminant validity than did Trait Anxiety. The correlation between the BAI and Diary Anxiety was significantly higher than that between BAI and Diary Depression, and, compared to Trait Anxiety, the BAI was significantly less confounded with depression as measured by the BDI. Scores for STAI-Y Trait Anxiety were highly confounded with measures of depression, but results for the STAI-Y State scale were more positive.

title: The Beck Anxiety Inventory: Psychometric Properties with Older Adults
abstract: 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.

title: Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation
abstract: Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.

title: An inventory for measuring clinical anxiety: psychometric properties.
abstract: Un nouvel inventaire auto-administre destine a mesurer l'anxiete pathologique, le «Beck Anxiety Cheklist» (BAI) est decrit, evalue et compare au «Hamilton Anxiety Rating Scale» (test avec lequel des correlations moderees sont trouvees)

title: Characterization of worry according to severity of anxiety in elderly living in the community
abstract: The goals of this study were to analyse the characteristics of the phenomenon of worry in old age, to analyse differential characteristics of worry in the elderly according to severity of anxiety, and to explore the discriminative ability of different DSM-IV criteria for generalized anxiety disorder (GAD) to reveal the presence of this disorder. Starting from a randomized sample of 97 individuals, those 85 representing three levels of severity of the anxiety were retained: 74 non-clinical, four with sub-threshold anxiety and seven with GAD. They were assessed with different variables typically considered to be relevant for the analysis and characterization of worry. Results indicate that the most remarkable differences in contents of worry as a function of severity of anxiety occurred in the domains of worries about health and personal worries. Furthermore, elderly people with high levels of anxiety worry more frequently, and about more issues, and perceive less control over their worrying. Significant differences between groups in past and present orientation of worry were found. Worries were more frequent in GAD and they were oriented mainly towards the present and minor everyday problems in both GAD and non-clinical people. Moreover, worry about minor things together with the extent to which worry interferes in daily life were the best discriminant variables for GAD, being better than the core DSM-IV GAD criteria. We conclude that this pattern of results suggests that the potential of a specific worry to affect daily well-being and quality of life is strongly related to the presence of a disorder.

title: Adult attachment as a moderator of treatment outcome for generalized anxiety disorder: Comparison between cognitive-behavioral therapy (CBT) plus supportive listening and CBT plus interpersonal and emotional processing therapy.
abstract: To determine whether baseline dimensions of adult insecure attachment (avoidant and anxious) moderated outcome in a secondary analysis of a randomized controlled trial comparing cognitive-behavioral therapy (CBT) plus supportive listening (CBT + SL) versus CBT plus interpersonal and emotional processing therapy (CBT + I/EP).



Eighty-three participants diagnosed with generalized anxiety disorder (GAD) were recruited from the community and assigned randomly to CBT + SL (n = 40) or to CBT + I/EP (n = 43) within a study using an additive design. PhD-level psychologists treated participants. Blind assessors evaluated participants at pretreatment, posttreatment, 6-month, 12-month, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (Penn State Worry Questionnaire, Hamilton Anxiety Rating Scale, Clinician's Severity Rating). Avoidant and anxious attachment were assessed using self-reported dismissing and angry states of mind, respectively, on the Perceptions of Adult Attachment Questionnaire.



Consistent with our prediction, at all assessments higher levels of dismissing styles in those who received CBT + I/EP predicted greater change in GAD symptoms compared with those who received CBT + SL for whom dismissiveness was unrelated to the change. At postassessment, higher angry attachment was associated with less change in GAD symptoms for those receiving CBT + I/EP, compared with CBT + SL, for whom anger was unrelated to change in GAD symptoms. Pretreatment attachment-related anger failed to moderate outcome at other time points and therefore, these moderation effects were more short-lived than the ones for dismissing attachment.



When compared with CBT + SL, CBT + I/EP may be better for individuals with GAD who have relatively higher dismissing styles of attachment.

title: Development and validation of the Penn State Worry Questionnaire.
abstract: The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.

title: Normative data for persons over 65 on the Penn State Worry Questionnaire
abstract: Normative data are presented for the Penn State Worry Questionnaire (PSWQ) from 255 healthy New Zealanders over the age of 65. The PSWQ was administered during the course of a two-year trial of the effect on cognition and mood of lowering homocysteine levels using vitamin and folate supplements. The scale proved to have good internal consistency, and there were no significant effects of sex, age, or premorbid IQ on the PSWQ scores. Mean scores and percentiles are presented for both the abbreviated an 8-item short-form (PSWQ-A) developed for use with the elderly by Hopko et al. (2003) and for the total score. Confirmatory factor analyses were conducted and provided evidence for the construct validity of both the short-form and the total scale score as single-factor measures of worry. The results of this study, taken together with findings from other studies in the literature suggest that a score on the PSWQ above 50 from a client above the age of 65 is suggestive of a need to assess further for generalised anxiety disorder.  The Penn State Worry Questionnaire (PSWQ) was developed by Meyer, Miller, Metzger, and Borkovec (1990) as a means of measuring the propensity to worry excessively, the core symptom of generalised anxiety disorder (GAD). Worry is a significant cognitive component of anxiety and as such is a frequent target for change in many cognitive therapies (e.g., Wells, 1995; 2005). The defining characteristic of worry is the presence of thoughts indicating a heightened anticipation of future personal or emotional threat, accompanied by an inability to resolve or exclude these cognitions (Borkovec, Shadick, & Hopkins, 1991; Matthews, 1990; Rapee, 1991). Although worrying is often considered to have the adaptive function of preparing for possible danger, when this thinking does not lead to a useful outcome or begins to involve scenarios which are unlikely to arise, worrying can be seen as pathological. Persons with GAD are assumed to be excessively sensitive to cues indicative of threat, or to have a maladaptive emotional or cognitive response to threat cues (Mathews, 1990). The PSWQ is a 16-item measure with a 5-point response scale ranging from 1 (not all like me) to 5 (very typical of me) and a maximum score of 80, widely used in clinical psychology practice. Eleven of the items are positive for the presence of worry ("Once I start worrying I cannot stop") and five, which are reverse scored, have content indicating an absence of worry ("I never worry about anything"). The psychometric characteristics of the PSWQ have been investigated in a number of studies and generally found to be satisfactory. In the series of eight studies in which the initial test construction process was described (Meyer et al., 1990), good evidence for the internal consistency (alpha > .90), retest stability (r > .74 over two to four weeks), and discriminative validity of the scale was presented. In subsequent studies, the internal consistency of the scales has been consistently found to be excellent, with estimates ranging from .80 to .95 (Brown, Antony, & Barlow, 1992; Crittendon & Hopko, 2006; Fresco, Mennin, Heimberg, & Turk, 2002; Stanley, Novy, Bourland, Beck, & Averill, 2001; Wetherell, Gatz, & Craske, 2003). Retest reliability has been found to be acceptable for younger college samples but more modest (r = .54) for older adults (Stanley et al., 2001). The convergent validity of the scale has been demonstrated in several studies (e.g., Brown et al. 1992; Davey, 1993; Stanley et al. 2001; Wetherell et al., 2003). In their study of 436 persons with anxiety disorders (including 50 persons with GAD), Brown et al. (1992) found that the PSWQ had good concurrent validity and was able to distinguish GAD from other anxiety disorders. For most research and clinical purposes, the sum of the scores on all 16 items is usually calculated and the scale treated as unidimensional. …

title: Treatment of generalized anxiety disorder in older adults.
abstract: Older adults with generalized anxiety disorder (GAD; N = 75; M age = 67.1 years) were randomly assigned to cognitive-behavioral therapy (CBT), a discussion group (DG) organized around worry-provoking topics, or a waiting period. Participants in both active conditions improved relative to the waiting list. Although CBT participants improved on more measures than DG participants, the authors found only I significant difference immediately after treatment and no differences at 6-month follow-up. Effect sizes were smaller than in younger samples, but CBT showed large effects and DG showed medium-sized effects Overall, results indicate that brief treatment of late-life GAD is beneficial, but they provide only limited support for the superiority of CBT to a credible comparison intervention.

title: Predictors of treatment satisfaction among older adults with anxiety in a primary care psychology program.
abstract: Increasing numbers of patients are treated in integrated primary care mental health programs. The current study examined predictors of satisfaction with treatment in patients from a randomized clinical trial of late-life generalized anxiety disorder (GAD) in primary care. Higher treatment satisfaction was associated with receiving CBT rather than enhanced usual care. Treatment credibility, treatment expectancies, social support, and improvements in depression and anxiety symptoms predicted higher treatment satisfaction in the total sample. In the CBT group, only credibility and adherence with treatment predicted satisfaction. This suggests that older patients receiving CBT who believe more strongly in the treatment rationale and follow the therapist's recommendations more closely are likely to report satisfaction at the end of treatment. In addition, this study found that adherence mediated the relationship between treatment credibility and treatment satisfaction. In other words, patients' perceptions that the treatment made sense for them led to greater treatment adherence which then increased their satisfaction with treatment.

title: Utility of telephone assessments in an older adult population.
abstract: Telephone assessments are commonly used in mental health research and may be especially beneficial in older populations. The current study assessed the psychometric properties of the Penn State Worry Questionnaire (T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990) and the Beck Depression Inventory--II (A. T. Beck, R. A. Steer, & G. K. Brown, 1996), when administered over the telephone in an older adult population. Results indicate no differences in mean symptom level or internal consistency across two modes of administration. Correlations between the in-person and telephone-administered measures and diagnostic categories suggest adequate validity of the telephone-administered measures. With this demonstrated evidence, the telephone assessment method can be applied in a variety of research and clinical settings.

title: Generalized anxiety disorder in older adults: Examining the relation between clinician severity ratings and patient self‐report measures
abstract: Generalized anxiety disorder (GAD) is the most prevalent of the chronic anxiety disorders for older adults. Although a variety of self‐report measures are beginning to be utilized to assess anxiety and related symptoms in older adults, there is a paucity of data regarding the convergence of self‐report measures with clinician ratings of symptom severity. This situation is problematic in that interpretability of assessment data is limited, as is our broader understanding of the construct of GAD in an older adult population. To address these issues, we examined convergence across assessment modalities among 64 older adults who met diagnostic criteria for GAD. In addition to two Anxiety Disorders Interview Schedule for DSM‐IV (ADIS‐IV) interviews conducted by independent raters, participants completed four self‐report measures (Penn State Worry Questionnaire [PSWQ], Worry Scale [WS], State‐Trait Anxiety Inventory [STAI], Beck Depression Inventory [BDI]) as part of a more extensive pretreatment assessment battery. Results revealed significant correlations between clinician‐rated GAD severity and the BDI, STAI, and PSWQ. Regression analyses indicated that the BDI (r2 = .15) and the PSWQ (r2 = .07) were particularly useful predictors of clinician‐rated GAD severity. A comorbid mood disorder, however, was identified as an important mediator of these relations. Specifically, presence of coexistent depression accounted for 17% of the variance in clinician severity ratings (CSR; P < .01), with individuals diagnosed with a comorbid mood disorder receiving higher clinician severity ratings. The only self‐report measure that accounted for additional significant variance was the PSWQ (7%). The study highlights the need to address coexistent psychological conditions when examining convergence between assessment modalities, and expands upon the relatively neglected area of anxiety assessment in older individuals. Specifically, the BDI and the PSWQ are identified as particularly useful screening instruments that may be helpful in conceptualizing GAD severity within an older adult population.  2000.

title: The role of executive functioning in CBT: a pilot study with anxious older adults.
abstract: Cognitive behavior therapy (CBT) is an effective treatment for late life anxiety and depression. The successful use of CBT is assumed to rely on cognitive skills known as executive functions (EF; e.g., hypothesis generation, allocation of attention, self-monitoring) governed by the prefrontal cortex. Because older adults sometimes have executive deficits as a consequence of normal aging, EF may be a mediator of CBT outcome in older samples. The current pilot study tested the hypothesis that older adults with executive deficits (as measured by neuropsychological tests) would show decreased therapeutic benefit from CBT for generalized anxiety disorder, as compared to a group with intact EF. Results indicated differential response to CBT within the dysfunction group depending on the stability (and possibly, the etiology) of executive deficits from pre- to posttreatment. Those whose EF scores remained low from pre- to posttreatment did not respond to CBT, while those whose scores improved responded quite well, similar to an Intact EF group. Results indicate that some, but not all, older adults with executive dysfunction show decreased benefit from CBT, and are consistent with the assumption that executive skills are important for the successful use of CBT. However, some participants may show improvement on both mood and cognitive skills during treatment, which is discussed further.

title: Measuring anxiety in the elderly: psychometric properties of the state trait inventory of cognitive and somatic anxiety (STICSA) in an elderly Italian sample
abstract: Despite its increasing personal and societal impact, assessment of late-life anxiety has received relatively little attention in psychiatric research. Differential symptom presentation and physical comorbidities among the elderly, relative to younger cohorts creates a need for anxiety measures that are psychometrically validated in the elderly.  The present study examined the factor structure and discriminant validity of the state-trait inventory for cognitive and somatic anxiety (STICSA) in a sample of Italian middle-aged and older adults. Participants were 396 community-dwelling middle-aged (50–64 years) and older (≥65 years) adults. In addition to the STICSA, participants completed two depression measures and a general well-being survey with physical and mental health subscales.  Factor analysis supported the validity of both state–trait and cognitive–somatic distinctions underlying the STICSA, all dimensions exhibited excellent internal consistency (Cronbach's α coefficients ≥ 0.86), and correlations with depression measures provided limited evidence for differentiation of anxious and depressive symptoms. The STICSA also showed evidence of discriminating anxious symptoms from physical health symptoms, a particularly relevant feature of a valid anxiety measure in elderly samples.  The STICSA appears to be a valid measure of cognitive and somatic anxiety in the elderly.

title: Distinguishing Cognitive and Somatic Dimensions of State and Trait Anxiety: Development and Validation of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA)
abstract: To date, little research has endeavoured to discriminate between cognitive and somatic dimensions of trait anxiety and, consequently, it remains uncertain whether these anxiety dimensions can be reliably distinguished at the trait level. The four studies presented here support the validity of the distinction between cognitive and somatic anxiety at both state and trait levels. The research involved the development and validation of a self-report questionnaire, the State-Trait Inventory for cognitive and somatic anxiety (STICSA). The nature of the anxiety dimensions assessed by this new measure was then investigated. The results indicate that the state scales of this new measure assess the degree of cognitive and somatic anxiety experienced at a particular point in time. The trait scales of the STICSA predict the situations in which different individuals will display elevations in cognitive and somatic state anxiety. Trait cognitive and somatic anxiety are indeed distinct constructs that can be reliably and validly assessed. Theoretical and applied implications of this finding are discussed.

title: The State-Trait Anxiety Inventory: Shadows and Lights on its Construct Validity
abstract: Past studies on the factor validity of the Trait subscale of the Spielberger’s State-Trait Anxiety Inventory (STAI-T) do unanimously agree on its structure. In fact, researchers are still debating whether the STAI-T is unidimensional or multidimensional. Our aim was to clarify what the STAI-T measures. The STAI-T, the Beck Depression Inventory–II, the Teate Depression Inventory, and the Beck Anxiety Inventory were administered to 1124 psychiatric outpatients and to 877 healthy subjects. A confirmatory factor analysis was performed in order to compare various models in the literature. The internal consistency and convergent and discriminant validity of the STAI-T as well as its factorial subscales were assessed. The one-construct two-method (i.e., the STAI-T measures one substantive anxiety construct plus artifacts due to negative–positive item polarity) and the bifactor (i.e., the STAI-T comprises two first-order specific factors [“Anxiety” and “Depression”] and one first-order general factor) models were the best-fitting solutions for the STAI–T in both the clinical and nonclinical samples. The STAI–T total score correlated more strongly with measures of depression than with a concurrent measure of anxiety. The STAI-T should be considered a measure of general negative affect, including specific aspects of cognitive anxiety and depression together.

title: Factor structure and validity of the State-Trait Inventory for Cognitive and Somatic Anxiety.
abstract: The State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA; Ree, French, MacLeod, & Locke, 2008) is a relatively new measure of anxiety. The current research investigated the factor structure and reliability of scores on the STICSA and the validity of the interpretation of STICSA scores in a sample of undergraduate students. Participants completed a battery of self-report questionnaires online, including measures of anxiety, depression, affect, and social desirability. Scores on the 4 subscales of the STICSA-Trait Cognitive, Trait Somatic, State Cognitive, and State Somatic-exhibited good internal consistencies (αs ≥ .92). Results of a confirmatory factor analysis provided support for a hierarchical model of the STICSA including a global anxiety factor plus 4 specific factors corresponding to the STICSA subscales. Support was also found for a four-factor model, with factors corresponding to the STICSA subscales. Pearson product-moment correlations with other measures of anxiety provided evidence of the convergent validity of the interpretation of STICSA scores, and Pearson product-moment correlations with measures of depression and affect provided evidence of the divergent validity of the interpretation of STICSA scores. The STICSA is the only existing self-report anxiety measure that contains scales measuring state and trait anxiety as well as cognitive and somatic anxiety. Comparisons between the convergent and divergent validity of test score interpretations of the STICSA and the State-Trait Anxiety Inventory (STAI; Spielberger et al., 1983) revealed that the STICSA has better convergent validity with measures of somatic anxiety and better divergent validity with measures of depression and affect.

title: Determining a diagnostic cut-off on the Teate Depression Inventory
abstract: A small but growing body of literature suggests that the Teate Depression Inventory (TDI) may be an “objective” measure of depression compared with other commonly used scales. Furthermore, the TDI has strong psychometric properties in both clinical and nonclinical samples. The present study aimed to extend the use of TDI by identifying cut-off scores that could differentiate varying levels of depression severity in a group of clinically diagnosed depression disorder patients (N=125). Three receiver operating characteristic curve analyses indicated cut-off scores of 21 (sensitivity =0.86, specificity =0.94, and classification accuracy =0.90); 36 (sensitivity =0.84, specificity =0.96, and classification accuracy =0.92); and 50 (sensitivity =0.81, specificity =0.93, and classification accuracy =0.90), for minimal, mild, moderate, and severe depression, respectively. Results suggest that the TDI measures depression severity across a broad range with high test accuracy and may be appropriately used to screen for depression.

title: Building a new Rasch-based self-report inventory of depression
abstract: This paper illustrates a sequential item development process to create a new self-report instrument of depression refined with Rasch analysis from a larger pool of potential diagnostic items elicited through a consensus approach by clinical experts according to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for major depression. A 51-item pool was administered to a sample of 529 subjects (300 healthy community-dwelling adults and 229 psychiatric outpatients). Item selection resulted in a 21-item set, named the Teate Depression Inventory, with an excellent Person Separation Index and no evidence of bias due to an item–trait interaction (χ2=147.71; df =168; P=0.48). Additional support for the unidimensionality, local independence, appropriateness of the response format, and discrimination ability between clinical and nonclinical subjects was provided. No substantial differential item functioning by sex was observed. The Teate Depression Inventory shows considerable promise as a unidimensional tool for the screening of depression. Finally, advantages and disadvantages of this methodology will be discussed in terms of subsequent possible mathematical analyses, statistical tests, and implications for clinical investigations.

title: A Validation Study of the Psychometric Properties of the Other As Shamer Scale–2
abstract: External shame is associated to social and emotional difficulties, which are predictors of psychological disorders. The aim of the present study was to investigate the psychometric properties of the shorter Italian version of the Other As Shamer Scale (OAS-2), a measure of external shame. Confirmatory factor analysis was used in a sample of 612 (54.2% male) Italian undergraduate students. Evidence for this model provided support for the assumption that the one-factor model was similar across the gender groups. The Italian OAS-2 fully replicated the one-factor structure of the original OAS. Cronbach’s alpha index, as well as test–retest stability provided satisfactory results. The OAS-2 showed good convergent and divergent validity, being highly correlated with measures of internal shame, trait anxiety, and depression. The OAS-2 can be considered a useful instrument for measuring external shame when time constraints impede the use of the 18-item OAS. Implications of the results are discussed and recommendations for future work with the scale are made.

title: Measurement of External Shame: An Inside View
abstract: The aims of this study were to investigate the construct validity of the Other as Shamer scale (OAS) using confirmatory factor analysis (CFA) and to examine the psychometric properties of its Italian version in a sample of 687 nonclinical individuals. The CFA results indicated that the hypothesized hierarchical model (with 1 higher order factor and 3 first-order factors) was the best fitting solution. Cronbach's alpha indexes, as well as test–retest stability, provided satisfactory results. Correlations of the OAS total score and its subscales with the Beck Depression Inventory–II (rs = .30–.48) and the Teate Depression Inventory (rs = .32–.45) were both substantial and significant (p < .01). Receiver operating characteristic curves were constructed to indicate sensitivity and specificity of the OAS and its subscales when determining those nonclinical subjects who met clinical thresholds for depression symptoms. A series of cutoff scores for the OAS scale and its subscales was developed, with sensitivity values between .70 and .62, and specificity values between .71 and .62, indicating good to fair discrimination between the 2 groups (depressed vs. nondepressed). The theoretical and practical implications of these results were discussed.

title: One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites.
abstract: One-month prevalence results were determined from 18,571 persons interviewed in the first-wave community samples of all five sites that constituted the National Institute of Mental Health Epidemiologic Catchment Area Program. US population estimates, based on combined site data, were that 15.4% of the population 18 years of age and over fulfilled criteria for at least one alcohol, drug abuse, or other mental disorder during the period one month before interview. Higher prevalence rates of most mental disorders were found among younger people (less than age 45 years), with the exception of severe cognitive impairments. Men had higher rates of substance abuse and antisocial personality, whereas women had higher rates of affective, anxiety, and somatization disorders. When restricted to the diagnostic categories covered in international studies based on the Present State Examination, results fell within the range reported for European and Australian studies.

title: Evidence-based psychological treatments for late-life anxiety.
abstract: 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.

title: Introduction to special issue: Evidence-based assessment in pediatric psychology.
abstract: In the past decade, there has been considerable attention devoted to evaluating the scientific merit of psychological treatments. In 1995,  embarked on an evaluation of evidence-based (formerly referred to as empirically supported) treatments for psychopathology (Task Force on Promotion and Dissemination of Psychological Procedures, 1995). A similar venture soon followed from Division 53 (Society of Child Clinical and Adolescent Psychology) to identify psychosocial interventions for children and adolescents, which were supported by research findings (Lonigan, Elbert, & Johnson, 1998).  (Society of Pediatric Psychology) of the APA conducted an evaluation yielding a series of articles on evidence-based treatments germane to pediatric psychology (Spirito, 1999). 
 
The efforts to identify, describe, and disseminate information about treatments that are supported by sound scientific evidence are important endeavors for advancing scientist-practitioner approaches to therapy and research in psychology. Scientist-practitioners are equally concerned about the research base supporting their assessment instruments. Thus, in 1999, Division 12 conducted one of the first systematic evaluations of evidence-based assessments (Ollendick, 1999). A particular emphasis was placed on identifying the treatment utility of the measures, which refers to the extent that they provide information that helps guide the design of interventions (Hayes, Nelson, & Jarrett, 1987; Nelson-Gray, 2003). Thus, there was more attention devoted to measures of malleable state-like variables than measures of stable trait-like characteristics. In addition, this task force limited the scope of the review to laboratory and performance-based measures (e.g., observations under standardized conditions) of child clinical psychology (e.g., autism, anxiety, depression, and attention deficit hyperactivity disorder). In a summary of the findings, Frick (2000) concluded that the measures were useful in providing additional information about the disorders under study, but the instruments did little in guiding the design of treatment interventions. An explanation is that many of the laboratory-based measures reviewed were developed and employed to examine specific hypotheses about disorders rather than for clinical use. 
 
In 2005, Division 53 published a special issue focusing on evidence-based assessment of child and adolescent disorders. In the lead article, Mash and Hunsley (2005) discussed some of the difficulties of conducting a review of evidence-based assessments, including the large number of measurement tools, the varied purposes of assessment, the rapid developmental changes in children, and the need for multiple sources of information (e.g., teachers and parents). This series detailed assessment approaches with children with anxiety, depression, bipolar disorder, attention deficit hyperactivity disorder, conduct problems, learning disabilities, and autism spectrum disorders. 
 
Whereas there is a overlap in the concerns and issues in the fields of child psychopathology and pediatric psychology, there are also some distinctions that should be noted. The populations evaluated and foci of concern of pediatric psychology are distinct. For example, adherence to medical regimens, psychosocial issues related to having a chronic illness, and evaluations of medical pain management are issues more commonly addressed by pediatric psychologists than clinical child psychologists. Given that pediatric psychologists are often working with medical professionals and in busy medical care settings, pragmatics (e.g., cost-effective, time-efficient, and ease of use; Roberts & McNeal, 1995) and whether results lead to clear treatment implications (Blount, Bunke, & Zaff, 2000) might be prioritized over theory development and richness of information. 
 
The systematic evaluation of assessment instruments is essential to many areas of scientist-practitioner endeavors. When conducting therapy, professionals rely on the accuracy of measures for diagnostic and case conceptualization purposes, and decisions regarding the course and efficacy of treatment are often based on results from assessment tools. In scientific research, the assessment tools are essential in the accurate examination of the constructs of interest. Given that the quality of the assessment measures are crucial to whether a psychosocial treatment is deemed to be “empirically supported,” it seems that the horse has been put before the cart, or perhaps the hitch has unwittingly come undone somewhere along the way in the movement to identify evidence-based treatments. 
 
Evaluating pediatric psychology assessment measures presents a host of challenges (La Greca & Lemanek, 1996). For example, the instrument might be used across a variety of populations, and the validity and reliability might vary across these groups. In addition to the question of whether an assessment instrument is valid for a particular population, there is also the question of whether the instrument is valid for a particular purpose. For instance, the researcher might be using the instrument to broaden the understanding of a construct or of factors associated with a disorder, identify avenues for intervention, or assess treatment outcome. A given measure might prove valid for some of these purposes but not others. Because there are multiple purposes for which an assessment instrument could be used, the scope of articles reviewed is diverse and could encompass practically any type of empirical investigation. These various considerations might help explain why evidence-based assessment reviews have lagged behind evidence-based treatment reviews in the literature. 
 
In 2002, Annette La Greca assembled a task force of Division 54 (Society of Pediatric Psychology) to identify, critique, and disseminate information regarding the assessment measures used in pediatric psychology. Valid and reliable assessment is essential to the efforts of health care professionals who work with children. Diagnostic and treatment decisions are made based largely on results from the assessment devices used with children in medical settings. Unfortunately, some of the measures used with pediatric populations have had questionable utility (La Greca, 1994). Specifically, many instruments commonly used in pediatric settings were initially developed for use with healthy children or those with psychopathology; thus, no relevant norms are available for use with pediatric populations. Furthermore, many measures included in pediatric investigations are the modifications of adult measures without adequate developmental considerations. Some instruments do not readily yield clear treatment implications (Quittner, 2000), and others are too long or complicated to use in many busy health care settings. Related, there appears to be a split between those measures used in research and those used in clinical practice, which is likely due to the failure of researchers to adequately develop and disseminate practical measures and also to clinicians for not selecting instruments based on research findings (Beutler, 2000; Frick, 2000). Thus, it is apparent that a systematic review of pediatric psychology measures is in warranted to examine the state of the assessment field and to help determine where attention should be focused. 
 
The goal of this series of articles is to identify and systematically critique the assessment tools available to the child health care community. The reviews are designed to help guide child health professionals in identifying and selecting instruments for particular purposes, to focus researchers’ efforts in developing and evaluating measurement tools, and to foster greater integration of science and practice.

title: Comorbid depression and anxiety in later life: patterns of association, subjective well-being, and impairment.
abstract: Very little epidemiological work has examined comorbidity between depression and anxiety disorders in community-dwelling older adults, despite the fact these disorders are known to co-occur in younger adults and that this co-occurrence is associated with greater clinical severity. In this study, the authors examine psychiatric comorbidity and associated impairment of four disorders (major depression, panic disorder, social phobia, and agoraphobia) in a community-based sample of adults aged 55 and older.  Population-based sample of older adults (N = 12,792) from the Canadian Community Health Survey—Mental Health and Well-Being (CCHS 1.2).  The World Mental Health Composite International Diagnostic Interview was used to identify cases of 12-month disorder. Descriptive analysis and regression analysis is used to examine patterns of association between disorders and related impairment.  Among adults aged 55 years and older, 4.4% met the criteria for at least one disorder and 0.8% had two or more. Social phobia was the most common comorbid disorder among respondents with depression, and depression was the most common comorbid disorder among respondents with any of the anxiety disorders. Respondents who report comorbid disorders reported significantly lower well-being and greater impairment.  Although comorbidity between physical health conditions and depression, and between dementias and depression, are well documented among older adults, these results suggest that comorbid depression and anxiety are also prevalent in later life. The significant impact of comorbidity on function and well-being underlines the need to screen for comorbid disorders in this population.

title: Anxiety and the risk of death in older men and women
abstract: There are inconsistent reports as to whether people with anxiety disorders have a higher mortality risk.  To determine whether anxiety disorders predict mortality in older men and women in the community Method Longitudinal data were used from a large, community-based random sample (n=3107) of older men and women (55–85 years) in The Netherlands, with a follow-up period of 7.5 years. Anxiety disorders were assessed according to DSM–III criteria in a two-stage screening design.  In men, the adjusted mortality risk was 1.78 (95% Cl 1.01–3.13) in cases with diagnosed anxiety disorders at baseline. In women, no significant association was found with mortality.  The study revealed a gender difference in the association between anxiety and mortality. For men, but not for women, an increased mortality risk was found for anxiety disorders.

title: Excess mortality among 3302 patients with 'pure' anxiety neurosis.
abstract: The survival probability and causes of death before the age of 70 years were analyzed among 3302 inpatients with "pure" anxiety neurosis in Stockholm County, Sweden, who were tracked in case registries by means of automated record linkage during a 14-year period. When all patients with other psychiatric diagnoses and substance abuse were excluded, and marital status controlled for, there was a significant excess of deaths due to verified and undetermined suicides, ie, nearly one third of all deaths. These unnatural deaths preempted any excess in natural causes before the age of 70 years, such as cardiovascular disease. Treatment policy with regard to the use of anxiolytic drugs was not found to influence mortality. We concluded that the risk of suicide in inpatients before the age of 70 years with anxiety disorders may be as high as that in persons with depression or other diagnoses who require inpatient care.

title: Handbook of Modern Item Response Theory
abstract: Item response theory has become an essential component in the toolkit of every researcher in the behavioral sciences. It provides a powerful means to study individual responses to a variety of stimuli, and the methodology has been extended and developed to cover many different models of interaction. This volume presents a wide-ranging handbook to item response theory - and its applications to educational and psychological testing. It will serve as both an introduction to the subject and also as a comprehensive reference volume for practitioners and researchers. It is organized into six major sections: the nominal categories model, models for response time or multiple attempts on items, models for multiple abilities or cognitive components, nonparametric models, models for nonmonotone items, and models with special assumptions. Each chapter in the book has been written by an expert of that particular topic, and the chapters have been carefully edited to ensure that a uniform style of notation and presentation is used throughout. As a result, all researchers whose work uses item response theory will find this an indispensable companion to their work and it will be the subject's reference volume for many years to come.

title: Item Response Theory: Principles and Applications
abstract: 1 Some Background to Item Response Theory.- 2 Assumptions of Item Response Theory.- 3 Item Response Models.- 4 Ability Scales.- 5 Estimation of Ability.- 6 Information Function and Its Application.- 7 Estimation of Item and Ability Parameters.- 8 Approaches for Addressing Model-Data Fit.- 9 Examples of Model-Data Fit Studies.- 10 Test Equating.- 11 Construction of Tests.- 12 Item Banking.- 13 Miscellaneous  14 Practical Considerations in Using IRT Models.-

title: Item response theory and clinical measurement.
abstract: In this review, we examine studies that use item response theory (IRT) to explore the psychometric properties of clinical measures. Next, we consider how IRT has been used in clinical research for: scale linking, computerized adaptive testing, and differential item functioning analysis. Finally, we consider the scale properties of IRT trait scores. We conclude that there are notable differences between cognitive and clinical measures that have relevance for IRT modeling. Future research should be directed toward a better understanding of the metric of the latent trait and the psychological processes that lead to individual differences in item response behaviors.

title: Using item response theory to understand comorbidity among anxiety and unipolar mood disorders.
abstract: The authors hypothesized that anxiety and unipolar mood disorders are often comorbid because each disorder indicates a broad, higher order factor. In a clinical subsample of the nationally representative National Comorbidity Survey participants (N = 251), a one-factor model fit the correlations among 7 dichotomous anxiety and unipolar mood diagnoses. Following the lead provided by literature on the structure of emotional and behavioral problems in children, we labeled this factor internalizing. Item response theory was used to explore how each diagnosis mapped onto the internalizing factor. The test information function derived from the 7 diagnoses suggested that they measure primarily the higher end of the factor. In addition, very high scores on internalizing (meeting criteria for 6-7 disorders) were associated with increased social costs, a phenomenon not well captured by the "comorbidity" concept. The results underscore the need to develop clinical assessment instruments that span the full range of the internalizing factor and measure both the shared and distinctive features of anxiety and unipolar mood disorders in a graded, continuous fashion.

title: Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators
abstract: BackgroundThere is robust epidemiological and clinical evidence that a greater number of women than men experience depression and anxiety. This study investigated a number of socio-demographic, health and lifestyle, psychological and social factors as possible mediators for the gender difference in depression and anxiety in three cohorts (20–24, 40–44, 60–64).MethodsResponses were from a representative, community based survey (n = 7,485) conducted in Canberra and Queanbeyan (NSW), in Australia. Depression and anxiety were measured using the self-report Goldberg Anxiety and Depression Scales. The analyses initially identified gender differences in the potential mediators, followed by univariate and multivariate mediation models.ResultsThe results indicated several shared mediators for depression and anxiety across the three age groups including: childhood adversity, mastery, behavioural inhibition, ruminative style, neuroticism, physical health, physical activity, and perceived interpersonal and employment problems. There was a decrease in the number of social mediators as age increased. The multivariate models accounted for gender differences in both conditions for all age groups, except for anxiety in the 20–24 years old. This suggests further important unmeasured mediators for this age group.ConclusionsThese findings add to the literature surrounding gender differences in depression and anxiety, and provide a basis for future research exploring variation in these gender disparities over the adult lifespan.

title: Gender bias in the sixteen-item Anxiety Sensitivity Index: an application of polytomous differential item functioning.
abstract: Gender differences in measures of anxiety sensitivity (AS) are similar to gender differences across anxiety disorders; females exhibit higher levels of AS and a greater prevalence of anxiety disorders than males. The current study confirms higher scores on the Anxiety Sensitivity Index (ASI) in females. Further analysis reveals, however, that gender differences on the ASI may arise from a single item's bias against women. Four different statistics examining differential item functioning (DIF) indicate that women are more likely to endorse the item, "It scares me when I feel faint", even if they score no higher on the ASI than males. Removing this biased item does not alter internal consistency of the scale, but eliminates the significant gender difference. The results suggest that differences on the ASI require careful interpretation as item bias may artificially inflate ASI scores in females.

title: Cultural aspects in social anxiety and social anxiety disorder
abstract: To examine cultural aspects in social anxiety and social anxiety disorder (SAD), we reviewed the literature on the prevalence rates, expressions, and treatments of social anxiety/SAD as they relate to culture, race, and ethnicity. We further reviewed factors that contribute to the differences in social anxiety/SAD between different cultures, including individualism/collectivism, perception of social norms, self‐construal, gender roles, and gender role identification. Our review suggests that the prevalence and expression of social anxiety/SAD depends on the particular culture. Asian cultures typically show the lowest rates, whereas Russian and US samples show the highest rates, of SAD. Taijin kyofusho is discussed as a possible culture‐specific expression of social anxiety, although the empirical evidence concerning the validity of this syndrome has been mixed. It is concluded that the individual's social concerns need to be examined in the context of the person's cultural, racial, and ethnic background in order to adequately assess the degree and expression of social anxiety and SAD. This has direct relevance for the upcoming DSM‐V. Depression and Anxiety, 2010.

title: Cross-Cultural Differences in Somatic Presentation in Patients With Generalized Anxiety Disorder
abstract: Little is known about cultural differences in the expression of distress in anxiety disorders. Previous cross-cultural studies of depression have found a greater somatic focus in Asian populations. We examined anxiety symptoms in patients with generalized anxiety disorder (GAD) in urban mental health settings in Nepal (N = 30) and in the United States (N = 23). Participants completed the Beck Anxiety Inventory (BAI). The overall BAI score and somatic and psychological subscales were compared. While there was no difference in total BAI scores, the Nepali group scored higher on the somatic subscale (i.e. “dizziness” and “indigestion,” t[df] = –2.63[50], p < 0.05), while the American group scored higher on the psychological subscale (i.e. “scared” and “nervous,” t[df] = 3.27[50], p < 0.01). Nepali patients with GAD had higher levels of somatic symptoms and lower levels of psychological symptoms than American patients with GAD. Possible explanations include differences in cultural traditions of describing distress and the mind-body dichotomy.

title: Never too late to be anxious: validation of the Geriatric Anxiety Inventory, Italian version.
abstract: The aim of this work was to validate the Italian version of GAI (GAI-It) and its short form (GAI-It SF) in an over 65-population.



In 3 recruitment areas across Italy, two raters reciprocally blind to results assessed eligible subjects; a semi-structured diagnostic clinical interview was performed by a psychiatrist.



Among the 76 enrolled subjects (mean age 72.7±6.8 years), anxiety symptoms were very common: 69.7% (moderate/ severe HADS-Anxiety), 76.3% (moderate/severe STAI-state), 71.0% (moderate/severe STAI-trait), 61.8% (GAI), 55.3% (GAI-SF). Sensitivity, specificity and positive predictive value of GAI confirmed a good reliability of the Italian version, with Cronbach's Alpha equal to 0.93 for GAI-It and to 0.77 for GAI-It SF, indicating a very good and good construct validity, respectively, of the scales. The Pearson correlation index demonstrated a moderately positive correlation among GAI, GAI-SF and STAI.



Our data confirm the validity of GAI-It as a valuable instrument to assess anxiety in an elderly population, for clinical and research purposes.

title: The impact of DSM-IV symptom and clinical significance criteria on the prevalence estimates of subthreshold and threshold anxiety in the older adult population.
abstract: Subthreshold anxiety refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met). The purpose of this study was to examine how the symptom and the clinical significance criteria may affect the prevalence estimates of anxiety problems in the older adult population and whether applying these criteria results in an identifiable older group showing more severe anxiety.



Data came from a large representative sample of community-dwelling older adults age 65 years and older (N = 2,784).



Results showed that the 12-month prevalence rate of any anxiety problem varied from 5.6% when DSM-IV criteria for anxiety disorders were used to 26.2% when all subthreshold manifestations of anxiety were considered. Findings also indicated that when compared with respondents without anxiety, older adults presenting different manifestations of subthreshold or threshold anxiety appear to be more similar than different in their health and health behavior characteristics.



Subthreshold anxiety has a high prevalence and may cause significant impairment. Both symptom and clinical significance criteria do not perfectly discriminate between older adults with or without a severe anxiety problem presenting comorbid disorders and needing psychiatric help.

title: Psychometric evaluation of the social phobia and anxiety inventory for children: concurrent validity and normative data.
abstract: Examined the relation of the Social Phobia and Anxiety Inventory for Children (SPAI-C) to the Social Anxiety Scale for Children-Revised (SASC-R). The association between the SPAI-C and the SASC-R was moderate, suggesting that the measures assess overlapping, although not identical, constructs. Initial normative data are reported on the SPAI-C for a community sample of 277 4th-through 6th-grade children. Girls reported higher social anxiety on both measures than did boys. Notably, a substantial proportion of children were found to exceed suggested cut-off scores on both measures for identifying children with high levels of social anxiety, which suggests the importance of screening elementary-age children for social fears.

title: The relationship between anxiety disorders in adults and recalled childhood teasing.
abstract: This study investigated the relationship between retrospective accounts of childhood teasing and anxiety disorders as well as the relationship between experiences of teasing and more global psychological well-being. Participants (N=377) with social anxiety disorder (SAD), obsessive compulsive disorder (OCD), or panic disorder with or without agoraphobia (PD) were compared on levels of self-reported teasing history using the Teasing Questionnaire-Revised (TQ-R; Storch et al., 2004). Teasing frequency scores were higher for the SAD group compared to both PD and OCD groups. Across all groups, teasing scores were significantly related to increased social anxiety, depression, stress, and greater impairment in functioning. Teasing frequency accounted for unique variance in severity of SAD symptoms even after controlling for concurrent mood, anxiety and stress. These results support and extend previous findings linking childhood teasing to anxiety disorders in adulthood.

title: Anxiety disorders in older adults: looking to DSM5 and beyond...
abstract: Anxiety in late life was for many years the ‘Cinderella’ of psychiatric disorders, often overshadowed by the focus on depression and dementia, and receiving little attention in research and clinical domains. As highlighted by an editorial published in this journal several years ago , the scientific study of anxiety in older age has a relatively brief history. Recently, however, there has been increased recognition of the prevalence and clinical consequences of anxiety disorders in older adults and lively debate about their nature and most appropriate diagnostic criteria [2, 3, 4]. The current evidence reveals that anxiety in older adults is more common than depression in community samples [5], often preceding depressive disorders [6]; moreover, co-morbid anxiety and depression has a poorer outcome than either condition alone [7]. Anxiety disorders are even more prevalent in clinical settings , and can have serious consequences for recovery from illness  and quality of life [10], as well as substantially increasing disability levels [11]. Therefore, anxiety disorders in older adults should be regarded as conditions of great public health importance.

title: Anxiety disorders: new developments in old age.
abstract: We are pleased to provide a guest editorial to this 5th special issue on geriatric anxiety in the American Journal of Geriatric Psychiatry (previous issues: January 2005, August 2007, October 2008, June 2009). Until about 10 years ago, geriatric anxiety disorders largely escaped clinicians' and researchers' attention for a variety of reasons that were specified in the first AJGP special issue in anxiety disorders 1 ; namely, anxiety disorders do not commonly present in geriatric psychiatry settings unless comorbid with depression or dementia, the disorders are difficult to detect and diagnose in this age group, many anxiety disorders (such as social phobia) typically present early in life, and many if not most anxious elders are reluctant to participate in treatment. Despite these obstacles to detection, diagnosis, and treatment, significant progress has been made in understanding the course, prognosis, and treatment of anxiety disorders in elderly. It is reasonable to ask now: what do we know, and what do we still need to know?

title: Introduction to the special section on incremental validity and utility in clinical assessment.
abstract: This special section focuses on the incremental validity and utility of clinical assessment data. The lack of replicated incremental validity research limits the ability of psychologists to establish their assessment practices on a solid empirical footing. The articles in this section deal with conceptual, methodological, and content issues in the development and use of clinical measures. The authors addressed several aspects of incremental validity research, including (a) the evaluation of the magnitude of validity increments, (b) the use of incremental validity data for test development and validation, (c) the costs of assessment, (d) the use of multi-informant and multimethod assessments, and (e) the treatment utility of assessment. Obstacles limiting the use of incremental validity research to inform and guide clinical practice are also emphasized.

title: Assessment in Geriatric Settings
abstract: This chapter addresses the clinical assessment of older adults. Its principal goal is to acquaint the reader with assessment issues that are relatively unique to older adults, with particular attention to factors that could influence the process or outcome of clinical assessment. We begin with the discussions of two intra- and interpersonal variables, bias in the form of ageism and cultural competence. Ignorance of the importance and influence of these variables can lead to the corruption, contamination, and invalidation of the entire assessment enterprise. We then consider biological and medical issues that are more common among older adults that can play a significant role in the interplay between biological and environmental factors. Next we shift to two conceptual issues, beginning with the assessment paradigms within which the clinician performs the assessment. We then address diagnostic issues and question the prudence of utilizing traditional diagnostic taxonomies with older adults. The complexities of carrying out clinical assessments are then addressed through discussions of multiple method and multidimensional assessment. We follow this with a discussion of psychometric considerations for developing or selecting assessment instruments suitable for older adults. We end the chapter with a conclusion and brief discussion of future directions in the assessment of older adults. 
 
 
 
 
aging; 
clinical gerontology; 
clinical geropsychology; 
geriatrics; 
gerontological assessment; 
geropsychological assessment