1 INTRODUCTION

Anxiety disorders are one of the most common psychiatric disorders (above 25%) among adults (Remes et al., 2016) that have negative effects on social functioning, mental and physical health, family and social relationships, and quality of life (Barlow, 2004; Kessler et al., 2007). Anxiety disorders also increase the risk of other disorders such as major depression and substance abuse (Khan et al., 2002; Leon et al., 1995).

In recent years, and through numerous studies, good tools have been proposed to evaluate, measure, and screen these disorders; nevertheless, in psychiatric and mental health settings, this class of disorders is less diagnosed and treated than it is (Combs & Markman, 2014; Kroenke et al., 2007). One reason for this is that the symptoms of these disorders overlap with other disorders or the symptoms of anxiety are ignored (Barnes et al., 2002; First, 1997), and therefore, the use of accurate and valid tools is necessary. Structured interviews such as the Anxiety Disorders Interview Program (Brown et al., 1994) and structured interviews for DSM-IV (SCID-IV) are good diagnostic tools used to assess anxiety disorders, but these tools require detailed and extensive training and a lot of time to implement (Antony & Rowa, 2005).

In addition, self-report tools for measuring anxiety symptoms (Crocetti et al., 2009; Lowe & Reynolds, 2004; Monga et al., 2000) and measuring specific anxiety disorders such as social anxiety disorders (SAD) and generalized anxiety disorders (GAD) (Boyd et al., 2003; Crocetti et al., 2009; Hale et al., 2011; Plummer et al., 2016; Wren et al., 2007); but the Screen for adult anxiety related disorders (SCAARED) evaluates all DSM-5 disorders and the symptoms of the disorders are based on DSM-5. Hence, it can be used in research and clinical work. Therefore, due to the need for accurate assessment of anxiety disorders and the importance of psychological tools along with interviews in clinical and therapeutic work as well as in research work and on the other hand due to the gap in current tools for anxiety disorders that can address all anxiety disorders. Considering the DSM-5, in this study, the aim is to investigate the psychometric properties of the SCAARED in patients with anxiety disorders in society of Iran.

2 METHODS

3 RESULTS

In the present study, the data obtained from 247 participants were analyzed in two groups of anxiety disorders with 107 participants (43.3%) and non-clinical with 140 participants (56.7%) (53 samples were excluded from the final analysis due to incomplete tests or lack of cooperation). No cases of schizophrenia and other psychotic disorders were observed in the clinical group. In this group, 12 participants (11.2%) have obsessive-compulsive disorder (OCD), 3 participants (2.8%) have bipolar disorder, 7 participants (6.5%) have substance abuse, 31 participants (29%) have several simultaneous disorders, 77 participants (72%) with GAD, 54 participants (50.5%) with panic disorder, 26 (24.3%) with separation anxiety disorder, 79 participants (73.8%) with social anxiety disorder (ASD), and 6 participants (5.6%) with other disorders (anorexia nervosa, somatization, and hypochondria disorders).

To quantify face validity, the effect size of each question was calculated. For this purpose, the translated original version was provided to five psychologists and psychiatrists to evaluate items such as compatibility of the translated text with the original text, comprehensibility for the subjects, and the order of the question. The quantitative effect method of the item was used to reduce and eliminate inappropriate phrases and determine the importance of each phrase. For this purpose, for each of the 44 tool items, a Likert scale from 1 to 4 was considered, which showed a higher importance of the item. After completing the questionnaire by experts, face validity was calculated using the formula of item effect method. The impact score of the questions was between 4 and 5, so the face validity of all the questions was accepted by the evaluators.

In studies that construct or evaluate the validity and reliability of tools, in order to examine the compatibility of the results obtained from the metrics with the theories on which the test is designed, it is necessary to examine the validity of the structure. Examining the factor structure of the test through factor analysis methods is the most well-known method of construct validity. Factor analysis is done in two ways: exploratory and confirmatory. Exploratory factor analysis is used when the researcher does not have sufficient prior and pre-empirical evidence to form a hypothesis about the number of factors underlying the data and is actually willing to dig into the data to determine the number or nature of factors that justify the overlap between variables. In confirmatory factor analysis, the researcher's goal is to confirm a specific factor structure, hypotheses about the number of factors are clearly stated, and the fit of the desired factor structure in the hypothesis with the covariance structure of the measured variables is tested (Sarmad et al., 2004).

Therefore, at first, the present study investigated the construct validity of the SCAARED through confirmatory factor analysis by LISREL software. Given that there is no general agreement among structural equation modeling experts as to which of the fit indices provides a better estimate of the model, it is suggested that a combination of three to four indices be reported. As a result, in the present study, in line with the main validation studies of the SCAARED, among the indicators of absolute fitness, the ratio of chi-square to degree of freedom (x2/df), the index of good fit (GFI), and the root mean square of the approximate estimation square (RMSEA) and among the indices of comparative or comparative fitness, Tucker–Lewis fit index or non-normed fit indexes fit index (NNFI) as well as adaptive fitness index (CFI) were used. The main manufacturers listed four factors for the SCAARED, which are determined by 44 items. The results obtained from confirmatory factor analysis by LISREL software showed that the fitness indicators of the 4-factor model indicated the lack of proper validity of the model. Table 2 shows the fitting information of the proposed models, and considering that the software proposals to modify the results and achieve the optimal model were very different from the original model, the exploratory factor analysis method was used through principal component analysis with the inclined rotation method to achieve new factors.

Examination of the standardized Cronbach's alpha of items to measure the internal reliability of the questionnaire showed that the SCAARED has a reliability of 0.966 and therefore the Persian version of this questionnaire is a reliable tool. The results of the correlation (Table 4) show that there was a strong correlation at the level (p < .01) between the questionnaire factors and the factors with the total score, and a strong correlation between the first and second performance in the four factors and the overall score. Therefore, it can be concluded that the test has good test–retest reliability. Also, as the results in Table 5 show, there is a positive correlation (p < .01) between the factors and the overall score of the SCAARED with anxiety disorders measured based on SCID-5-CV (p < .01), which indicates optimal convergent validity. There is a negative correlation between the factors and the overall score of the SCAARED with the PWI-A at the level (p < .01), which indicates the favorable divergent validity of the SCAARED.

4 DISCUSSIONS

In this study, the psychometric properties of SCAARED, a self-report scale for the screening of anxiety disorders in the adult population, were evaluated. In summary, SCAARED is a new tool with good psychometric properties for use in research and clinical practice as well as a promising tool for screening anxiety disorders in a variety of treatment settings.

The results of the present study confirm the face and content validity of the SCAARED. A review of the Cronbach's standardized alpha of the questions to measure the internal reliability of the instrument showed that SCAARED has a good reliability and therefore the Persian version of these questionnaires is a reliable tool. Also, the results showed a strong correlation between the first and second implementation in four factors and the overall score. Therefore, it can be concluded that the SCAARED has good test–retest reliability. Also, there is a positive correlation between the factors and the overall score of the SCAARED scale with anxiety disorders based on SCID-5-CV, which indicates the favorable convergent validity of the SCAARED. There is a negative correlation between the factors and the overall score of the SCAARED with the PWI-A at the level, which indicates the favorable divergent validity of the SCAARED, and the results of exploratory factor analysis of the SCAARED were confirmed.

The results of the present study are in line with the findings of the only study reviewed of the SCAARED. In this study, SCAARED had a good internal consistency and four factors were reported: somatic/panic/agoraphobia, generalized anxiety, social anxiety, and separation anxiety. In fact, these factors are consistent with the diagnostic classes in the DSM-5. Also, the results of this study showed good discriminant validity between participants with and without anxiety disorder in two independent samples. Also, despite the usual comorbidity of anxiety and depression, SCAARED separated participants with anxiety and participants with depression only. Individual and general analysis scores were more significant in women. Individual and total SCAARED analysis scores showed stability over time (Angulo et al., 2017). These results suggest that SCAARED is a suitable tool for screening for anxiety disorders in the adult population. SCAARED is sensitive to response to treatment (Compton, Peris, et al. 2014; Compton, Walkup, et al., 2014) and biological changes in the brain (Perlman et al., 2014). In future studies, SCAARED could be useful for screening for anxiety disorders in psychiatric settings and primary care and psychiatric clinics, and In future studies, SCAARED could be useful for screening for anxiety disorders in psychiatric settings and primary care and psychiatric clinics.

One of the limitations of the present study is that SCAARED was performed on a sample of the Iranian population in a specific geographical area. Therefore, it is suggested that this tool be examined in other communities and with a wider sample to generalize the results more accurately. Also, in some diagnostic stages, anxiety disorder was a small sample, and therefore, it is suggested to compare the results in another group considering the higher sample size in anxiety disorder groups. SCAARED does not include specific phobias and all people with agoraphobia in this questionnaire with panic disorder are on the same factor. However, given that agoraphobia without panic disorder is less common than agoraphobia without panic disorder (Kessler et al., 2005), SCAARED is a useful tool for screening patients with any of these disorders. For patients with high scores on the panic/agoraphobia factor, it is recommended that specialists consider items related to agoraphobia (Bramley et al., 1988; Reynolds et al., 2003; Zimmerman & Mattia, 1999).

5 CONCLUSIONS

Based on the findings of this study, SCAARED is a tool with appropriate validity and reliability. This tool can be used in psychiatric and psychological clinics for screening patients with anxiety disorders in accordance with the diagnoses presented in DSM-5, as well as in research, clinical, and therapeutic practice to assess the patients during treatment, the outcome of treatment, and the improvement of patients' symptoms.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.