Korean Journal of Clinical Psychology Original Article 2016. Vol. 35, No. 4, 822-830 © 2016 Korean Clinical Psychology Association http://dx.doi.org/10.15842/kjcp.2016.35.4.010 ISSN 1229-0335 | eISSN 2733-4538 Psychometric Properties of the Beck Anxiety Inventory in the Community-dwelling Sample of Korean Adults Han-Kyeong Lee1 Eun-Ho Lee2 Soon-Taeg Hwang3 Sang-Hwang Hong4 Ji-Hae Kim1† 1Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; 2Depression Center, Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; 3Department of Psychology, Chungbuk National University, Cheongju; 4Department of Education, Chinju National University of Education, Jinju, Korea The Beck Anxiety Inventory (BAI) has been used in many countries since its psychological properties have been verified. However, as there is significant heterogeneity in affective experiences among cultures, a population-specific validation study is necessary. This study examined the psychometric properties of the BAI in a non-clinical Korean population. The BAI, Spielberger State-Trait Anxiety Inventory (STAI), and Patient Health Questionnaire-9 were used to assess the concurrent and discriminant validity. The factorial structures suggested by previous research were examined using the mean- and variance- adjusted weighted least squares estimation. The internal consistency and the item-total correlations were favorable. The test- retest reliability was slightly higher in this present study compared with that in previously reported studies. There was a mod- erate correlation between the BAI and the STAI. Among the five different factor structures, the four-factor model provided the best overall fit. Overall, the current results support the use of the BAI to assess the anxiety severity in community-dwelling populations of Korean adults. Keywords: Beck Anxiety Inventory, anxiety, reliability, validity, factor analysis Anxiety is a widespread condition. According to a recent meta- lic health, psychometrically sound methods for assessing anxious analysis, the lifetime prevalence of total anxiety disorders was symptomatology are critical for theory and research on, and treat- 16.6%, and the 1-year prevalence was 10.6% (Somers, Goldner, ment of, the emotional conditions (Contreras, Fernandez, Mal- Waraich, & Hsu, 2006). In Korea, about 12% of females and 5.3% carne, Ingram, & Vaccarino, 2004). of males experience anxiety disorders during their lifetime, and In primary care, many patients present with anxiety but this is the prevalence of anxiety disorders has increased from 5% in 2006 seldom systematically assessed (Bakker et al., 2010). To improve to 8.7% in 2011 (Cho, 2011). Not only are anxiety disorders highly anxiety management, assessment of the severity of anxiety is es- prevalent, the subjective and social burden of the illness is consid- sential. However, as anxiety disorders differ in types and symp- erable (Teachman, 2006; Wittchen, Zhao, Kessler, & Eaton, 1994). toms, assessing the severity of anxiety in general may be difficult. Even mild to moderate levels of anxiety can be accompanied by Among the most widely used anxiety measures, the Beck Anxiety considerable distress, diminished functioning, and an increased Inventory (BAI) has an advantage in that its validity and reliability risk of development of diagnosable disorders (Barlow, 2004; Rap- have been verified. Also, its brevity and simplicity render it suit- ee, 1991). Given the considerable toll taken by the disorder on pub- able for a range of research paradigms, and add to its clinical value (Creamer, Foran, & Bell, 1995). Since its development, the BAI has †Correspondence to Ji-Hae Kim, Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam- been widely used in clinical research in mental health care, mainly gu, Seoul 06351, Korea; E-mail: [email protected] as a measure of general anxiety (Creamer et al., 1995; Osman, Received Jul 14, 2016; Revised Sep 13, 2016; Accepted Oct 7, 2016 Kopper, Barrios, Osman, & Wade, 1997; Piotrowski, 1999). Pa- www.kcp.or.kr 822 Psychometric Properties of the BAI in Korea tients with any anxiety disorders had a significantly higher mean den, Peterson, & Jackson, 1991). The reason why the BAI factor score than the controls, suggesting that the BAI can be used as an structure did not reach an agreement may be due to the factor-an- indicator of anxiety severity in primary care (Muntingh et al., alytic approach used or the particular sample characteristics. For 2011). General rating scales may not be sufficiently specific to as- example, the original study by Beck et al. (1988) was conducted on sess the severity of a certain anxiety disorder. However, extensive psychiatric outpatients who met the criteria for DSM-III anxiety testing for different forms of anxiety is also not feasible during a and/or depressive disorders using exploratory factor analysis short consultation in primary care. Thus, the BAI may serve as a (EFA) by oblique rotation. In contrast, Osman et al. derived a four- reliable supplementary tool for clinician’s, and may be reasonable factor conclusion in both a psychiatric inpatient adolescent sample compromise between sensitivity and specificity (Muntingh et al., (Osman et al., 2002) and a non-clinical undergraduate sample by 2011). Due to its multiple strengths, the BAI has been used in di- confirmatory factor analysis (CFA) (Osman et al., 1997). verse clinical settings, and research on demographic factors such Anxiety disorders are directly related to work capacity, and are as age and sex is ongoing (Bergua et al., 2012; Jolly, Aruffo, Wher- more chronic in nature than depressive disorders (Hendriks et al., ry, & Livingston, 1993; Somers et al., 2006). 2015). Thus, managing the subthreshold anxiety level is also cru- The scale was validated in a sample of 160 psychiatric outpa- cial in nonclinical clinical samples to reduce potential obstacles in tients with various anxiety and depressive disorders, and the au- everyday life. However, the optimal cut-off values are specific to thors reported a high level of internal consistency (Cronbach’s α each study population, because healthier populations would likely =.92) and a good test-retest reliability over one week of .75 (Beck, have lower cut-offs (Creamer et al., 1995; Kjærgaard, Arfwedson Epstein, Brown, & Steer, 1988). The psychometric properties of the Wang, Waterloo, & Jorde, 2014). Therefore, it is important to ex- BAI are well established. In a review of studies on the psychomet- amine the properties of the scale using a variety of non-clinical rics of the BAI, it has good internal consistency and test-retest reli- populations. Also, epidemiological studies suggest that anxiety ability (Wilson, De Beurs, Palmer, & Chambless, 1999). The con- occurs in all countries, but there is significant heterogeneity in vergent validity of the BAI is demonstrated by significant correla- prevalence according to biological, psychological, and social vari- tions with anxiety diaries, self-report instruments, and clinician ables (Tseng & Streltzer, 2013). This signals the need for a popula- rating scales (Beck, Brown, Steer, Eidelson, & Riskind, 1987; Fy- tion-specific validation study because proper assessment of this drich, 1992; Steer, Ranieri, Beck, & Clark, 1993). Also, it has good condition has significant implications for understanding the com- discriminant validity, showing a low correlation with the clini- monalities and distinctions of affective experiences across cultures cian-rated Hamilton Depression Rating Scale (Beck et al., 1988). and may also be crucial for treatment considerations (Contreras et Moreover, subfactors of the BAI were useful in differentiating spe- al., 2004; Somers et al., 2006). cific anxiety disorders (Beck, Steer, & Beck, 1993), and differenti- In Korea, an effort to examine psychometric properties of the ated anxiety from depression better than the Spielberger State- BAI has been made but has been relatively limited considering its Trait Anxiety Inventory (Creamer et al., 1995). extensive usage. There was one EFA study which revealed two- The factor structure of the BAI remains a subject of debate. The factor solutions in psychiatric and normal adult populations original developmental study yielded a two-factor structure con- (Yook & Kim, 1997). Han et al. (2003) concluded that a modified sisting of subjective and somatic factors, using exploratory factor second-order four-factor model provided the best overall fit in a analysis (Beck et al., 1988). Many other reports supported this sample of psychiatric outpatients using CFA (Han, Cho, Park, two-factor model (Creamer et al., 1995; Kabacoff, Segal, Hersen, & Kim, & Kim, 2003). This solution was verified by two other stud- Van Hasselt, 1997; Steer et al., 1993). Some others suggested a four- ies, each of which was conducted on general psychiatric outpa- factor structure consisting of subjective, neurophysiological, auto- tients (Kim & Kim, 2007) and alcohol dependent patients (Chai & nomic, and panic symptoms (Beck & Steer, 1991; Steer et al., 1993), Cho, 2011). Reproduction of the second-order four-factor model and still others argued five-factor components to be optimal (Bor- seems encouraging. However, the fact that limitations of the previ- http://dx.doi.org/10.15842/kjcp.2016.35.4.010 823 Lee et al. ous studies have not yet been compensated for leaves much to be depression