|Year : 2020 | Volume
| Issue : 2 | Page : 361-366
Standardization of the Arabic version of Beck anxiety inventory in Egyptian population
Hossam S Talaat1, Enas I Abdelfatah2, Ahmed M. Z. El Abedein3
1 Department of Audiology, Head of Audiology Unit, Menofia University, Menofia, Egypt
2 Department of Audiovestibular Medicine, Nasr City Health Insurance Hospital, Cairo, Egypt
3 Department of Audiology, Faculty of Medicine, Menofia University, Menofia, Egypt
|Date of Submission||12-Jan-2020|
|Date of Decision||01-Mar-2020|
|Date of Acceptance||09-Mar-2020|
|Date of Web Publication||27-Jun-2020|
Enas I Abdelfatah
3 Gorab Street, Quesna, Menofia
Source of Support: None, Conflict of Interest: None
The aim was to diagnose anxiety in patients with tinnitus using Beck anxiety inventory (BAI) after modification and standardization on the Egyptian population.
Tinnitus is a common complaint that can affect life aspects, such as emotions, increasing anxiety. Early diagnosis of anxiety helps treatment of tinnitus. The aim of this study was to standardize the Arabic version of BAI in the Egyptians and apply the standardized form on patients with tinnitus.
Patients and methods
BAI was modified to suite Egyptians. It was backtranslated and judged by an expert committee. It was then applied on 100 healthy adult participants, and then on 30 patients with anxiety for standardization. It was then applied on 30 patients with tinnitus for diagnosis. Examination of reliability and the validity was done. The authors used the receiver operating characteristic curve for getting the possible cutoff value.
It showed a good reliability by Cronbach's α of 0.73 among controls and patients with anxiety and 0.84 among patients with tinnitus. Test-retest reliability was done after 1 week. Repeatability was significant for the total score using Spearman's correlation. The mean value of the items of Arabic BAI was higher among patients than controls. The discriminant validity found that patients with tinnitus and patients with anxiety scored higher than controls. The authors found that 73.3% of patients with tinnitus experienced anxiety.
This study confirms that anxiety is a commonly associated complaint with patients with tinnitus. The modified-Arabic version of BAI was found to be a reliable and effective scale for diagnosis of anxiety among Egyptians.
Keywords: anxiety, Beck anxiety inventory, Egyptian population, reliability, tinnitus, validity
|How to cite this article:|
Talaat HS, Abdelfatah EI, El Abedein AM. Standardization of the Arabic version of Beck anxiety inventory in Egyptian population. Menoufia Med J 2020;33:361-6
|How to cite this URL:|
Talaat HS, Abdelfatah EI, El Abedein AM. Standardization of the Arabic version of Beck anxiety inventory in Egyptian population. Menoufia Med J [serial online] 2020 [cited 2020 Jul 16];33:361-6. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/361/287808
| Introduction|| |
Tinnitus is a spontaneous perception of sound in the head. Tinnitus can be perceived unilaterally, bilaterally, or in the middle of the head. The most common causes are noise exposure, head trauma, aging, and medications. Sometimes, the causes cannot be known. The tinnitus prevalence in adults is 10–15%. Factors such as age, hearing loss, and previous noise exposure affect the prevalence. The percent of people with bothering tinnitus is less than the total prevalence, as many people are not that annoyed by their tinnitus. The tinnitus prevalence in children has been reported. It ranges from 3 to 58%. Approximately 0.5% of the populations experiencing tinnitus have severe symptoms that interfere with their ability to have a normal life, whereas the latest figures estimate 9.6% of the population experienced tinnitus within 1 year.
Anxiety disorder is defined as a neurosis characterized by anxious over-concern and frequently associated with somatic symptoms. It affects how we feel and behave. Although mild anxiety is vague and unsettling, the severe form can be extremely debilitating, having a serious effect on daily life. A positive history of psychiatric disorder is a strong predictor for the development of psychiatric disorders following vertigo.
The relationship between tinnitus and psychiatric disorders has long been recognized. Lifetime anxiety disorders were recorded in 45% of the cases, but only 34% had contact with any health care facility for emotional disturbances. Only 7% reported having tinnitus before their anxiety. The added load of tinnitus can often outrage existing or worsen anxiety and depression. In turn, these patients are usually more sensitive to any stressor and can perceive tinnitus to be worse than usual compared with the rest of the population. It was proved that many patients with tinnitus experience depression and anxiety. Therefore, in the work up of a patient with tinnitus, there is a necessity for a psychological assessment screening. Once making a psychological diagnosis, treating tinnitus only cannot be adequate. Therefore, effective treatment of anxiety and depression can make treating tinnitus more easy and effective. That is why clinicians treating those patients should be participating in an interdisciplinary team consisting of different specialties to ensure a treatment plan dealing with every aspect of this complicated disease process.
The aim of this study was to standardize the Arabic version of Beck anxiety inventory (BAI) in the Egyptian population and to apply the standardized form on the patients with tinnitus.
| Patients and Methods|| |
The Ethical Committee in Menoufia University has approved this study (number: 421\4\12\2017). Participants were recruited from the Audiology Unit. Controls were recruited from colleagues, neighbors, medical students, medical staff, and relatives of patients in the audiology unit. Patients with tinnitus were chosen randomly from the Audiology Unit. Patients with anxiety were diagnosed and referred from the psychiatric clinic. All of them are located in the Menoufia University. The study is a prospective study which was conducted in the period between January 2018 and January 2019.
This study consisted of three groups: controls, patients with anxiety, and patients with tinnitus.
The control group included 100 normal adult participants. The anxiety group included 30 patients with anxiety, who were diagnosed according to DSM-5 criteria. The tinnitus group included 30 patients complaining of tinnitus of varying intensities, with and without hearing loss, assessed by thorough history taking. All the participants in the three groups were in the age range of 18–45 years.
Exclusion criteria were participants with chronic medical problems such as diabetes, cardiac patients, high blood pressure, and allergies. Moreover, any participant with audiovestibular complaint such as hearing loss, tinnitus, or vertigo, and any participant with diagnosed anxiety were excluded from the control group. Any patients with audiovestibular complaint such as hearing loss, tinnitus, or vertigo were not included in the anxiety group. Patients with other main presenting symptoms as mainly complaining of hearing loss or vertigo were not included in the tinnitus group. All the participants in the study can read and write, with varying educational and socioeconomic standards to ensure variability.
The BAI, which was developed by professor Beck et al. back in 1988, consists of 21 items to be answered, assessed on a scale from 0 to 3, where 0 is not at all, 1 is mildly bothered, 2 is moderately bothered, and 3 is severely bothered. In this study, we used its Arabic form developed in 2015 by Al-Shatti in Kuwait.
The Arabic version of BAI was revised, and the words and phrases that were difficult to be understood by the Egyptian lay participants were changed to more suitable terms. Back translation was done by a professional translator who had no prior knowledge of the original English version of the BAI. This version was judged by expert committee to confirm its faithfulness to the original English version. The final revised Arabic version was applied to pre-testing on a pilot study of 10 participants to discover any errors or unfamiliar words. The final adapted Arabic version of the BAI was introduced to the control, anxiety, and tinnitus groups after taking their consents. The maximum total score of the Arabic BAI is 63; the score is calculated by addition of the scores of every item. All the study groups were subjected to history taking and general examination.
Results were statistically analyzed by Statistical Package for the Social Sciences version 20 (SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done: descriptive, for example, percentage, mean, and SD, and analytical, for example, one-way analysis of variance (F test), which is a single test used to collectively indicate the presence of any significant difference between several groups for a normally distributed quantitative variable. P value is significant difference if less than 0.05. Spearman correlation analysis is used to show strength and direction of association between one quantitative variable and ordinal qualitative variable. Cronbach's α was used to assess internal consistency. Receiver operating characteristic (ROC curve) is a graphical plot of the sensitivity versus false-positive rate (one minus the specificity). The ROC is also known as a relative operating characteristic curve, because it is a comparison of two operating characteristics (TPR [true positive rate] and FPR [false positive rate]). Positive predictive value, negative predictive value, sensitivity, and specificity were calculated for a possible cutoff value.
A statistical power analysis was performed after sample size estimation, based on data from the current study (N = 160), comparing patients (n = 6) with controls (n = 100). The effect size for this study was 0.48, considered to be large using Cohen's (1988) criteria, with an α = 0.05 and sample size = 160, distributed as 60 patients (30 tinnitus and 30 anxiety) and 100 controls. A post-hoc power analysis was conducted with this effect size (G Power 3.1, Zurück zur, Psychologie-Berline-Germany), and it is approximately (1−β)=0.99. Thus, our power analysis for this sample size is adequate for the objectives of this study.
| Results|| |
Our study included 100 controls, 30 patients with anxiety, and 30 patients with tinnitus. It was proved that there was no significant difference between the studied groups regarding their age or sex (P value is 0.265 for age, 0.135 for sex) using F-test and χ2-test, respectively. It was also proved that all items shared quite enough in the internal consistency of the questionnaire with acceptable reliability among controls and anxiety groups translated in Cronbach's α with 0.731 and 0.721, respectively, and good reliability among tinnitus groups translated in Cronbach's α with 0.841 [Table 1]. Meanwhile, we found that the mean value of most of the items of Arabic BAI was significantly higher among patients with anxiety and patients with tinnitus than controls (P < 0.001) [Table 2]. In items number 5 and 18, the scores of both the patients with anxiety and patients with tinnitus were not significantly different than the control scores. The patients with tinnitus scored higher than the patients with anxiety in items 1 and 4, reflecting that the patients with tinnitus tend to complain of these symptoms more than other people. The patients with anxiety scored higher than patients with tinnitus in items 6, 11, 12, 15, 16, 20, and 21, reflecting that the patients with anxiety experience these symptoms more than other people [Table 2]. On doing test retest for controls and anxiety groups, we found that there was a significant agreement between items of Arabic BAI in the first and second visit among the two groups (P < 0.001) [Figure 1]. It was shown that AUC of the BAI is 0.88 for predicting anxiety among patients with anxiety. Values of 0.88 and higher would be considered high predictors [Figure 2]. The cutoff point of 16.5 had the highest sensitivity and specificity among patients with anxiety [Table 3]. The control group was revised considering our cutoff point. The percentage of participants scoring more than the cutoff point was 41%. In the tinnitus group, we found that 73.3% of patients scored more than the cutoff point, so patients with tinnitus have more anxiety than controls.
|Table 1: Reliability and internal consistency of the adapted Arabic Beck anxiety inventory among control, anxiety, and tinnitus groups |
Click here to view
|Table 2: Distribution of the mean of items scores and total score of control, anxiety, and tinnitus groups regarding items of the adapted Arabic Beck anxiety inventory|
Click here to view
|Figure 1: Test-retest reliability and repeatability measures of adapted Arabic BAI in the first and second visit among controls and patients with anxiety. BAI, Beck anxiety inventory.|
Click here to view
|Figure 2: Sensitivity and specificity of Arabic form of BAI between anxiety cases and controls. BAI, Beck anxiety inventory.|
Click here to view
|Table 3: Validity of Arabic form of Beck anxiety inventory for anxiety group|
Click here to view
| Discussion|| |
The mean age was 32.62 ± 6.87 years for the control group. The mean age of the anxiety group was 33.86 ± 7.46 years. The mean age of tinnitus group was 35.0 ± 8.41 years. They were handed the modified Arabic form of BAI, where all the study groups completed all the items of the questionnaire. It was found that there were no significant differences between the study groups based on age or sex. BAI was tested using Cronbach's α coefficient, which was considered significant if it was equal to or more than 0.7. The BAI conducted on control group showed that all items shared quite enough in the internal consistency, with good reliability translated in Cronbach's α with 0.73. Meanwhile in the anxiety group, it showed that all items shared quite enough in the internal consistency, with good reliability translated in Cronbach's α with 0.721. The tinnitus group showed that all items shared quite enough in the internal consistency, with very good reliability translated in Cronbach's α with 0.841. Cronbach's α if item deleted is a measure of internal consistency. It was significant in all items among the study groups. The scores from the first and second time were correlated to evaluate the test for stability over time. In the control group, test-retest reliability was estimated by Spearman correlation, with the mean of the total score in the second visit of 15.5, reflecting significant positive correlations between items of Arabic BAI in the first and second visit. The patients with anxiety were retested 1 week later with the same scale, and the mean of the total score in the second visit was 28.1, reflecting a significant positive correlations between items of Arabic BAI in the first and second visit. The results were suggestive of acceptable stability of BAI overtime. When it came to validity, content validity was done by asking the participants about their comprehension to reveal any deceptive or confusing items. The participants were asked to rephrase all items by their own to reveal any misunderstood items. All items were clear and did not need to be changed. The discriminant validity was done by the Mann − Whitney test and the ROC curve. It was found that the tinnitus and anxiety groups scored higher than controls in most of the items, which indicates that the modified Arabic version of BAI has good ability to differentiate between controls and patients with anxiety. In items number 5 and 18, which were fear of worst happening and indigestion, the control scores were not very different from the anxiety and tinnitus scores, which can be explained by the socioeconomic difficulties the whole Egyptian population is going through and its effect on their health. The patients with tinnitus scored higher than the patients with anxiety in items 1 and 4, reflecting that the patients with tinnitus tend to complain of these symptoms more than other people. The item number 1 was numbness or tingling, which may be explained by the etiology of the tinnitus. The item number 4 was unable to relax, which can be owing to the severity of the tinnitus perceived. The patients with anxiety scored higher than patients with tinnitus on items 6, 11, 12, 15, 16, 20, and 21 reflecting that the patients with anxiety experience these symptoms more than other people. Most of the following symptoms-They are dizzy or lightheaded, feeling of chocking, hands trembling, difficulty in breathing, fear of dying, face flushed, and hot and cold sweats- represent autonomic manifestations and other symptoms of anxiety usually found in different types of anxiety patients. Our cutoff value for the anxiety group is 16.5. Using this cutoff point, sensitivity was 93% and specificity was 61%. The BAI used for patients with anxiety is a good positive screening test and can detect anxiety cases by a sensitivity rate of 93%. After confirming the reliability and validity of our scale, we applied the cutoff point at the control group, and we found that 41% of the normal Egyptian population may have anxiety and need psychiatric consultation for confirming the diagnosis and for treatment. Anxiety disorders affect up to 33.7% of the population during their lifetime. This high percent in Egyptian population may be owing to the economic status, which greatly affected mood and stability of mind, which may be also owing to the last political issues that Egyptians have been through in the past few years. When it comes to the tinnitus group, by applying the cut-off point, we found that 73.3% of the patients with tinnitus may have associated anxiety and should be referred to psychiatric clinic for confirmation of diagnosis and for proper treatment. Many studies have linked anxiety and tinnitus. Patients with tinnitus may have up to 45% anxiety. In a systematic review, it was found that 50–90% of patients with tinnitus have experienced anxiety or depression, which greatly matches our results in this study. Our study confirms that anxiety is a commonly associated complaint with patients with tinnitus. The modified Arabic version of BAI was found to be a reliable and effective scale for primary diagnosis of anxiety in the Egyptian environment.
| Conclusion|| |
The modified Arabic version of BAI is a sensitive screening tool for primary diagnosis of anxiety in the Egyptian population as a whole, and our audiovestibular patients specifically.
The anxiety is a very common problem facing patients with tinnitus which needs more attention. Future research should address whether anxiety and vertigo or hearing loss are related.
The authors like to thank members of Audiology Unit, Menoufia University Hospitals, for research support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Richard ST, William N, Claudia C, Eveling RR, Hyung JJ. Tinnitus and hyperacusis. In: Handbook of clinical audiology. 7th
edition. 2013. p. 647-58.
Nemholt S, Schmidt JH, Wedderkopp N, Baguley DM. Prevalence of tinnitus and/or hyperacusis in children and adolescents: study protocol for a systematic review. BMJ Open 2015; 5
Bhatt JM, Lin HW, Bhattacharyya N. Prevalence, severity, exposures, and treatment patterns of tinnitus in the United States. JAMA Otolaryngol Head Neck Surg 2016; 142
Martin EI, Ressler KJ, Binder E, Nemeroff CB. The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. Psychiatric Clin North Am 2009; 32
Martin LM, Fleming KC, Evans JM. Recognition and management of anxiety and depression in elderly patients. Mayo Clin Proc 1995; 70
Zoger S, Svedlund J, Holgers KM. Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic. Audiology 2001; 40
Ziai K, Moshtaghi O, Mahboubi H, Djalilian HR. Tinnitus patients suffering from anxiety and depression: a review. Int Tinnitus J 2017; 21
Ramos K, Stanley MA. Anxiety Disorders in Late Life. Psychiatr Clin North Am 2018;41:55-64. doi:10.1016/j.psc.2017.10.005.
Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56
Al-Shatti T. Psychometric properties of the Arabic version of the Back anxiety Inventory in the state of Kuwait. J Educ Psychol Sci 2015; 16
Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st
century. Dialogues Clin Neurosci 2015; 17
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]