Received 12/26/14

Revised 02/22/15
Accepted 03/02/15

Assessment & Diagnosis

DOI: 10.1002/jcad.12090

Psychometric Meta-Analysis
of the English Version of the
Beck Anxiety Inventory
Gerta Bardhoshi, Kelly Duncan, and Bradley T. Erford

This meta-analysis reviewed 192 scholarly works from 1993 to 2013 using the Beck Anxiety Inventory (Beck & Steer,
1993). Aggregated internal consistency (coefficient alpha) was .91 (k = 117), and test–retest reliability was .65 (k = 18).
Convergent comparisons were robust across 33 different anxiety instruments and the Beck Depression Inventory–II
(Beck, Steer, & Brown, 1996). Structural validity primarily supported the original 2-factor solution proposed by Beck
and Steer (1993), and diagnostic accuracy varied according to the sample size and criterion cutoff score.

Keywords: Beck Anxiety Inventory, anxiety, meta-analysis

The Beck Anxiety Inventory (BAI; Beck & Steer, 1993) is much they have been bothered by each symptom during the
one of the most popular screening and outcome research past week on a 4-point Likert-type scale, with 0 meaning not
instruments for measuring the construct of anxiety. Although at all, 1 meaning mildly (i.e., “It did not bother me much”), 2
most appropriate for use with psychiatric outpatients 17 years meaning moderately (i.e., “It was very unpleasant, but I could
and older, it has been used in research studies with both clini- stand it”), and 3 meaning severely (i.e., “I could barely stand
cal and nonclinical samples. Among counselors, the BAI is it”). Score interpretation guidelines for the BAI indicate that
reported to be the ninth most commonly used instrument (C. scores of 0–7 denote minimal anxiety, 8–15 mild anxiety,
H. Peterson, Lomas, Neukrug, & Bonner, 2014). Similarly, 16–25 moderate anxiety, and 26–63 severe anxiety.
Neukrug, Peterson, Bonner, and Lomas (2013) reported that Beck, Epstein, Brown, and Steer (1988) explained that
the BAI was the ninth most commonly taught instrument the final 21 BAI items were developed from a pool of 86
by counselor educators. The BAI is a popular screening and items from three preexisting anxiety rating scales developed
evaluation tool in clinical practice and is commonly used in by Beck. Beck and Steer (1993) reported use of clinical and
anxiety treatment research as an outcome measure; thus, it nonclinical standardization samples. The clinical sample was
is important for counselors to understand the psychometric composed of 393 outpatients (236 women, 157 men) with a
characteristics that have accumulated over the past 2 decades mean age of 37 years. Beck and Steer (1993) reported an alpha
related to this commonly used instrument. of .93 for this outpatient sample. The suggested cutoff score in
The BAI consists of 21 self-report items designed to the manual for clinically significant anxiety is 16. No norm-
measure the occurrence and severity of symptoms of anxiety referenced interpretive data are available, although Beck and
disorders as defined by the Diagnostic and Statistical Manual Steer (1993) did report means and standard deviations for
of Mental Disorders (4th ed.; DSM-IV; American Psychiatric three small nonclinical samples composing the nonclinical
Association, 1994). It was designed specifically to differenti- standardization sample: 65 university students (75% women;
ate between anxiety and depression, although it should not mean age of 19 years; M = 11.08, SD = 9.10), 142 medical
be used alone for diagnostic purposes. As a copyrighted students (51% women; M = 8.89, SD = 7.30), and 36 adults
measure, it is available for purchase and is distributed by who were not students (78% women; mean age of 29 years;
Pearson Assessments in both English and Spanish. The BAI M = 7.78, SD = 5.65).
takes about 5–10 minutes to administer (oral administration Beck and Steer’s (1993) final validation sample was 160
is about 10 minutes) and less than 5 minutes to score and participants with anxiety and depressive disorders. The coef-
interpret. The BAI total raw score is obtained by a simple ficient alpha for the total scale for this sample was .92, and
sum of the 21 item scores, with respondents indicating how a 1-week test–retest study of scores from 83 of these partici-
Gerta Bardhoshi and Kelly Duncan, Division of Counseling and Psychology, University of South Dakota; Bradley T. Erford, Depart-
ment 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).

© 2016 by the American Counseling Association. All rights reserved.

356 Journal of Counseling & Development  ■  July 2016  ■  Volume 94
Psychometric Meta-Analysis of the English Version of the Beck Anxiety Inventory
pants resulted in an rtt 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 avail-
able published and dissertation studies of the BAI’s internal
consistency, test–retest reliability, external (convergent) va-
lidity with other anxiety instruments, internal validity (i.e.,
exploratory factor analysis [EFA] and confirmatory factor
analysis [CFA]), diagnostic validity (i.e., sensitivity, specific-
ity, positive predictive power [PPP], negative predictive power
[NPP], percentage of correct classification, and area under
the curve [AUC] estimates), and average responses (by non-
clinical samples) since 1993. This summary of psychometric
evidence will highlight how the BAI performs under normal
circumstances across cumulative studies and explore implica-
tions 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 rtt 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
Journal of Counseling & Development  ■  July 2016  ■  Volume 94
implications for over- or underdiagnosis of men and women
with anxiety disorders?
Method
Journal articles, dissertations, and other electronically avail-
able 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, Ser-
bian, 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 As-
sociation, & 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 ad-
ditional 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 pro-
cedures, including an electronic search, followed by a hand
search of the reference lists of selected and synthesis articles.
PsycINFO, ERIC, Academic Search Premier, Cochrane Cen-
tral 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 selec-
tion 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 reliabil-
ity, (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
357

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 (½log[(1 + r)
(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 ±.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 ±.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 com-
puterized 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-Tröster et al., 2000; Swan, Watson, & Nathan,
2009), whereas the nonclinical samples (k = 10, n = 2,101)
358 Journal of Counseling & Development  ■  July 2016  ■  Volume 94
Bardhoshi, Duncan, & Erford
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 & Lovi-
bond, 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 com-
bined 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 I2 (less than the 50% criterion). Thus, explora-
tion 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
 Psychometric Meta-Analysis of the English Version of the Beck Anxiety Inventory

Table 1
Convergent Validity Studies With the Beck Anxiety Inventory
Instrument k n r 95% CI Study
Anxiety Control Questionnaire 1 364 .35 [0.25, 0.45] Ballash et al. (2006)
Anxiety Sensitivity Index–3 4 917 .60 [0.53, 0.67] Cox et al. (2008); De Coteau et al. (2003); Hirai et
al. (2006); Novy et al. (2001)
Anxious Self-Statements Questionnaire 1 135 .70 [0.53, 0.87] Lamberton & Oei (2008)
Beck Depression Inventory–II 109 28,533 .59 [0.58, 0.60] 106 different articles
Brief Symptom Inventory 3 976 .73 [0.67, 0.79] Morin et al. (1999); Osman et al. (1993); Steer,
Rissmiller, et al. (1993)
Brief Symptom Inventory–Anxiety 4 1,127 .74 [0.68, 0.80] De Beurs et al. (1997); Osman et al. (1993); Osman
et al. (1997); Steer, Rissmiller, et al. (1993)
Brief Symptom Inventory–Phobic Anxiety 2 695 .55 [0.47, 0.63] Osman et al. (1993); Steer, Rissmiller, et al. (1993)
Brief Symptom Questionnaire 1 87 .68 [0.47, 0.89] Hirai et al. (2006)
Clinical Global Impression Scale (OCD subscale only) 1 75 .12 [–0.11, 0.35] Williams et al. (2013)
Depression Anxiety Stress Scales (Anxiety subscale) 4 1,212 .81 [0.75, 0.87] Carty (2001); Dammeyer (2000); Lovibond & Lovibond
(1995); Rector et al. (2011)
Elkins Distress Inventory (Anxiety subscale) 1 113 .63 [0.44, 0.82] Gartner (2012)
Experiences in Close Relationships–Anxious Attachment 1 176 .44 [0.29, 0.59] Brock et al. (2012)
Generalized Anxiety Disorder Questionnaire for DSM-IV 1 66 .38 [0.13, 0.63] Diefenbach et al. (2009)
Generalized Anxiety Disorder Severity Scale 1 66 .54 [0.29, 0.79] Diefenbach et al. (2009)
Geriatric Anxiety Inventory 2 183 .46 [0.31, 0.61] Diefenbach et al. (2009); Yochim et al. (2011)
Geriatric Anxiety Scale 1 117 .61 [0.43, 0.79] Yochim et al. (2011)
Glasgow Anxiety Scale–Intellectual Disability 1 19 .72 [0.26, 1.00] Mindham & Espie (2003)
Geriatric Worry Scale 1 66 .50 [0.25, 0.75] Diefenbach et al. (2009)
Hamilton Anxiety Rating Scale 12 2,104 .57 [0.53, 0.61] 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 Scale–Self-Report 4 492 .42 [0.33, 0.51] Cukrowicz (2008); Gould et al. (2012); Hedman et
al. (2010)
Millon Clinical Multiaxial Inventory–Anxiety 1 186 .72 [0.57, 0.87] Hesse et al. (2012)
Minnesota Multiphasic Personality Inventory–Adolescent
Anxiety 1 240 .56 [0.43, 0.69] Osman et al. (2002)
Multidimensional Anxiety Scale for Children 1 43 .34 [0.04, 0.64] Fulcher et al. (2008)
Older Adult Social-Evaluative Situations Questionnaire 1 133 .44 [0.27, 0.61] Gould et al. (2012)
Perceived Stress Scale 1 84 .40 [0.18, 0.62] Kit et al. (2007)
Penn State Worry Questionnaire 4 260 .35 [0.23, 0.47] Diefenbach et al. (2009); Hirai et al. (2006); Wetherell
& Gatz (2005)
Penn State Worry Questionnaire–Abbreviated 1 66 .32 [0.07, 0.57] Diefenbach et al. (2009)
Positive and Negative Affect Schedule–Negative Affect 1 176 .40 [0.25, 0.55] Brock et al. (2012)
Revised Children’s Manifest Anxiety Scale 2 204 .58 [0.47, 0.69] Anthony (1998); Weir & Jose (2007)
Social Interaction Anxiety Scale 1 89 .58 [0.37, 0.79] Hyde (2003)
Social Phobia and Anxiety Inventory–Social Phobia 3 801 .41 [0.34, 0.48] Anhalt & Morris (2008); Gould et al. (2012); Neal et
al. (2002)
Social Phobia and Anxiety Inventory–Agoraphobia 2 367 .60 [0.50, 0.70] Gould et al. (2012); Neal et al. (2002)
Social Phobia Scale 1 89 .61 [0.40, 0.82] Hyde (2003)
State–Trait Anxiety Inventory–State 12 2,483 .53 [0.49, 0.57] Chapman & Woodruff-Borden (2009); 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 Inventory–Trait 12 3,884 .56 [0.53, 0.59] Balsamo et al. (2013); Borden et 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 the DSM-IV–GAD 1 911 .38 [0.31, 0.45] Watson et al. (2008)
Structured Clinical Interview for the DSM-IV–PTSD 1 911 .36 [0.29, 0.43] Watson et al. (2008)
Structured Clinical Interview for the DSM-IV–Panic 1 911 .50 [0.43, 0.57] Watson et al. (2008)
Structured Clinical Interview for the DSM-IV–Social Phobia 1 911 .24 [0.17, 0.31] Watson et al. (2008)
Structured Clinical Interview for the DSM-IV–OCD 1 911 .24 [0.17, 0.31] Watson et al. (2008)
Worry Scale 2 185 .78 [0.63, 0.93] Hirai et al. (2006); Novy et al. (2001)
Yale–Brown Obsessive Compulsive Scale 1 75 .16 [–0.07, 0.39] Williams et al. (2013)
Youth Self-Report 2 70 .52 [0.28, 0.76] Pencer (2005)
Zung Self-Rating Anxiety Scale 1 50 .77 [0.49, 1.00] Durham (2010)

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

Journal of Counseling & Development  ■  July 2016  ■  Volume 94 359

 Bardhoshi, Duncan, & Erford

Article
Hewitt & Norton (1993)
Steer, Beck, et al. (1993)
Steer, Rissmiller, et al. (1993)
Beck & Steer (1991)
Kabacoff et al. (1997)
Steer, Kumar, et al. (1995)
Lovibond & Lovibond (1995)
Morin et al. (1999)
Durham (2010)
Lindsay & Skene (2007)
Contreras et al. (2004)
Steer (2009)
Osman et al. (1993)
Sanford et al. (2008)
Osman et al. (2002)
Creamer et al. (1995)
Kumar et al. (1993)
D. R. Peterson (1995)
Note. PFA = principal factor analysis; PCA = principal components analysis; PAF = principal axis factoring.
a
Percentage of explained variance is given in parentheses.
Table 2
Exploratory Factor Analysis Study Results
Sample No. of Factors/Itemsa
291 psychiatric patients PFA with varimax 2 factors: Somatic, Cognitive (50%)
470 outpatients with mixed psychiatric diagnoses PCA with varimax 4 factors: Subjective, Neurophysiological,
Autonomic, Panic
250 inpatients with mixed psychiatric diagnoses PFA with promax: 2 factors: Somatic, Subjective (90%)
367 outpatients with anxiety disorders PCA with varimax 4 factors: Subjective, Neurophysiological,
Autonomic, Panic
217 older adults PAF with promax 2 factors: Somatic, Subjective
105 outpatients with psychiatric disorders PFA with promax 2 factors: Somatic, Subjective (82%)
717 undergraduates PFA oblique 2 factors: Somatic, Subjective
281 older adults PAF with varimax 6 factors: Somatic, Fear, Autonomic
Hyperactivity, Panic, Nervousness, Motor Tension (65%)
50 undergraduates with hearing impairments 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
108 patients PCA quartimax 5 factors: Somatic/Balance, Subjective,
Somatic/Hot, Physical/Choking, Physical/Panic
3,813 undergraduates 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
525 outpatients with anxiety diagnoses 2nd-order factor (70%); Somatic (37%) and Subjective (6%)
were two 1st-order factors
225 community members PCA 4 factors (65%): Subjective, Neurophysiological,
Autonomic, Panic
303 adults with sleep apnea PAF with varimax 1 factor
240 adolescent inpatients PAF with varimax and promax, then tweaked Kumar et al.’s
(1993) 4-factor model
326 undergraduates PAF with promax 2 factors: Somatic, Cognitive (79%)
108 adolescent inpatients PAF with promax 2 factors: Subjective, Somatic (79%)
420 clinical adults and undergraduates PAF with varimax 2 factors: Somatic, Subjective

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 Subjec-
tive. 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., So-
matic, 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 Sub-
jective 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

360 Journal of Counseling & Development  ■  July 2016  ■  Volume 94

Psychometric Meta-Analysis of the English Version of the Beck Anxiety Inventory

Table 3
Confirmatory Factor Analysis (CFA) Study Results
Article Sample No. of Factors CFI TLI NNFI GFI NFI RMSEA
Osman et 225 community 2-factor (Beck et al., 1988) .72 .12
al. (1993) members 1-factor .56
Borden et al. (1991) 5-factor (Subjective, Somatic, .81 .08
Neurophysiological, Muscular/Motoric, Respiration)
Chapman 120 White nonclinical Beck et al. (1988) 2-factor (Somatic, Subjective) .90 .91 .14
et al. adults Osman et al. (2002) 4-factor (Neurophysiological, Subjective, .92 .94 .12
(2009) Autonomic, Panic)
Morin et al. (1999) 6-factor (Somatic, Fear, Autonomic .97 .98 .07
Hyperactivity, Panic, Nervousness, Motor Tension)
Current study 2-factor (Somatic, Cognitive) .97 .98 .06
Chapman 100 African American Beck et al. (1988) 2-factor (Somatic, Subjective) .88 .86 .12
et al. nonclinical adults Osman et al. (2002) 4-factor (Neurophysiological, Subjective, .89 .91 .11
(2009) Autonomic, Panic)
Morin et al. (1999) 6-factor (Somatic, Fear, Autonomic .92 .93 .09
Hyperactivity, Panic, Nervousness, Motor Tension)
Current study 2-factor (Somatic, Cognitive) .92 .93 .09
Osman et 240 adolescent CFA Beck et al. (1988) 2-factor (Somatic, Subjective) .77 .75 .11
al. (2002) inpatients CFA Kumar et al. (1993) 2-factor (Somatic, Subjective) .83 .81 .10
Enns et al. 137 outpatients 1-factor .66 .62 .66
(1998) Hewitt & Norton (1993) 2-factor (Somatic, Cognitive) .73 .70 .72
Steer, Beck, et al. (1993) 2-factor (Somatic, Subjective) .69 .66 .70
Steer, Kumar, & Beck (1993) 4-factor (Cognitive, Autonomic, .86 .84 .86
Neuromotor, Panic)
Wetherell 197 older adults 1-factor .79
& Arean 2-factor (Beck et al., 1988) .86
(1997) 3-factor (Cognitive, Somatic, Panic) .87
4-factor (Cognitive, Autonomic, Neuromotor, Panic) .88
2nd-order 4-factor .88
Osman et 350 undergraduates 1-factor .89 .87 .86 .04
al. (1997) Beck et al. (1988) 2-factor (Somatic, Subjective) .89 .89 .87 .04
Beck & Steer (1991) and Osman et al. (1993) 4-factor .93 .92 .91 .03
(Subjective, Neurophysiological, Autonomic, and Panic)
2nd order 4-factor .93 .92 .91 .03
D. R. 420 clinical adults 1-factor .79 .76
Peterson and undergradu- Beck et al. (1988) 2-factor (Somatic, Subjective) .86 .84
(1995) ates EFA-derived 3-factor .88 .86
Beck & Steer (1991) 4-factor (Subjective, Neurophysiological, .93 .92
Autonomic, Panic)
Borden et al. (1991) 5-factor (Subjective, Somatic, .93 .92
Neurophysiological, Muscular, Respiratory)
2nd-order factor .93 .92

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.

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, Au-
tonomic, 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 ar-
ticles, 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 di-
mensions proposed by Morin et al. (1999). The CFIs ranged
from .92 to .97 and the RMSEAs ranged from .07 to .09, thus

Journal of Counseling & Development  ■  July 2016  ■  Volume 94 361

 Bardhoshi, Duncan, & Erford

indicating a marginal-to-adequate fit of the data to the Morin Diagnostic Validity

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) un-
derlies 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.
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 sum-
marized 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. Prac-
titioners 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. Sen-
sitivity measures the proportion of participants with sig-
nificant 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,

Table 4
Diagnostic Validity Study Results
Article Cutoff Sensitivity Specificity PPP NPP % CC AUC Sample
Hopko et al. (2008) 10 .83 .89 .95 NPV 85 33 patients with cancer
16 .67 .89 .94 73
Carney et al. (2011) 16 .55 .78 .71 207 patients with insomnia
8 .82 .49
Blom et al. (2010) 13 .77 136 females with depression/anxiety
Diefenbach et al. (2009) 7 .77 .49 .37 .84 57 .63 66 older adults with home care services
Eack et al. (2008) 288 distressed adult women (child
Minimum sensitivity 7 .87 .53 .60 .83 treatment)
Optimal 12 .70 .74 .69 .75
Minimum specificity 14 .62 .80 .72 .72 40 older adults
Dennis et al. (2007) 7 .85 .25 55
15 .70 .75 72
Leyfer et al. (2006) 193 undergraduates
Panic disorder 8 .89 .97 .41 1.00
GAD 3 .75 .73 .08 .99
Phobia 5 .68 .86 .46 .94
Any anxiety diagnosis 5 .76 .77 .41 .94
Manne et al. (2001) 14 .73 .43 .28 .84 50 115 mothers with children with cancer
16 .60 .57 .30 .82 58
18 .53 .65 .32 .82 63
Cochrane-Brink et al. (2000) 26 1.00 .38 1.00 .28 55 adults with suicidal ideation
Kabacoff et al. (1997) 10 .94 .45 .30 .97 55 170 older adults with mixed psychiatric
12 .86 .49 .30 .93 56 disorders
14 .69 .55 .28 .88 58
16 .67 .62 .31 .88 63
Somoza et al. (1994) 25 .70 142 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.

362 Journal of Counseling & Development  ■  July 2016  ■  Volume 94

Psychometric Meta-Analysis of the English Version of the Beck Anxiety Inventory
however, may rely on the lowest difference between sen-
sitivity 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 de-
termined 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 psycho-
metric characteristics of this instrument. These results provide
strong estimates of internal consistency across both clinical
(α = .91, k = 61, n = 18,015) and nonclinical (α = .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
Journal of Counseling & Development  ■  July 2016  ■  Volume 94
consistency estimates exceed the recommended minimum
criteria for both screening level and diagnostic evaluation
purposes—suggested by Erford (2013) as α = .80 and α =
.90, respectively—and give counselors confidence that client
scores can be consistently derived.
Conversely, the test–retest reliability estimates for the cur-
rent 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 substan-
tially 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 esti-
mates by analyzing results across 12 articles, with an overall rtt
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 valid-
ity coefficients presented in Table 1 yielded robust estimates
across all 33 discrete anxiety and related measures identi-
fied 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 cor-
relations 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 re-
ported 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 (Ameri-
can 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
363

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 nonclini-
cal 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 combina-
tion 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 Cogni-
tive dimensions, was reported by two EFA studies. Four EFA
studies proposed a four-factor model (i.e., Subjective, Neuro-
physiological, 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 indi-
cated 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., Sub-
jective, 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.
364 Journal of Counseling & Development  ■  July 2016  ■  Volume 94
Bardhoshi, Duncan, & Erford
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 stud-
ies 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 dimensional-
ity 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 re-
spect 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 stud-
ies 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 war-
ranted to determine the potential clinical significance of the
Psychometric Meta-Analysis of the English Version of the Beck Anxiety Inventory
BAI’s overidentification of anxiety in females and underi-
dentification 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 instru-
ment, 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 psychomet-
ric 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 popula-
tions, 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 con-
vergent 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, conserva-
tive 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 ver-
sion 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 cor-
Journal of Counseling & Development  ■  July 2016  ■  Volume 94
relations 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, suf-
ficient 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 con-
sistency across clinical and nonclinical samples, thus indicat-
ing 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 dif-
ferentiate 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).
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