Artigo Original
Validity and reliability of the social phobia
safety
behaviour scale in social anxiety
Validade e fidedignidade da Escala de Comportamento
de Segurança na Ansiedade Social (ECSAS)
Kátia Regina Soares da Silva Burato1,
José Alexandre de Souza Crippa2,
Sonia Regina Loureiro3
1
Mestre em Ciências Médicas-Saúde Mental –
Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo. Bolsista CNPq.
2 Professor Doutor do Departamento
de Neurociências e Ciências do Comportamento – Divisão
de Psiquiatria, da Faculdade de Medicina de Ribeirão Preto da
Universidade de São Paulo.
3 Professora Doutora do Departamento
de Neurociências e Ciências do Comportamento – Divisão
de Psiquiatria, da Faculdade de Medicina de Ribeirão Preto da
Universidade de São Paulo.
Recebido: 3/11/2008
– Aceito: 12/3/2009
Abstract
Context: The use of safety behaviours
stresses the cognitive failure and tends to distort the evaluation of
interpersonal experiences. Objective: To assess the
reliability of the self-administered Social Phobia Safety Behaviors
Scale (ECSAS in the Portuguese acronym) in order to determine the association
of social anxiety disorder (SAD) with processes related to safety behaviors.
Method: A total of 155 university students of both
genders with no previous history of psychiatric treatment, divided into
two groups (80 cases and 75 non-cases of SAD), were systematically assessed
using the Social Phobia Inventory (SPIN) and the Structured Clinical
Interview for the DSM-IV (SCID-IV) for diagnostic confirmation and for
the exclusion of other psychiatric disorders. Results:
The internal consistency of the ECSAS measured by the Cronbach alpha
was 0.92, and, based on the test-retest method separated by a two-week
interval, it reached satisfactory levels of temporal stability, with
a weighted Kappa of 0.73. Regarding discriminant validity, the ECSAS
had 0.963 sensitivity and 1 specificity. Regarding convergent validity,
it presented a correlation (r) of 0.60. Conclusion:
The ECSAS presented good psychometric indicators, contributing to a
systematic assessment of the safety and avoidance behaviors associated
with SAD.
Burato KRSSB, Crippa JAS, Loureiro SR / Rev
Psiq Clín. 2009;36(5):175-81
Keywords: Social anxiety, scales,
reliability, validity.
Resumo
Contexto: A utilização
dos comportamentos de segurança acentua a falha no processamento
cognitivo e tende a distorcer a avaliação de experiências
interpessoais. Objetivo: Avaliar a fidedignidade e
a validade da escala autoaplicável Social Phobia Safety Behaviours
Scale (ECSAS), visando a verificar a associação do transtorno
de ansiedade social (TAS) a processos cognitivos e a comportamentos
de segurança. Método: Participou deste
estudo uma amostra de 155 universitários, de ambos os sexos,
sem história prévia de tratamento psiquiátrico,
distribuídos em dois grupos (80 casos de TAS e 75 não
casos), avaliados sistematicamente pelo Inventário de Fobia Social
(SPIN) e pela Entrevista Clínica Estruturada para o DSM-IV (SCID-IV),
como recurso de confirmação diagnóstica e exclusão
de outros transtornos psiquiátricos. Resultados:
A ECSAS apresentou consistência interna, medida pelo alfa de Cronbach,
de 0,92, e, com base no método de teste e reteste, com um intervalo
de duas semanas, atingiu níveis satisfatórios de estabilidade
temporal, com Kappa ponderado de 0,73. Quanto à validade discriminante,
apresentou valores de sensibilidade de 0,963 e de especificidade de
1. Na validade convergente apresentou correlação (r) de
0,60. Conclusão: A ECSAS apresentou boas características
psicométricas, contribuindo para a avaliação sistemática
dos padrões de comportamentos de segurança e evitação
associados ao TAS.
Burato KRSSB, Crippa JAS, Loureiro SR / Rev Psiq Clín. 2009;36(5):175-81
Palavras-chave: FAnsiedade social, escalas, fidedignidade,
validade.
Introduction
Social anxiety disorder (SAD) or social phobia
usually starts at the beginning of adolescence and follows a chronic
course, with a high proportion of comorbidities, thus being considered
to be and important, though under-recognized and underdiagnosed, public
health problem1-3.
SAD is characterized by a strong and persistent fear of social interaction
or performance situations in which an individual is afraid to be ashamed
or embarrassed, with the central characteristic being the fear of being
observed and/or judged by another person4.
The main fears are related to exposure, i.e., to appear ridiculous,
to say stupid things, to be observed by other persons, to interact with
strangers or persons of the opposite sex, to be the center of attention,
to eat, drink or write in public, to speak on the telephone, and to
use public restrooms5.
As proposed by Clark and Wells6,
from the theoretical perspective of cognitive models, when a person
with SAD faces a social situation, a set of representations is activated,
producing anxiety. According to this model, persons with social phobia,
when in contact with social situations, establish avoidance strategies
in order to cope with these situations, which are perceived as a source
of danger. The use of avoidance strategies produces a vicious cycle
(anxiety/avoidance/more anxiety) that can contribute to the maintenance
of the disorder7.
Subjects with social phobia tend to be more critical about themselves
and tend to assess situations as having more negative components8-9.
To reduce the perception of a threat in view of the anticipated risk
of being evaluated in a negative manner, subjects with SAD use strategies
for the avoidance of situations of social anxiety, expressed as safety
behaviors. The use of safety behaviors increases the failure of cognitive
processing, which tends to distort the assessment of interpersonal experiences,
with the persistence of negative thoughts about oneself, one’s
experiences and one’s possibilities in the future. In a selective
manner, these behaviors are characterized by the search for evidence
that will reaffirm one’s negative view of oneself, reinforcing
beliefs and maintaining the cognitive, behavioral and physiological
behaviors. In this respect, safety behavior reflects systematic errors
of cognitive processing favoring the maintenance of social anxiety7,10,11.
Several studies have dealt with these distorted beliefs and their role
in the maintenance of social phobia. Empirical studies9,12,13
have reported the association of negative beliefs with a negative self-perception
and with increased social anxiety.
Instruments for the assessment of the negative beliefs associated with
SAD have been proposed in the literature10,14.
Turner et al.14 proposed
the Social Thoughts and Beliefs Scale for the identification of the
presence of negative thoughts and of cognitive changes associated with
SAD in comparison with other psychiatric disorders and reported positive
indicators of reliability and discriminant validity of the instrument.
Pinto-Gouveia et al.10
proposed the Social Interaction and Performance Anxiety and Avoidance
Scale (SIPAAS) for the assessment of discomfort and avoidance in social
situations and the Social Phobia Safety Behaviours Scale (SPSBS) for
the assessment of the safety behaviors used by persons with social phobia
when facing feared social situations. Regarding the psychometric qualities
of the two scales, good test-retest reliability and positive indices
of discriminant validity were observed in the discrimination between
subjects with SAD and persons without the disorder.
The systematic identification of safety behaviors and of negative thoughts
present in SAD by means of specific instruments may favor the diagnosis
and treatment of social anxiety. Elucidating the degree of discomfort
experienced in social situations is considered to be useful for the
implementation of intervention procedures that take into account the
behavioral aspects present in interactions and in performance situations.
No validated instruments are available in Brazil for the assessment
of these specific aspects.
Regarding SAD, systematic reviews in the literatures Osório et
al.15 have pointed to the
diversity of instruments available, including some which are widely
known and used in experimental clinical studies, especially those which
evaluate symptomatological aspects of SAD. In this sense, it is considered
that more studies with accurate and validated instruments may contribute
to the clinical practice and for other systematic studies on SAD. In
our context, the lack is noticed of validated instruments of Brazilian
Portuguese which approach the different types of difficulties shown
by people with SAD, namely, the evaluation of specific aspects such
as public speaking and the safety behaviours. It is, thus, necessary
to improve the stydies of validation and reliability, which may contribute
to the diagnosis, for the planning and evaluation of efficacy of therapeutical
approaches of SAD16.
On this basis, the objective of the present study was to assess the
reliability and validity of the Social Phobia Safety Behaviours Scale
proposed by Pinto-Gouveia et al.10,
after its semantic adaptation to Brazilian Portuguese.
Methods
Participants
The study sample derives from a broader investigation aiming at the
assessment of the clinical and epidemiological aspects associated with
SAD using instruments applied to university students enrolled in different
undergraduate courses at two universities, a public one and a private
one, located in medium-sized cities in the Northeast region of the state
of São Paulo, Brazil.
A total of 155 subjects of both genders were divided into two groups:
a) case group - consisting of 80 university students with SAD, with
no previous psychotherapeutic or pharmacological treatment, whose diagnosis
was based on positive indicators of such disorder in a screening instrument
(Mini-SPIN) and confirmed by the SCID-IV;
b) non-case group - consisting of 75 university students who did not
fulfill the criteria for a diagnosis of SAD or of other psychiatric
disorders, systematically assessed by means of a social phobia screening
inventory (Mini-SPIN), with confirmation of the absence of a diagnosis
of a psychiatric disorder by means of the SCID-IV.
The subjects included in the present study were selected from a sample
of 372 students from the two universities, 178 of whom fulfilled the
diagnostic criteria of SAD, while 194 did not. It is, thus, a sample
of convenience which does not reflect the incidence of SAD in the sample
that was evaluated. Of these, 95 did not accept to continue in the study,
73 were not located after three attempts of contact by telephone and
e-mail, 26 filled out the instrument in an incorrect manner, and 23
presented comorbidities, with the final sample thus consisting of 155
subjects.
The inclusion criterion was adults of both genders aged 17 to 35 years
regardless of socioeconomic level and the exclusion criteria were subjects
taking neuroleptics and having current or previous psychiatric comorbidities,
eating disorders, recurrent depressive disorders, and dependence on
psychoactive substances. Participants with a history of episodes of
depression, of generalized anxiety disorder and simple phobia were accepted
for inclusion in the study in view of the high prevalence of the association
of these comorbidities with SAD17.
Instruments
Social Phobia Inventory (SPIN) proposed by Connor
et. al.18 and translated
and adapted to Brazilian Portuguese by Osório et al.15
for the university population. The instrument presented good
psychometric qualities in both the original study and in the study conducted
in Brazil, with internal consistency of 0.90 and good discriminant validity
in the identification of cases and non-cases (0.96 sensitivity and 0.87
specificity) according to data reported by Osório et al.15
Mini-SPIN (MS) is a brief form of the SPIN proposed by Connor et
al.18 and translated and
adapted to Brazilian Portuguese by Osório et al.16. It is a self-applicable
inventory consisting of three items (items 6, 9 and 15) that assess
avoidance and fear of embarrassment. This brief form demonstrated good
discriminant power in both the original psychometric study and in the
study conducted in Brazil, with 0.46 specificity and 0.94 sensitivity.
Structured Clinical Interview for the DSM-IV (SCID-IV), translated and
adapted to Portuguese by Del-Ben et al.19. It is an instrument used
to form psychiatric clinical diagnosis based on DSM-IV.
Social Phobia Safety Behaviours Scale (SPSBS) – proposed by Pinto-Gouveia
et al.10 and called
Safety Behavior in Social Anxiety Scale (ECSAS in the Portuguese acronym).
Its objective is to assess a set of safety behaviors that subjects with
social anxiety use when facing social situations so as to prevent possible
negative evaluations attributed to others. The version contains 17 items
on a Likert-type scale scored from one to four, corresponding to “never”,
“at times”, “many times”, and “almost
always”. The score of the scale is obtained by the sum of the
responses to the 17 items and the total score ranges from 17 to 68 points.
In the current study, we used the version in Portuguese of Portugal
provided by the author.
The study was approved by the Research Ethics Committee of the Faculty
of Medicine of Ribeirão Preto, University of São Paulo
(CEP/SPC 11570/2003).
Procedure
Adaptation of the Safety Behavior in Social Anxiety Scale
After authorization by the authors, the scale was
modified semantically for adaptation to Brazilian Portuguese. Three
raters who dominated the Portuguese of Portugal were asked to assess
the scale independently, with priority being given in the final version
to a colloquial vocabulary with which the target population, university
students, would feel familiar.
Selection of the participants
After explanation of the objectives of the study, the university
students who accepted to enter the study on a voluntary basis gave written
informed consent to participate. The students who did not accept to
participate were dismissed, having it clear that there were no consequences
and that the participation was voluntary.
In a first stage, 372 university students were collectively assessed
in a classroom in order to obtain clinical and demographic data. The
score of the Mini-SPIN proposed by Connor et al.18
and translated and adapted to Brazilian Portuguese by Osório
et al.16 was used to
select the participants. On the basis of the results obtained with this
instrument, participants who fulfilled the criteria for SAD (a score
of 6 or more) were selected for inter-group comparison and participants
with similar demographic characteristics with a negative result for
SAD (a score of less than 6) were also included.
In a second phase, the participants were contacted by telephone and
responded to the SCID-IV (module F), which was used as the gold standard,
for the diagnostic confirmation of SAD. These subjects were assessed
by a psychiatrist and a psychologist with vast clinical experience.
Based on the concordance of the Mini-Spin and SCID-IV assessments, a
sample containing the possible participants was assembled in a third
stage in order to confirm the presence or absence of SAD. The participants
were contacted by phone and responded to all SCID-IV modules. The interviews
were conducted by mental health professionals who were unaware of the
previous classification of the subjects in order to confirm the diagnosis
and to exclude other psychiatric comorbidities. In a subgroup of positive
and negative MS subjects, we found a degree of concordance between the
first and the second telephone interview of 0.80, with the overall concordance
between the first telephone interview and the face-to-face interview
being 0.84, a benchmark indication of an excellent20 level of agreement21.
This stage was concluded with the scheduling of a new assessment of
the subjects who agreed to participate in the actual study.
Data collection for the study
The selected participants were assessed in small groups of three
to five persons in rooms with appropriate privacy conditions. They received
the printed instrument containing instructions and the rater remained
present during application in order to clarify any possible doubts or
questions.
The same conditions of collective assessment and the same instructions
were used for the test-retest, with a 15 day interval, which was considered
to be reasonable in view of the fact that the type of variable involved
is little related to memory.
All the participants included in the study took part in two evaluations.
In case of absence, the sessions were rescheduled within a period of
20 days.
Statistical analysis
The data obtained in the present study were analyzed statistically using
the SPSS for Windows software, version 1022.
The demographic and clinical data were analyzed by descriptive statistics
and by the chi-square and Mann-Whitney tests for group comparison.
Reliability was determined by the Cronbach alpha and by the weighted
Kappa for test-retest evaluations separated by a two-week interval.
The ROC curve analysis was used to determine the discriminant validity,
sensitivity and specificity of the Safety Behavior Scale. Convergent
validity was calculated by the Pearson correlation coefficient between
the individual and total scores of the Safety Behavior Scale and the
SPIN score. The level of significance was set at p = 0.05 in all analyses.
Results
Characteristics of the sample
The sociodemographic characterization of the sample showed a predominance
of female gender in both groups (63.2%). Mean age was 20.9 ±
2.21 years (range: 17 to 21 years) and most students (74.2%) were enrolled
in the first and second year of the courses, with no difference between
the public and private university under study. Most students were enrolled
in the area of Biological Sciences, followed by Exact Sciences, and
most were full-time students, with no other occupational activities.
Twenty-five percent of the students reported the use of medication,
the most frequent being contraceptives, vitamin complexes, and anti-inflammatory
and anti-allergic agents. When the case and non-case groups were compared
by the chi-square test, no significant differences were observed regarding
sociodemographic or clinical variables, indicating that the two groups
were comparable.
Scores for Scale Items
ECSAS scores, reported as means ± SD for cases and non-cases
of SAD, are presented in table 1.
There was similarity in the ordering of the items with highest mean
scores. Group comparison revealed significant differences as to the
total score in 16 of the 17 items of the scale. In all statistically
significant comparisons, the SAD Case group presented higher values
than the SAD non-case group. Regarding the only item for which no
significant difference was observed (item 10: “Putting one’s
hands in one’s pocket”), the value tended to be higher
(p 0.08) for the case group. It should be pointed out that, the higher
the score, the greater the presence of safety behavior.
Reliability
The internal consistency of the ECSAS, calculated by the Cronbach alpha
for the scale as a whole, was a = 0.92.
The analysis of correlation of each item with the total score reveals
that all the items presented positive values of correlation in case
they were removed from the instrument, and that its internal consistency
would not be reduced.
Based on the test-retest comparison for the total scale score, the
weighted Kappa value was 0.73, corresponding to a satisfactory rate
of concordance20. Concerning the items, ten of them presented excellent
concordance and seven satisfactory concordance, with item 10 (“Putting
one’s
hands in one’s pocket”) showing the lowest level of
concordance (0.41), which, however, was still considered to be satisfactory20.
Validity
ROC analysis was performed in order to obtain the profile of discrimination
of the ECSAS within all cut-off possibilities, and the curve is illustrated
in figure 1.
Using a clinical interview (SCID-IV) as the gold standard, the area
under the ROC curve was found to be 0.871, with a standard error of
0.028 for the 95% confidence interval, with estimated sensitivity
of 0.963 and specificity of 1 (p < 0.001).
When the cut-off note (36) proposed in the original study by Pinto-Gouveia
et al.10 was applied,
almost all 80 participants in the case group satisfied this criterion
and only three participants in the non-case group had a score equal
to or higher than this value. The cut-off notes of 36 and 37 were
found to be those that best equilibrated the diagnostic efficiency,
with respective sensitivity of 0.81 and 0.78, specificity of 0.76
and 0.79, PPV of 0.78 and 0.79, NPV of 0.74 and 0.77, and an incorrect
classification rate of 0.21 and 0.22.
The correlation of the ECSAS total score with the total SPIN score
was 0.60, which is considered to be satisfactory23.
The correlations of the ECSAS items with the total score for the SPIN16
ranged from 0.11 to 0.47, with significant correlations being observed
for 16 ECSAS items. Only item 10 (“Putting one’s hands
in one’s pockets”) was not significantly correlated
with the total score for the SPIN.
Sixteen ECSAS items were significantly correlated with the SPIN items,
with the highest correlation being observed between item 7 of the
ECSAS and item 11 of the SPIN (“I avoid speaking to an audience
or making speeches – e.g. presentations in the classroom”).
Analysis of the correlations between items revealed that the larger
number of correlations of the ECSAS occurred with the three SPIN items
that constitute the Mini-SPIN (6, 9 and 15).
Seven items of the ECSAS (1, 6, 8, 12, 13, 16 and 17) were found to
be more correlated with item 6 of the SPIN/MS (“I avoid
doing things with or talking to certain persons for fear of being
ashamed”).
Similarly, seven items of the ECSAS (2, 3, 4, 9, 11, 14 and 15) were
more correlated with item 9 of the SPIN/MS (“I avoid activities
in which I am the center of attention”). Only the items
5, 6 and 8 of ECSAS were more correlated with item 15 of the SPIN/MS
(“Being
ashamed or looking silly are my greatest fears”).
Discussion
Subjects with SAD had total ECSAS scores significantly higher than
the group without such psychiatric disorder, characterizing the presence
of more safety behaviors which express attempts at masking the discomfort
in the presence of social situations as a form of self-control, in
agreement with the propositions of Clark and Wells6.
The presence of more safety behaviors and avoidance of social situations
in the group Case of SAD suggests the adaptative effort made by affected
subjects when facing the anxiety raised by social situations, in agreement
with literature reports7,9,11-13.
Regarding the psychometric qualities of the ECSAS, a satisfactory internal
consistency was detected by the Cronbach alpha and by the test-retest
method, with the correlations showing positive indications in terms
of temporal stability. These data are similar to those reported in
the original study by Pinto-Gouveia et al.10,
suggesting the presence of stability in the use of safety behavior
strategies and the reliability of the instrument.
Analysis of discriminant validity revealed that the ECSAS had adequate
sensitivity and specificity in identifying subjects with SAD compared
to the gold standard instrument (SCID-IV). In view of its peculiarities
regarding the assessment of negative thoughts and of cognitive alterations
associated with SAD, as proposed by Pinto-Gouveia et al.10
and Turner et al.14,
the scale can be considered adequate for the assessment of these variables
in the Brazilian population.
For the analysis of the concurrent validity of the ECSAS, in view of
the lack of another specific tested instrument for the assessment
of safety behaviors, it was decided to correlate the ECSAS scores
with those of the SPIN. Significant correlations were obtained for
the total score and for the items of the ECSAS, confirming the original
study of Pinto-Gouveia et al.10
which detected a moderate correlation when comparing the instrument
with scales for the assessment of social anxiety. We emphasize that
in the present study the most significant correlations were observed
between the items of the ECSAS and the brief form of the SPIN (Mini-SPIN),
suggesting the association of the behavioral pattern of looking for
safety and avoiding social situations with the typical manifestations
of SAD regarding the fear of being ashamed, fear of being the center
of attention, and fear of being exposed to humiliation, in agreement
with recent literature reports5,8,9.
As to the limits of the study, the specificity stands out of the sample
which came exclusively from two cities of São Paulo mid-state,
as well as the number of participants who ceased the participation
in the course of the study, which may suggest that the remaining
ones had less difficulty. A significant number of subjects abandoned
the study during the process to select the participants. This fact
may be associated with one of the core characteristics of SAD which
reflects the fear of being observed and/or judged in situations of
performance by other people. Such anticipated abandonment, in its
turn, may have interfered in the profile of the sample which was
evaluated, in terms of being characterised by individuals with less
severe clinical manifestations of SAD.
Conclusion
With appropriate inclusion and exclusion criteria, the present study
permitted the validation of a scale for the assessment of safety behaviors
of Brazilian university students in social situations, identifying
the discomfort experienced and the avoidance strategies used by subjects
with SAD. The ECSAS showed positive psychometric indicators regarding
reliability, demonstrating stability of behavioral patterns, good
indicators of discriminant validity with the structured clinical interview,
and good convergent validity with an inventory of SAD symptoms. These
results suggest an association of safety and avoidance behaviors with
the symptomatic manifestations of SAD, characterizing the involvement
of cognitions associated with social anxiety. Future studies assessing
the predictive validity of the ECSAS regarding psychotherapeutic and/or
pharmacological treatment of SAD in clinical samples appear to be
necessary and opportune.
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