A psychometric reanalysis of the Albany Panic and Phobia Questionnaire
Introduction
Fear and avoidance are hallmark features of the phobic disorders (panic disorder with agoraphobia, social phobia, specific phobia). The breadth and depth of the fear and avoidance can range from overt situational avoidance (e.g., public speaking, heights) to more subtle fears of substances or situations that may provoke autonomic symptoms similar to anxiety and panic (e.g., caffeine, aerobic activity). This distinction between the obvious and subtle forms of fear and avoidance is particularly evident in panic disorder. Phobic avoidance in panic disorder (i.e., agoraphobia) can be established from any one of the following criteria: (1) situational avoidance, (2) anxiety and distress in the phobic situation, or (3) requiring the presence of a companion in the phobic situation (American Psychiatric Association, 1994). As such, an individual may have no or few overtly avoided situations but may still have considerable fear, distress, and subtle avoidance behavior in the phobic situation. In short, the fear associated with agoraphobia is focused on the onset of distressing symptoms in situations, not the avoided situation itself. Because of this “fear of fear” (Goldstein & Chambless, 1978), a continuum of situational fears and restrictions may develop.
Whereas early conceptualizations of panic disorder with agoraphobia (PDA) centered on overt situational avoidance (e.g., Marks, 1969; Snaith, 1968), contemporary theories of PDA have emphasized the fears of autonomic sensations that are similar to those of a panic attack (Barlow, 2002; Clark, 1986). Indeed, many modern empirically supported treatments target exposure to both the phobic situations as well as the autonomic (or interoceptive) symptoms and situations (Barlow, Gorman, Shear, & Woods, 2000; Spiegel & Barlow, 2000). Because of the important role of interoceptive fear and avoidance in the development and treatment of PDA, thorough assessment of the feared sensations and activities that may produce them are essential. From a clinical standpoint, this assessment can serve as the foundation for designing interoceptive exposure exercises—a vital treatment component for decreasing a patient's anxiety about and sensitivity to physical sensations (Craske & Barlow, 2001; White & Barlow, 2002). In addition to its clinical importance, comprehensive assessment of dimensions of phobic fear and avoidance may have significant etiological and theoretical relevance for research in understanding PDA and the phobias.
Although a number of scales have been developed to assess integral aspects of PDA (cf. Antony, 2001), the assessment of interoceptive fear and avoidance has been largely neglected. An exception is the Albany Panic and Phobia Questionnaire (APPQ; Rapee, Craske, & Barlow, 1994/1995), a scale that was designed to measure the distinct dimension of fear of sensation-producing activities, in addition to fear of common agoraphobic and social phobic situations. Using principal components analysis (PCA) with equamax rotation, Rapee et al. (1994/1995) reported findings in support of the posited 3-factor solution in a sample of 405 patients with anxiety disorders and 33 persons with no mental disorder. After examination of internal consistency and factor structure (and removal of items failing to meet salient loading criteria), the final scale consisted of 27 items forming three subscales, interpreted as reflecting fear of agoraphobic situations (“Agoraphobia,” 9 items), fear of activities that produce somatic sensations (“Interoceptive,” 8 items), and fear of social situations (“Social Phobia,” 10 items). Rapee et al. (1994/1995) subjected the APPQ to additional tests of internal consistency, temporal stability, validity, and sensitivity to change during treatment, and all evidences attested to the favorable psychometric qualities of the scale (e.g., ranged from .87 to .90). For instance, support for the convergent/discriminant validity of the APPQ was evidenced by a differential pattern of correlations with other clinical ratings and self-report measures of social phobia and panic disorder and agoraphobia in the predicted direction (e.g., APPQ-Social Phobia was more strongly associated with presence/absence of social phobia and a social anxiety questionnaire than was APPQ-Agoraphobia and APPQ-Interoceptive). Moreover, a significant decrease in all three subscales was observed following cognitive-behavioral treatment of 45 patients with panic disorder with or without agoraphobia, lending support for the utility of the APPQ as a treatment outcome measure (Rapee et al., 1994/1995). More recently, Novy, Stanley, Averill, and Daza (2001) extended these results by reporting equivalent reliability and norms, as well as favorable convergent and discriminant validity, for an English and Spanish language translation of the APPQ in a bilingual sample. However, the small sample size () restricted this investigation to predominantly descriptive and univariate analyses of the scale (e.g., no replication of factor structure).
Since its development, the APPQ has been used in a wide variety of contexts (cf. Antony, 2001), including large-scale treatment outcome studies (e.g., Barlow et al., 2000), latent structural analyses of the DSM-IV anxiety and mood disorder constructs (e.g., Brown, Chorpita, & Barlow, 1998), and analog (e.g., Veljaca & Rapee, 1998) and cross-cultural research (Novy et al., 2001). Nevertheless, this applied research has proceeded in absence of comprehensive examination of the measurement properties of the APPQ. For instance, Rapee et al. (1994/1995) represent the only published study to date that has examined the latent structure of the APPQ. Unfortunately, these analyses were limited in several ways, including: (a) use of PCA as the method of extraction, a procedure that is not based on the common factor model (cf. Fabrigar, Wegener, MacCallum, & Strahan, 1999; Thurstone, 1947; Widaman, 1993); (b) retention in the final solution of several items with salient loadings (>.30) on nonprimary factors; and (c) inability to cross-validate the final solution in independent samples. Moreover, Rapee et al. (1994/1995) aimed to evaluate the “factorial invariance” of the final solution between males and females. However, this objective was addressed simply by visual inspection of the structural similarities of PCAs conducted separately for males and females.
Thus, the primary aim of the current study was to provide a thorough evaluation of the latent structure of the APPQ in a large sample of patients with anxiety and mood disorders. Given the aforementioned methodological limitations of Rapee et al. (1994/1995), we began by conducting cross-validated exploratory factor analyses to better ascertain the latent form of the APPQ and to identify any poorly behaved items. Subsequent analyses on independent samples were conducted in the confirmatory factor analysis (CFA) framework which provided further replication of factor structure, and allowed for the evaluation of potential nonrandom measurement error, scale reliability, and direct statistical examination of the form and measurement invariance of the APPQ between male and female patients. Moreover, the convergent and discriminant validity of the APPQ dimensions were examined in context of the CFA solutions.
Section snippets
Participants
The sample consisted of 1930 outpatients who were presented for assessment and treatment at the Center for Anxiety and Related Disorders. Women constituted the larger portion of the sample (61%); average age was 33.26 (SD=11.16, range=18–79). The sample was predominantly Caucasian (89%; African-American=3.5%, Asian=4%, Latino/Hispanic=3%). Diagnoses were established with the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L; Di Nardo, Brown, & Barlow, 1994), a
Procedure
Patients completed the APPQ as part of their initial intake evaluation (consisting of the ADIS-IV-L and a questionnaire battery) at the Center for Anxiety and Related Disorders. To thoroughly examine and cross-validate the APPQ factor structure, the total sample () was randomly divided into four subsamples. The first two samples (Sample 1: , 110 males, 190 females; Sample 2: , 129 males, 171 females) were used to conduct initial exploratory factor analyses of the original
Exploratory factor analyses
Using Sample 1 (), the 27 APPQ items were submitted to an EFA (maximum likelihood estimation, promax rotation). Acceptability of the factor models (e.g., factor selection) was evaluated by goodness of model fit (RMSEA<.08, upper bound of 90% CI<.08), the interpretability of the solution, and the strength of the parameter estimates (e.g., primary factor loadings>.30, absence of salient cross-loadings). Consistent with the findings of Rapee et al. (1994/1995), a 3-factor solution fit the
Discussion
The present findings extend the psychometric basis of the APPQ (Novy et al., 2001; Rapee et al., 1994/1995) by providing cross-validated EFAs and CFAs and tests of measurement variance and concurrent validity in large samples of outpatients with DSM-IV anxiety and mood disorders. Although a tripartite latent structure was upheld (Agoraphobia, Interoceptive, Social), these initial analyses revealed that three of the APPQ's original 27 items (items 7, 17, 26) failed to load on their conjectured
References (54)
Confirmatory factor analysis of the Penn State Worry QuestionnaireMultiple factors or method effects?
Behaviour Research and Therapy
(2003)- et al.
The utility of the ASI factors in predicting response to voluntary hyperventilation among nonclinical participants
Journal of Anxiety Disorders
(2001) - et al.
The mobility inventory for agoraphobia
Behaviour Research and Therapy
(1985) A cognitive approach to panic
Behaviour Research and Therapy
(1986)- et al.
Consideration of the APA practice guideline for the treatment of patients with panic disorderStrengths and limitations for behavior therapy
Behavior Therapy
(2001) - et al.
Self-treatment of agoraphobia by exposure
Behavior Therapy
(1987) - et al.
A reanalysis of agoraphobia
Behavior Therapy
(1978) - et al.
Development and validation of measures of social phobia scrutiny fear and social interaction anxiety fear
Behaviour Research and Therapy
(1998) Behavioral scale reliability and measurement invariance evaluation using latent variable modeling
Behavior Therapy
(2004)- et al.
Detection of negative and positive audience behaviours by socially anxious subjects
Behaviour Research and Therapy
(1998)
Measures for panic disorder and agoraphobia
Anxiety and its disordersThe nature and treatment of anxiety and panic
Cognitive-behavioral therapy, imipramine, or their combination for panic disorderA randomized control trial
Journal of the American Medical Association
Comparative fit indices in structural models
Psychological Bulletin
Structural equations with latent variables
Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal
Journal of Abnormal Psychology
Reliability of DSM-IV anxiety and mood disordersImplications for the classification of emotional disorders
Journal of Abnormal Psychology
Testing for the equivalence of factor covariance and mean structuresThe issue of partial measurement invariance
Psychological Bulletin
Empirically supported psychological interventionsControversies and evidence
Annual Review of Psychology
Panic disorder and agoraphobia
Evaluating the use of exploratory factor analysis in psychological research
Psychological Methods
On the meaning of within-factor correlated measurement errors
Journal of Consumer Research
Factor analysis
Computing and evaluating factor scores
Psychological Methods
LISREL approaches to interaction effects in multiple regression
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