- Email: [email protected]
The fear questionnaire: a validity study
Behor.
Res.
Thu.
Vol.
24. No.
I, pp.
83-85.
0005-7967186
1986
53.00
+ 0.00
Copyright c 1986Pergamon Press Ltd
Printed in Great Britain. All nghts reserved
The Fear Questionnaire:
a validity study
MATIG MAVISSAKALIAN Western Psychiatric Institute and Clinic, University of Pittsburgh, School of Medicine, Departmenr of Psychiarry, 3811 O’Hara Street, Pittsburgh, PA 15213, U.S.A. (Received 22 May 1985)
a rigorously selected sample of 48 agoraphobic patients, the Agoraphobia scale was more sensitive and it alone discriminated between the rates of improvement in two independently identified subgroups of outcome than the Social Phobia or the Blood-Injury Phobia scales of the Fear Questionnaire (Marks and Matthews, 1979). The results also suggested that cutoff scores of 30 on the questionnaire may prove potentially useful as a diagnostic aid of adequate sensitivity and specificity. Summary-In
INTRODUCTION
The brief standard Fear Questionnaire (FQ) developed by Marks and Mathews (1979) yields scores on three categories of clinical phobias: agoraphobia, social phobia and blood and injury phobia. Each category is represented by 5, factor-analytically derived items rated on a O-8 scale of severity (maximum score possible per scale 40) where 0 means ‘would not avoid it’, 4 means ‘definitely avoid it’ and 8 means ‘always avoid it’. The originators of the questionnaire provided evidence for satisfactory test-retest reliability and suggestive evidence for the sensitivity of the scales to detect clinical improvement. The present paper explores the validity of the FQ in a rigorously selected sample of chronic agoraphobics receiving specific treatment. Following the suggestion that “on the agoraphobic subscore the (9) agoraphobics scored higher and improved more than did social and other phobics” (p. 265). it was expected that in this sample the Agoraphobia scale would be more sensitive to change than either of the other two scales. METHOD
Subjects
The Ss of this study were agoraphobic patients participating in a controlled 12-week study of the relative and combined effects of imipramine and therapist-assisted in uivo exposure. All patients in addition received systematic rationale and instructions for self-directed in vivo exposure (programmed practice). The results presented in this paper are based on data of 48 Ss on whom a complete set of FQ measures was administered at pretreatment, after 4 and 8 weeks of treatment and at posttreatment. They all met the DSM-III diagnosis of agoraphobia of at least 1 yr duration and onset prior to age 40; they had a mean age of 36.6 yr (range 18-62); 40 were female and 8 were male. The average duration of illness in this sample was 9 yr (range l-25). Measures reported include the Agoraphobia (FQ-AG), Social Phobia (FQ-S) and Blood-Injury Phobia (FQ-BI) subscales of the FQ (Marks and Mathews, 1979). In addition, a composite operationalized index of outcome was used to identify with confidence high endstate functioning (HEF) patients at posttreatment. To be classified as HEF, SS had to meet at least three out of the four following criteria: (1) a score of < 2 on a 5-point clinician global assessment rating where 2 meant mild symptoms without interference with normal work or social activities; (2) a score of < 2 on a 9-point self-rating scale of severity of ‘phobias’ where 2 meant slightly disturbing-not really disabling; (3) a score of Q 2 on an individualized clinical measure of phobic anxiety and avoidance consisting of the mean rating of each patient’s five most feared situations on a 9-point scale where 2 meant slight anxiety/hesitation to enter but rare avoidance; and (4) completion of all 20 steps of a behavioural avoidance test consisting of walking alone, along a 0.4 mile course in a crowded urban center with a mean subjective anxiety of 62 (slightly anxious) measured on a O-8 SUDS scale. [For further details of the general design, selection of patients, treatment conditions and assessment instruments, see Mavissakalian and Michelson (1982, 1983) and Mavissakalian and Perel (1985).] RESULTS
A scales (3) x time (4) repeated-measures in Fig. I.
ANOVA showed significant main and interaction effects which are illustrated
(I) Scales [F(2,94) = 36.33, P c O.oOI]. The FQ-AG scores were significantly higher than the scores of the FQ-S and FQ-BI subscales. Separate ANOVAs at each assessment revealed that this difference gradually declined from being highly significant at pretreatment (F = 80.91, P c 0.001) to a mere trend at posttreatment (F = 3.29, P = 0.04). (2) Time (F(3,14I) = 75.08, P < OJUI]. There was significant improvement over time which held true for each scale analyzed separately. (3) Scales x time interaction [F(6,282) = 33.02, P < 0.001]. Improvement over time differed significantly between the scales. The linear model accounted for the data [F(2,94) = 66.3, P < O.OOl]indicating that the rate of improvement was significantly greater on the FQ-AG subscale than on the FQ-S or FQ-BI subscales. As a finer grain analysis of their differential sensitivity to change, the rate of improvement (linear slope) on each scale was compared between patients classified as high endstate functioning (HEF, N = 23) and nonHEF at posttreatment using a 2 (patient groups) x 4 (assessments) repeated-measures ANOVA (see Fig. 2). There was a significant main effect of group for all scales but significant interaction effects between group and slope of change were found only for the FQ-AG subscale 83
84
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
40 35 30 ‘. 25
.
. .
.
20
Table I. Correlations (Pearson r) between tbe thm ohobia subscales FS-Q
FQ-BI
0.25 -
0.28 0.54
FQ-AG FQ-S
-+-.
75 10 i
,\,
5
Pre
4 Weeks
8 Weeks
t’osl
FO-AG 40 z
35 -
sj” tn 25 z a w I
-
20 ;;I
--_
5-
40 35
D
FO-AG
0
FO-81
i
I Pre
I
FO-
40r
@Weeks
4Weeks
I POS?
eI
35 30 25
20 ::I
v
5-
I
I Pre
Post
STAGE OF TREATMENT Fig. I. Improvement in 48 agoraphobic treated with exposure in vivo.
I 4 Weeks
I
J
8 Weeks
Post
FO-S
patients
Fig.
(->
2.
Differential rates of improvement in HEF N = 28) and non HEF (---, N = 25) subgroups.
= 28.48, P < O.OOi]. Thus, imp~vement on all scales was greater in HEF patients but only in the case of the FQ-AG subscale was the rate of improvement significantly different between HEF and nonHEF patients. At pretreatment, the proportion of patients scoring positively on the FQ-AG subscaie was 77 and 96% with cutoff scores of 30 and 20 respectively. The corresponding figures for the other subscales were 10 and 38% for FQ-S and 6 and 40% for FQ-BI. At posttreatment, none of the 23 HEF patients obtained a score of 320 on any of the scales. Intercorrelations between the three phobia scales are shown in Table 1. As can be seen. the FQ-AG subscale correlated minimally with the FQ-S and FQ-BI subscales. However, there was a stronger association between the FQ-S and FQ-BI subscales which may suggest that they were measuring in part a third factor common to both, perhaps of generalized fearfulness, Finally, because of the commonly observed overlap between agoraphobic and social phobic situations, the frequency with which the present sample of agoraphobics had endorsed each of the FQ-S items among their worst fears (PAA) was calculated. Results showed that “Eating or drinking with other people” figured among the worst fears in 65% of patients second only to the most frequently (88%) endorsed item on the FQ-AG subscale: “Going into crowded shops”. However. none of the other items, e.g. “Being watched or stared at”, ” Talking to people in authority”, “Being criticized”, “Speaking or acting to an audience”, was present while the FQ-AG item “Large open spaces” was endorsed by only I S
[F(i,46)
(2:/,). DfSCUSSION The results confirm the validity of the Agoraphobia subscale of the FQ. As expected in this diagnostically homogenous group of agoraphobics, the FQ-AG, subscale was more sensitive than the control scales to depict improvement. Indeed, it alone discriminated between the rates of improvement of two externally validated agoraphobia outcome subgroups. Furthermore, 77% of patients scored > 30 on the FQ-AG subscale at pretreatment while only IO and 6% of them had similar scores on the social FQ-S and FQ-BI subscales, respectively. This would suggest that a cutoff score of 30 may have potential usefulness as a diagnostic aid in identifying homogenous groups of agoraphobic patients without severe social phobia. The results also found that the FQ-AG subscale correlated minimally with the other two subscales. Interestingly, the four FQ-S items reflecting the characteristic fear of negative evaluation of social phobics did not figure prominently in this
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
85
sample in whom the fear of panicking or losing control was the central phenomenon. However, fear of eating in public was endorsed frequently while the FQ-AG item of open spaces was not. Slight modification in the agoraphobia items. for example, by replacing open spaces with eating in restaurants warrants consideration. It is hoped that large-scale studies with a variety of anxious disorders will be conducted to determine the sensitivity, specificity and diagnostic predictive value of the various scales of this versatile and standard FQ. Acknowledgements--Supported by Grants MH34177 and MH40141 from the National Institute of Mental Health. Mary Sue Hamann assisted with the statistical analyses.
REFERENCES Marks 1. M. and Mathews A. M. (1979) Brief standard self-rating for phobic patients. Behac. Res. Ther. 17, 263-267. Mavissakalian M. and Michelson L. (1982) Agoraphobia: behavioral and pharmacological treatments. Preliminary, outcome and process findings. Psychopharmac. Bull. 18, 91-103. Mavissakalian M. and Michelson L. (1983) Self-directed in uiuo exposure practice in behavioral and pharmacological treatments of agoraphobia. Behm. Ther. 14, 506519. Mavissakalian M. and Perel J. (1985) lmipramine in the treatment of agoraphobia: dose-response relationships. Am. J. Psychiof. In press.
Res.
Thu.
Vol.
24. No.
I, pp.
83-85.
0005-7967186
1986
53.00
+ 0.00
Copyright c 1986Pergamon Press Ltd
Printed in Great Britain. All nghts reserved
The Fear Questionnaire:
a validity study
MATIG MAVISSAKALIAN Western Psychiatric Institute and Clinic, University of Pittsburgh, School of Medicine, Departmenr of Psychiarry, 3811 O’Hara Street, Pittsburgh, PA 15213, U.S.A. (Received 22 May 1985)
a rigorously selected sample of 48 agoraphobic patients, the Agoraphobia scale was more sensitive and it alone discriminated between the rates of improvement in two independently identified subgroups of outcome than the Social Phobia or the Blood-Injury Phobia scales of the Fear Questionnaire (Marks and Matthews, 1979). The results also suggested that cutoff scores of 30 on the questionnaire may prove potentially useful as a diagnostic aid of adequate sensitivity and specificity. Summary-In
INTRODUCTION
The brief standard Fear Questionnaire (FQ) developed by Marks and Mathews (1979) yields scores on three categories of clinical phobias: agoraphobia, social phobia and blood and injury phobia. Each category is represented by 5, factor-analytically derived items rated on a O-8 scale of severity (maximum score possible per scale 40) where 0 means ‘would not avoid it’, 4 means ‘definitely avoid it’ and 8 means ‘always avoid it’. The originators of the questionnaire provided evidence for satisfactory test-retest reliability and suggestive evidence for the sensitivity of the scales to detect clinical improvement. The present paper explores the validity of the FQ in a rigorously selected sample of chronic agoraphobics receiving specific treatment. Following the suggestion that “on the agoraphobic subscore the (9) agoraphobics scored higher and improved more than did social and other phobics” (p. 265). it was expected that in this sample the Agoraphobia scale would be more sensitive to change than either of the other two scales. METHOD
Subjects
The Ss of this study were agoraphobic patients participating in a controlled 12-week study of the relative and combined effects of imipramine and therapist-assisted in uivo exposure. All patients in addition received systematic rationale and instructions for self-directed in vivo exposure (programmed practice). The results presented in this paper are based on data of 48 Ss on whom a complete set of FQ measures was administered at pretreatment, after 4 and 8 weeks of treatment and at posttreatment. They all met the DSM-III diagnosis of agoraphobia of at least 1 yr duration and onset prior to age 40; they had a mean age of 36.6 yr (range 18-62); 40 were female and 8 were male. The average duration of illness in this sample was 9 yr (range l-25). Measures reported include the Agoraphobia (FQ-AG), Social Phobia (FQ-S) and Blood-Injury Phobia (FQ-BI) subscales of the FQ (Marks and Mathews, 1979). In addition, a composite operationalized index of outcome was used to identify with confidence high endstate functioning (HEF) patients at posttreatment. To be classified as HEF, SS had to meet at least three out of the four following criteria: (1) a score of < 2 on a 5-point clinician global assessment rating where 2 meant mild symptoms without interference with normal work or social activities; (2) a score of < 2 on a 9-point self-rating scale of severity of ‘phobias’ where 2 meant slightly disturbing-not really disabling; (3) a score of Q 2 on an individualized clinical measure of phobic anxiety and avoidance consisting of the mean rating of each patient’s five most feared situations on a 9-point scale where 2 meant slight anxiety/hesitation to enter but rare avoidance; and (4) completion of all 20 steps of a behavioural avoidance test consisting of walking alone, along a 0.4 mile course in a crowded urban center with a mean subjective anxiety of 62 (slightly anxious) measured on a O-8 SUDS scale. [For further details of the general design, selection of patients, treatment conditions and assessment instruments, see Mavissakalian and Michelson (1982, 1983) and Mavissakalian and Perel (1985).] RESULTS
A scales (3) x time (4) repeated-measures in Fig. I.
ANOVA showed significant main and interaction effects which are illustrated
(I) Scales [F(2,94) = 36.33, P c O.oOI]. The FQ-AG scores were significantly higher than the scores of the FQ-S and FQ-BI subscales. Separate ANOVAs at each assessment revealed that this difference gradually declined from being highly significant at pretreatment (F = 80.91, P c 0.001) to a mere trend at posttreatment (F = 3.29, P = 0.04). (2) Time (F(3,14I) = 75.08, P < OJUI]. There was significant improvement over time which held true for each scale analyzed separately. (3) Scales x time interaction [F(6,282) = 33.02, P < 0.001]. Improvement over time differed significantly between the scales. The linear model accounted for the data [F(2,94) = 66.3, P < O.OOl]indicating that the rate of improvement was significantly greater on the FQ-AG subscale than on the FQ-S or FQ-BI subscales. As a finer grain analysis of their differential sensitivity to change, the rate of improvement (linear slope) on each scale was compared between patients classified as high endstate functioning (HEF, N = 23) and nonHEF at posttreatment using a 2 (patient groups) x 4 (assessments) repeated-measures ANOVA (see Fig. 2). There was a significant main effect of group for all scales but significant interaction effects between group and slope of change were found only for the FQ-AG subscale 83
84
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
40 35 30 ‘. 25
.
. .
.
20
Table I. Correlations (Pearson r) between tbe thm ohobia subscales FS-Q
FQ-BI
0.25 -
0.28 0.54
FQ-AG FQ-S
-+-.
75 10 i
,\,
5
Pre
4 Weeks
8 Weeks
t’osl
FO-AG 40 z
35 -
sj” tn 25 z a w I
-
20 ;;I
--_
5-
40 35
D
FO-AG
0
FO-81
i
I Pre
I
FO-
40r
@Weeks
4Weeks
I POS?
eI
35 30 25
20 ::I
v
5-
I
I Pre
Post
STAGE OF TREATMENT Fig. I. Improvement in 48 agoraphobic treated with exposure in vivo.
I 4 Weeks
I
J
8 Weeks
Post
FO-S
patients
Fig.
(->
2.
Differential rates of improvement in HEF N = 28) and non HEF (---, N = 25) subgroups.
= 28.48, P < O.OOi]. Thus, imp~vement on all scales was greater in HEF patients but only in the case of the FQ-AG subscale was the rate of improvement significantly different between HEF and nonHEF patients. At pretreatment, the proportion of patients scoring positively on the FQ-AG subscaie was 77 and 96% with cutoff scores of 30 and 20 respectively. The corresponding figures for the other subscales were 10 and 38% for FQ-S and 6 and 40% for FQ-BI. At posttreatment, none of the 23 HEF patients obtained a score of 320 on any of the scales. Intercorrelations between the three phobia scales are shown in Table 1. As can be seen. the FQ-AG subscale correlated minimally with the FQ-S and FQ-BI subscales. However, there was a stronger association between the FQ-S and FQ-BI subscales which may suggest that they were measuring in part a third factor common to both, perhaps of generalized fearfulness, Finally, because of the commonly observed overlap between agoraphobic and social phobic situations, the frequency with which the present sample of agoraphobics had endorsed each of the FQ-S items among their worst fears (PAA) was calculated. Results showed that “Eating or drinking with other people” figured among the worst fears in 65% of patients second only to the most frequently (88%) endorsed item on the FQ-AG subscale: “Going into crowded shops”. However. none of the other items, e.g. “Being watched or stared at”, ” Talking to people in authority”, “Being criticized”, “Speaking or acting to an audience”, was present while the FQ-AG item “Large open spaces” was endorsed by only I S
[F(i,46)
(2:/,). DfSCUSSION The results confirm the validity of the Agoraphobia subscale of the FQ. As expected in this diagnostically homogenous group of agoraphobics, the FQ-AG, subscale was more sensitive than the control scales to depict improvement. Indeed, it alone discriminated between the rates of improvement of two externally validated agoraphobia outcome subgroups. Furthermore, 77% of patients scored > 30 on the FQ-AG subscale at pretreatment while only IO and 6% of them had similar scores on the social FQ-S and FQ-BI subscales, respectively. This would suggest that a cutoff score of 30 may have potential usefulness as a diagnostic aid in identifying homogenous groups of agoraphobic patients without severe social phobia. The results also found that the FQ-AG subscale correlated minimally with the other two subscales. Interestingly, the four FQ-S items reflecting the characteristic fear of negative evaluation of social phobics did not figure prominently in this
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
85
sample in whom the fear of panicking or losing control was the central phenomenon. However, fear of eating in public was endorsed frequently while the FQ-AG item of open spaces was not. Slight modification in the agoraphobia items. for example, by replacing open spaces with eating in restaurants warrants consideration. It is hoped that large-scale studies with a variety of anxious disorders will be conducted to determine the sensitivity, specificity and diagnostic predictive value of the various scales of this versatile and standard FQ. Acknowledgements--Supported by Grants MH34177 and MH40141 from the National Institute of Mental Health. Mary Sue Hamann assisted with the statistical analyses.
REFERENCES Marks 1. M. and Mathews A. M. (1979) Brief standard self-rating for phobic patients. Behac. Res. Ther. 17, 263-267. Mavissakalian M. and Michelson L. (1982) Agoraphobia: behavioral and pharmacological treatments. Preliminary, outcome and process findings. Psychopharmac. Bull. 18, 91-103. Mavissakalian M. and Michelson L. (1983) Self-directed in uiuo exposure practice in behavioral and pharmacological treatments of agoraphobia. Behm. Ther. 14, 506519. Mavissakalian M. and Perel J. (1985) lmipramine in the treatment of agoraphobia: dose-response relationships. Am. J. Psychiof. In press.