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Psychometric meta-analysis of the English version of the Beck Anxiety Inventory.

The Beck Anxiety Inventory (BAI; Beck & Steer, 1993) is one of the most popular screening and outcome research instruments for measuring the construct of anxiety. Although most appropriate for use with psychiatric outpatients 17 years and older, it has been used in research studies with both clinical and nonclinical samples. Among counselors, the BAI is reported to be the ninth most commonly used instrument (C. H. Peterson, Lomas, Neukrug, & Bonner, 2014). Similarly, Neukrug, Peterson, Bonner, and Lomas (2013) reported that the BAI was the ninth most commonly taught instrument by counselor educators. The BAI is a popular screening and evaluation tool in clinical practice and is commonly used in anxiety treatment research as an outcome measure; thus, it is important for counselors to understand the psychometric characteristics that have accumulated over the past 2 decades related to this commonly used instrument.

The BAI consists of 21 self-report items designed to measure the occurrence and severity of symptoms of anxiety disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994). It was designed specifically to differentiate between anxiety and depression, although it should not be used alone for diagnostic purposes. As a copyrighted measure, it is available for purchase and is distributed by Pearson Assessments in both English and Spanish. The BAI takes about 5-10 minutes to administer (oral administration is about 10 minutes) and less than 5 minutes to score and interpret. The BAI total raw score is obtained by a simple sum of the 21 item scores, with respondents indicating how much they have been bothered by each symptom during the past week on a 4-point Likert-type scale, with 0 meaning not at all, 1 meaning mildly (i.e., "It did not bother me much"), 2 meaning moderately (i.e., "It was very unpleasant, but I could stand it"), and 3 meaning severely (i.e., "I could barely stand it"). Score interpretation guidelines for the BAI indicate that scores of 0-7 denote minimal anxiety, 8-15 mild anxiety, 16-25 moderate anxiety, and 26-63 severe anxiety.

Beck, Epstein, Brown, and Steer (1988) explained that the final 21 BAI items were developed from a pool of 86 items from three preexisting anxiety rating scales developed by Beck. Beck and Steer (1993) reported use of clinical and nonclinical standardization samples. The clinical sample was composed of 393 outpatients (236 women, 157 men) with a mean age of 37 years. Beck and Steer (1993) reported an alpha of .93 for this outpatient sample. The suggested cutoff score in the manual for clinically significant anxiety is 16. No norm-referenced interpretive data are available, although Beck and Steer (1993) did report means and standard deviations for three small nonclinical samples composing the nonclinical standardization sample: 65 university students (75% women; mean age of 19 years; M= 11.08, SD = 9.10), 142 medical students (51% women; M= 8.89, SD = 7.30), and 36 adults who were not students (78% women; mean age of 29 years; M = 7.78, SD = 5.65).

Beck and Steer's (1993) final validation sample was 160 participants with anxiety and depressive disorders. The coefficient alpha for the total scale for this sample was .92, and a 1-week test-retest study of scores from 83 of these participants resulted in an [r.sub.tt] of .75. Principal factor analysis with promax rotation on the 160 participant protocols specified two factors: Factor I--Somatic Symptoms, composed of physical symptoms such as numbness and difficulty breathing (i.e., Items 1, 2, 3, 6, 7, 8, 12, 13, 17, 19, 20, and 21), and Factor II-Subjective Affective and Panic Symptoms, composed of psychological symptoms such as feeling unable to relax and nervous (i.e., Items 4, 5, 9, 10, 11, 14, 15, 16, and 18). These two factors correlated at r = .56. The BAI displayed discrimination between participants with and without anxiety and correlated moderately with the Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1959; r = .51, n = 151) while at the same time yielding a low relationship with the Hamilton Rating Scale for Depression (Hamilton, 1960; r = .25, n = 154), although the correlation between the BAI and Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) in that same study was r = .48.

Since the BAI was originally released in 1987 and most recently revised and reissued in 1993, numerous studies have been published reporting psychometric data on the BAI. The purpose of this meta-analysis was to review all available published and dissertation studies of the BAI's internal consistency, test-retest reliability, external (convergent) validity with other anxiety instruments, internal validity (i.e., exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]), diagnostic validity (i.e., sensitivity, specificity, positive predictive power [PPP], negative predictive power [NPP], percentage of correct classification, and area under the curve [AUC] estimates), and average responses (by nonclinical samples) since 1993. This summary of psychometric evidence will highlight how the BAI performs under normal circumstances across cumulative studies and explore implications of interpretations using the BAI. No study to date has attempted an omnibus psychometric analysis of this type on the BAI, although Erford, Johnson, and Bardoshi (2016) used a similar methodology for the BDI-II (Beck, Steer, & Brown, 1996). However, De Ayala, Vonderharr-Carlson, and Kim (2005) did conduct a reliability generalization study in which they located 43 studies of the BAI's internal consistency and 12 studies of the BAI's test-retest reliability published before 2003. Results indicated an overall mean alpha of .91 and an overall [r.sub.tt] of .66. These articles actually compose a small subset of the studies selected into the current meta-analysis.

The following research questions formed the foundation of this meta-analysis: (a) What are the internal consistency and test-retest reliability of BAI scores for both clinical and nonclinical participants? (b) How substantially do BAI scores correlate with other measures of anxiety? (c) Which factor structure of BAI scores seems most parsimonious, and what is the veracity of that structure when subjected to CFA? (d) What BAI cutoff score or scores yield optimal decision accuracy estimates across clinical trials? and (e) Is there a gender difference in nonclinical participant results with implications for over- or underdiagnosis of men and women with anxiety disorders?

* Method

Journal articles, dissertations, and other electronically available sources were included in this meta-analysis if they met the following criteria: (a) published between 1993 and 2013, (b) used the English version of the BAI (Beck & Steer, 1993), and (c) provided some type of reliability or validity data. A review of the extant literature revealed numerous translated versions of the BAI, including Arabic, Brazilian, Chinese (Mandarin), Croatian, Czech, Danish, Dutch, Farsi, Finnish, French, German, Hebrew, Hindi (India), Icelandic, Italian, Japanese, Korean, Nepalese, Norwegian, Polish, Serbian, Spanish, Swedish, Turkish, and Xhosa (South Africa). However, because other language versions generally did not conform to best practice translation procedures (American Educational Research American, American Psychological Association, & National Council on Measurement in Education, 1999, Standard 9.7), only studies using the English version of the BAI were selected into the present study. Several additional studies used brief or modified versions of the BAI and were eliminated. Thus, all studies selected for analysis involved the same version of the test in the English language.

Search Strategies

We identified candidate studies using redundant search procedures, including an electronic search, followed by a hand search of the reference lists of selected and synthesis articles. PsycINFO, ERIC, Academic Search Premier, Cochrane Central Register of Controlled Trials, and MEDLINE articles from 1993 to 2013 were searched using the keyword Beck Anxiety Inventory in the text and for English-only versions. We then searched the reference lists of selected articles and synthesis studies to locate additional BAI candidate studies. Next, we inspected the full text of each article and applied the selection criteria. All articles meeting the selection criteria were submitted to analysis.

Psychometric Variables Analyzed and Statistical Methods Used

Six primary variables were of interest in this psychometric meta-analysis: (a) internal consistency, (b) test-retest reliability, (c) convergent correlations with other anxiety measures, (d) structural validity (i.e., EFA and CFA), (e) diagnostic validity (i.e., sensitivity, specificity, PPP, NPP, percentage of correct classification, and AUC estimates) across various cutoff scores and samples, and (f) descriptive statistics (i.e., means and standard deviations) from nonclinical samples.

All correlations were independent, and only comparable effect-size estimates across studies were combined (Erford, Savin-Murphy, & Butler, 2010). Coefficient alpha was the test statistic in all internal consistency analyses. The effect-size estimate used for test--retest reliability and convergent validity analyses was Pearson's r. We applied sample size weighting procedures to correct for sampling bias. Coefficient alphas and test-retest coefficients were directly weighted by sample size and analyzed. Pearson's rs for the convergent analyses were first transformed into z values ([1/2]log[[sup.(1 + r).sub.(1 - r)]]; Hedges & Olkin, 1985), then weighted by sample size, summed, and averaged. Finally, the grand z was back-transformed to r. We calculated standard errors and 95% confidence intervals (CIs) to assess whether a convergent validity effect size was greater than zero. For example, if a 95% CI for r=. 31 is [+ or -] .10, the range of .21 to .41 is obtained, and the null hypothesis of r = 0 can be rejected because the complete range for r is greater than zero. However, if r = .05 with a 95% CI of [+ or -]. 10, the range produced would be -.05 to .15. With a portion of the 95% CI range less than zero, the null hypothesis of no difference is retained.

* Results

Of the candidate articles, 1,546 were identified through computerized searches and nine more via hand searches, for a total of 1,555 candidate articles. Full text review of all candidate articles eliminated 1,363 articles that violated one or more inclusion criteria. Thus, 192 articles were analyzed. Eleven of the 192 selected articles used more than one sample, so the results that follow involve an analysis of k = 203 studies.

Internal Consistency

A total of 117 studies with a combined sample size of 43,932 participants reported coefficient alpha results. After weighting and averaging all studies, we found an alpha of .91 (95% CI [0.90, 0.92]). Alphas for the studies ranged from .81 to .95. In clinical samples (k = 61, n = 18,015), the alpha was .91 (95% CI [0.90, 0.92]), with study alphas ranging from .83 (Andersson, 1999) to .95 (Broffman, 2002; Resnick et al., 2007). In nonclinical samples (k = 56, n = 25,917), the alpha was .91 (95% CI [0.90,0.92]), with study alphas ranging from .81 (Wetherell & Gatz, 2005) to .95 (Novy, Stanley, Averill, & Daza, 2001).

Test-Retest Reliability

A total of 18 studies (n = 2,800) were weighted and then combined to yield a test-retest reliability coefficient of .65 (95% CI [0.61, 0.69]; mean and median time lapse of 6 weeks). The average test-retest reliability coefficient for the clinical samples (k= 8, n = 699) was .66 (95% CI [0.58, 0.74]; De Beurs, Wilson, Chambless, Goldstein, & Feske, 1997; Fydrich, Dowdall, & Chambless, 1993; Heimlich, 1999; Lindsay & Lees, 2003; Mantere et al., 2010; Osman et al., 2002; Straits-Troster et al., 2000; Swan, Watson, & Nathan, 2009), whereas the nonclinical samples (k = 10, n = 2,101) yielded an average test-retest reliability coefficient of .65 (95% CI [0.61, 0.69]; Alford & Gerrity, 2003; Alford, Lester, Patel, Buchanan, & Giunta, 1995; Blalock & Joiner, 2000; Brock, Barry, & Lawrence, 2012; Cox, Taylor, Clara, Roberts, & Enns, 2008; Creamer, Foran, & Bell, 1995; Cukrowicz, 2008; Cukrowicz & Joiner, 2007; Kohn, Kantor, DeCicco, & Beck, 2008; K. D. Vohs et al., 2001).

External (Convergent) Validity

Pearson's rs were calculated and combined to represent external (convergent) validity between the BAI and 33 other discrete anxiety and related inventories. These comparisons yielded robust convergent rs ranging from .24 (Structured Clinical Interview for the DSM-IV [SCID] Social Phobia subscale; Watson et al., 2008) to .81 (Depression Anxiety Stress Scales [DASS] Anxiety subscale; Lovibond & Lovibond, 1995; k = 4, n = 1,212). These results are reported in Table 1. The majority of these instruments appeared in only one or several studies, but two anxiety instruments warrant special mention because each provided a dozen convergent comparisons. The clinician-report HAM-A was compared with the BAI in 12 studies (combined n = 2,104), resulting in a weighted average r of .57 (95% CI [0.53, 0.61]). A self-report instrument, the State-Trait Anxiety Inventory (STAI; Spielberger, Gorssuch, Lushene, Vagg, & Jacobs, 1983), was compared with the BAI in 12 studies, resulting in a combined r of .53 (95% CI [0.49, 0.57], n = 2,483) for the State subscale and a combined r of .56 (95% CI [0.53, 0.59], n = 3,884) for the Trait subscale. The BDI-II was administered concurrently with the BAI at least 109 times since the BDI-II was revised and published in 1996, resulting in an average r of .59 (95% CI [0.58, 0.60], n = 28,533). It is interesting that only two comparisons yielded average correlations that were not greater than zero--that is, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989; r = .16, 95% CI [-0.11, 0.35], k = 1, n = 75) and the Clinical Global Impression Scale (CGI) Obsessive-Compulsive Disorder (OCD) subscale (Guy, 1976; r = .12, 95% CI [-0.07, 0.39], k = 1, n = 75)--and both were measures of OCD (Williams, Wetterneck, Thibodeau, & Duque, 2013). In the DSM-5 (American Psychiatric Association, 2013), OCD was moved out of the section on anxiety disorders and into a new section called Obsessive-Compulsive and Related Disorders. These results substantiate that decision. Using a random-effects model, we noted homogeneity in effect-size distributions in all comparisons through computations of both Cochran's Q statistic and [I.sup.2] (less than the 50% criterion). Thus, exploration of moderator and mediator variables was unnecessary.

Structural Validity

EFA. We located 18 studies (see Table 2) that provided EFAs of the BAI. The EFAs suggested that between one and six factors underlie the 21 items. However, four of these studies were judged to be underpowered because each did not meet the minimum 10:1 participants-to-items ratio (Tabachnick & Fidell, 2013) for establishing stable factor solutions. Eleven of the EFAs supported two-factor solutions, which accounted for between 43% and 90% of the item variance. Nine of these studies yielded two dimensions that were highly similar to the original Beck et al. (1988) EFA: Somatic and Subjective. Two other EFA studies (Creamer et al., 1995; Hewitt & Norton, 1993) yielded a two-factor solution identifying two slightly different dimensions: Somatic and Cognitive.

Of the remaining EFAs, four studies (Beck & Steer, 1991; Durham, 2010; Osman, Barrios, Aukes, Osman, & Markway, 1993; Osman et al., 2002) proposed that four dimensions underlie the BAI data: Subjective, Neurophysiological, Autonomic, and Panic. Lindsay and Skene (2007) proposed a five-factor solution (i.e., Somatic/Balance, Subjective, Somatic/Hot, Physical/Choking, and Physical/Panic), and Morin et al. (1999) proposed a six-factor solution (i.e., Somatic, Fear, Autonomic Hyperactivity, Panic, Nervousness, and Motor Tension).

CFA. We located eight studies that applied CFA to test various models of the BAI. In all, 34 tests of 12 different BAI models reported and summarized the available output statistics (see Table 3). Three of the eight studies (17 of the 34 analyses) used samples that were underpowered. The unidimensional model was tested in five samples across five articles, and two of these samples were underpowered (Enns, Cox, Parker, & Guertin, 1998; Wetherell & Arean, 1997). Comparative fit index (CFI) estimates across these five studies ranged from .66 to .89 (Mdn = .79). Adequate-fitting models have CFIs greater than .90, with .95 indicating an excellent fit (Dimitrov, 2012); thus, none of the samples' data fit the unidimensional model well.

All seven articles and the one dissertation included tested the Beck et al. (1988) two-factor model of Somatic and Subjective dimensions. The CFIs ranged from .69 to .90 (Mdn = .88), and the root mean square of approximations (RMSEAs) ranged from .04 to .14 (Mdn = .12), thus indicating a poor fit of the data to the model in nearly every case. RMSEAs less than .06 indicate an adequate fit of the model to the data (Dimitrov, 2012). The Hewitt and Norton (1993) two-factor model (i.e., Somatic and Cognitive) was tested in three CFA studies, with CFIs ranging from .73 to .97 (Mdn = .92) and RMSEAs ranging from .06 to .09 (Mdn = .07), thus indicating a marginal-to-adequate fit of the data to the model. However, all three of these studies were underpowered, so the results should be viewed with caution.

Two studies across an article and a dissertation tested two-factor models. The CFA study in the article specified Cognitive, Somatic, and Panic dimensions, whereas the study conducted with the dissertation sample tested a model derived from an EFA solution. Reported CFIs ranged from .87 to .88, which indicated a poor fit of the data to a three-factor model in both cases.

Ten studies across six articles and one dissertation tested four-factor models. The most frequently tested four-factor model consisted of the Subjective, Neurophysiological, Autonomic, and Panic dimensions proposed by Beck and Steer (1991) and Osman et al. (1993), and was tested across six CFA studies. Reported CFIs ranged from .83 to .93, and RMSEAs ranged from .03 to .12. Thus, the results indicated a marginal-to-poor fit of the data to the four-factor model in most studies. In a study of 350 undergraduates, Osman, Kopper, Barrios, Osman, and Wade (1997) derived a CFI of .93 and an RMSEA of .03, which indicated an excellent-fitting model. The other four-factor model, tested across three CFA studies in two articles, included the Cognitive, Autonomic, Neuromotor, and Panic dimensions proposed by Steer, Beck, Brown, and Beck (1993). Reported CFIs ranged from .86 to .88, thus indicating a poor fit of the data to the four-factor model.

Two CFA studies across one article and one dissertation tested a five-factor model proposed by Borden, Peterson, and Jackson (1991) with the following dimensions: Subjective, Somatic, Neurophysiological, Muscular, and Respiratory. The reported CFI of .93 for one study and the RMSEA of .08 for the other indicated a marginal-to-good fit of the data to the five-factor model. Two studies across two articles tested a six-factor model consisting of Somatic, Fear, Autonomic Hyperactivity, Panic, Nervousness, and Motor Tension dimensions proposed by Morin et al. (1999). The CFIs ranged from .92 to .97 and the RMSEAs ranged from .07 to .09, thus indicating a marginal-to-adequate fit of the data to the Morin et al. six-factor model.

It should be noted that most of the analyses reported did not use nested models; therefore, we were not able to make direct comparisons across the two-, three-, four-, five-, and six-factor solutions to determine whether one model fits better than another. Also, all solutions are data dependent, so variations will normally occur in which models fit best.

Only one of the 18 EFA studies, composed of a sample of 303 patients with sleep apnea (Sanford, Bush, Stone, Lichstein, & Aguillard, 2008), revealed a single-dimension solution, but another EFA (Steer, 2009) and three CFA studies (Osman et al., 1997; D. R. Peterson, 1995; Wetherell & Arean, 1997) proposed that a second-order factor (i.e., Anxiety) underlies the 21 BAI items, accounts for the majority of shared variance, and fits the data as well as or better than any other model. In summary, the results of the 18 EFA and eight CFA studies indicated an emerging consensus in which 2 first-order dimensions (i.e., Somatic and Subjective) underlie the 21 BAI items, although the data did not adequately fit this model. However, it is more likely that a second-order factor (i.e., Anxiety) represents the data and scale structure in a more meaningful way. In addition, future large-sample studies of the BAI should use CFA (not EFA) procedures to confirm whether the second-order factor model is superior to either of the current two-factor or four-factor models.

Diagnostic Validity

The BAI is a criterion-referenced (not norm-referenced) instrument. We identified 11 studies that reported diagnostic validity (i.e., decision reliability) results, which are summarized in Table 4. Given the sample variability across the studies, cutoff scores were at times reported on the basis of what the study authors considered optimal for the sample, whereas other study authors included multiple cutoff scores to facilitate clinical utility given specific parameters. Practitioners may have different preferences when determining diagnostic validity, with some being interested in percentage of correct classification, whereas others are concerned with instrument sensitivity. When studies reported multiple cutoff scores, we selected the scores that appeared most frequently to facilitate readers' comparisons across studies.

Several factors, including sample characteristics (e.g., sample size, clinical vs. nonclinical participants) and types of conditions (e.g., insomnia, anxiety, suicidal ideation), make interpretation of optimal cutoff scores difficult. Sensitivity measures the proportion of participants with significant anxiety correctly identified by the BAI. Specificity measures the proportion of participants without anxiety not identified by the BAI. Although lower cutoff scores result in higher sensitivity and lower specificity, some authors also take into account AUC and receiver-operating characteristic curve statistics to establish optimal cutoff scores. Others, however, may rely on the lowest difference between sensitivity and specificity, while also taking into account the lowest difference between PPP and NPP. As shown in Table 4, the percentage of correct classification or AUC estimate was reported in only eight out of the 11 studies that examined the diagnostic validity of the BAI. Only one study reported both, three studies reported only AUC data, and four studies reported only percentage of correct classification results.

When considering the available literature on the diagnostic validity of the BAI, one should note that five of the 11 located studies reported results based on only what those authors determined to be optimal cutoff scores. Across the 11 diagnostic validity studies, optimal cutoff scores (reported or judged) ranged from 7 to 26, with a median cutoff value of 14. Four of the studies chose 16 as the optimal cutoff value, whereas two studies each chose 7, 10, or 14 as the cutoff score for optimal identification.

Nonclinical Sample Distribution Characteristics

Finally, we identified many nonclinical samples from the extant literature that reported sample statistics (i.e., means and standard deviations), with some studies even breaking these statistics down by gender. Ten samples reported means and standard deviations disaggregated by gender, and when weighted and combined, they yielded a combined male sample size of 2,184, with a mean of 8.10 and a standard deviation of 7.96. The combined female sample size was 3,665, with a mean of 11.09 and a standard deviation of 9.13. Thus, females self-reported significantly higher (+2.99) BAI raw scores than did males. Overall, 59 studies across 53 articles reported total sample statistics for nonclinical participants. When these samples were combined and weighted 20,603 participants composed the grand nonclinical sample, yielding a grand mean of 9.89 and a standard deviation of 8.76. Note that, with regard to gender, this combined nonclinical sample was primarily female.

* Discussion

Summary and Implications for Counseling Practice

Although numerous studies have undertaken the examination of the psychometric properties of the BAI, our meta-analysis of 192 articles is the first comprehensive study to date to provide combinatorial analysis and description of the psychometric characteristics of this instrument. These results provide strong estimates of internal consistency across both clinical ([alpha] = .91, k = 61, n = 18,015) and nonclinical ([alpha] = .91, k = 56, n = 25,917) samples. These results are slightly lower than the coefficient alpha reported by Beck and Steer (1993) for their clinical sample (.93), but similar to the results reported by De Ayala et al. (2005) in their reliability generalization study, which determined an internal consistency (coefficient alpha) estimate across 43 articles of .91. These internal consistency estimates exceed the recommended minimum criteria for both screening level and diagnostic evaluation purposes--suggested by Erford (2013) as [alpha] = .80 and [alpha] = .90, respectively--and give counselors confidence that client scores can be consistently derived.

Conversely, the test-retest reliability estimates for the current meta-analysis were .66 (k = 8, n = 699, Mdn = 6 weeks) for the clinical samples and .65 (k= 10, n = 2,101, Mdn = 6 weeks) for the nonclinical samples. These results are substantially lower than the 1-week test-retest reliability coefficient of .75 reported by Beck and Steer (1993) in their clinical sample. However, our results do align with estimates reported by De Ayala et al. (2005), who provided test-retest reliability estimates by analyzing results across 12 articles, with an overall [r.sub.u] of .66 and a median of 28 days. It should be noted that although the instability of a construct such as anxiety over a 6-week time frame is not atypical, practitioners and researchers who are readministering the BAI beyond a 1-week interval should exercise caution when interpreting results.

This meta-analysis also explored external and structural elements of the validity of BAI scores. The convergent validity coefficients presented in Table 1 yielded robust estimates across all 33 discrete anxiety and related measures identified in the extant literature. According to Lipsey and Wilson (2001), Pearson rs of .10 denote a small effect size, .30 a moderate effect size, and .50 a large effect size. Thus, the majority of convergent instruments displayed large effect sizes. Two instruments provided a dozen comparisons each: the HAM-A (clinician report) and the STAI (self-report). The highest correlations with the BAI were seen with other self-report instruments (e.g., DASS Anxiety subscale, Brief Symptom Inventory Anxiety subscale [Derogatis, 1993]). Common method variance can typically lead to higher correlations between two anxiety self-rating inventories than can score comparisons between inventories with unlike methods (e.g., self-report vs. clinician administered; Erford, 2013). The exception to this tendency was a very strong correlation between the BAI and the clinician-report HAM-A scores reported across 12 studies, with an average r of .57. Only four convergent comparisons revealed correlations with a small effect size--the CGI OCD subscale (r = .12), the Y-BOCS (r = .16), the SCID OCD subscale (r = .24), and the SCID Social Phobia subscale (r = .24). Given that the first three of these four BAI score comparisons involved measures of OCD, our results seem to support the recent DSM-5 (American Psychiatric Association, 2013) decision to remove OCD from the Anxiety Disorders section.

Counseling practitioners should recall that Beck and Steer (1993) designated 16 as the optimal cutoff score for clinical purposes. Yet how accurate would a BAI score of 16 be in clinical and research settings? Four BAI diagnostic validity studies reported data for a cutoff score of 16, and when the studies were combined, the results indicated a mean sensitivity of .62, a mean specificity of .69, a mean PPP of .52, and a mean NPP of .85, which resulted in an estimated percentage of correct classification of approximately 65%. Therefore, in terms of diagnostic validity (see Table 4), it appears that a cutoff score of about 15-16 should lead to an optimal correct identification of clinical and nonclinical participants in diverse samples. However, practitioners and researchers should base such decisions on the relative importance of sensitivity and specificity.

In addition to the original study by Beck et al. (1988) that provided EFA results for the BAI, 18 studies were located that conducted EFAs. It should be noted that a diverse combination of methodologies and samples (e.g., clinical, nonclinical) also led to the varying outcomes summarized in Table 2. The majority of these studies (i.e., 11 of the 18 EFAs) supported two-factor solutions, with nine studies deriving two dimensions that were largely similar to the two dimensions reported by the original Beck et al. (1988) study: Somatic and Subjective. Another two-factor solution, consisting of Somatic and Cognitive dimensions, was reported by two EFA studies. Four EFA studies proposed a four-factor model (i.e., Subjective, Neurophysiological, Autonomic, and Panic), one study proposed a five-factor model (i.e., Somatic/Balance, Subjective, Somatic/ Hot, Physical/Choking, and Physical/Panic), and one study proposed a six-factor model (i.e., Somatic, Fear, Autonomic Hyperactivity, Panic, Nervousness, and Motor Tension). Taken as a whole, these studies suggest that up to six factors could underlie the 21 BAI items. However, given that four of the 18 studies were underpowered, and that most studies used multiple methodologies and sample characteristics, CFA procedures testing the fit of the two-dimensional Somatic and Subjective model proposed by Beck and Steer (1993) may have made a greater impact on the BAI validity literature.

Appropriately, of the eight CFA publications located, all tested the Beck and Steer (1993) two-factor model of Somatic and Subjective dimensions. Data from these studies did not support an adequate fit of the data to the model (see Table 3). The other two-factor model proposed by Hewitt and Norton (1993) consisting of Somatic and Cognitive dimensions indicated a marginal-to-adequate fit, but caution should be applied when interpreting these results given that both samples from the Chapman et al. (2009) study were underpowered. The other most frequently tested model consisted of four factors (i.e., Subjective, Neurophysiological, Autonomic, and Panic) proposed by Beck and Steer (1991) and Osman et al. (1993) and was tested across six CFAs, with results generally indicating a poor fit of the data except in one study. Of the remaining studies, two CFAs tested three-factor models, three CFAs tested a different four-factor model, two CFAs tested a five-factor model, and two CFAs tested a six-factor model, with results generally not supporting a good fit of the model to the data. In addition, one EFA and three CFA studies proposed a second-order factor (i.e., Anxiety) as underlying the BAI items.

Although the underlying dimensions of the BAI are a commonly debated topic in the literature, few CFA studies have added valuable insights by starting with testing the two-dimensional model provided in the original Beck et al. (1988) study, then adding new models by using nested procedures to facilitate direct comparisons. It appears from the located studies that 2 first-order dimensions, consisting of Somatic and Subjective factors, may underlie the 21 BAI items, although a second-order factor (i.e., Anxiety) may also prove meaningful when examining the BAI scale structure. Future studies should address the adequacy of the second-order factorial solution through CFA procedures to provide meaningful comparisons with the two-factor and four-factor first-order solutions most commonly identified in the literature. Although dimensionality of the BAI is an interesting psychometric question, the fact is that only the total score is interpreted and applied to clinical decision making.

A question of significant importance to practitioners that frequently arises when assessing the psychometric properties of the BAI is whether there are significant gender differences between male and female respondents with respect to anxiety. Because the BAI is a criterion-referenced instrument with score interpretation guidelines of 0-7 (minimal), 8-15 (mild), 16-25 (moderate), and 26-63 (severe), and a suggested cutoff score of 16 for clinical relevance, significant gender differences of only a few points could lead to actual overidentification of females or underidentification of males with anxiety. Indeed, the results of this meta-analysis with nonclinical samples suggested that statistically significant gender differences are likely to be around 3 raw score points. Combining the sample means and standard deviations across the 10 studies reporting disaggregated male and female data from nonclinical samples, we found that the BAI raw score difference was 2.99 (for females, M = 11.09, SD = 9.13, n = 3,665; for males, M = 8.10, SD = 7.96, n = 2,184), which has potential clinical implications. Although our results make apparent that gender differences do exist, in nonclinical samples, these differences would probably translate to only a slight overidentification of anxiety in females and an underidentification of anxiety in males. Because females may generally endorse higher levels of anxiety on the BAI, counselors and researchers using the instrument for screening purposes should take gender into consideration and interpret results thoughtfully. It is interesting that using one standard deviation as the cutoff score for males means a raw score of 16 (8.10 + 7.96 = 16.06), whereas the same cutoff score for females rises to 20 (11.09 + 9.13 = 20.22).

Implications for Counseling Research

Future research regarding gender differences may be warranted to determine the potential clinical significance of the BAI's overidentification of anxiety in females and underidentification of anxiety in males. Cultural considerations are especially important when considering the diagnostic validity of a widely used instrument such as the BAI that lacks normative data. Research about the use of the BAI with varying racial and ethnic groups would be valuable, especially because diagnostic validity studies tend to be sample dependent and the infusion of diversity in samples could lead to differing results.

Given that the BAI is an already-established instrument, future studies examining the structural validity of this instrument should use CFA procedures to test existing models, explore the presence of a second-order factor (e.g., Anxiety), and use nested analyses to facilitate comparison. In addition, researchers using translated versions of the BAI may benefit from cross-referencing their results to those of this meta-analysis to determine the psychometric equivalence of their version. There is great potential for the BAI to be of utility to international counselors and researchers, and additional research on the factorial structure of the BAI across cultures and languages would cement the use of the BAI as a solid tool for measuring the construct of anxiety.

With the increased use of the BAI with adolescent populations, future convergent validity studies could be enhanced by also including parent and teacher versions of other anxiety scales to reduce overreliance on adolescent self-report. Given that only a few studies were identified that examined BAI convergent validity with an instrument that was not self-report, we recommend that assessment best practices with children and adolescents be taken into consideration in future study designs by triangulating self-report with parent and teacher estimates. Finally, including a validity or response bias scale on the BAI would be an important future step in addressing self-report bias and social desirability.

Study Limitations

Meta-analysis is used to improve the power of conclusions made across multiple studies. However, meta-analysis is not without limitations. In the current meta-analysis, conservative and rigorous methodological procedures were used. An exhaustive electronic search of the literature was undertaken, followed by a hand search of reference lists of selected and synthesis articles. Criteria were established for inclusion that required articles to have been published during the 20-year time period of 1993-2013 and to have used the English version of the BAI. Although we identified several studies that were conducted using a translated version of the BAI, we opted to not include those studies in our analysis because of potential language variations and potential implications in introducing error. All articles included had to provide some type of reliability or validity data. In the analysis of results, internal consistency, test-retest reliability, convergent correlations with other anxiety measures, structural validity, diagnostic validity, and descriptive statistics were assessed.

Even with these stringent protocols, study limitations exist. For example, some of the comparisons may have been affected by the small number of studies available for comparison, such as the test-retest reliability in which only 18 studies were available for comparison. The same may have been true concerning the results related to structural validity for which lower numbers of comparisons were available. In general, sufficient power is available when undertaking a meta-analysis when 20 or more similar studies are simultaneously analyzed (Cornwell & Ladd, 1993).

* Conclusion

Our meta-analysis showed strong estimates of internal consistency across clinical and nonclinical samples, thus indicating that the BAI is an appropriate screening tool. The BAI's low cost makes it a popular instrument in clinical practice for measuring the occurrence and severity of symptoms of anxiety. The ease of administration and interpretation add to its utility as an instrument for practitioners wishing to differentiate between anxiety and depression. Furthermore, its low cost and ease of administration and interpretation add value to its use in counselor preparation programs (Neukrug et al., 2013; C. H. Peterson et al., 2014).

Received 12/26/14

Revised 02/22/15

Accepted 03/02/15

DOI: 10.1002/jcad.12090

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Gerta Bardhoshi and Kelly Duncan, Division of Counseling and Psychology, University of South Dakota; Bradley T. Erford, Department of Education Specialties, Loyola University Maryland. Gerta Bardhoshi is now at Department of Rehabilitation and Counselor Education, University of Iowa. Kelly Duncan is now at School of Education, Northern State University. Correspondence concerning this article should be addressed to Bradley T. Erford, Department of Education Specialties, Loyola University Maryland, Timonium Graduate Center, 2034 Greenspring Drive, Timonium, MD 21093 (e-mail: berford@loyola.edu).
TABLE 1
Convergent Validity Studies With the Beck Anxiety Inventory

Instrument                           k       n      r        95% CI

Anxiety Control Questionnaire         1      364   .35    [0.25, 0.45]
Anxiety Sensitivity Index--3          4      917   .60    [0.53, 0.67]
Anxious Self-Statements               1      135   .70    [0.53, 0.87]
  Questionnaire
Beck Depression Inventory--II       109   28,533   .59    [0.58, 0.60]
Brief Symptom Inventory               3      976   .73    [0.67, 0.79]
Brief Symptom Inventory--Anxiety      4    1,127   .74    [0.68, 0.80]
Brief Symptom Inventory--Phobic       2      695   .55    [0.47, 0.63]
  Anxiety
Brief Symptom Questionnaire           1       87   .68    [0.47, 0.89]
Clinical Global Impression Scale      1       75   .12    [-0.11, 0.35]
  (OCD subscale only)
Depression Anxiety Stress Scales      4    1,212   .81    [0.75, 0.87]
  (Anxiety subscale)
Elkins Distress Inventory             1      113   .63    [0.44, 0.82]
  (Anxiety subscale)
Experiences in Close                  1      176   .44    [0.29, 0.59]
  Relationships--Anxious
  Attachment
Generalized Anxiety Disorder          1       66   .38    [0.13, 0.63]
  Questionnaire for DSM-IV
Generalized Anxiety Disorder          1       66   .54    [0.29, 0.79]
  Severity Scale
Geriatric Anxiety Inventory           2      183   .46    [0.31, 0.61]
Geriatric Anxiety Scale               1      117   .61    [0.43, 0.79]
Glasgow Anxiety                       1       19   .72    [0.26, 1.00]
  Scale--Intellectual Disability
Geriatric Worry Scale                 1       66   .50    [0.25, 0.75]
Hamilton Anxiety Rating Scale        12    2,104   .57    [0.53, 0.61]
Liebowictz Social Anxiety             4      492   .42    [0.33, 0.51]
  Scale--Self-Report
Millon Clinical Multiaxial            1      186   .72    [0.57, 0.87]
  Inventory--Anxiety
Minnesota Multiphasic Personality     1      240   .56    [0.43, 0.69]
  Inventory--Adolescent Anxiety
Multidimensional Anxiety Scale        1       43   .34    [0.04, 0.64]
  for Children
Older Adult Social-Evaluative         1      133   .44    [0.27, 0.61]
  Situations Questionnaire
Perceived Stress Scale                1       84   .40    [0.18, 0.62]
Penn State Worry Questionnaire        4      260   .35    [0.23, 0.47]
Penn State Worry                      1       66   .32    [0.07, 0.57]
  Questionnaire--Abbreviated
Positive and Negative Affect          1      176   .40    [0.25, 0.55]
  Schedule--Negative Affect
Revised Children's Manifest           2      204   .58    [0.47, 0.69]
  Anxiety Scale
Social Interaction Anxiety Scale      1       89   .58    [0.37, 0.79]
Social Phobia and Anxiety             3      801   .41    [0.34, 0.48]
  Inventory-Social Phobia
Social Phobia and Anxiety             2      367   .60    [0.50, 0.70]
  Inventory--Agoraphobia
Social Phobia Scale                   1       89   .61    [0.40, 0.82]
State-Trait Anxiety                  12    2,483   .53    [0.49, 0.57]
  Inventory--State
State--Trait Anxiety                 12    3,884   .56    [0.53, 0.59]
  Inventory--Trait
Structured Clinical Interview for     1      911   .38    [0.31, 0.45]
  the DSM-IV--GAD
Structured Clinical Interview for     1      911   .36    [0.29, 0.43]
  the DSM-IV--PTSD
Structured Clinical Interview for     1      911   .50    [0.43, 0.57]
  the DSM-IV--Panic
Structured Clinical Interview for     1      911   .24    [0.17, 0.31]
  the DSM-IV--Social Phobia
Structured Clinical Interview for     1      911   .24    [0.17, 0.31]
  the DSM-IV--OCD
Worry Scale                           2      185   .78    [0.63, 0.93]
Yale--Brown Obsessive Compulsive      1       75   .16    [-0.07, 0.39]
  Scale
Youth Self-Report                     2       70   .52    [0.28, 0.76]
Zung Self-Rating Anxiety Scale        1       50   .77    [0.49, 1.00]

Instrument                                        Study

Anxiety Control Questionnaire       Ballash et al. (2006)
Anxiety Sensitivity Index--3        Cox et al. (2008); De Coteau et
                                      al. (2003); Hirai et al. (2006);
                                      Novy et al. (2001)
Anxious Self-Statements             Lamberton & Oei (2008)
  Questionnaire
Beck Depression Inventory--II       106 different articles
Brief Symptom Inventory             Morin et al. (1999); Osman et al.
                                      (1993); Steer, Rissmiller, et
                                      al. (1993)
Brief Symptom Inventory--Anxiety    De Beurs et al. (1997); Osman et
                                      al. (1993); Osman et al. (1997);
                                      Steer, Rissmiller, et al. (1993)
Brief Symptom Inventory--Phobic     Osman et al. (1993); Steer,
  Anxiety                             Rissmiller, et al. (1993)
Brief Symptom Questionnaire         Hirai et al. (2006)
Clinical Global Impression Scale    Williams et al. (2013)
  (OCD subscale only)
Depression Anxiety Stress Scales    Carty (2001); Dammeyer (2000);
  (Anxiety subscale)                  Lovibond & Lovibond (1995);
                                      Rector et al. (2011)
Elkins Distress Inventory           Gartner (2012)
  (Anxiety subscale)
Experiences in Close                Brock et al. (2012)
  Relationships--Anxious
  Attachment
Generalized Anxiety Disorder        Diefenbach et al. (2009)
  Questionnaire for DSM-IV
Generalized Anxiety Disorder        Diefenbach et al. (2009)
  Severity Scale
Geriatric Anxiety Inventory         Diefenbach et al. (2009); Yochim
                                      et al. (2011)
Geriatric Anxiety Scale             Yochim et al. (2011)
Glasgow Anxiety                     Mindham & Espie (2003)
  Scale--Intellectual Disability
Geriatric Worry Scale               Diefenbach et al. (2009)
Hamilton Anxiety Rating Scale       Beck & Steer (1991); Beck, Steer,
                                      & Beck (1993); Dennis et al.
                                      (2007); Durham (2010); Jolly et
                                      al. (1993); Jolly et al. (1994);
                                      Martinez-Martin et al. (2013);
                                      Morin et al. (1999); Moustgaard
                                      (2005); Tennyson (2004);
                                      Wetherell & Gatz (2005)
Liebowictz Social Anxiety           Cukrowicz (2008); Gould et al.
  Scale--Self-Report                  (2012); Hedman et al. (2010)
Millon Clinical Multiaxial          Hesse et al. (2012)
  Inventory--Anxiety
Minnesota Multiphasic Personality   Osman et al. (2002)
  Inventory--Adolescent Anxiety
Multidimensional Anxiety Scale      Fulcher et al. (2008)
  for Children
Older Adult Social-Evaluative       Gould et al. (2012)
  Situations Questionnaire
Perceived Stress Scale              Kit et al. (2007)
Penn State Worry Questionnaire      Diefenbach et al. (2009); Hirai et
                                      al. (2006); Wetherell & Gatz
                                      (2005)
Penn State Worry                    Diefenbach et al. (2009)
  Questionnaire--Abbreviated
Positive and Negative Affect        Brock et al. (2012)
  Schedule--Negative Affect
Revised Children's Manifest         Anthony (1998); Weir & Jose (2007)
  Anxiety Scale
Social Interaction Anxiety Scale    Hyde (2003)
Social Phobia and Anxiety           Anhalt & Morris (2008); Gould et
  Inventory-Social Phobia             al. (2012); Neal et al. (2002)
Social Phobia and Anxiety           Gould et al. (2012); Neal et al.
  Inventory--Agoraphobia              (2002)
Social Phobia Scale                 Hyde (2003)
State-Trait Anxiety                 Chapman & Woodruff-Borden (2009);
  Inventory--State                    Creamer et al. (1995);
                                      Flarity-White (1996); Fydrich et
                                      al. (1993); Grunes (1999);
                                      Kabacoff et al. (1997); Khawaja
                                      et al. (1994); Nguyen (1999);
                                      Osman et al. (1997); Stuart et
                                      al. (1998); Williams et al.
                                      (2012)
State--Trait Anxiety                Balsamo et al. (2013); Borden et
  Inventory--Trait                    al. (1991); Chapman &
                                      Woodruff-Borden (2009); Creamer
                                      et al. (1995); Flarity-White
                                      (1996); Fydrich et al. (1993);
                                      Kabacoff et al. (1997); Khawaja
                                      et al. (1994); Nguyen (1999);
                                      Osman et al. (1997); Stuart et
                                      al. (1998)
Structured Clinical Interview for   Watson et al. (2008)
  the DSM-IV--GAD
Structured Clinical Interview for   Watson et al. (2008)
  the DSM-IV--PTSD
Structured Clinical Interview for   Watson et al. (2008)
  the DSM-IV--Panic
Structured Clinical Interview for   Watson et al. (2008)
  the DSM-IV--Social Phobia
Structured Clinical Interview for   Watson et al. (2008)
  the DSM-IV--OCD
Worry Scale                         Hirai et al. (2006); Novy et al.
                                      (2001)
Yale--Brown Obsessive Compulsive    Williams et al. (2013)
  Scale
Youth Self-Report                   Pencer (2005)
Zung Self-Rating Anxiety Scale      Durham (2010)

Note. CI = confidence interval; OCD = obsessive-compulsive disorder;
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th
ed.; American Psychiatric Association, 1994); GAD = generalized
anxiety disorder; PTSD = posttraumatic stress disorder.

TABLE 2
Exploratory Factor Analysis Study Results

Article                                        Sample

Hewitt & Norton (1993)        291 psychiatric patients
Steer, Beck, et al. (1993)    470 outpatients with mixed psychiatric
                                diagnoses
Steer, Rissmiller, et         250 inpatients with mixed psychiatric
  al. (1993)                    diagnoses
Beck & Steer (1991)           367 outpatients with anxiety disorders
Kabacoff et al. (1997)        217 older adults
Steer, Kumar, et al. (1995)   105 outpatients with psychiatric
                                disorders
Lovibond & Lovibond (1995)    717 undergraduates
Morin et al. (1999)           281 older adults
Durham (2010)                 50 undergraduates with hearing
                                impairments
Lindsay & Skene (2007)        108 patients
Contreras et al. (2004)       3,813 undergraduates
Steer (2009)                  525 outpatients with anxiety diagnoses
Osman et al. (1993)           225 community members
Sanford et al. (2008)         303 adults with sleep apnea
Osman et ai. (2002)           240 adolescent inpatients
Creamer et al. (1995)         326 undergraduates
Kumar et al. (1993)           108 adolescent inpatients
D. R. Peterson (1995)         420 clinical adults and undergraduates

Article                               No. of Factors/Items (a)

Hewitt & Norton (1993)        PFA with varimax 2 factors: Somatic,
                                Cognitive (50%)
Steer, Beck, et al. (1993)    PCA with varimax 4 factors: Subjective,
                                Neurophysiological Autonomic, Panic
Steer, Rissmiller, et         PFA with promax: 2 factors: Somatic,
  al. (1993)                    Subjective (90%)
Beck & Steer (1991)           PCA with varimax 4 factors: Subjective,
                                Neurophysiological Autonomic, Panic
Kabacoff et al. (1997)        PAF with promax 2 factors: Somatic,
                                Subjective
Steer, Kumar, et al. (1995)   PFA with promax 2 factors: Somatic,
                                Subjective (82%)
Lovibond & Lovibond (1995)    PFA oblique 2 factors: Somatic,
                                Subjective
Morin et al. (1999)           PAF with varimax 6 factors: Somatic,
                                Fear, Autonomic Hyperactivity, Panic,
                                Nervousness, Motor Tension (65%)
Durham (2010)                 PAF promax 4 factors: I (Subjective):
                                Items 4, 5, 14, 16-18 21; II
                                (Neurophysiological): Items 1, 7, 9,
                                10, 12, 13; III (Panic): Items 2, 6,
                                8, 15, 20; IV (Autonomic):
                                Items 11, 19
Lindsay & Skene (2007)        PCA quartimax 5 factors: Somatic/
                                Balance, Subjective, Somatic/Hot,
                                Physical/Choking, Physical/Panic
Contreras et al. (2004)       PCA promax 2 factors: I (Somatic): Items
                                1-3, 6-8, 11-13, 15, 18-21; II
                                (Subjective): Items 4, 5, 9, 10, 14,
                                16, 17
Steer (2009)                  2nd-order factor (70%); Somatic (37%)
                                and Subjective (6%) were two
                                1st-order factors
Osman et al. (1993)           PCA 4 factors (65%): Subjective,
                                Neurophysiological Autonomic, Panic
Sanford et al. (2008)         PAF with varimax 1 factor
Osman et ai. (2002)           PAF with varimax and promax, then
                                tweaked Kumar et al.'s (1993)
                                4-factor model
Creamer et al. (1995)         PAF with promax 2 factors: Somatic,
                                Cognitive (79%)
Kumar et al. (1993)           PAF with promax 2 factors: Subjective,
                                Somatic (79%)
D. R. Peterson (1995)         PAF with varimax 2 factors: Somatic,
                                Subjective

Note. PFA = principal factor analysis; PCA = principal components
analysis; PAF = principal axis factoring.

(a) Percentage of explained variance is given in parentheses.

TABLE 3
Confirmatory Factor Analysis (CFA) Study Results

Article     Sample         No. of Factors                   CFI   TLI

Osman       225            2-factor (Beck et al., 1988)
  et al.      community    1-factor
  (1993)      members      Borden et al. (1991) 5-factor
                             (Subjective, Somatic,
                             Neurophysiological,
                             Muscular/Motoric,
                             Respiration)
Chapman     120 White      Beck et al. (1988) 2-factor      .90   .91
  et al.      nonclinical    (Somatic, Subjective)
  (2009)      adults       Osman et al. (2002) 4-factor     .92   .94
                             (Neurophysiological,
                             Subjective, Autonomic,
                             Panic)
                           Morin et al. (1999) 6-factor     .97   .98
                             (Somatic, Fear, Autonomic
                             Hyperactivity, Panic,
                             Nervousness, Motor Tension)
                           Current study 2-factor           .97   .98
                             (Somatic, Cognitive)
Chapman     100 African    Beck et al. (1988) 2-factor      .88   .86
  et al.      American       (Somatic, Subjective)
  (2009)      nonclinical  Osman et al. (2002) 4-factor     .89   .91
              adults         (Neurophysiological,
                             Subjective, Autonomic,
                             Panic)
                           Morin et al. (1999) 6-factor     .92   .93
                             (Somatic, Fear, Autonomic
                             Hyperactivity, Panic,
                             Nervousness, Motor Tension)
                           Current study 2-factor           .92   .93
                             (Somatic, Cognitive)
Osman       240            CFA Beck et al. (1988)           .77
  et al.      adolescent     2-factor (Somatic,
  (2002)      inpatients     Subjective)                    .83
                           CFA Kumar et al. (1993)
                             2-factor (Somatic,
                             Subjective)
Enns        137            1-factor                         .66
  et al.      outpatients  Hewitt & Norton (1993)           .73
  (1998)                     2-factor (Somatic,
                             Cognitive)
                           Steer, Beck, et al. (1993)       .69
                             2-factor (Somatic,
                             Subjective)
                           Steer, Kumar, & Beck (1993)      .86
                             4-factor (Cognitive,
                             Autonomic, Neuromotor,
                             Panic)
Wetherell   197 older      1-factor                         .79
  & Arean     adults       2-factor (Beck et al., 1988)     .86
  (1997)                   3-factor (Cognitive, Somatic,    .87
                             Panic)
                           4-factor (Cognitive,             .88
                             Autonomic, Neuromotor,
                             Panic)
                           2nd-order 4-factor               .88
Osman       350            1-factor                         .89
  et al.      under-       Beck et al. (1988) 2-factor      .89
  (1997)      graduates      (Somatic, Subjective)
                           Beck & Steer (1991) and Osman    .93
                             et al. (1993) 4-factor
                             (Subjective,
                             Neurophysiological,
                             Autonomic, and Panic)
                           2nd order 4-factor               .93
D.R.        420 clinical   1-factor                         .79
  Peterson    adults and   Beck et al. (1988) 2-factor      .86
  (1995)      under-         (Somatic, Subjective)
              graduates    EFA-derived 3-factor             .88
                           Beck & Steer (1991) 4-factor     .93
                             (Subjective,
                             Neurophysiological,
                             Autonomic, Panic)
                           Borden et al. (1991) 5-factor    .93
                             (Subjective, Somatic,
                             Neurophysiological,
                             Muscular, Respiratory)
                           2nd-order factor                 .93

Article     Sample         No. of Factors                   NNFI   GFI

Osman       225            2-factor (Beck et al., 1988)            .72
  et al.      community    1-factor                                .56
  (1993)      members      Borden et al. (1991) 5-factor           .81
                             (Subjective, Somatic,
                             Neurophysiological,
                             Muscular/Motoric,
                             Respiration)
Chapman     120 White      Beck et al. (1988) 2-factor
  et al.      nonclinical    (Somatic, Subjective)
  (2009)      adults       Osman et al. (2002) 4-factor
                             (Neurophysiological,
                             Subjective, Autonomic,
                             Panic)
                           Morin et al. (1999) 6-factor
                             (Somatic, Fear, Autonomic
                             Hyperactivity, Panic,
                             Nervousness, Motor Tension)
                           Current study 2-factor
                             (Somatic, Cognitive)
Chapman     100 African    Beck et al. (1988) 2-factor
  et al.      American       (Somatic, Subjective)
  (2009)      nonclinical  Osman et al. (2002) 4-factor
              adults         (Neurophysiological,
                             Subjective, Autonomic,
                             Panic)
                           Morin et al. (1999) 6-factor
                             (Somatic, Fear, Autonomic
                             Hyperactivity, Panic,
                             Nervousness, Motor Tension)
                           Current study 2-factor
                             (Somatic, Cognitive)
Osman       240            CFA Beck et al. (1988)           .75
  et al.      adolescent     2-factor (Somatic,
  (2002)      inpatients     Subjective)                    .81
                           CFA Kumar et al. (1993)
                             2-factor (Somatic,
                             Subjective)
Enns        137            1-factor                         .62    .66
  et al.      outpatients  Hewitt & Norton (1993)           .70    .72
  (1998)                     2-factor (Somatic,
                             Cognitive)
                           Steer, Beck, et al. (1993)       .66    .70
                             2-factor (Somatic,
                             Subjective)
                           Steer, Kumar, & Beck (1993)      .84    .86
                             4-factor (Cognitive,
                             Autonomic, Neuromotor,
                             Panic)
Wetherell   197 older      1-factor
  & Arean     adults       2-factor (Beck et al., 1988)
  (1997)                   3-factor (Cognitive, Somatic,
                             Panic)
                           4-factor (Cognitive,
                             Autonomic, Neuromotor,
                             Panic)
                           2nd-order 4-factor
Osman       350            1-factor                         .87
  et al.      under-       Beck et al. (1988) 2-factor      .89
  (1997)      graduates      (Somatic, Subjective)
                           Beck & Steer (1991) and Osman    .92
                             et al. (1993) 4-factor
                             (Subjective,
                             Neurophysiological,
                             Autonomic, and Panic)
                           2nd order 4-factor               .92
D.R.        420 clinical   1-factor                         .76
  Peterson    adults and   Beck et al. (1988) 2-factor      .84
  (1995)      under-         (Somatic, Subjective)
              graduates    EFA-derived 3-factor             .86
                           Beck & Steer (1991) 4-factor     .92
                             (Subjective,
                             Neurophysiological,
                             Autonomic, Panic)
                           Borden et al. (1991) 5-factor    .92
                             (Subjective, Somatic,
                             Neurophysiological,
                             Muscular, Respiratory)
                           2nd-order factor                 .92

Article     Sample         No. of Factors                   NFI   RMSEA

Osman       225            2-factor (Beck et al., 1988)            .12
  et al.      community    1-factor
  (1993)      members      Borden et al. (1991) 5-factor           .08
                             (Subjective, Somatic,
                             Neurophysiological,
                             Muscular/Motoric,
                             Respiration)
Chapman     120 White      Beck et al. (1988) 2-factor             .14
  et al.      nonclinical    (Somatic, Subjective)
  (2009)      adults       Osman et al. (2002) 4-factor            .12
                             (Neurophysiological,
                             Subjective, Autonomic,
                             Panic)
                           Morin et al. (1999) 6-factor            .07
                             (Somatic, Fear, Autonomic
                             Hyperactivity, Panic,
                             Nervousness, Motor Tension)
                           Current study 2-factor                  .06
                             (Somatic, Cognitive)
Chapman     100 African    Beck et al. (1988) 2-factor             .12
  et al.      American       (Somatic, Subjective)
  (2009)      nonclinical  Osman et al. (2002) 4-factor            .11
              adults         (Neurophysiological,
                             Subjective, Autonomic,
                             Panic)
                           Morin et al. (1999) 6-factor            .09
                             (Somatic, Fear, Autonomic
                             Hyperactivity, Panic,
                             Nervousness, Motor Tension)
                           Current study 2-factor                  .09
                             (Somatic, Cognitive)
Osman       240            CFA Beck et al. (1988)                  .11
  et al.      adolescent     2-factor (Somatic,
  (2002)      inpatients     Subjective)                           .10
                           CFA Kumar et al. (1993)
                             2-factor (Somatic,
                             Subjective)
Enns        137            1-factor
  et al.      outpatients  Hewitt & Norton (1993)
  (1998)                     2-factor (Somatic,
                             Cognitive)
                           Steer, Beck, et al. (1993)
                             2-factor (Somatic,
                             Subjective)
                           Steer, Kumar, & Beck (1993)
                             4-factor (Cognitive,
                             Autonomic, Neuromotor,
                             Panic)
Wetherell   197 older      1-factor
  & Arean     adults       2-factor (Beck et al., 1988)
  (1997)                   3-factor (Cognitive, Somatic,
                             Panic)
                           4-factor (Cognitive,
                             Autonomic, Neuromotor,
                             Panic)
                           2nd-order 4-factor
Osman       350            1-factor                         .86    .04
  et al.      under-       Beck et al. (1988) 2-factor      .87    .04
  (1997)      graduates      (Somatic, Subjective)
                           Beck & Steer (1991) and Osman    .91    .03
                             et al. (1993) 4-factor
                             (Subjective,
                             Neurophysiological,
                             Autonomic, and Panic)
                           2nd order 4-factor               .91    .03
D.R.        420 clinical   1-factor
  Peterson    adults and   Beck et al. (1988) 2-factor
  (1995)      under-         (Somatic, Subjective)
              graduates    EFA-derived 3-factor
                           Beck & Steer (1991) 4-factor
                             (Subjective,
                             Neurophysiological,
                             Autonomic, Panic)
                           Borden et al. (1991) 5-factor
                             (Subjective, Somatic,
                             Neurophysiological,
                             Muscular, Respiratory)
                           2nd-order factor

Note. CFI = comparative fit index; TLI = Tucker-Lewis index;
NNFI = nonnormed fit index; GFI = goodness-of-fit index; NFI = normed
fit index; RMSEA = root mean squared error of approximation;
EFA = exploratory factor analysis.

TABLE 4
Diagnostic Validity Study Results

Article                        Cutoff   Sensitivity   Specificity

Hopko et al. (2008)              10         .83           .89
                                 16         .67           .89
Carney et al. (2011)             16         .55           .78
                                  8         .82           .49
Blom et al. (2010)               13
Diefenbach et al. (2009)          7         .77           .49
Eack et al. (2008)
  Minimum sensitivity             7         .87           .53
  Optimal                        12         .70           .74
  Minimum specificity            14         .62           .80
Dennis et al. (2007)              7         .85           .25
                                 15         .70           .75
Leyfer et al. (2006)
  Panic disorder                  8         .89           .97
  GAD                             3         .75           .73
  Phobia                          5         .68           .86
  Any anxiety diagnosis           5         .76           .77
Manne et al. (2001)              14         .73           .43
                                 16         .60           .57
                                 18         .53           .65
Cochrane-Brink et al. (2000)     26        1.00           .38
Kabacoff et al. (1997)           10         .94           .45
                                 12         .86           .49
                                 14         .69           .55
                                 16         .67           .62
Somoza et al. (1994)             25

Article                        PPP    NPP    % CC   AUC

Hopko et al. (2008)            .95    NPV     85
                               .94            73
Carney et al. (2011)                                .71

Blom et al. (2010)                                  .77
Diefenbach et al. (2009)       .37    .84     57    .63
Eack et al. (2008)
  Minimum sensitivity          .60    .83
  Optimal                      .69    .75
  Minimum specificity          .72    .72
Dennis et al. (2007)                          55
                                              72
Leyfer et al. (2006)
  Panic disorder               .41   1.00
  GAD                          .08    .99
  Phobia                       .46    .94
  Any anxiety diagnosis        .41    .94
Manne et al. (2001)            .28    .84     50
                               .30    .82     58
                               .32    .82     63
Cochrane-Brink et al. (2000)  1.00    .28
Kabacoff et al. (1997)         .30    .97     55
                               .30    .93     56
                               .28    .88     58
                               .31    .88     63
Somoza et al. (1994)                                .70

Article                                        Sample

Hopko et al. (2008)            33 patients with cancer
Carney et al. (2011)           207 patients with insomnia
Blom et al. (2010)             136 females with depression/anxiety
Diefenbach et al. (2009)       66 older adults with home care services
Eack et al. (2008)             288 distressed adult women (child
  Minimum sensitivity            treatment)
  Optimal
  Minimum specificity          40 older adults
Dennis et al. (2007)
Leyfer et al. (2006)           193 undergraduates
  Panic disorder
  GAD
  Phobia
  Any anxiety diagnosis
Manne et al. (2001)            115 mothers with children with cancer
Cochrane-Brink et al. (2000)   55 adults with suicidal ideation
Kabacoff et al. (1997)         170 older adults with mixed psychiatric
                                 disorders
Somoza et al. (1994)           142 outpatients with anxiety disorders

Note. PPP = positive predictive power; NPP = negative predictive
power; % CC = percentage of correct classification; AUC = area under
the curve; GAD = generalized anxiety disorder.
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Title Annotation:Assessment & Diagnosis
Author:Bardhoshi, Gerta; Duncan, Kelly; Erford, Bradley T.
Publication:Journal of Counseling and Development
Article Type:Report
Date:Jul 1, 2016
Words:16016
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