Journal of Anxiety Disorders, Vol. 11, No. 1, pp.

33-47, 1997
Copyright Q 1997 Elsevier Science Ltd
Printed in the USA. All rights reserved
0887-6185/97 $17.00 + .OO

Pergamon

PII SO887-6185(96)00033-3

Psychometric Properties and

Diagnostic Utility of the
Beck Anxiety Inventory and the
State-Trait Anxiety Inventory With
Older Adult Psychiatric Outpatients
ROBERT

I.

Nova

KABACOFF,

Southeastern

PH.D.,
DANIEL
AND VINCENT
University

L.
B.

SEGAL, PH.D.,* MICHEL

VAN HASSELT, PH.D.

and University

of Colorado

HERSEN,

at Colorado

PH.D.,~

Springs

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 STAl 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. 0
1997 Elsevier Science Ltd
Words
outpatients,

Key

- Beck Anxiety
Clinical cutoffs.

Inventory,

State-Trait

Anxiety

Inventory,

Older psychiatric

Requests for reprints should be sent to Robert Kabacoff, Ph.D., Nova Southeastern
Center for Psychological
Studies, 3301 College Avenue, Fort Lauderdale,
FL 33314.
33

University,

34

R. I. KABACOFF

ET AL.

Epidemiological data suggest that anxiety is a common and debilitating

disorder affecting a significant number of older adults. In the general community, 5.5% of people 65 years or older meet strict diagnostic criteria for an
anxiety disorder (Reiger et al., 1988), with a similar rate found among elderly
medical inpatients (Rapp, Parisi, & Walsh, 1988). Rates are even higher when
significant but subsyndromal levels of anxiety are assessed in older adults. For
example, in a survey of community dwelling elders, Himmelfarb and Murrell
(1984) found that 17% of males and 21% of females experienced anxiety
symptoms of sufficient severity to warrant intervention. Prevalence rates for
anxiety disorders in older adults seeking mental health services are even more
substantial. Within our own clinics, almost 30% of elder clients seeking
outpatient services meet diagnostic criteria for an anxiety disorder.
Given such high prevalence rates for anxiety disorders in the elderly, there
is a pressing need for assessment instruments that can accurately measure
anxiety related symptomatology features in older adults. To avoid the fatigue
effects common in long test batteries and structured interviews, instruments that
can be quickly administered and easily completed are particularly desirable.
Two of the most commonly used self-report measures of anxiety are the Beck
Anxiety Inventory (BAI; Beck & Steer, 1990) and the State-Trait Anxiety
Inventory (STAI; Spielberger, 1985). Due to the overlap in measurement
between the clinical syndromes of anxiety and depression, the BAI was specifically developed to tap anxiety symptoms with minimal presence of depressive items. The STAI was developed earlier and designed to measure and
differentiate between anxiety as a state and trait variable (Oei, Evans, & Cook,
1990).
Both instruments have been widely applied by clinical researchers, and the
psychometric properties of these devices have been evaluated in a number of
different clinical populations. For example, the operating characteristics of the
BAI and its efficiency in screening for anxiety has been investigated with
adolescent inpatients (Jolly, Aruffo, Wherry, & Livingston, 1993; Kumar, Steer,
& Beck, 1993), adult outpatients with mixed psychiatric disorders (Beck,
Epstein, Brown, & Steer, 1988; Steer, Beck, Brown, & Beck, 1993; Steer,
Ranieri, Beck, & Clark, 1993), adult inpatients with mixed psychiatric disorders
(Steer, Rissmiller, Ranieri, & Beck, 1993), anxious adult outpatients (Beck &
Steer, 1991; Beck, Steer, & Beck, 1993), and non-clinical college undergraduates (Fydrich, Dowdall, & Chambless, 1992). Similarly, the STAI is a widely
employed and reliable self-report scale that has been used extensively in applied
psychology practice and research (see review by Spielberger, 1985). Indeed,
Spielberger (1985) noted that the revised STAI (STAI-Y) had been successfully
applied to high school and college students, adults, military personnel, prison
inmates, and a wide variety of psychiatric and medical patients.
Despite popularity of these devices, to our knowledge there are no studies
that specifically evaluate the psychometric properties and diagnostic utility of
these instruments with the elderly. Indeed, in a recent review of the literature

ASSESSMENT

OF ANXIETY

IN THE ELDERLY

35

concerning the behavioral assessment and treatment of anxiety in the elderly,

Hersen & Van Hasselt (1992) found that existing self-report and interviewadministered instruments initially developed for younger adults have not been
evaluated psychometrically with older populations in terms of norms, internal
consistency, reliability, factorial structure, and validity.
Determining the reliability and validity of assessment instruments for anxiety in the elderly is an essential step in the identification and treatment of
anxiety related disorders within that population. Since clinicians rarely have the
luxury of administering a complete structured interview schedule (which can
take up to 2 hours), short and valid measures of anxiety are particularly needed.
The current study was designed to evaluate the psychometric properties and
diagnostic utility of the BAI and STAI when used with older adults seeking
outpatient mental health services. Each instrument was evaluated for internal
reliability, factorial validity, and discriminant validity. In addition, the predictive accuracy of the BAI and STAI for identifying presence or absence of an
anxiety disorder in this population was investigated. Specifically, the sensitivity,
specificity, positive predictive power, negative predictive power, and hit rate for
detecting presence of a DSM-III-R anxiety disorder in older adults at various
cutoff scores of the BAI and STAI were determined. Finally, the study evaluated
whether or not combining BAI and STAI measures improved accuracy of
diagnostic prediction.

METHOD
Subjects
The present study was part of a comprehensive evaluation of social and
emotional adjustment in older adult psychiatric outpatients. The sample included 217 consecutive admissions to the Nova Community Clinic for Older
Adults (NCCOA), a community-based outpatient facility that provides psychiatric services for non-psychotic adults who are 55 years of age and older.
The total sample was composed of 154 (71%) women and 63 (29%) men.
The mean age was 65.86 years (SD = 8.54). Almost all subjects were White
(96%), 44% were married, and 99% were living in an apartment, condominium,
or private home. The median SES was 3 (on a scale of 1-5) as measured by the
Hollingshead Socio-Economic Scale (2-factor index) (Hollingshead, 1975).
Sixty-three (29%) of the 217 subjects met criteria for a current anxiety
disorder. Of the remaining 154 subjects, 133 (61%) met criteria for various
current Axis I diagnoses (other than anxiety disorder), and 21 (10%) did not
meet criteria for any current Axis I diagnosis.
Instruments
Structured Clinical Interview for DSM-III-R, Patient Edition With Psychotic
Screen (SCID-P). The SCID-P (Spitzer, Williams, Gibbon, & First, 1988) is a

36

R. 1. KABACOFF

ET AL.

semi-structured interview schedule employed to yield current and lifetime Axis

I diagnoses. The SCID was selected as the validity criterion for anxiety disorder
because of its formal ties to DSM criteria (American Psychiatric Association,
1987), and highly reliable diagnoses for similar older adult outpatients and
inpatients. Subjects were considered as suffering from an anxiety disorder if
they met formal criteria for any DSM-III-R anxiety disorder. Evidence for the
reliability of SCID-based diagnoses with a subset of the current study sample
(n = 40) was provided by Segal, Kabacoff, Hersen, Van Hasselt, and Ryan
(1995), who reported kappa coefficients of .73 for the broad category of anxiety
disorders, and .80 for the specific diagnosis of panic disorder. In an earlier
study, the SCID had been found to yield highly reliable diagnoses for the broad
diagnostic category of anxiety disorders (kappa = .77) in a mixed inpatient and
outpatient older adult sample (Segal, Hersen, Van Hasselt, Kabacoff, & Roth,
1993).
Beck Anxiety Inventory (BAZ). The BAI (Beck et al., 1988) is a 21-item Likert
scale self-report questionnaire measuring common symptoms of clinical anxiety, such as nervousness and fear of losing control. Respondents indicate the
degree to which they are bothered by each symptom. Each symptom is rated on
a 4-point scale ranging from 0 (not at all) to 3 (severely, I could barely stand it),
and the total scores can range from 0 to 63, with higher scores corresponding
to higher levels of anxiety. Thirteen items assess physiological symptoms, five
describe cognitive aspects, and three represent both somatic and cognitive
symptoms. The BAI has excellent internal consistency with psychiatric outpatients (alpha = .92, Beck et al., 1988; alpha = .94, Fydrich et al. 1992). The BAI
has high concurrent validity with the SCL-90-R (Derogatis, 1983) Anxiety
subscale (r = .81: Steer et al., 1993), and moderate concurrent validity with the
Hamilton Anxiety Rating Scale (Hamilton, 1959) in 367 outpatients with
anxiety disorders (r = S6: Beck & Steer, 1991). Common cutting scores of 10
suggest mild anxiety, with 19 reflecting moderate anxiety.
State-Trait Anxiety Inventory, Form Y (STAZ). The STAI-Y (Spielberger, 1985)
is a 40-item Likert scale that assesses separate dimensions of state anxiety
(items l-20) as well as trait anxiety (items 21-40). Each item is rated on a
4-point intensity scale. Both STAI-Y State (S-Anxiety) and Trait (T-Anxiety)
scales were developed as unidimensional measures.

Procedure
As part of the normal clinic routine, clients were administered the SCID-P,
BAI, and STAI-Y as part of the standard intake battery of psychological tests
given to all clients evaluated at NCCOA. All assessment instruments were
completed within an initial evaluation time of two weeks, and prior to inter-

ASSESSMENT

OF ANXIETY

IN THE ELDERLY

37

vention. All measures were administered by advanced doctoral level students,

all of whom were trained in administration and scoring.

RESULTS
Characteristics

qf the BAI

Cronbachs coefficient alpha for the BAI was 0.9, with item-total correlations ranging from 0.37 to 0.69. Discriminant validity was assessed by examining mean score differences between patients who met criteria for a current
diagnosis of an anxiety disorder, and patients who did not meet criteria for a
current anxiety disorder. As expected, a significant mean total score difference
between patients with an anxiety disorder (M = 21.75, SD = 13.11) and patients
without an anxiety disorder (M = 14.44, SD = 10.93) was obtained (t(215) =
4.38, p < .00001).
To investigate the factorial validity of the BAI item pool, the 21 items were
submitted to a common factor analysis using an iterated principal axis factoring
with squared multiple correlations as initial communality estimates, and subsequent promax rotation to an oblique simple structure. The first two eigenvalues were 7.73 and 1.38, with all remaining eigenvalues falling below 1.0. A two
factor solution (accounting for 84% of the variance) was selected based on
previous researching findings, and an examination of the scree plot. Item
communalities for the two factor solution ranged from 0.23 to 0.67, with a mean
of 0.43. Following factor rotation, the two factors correlated 0.59. The factor
pattern matrix, consisting of standardized regression coefficients for predicting the items from the factors, and the item communalities are presented in
Table 1.
As can be seen from Table 1, a high degree of simple structure was obtained.
Factor I clearly consists of items describing somatic aspects of anxiety, while
Factor II clearly consists of items describing subjective aspects of anxiety.
For the purpose of further investigation, the 14 items with salient loads on
Factor I (items 1-3, 6-8, 11-13, 15, 18-21) were summed to form a BAIsomatic subscale, and the 7 items with salient loadings on Factor II (items 4, 5,
9, 10, 14, 16, 17) were summed to form a BAI-subjective subscale. Coefficient
alpha for the BAI-somatic subscale was 0.89, while the coefficient alpha for the
BAI-Subject subscale was 0.86. With regard to discriminant validity, the
BAI-somatic subscale yielded a significant mean difference (t( 124.4) = 3.42, p
< .OOOl) between patients with an anxiety disorder (M = 11.54, SD = 9.05) and
patients without an anxiety disorder (M = 7.46, SD = 6.99). Similarly, a
significant mean difference (t(215) = 4.75, p < .OOOOl) between patients with
(M = 10.21, SD = 5.40) and without an anxiety disorder (M = 6.73, SD = 5.00)
was obtained on the BAI-subjective subscale.

38

R. 1. KABACOFF

TABLE
FACTOR

PATTERN

AND COMMUNALITIES

ET AL.

1
ANXIETY INVENTORY ITEMS

FOR BECK

Factor
I

Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

.49
.44
S6
.26
-.09
.77
.49
.57
.12
.lO
.45
.55
.55
.21
.44
-04
-.ll
.51
.69
.78
.60

Numbness or tingling
Feeling hot
Wobbliness
in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding or racing
Unsteady
Terrified
Nervous
Feelings of choking
Hands trembling
Shaky
Fear of losing control
Difficulty
breathing
Fear of dying
Scared
Indigestion
or discomfort
in abdomen
Faint
Face flushed
Sweating (not due to heat)

Note. Interfactor
cients.

Characteristics

correlation

= 0.59. Factor

loadings

are standardized

Loading
II

-.oo
.14
-.08
.46
.86
.02
.28
.09
.70
.67
.13
.12
.21
.54
.24
.50
.88
-.Ol
-.07
-.06
.I0
regression

.24
.28
.27
.42
.66
.62
.48
.39
.60
.54
.28
.39
.48
.48
.38
.23
.68
.26
.43
.56
.45
coeffi-

of the STAI-Y

Coefficient alpha for the S-Anxiety scale (state measure) was 0.92, with
item-total correlations ranging from 0.49 to 0.64. Coefficient alpha for the
T-Anxiety scale (trait measure) was 0.90 with item-total correlations ranging
from 0.38 to 0.69. With regard to discriminant validity, the T-Anxiety scale
yielded a smaller, though significant mean score difference (t(215) = 2.11, p <
.05) between patients with an anxiety disorder (M = 55.92, SD = 13.35) and
patients without an anxiety disorder (M = 52.64, SD = 52.65) than that found
with the BAI. No significant differences were found (t(215 = 1.44, p > .05)
between the anxiety disorder group (M = 53.28, SD = 13.35) and the nonanxiety disorder group (M = 50.55, SD = 13.21) on the S-Anxiety measure.
The factorial validity of the STAI-Y was investigated in a fashion similar to
that used for the BAI. A common factor analysis was performed via an interated
principal axis factoring, squared multiple correlations as initial communality
estimates, and promax rotation of factors. The first two eigenvalues were 13.03

39

ASSESSMENT OF ANXIETY IN THE ELDERLY

FACTOR PATTERN AND COMMUNAL~TIES

TABLE 2
FOR STATE-TRAIT ANXIETY INVENTORY ITEMS
Factor

Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

I feel calm
I feel secure
I am tense
I am strained
I feel at ease
I feel upset
I am presently worrying
I feel satisfied
I feel frightened
I feel comfortable
I feel self-confident
I feel nervous
I feel jittery
I feel indecisive
I am relaxed
I feel content
I am worried
I feel confused
I feel steady
I feel pleasant
I feel pleasant
I tire nervous and restless
I feel satisfied with myself
I wish I could be as happy as others seem
I feel like a failure
I feel rested
I am calm, cool, and collected
I feel that difficulties are piling...
I worry too much over something...
I am happy
I am inclined to take things hard
I lack self-confidence
I have disturbing thoughts
I make decisions easily
I feel inadequate
I am content
Some unimportant
thought runs...
I take disappointments
so keenly...
I am a steady person
I get in a state of tension or turmoil...

Note. Interfactor
cients.

correlation

= -0.52.

Factor

loadings

Loading

II

h2

.50
.61
.Ol
.05
.59
.03
-.Ol
.57
-.03
.59
.70
.05
.Ol
-.09
.58
.62
.12
-.lO
.69
.68
64
-.32
.79
-.20
-.48
.61
.67
-.34
-.06
.70
-.20
-.38
.78
.50
-.38
.70
-.lO
-.26
.52
-.38

-.21
-.lO
.63
.59
-.05
.78
.57
-.lO
.69
-.19
.04
.76
.73
.55
-.lO
.06
.79
.62
-.Ol
.05
.02
44
.09
.23
.15
.09
.03
.38
.37
-.05
.38
.17
.03
.02
.21
-.07
.34
.28
-.08
.30

.41
.45
.39
.32
.38
.58
.33
.39
.50
.51
.46
.54
.52
.37
.41
.35
54
.45
.47
.43
.40
.44
.56
.14
.32
.33
.43
.39
.16
.52
.27
.25
.59
.27
.27
.55
.16
.22
.32
.35

are standardized

regression

coeffi-

40

R. 1. KABACOFF

ET AL.

TABLE 3
CORRELATIONS AMONG BAI AND STAI-Y
Scale
1.
2.
3.
4.
5.

BAI-Tot
BAI-somatic
BAI-subjective
S-Anxiety
T-Anxiety

SCALES

1.

2.

3.

4.

5.

1 .oo
0.93
0.84
0.52
0.44

1.00
0.63
0.46
0.36

1.00
0.50
,047

1.oo
0.72

1.00

Note. N = 217, all correlations

significant

at p < .OOOl.

and 2.97, and the first two factors accounted for 71% of the variance. Item
communalities for the two-factor solution ranged from 0.16 to 0.58, with a
mean of 0.39. Since the STAI-Y was initially developed to yield two unidimensional and correlated factors a two-factor solution was employed. Examination of the scree plot supported this decision. Following factor rotation, the
two factors correlated -0.52 and a high degree of simple structure was obtained.
The factor pattern and item communalities are presented in Table 2.
Previous research would suggest that the first 20 items should load on one
factor and represent state anxiety, while the remaining 20 items should load on
a second factor and represent trait anxiety. Examination of Table 2 indicates that
this clearly is not the case. Factor I consists of items worded to score in a
negative direction (higher endorsement indicates less anxiety), while Factor II
consists of items worded in a positive direction (higher endorsement indicates
more anxiety). Thus, both Factor I and II appear to be method factors, response
set artifacts.
Relationships

Between Scales

Intercorrelations between the BAI total score, BAI derived subscales, and
the STAI-Y scales are presented in Table 3. As can be seen from the table, the
BAI-somatic and BAI-subjective subscales were each strongly positively correlated with the BAI total score and moderately positively correlated with each
other. The STAI-Y scales were strongly positively correlated with each other.
Correlations between the BAI scales and the STAI-Y scales were positive and
moderate in size.
Predictive Accuracy

To evaluate the predictive accuracy of the BAI and STAI-Y, the sensitivity,
specificity, positive predictive power, negative predictive power, and hit rate for
classifying subjects into the anxiety disorder group or non-anxiety disorder
group at various test cutoff scores were evaluated. Sensitivity here refers to the

ASSESSMENT

OF ANXIETY

IN THE

ELDERLY

41

proportion of correctly identified anxiety-disordered clients, while specificity

denotes the proportion of correctly identified non-anxiety-disordered clients.
Two other measures (positive predictive power and negative predictive power)
provide important estimates of diagnostic utility because they take into account
the base rate or prevalence of the disorder in question, and base rates vary
widely depending on the setting, population, and specific disorder addressed
(Garlos & Kline, 1988; Meehl & Rosen, 1955). Indeed, in a recent review of the
problem of base rates, Elwood (1993) noted that discriminant ability of a test
can only be evaluated after the base rate of a disorder for the specified
population is determined. For a given base rate, the positive predictive power
(probability that a score above the cutoff corresponds to an anxiety diagnosis),
negative predictive power (probability that a score below the cutoff corresponds
to an absence of an anxiety diagnosis), and hit rate (proportion of accurate
decisions) of a test can be determined at various cutoff scores.
Results at varying cutoff scores for the BAI are presented in Table 4. As can
be seen from this table, no single cutoff score provided both high sensitivity and
high specificity. For example, at a cutoff score of 10 (mild anxiety), 94% of the
anxiety group was correctly identified, 45% of the non-anxiety group was
correctly identified, and 55% of the total sample was correctly identified. Given
a score above 10, the probability of actually having an anxiety disorder was
0.30, while the probability of not having an anxiety disorder when the score was
below ten was 0.97. For a cutoff score of 19 (moderate anxiety), 56% of the
anxiety group was correctly identified, 72% of the non-anxiety group was
correctly identified, and 69% of the total sample was correctly identified. Given
a score above 19, the probability of actually having an anxiety disorder was
0.34, while the probability of not having an anxiety disorder for scores below
19 was 0.86. Again, it must be emphasized that these probabilities are highly
dependent on the base rate (29%) for anxiety disorders encountered in this
sample.
Predictive accuracy figures at various cutoff scores of the T-Anxiety scale of
the STAI-Y were examined in a similar fashion. As with the BAI, no single
cutoff score produced both high sensitivity and high specificity. In general, the
T-Anxiety scale was less accurate than the BAI in detecting anxiety disorders.
Since no significant mean difference between diagnostic groups was obtained
for the S-Anxiety scale, its predictive accuracy was not further addressed.
Since the Subjective Anxiety subscale of the BAI demonstrated a larger b-test
difference between the anxiety disorders group and the non-anxiety disorders
group than either the BAI total score or the T-Anxiety scale of the STAI-Y, its
predictive accuracy was investigated. As with the previous measures, high
sensitivity or specificity was possible (depending on cutoff score) but not both.
Diagnostic accuracy was slightly higher than found with the BAI, and required
14 fewer items (7 as opposed to 21). For a cutoff score of 8, sensitivity was .72,
specificity was .62, positive predictive power was 0.33, negative predictive
power was 0.90, and the overall hit rate was 64%. Predictive accuracy tables for

42

R I. KABACOFF

ET AL.

the T-Anxiety scale of the STAI-Y and the Subjective Anxiety subscale of the
BAI are available from the authors.
The question of whether or not anxiety measures could be combined to
improve diagnostic accuracy was addressed using stepwise logistic regression.
The binary dependent variable (presence vs. absence of an anxiety disorder)
was the predicted variable, and the BAI total score, T-Anxiety and S-Anxiety
scales were the predictor variables. After entry of the BAI (x2 = 16.14, p <
.OOOl), neither T-Anxiety or S-Anxiety made a significant contribution to
prediction at the p < .05 level. A second stepwise logistic regression was
performed using the BAI-subjective and BAI-somatic subscales in place of the
BAI-total score. After BAI-subjective was added to the equation (x2 = 18.89, p
< .OOOl), none of the remaining three variables made a significant contribution
at the p < .05 level. Results indicate that using the BAI-total score or
BAI-subjective score alone provided maximal prediction, and that combining
either with the other scales did not improve their predictive power.

DISCUSSION
Results from this study provide information on the psychometric properties
and diagnostic utility of BAI and STAI-Y when used with older adult outpatients. The BAI demonstrated a high degree of internal reliability, a significant
mean difference between anxiety and non-anxiety disorder groups, and evidence supporting factorial validity. Two clearly interpretable factors emerged
from BAI item pool, and a high degree of simple structure was obtained. The
first factor, represented by 14 items, described somatic aspects of anxiety. The
second factor, represented by 7 items, described subjective aspects of anxiety.
When formed into subscales using simple summation, the BAI-somatic and
BAI-subjective subscales demonstrated a high degree of internal reliability and
a moderate to strong inter-correlation (r = 0.67).
The STAI-Y T-Anxiety and S-Anxiety scales also evidenced a high degree of
internal reliability. While the T-Anxiety scale demonstrated discriminant validity, the mean difference between anxiety and non anxiety disorder groups on the
S-Anxiety scale was nonsignificant. In addition, a factor analysis of the STAI-Y
item pool did not yield anticipated trait and state anxiety factors. Two interpretable factors emerged, but appeared to be method factors unrelated to
anxiety constructs. The first factor was represented by items suggesting a lack
of anxiety, while the second factor was represented by items suggesting the
presence of anxiety. Taken together, these findings suggest a lack of construct
validity for the STAI-Y in this older adult sample.
Although the BAI demonstrated slightly greater predictive accuracy than the
STAI-Y, no single cutting score for predicting the presence of an anxiety
disorder was found to be optimal for either scale. This result can be explained
by the presence of a significant trade-off between sensitivity and specificity as
one chooses various cut-off scores. The appropriate cut-off score for a given

ASSESSMENT

PREDICTION

BAI

4
AT SELECTED

CUTOFF

SCORES

Positive
Predictive

Negative
Predictive

Power

Power

Specificity

1.00
1.00
1.00

0.08

0.22

1.00

0.27

0.14
0.17

0.23
0.24

1.00
1.00

0.32
0.34

1 .oo
0.97

0.22
0.23

0.25
0.24

1.00
0.97

0.97

0.25
0.26

0.97
0.96

0.94
0.94

0.26
0.32

0.38
0.38
0.41

0.35

0.27

0.96

0.94
0.94

0.40
0.45

0.29
0.30

0.97
0.97

0.55

12
13
14

0.89
0.86

0.46
0.49

0.30
0.30

0.72
0.69
0.67
0.67

0.28
0.28
0.30

0.55
0.56
0.56

15
16

0.52
0.55
0.60

0.94
0.93
0.88

0.87

0.67
0.72

0.31
0.34

0.86
0.86

0.63
0.66

19
20

0.61
0.58
0.56

0.31
0.30

0.58
0.61
0.63

17
18

0.62
0.64

0.88
0.88
0.88

0.69

0.50

0.76

0.35

21
22

0.44
0.36

0.77
0.79

0.33
0.30

0.86
0.84

0.71
0.70

23

0.36

0.70
0.72

0.36
0.33
0.28

0.33
0.34

0.83
0.83

24
25
26

0.82
0.82

0.83

0.73

0.84
0.85

0.34
0.32

0.83
0.82

0.73
0.73

27
28

0.28
0.25
0.25

0.87
0.89
0.91

0.36
0.38
0.43

0.83
0.82
0.83

0.75
0.76
0.78

0.22
0.19

0.91
0.93

0.19
0.19

0.94
0.94

0.40
0.41
0.44

0.82
0.82
0.82

0.77
0.78
0.79

0.47

0.82

0.79

0.17
0.14

0.96
0.96

0.50
0.45

0.82
0.81

0.80
0.79

9
10
11

29
30
31
32
33
34

Score

TABLE
OF THE BAI

43

IN THE ELDERLY

Sensitivity

2
3

Cutoff

ACCURACY

OF ANXIETY

Hit

Rate

0.45
0.47
0.51

35
36

0.14

0.96

0.50

37
38
39
40
41

0.14
0.14
0.11
0.11
0.11

0.96
0.96
0.96
0.97
0.99

0.50
0.50
0.44
0.50
0.67

0.81
0.81

0.80
0.80

0.81
0.81
0.81
0.81

0.80
0.79
0.80
0.81

42
43
44

0.11
0.08
0.06

0.99
0.99
0.99

0.67
0.60
0.67

0.81
0.81
0.80

0.81
0.80
0.80

(continued

on next page)

44

R. 1. KABACOFF

TABLE

BAI Cutoff

Score

Sensitivity

45
46
41
48
49
50
51
52
53
54
55
56
51
58
Note. Positive

0.03
0.03
0.03
0.03
0.03
0.03
0.03
0.03
0.03
0.03
0.00
0.00
0.00
0.00
and negative

predictive

ET AL.

~--CONTINUED

Specificity
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
0.99
powers

Positive
Predictive
Power
0.50
0.50
0.50
0.50
0.50
0.50
0.50
0.50
0.50
0.50
0.00
0.00
0.00
0.00

Negative
Predictive
Power
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80

Hit Rate
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.79
0.79
0.79
0.79

are based on a base rate of .29.

setting will depend on the relative importance of accurately identifying individuals with or without an anxiety disorder, coupled with an estimate of the
disorders prevalence. Tables 4 and 5 demonstrate this trade-off, and provide
information useful in choosing an appropriate cutting score for various purposes.
Combining the BAI and the STAI-Y did not improve diagnostic prediction
above that found for the BAI alone. In addition, the BAI-subjective subscale
produced slightly better classification accuracy than either the BAI-somatic
subscale or BAI total score. This finding suggests a greater relative importance
of subjective/cognitive aspects of anxiety over somatic symptomatology when
screening for the presence of anxiety disorders. Information for selecting
appropriate cutting scores for the BAI-subject subscale can be found in Table 6.
In general, these instruments had lower diagnostic accuracies than has been
reported for measures used to screen for major depression. Kogan, Kabacoff,
Hersen, and Van Hasselt (1994) found the Beck Depression Inventory and the
Geriatric Depressional Scale to have higher screening accuracies with older
adults than those reported here. This finding is consistent with a view that the
diagnosis of a major depressive episode is a more discrete and circumscribed
process than the diagnosis of an anxiety disorder. Specifically, anxiety symptomatology is more likely to be found across of range of DSM diagnoses,
resulting in lower predictive accuracies for these screening tests.
In summary, the BAI was found to have good psychometric properties,
including internal reliability, discriminant validity, and factorial validity when
use with an older adult outpatient population. The STAI-Y demonstrated

ASSESSMENT

OF ANXIETY

IN THE

ELDERLY

45

notable deficits in both discriminant and factorial validity and cannot be

recommended for use with this population. Results suggest that both the BAI
total score and the BAI-subjective subscale can be moderately successful as a
quick screening device for the presence of an anxiety disorder. Since the
BAI-subject subscale consists of seven items, it is particularly promising as a
brief addition to a test battery. However, care should be exercised in selecting
an appropriate cutting score, with both the expected prevalence rate and the
relative importance of false positives and false negatives considered.
There are several limitations in the current study. Subjects were primarily
white outpatients capable of independent living. Results may not generalize to
more seriously impaired older adults, or to other ethnic groups. Additionally,
this study concentrated on a discrimination between the presence and absence
of an anxiety disorder, leading to the inclusion of a variety of anxiety disorders
under one broad heading. Finer analyses were not possible due to sample size
limitations. However, results may vary by type of anxiety disorder. Finally,
older adults were not subdivided by age, again due to sample size considerations. Results may vary by age, even within this population.
These findings highlight the need to investigate the psychometric properties
and diagnostic accuracies of popular assessment instruments when used with
older adults. Test characteristics reported for younger adults may not accurately
generalize to older populations. Since the value of research with older populations is dependent of the accuracy of the instrumentation employed, such
investigations are quite important. Additionally, studies investigating the performance of these measures with older adults in other settings and with other
ethnic groups are needed.

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