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A preliminary investigation of developmentally sensitive items for the assessment of social anxiety in late life
Journal of Anxiety Disorders 25 (2011) 686–689
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
A preliminary investigation of developmentally sensitive items for the assessment of social anxiety in late life Caroline Ciliberti a , Christine Gould a , Merideth Smith a , Daniel Chorney b , Barry Edelstein a,∗ a b
West Virginia University, Department of Psychology, Morgantown, WV 26505, United States IWK Health Centre, Halifax, Nova Scotia, Canada
a r t i c l e
i n f o
Article history: Received 10 October 2010 Received in revised form 4 March 2011 Accepted 7 March 2011 Keywords: Aging Social anxiety Measurement Elderly
a b s t r a c t The current study aimed to examine the salience of anxiety-provoking social situations for older adults. A list of potentially anxiety-provoking situations was developed from a review of existing measures of social anxiety. In addition to items derived from existing measures, the investigators generated items thought to be particularly relevant for older adults. One hundred and four older adults were asked, “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Participants were also prompted to record any additional situations in which they experienced anxiety. Older adults endorsed items not included on typical measures of social anxiety at high rates. Exploratory analyses of the effects of gender on item endorsement were examined and significant differences were found for several items. The authors discuss these findings and their implications for the assessment of late-life social anxiety. © 2011 Elsevier Ltd. All rights reserved.
Social anxiety is characterized by a marked fear of embarrassment or humiliation in social situations. These social-evaluative fears are experienced by individuals across the lifespan, with many individuals reporting symptoms of anxiety and shyness from a very early age in childhood. Until recently, both researchers and clinicians have erred in the direction of approaching the assessment of anxiety in older adults with the incorrect assumption that the experience and presentation of anxiety are the same as those of younger adults (Kogan, Edelstein, & McKee, 2000). While a number of agerelevant self-report measures have been designed to assess social anxiety of children and adults, none have focused on older adults despite evidence suggesting that anxiety and phobic disorders are prevalent among this population. Recent epidemiological studies suggest that upwards of 6.6% of older adults have met criteria for social anxiety disorder in their lifetime (Kessler et al., 2005), while the 12-month prevalence rate for social anxiety is 2.3% within this age group (Gum, King-Kalimanis, & Kohn, 2009). As many existing measures used to assess anxiety were developed for use with younger adults, these prevalence estimates may actually be underestimating rates of anxiety disorders in this population (Palmer, Jeste, & Shiekh, 1997). As adults age, both the content and expression of fears and worries may change in accordance with one’s developmental life stage and may differ from fears experienced earlier in life in a number of ways (Kogan & Edelstein, 2004; Wisocki, Handen, &
∗ Corresponding author. Tel.: +1 304 293 2001; fax: +1 304 293 6606. E-mail address: [email protected] (B. Edelstein). 0887-6185/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2011.03.003
Morse, 1986). The interaction of anxiety with existing medical conditions, physical factors related to the aging process, and differences in emotional expression experienced by older adults may all contribute to symptom experience and expression in older adults (Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010). Several content valid measures of anxiety and fear have been developed for older adults, including the Worry Scale (WS: Wisocki et al., 1986) and the Fear Survey Schedule II modified for Older Adults (FSS-II-OA; Kogan & Edelstein, 2004). However, there are no olderadult specific measures of social-evaluative fear and worry. Older adults are frequently faced with different social settings and types of social interactions than younger adults, potentially leading to subtle changes in the types of fears experienced that may not be currently captured on assessment measures. Taken together, these issues call into question the content validity of existing measures of anxiety in older adults. Content validity is important for a variety of reasons, including but not limited to its effect on clinical inferences that can be drawn from scores obtained with the instrument, the latent factor structure of the instrument, and the ability of the instrument to predict behavior (Haynes, Richard, & Kubany, 1995). Haynes et al. noted that “Clinical inferences from assessment instruments with unsatisfactory content validity will be suspect, even when other indices of validity are satisfactory” (p. 240). Kogan and Edelstein (2004) have summarized three major ways in which current fear assessment measures for this population may not be adequate: (1) the fears listed on current questionnaires were developed for younger adults and may not be representative of fears in older adults, (2) they are limited to measuring fear levels only which may not accurately reflect actual impairment in functioning,
C. Ciliberti et al. / Journal of Anxiety Disorders 25 (2011) 686–689
and (3) existing measures have not been shown to be psychometrically sound for use with older adults. Past research in this area has supported these notions, finding a number of worries experienced in social-evaluative contexts that were not contained on existing fear surveys (Kogan & Edelstein, 2004). For example, the Worry Scale (Wisocki et al., 1986) includes items that assess worries associated with declines in physical or cognitive functioning (e.g., “I’ll have to be taken care of by my family”), which may be more relevant to older adults. In contrast to this, some of the more commonly surveyed situations for younger adults may not be as salient for individuals later in life (e.g., anxiety within the workplace or business setting). Other situations, such as anxiety regarding the use of new technology in front of others or asking others for help or assistance with the potential consequence of looking incompetent of feeling embarrassed, are also lacking in previously developed measures as these situations tend to be unique to older adults. These shortcomings in the assessment of anxiety in older adults require further research (Hersen and Van Hasselt, 1993), as they have important clinical implications for both the proper assessment and treatment of psychiatric disorders in older adults. Although there are a number of self- and clinician rated measures of anxiety that can potentially be used with older adults (see Kogan et al., 2000 for a more thorough review), to date only one study (Gretarsdottir, Woodruff-Borden, Meeks, & Depp, 2004) has specifically assessed the psychometric properties of a measure assessing social anxiety in older adults using the Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley, 1989), a commonly used measure of social anxiety developed for younger adults. The results obtained from this study suggest that the questionnaire is difficult for older adults to complete (by virtue of it being both lengthy and somewhat complicated to fill out), as evidenced by large amounts of missing data (18.7% of the original sample data was excluded due to missing data, compared to .6% of data obtained from younger adults). The combination of missing data and an examination of the items on the SPAI led these researchers to call into question the content validity of the SPAI, specifically with older adults, stating “it is likely that the relevance of social situations is related to age and that the current measures of social anxiety do not include some of the most anxiety-provoking situations for the elderly.” In order to assess for social anxiety in later life, it is important to first know whether the items included on measures of social anxiety are relevant for older adults. The current study aims to characterize the situations in which older adults experience discomfort. To accomplish this, the current study examines endorsement of discomfort in potentially anxiety provoking situations. These situations were derived from items on the SPAI, as well as potentially anxiety-evoking situations that are not typically included on measures of social anxiety, but may be salient for older adults. Participants were also given the opportunity to generate situations in which they experienced anxiety. An exploratory aim of this study was to examine whether there are gender differences in the endorsement of anxiety provoking situations.
1. Methods 1.1. Participants One hundred and four community-dwelling adults over the age of 60 (M = 74.16, SD = 8.61) were recruited. Participants were not assessed for social anxiety disorder. Participants were recruited through a targeted sample mailing across five states and the community using flyers, a television ad, visits to senior centers, and word of mouth. Those who participated were offered the chance to be entered into two drawings to win $50.
687
Table 1 Demographic information for sample. M (SD) Age Education (years) Gender Female Male Race/ethnicity White/Caucasian Black/African-American Asian-American Hispanic Marital status Single Married Live-in partner Separated Divorced Widowed Current job status Working full time Working part time Homemaker Retired Disabled, unable to work
Frequency (%)
74.16 (8.61) 14.15 (3.05) 69.5 28.6 89.5 5.7 1 1 9.5 45.7 1.9 1 9.5 28.6 4.8 6.7 7.6 73.3 4.8
1.2. Measures Older Adult Social Anxiety Check List. A list of 34 potentially anxiety-provoking situations was developed through a review of items included in established measures of social anxiety including the Social Phobia and Anxiety Inventory (SPAI; Turner et al., 1989), the Fear of Negative Evaluation Scale (Watson & Friend, 1969), and the Fear Survey Schedule II for Older Adults (Kogan & Edelstein, 2004). Additionally, after a review of the literature addressing social anxiety in older adults, the investigators generated age-specific situations to include in the check list measure. These age-specific situations were generated through group input. Participants were instructed to “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Participants were given opportunities to record additional situations that were not included in the 34 listed situations. Open-ended responses were coded into themes and used to develop new items or clarify existing items to be used in future studies evaluating the assessment of social anxiety in older adults. Additional themes developed through the open-ended responses include airport travel, learning a new skill, performing in front of others, sensory difficulties, receiving personal care from others, have a conversation with other people, and being in the presence of people with more knowledge or skills 2. Results The sample consisted of 104 participants ranging in age from 60 to 89. The average age was 74.16 years (SD = 8.61). Most were women (71%) and Caucasian (90%). Participants had an average of 14.15 years of education (SD = 3.01). Most of those who responded were retired (76%), though 12% were working outside of the home on a full or part-time basis, 8% were homemakers, and 5% were unable to work because of a disability. Demographic data can be found in Table 1. To examine the salience of each of the 34 items in this sample, investigators observed the frequency of endorsement for each item, comparing the frequency of items on the measure that are similar to those by the SPAI and items on the measure that are not included on the SPAI. Ten of the 34 items were semantically similar to items found on the SPAI (e.g., “Giving a presentation in front of others” and “Speaking in front of others”). Of those items, three were endorsed
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C. Ciliberti et al. / Journal of Anxiety Disorders 25 (2011) 686–689
Table 2 Percent positively endorsing items similar to items found on the SPAI.
3. Discussion
Item
Percent endorsing
Giving a presentation in front of others Speaking in front of others Telling others you disagree with them Attending a party or large social gathering Talking with people you do not know very well Initial interactions with strangers Driving a car Eating in front of others Participating in games or other social activities Writing in front of others
61.54 50.00 34.62 32.69 28.85 18.27 18.21 8.65 8.65 7.69
by at least one-third of the sample (see Table 2). Twenty-four items were semantically different from items on the SPAI and potentially more salient for older adults (e.g., “Using new technology in front of others” and “Forgetting information in front of others”). Ten of the 24 items were endorsed by at least one-third of the sample (see Table 3). The investigators also examined the data for differences in item endorsement according to gender. A series of 2 × 2 Chi-square analyses revealed several significant associations between gender and item. Nearly half (47%) of women endorsed feeling uncomfortable wearing revealing clothing, while only 20% of men endorsed this item, 2 (1) = 6.32, p < .01. While women were more likely to endorse feeling uncomfortable wearing revealing clothing, men were more likely to endorse feeling uncomfortable talking with people they do not know very well. Specifically, 23% of women, compared to 43% of men, endorsed this item, 2 (1) = 4.14, p < .05. Men were also more likely to endorse feeling uncomfortable visiting friends in a nursing home, assisted living facility, or hospital. Only 7% of women endorsed this item, compared to 43% of men, 2 (1) = 19.62, p < .001.
Table 3 Percent positively endorsing items not found on the SPAI. Item
Percent endorsing
Asking others for favors or for help Looking incompetent in front of others Doctors visits/dentist visit/occupational therapy visits Forgetting information in front of others Wearing clothing that reveals parts of your body in public Using new technology in front of others Causing others to wait for you Socializing as a single adult in situations with couples Exercising in public Going out on a date/outing with a potential dating partnera Reading and processing information quickly in public Speaking up for yourselfa Using a public bathroom in front of others Receiving compliments from others Using medical treatments in public Visiting friends in a nursing home/assisted living/hospital Attending a class Using assisted devices in public Religious ceremonies Using any private bathroom not at your home Interacting with son/daughter-in-laws or parents Hair salon/barbershop visits Walking in public Grocery shopping
43.27 43.27 42.31 42.31 39.42 36.54 35.58 30.77 24.04 24.04 21.15 21.15 20.19 18.27 18.27 18.27 15.38 14.42 13.46 11.54 9.62 8.65 6.73 3.85
a Items that are distinct, but conceptually similar to items found on the SPAI are marked.
The results of this study revealed age-related and gender-related social situations in which older adults experience social anxiety. Two content validity issues are raised by the present findings. First, the vast majority of the social anxiety situations endorsed by participants in the present study are not represented in current measures of social anxiety (e.g., SPAI, Turner et al., 1989; Liebowitz Social Anxiety Self-Report Scale, Baker, Heinrichs, Kim, & Hofmann, 2002). This finding is consistent with those of Wisocki (1988) with regard to older adult worry content (e.g., “concern over sensory and motor losses, failing memory, illness or accident affecting close family members, relocation, loss of independence, becoming depressed, and losing family and friends”) and those of Kogan and Edelstein (2004) with regard to older adult fears (e.g., mental decline, poor well being of loved ones, inability to care for oneself, diminished health, being robbed or attacked, falling, being physically disabled, and being a burden to others). The findings of the present study offer empirical support for the notion that measures of anxiety developed for younger adults are not content valid for older adults (Kogan et al., 2000). That is not to say that the younger adult items are irrelevant for older adults. Rather, the present findings, and those of Wisocki (1988) and Kogan and Edelstein (2004), suggest that item content should be relevant for the ages of the individuals for whom an anxiety assessment instrument is being used. The present findings argue against the use of social anxiety measures developed with younger adults when assessing social anxiety among older adults. A second content validity issue is raised by the differential social situation endorsement by participants of different genders. This finding suggests that item content should be relevant not only for the age of the individual completing a measure of social anxiety, but also for the gender of the individual. Gender differences in the endorsement of social fears have been documented in a community sample of young adults (Pollard & Henderson, 1988) and young adults with social phobia (Turk et al., 1999). In the community sample, fears of using public restrooms and speaking or performing in public were more common in women (Pollard & Henderson, 1988). Alternatively, fears of urinating in a public bathroom and returning goods to a store were more frequently endorsed by men with social anxiety compared to women. Women were more likely to endorse several fears related to situations in the workplace (e.g., working while being observed, talking to authority, giving a report to a group, and speaking up at a meeting; Turk et al.). The gender difference in work-place related fears may be influenced by the greater percentage of men that are employed compared to women (Turk et al.). Greater severity of social fears was reported by women than men (Turk et al.). In the present study, the endorsement of social situations in which older adults experience anxiety was not confounded by severity ratings. Varied patterns of gender differences have been observed for clinical and non-clinical samples, yet prior to the present study, no examinations have extended these results to older adults. Furthermore, gender differences were found on items that were not included in other measures of social anxiety. For example, twice as many women endorsed discomfort in wearing revealing clothing as men. Men were six times more likely to endorse discomfort when visiting friends in nursing homes, assisted living facilities or hospitals. These two examples highlight the need to have items that include situations that are content valid for both genders in order to identify social anxiety and subsequent avoidance behavior. Furthermore, different life trajectories have been observed for men with shyness, a symptom of social anxiety, compared to men without shyness. Shy men marry, become parents, and enter stable careers later in life compared to non-shy men (Caspi, Elder, & Bern, 1988; Kerr, Lambert, & Bem, 1996). Thus an individual’s gender can
C. Ciliberti et al. / Journal of Anxiety Disorders 25 (2011) 686–689
impact one’s development and experience of social anxiety in late life. There are several limitations to these findings. First, the sample was relatively small and the study participants were mostly white, female, and well-educated. The observed gender differences should be interpreted with caution in light of differences in sample size between men and women. It is possible that results from this sample would not generalize to all older adults. In addition, those who responded to recruitment efforts at senior centers and community postings could have qualitatively different responses than older adults who are less active and more socially isolated within the community. Though the targeted mailings aimed to reach a broader range of older adults, the response rate from these mailings was low. It is possible that those who replied were also qualitatively different from those who did not. These findings are also limited by the lack of information about the prevalence and severity of symptoms of social anxiety disorder in the sample. Neither a diagnostic interview nor an established measure of social anxiety was administered in this study. The investigators did not assess for social anxiety among participants, and one cannot assume that endorsing anxiety in one or many social situations suggests the presence of social anxiety disorder. Older adults may experience anxiety in situations without distress or impairment. Several methodological factors limit the interpretation of the findings. First, the purpose of the current study was to elicit situations in which older adults feel social anxiety. Because the investigators intended to only to examine the content of social situation in which older adults experience anxiety, there was no index or measure of severity on the checklist. It is possible that older adults endorsed anxiety in certain social situations, experience subclinical levels of anxiety in certain situations. Also, the measure instructed participants to, “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Many of the items specified a social-evaluative component to the situation (e.g., “Forgetting information in front of others”), but some did not (e.g., “Driving a car”). It is possible that older adults could feel anxious in such situations for reasons other than social-evaluative ones. As the current study only included a sample of older adults, it did not show that these situations are unique to people age 60 and older. Future studies may examine agerelated qualitative differences in the content of social-evaluative fears and worries. 4. Conclusions and future directions The results of the current study indicate that older adults feel anxious in situations that are not typically surveyed on measures of social anxiety. These findings indicate a need for an age-specific measure of social anxiety. It is possible that a measure that is content valid for older adults could result in better measurement and detection of social anxiety in late life. Few studies have examined the experience of social anxiety among older adults with social anxiety disorder (for an exception, see Grossman, Wilhelm, Kawachi, & Sparro, 2001). Although the present study did not aim to identify individuals with social anxiety disorder, it identified social situations not present in oft-used social anxiety assessment measures. In sum, the results of the current study highlight the importance
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of considering the content validity of assessment tools used with older adults in order to increase the identification of social anxiety in late life. The current study explored content validity of measures of social anxiety in late-life. Though this was a preliminary investigation, the results suggest that study of social anxiety in late-life may benefit from the creation of a measure developed specifically for use with older adults. Future research may focus on developing a measure of social anxiety for older adults that encompasses a range of content valid social situations, along with an indication of symptom severity. As current findings were limited by both sample size and distribution, future studies would benefit from including a larger sample size that also includes a larger representation of men to ensure potential gender differences can further be examined. References Baker, S. L., Heinrichs, N., Kim, H. J., & Hofmann, S. G. (2002). The Liebowitz Social Anxiety Scale as a self-report instrument: a preliminary psychometric analysis. Behaviour Research and Therapy, 40, 701–715. Caspi, A., Elder, G. H., Jr., & Bem, D. J. (1988). Moving away from the world: life-course patterns of shy children. Developmental Psychology, 24, 824–831. Gretarsdottir, E., Woodruff-Borden, J., Meeks, S., & Depp, C. (2004). Social anxiety in older adults: phenomenology, prevalence, and measurement. Behaviour Research and Therapy, 42, 459–475. Grossman, P., Wilhelm, F. H., Kawachi, I., & Sparro, D. (2001). Gender differences in psychophysiological responses to speech stress among older social phobics: congruence and incongruence between self-evaluative and cardiovascular reactions. Psychosomatic Medicine, 63, 765–777. Gum, A. M., King-Kalimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-use disorders for older Americans in the National Comorbidity Survey replication. American Journal of Geriatric Psychiatry, 17, 769–781. Haynes, S. N., Richard, D. C. S., & Kubany, E. S. (1995). Content validity in psychological assessment: a functional approach to concepts and methods. Psychological Assessment, 7, 238–247. Hersen, M., & Van Hasselt, V. B. (1993). Behavioral assessment and treatment of anxiety in the elderly. Clinical Psychology Review, 12, 619–640. Kerr, M., Lambert, W. W., & Bem, D. J. (1996). Life course sequelae of childhood shyness in Sweden: comparison with the United States. Developmental Psychology, 32, 1100–1105. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62, 593–602. Kogan, J. N., & Edelstein, B. A. (2004). Modification and psychometric examination of a self-report measure of fear in older adults. Journal of Anxiety Disorders, 18, 397–409. Kogan, J. N., Edelstein, B. A., & McKee, D. R. (2000). Assessment of anxiety in older adults: current status. Journal of Anxiety Disorders, 14, 109–132. Palmer, B. W., Jeste, D. V., & Sheikh, J. I. (1997). Anxiety disorders in the elderly: DSMIV and other barriers to diagnosis and treatment. Journal of Affective Disorders, 46, 183–190. Pollard, C. A., & Henderson, J. G. (1988). Four types of social phobia in a community sample. Journal of Nervous and Mental Disease, 176, 440–445. Turk, C. L., Heimberg, R. G., Orsillo, S. M., Holt, C. S., Gitow, A., Street, L. L., et al. (1999). An investigation of gender differences in social phobia. Journal of Anxiety Disorders, 12, 209–223. Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley, M. A. (1989). An empirically derived inventory to measure social fears and anxiety: the social phobia and anxiety inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 35–40. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33, 448–457. Wisocki, P., Handen, B., & Morse, C. (1986). The worry scale as a measure of anxiety: anxiety among the homebound and community active elderly. Behavior Therapist, 5, 91–95. Wisocki, P. A. (1988). Worry as a phenomenon relevant to the elderly. Behavior Therapy, 19(3), 369–379. Wolitzky-Taylor, K. B., Castriotta, N., Lenze, E. J., Stanley, M. A., & Craske, M. G. (2010). Anxiety disorders in older adults: a comprehensive review. Depression and Anxiety, 27, 190–211.
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
A preliminary investigation of developmentally sensitive items for the assessment of social anxiety in late life Caroline Ciliberti a , Christine Gould a , Merideth Smith a , Daniel Chorney b , Barry Edelstein a,∗ a b
West Virginia University, Department of Psychology, Morgantown, WV 26505, United States IWK Health Centre, Halifax, Nova Scotia, Canada
a r t i c l e
i n f o
Article history: Received 10 October 2010 Received in revised form 4 March 2011 Accepted 7 March 2011 Keywords: Aging Social anxiety Measurement Elderly
a b s t r a c t The current study aimed to examine the salience of anxiety-provoking social situations for older adults. A list of potentially anxiety-provoking situations was developed from a review of existing measures of social anxiety. In addition to items derived from existing measures, the investigators generated items thought to be particularly relevant for older adults. One hundred and four older adults were asked, “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Participants were also prompted to record any additional situations in which they experienced anxiety. Older adults endorsed items not included on typical measures of social anxiety at high rates. Exploratory analyses of the effects of gender on item endorsement were examined and significant differences were found for several items. The authors discuss these findings and their implications for the assessment of late-life social anxiety. © 2011 Elsevier Ltd. All rights reserved.
Social anxiety is characterized by a marked fear of embarrassment or humiliation in social situations. These social-evaluative fears are experienced by individuals across the lifespan, with many individuals reporting symptoms of anxiety and shyness from a very early age in childhood. Until recently, both researchers and clinicians have erred in the direction of approaching the assessment of anxiety in older adults with the incorrect assumption that the experience and presentation of anxiety are the same as those of younger adults (Kogan, Edelstein, & McKee, 2000). While a number of agerelevant self-report measures have been designed to assess social anxiety of children and adults, none have focused on older adults despite evidence suggesting that anxiety and phobic disorders are prevalent among this population. Recent epidemiological studies suggest that upwards of 6.6% of older adults have met criteria for social anxiety disorder in their lifetime (Kessler et al., 2005), while the 12-month prevalence rate for social anxiety is 2.3% within this age group (Gum, King-Kalimanis, & Kohn, 2009). As many existing measures used to assess anxiety were developed for use with younger adults, these prevalence estimates may actually be underestimating rates of anxiety disorders in this population (Palmer, Jeste, & Shiekh, 1997). As adults age, both the content and expression of fears and worries may change in accordance with one’s developmental life stage and may differ from fears experienced earlier in life in a number of ways (Kogan & Edelstein, 2004; Wisocki, Handen, &
∗ Corresponding author. Tel.: +1 304 293 2001; fax: +1 304 293 6606. E-mail address: [email protected] (B. Edelstein). 0887-6185/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2011.03.003
Morse, 1986). The interaction of anxiety with existing medical conditions, physical factors related to the aging process, and differences in emotional expression experienced by older adults may all contribute to symptom experience and expression in older adults (Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010). Several content valid measures of anxiety and fear have been developed for older adults, including the Worry Scale (WS: Wisocki et al., 1986) and the Fear Survey Schedule II modified for Older Adults (FSS-II-OA; Kogan & Edelstein, 2004). However, there are no olderadult specific measures of social-evaluative fear and worry. Older adults are frequently faced with different social settings and types of social interactions than younger adults, potentially leading to subtle changes in the types of fears experienced that may not be currently captured on assessment measures. Taken together, these issues call into question the content validity of existing measures of anxiety in older adults. Content validity is important for a variety of reasons, including but not limited to its effect on clinical inferences that can be drawn from scores obtained with the instrument, the latent factor structure of the instrument, and the ability of the instrument to predict behavior (Haynes, Richard, & Kubany, 1995). Haynes et al. noted that “Clinical inferences from assessment instruments with unsatisfactory content validity will be suspect, even when other indices of validity are satisfactory” (p. 240). Kogan and Edelstein (2004) have summarized three major ways in which current fear assessment measures for this population may not be adequate: (1) the fears listed on current questionnaires were developed for younger adults and may not be representative of fears in older adults, (2) they are limited to measuring fear levels only which may not accurately reflect actual impairment in functioning,
C. Ciliberti et al. / Journal of Anxiety Disorders 25 (2011) 686–689
and (3) existing measures have not been shown to be psychometrically sound for use with older adults. Past research in this area has supported these notions, finding a number of worries experienced in social-evaluative contexts that were not contained on existing fear surveys (Kogan & Edelstein, 2004). For example, the Worry Scale (Wisocki et al., 1986) includes items that assess worries associated with declines in physical or cognitive functioning (e.g., “I’ll have to be taken care of by my family”), which may be more relevant to older adults. In contrast to this, some of the more commonly surveyed situations for younger adults may not be as salient for individuals later in life (e.g., anxiety within the workplace or business setting). Other situations, such as anxiety regarding the use of new technology in front of others or asking others for help or assistance with the potential consequence of looking incompetent of feeling embarrassed, are also lacking in previously developed measures as these situations tend to be unique to older adults. These shortcomings in the assessment of anxiety in older adults require further research (Hersen and Van Hasselt, 1993), as they have important clinical implications for both the proper assessment and treatment of psychiatric disorders in older adults. Although there are a number of self- and clinician rated measures of anxiety that can potentially be used with older adults (see Kogan et al., 2000 for a more thorough review), to date only one study (Gretarsdottir, Woodruff-Borden, Meeks, & Depp, 2004) has specifically assessed the psychometric properties of a measure assessing social anxiety in older adults using the Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley, 1989), a commonly used measure of social anxiety developed for younger adults. The results obtained from this study suggest that the questionnaire is difficult for older adults to complete (by virtue of it being both lengthy and somewhat complicated to fill out), as evidenced by large amounts of missing data (18.7% of the original sample data was excluded due to missing data, compared to .6% of data obtained from younger adults). The combination of missing data and an examination of the items on the SPAI led these researchers to call into question the content validity of the SPAI, specifically with older adults, stating “it is likely that the relevance of social situations is related to age and that the current measures of social anxiety do not include some of the most anxiety-provoking situations for the elderly.” In order to assess for social anxiety in later life, it is important to first know whether the items included on measures of social anxiety are relevant for older adults. The current study aims to characterize the situations in which older adults experience discomfort. To accomplish this, the current study examines endorsement of discomfort in potentially anxiety provoking situations. These situations were derived from items on the SPAI, as well as potentially anxiety-evoking situations that are not typically included on measures of social anxiety, but may be salient for older adults. Participants were also given the opportunity to generate situations in which they experienced anxiety. An exploratory aim of this study was to examine whether there are gender differences in the endorsement of anxiety provoking situations.
1. Methods 1.1. Participants One hundred and four community-dwelling adults over the age of 60 (M = 74.16, SD = 8.61) were recruited. Participants were not assessed for social anxiety disorder. Participants were recruited through a targeted sample mailing across five states and the community using flyers, a television ad, visits to senior centers, and word of mouth. Those who participated were offered the chance to be entered into two drawings to win $50.
687
Table 1 Demographic information for sample. M (SD) Age Education (years) Gender Female Male Race/ethnicity White/Caucasian Black/African-American Asian-American Hispanic Marital status Single Married Live-in partner Separated Divorced Widowed Current job status Working full time Working part time Homemaker Retired Disabled, unable to work
Frequency (%)
74.16 (8.61) 14.15 (3.05) 69.5 28.6 89.5 5.7 1 1 9.5 45.7 1.9 1 9.5 28.6 4.8 6.7 7.6 73.3 4.8
1.2. Measures Older Adult Social Anxiety Check List. A list of 34 potentially anxiety-provoking situations was developed through a review of items included in established measures of social anxiety including the Social Phobia and Anxiety Inventory (SPAI; Turner et al., 1989), the Fear of Negative Evaluation Scale (Watson & Friend, 1969), and the Fear Survey Schedule II for Older Adults (Kogan & Edelstein, 2004). Additionally, after a review of the literature addressing social anxiety in older adults, the investigators generated age-specific situations to include in the check list measure. These age-specific situations were generated through group input. Participants were instructed to “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Participants were given opportunities to record additional situations that were not included in the 34 listed situations. Open-ended responses were coded into themes and used to develop new items or clarify existing items to be used in future studies evaluating the assessment of social anxiety in older adults. Additional themes developed through the open-ended responses include airport travel, learning a new skill, performing in front of others, sensory difficulties, receiving personal care from others, have a conversation with other people, and being in the presence of people with more knowledge or skills 2. Results The sample consisted of 104 participants ranging in age from 60 to 89. The average age was 74.16 years (SD = 8.61). Most were women (71%) and Caucasian (90%). Participants had an average of 14.15 years of education (SD = 3.01). Most of those who responded were retired (76%), though 12% were working outside of the home on a full or part-time basis, 8% were homemakers, and 5% were unable to work because of a disability. Demographic data can be found in Table 1. To examine the salience of each of the 34 items in this sample, investigators observed the frequency of endorsement for each item, comparing the frequency of items on the measure that are similar to those by the SPAI and items on the measure that are not included on the SPAI. Ten of the 34 items were semantically similar to items found on the SPAI (e.g., “Giving a presentation in front of others” and “Speaking in front of others”). Of those items, three were endorsed
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Table 2 Percent positively endorsing items similar to items found on the SPAI.
3. Discussion
Item
Percent endorsing
Giving a presentation in front of others Speaking in front of others Telling others you disagree with them Attending a party or large social gathering Talking with people you do not know very well Initial interactions with strangers Driving a car Eating in front of others Participating in games or other social activities Writing in front of others
61.54 50.00 34.62 32.69 28.85 18.27 18.21 8.65 8.65 7.69
by at least one-third of the sample (see Table 2). Twenty-four items were semantically different from items on the SPAI and potentially more salient for older adults (e.g., “Using new technology in front of others” and “Forgetting information in front of others”). Ten of the 24 items were endorsed by at least one-third of the sample (see Table 3). The investigators also examined the data for differences in item endorsement according to gender. A series of 2 × 2 Chi-square analyses revealed several significant associations between gender and item. Nearly half (47%) of women endorsed feeling uncomfortable wearing revealing clothing, while only 20% of men endorsed this item, 2 (1) = 6.32, p < .01. While women were more likely to endorse feeling uncomfortable wearing revealing clothing, men were more likely to endorse feeling uncomfortable talking with people they do not know very well. Specifically, 23% of women, compared to 43% of men, endorsed this item, 2 (1) = 4.14, p < .05. Men were also more likely to endorse feeling uncomfortable visiting friends in a nursing home, assisted living facility, or hospital. Only 7% of women endorsed this item, compared to 43% of men, 2 (1) = 19.62, p < .001.
Table 3 Percent positively endorsing items not found on the SPAI. Item
Percent endorsing
Asking others for favors or for help Looking incompetent in front of others Doctors visits/dentist visit/occupational therapy visits Forgetting information in front of others Wearing clothing that reveals parts of your body in public Using new technology in front of others Causing others to wait for you Socializing as a single adult in situations with couples Exercising in public Going out on a date/outing with a potential dating partnera Reading and processing information quickly in public Speaking up for yourselfa Using a public bathroom in front of others Receiving compliments from others Using medical treatments in public Visiting friends in a nursing home/assisted living/hospital Attending a class Using assisted devices in public Religious ceremonies Using any private bathroom not at your home Interacting with son/daughter-in-laws or parents Hair salon/barbershop visits Walking in public Grocery shopping
43.27 43.27 42.31 42.31 39.42 36.54 35.58 30.77 24.04 24.04 21.15 21.15 20.19 18.27 18.27 18.27 15.38 14.42 13.46 11.54 9.62 8.65 6.73 3.85
a Items that are distinct, but conceptually similar to items found on the SPAI are marked.
The results of this study revealed age-related and gender-related social situations in which older adults experience social anxiety. Two content validity issues are raised by the present findings. First, the vast majority of the social anxiety situations endorsed by participants in the present study are not represented in current measures of social anxiety (e.g., SPAI, Turner et al., 1989; Liebowitz Social Anxiety Self-Report Scale, Baker, Heinrichs, Kim, & Hofmann, 2002). This finding is consistent with those of Wisocki (1988) with regard to older adult worry content (e.g., “concern over sensory and motor losses, failing memory, illness or accident affecting close family members, relocation, loss of independence, becoming depressed, and losing family and friends”) and those of Kogan and Edelstein (2004) with regard to older adult fears (e.g., mental decline, poor well being of loved ones, inability to care for oneself, diminished health, being robbed or attacked, falling, being physically disabled, and being a burden to others). The findings of the present study offer empirical support for the notion that measures of anxiety developed for younger adults are not content valid for older adults (Kogan et al., 2000). That is not to say that the younger adult items are irrelevant for older adults. Rather, the present findings, and those of Wisocki (1988) and Kogan and Edelstein (2004), suggest that item content should be relevant for the ages of the individuals for whom an anxiety assessment instrument is being used. The present findings argue against the use of social anxiety measures developed with younger adults when assessing social anxiety among older adults. A second content validity issue is raised by the differential social situation endorsement by participants of different genders. This finding suggests that item content should be relevant not only for the age of the individual completing a measure of social anxiety, but also for the gender of the individual. Gender differences in the endorsement of social fears have been documented in a community sample of young adults (Pollard & Henderson, 1988) and young adults with social phobia (Turk et al., 1999). In the community sample, fears of using public restrooms and speaking or performing in public were more common in women (Pollard & Henderson, 1988). Alternatively, fears of urinating in a public bathroom and returning goods to a store were more frequently endorsed by men with social anxiety compared to women. Women were more likely to endorse several fears related to situations in the workplace (e.g., working while being observed, talking to authority, giving a report to a group, and speaking up at a meeting; Turk et al.). The gender difference in work-place related fears may be influenced by the greater percentage of men that are employed compared to women (Turk et al.). Greater severity of social fears was reported by women than men (Turk et al.). In the present study, the endorsement of social situations in which older adults experience anxiety was not confounded by severity ratings. Varied patterns of gender differences have been observed for clinical and non-clinical samples, yet prior to the present study, no examinations have extended these results to older adults. Furthermore, gender differences were found on items that were not included in other measures of social anxiety. For example, twice as many women endorsed discomfort in wearing revealing clothing as men. Men were six times more likely to endorse discomfort when visiting friends in nursing homes, assisted living facilities or hospitals. These two examples highlight the need to have items that include situations that are content valid for both genders in order to identify social anxiety and subsequent avoidance behavior. Furthermore, different life trajectories have been observed for men with shyness, a symptom of social anxiety, compared to men without shyness. Shy men marry, become parents, and enter stable careers later in life compared to non-shy men (Caspi, Elder, & Bern, 1988; Kerr, Lambert, & Bem, 1996). Thus an individual’s gender can
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impact one’s development and experience of social anxiety in late life. There are several limitations to these findings. First, the sample was relatively small and the study participants were mostly white, female, and well-educated. The observed gender differences should be interpreted with caution in light of differences in sample size between men and women. It is possible that results from this sample would not generalize to all older adults. In addition, those who responded to recruitment efforts at senior centers and community postings could have qualitatively different responses than older adults who are less active and more socially isolated within the community. Though the targeted mailings aimed to reach a broader range of older adults, the response rate from these mailings was low. It is possible that those who replied were also qualitatively different from those who did not. These findings are also limited by the lack of information about the prevalence and severity of symptoms of social anxiety disorder in the sample. Neither a diagnostic interview nor an established measure of social anxiety was administered in this study. The investigators did not assess for social anxiety among participants, and one cannot assume that endorsing anxiety in one or many social situations suggests the presence of social anxiety disorder. Older adults may experience anxiety in situations without distress or impairment. Several methodological factors limit the interpretation of the findings. First, the purpose of the current study was to elicit situations in which older adults feel social anxiety. Because the investigators intended to only to examine the content of social situation in which older adults experience anxiety, there was no index or measure of severity on the checklist. It is possible that older adults endorsed anxiety in certain social situations, experience subclinical levels of anxiety in certain situations. Also, the measure instructed participants to, “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Many of the items specified a social-evaluative component to the situation (e.g., “Forgetting information in front of others”), but some did not (e.g., “Driving a car”). It is possible that older adults could feel anxious in such situations for reasons other than social-evaluative ones. As the current study only included a sample of older adults, it did not show that these situations are unique to people age 60 and older. Future studies may examine agerelated qualitative differences in the content of social-evaluative fears and worries. 4. Conclusions and future directions The results of the current study indicate that older adults feel anxious in situations that are not typically surveyed on measures of social anxiety. These findings indicate a need for an age-specific measure of social anxiety. It is possible that a measure that is content valid for older adults could result in better measurement and detection of social anxiety in late life. Few studies have examined the experience of social anxiety among older adults with social anxiety disorder (for an exception, see Grossman, Wilhelm, Kawachi, & Sparro, 2001). Although the present study did not aim to identify individuals with social anxiety disorder, it identified social situations not present in oft-used social anxiety assessment measures. In sum, the results of the current study highlight the importance
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of considering the content validity of assessment tools used with older adults in order to increase the identification of social anxiety in late life. The current study explored content validity of measures of social anxiety in late-life. Though this was a preliminary investigation, the results suggest that study of social anxiety in late-life may benefit from the creation of a measure developed specifically for use with older adults. Future research may focus on developing a measure of social anxiety for older adults that encompasses a range of content valid social situations, along with an indication of symptom severity. As current findings were limited by both sample size and distribution, future studies would benefit from including a larger sample size that also includes a larger representation of men to ensure potential gender differences can further be examined. References Baker, S. L., Heinrichs, N., Kim, H. J., & Hofmann, S. G. (2002). The Liebowitz Social Anxiety Scale as a self-report instrument: a preliminary psychometric analysis. Behaviour Research and Therapy, 40, 701–715. Caspi, A., Elder, G. H., Jr., & Bem, D. J. (1988). Moving away from the world: life-course patterns of shy children. Developmental Psychology, 24, 824–831. Gretarsdottir, E., Woodruff-Borden, J., Meeks, S., & Depp, C. (2004). Social anxiety in older adults: phenomenology, prevalence, and measurement. Behaviour Research and Therapy, 42, 459–475. Grossman, P., Wilhelm, F. H., Kawachi, I., & Sparro, D. (2001). Gender differences in psychophysiological responses to speech stress among older social phobics: congruence and incongruence between self-evaluative and cardiovascular reactions. Psychosomatic Medicine, 63, 765–777. Gum, A. M., King-Kalimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-use disorders for older Americans in the National Comorbidity Survey replication. American Journal of Geriatric Psychiatry, 17, 769–781. Haynes, S. N., Richard, D. C. S., & Kubany, E. S. (1995). Content validity in psychological assessment: a functional approach to concepts and methods. Psychological Assessment, 7, 238–247. Hersen, M., & Van Hasselt, V. B. (1993). Behavioral assessment and treatment of anxiety in the elderly. Clinical Psychology Review, 12, 619–640. Kerr, M., Lambert, W. W., & Bem, D. J. (1996). Life course sequelae of childhood shyness in Sweden: comparison with the United States. Developmental Psychology, 32, 1100–1105. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62, 593–602. Kogan, J. N., & Edelstein, B. A. (2004). Modification and psychometric examination of a self-report measure of fear in older adults. Journal of Anxiety Disorders, 18, 397–409. Kogan, J. N., Edelstein, B. A., & McKee, D. R. (2000). Assessment of anxiety in older adults: current status. Journal of Anxiety Disorders, 14, 109–132. Palmer, B. W., Jeste, D. V., & Sheikh, J. I. (1997). Anxiety disorders in the elderly: DSMIV and other barriers to diagnosis and treatment. Journal of Affective Disorders, 46, 183–190. Pollard, C. A., & Henderson, J. G. (1988). Four types of social phobia in a community sample. Journal of Nervous and Mental Disease, 176, 440–445. Turk, C. L., Heimberg, R. G., Orsillo, S. M., Holt, C. S., Gitow, A., Street, L. L., et al. (1999). An investigation of gender differences in social phobia. Journal of Anxiety Disorders, 12, 209–223. Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley, M. A. (1989). An empirically derived inventory to measure social fears and anxiety: the social phobia and anxiety inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 35–40. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33, 448–457. Wisocki, P., Handen, B., & Morse, C. (1986). The worry scale as a measure of anxiety: anxiety among the homebound and community active elderly. Behavior Therapist, 5, 91–95. Wisocki, P. A. (1988). Worry as a phenomenon relevant to the elderly. Behavior Therapy, 19(3), 369–379. Wolitzky-Taylor, K. B., Castriotta, N., Lenze, E. J., Stanley, M. A., & Craske, M. G. (2010). Anxiety disorders in older adults: a comprehensive review. Depression and Anxiety, 27, 190–211.