Behac. Rex Thu.
Vol. 28, No. 4. pp. 323-329,
1990
0005-7967
90 53.00 + 0.00
Copynght E 1990Pcrgamon Press
Pnnted in Great Britain. All rights reserved
THE AGORAPHOBIA SCALE: AN EVALUATION ITS RELIABILITY AND VALIDITY
plc
OF
LARS-GORAN 0s~ Psychiatric Research Center, University of Uppsala. Ulleraker S-75017, Uppsala, Sweden (Received
22 February
1990)
Summary-This article presents the Agoraphobia Scale (AS), and evidence for its reliability, validity, and sensitivity to change after treatment. The scale consists of 20 items depicting various typical agoraphibic situations, which are rated for anxiety/discomfort (O-4) and avoidance (O-2). The results show that AS has high internal consistency. Regarding concurrent validity it correlated significantly with other self-reported measures of agoraphobia (Mobility Inventory and Fear Questionnaire). The scale’s predictive validity was shown as it correlated with avoidance behavior and self-rated anxiety during both an individualized and a standardized behavioral test of agoraphobia. The AS also discriminated between an agoraphobic sample and a normal sample, and a sample of simple phobia patients. Finally. it was sensitive to changes after behavioral treatment. The AS is useful both as a state, and as an outcome self-report measure of agoraphobia.
INTRODUCTION
Agoraphobia is probably the phobic disorder most frequently encountered in a psychiatric setting (Marks, 1987). This is reflected by the number of controlled outcome studies on different behavioral methods for clinical patients, which is larger than for any other type of phobia. These controlled studies have been published since 1966, but when the present work was initiated in 1980, after 15 yr of research, still no specific fear scale for agoraphobia had been developed, psychometrically evaluated, and published. The closest to such a scale (in 1980) was the Fear Questionnaire (Marks & Mathews, 1979) which has a subscale on agoraphobia consisting of 5 items. In 1980 Zitrin, Klein and Woerner described the use of a scale called the Agoraphobia Questionnaire in a treatment study. The AQ consists of 15 items, 13 of which were rated on a l-8 scale, one is rated l-7 and one 1-6, with individual descriptions of the scale steps for each item. The items also specifies if the situation concerns being alone or accompanied. However, no data on the psychometric characteristics of AQ has, as far as I know been published. Another scale on agoraphobia that was published without psychometric data is the Agoraphobia Questionnaire-Section 39 (Thorpe & Burns, 1983). This scale consists of 25 items rated on a l-5 scale, and the patient has to do a combined rating of fear and avoidance. The first well documented specific scale for assessing agoraphobia was the Mobility Inventory for Agoraphobia, published by Chambless, Caputo, Jasin, Gracely and Williams in 1985. This scale consists of 26 items rated for avoidance when alone, and 25 of these when accompanied. In both cases a l-5 scale is used. The MI was shown to possess high test-retest reliability, internal consistency, concurrent and discriminant validity, and to be sensitive to change after treatment. Due to the high correlation between the avoidance and discomfort versions of the scale only the former was used in the final version. The MI has the advantage of yielding two scores, for avoidance alone and accompanied, respectively. The purpose of the present study is to present psychometric data on the Agoraphobia Scale, developed within the author’s project on phobias. The AS consists of two subscales-Anxiety and Avoidance-and data pertaining to its reliability, validity, and sensitivity to change will be presented. METHOD
The Agoraphobia
Scale (AS)
In all types of phobias fear and avoidance are two prominent components. They covary to a large extent, but not perfectly, and thus it would seem informative to assess them separately. This 323
321
LASG&AS
bsr
has indeed been done via independent assessor ratings in may treatment studies (see ijst & Jansson, 1987 for a review). Consequently it was decided to construct a scale with two parts, the first containing agoraphobic situations rated for anxiety (discomfort), and the second part having the same situations rated for tendency to avoid. To generate items for the scale two procedures were used. The first was to go through the available literature as of 1980 containing factor analyses of fear survey schedules yielding information about what situations agoraphobics fear or avoid. The second procedure was to scrutinize the author’s files on past and present agoraphobic patients to obtain an.~ety-arousing situations. The number of items thus generated was 40, and these were rank ordered by a number of colleagues according to how representative they were considered to be for the agoraphobic syndrome. After eliminating 3 items with similar wording and content, the 20 items considered most representative were kept. The patient first rates the situations for anxiety/discomfort after having read the foIlowing instruction: “Below foliows a short description of situations that may arouse fear, anxiety or other unpleasant feelings. Read each item and rate how much anxiety you nowadays experience in the depicted situation. Then circle the figure that best corresponds to your feeling. The figures mean: 0 = no anxiety whatsoever, 1 = a little, 2 = moderate, 3 = much, and 4 = very much anxiety”. Then the same situations are rated for avoidance, using a O-2 scale, where 0 = do not avoid at all, 1 = avoids if possible, and 2 = always avoid. Basically the same instruction as above is used, except for the following: (a) ‘other unpleasant feelings’ is replaced with ‘avoidance of the situation’, (b) ‘anxiety you experience in’ is replaced with ‘you nowadays tend to avoid’, and (c) ‘feeling’ is replaced with ‘avoidance’. Agoraphobic patients Sample 1. All patients in this sample (n = 80) had been referred to the author’s unit for research on behaviourai treatments of phobias (1981-1984), or applied for treatment at a private practice. The patients went through a screening interview and all fulfilled the DSM-III (APA, 1980) criteria for agoraphobia with panic attacks and had a mean duration of their phobias of 8.3 yr (SD = 4.7). The sample consisted of 73 femaies (91%) and 7 males, and had a mean age of 36.0 yr (SD = 8.5). Forty of the patients took part in an outcome study comparing exposure in ciao and applied relaxation (Cist, Jerremalm & Jansson, 1984). Sample 2. During the period 1986-1988 another sample of agoraphobic patients fn = 50) was recruited, through referrals from psychiatrists, for a new outcome study (ijst, Westling & Hellstrom, 1990). AI1 of the patients went through a screening interview with the Anxiety Disorders Interview Schedule (ADIS; Di Nardo, O’Brien, Barlow, Waddell & Blanchard, 1983) and fulfilled the DSM-III criteria for agoraphobia with panic attacks. This sample consisted of 34 females (68%) and 16 males. They had a mean age of 36.5 yr (SD = 8.9), and the mean duration of their phobias was 9.1 yr (SD = 6.4). Comparison samples
A random community sample of non-agoraphobic persons was obtained by contacting women visiting a gynecological health control center for a routine check-up. During a 2 week period all women visiting the center were asked if they were willing to answer a simple questionnaire anonymously, and all complied. Males to match the 7 agoraphobic men were obtained among the staff of the hospital. The normal group (n = 80) had a mean age of 35.9 yr {SD = 7.8). A sample consisting of 50 patients with simple phobia (35 injection and 15 spider phobics) who took part in ongoing treatment outcome studies 1989-1990 answered the AS as part of the pre-treatment assessment batteries. These patients went th; + ‘=vh a screening interview in which the ADIS-R (Di Nardo, Barlow, Cerny, Vermilyea, Vermilye:=. iiimadi & Waddell, 1985) was used to arrive at DSM-IIIR diagnoses. All patients fulfilled the DSM-IIIR criteria for simple phobia.
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SEC
ayl.
LAM-G&LAN
326 Table
I. The
stems of the Agoraphobia
c)sr
Scale
with
item-total
score correlations
Item
I
Being
Anxxty alone
2 Shoppmg 3 Crossing 4 Being
in your
unaccompanied a street
in a crowd
7 Driving 9 Going
without riding
straight away by train
IO Standing
in long
I2
Eating
at a restaurant
Crossing
I6
Driving
17 Having I8
Shopping
a haircut
Riding
where
time,
walking
when bank
e.g. a square
it is crowded
or department
in company
of other
store,
unaccompanied
people
bar and
sitting
there
store
is a lot of traffic,
in crowded
0.62”’ 0.65”.
0.64***
0.60*”
0.53”’
0.50.”
0.65”’
0.61”’
0.62***
0.58***
0.38”’
0.45”.
0.48***
0.499”
0.42***
0.44.0.
0.53***
0.478.’
0.52***
0.38.“ 0.46”*
0.54***
0.49.0.
unaccompanied
0.60***
0.69’”
0.60*** 0.72”’
0.59.9’
0.52’9.
0.42***
unaccompanied supermarket.
crowded
with
people
streets
alone
lf < 0.05; **:p < 0.01; ***p
0.28.
o.;o*** 0.72***
of people
full
of a row
or bridge
in a large
Avoidance
0.‘4’
0.53***
in the middle
in a department
at the hairdresser,
in an elevator
or pharmacy
tunnel
over a viaduct
unaccompanied
19 Unaccompanied 20
shop.
of a friend
unaccompanied,
or theatre
a car alone
tobacco
alone
or lunch
unaccompanied a bridge
a long
for a long
to a cinema
e.g. a grocery.
spaces in the city,
lines in the post office.
on a chair
I5
open
home
or subway
Sitting
14 Shopping
large
your
II
13 Going
the company
through
from
shops,
alone
the bus at rush hour
across
a car alone
8 Walking
in small
in the city
5 Unaccompanied 6 Walking
home
0.63***
0.719”
0.67.‘.
0.34..
0.24’
< 0.0001
Correlations between the AS and other questionnaire measures used for sample 2 are presented in Table 2. Both subscales of the AS correlated highly with the Agoraphobic subscale of FQ and even higher (r = 0.83 and 0.81) with the MI-Avoidance alone. However, they did not correlate significantly with the MI-Avoidance accompanied subscale. This is quite understandable as most items of the AS specify that the situation under description has to be performed alone. Construct calidity. In order to be a specific measure of agoraphobia the AS should not correlate as highly with measures of generalized anxiety and depression as it does with other measures of agoraphobia. As is evident from Table 2 both of the AS subscales show positive, albeit not significant correlations with STAI, HAS, HDS, and BDI. Discriminant aalidity. In order for the scale to be useful in research and clinical practice it must discriminate between groups having and not having the disorder, respectively. Table 3 presents the means for each item of both subscales for the agoraphobic patients in sample 1 and the community comparison group. As is evident from the table the patients had a significantly higher mean on each item than the normal group, and this was true for both subscales. The total mean scores were 50.5 and 4.8 [t (158) = 22.9, P < O.OOOl] for the Anxiety subscale, and 22.0 and 4.4 [t( 158) = 20.0, P < O.OOOl] for the Avoidance subscale. The distributions of total scores for patients and normals were almost non-overlapping. On the Anxiety subscale only 4 normals had higher scores (30-61) than the lowest score for the phobic sample. Regarding the Avoidance subscale 5 normals had higher scores (9-29) than the lowest phobic. A more stringent test of the AS’s discriminant validity is presented in Table 4, in which sample 2 is tested against the comparison group of simple phobia patients. For both the Anxiety and Avoidance subscales the agoraphobic sample had significantly higher scores on each individual item. The total mean scores were 46.8 and 2.2 [t(98) = 24.3, P < 0.0001) for the Anxiety subscale, and 20.9 and 1.O [t = 19.9, P < 0.000 I] for the Avoidance subscale. The distributions of the two Table
2.
Product-moment
correlations
sample
among
AS-Anxiety AS-Avoidance
0.85***
AS-Avoidance
0.58***
FQ-Agoraphobia
0.60***
MI-Alone
0.83***
0.81’”
MI-Accompanied
0.16
0.16
AcQ BsQ
0.32’
0.28.
0.32.
0.37**
STAI-T
0.14
0.09
STAI-S
0.06
0.07
HAS
0.15
0.19
HDS
0.21
0.14
BDI
0.20
lP < 0.05; l*P
Vol. 28, No. 4. pp. 323-329,
1990
0005-7967
90 53.00 + 0.00
Copynght E 1990Pcrgamon Press
Pnnted in Great Britain. All rights reserved
THE AGORAPHOBIA SCALE: AN EVALUATION ITS RELIABILITY AND VALIDITY
plc
OF
LARS-GORAN 0s~ Psychiatric Research Center, University of Uppsala. Ulleraker S-75017, Uppsala, Sweden (Received
22 February
1990)
Summary-This article presents the Agoraphobia Scale (AS), and evidence for its reliability, validity, and sensitivity to change after treatment. The scale consists of 20 items depicting various typical agoraphibic situations, which are rated for anxiety/discomfort (O-4) and avoidance (O-2). The results show that AS has high internal consistency. Regarding concurrent validity it correlated significantly with other self-reported measures of agoraphobia (Mobility Inventory and Fear Questionnaire). The scale’s predictive validity was shown as it correlated with avoidance behavior and self-rated anxiety during both an individualized and a standardized behavioral test of agoraphobia. The AS also discriminated between an agoraphobic sample and a normal sample, and a sample of simple phobia patients. Finally. it was sensitive to changes after behavioral treatment. The AS is useful both as a state, and as an outcome self-report measure of agoraphobia.
INTRODUCTION
Agoraphobia is probably the phobic disorder most frequently encountered in a psychiatric setting (Marks, 1987). This is reflected by the number of controlled outcome studies on different behavioral methods for clinical patients, which is larger than for any other type of phobia. These controlled studies have been published since 1966, but when the present work was initiated in 1980, after 15 yr of research, still no specific fear scale for agoraphobia had been developed, psychometrically evaluated, and published. The closest to such a scale (in 1980) was the Fear Questionnaire (Marks & Mathews, 1979) which has a subscale on agoraphobia consisting of 5 items. In 1980 Zitrin, Klein and Woerner described the use of a scale called the Agoraphobia Questionnaire in a treatment study. The AQ consists of 15 items, 13 of which were rated on a l-8 scale, one is rated l-7 and one 1-6, with individual descriptions of the scale steps for each item. The items also specifies if the situation concerns being alone or accompanied. However, no data on the psychometric characteristics of AQ has, as far as I know been published. Another scale on agoraphobia that was published without psychometric data is the Agoraphobia Questionnaire-Section 39 (Thorpe & Burns, 1983). This scale consists of 25 items rated on a l-5 scale, and the patient has to do a combined rating of fear and avoidance. The first well documented specific scale for assessing agoraphobia was the Mobility Inventory for Agoraphobia, published by Chambless, Caputo, Jasin, Gracely and Williams in 1985. This scale consists of 26 items rated for avoidance when alone, and 25 of these when accompanied. In both cases a l-5 scale is used. The MI was shown to possess high test-retest reliability, internal consistency, concurrent and discriminant validity, and to be sensitive to change after treatment. Due to the high correlation between the avoidance and discomfort versions of the scale only the former was used in the final version. The MI has the advantage of yielding two scores, for avoidance alone and accompanied, respectively. The purpose of the present study is to present psychometric data on the Agoraphobia Scale, developed within the author’s project on phobias. The AS consists of two subscales-Anxiety and Avoidance-and data pertaining to its reliability, validity, and sensitivity to change will be presented. METHOD
The Agoraphobia
Scale (AS)
In all types of phobias fear and avoidance are two prominent components. They covary to a large extent, but not perfectly, and thus it would seem informative to assess them separately. This 323
321
LASG&AS
bsr
has indeed been done via independent assessor ratings in may treatment studies (see ijst & Jansson, 1987 for a review). Consequently it was decided to construct a scale with two parts, the first containing agoraphobic situations rated for anxiety (discomfort), and the second part having the same situations rated for tendency to avoid. To generate items for the scale two procedures were used. The first was to go through the available literature as of 1980 containing factor analyses of fear survey schedules yielding information about what situations agoraphobics fear or avoid. The second procedure was to scrutinize the author’s files on past and present agoraphobic patients to obtain an.~ety-arousing situations. The number of items thus generated was 40, and these were rank ordered by a number of colleagues according to how representative they were considered to be for the agoraphobic syndrome. After eliminating 3 items with similar wording and content, the 20 items considered most representative were kept. The patient first rates the situations for anxiety/discomfort after having read the foIlowing instruction: “Below foliows a short description of situations that may arouse fear, anxiety or other unpleasant feelings. Read each item and rate how much anxiety you nowadays experience in the depicted situation. Then circle the figure that best corresponds to your feeling. The figures mean: 0 = no anxiety whatsoever, 1 = a little, 2 = moderate, 3 = much, and 4 = very much anxiety”. Then the same situations are rated for avoidance, using a O-2 scale, where 0 = do not avoid at all, 1 = avoids if possible, and 2 = always avoid. Basically the same instruction as above is used, except for the following: (a) ‘other unpleasant feelings’ is replaced with ‘avoidance of the situation’, (b) ‘anxiety you experience in’ is replaced with ‘you nowadays tend to avoid’, and (c) ‘feeling’ is replaced with ‘avoidance’. Agoraphobic patients Sample 1. All patients in this sample (n = 80) had been referred to the author’s unit for research on behaviourai treatments of phobias (1981-1984), or applied for treatment at a private practice. The patients went through a screening interview and all fulfilled the DSM-III (APA, 1980) criteria for agoraphobia with panic attacks and had a mean duration of their phobias of 8.3 yr (SD = 4.7). The sample consisted of 73 femaies (91%) and 7 males, and had a mean age of 36.0 yr (SD = 8.5). Forty of the patients took part in an outcome study comparing exposure in ciao and applied relaxation (Cist, Jerremalm & Jansson, 1984). Sample 2. During the period 1986-1988 another sample of agoraphobic patients fn = 50) was recruited, through referrals from psychiatrists, for a new outcome study (ijst, Westling & Hellstrom, 1990). AI1 of the patients went through a screening interview with the Anxiety Disorders Interview Schedule (ADIS; Di Nardo, O’Brien, Barlow, Waddell & Blanchard, 1983) and fulfilled the DSM-III criteria for agoraphobia with panic attacks. This sample consisted of 34 females (68%) and 16 males. They had a mean age of 36.5 yr (SD = 8.9), and the mean duration of their phobias was 9.1 yr (SD = 6.4). Comparison samples
A random community sample of non-agoraphobic persons was obtained by contacting women visiting a gynecological health control center for a routine check-up. During a 2 week period all women visiting the center were asked if they were willing to answer a simple questionnaire anonymously, and all complied. Males to match the 7 agoraphobic men were obtained among the staff of the hospital. The normal group (n = 80) had a mean age of 35.9 yr {SD = 7.8). A sample consisting of 50 patients with simple phobia (35 injection and 15 spider phobics) who took part in ongoing treatment outcome studies 1989-1990 answered the AS as part of the pre-treatment assessment batteries. These patients went th; + ‘=vh a screening interview in which the ADIS-R (Di Nardo, Barlow, Cerny, Vermilyea, Vermilye:=. iiimadi & Waddell, 1985) was used to arrive at DSM-IIIR diagnoses. All patients fulfilled the DSM-IIIR criteria for simple phobia.
‘([()O()‘() > d ‘65’0 = J)a[EXqllS a3Uep!oAv aql p!p os pue'(1()0()'() > d ‘fg'() = .!)aJ!CUuO!lSan~ R!q -oqdelo8v aq] ql!M Ljlue3y!u%!spale~a3Josa~a3sqnsiila!XUVaql1 a1du.w UI ~ii~.i,?y]v.l lua.unsuo~ ‘il!p!!jV/j
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SEC
ayl.
LAM-G&LAN
326 Table
I. The
stems of the Agoraphobia
c)sr
Scale
with
item-total
score correlations
Item
I
Being
Anxxty alone
2 Shoppmg 3 Crossing 4 Being
in your
unaccompanied a street
in a crowd
7 Driving 9 Going
without riding
straight away by train
IO Standing
in long
I2
Eating
at a restaurant
Crossing
I6
Driving
17 Having I8
Shopping
a haircut
Riding
where
time,
walking
when bank
e.g. a square
it is crowded
or department
in company
of other
store,
unaccompanied
people
bar and
sitting
there
store
is a lot of traffic,
in crowded
0.62”’ 0.65”.
0.64***
0.60*”
0.53”’
0.50.”
0.65”’
0.61”’
0.62***
0.58***
0.38”’
0.45”.
0.48***
0.499”
0.42***
0.44.0.
0.53***
0.478.’
0.52***
0.38.“ 0.46”*
0.54***
0.49.0.
unaccompanied
0.60***
0.69’”
0.60*** 0.72”’
0.59.9’
0.52’9.
0.42***
unaccompanied supermarket.
crowded
with
people
streets
alone
lf < 0.05; **:p < 0.01; ***p
0.28.
o.;o*** 0.72***
of people
full
of a row
or bridge
in a large
Avoidance
0.‘4’
0.53***
in the middle
in a department
at the hairdresser,
in an elevator
or pharmacy
tunnel
over a viaduct
unaccompanied
19 Unaccompanied 20
shop.
of a friend
unaccompanied,
or theatre
a car alone
tobacco
alone
or lunch
unaccompanied a bridge
a long
for a long
to a cinema
e.g. a grocery.
spaces in the city,
lines in the post office.
on a chair
I5
open
home
or subway
Sitting
14 Shopping
large
your
II
13 Going
the company
through
from
shops,
alone
the bus at rush hour
across
a car alone
8 Walking
in small
in the city
5 Unaccompanied 6 Walking
home
0.63***
0.719”
0.67.‘.
0.34..
0.24’
< 0.0001
Correlations between the AS and other questionnaire measures used for sample 2 are presented in Table 2. Both subscales of the AS correlated highly with the Agoraphobic subscale of FQ and even higher (r = 0.83 and 0.81) with the MI-Avoidance alone. However, they did not correlate significantly with the MI-Avoidance accompanied subscale. This is quite understandable as most items of the AS specify that the situation under description has to be performed alone. Construct calidity. In order to be a specific measure of agoraphobia the AS should not correlate as highly with measures of generalized anxiety and depression as it does with other measures of agoraphobia. As is evident from Table 2 both of the AS subscales show positive, albeit not significant correlations with STAI, HAS, HDS, and BDI. Discriminant aalidity. In order for the scale to be useful in research and clinical practice it must discriminate between groups having and not having the disorder, respectively. Table 3 presents the means for each item of both subscales for the agoraphobic patients in sample 1 and the community comparison group. As is evident from the table the patients had a significantly higher mean on each item than the normal group, and this was true for both subscales. The total mean scores were 50.5 and 4.8 [t (158) = 22.9, P < O.OOOl] for the Anxiety subscale, and 22.0 and 4.4 [t( 158) = 20.0, P < O.OOOl] for the Avoidance subscale. The distributions of total scores for patients and normals were almost non-overlapping. On the Anxiety subscale only 4 normals had higher scores (30-61) than the lowest score for the phobic sample. Regarding the Avoidance subscale 5 normals had higher scores (9-29) than the lowest phobic. A more stringent test of the AS’s discriminant validity is presented in Table 4, in which sample 2 is tested against the comparison group of simple phobia patients. For both the Anxiety and Avoidance subscales the agoraphobic sample had significantly higher scores on each individual item. The total mean scores were 46.8 and 2.2 [t(98) = 24.3, P < 0.0001) for the Anxiety subscale, and 20.9 and 1.O [t = 19.9, P < 0.000 I] for the Avoidance subscale. The distributions of the two Table
2.
Product-moment
correlations
sample
among
AS-Anxiety AS-Avoidance
0.85***
AS-Avoidance
0.58***
FQ-Agoraphobia
0.60***
MI-Alone
0.83***
0.81’”
MI-Accompanied
0.16
0.16
AcQ BsQ
0.32’
0.28.
0.32.
0.37**
STAI-T
0.14
0.09
STAI-S
0.06
0.07
HAS
0.15
0.19
HDS
0.21
0.14
BDI
0.20
lP < 0.05; l*P
