Beck Anxiety Inventory

Aim: To measure the symptoms of anxiety using ‘Beck Anxiety Inventory’ (Beck and Steel,
1993).

Basic Concepts:

Experience of anxiety

Anxiety

The term anxiety is usually defined as a very unpleasant feeling or apprehension accompanied by
feelings of impending doom. It is free floating and not attached to a specific object.

Fear and anxiety

Anxiety is often distinguished from fear which is attached to a specific object. Also while
anxiety is more future oriented; fear is more present oriented or related to imminent danger.

Lang [1968] classified the symptoms of fear and anxiety into a system of three-responses:
verbal-subjective, overt motor acts, and somato-visceral activity. In this system, the symptoms of
anxiety include

• (verbal-subjective), Worry involves thoughts of future threat. It involves ‘self talk’ is

considered the cognitive element of anxiety.

• (overt motor acts), avoidance

• (somato-visceral activity), Central nervous system hyperarousal (especially cortical regions)

leading to over responsiveness or hyper alertness (‘hypervigilance’). This can cause symptoms
such as restlessness, and muscle tension

Fear symptoms include

• (verbal-subjective), thoughts of imminent threat

• (overt motor), escape and

• (somato-visceral,) Autonomic hyperarousal (peripheral nervous system) resulting in
overstimulation of the sympathetic system leading to physical symptoms such as sweating,
trembling, heart palpitations, and nausea. This system is associated with ‘flight’ or ‘fight’
reaction.

Normal versus abnormal anxiety response

Anxiety is a natural and a necessary response to threat or stress as it alerts the person to carry out
certain acts that reduce the danger (e.g. working hard for the exam). However, anxiety can
become a pathologic disorder when it is ‘excessive and uncontrollable’ i.e., if it is
developmentally inappropriate (e.g., fear of separation in a 10-year-old child) or if it is
inappropriate to an individual's life circumstances (e.g., worries about unemployment in a
successful business executive).

ICD – 10 (F40-F48)

Neurotic, stress-related, and somatoform disorders

Neurotic, stress-related, and somatoform disorders have been brought together in one large
overall group because of their historical association with the concept of neurosis and the
association of a substantial (though uncertain) proportion of these disorders with psychological
causation.

F40 Phobic anxiety disorder

In this group of disorders, anxiety is evoked only, or predominantly, by certain well-defined

situations or objects (external to the individual) which are not currently dangerous. As a result,
these situations or objects are characteristically avoided or endured with dread. Phobic anxiety is
indistinguishable subjectively, physiologically, and behaviourally from other types of anxiety
and may vary in severity from mild unease to terror. The individual's concern may focus on
individual symptoms such as palpitations or feeling faint and is often associated with secondary
fears of dying, losing control, or going mad. The anxiety is not relieved by the knowledge that
other people do not regard the situation in question as dangerous or threatening. Mere
contemplation of entry to the phobic situation usually generates anticipatory anxiety.
● F40.0 Agoraphobia
● .00 Without panic disorder
● .01 With panic disorder
● F40.1 Social phobias
● F40.2 Specific (isolated) phobias
● F40.8 Other phobic anxiety disorders
● F40.9 Phobic anxiety disorder, unspecified

F41 Other anxiety disorders

Manifestations of anxiety are the major symptoms of these disorders and are not restricted to any
particular environmental situation. Depressive and obsessional symptoms, and even some
elements of phobic anxiety, may also be present, provided that they are clearly secondary or less
severe.

● F41.0 Panic disorder [episodic paroxysmal anxiety]

● F41.1 Generalized anxiety disorder
● F41.2 Mixed anxiety and depressive disorder
● F41.3 Other mixed anxiety disorders
● F41.8 Other specified anxiety disorders
● F41.9 Anxiety disorder, unspecified

F42 Obsessive-Compulsive disorder

The essential feature of this disorder is recurrent obsessional thoughts or compulsive acts. (For
brevity, "obsessional" will be used subsequently in place of "obsessive-compulsive" when
referring to symptoms.) Obsessional thoughts are ideas, images or impulses that enter the
individual's mind again and again in a stereotyped form. They are almost invariably distressing
(because they are violent or obscene, or simply because they are perceived as senseless) and the
sufferer often tries, unsuccessfully, to resist them. They are, however, recognized as the
individual's own thoughts, even though they are involuntary and often repugnant. Compulsive
acts or rituals are stereotyped behaviours that are repeated again and again. They are not
inherently enjoyable, nor do they result in the completion of inherently useful tasks. The
individual often views them as preventing some objectively unlikely event, often involving harm
to or caused by himself or herself. Usually, though not invariably, this behaviour is recognized
by the individual as pointless or ineffectual and repeated attempts are made to resist it; in very
long-standing cases, resistance may be minimal. Autonomic anxiety symptoms are often present,
but distressing feelings of internal or psychic tension without obvious autonomic arousal are also
common.

● F42.0 Predominantly obsessional thoughts or ruminations

● F42.1 Predominantly compulsive acts [obsessional rituals]
● F42.2 Mixed obsessional thoughts and acts
● F42.8 Other obsessive-compulsive disorders
● F42.9 Obsessive-compulsive disorder, unspecified

F43Reaction to severe stress and adjustment disorder

This category differs from others in that it includes disorders identifiable not only on grounds of
symptomatology and course but also on the basis of one or other of two causative influences - an
exceptionally stressful life event producing an acute stress reaction, or a significant life change
leading to continued unpleasant circumstances that result in an adjustment disorder. Less severe
psychosocial stress ("life events") may precipitate the onset or contribute to the presentation of a
very wide range of disorders classified elsewhere in this work, but the etiological importance of
such stress is not always clear and in each case will be found to depend on individual, often
idiosyncratic, vulnerability. In other words, the stress is neither necessary nor sufficient to
explain the occurrence and form of the disorder. In contrast, the disorders brought together in
this category are thought to arise always as a direct consequence of the acute severe stress or
continued trauma. The stressful event or the continuing unpleasantness of circumstances is the
primary and overriding causal factor, and the disorder would not have occurred without its
impact.

● F43.0 Acute stress reaction

● F43.1 Post-traumatic stress disorder
● F43.2 Adjustment disorders
● .20 Brief depressive reaction
● .21 Prolonged depressive reaction
● .22 Mixed anxiety and depressive reaction
● .23 With predominant disturbance of other emotions
● .24 With predominant disturbance of conduct
● .25 With mixed disturbance of emotions and conduct
● .28 With other specified predominant symptoms
● F43.8 Other reactions to severe stress
● F43.9 Reaction to severe stress, unspecified

F44 Dissociative or conversion disorders

The common theme shared by dissociative (or conversion) disorders is a partial or complete loss
of the normal integration between memories of the past, awareness of identity, immediate
sensations, and control of bodily movements. There is normally a considerable degree of
conscious control over the memories and sensations that can be selected for immediate attention,
and the movements that are to be carried out. In the dissociative disorders it is presumed that this
ability to exercise a conscious and selective control is impaired, to a degree that can vary from
day to day or even from hour to hour. It is usually very difficult to assess the extent to which
some of the loss of functions might be under voluntary control.

● F44.0 Dissociative amnesia

● F44.1 Dissociative fugue
● F44.2 Dissociative stupor
● F44.3 Trance and possession disorders
● F44.4 Dissociative motor disorders
● F44.5 Dissociative convulsions
● F44.6 Dissociative anaesthesia and sensory loss
● F44.7 Mixed dissociative [conversion] disorders
● F44.8 Other dissociative [conversion] disorders
-.80 Ganser's syndrome
-.81 Multiple personality disorder
-.82 Transient dissociative [conversion] disorders occurring in childhood and adolescence
-.88 Other specified dissociative [conversion] disorders
● F44.9 Dissociative [conversion] disorder, unspecified

F45 Somatoform disorders

The main feature of somatoform disorders is repeated presentation of physical symptoms,

together with persistent requests for medical investigations, in spite of repeated negative findings
and reassurances by doctors that the symptoms have no physical basis. If any physical disorders
are present, they do not explain the nature and extent of the symptoms or the distress and
preoccupation of the patient. Even when the onset and continuation of the symptoms bear a close
relationship with unpleasant life events or with difficulties or conflicts, the patient usually resists
attempts to discuss the possibility of psychological causation; this may even be the case in the
presence of obvious depressive and anxiety symptoms. The degree of understanding, either
physical or psychological, that can be achieved about the cause of the symptoms is often
disappointing and frustrating for both patient and doctor.
In these disorders there is often a degree of attention-seeking (histrionic) behaviour, particularly
in patients who are resentful of their failure to persuade doctors of the essentially physical nature
of their illness and of the need for further investigations or examinations.

● F45.0 Somatization disorder

● F45.1 Undifferentiated somatoform disorder
● F45.2 Hypochondriacal disorder
● F45.3 Somatoform autonomic dysfunction
-.30 Heart and cardiovascular system
-.31 Upper gastrointestinal tract
-.32 Lower gastrointestinal tract
-.33 Respiratory system
-.34 Genitourinary system
-.38 Other organ or system
● F45.4 Persistent somatoform pain disorder
● F45.8 Other somatoform disorders
● F45.9 Somatoform disorder, unspecified

F48 Other neurotic disorders

Neurasthemia

Considerable cultural variations occur in the presentation of this disorder; two main types occur,
with substantial overlap. In one type, the main feature is a complaint of increased fatigue after
mental effort, often associated with some decrease in occupational performance or coping
efficiency in daily tasks. The mental fatiguability is typically described as an unpleasant
intrusion of distracting associations or recollections, difficulty in concentrating, and generally
inefficient thinking. In the other type, the emphasis is on feelings of bodily or physical weakness
and exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pains
and inability to relax. In both types, a variety of other unpleasant physical feelings, such as
dizziness, tension headaches, and a sense of general instability, is common. Worry about
decreasing mental and bodily well-being, irritability, anhedonia, and varying minor degrees of
both depression and anxiety are all common. Sleep is often disturbed in its initial and middle
phases but hypersomnia may also be prominent.

Depersonalization-derealization disorder
A disorder in which the sufferer complains that his or her mental activity, body, and/or
surroundings are changed in their quality, so as to be unreal, remote, or automatized. Individuals
may feel that they are no longer doing their own thinking, imaging, or remembering; that their
movements and behaviour are somehow not their own; that their body seems lifeless, detached,
or otherwise anomalous; and that their surroundings seem to lack colour and life and appear as
artificial, or as a stage on which people are acting contrived roles. In some cases, they may feel
as if they were viewing themselves from a distance or as if they were dead. The complaint of loss
of emotions is the most frequent among these varied phenomena.

DSM IV-TR

Panic Disorder

A Panic Attack is a discrete period in which there is the sudden onset of intense apprehension,
fearfulness, or terror, often associated with fee lings of impending doom. During these attacks,
symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or
smothering sensations, and fear of "going crazy" or losing control are present.

The essential feature of Panic Disorder is the presence of recurrent, unexpected Panic Attacks
followed by at least 1 month of persistent concern about having another Panic Attack, worry
about the possible implications or consequences of the Panic Attacks, or a Significant behavioral
change related to the attacks (Criterion A). The Panic Attacks are not due to the direct
physiological effects of a substance (e.g., Caffeine Intoxication) or a general medical condition
(e.g., hyperthyroidism) (Criterion C). Finally, the Panic Attacks are not better accounted for by
another mental disorder (e.g., Specific or Social Phobia, Obsessive-Compulsive Disorder,
Posttraumatic Stress Disorder, or Separation Anxiety Disorder) (Criterion D).

An unexpected (spontaneous, uncued) Panic Attack is defined as one that an individual does not
immediately associate with a situational trigger (i.e., it is perceived as occurring "out of the
blue"). Situational triggers can include stimuli that are either external (e.g., a phobic object or
situation) or internal (e.g., physiological arousal) to the individual. In some instances, although a
situational trigger may be apparent to the clinician, it may not be readily identifiable to the
individual experiencing the Panic Attack.
Phobia

Phobia is characterized by clinically significant anxiety provoked by exposure to a specific

feared object or situation, often leading to avoidance behavior.

The essential feature of Specific Phobia is marked and persistent fear of clearly discernible,
circumscribed objects or situations (Criterion A). Exposure to the phobic stimulus almost
invariably provokes an immediate anxiety response (Criterion B). This response may take the
form of a situationally bound or situationally predisposed Panic Attack. Although adolescents
and adults with this disorder recognize that their fear is excessive or reasonable (Criterion C),
this may not be the case with children. Most often, the phobic stimulus is avoided, although it is
sometimes endured with d read (Criterion D). The diagnosis is appropriate only if the avoidance,
fear, or anxious anticipation of encountering the phobic stimulus interferes significantly with the
person's daily routine, occupational functioning, or social life, or if the person is markedly
distressed about having the phobia (Criterion E). In individuals under age 18 years, symptoms
must have persisted for at least 6 months before Specific Phobia is diagnosed (Criterion F). The
anxiety, Panic Attacks, or phobic avoidance are not better accounted for by another mental
disorder (e.g., Obsessive Compulsive Disorder, Posttraumatic Stress Disorder, Separation
Anxiety Disorder, Social Phobia, Panic Disorder With Agoraphobia, or Agoraphobia Without
History of Panic Disorder) (Criterion G).

The individual experiences a marked, persistent, and excessive or unreasonable fear when in the
presence of, or when anticipating an encounter with, a specific object or situation. The focus of
the fear may be anticipated harm from some aspect of the object or situation (e.g., an individual
may fear air travel because of a concern about crashing, may fear dogs because of concerns
about being bitten, or may fear driving because of concerns about being hi t by other vehicles on
the road). Specific Phobias may also involve concerns about losing control, panicking, somatic
manifestations of anxiety and fear (such as increased heart rate or shortness of breath), and
fainting that might occur on exposure to the feared object.

Anxiety is almost invariably felt immediately on confronting the phobic stimulus (e.g., a person
with a Specific Phobia of cats will almost invariably have an immediate anxiety response when
forced to confront a cat). The level of anxiety or fear usually varies as a function of both the
degree of proximity to the phobic stimulus (e.g., fear intensifies as the cat approaches and
decreases as the cat withdraws) and the degree to which escape from the phobic stimulus is
limited (e.g., fear intensifies as the elevator approaches the midway point between floors and
decreases as the doors open at the next floor).

Obsessive-Compulsive disorder

Obsessive-Compulsive Disorder is characterized by obsessions (which cause marked anxiety or

distress) and / or by compulsions (which serve to neutralize anxiety).

The essential features of Obsessive-Compulsive Disorder are recurrent obsessions or

compulsions (Criterion A) that are severe enough to be time consuming (i.e., they take more than
1 hour a day) or cause marked distress or significant impairment (Criterion C). At some point
during the course of the disorder, the person has recognized that the obsessions or compulsions
are excessive or unreasonable (Criterion B). 1f another Axis I disorder is present, the content of
the obsessions or compulsions is not restricted to it (Criterion D). The disturbance is not due to
the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (Criterion E).

Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive
and inappropriate and that cause marked anxiety or distress. The most common obsessions are
repeated thoughts about contamination (e.g., becoming contaminated by shaking hands),
repeated doubts (e.g., wondering whether one has performed some act such as having hurt
someone in a traffic accident or having left a door unlocked), a need to have things in a particular
order (e.g., intense distress when objects are disordered or asymmetrical), aggressive or horrific
impulses (e.g., to hurt one's child or to shout an obscenity in church), and sexual imagery (e.g., a
recurrent pornographic image). The individual with obsessions usually attempts to ignore or
suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e.,
a compulsion).

Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts
(e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce
anxiety or distress, not to provide pleasure or g ratification. In most cases, the person feels driven
to perform the compulsion to reduce the distress that accompanies an obsession or to prevent
some dreaded event or situation.

The obsessions or compulsions must cause marked distress, be time consuming (take more than
1 hour per day), or Significantly interfere with the individual's normal routine, occupational
functioning, or usual social activities or relationships with others. Obsessions or compulsions can
displace useful and satisfying behavior and can be highly disruptive to overall functiOning.
Because obsessive intrusions can be distracting, they frequently result in inefficient performance
of cognitive tasks that require concentration, such as reading or computation. In addition, many
individuals avoid objects or situations that provoke obsessions or compulsions. Such avoidance
can become extensive and can severely restrict general functioning.

Posttraumatic stress disorder

Posttraumatic Stress Disorder is characterized by the re-experiencing of an extremely traumatic

event accompanied by symptoms of increased arousal and by avoidance of stimuli associated
with the trauma.

The essential feature of Posttraumatic Stress Disorder is the development of characteristic

symptoms following expose to an extreme traumatic stress or involving direct personal
experience of an even t that involves actual or threatened death or serious injury, or other threat
to one's physical integrity ; o r witnessing an even t that involves death, injury , o r a threat to the
physical integrity o f another person; or learning about unexpected or violent death, serious
harm, or threalt of death or injury experienced by a family member o r other close associate
(Criterion AI ). The person's response to the event must involve intense fear, helplessness, or
horror (or in children, the response must involve disorganized or agitated behavior) (Criterion
A2). The characteristic symptoms resulting from the expose to the extreme trauma include
persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli
associated with the trauma and numbing of general responsiveness (Criterion C), and persistent
symptoms of increased arousal (Criterion D). The full symptom picture must be present fo r
more than 1 month (Criterion E), and the disturbance must cause clinically significant di tress or
impairment in social, occupational, or other important areas of functioning (Criterion F).

Acute stress disorder

Acute Stress Disorder is characterized by symptoms similar to those of Posttraumatic Stress
Disorder that occur immediately in the aftermath of an extremely traumatic event.

The essential feature of Acute Stress Disorder is the development of characteristic anxiety,
dissociative, and other symptoms that occurs within 1 month after exposure to an extreme
traumatic stressor (Criterion A). For a discussion of the types of stressors involved, see the
description of Posttraumatic Stress Disorder. Either while experiencing the traumatic event or
after the event, the individual has at least three of the following dissociative symptoms: a
subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in
awareness of his or her surroundings; derealization; depersonalization; or dissociative amnesia
(Criterion B). Following the trauma, the traumatic event is persistently reexperienced (Criterion
C), and the individual displays marked avoidance of stimuli that may arouse recollections of the
trauma (Criterion D) and has marked symptoms of anxiety or increased arousal (Criterion E).
The symptoms must cause clinically significant distress, significantly interfere with normal
functioning, or impair the individual's ability to pursue necessary tasks (Criterion F). The
disturbance lasts for a minimum of 2 days and a maximum of 4 weeks after the traumatic event
(Criterion G); if symptoms persist beyond 4 weeks, the diagnosis of Posttraumatic Stress
Disorder may be applied. The symptoms are not due to the direct physiological effects of a
substance (i.e., a drug of abuse, a medication) or a general medical condition, are not better
accounted for by Brief Psychotic Disorder, and are not merely an exacerbation of a preexisting
mental disorder (Criterion H).

As a response to the traumatic event, the individual develops dissociative symptoms. Individuals
with Acute Stress Disorder may have a decrease in emotional responsiveness, often finding it
difficult or impossible to experience pleasure in previously enjoyable activities, and frequently
feel guilty about pursuing usual life tasks. They may experience difficulty concentrating, feel
detached from their bodies, experience the world as unreal or dreamlike, or have increasing
difficulty recalling specific details of the traumatic event (dissociative amnesia). In addition, at
least one symptom from each of the symptom clusters required foe Posttraumatic Stress Disorder
is present. First, the traumatic event is persistently reexperienced (e.g., images, thoughts, dreams,
illusions, flashback episodes, a sense of reliving the event, or distress on exposure to reminders
of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided.
Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty
sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and
motor restlessness).

Generalized anxiety disorder

The essential feature of Generalized Anxiety Disorder is excessive anxiety and worry
(apprehensive expectation), occurring more days than not for a period of at least 6 months, about
a number of events or activities (Criterion A). The individual finds it difficult to control the
worry (Criterion B). The anxiety and worry are accompanied by at least three additional
symptoms from a list that includes restlessness, being easily fatigued, difficulty concentrating,
irritability, muscle tension, and disturbed sleep (only one add tional symptom is required in
children) (Criterion C). The focus of the anxiety and worry is not confined to features of another
Axis I disorder such as having a Panic Attack (as in Panic Disorder), being embarrassed in public
(as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away
from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia
Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious
illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during
Posttraumatic Stress Disorder (Criterion D). Although individuals with Generalized Anxiety
Disorder may not always identify the worries as "excessive," they report subjective distress due
to constant worry, have difficulty controlling the worry, or experience related impairment in
social, occupational, or other important areas of functioning (Criterion E). The disturbance is nol
due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin
exposure) or a general medical condition and does not occur exclusively during a Mood
Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder (Criterion F).

The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the
actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome
thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry.
Adults with Generalized Anxiety Disorder often worry about everyday routine We circumstances
such as possible job responsibilities, finances, the health of family members, misfortune to their
children, or minor matters (such as household chores, car repairs, or being late for appointments).
Children with Generalized Anxiety Disorder tend to worry excessively about their competence or
the quality of their performance. During the course of the disorder, the focus of worry may shift
from one concern to another.

Changes from DSM IV-TR to DSM V

The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder

(which is included with the obsessive-compulsive and related disorders) or posttraumatic stress
disorder and acute stress disorder (which is included with the trauma- and stressor-related
disorders). However, the sequential order of these chapters in DSM-5 reflects the close
relationships among them.

Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia)

Changes in criteria for agoraphobia, specific phobia, and social anxiety disorder (social phobia)
include deletion of the requirement that individuals over age 18 years recognize that their anxiety
is excessive or unreasonable. This change is based on evidence that individuals with such
disorders often overestimate the danger in “phobic” situations and that older individuals often
misattribute “phobic” fears to aging. Instead, the anxiety must be out of proportion to the actual
danger or threat in the situation, after taking cultural contextual factors into account. In addition,
the 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now
extended to all ages. This change is intended to minimize overdiagnosis of transient fears.

Panic Attack

The essential features of panic attacks remain unchanged, although the complicated DSM-IV
terminology for describing different types of panic attacks (i.e., situationally bound/cued,
situationally predisposed, and unexpected/uncued) is replaced with the terms unexpected and
expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of
diagnosis, course, and comorbidity across an array of disorders, including but not limited to
anxiety disorders. Hence, panic attack can be listed as a specifier that is applicable to all DSM-5
disorders.

Panic Disorder and Agoraphobia

Panic disorder and agoraphobia are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of
panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without
history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia,
each with separate criteria. The co-occurrence of panic disorder and agoraphobia is now coded
with two diagnoses. This change recognizes that a substantial number of individuals with
agoraphobia do not experience panic symptoms. The diagnostic criteria for agoraphobia are
derived from the DSM-IV descriptors for agoraphobia, although endorsement of fears from two
or more agoraphobia situations is now required, because this is a robust means for distinguishing
agoraphobia from specific phobias. Also, the criteria for agoraphobia are extended to be
consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as
being out of proportion to the actual danger in the situation, with a typical duration of 6 months
or more).

Specific Phobia

The core features of specific phobia remain the same, but there is no longer a requirement that
individuals over age 18 years must recognize that their fear and anxiety are excessive or
unreasonable, and the duration requirement (“typically lasting for 6 months or more”) now
applies to all ages. Although they are now referred to as specifiers, the different types of specific
phobia have essentially remained unchanged.

Social Anxiety Disorder (Social Phobia)

The essential features of social anxiety disorder (social phobia) (formerly called social phobia)
remain the same. However, a number of changes have been made, including deletion of the
requirement that individuals over age 18 years must recognize that their fear or anxiety is
excessive or unreasonable, and duration criterion of “typically lasting for 6 months or more” is
now required for all ages. A more significant change is that the “generalized” specifier has been
deleted and replaced with a “performance only” specifier. The DSM-IV generalized specifier
was problematic in that “fears include most social situations” was difficult to operationalize.
Individuals who fear only performance situations (i.e., speaking or performing in front of an
audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age
at onset, physiological response, and treatment response.
Separation Anxiety Disorder

Although in DSM-IV, separation anxiety disorder was classified in the section “Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence,” it is now classified as an
anxiety disorder. The core features remain mostly unchanged, although the wording of the
criteria has been modified to more adequately represent the expression of separation anxiety
symptoms in adulthood. For example, attachment figures may include the children of adults with
separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at
school. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset
must be before 18 years, because a substantial number of adults report onset of separation
anxiety after age 18. Also, a duration criterion—“typically lasting for 6 months or more”—has
been added for adults to minimize overdiagnosis of transient fears.

Selective Mutism

In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence.” It is now classified as an anxiety disorder, given that a
large majority of children with selective mutism are anxious. The diagnostic criteria are largely
unchanged from DSM-IV.

Tool Used; Beck Anxiety Inventory (Beck and Steer, 1993)

Purpose

The BAI is a self-report questionnaire measuring 21 common somatic and cognitive symptoms
of anxiety. It is a rating scale used to evaluate the severity of anxiety symptoms.

Content

The items reflect symptoms of anxiety, including: numbness or tingling, feeling hot, wobbliness
in legs, ability to relax, fear of the worst happening, dizziness or lightheadedness, pounding or
racing heart, unsteadiness, feeling terrified, feeling nervous, feeling of choking, hands trembling,
feeling shaky, fear of losing control, difficulty breathing, fear of dying, feeling scared,
indigestion or abdominal discomfort, faintness, face flushing, and sweating.
Number of items

It consists of 21 items.

Response options/scale

It uses Likert scale ranging from 0 to 3. Each item allows the patient four choices from no
symptom to severe symptom. For each item, the patient is asked to report how he or she has felt
during the past week. The items are scored as 0, 1, 2, or 3. The score range is 0–63. A total score
of 0–7 is considered minimal range, 8–15 is mild, 16–25 is moderate, and 26–63 is severe.

Examples of use

The BAI is used in efforts to obtain a purer measure of anxiety that is relatively independent of
depression. Increasing use of this measure has been observed in a number of rheumatic
conditions including fibromyalgia and arthritis.

Method of administration

Self-administered or verbally by a trained administrator

Score interpretation

Manual scoring- Scoring is easily accomplished by summing scores for items. The total score
ranges from 0–63. The following guidelines are recommended for the interpretation of scores: 0–
9, normal or no anxiety; 10–18, mild to moderate anxiety; 19–29, moderate to severe anxiety;
and 30–63, severe anxiety. Q-global scoring is also available.

Reading level required

The instructions for the BAI are written at an 8.3 grade level.

Time for completion

The BAI takes 5 to 10 minutes when it is self-administered. Oral administration usually takes 10
minutes.

Translations/adaptations
The BAI is distributed by Pearson Assessments in English and Spanish. It is also validated in a
number of languages, including German, French, Chinese, Spanish, Persian, Nepal, Icelandic,
and others

Psychometric information

Reliability-
Robles et al. [26] reported good internal consistency (α = 0.83), a high weekly test-retest
correlation (r = 0.75) and high correlations with states of anxiety (r = 0.60) and STAI anxiety
traits (r = 0.59) in the adult population

With their diagnostically mixed sample of 160 outpatients, Beck, Epstein, Brown, & Steer
(1988) reported that the BAI had high internal consistency reliability (alpha=.92). Fydrich,
Dowdall, & Chambless (1992) found a slightly higher level of internal consistency (.94) in 40
patients diagnosed as having DSM-III-R anxiety disorders.

A sub sample of 83 outpatients from Beck, Epstein et al. (1988) study completed the BAI one
week after their intake evaluation and before starting cognitive therapy. The correlation between
intake and one week scores was .75 (p <.001)

Validity-
Numerous studies have examined the BAI’s relationship to other measures and have found
evidence for its convergent and discriminant validity. The BAI has been found to correlate
moderately with the Hamilton Anxiety Rating scale (Beck et al., 1988) and the State-Trait
Anxiety Inventory (STAI), with no difference between correlations with Trait and State scales
(Creamer et al., 1995). The BAI typically shows lower correlations with the BDI than does the
STAI or other measures of anxiety, suggesting it has better discriminant validity.

Although the BAI appears to be less correlated with depression scales than the STAI,
correlations with depression scales remain substantial (e.g., correlation with Beck Depression
Inventory r = 0.61).
Numerous studies, including in other cultures, have identified a gender difference, with females
scoring higher than males, in both adult and adolescent samples. Osman et al. (2002) suggest that
this difference suggests the need for validating the BAI separately by gender.

Ability to Detext Change: the BAI has been demonstrated to be responsive to change over time
both on psychiatric populations (27) and in medical populations (28). One study tested the BAI
longitudinally over the course of a treatment trial (duloxetine) for the treatment of fibromyalgia
and did not show a significant BAI change over time; however, it is important to note that
anxiety was not the targeted outcome of this study.

Critical appraisal

Strengths:

• The BAI is a relatively brief, easily administered, and easily scored measure of anxiety.

• It has sound psychometric properties and has demonstrated sensitivity to change.

• The 21 questions are accurate predictors of anxiety disorders, which makes this screening tool
useful in diagnosing clients.

• The measure can either be self-reported or orally administered

• Compared to other measures of anxiety, the BAI better discriminates anxiety symptoms from
depression.

Limitation:

• The BAI has been criticized for its predominant focus on physical symptoms of anxiety (most
akin to a panic response).

• The primary limitations for the BAI are the relatively limited scope of symptoms evaluated and
the lack of validation studies specific to rheumatology populations.

• More research is needed involving samples with greater ethnic and socioeconomic diversity.
• The BAI was developed in an attempt to reduce overlap with depressive symptoms, and as a
result tends to focus more exclusively on somatic (e.g., heart racing, dizziness) symptoms. In
medical conditions, these symptoms have the propensity to overlap with some physical aspects
of medical conditions and, therefore, cautious interpretation would be warranted.

• A number of researchers have suggested that the BAI may be tapping more physiological
aspects of anxiety such as panic. The physiological aspect of anxiety is, however, an important
aspect to assess in PTSD, given the high comorbidity of PTSD and panic and research studies
showing that many individuals experience panic symptoms during trauma exposure and that such
symptoms are related to later symptomatology (Bryant & Panasetis, 2001; Nixon & Bryant,
2003).

• The BAI does not assess other primary symptoms of anxiety, most notably worry and other
cognitive aspects of anxiety.

• Given the research suggesting that females score higher than males, separate norms are needed
by gender.

Related Studies
Eack, Singer & Greeno (2008) examined the ability of the Beck Anxiety and Depression
Inventories to identify anxiety and depression in community settings. The diagnostic accuracy of
these instruments was compared with the Structured Clinical Interview for DSM-IV in a sample
of 288 distressed women seeking treatment for their children. Operating characteristic curves
indicated the Beck Anxiety and Depression Inventories hold utility as screens for panic and
major depressive disorder, respectively. For the BAI, our results suggest that this instrument may
be useful primarily for screening for panic disorder, as its diagnostic accuracy for other anxiety
disorders was generally poor. This is consistent with evidence indicating that the BAI is
primarily a measure of panic symptomatology (e.g., Cox et al. 1996), and therefore its diagnostic
utility may only be appropriate to assess with regard to panic disorder. In addition, findings
regarding the accuracy of the instrument in identifying individuals with agoraphobia, obsessive-
compulsive disorder, and anxiety disorder NOS are tentative and must be interpreted with
caution, given the low prevalence rates of the disorders in our sample.

Creamer, Foran & Bell (1995) investigated the properties of the Beck Anxiety Inventory (BAI)
in a sample of 326 undergraduate students. Scores on the BAI were compared with data from the
State-Trait Anxiety Inventory and the Beck Depression Inventory. The BAI demonstrated good
psychometric properties, with a high level of internal consistency. Relatively low test-retest
correlations, in comparison with the STAI-Trait, suggested that the scale was functioning as a
state measure. Factor analysis revealed a unifactorial solution on the first administration (a time
of low stress), but a two factor solution similar to that proposed initially by Beck, Epstein,
Brown and Steer (Journal of Consulting and Clinical Psychology, 56, 893–897, 1988) at the
second administration (hypothesised to be a time of increased stress). Thus, the two factor
structure of the BAI (characterised by physical and cognitive symptoms) may not be
distinguishable in the normal population in the absence of an external stressor. An apparent
strength of the BAI was its superior ability in differentiating anxiety from depression when
compared with the STAI. A combined factor analysis of the BAI and STAI-State revealed two
distinct factors, suggesting that the scales may actually be measuring separate, although not
necessarily independent, constructs. It is suggested that the high discriminant validity
demonstrated by the BAI may have been achieved at the expense of some construct validity.

Leyfer, Ruberg & Woodruff-Borden (2006) examined the utility of the Beck Anxiety Inventory
and its factors as a screener for anxiety disorders. The Beck Anxiety Inventory (BAI) and the
Anxiety Disorders Interview Schedule (ADIS-IV) were administered to 193 adults at a major
Midwestern university recruited from an anxiety research and treatment center. The BAI and its
four factor scores were compared from individuals with a primary diagnosis of generalized
anxiety disorder (GAD), specific or social phobia, panic disorder with or without agoraphobia,
obsessive– compulsive disorder (OCD), and no psychiatric diagnosis. The cut scores on the BAI
and its factors, their sensitivity, specificity, as well as positive and negative predictive values
were calculated for each group. Overall, the results of this study support the findings made by
Cox et al. (1996) that the strongest quality of the BAI is its ability to assess panic
symptomatology. The present study also expands on this notion by establishing that the BAI can
be used as an efficient screening tool for distinguishing between panic-disordered and non-panic
disordered individuals as evidenced by the cut scores obtained. The results of their study
demonstrated that person with a panic disorder will be considered as more anxious based on the
BAI than a person with non-panic-related anxiety disorder. This may be due to the fact that the
BAI was created not only to assess anxiety, but also to be largely independent of the symptoms
of depression, as assessed by Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996)
hence excluding those anxiety symptoms that overlap with those of depression. While the BAI
has attained significant discriminant validity, it seems to have sacrificed some of its construct
validity in assessing overall anxiety. Because of the high overlap of symptoms between anxiety
disorders, particularly GAD and major depression (Barlow, DiNardo, Vermilyea, Vermilyea, &
Blanchard, 1986), it may be impossible to develop a self-report assessor of overall anxiety that is
both independent of depression and comprehensive of all of the aspects of anxiety. Thus, any
clinician or researcher using the BAI must be cognizant of its limitations, and should consider
that the BAI does not provide a truly valid quantitative assessment of anxiety symptomatology,
but rather an appraisal of one aspect of anxiety that may need to be augmented with other forms
of data collection, depending on the purposes of and reasons for the assessment.

Oehlert et al (2019) examined the use of Beck Anxiety Inventory in veteran population. The BAI
is widely used within the Veterans Health Administration (VHA), both as an assessment tool and
as a part of measurement-based care practices. However, there is preliminary evidence that the
BAI may perform uniquely in veteran samples, emphasizing the need for a comprehensive
investigation of the BAI in this population. The present study compared the normative data
reported by Beck and Steer (1993) to secondary data generated by a nationwide sample of U.S.
military veterans receiving treatment through the VHA. Secondary data, including initial BAI
scores, demographic characteristics, treatment location, and diagnoses originally recorded during
the course of usual VHA care over a 5-year period for 57,088 individual veterans, were extracted
through the VA Informatics and Computing Infrastructure. BAI scores were compared across
samples and various veteran subgroups. Exploratory and confirmatory factor analyses were also
conducted. Results revealed that the BAI performed similarly across veteran and normative
samples. Male and older veterans were found to have lower BAI scores than their respective
counterparts. Factor analyses indicated that a three-factor model best fit the veteran data.
Additionally, a cut score of 18 best differentiated between veterans with and without anxiety and
related disorders. This study helps support the use of the BAI as a reliable and valid instrument
for assessing anxiety symptoms in veterans. Additional research is recommended to better guide
BAI interpretation across age groups and sexes/genders.

References
● American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed., Text Revision). Washington, DC: Author.
● Creamer, M., Foran, J., & Bell, R. (1995). The Beck Anxiety Inventory in a non-clinical
sample. Behaviour research and Therapy, 33(4), 477-485.
● Eack, S. M., Singer, J. B., & Greeno, C. G. (2008). Screening for anxiety and depression in
community mental health: the beck anxiety and depression inventories. Community mental
health journal, 44(6), 465-474.
● Headquarters, A. P. A., Rule, G., Sites, A. P. A., & Center, A. L.
● Leyfer, O. T., Ruberg, J. L., & Woodruff-Borden, J. (2006). Examination of the utility of the
Beck Anxiety Inventory and its factors as a screener for anxiety disorders. Journal of anxiety
disorders, 20(4), 444-458.
● Oehlert, M. E., Nelson, K. G., King, N., Reis, D. J., Sumerall, S., Neal, C., & Henry, P.
(2019). Measurement-based care: Use of the Beck Anxiety Inventory (BAI) in a veteran
population. Psychological services, 17(3), 372-379.
● World Health Organization (WHO). (1993). The ICD-10 classification of mental and
behavioural disorders. World Health Organization.