Development and validation of a DSM-5-based generalized anxiety disorder self-report Scale: Investigating frequency and intensity rating differences

  • Imelu G. Mordeno
  • Ma. Jenina N. NalipayEmail author
  • Jelli Grace C. Luzano
  • Debi S. Galela
  • Michelle Anne L. Ferolino


There are limitations in the currently available measures for the assessment of generalized anxiety disorder (GAD). While changes have been made in the diagnostic criteria for GAD from DSM-IV to DSM-5, there are no scales which items correspond directly to DSM-5-based GAD symptomatology. Moreover, although recent studies support measuring both symptom frequency and intensity of mental disorders, most GAD measures assess only either symptom frequency or intensity, and there is no DSM-5-based self-report measure of GAD that assesses both. In order to address these limitations, two studies were conducted to develop and validate a new GAD self-report scale, the Generalized Anxiety Symptom Severity Inventory (GASSI), which measures symptom severity by assessing both the frequency and intensity of DSM-5-based GAD symptoms in samples of undergraduates and natural disaster survivors. Study 1 provides evidence for a one-factor summed frequency and intensity GAD score using exploratory factor analysis. GASSI was found to have good reliability and evidence of construct validity. Study 2 suggests that both frequency and intensity of symptoms are needed in assessing GAD severity based on the results of invariance testing. These findings have implications for the measurement of GAD symptoms, as well as in the development of interventions for GAD.


Generalized anxiety disorder DSM-5 Symptom frequency and intensity Generalized anxiety symptom severity inventory Scale development 


Compliance with Ethical Standards

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

12144_2019_475_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 19 kb)


  1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: APA Publishing.Google Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: APA Publishing.CrossRefGoogle Scholar
  3. Arrieta, J., Aguerrebere, M., Raviola, G., Flores, H., Elliott, P., Espinosa, A., et al. (2017). Validity and utility of the patient health questionnaire (PHQ)-2 and PHQ-9 for screening and diagnosis of depression in rural Chiapas, Mexico: A cross-sectional Ssudy. Journal of Clinical Psychology, 73(9), 1076–1090.PubMedPubMedCentralCrossRefGoogle Scholar
  4. Axelsson, E., Andersson, E., Ljótsson, B., Wallhed Finn, D., & Hedman, E. (2016). The health preoccupation diagnostic interview: Inter-rater reliability of a structured interview for diagnostic assessment of DSM-5 somatic symptom disorder and illness anxiety disorder. Cognitive Behaviour Therapy, 45(4), 259–269.PubMedCrossRefGoogle Scholar
  5. Batterham, P. J., Sunderland, M., Carragher, N., Calear, A. L., Mackinnon, A. J., & Slade, T. (2016). The distress Questionnaire-5: Population screener for psychological distress was more accurate than the K6/K10. Journal of Clinical Epidemiology, 71, 35–42.PubMedCrossRefGoogle Scholar
  6. Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Gusman, F., Charney, D., & Keane, T. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8(1), 75–90.PubMedCrossRefGoogle Scholar
  7. Bondolfi, G., Jermann, F., Weber Rouget, B., Gex-Fabry, M., McQuillan, A., Dupont-Willemin, A., Aubry, J. M., & Nguyen, C. (2010). Self- and clinician-rated Montgomery-Åsberg depression rating scale: Evaluation in clinical practice. Journal of Affective Disorders, 121, 268–272.PubMedCrossRefGoogle Scholar
  8. Brown, T. A. (2006). Confirmatory factor analysis for applied research. New York: The Guilford Press.Google Scholar
  9. Brown, T. A., & Barlow, D. H. (2014). Anxiety and related disorders interview schedule for DSM-5 (ADIS-5): Clinician manual. New York: Oxford.Google Scholar
  10. Byrne, B. M., Shavelson, R. J., & Muthén, B. O. (1989). Testing for the equivalence of factor covariance and mean structures: The issue of partial measurement invariance. Psychological Bulletin, 105, 456–466.CrossRefGoogle Scholar
  11. Chang, C. H., Cella, D., Clarke, S., Heinemann, A. W., von Roenn, J. H., & Harvey, R. (2003). Should symptoms be scaled for intensity, frequency, or both? Palliative & Supportive Care, 1, 51–60.CrossRefGoogle Scholar
  12. Christensen, K. S., Oernboel, E., Zatzick, D., & Russo, J. (2017). Screening for depression: Rasch analysis of the structural validity of the PHQ-9 in acutely injured trauma survivors. Journal of Psychosomatic Research, 97, 18–22.PubMedCrossRefGoogle Scholar
  13. Cody, M. W., Jones, J. M., Woodward, M. J., Simmons, C. A., & Gayle Beck, J. (2015). Correspondence between self-report measures and clinician assessments of psychopathology in female intimate partner violence survivors. Journal of Interpersonal Violence, 32(10), 1501–1523.PubMedCrossRefGoogle Scholar
  14. Çokluk, Ö., & Koçak, D. (2016). Using Horn’s parallel analysis method in exploratory factor analysis for determining the number of factors. Educational Sciences: Theory & Practice, 16, 537–551.Google Scholar
  15. Cole, D. A., Ciesla, J. A., & Steiger, J. H. (2007). The insidious effects of failing to include design-driven correlated residuals in latent-variable covariance structure analysis. Psychological Methods, 12(4), 381–398.PubMedCrossRefGoogle Scholar
  16. Cornelius, B. L., Groothoff, J. W., van der Klink, J. J., & Brouwer, S. (2013). The performance of the K10, K6 and GHQ-12 to screen for present state DSM-IV disorders among disability claimants. BMC Public Health, 13(1), 128.Google Scholar
  17. Elhai, J. D., Lindsay, B. M., Gray, M. J., Grubaugh, A. L., North, T. C., & Frueh, B. C. (2006). Examining the uniqueness of frequency and intensity symptom ratings in posttraumatic stress disorder assessment. The Journal of Nervous & Mental Disease, 194(12), 940–944.CrossRefGoogle Scholar
  18. Elhai, J. D., Palmieri, P. A., Biehn, T. L., Frueh, B. C., & Magruder, K. M. (2010). Posttraumatic stress disorder's frequency and intensity ratings are associated with factor structure differences in military veterans. Psychological Assessment, 22(4), 723–728.PubMedCrossRefGoogle Scholar
  19. Farrer, L. M., Gulliver, A., Bennett, K., Fassnacht, D. B., & Griffiths, K. M. (2016). Demographic and psychosocial predictors of major depression and generalised anxiety disorder in Australian university students. BMC Psychiatry, 16(1), 241.PubMedPubMedCentralCrossRefGoogle Scholar
  20. First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015). Structured clinical interview for DSM-5 disorders, clinician version (SCID-5-CV). Arlington: American Psychiatric Association.Google Scholar
  21. Fresco, D. M., Coles, M. E., Heimberg, R. G., Liebowitz, M. R., Hami, S., Stein, M. B., & Goetz, D. (2001). The Liebowitz social anxiety scale: A comparison of the psychometric properties of self-report and clinician-administered formats. Psychological Medicine, 31, 1025–1035.PubMedCrossRefGoogle Scholar
  22. Goldberg, D., McDowell, I., & Newell, C. (1972). General Health Questionnaire (GHQ), 12 item version, 20 item version, 30 item version, 60 item version [GHQ12, GHQ20, GHQ30, GHQ60]. Measuring health: A guide to rating scales and questionnaire, 225–236.Google Scholar
  23. Goldberg, D. P., Prisciandaro, J. J., & Williams, P. (2012). The primary health care version of ICD-11: The detection of common mental disorders in general medical settings. General Hospital Psychiatry, 34(6), 665–670.PubMedCrossRefGoogle Scholar
  24. Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public Health, 35, 169–183.PubMedCrossRefGoogle Scholar
  25. Hambleton, R. K., & Jones, R. W. (2012). Comparison of classical test theory and item response theory and their applications to test development, Instructional Topics in Educational Measurement Series 16.Google Scholar
  26. Hayton, J. C., Allen, D. G., & Scarpello, V. (2004). Factor retention decisions in exploratory factor analysis: A tutorial on parallel analysis. Organizational Research Methods, 7(2), 191–205.CrossRefGoogle Scholar
  27. Hinz, A., Klein, A. M., Brähler, E., Glaesmer, H., Luck, T., Riedel-Heller, S. G., et al. (2017). Psychometric evaluation of the generalized anxiety disorder screener GAD-7, based on a large German general population sample. Journal of Affective Disorders, 210, 338–344.PubMedCrossRefGoogle Scholar
  28. Hobbs, M. J., Anderson, T. M., Slade, T., & Andrews, G. (2014). Structure of the DSM-5 generalized anxiety disorder criteria among a large community sample of worriers. Journal of Affective Disorders, 157, 18–24.PubMedCrossRefGoogle Scholar
  29. Hook, J. N., Hook, J. P., Davis, D. E., Worthington Jr., E. L., & Penberthy, J. K. (2010). Measuring sexual addiction and compulsivity: A critical review of instruments. Journal of Sex & Marital Therapy, 36, 227–260. Scholar
  30. Hu, L., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods, 3(4), 424–453.CrossRefGoogle Scholar
  31. Kessler, R. C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., & Yonkers, K. A. (2008). Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological Medicine, 38(3), 365–374.PubMedCrossRefGoogle Scholar
  32. Kline, T. (2005). Psychological Testing: A Practical Approach to Design and Evaluation. Thousand Oaks: Sage Publications.Google Scholar
  33. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9—Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.PubMedPubMedCentralCrossRefGoogle Scholar
  34. Lamers, F., van Oppen, P., Comijs, H. C., Smit, J. H., Spinhoven, P., van Balkom, A. J. L. M., et al. (2011). Comorbidity patterns of anxiety and depressive disorders in a large cohort study. The Journal of Clinical Psychiatry, 72(03), 341–348.PubMedCrossRefGoogle Scholar
  35. Lenz, A. S., & Williams, R. T. (2014). Comparative efficacy between self-report and clinician-administered assessments of posttraumatic stress disorder symptoms across seven studies. Counseling Outcome Research & Evaluation, 5(2), 75–88.CrossRefGoogle Scholar
  36. Liang, Y., Wang, L., & Yin, X. (2016). The factor structure of the 12-item general health questionnaire (GHQ-12) in young Chinese civil servants. Health and Quality of Life Outcomes, 14(1), 136.Google Scholar
  37. Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care, 46(3), 266–274.Google Scholar
  38. Lundin, A., Hallgren, M., Theobald, H., Hellgren, C., & Torgén, M. (2016). Validity of the 12-item version of the General Health Questionnaire in detecting depression in the general population. Public Health, 136, 66–74.Google Scholar
  39. McKenzie, D. P., Ikin, J. F., McFarlane, A. C., Creamer, M., Forbes, A. B., Kelsall, H. L., ... & Sim, M. R. (2004). Psychological health of Australian veterans of the 1991 Gulf War: an assessment using the SF-12, GHQ-12 and PCL-S. Psychological Medicine, 34(8), 1419–1430.Google Scholar
  40. Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., & Poulton, R. (2007). Depression and generalized anxiety disorder. Archives of General Psychiatry, 64(6), 651.PubMedCrossRefGoogle Scholar
  41. Muthén, L. K., & Muthén, B. O. (2013). Mplus version 7.11. Computer software. Los Angeles: Muthén & Muthén.Google Scholar
  42. Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., Przeworski, A., Erickson, T., & Cashman-McGrath, L. (2002). Preliminary reliability and validity of the generalized anxiety disorder questionnaire-IV: A revised self-report diagnostic measure of generalized anxiety disorder. Behavior Therapy, 33(2), 215–233.CrossRefGoogle Scholar
  43. Omani-Samani, R., Maroufizadeh, S., Ghaheri, A., & Navid, B. (2018). Generalized anxiety Disorder-7 (GAD-7) in people with infertility: A reliability and validity study. Middle East Fertility Society Journal, 23(4), 446–449.CrossRefGoogle Scholar
  44. Pimenta, F., Leal, I., Maroco, J., & Ramos, C. (2012). Menopause symptoms’ severity inventory (MSSI-38): Assessing the frequency and intensity of symptoms. Climacteric, 15(2), 143–152.PubMedCrossRefGoogle Scholar
  45. Reynolds, C. R., Richmond, B. O., & Löwe, P. A. (2003). The adult manifest anxiety scale–adult version (AMAS-A). Los Angeles: Western Psychological Services.Google Scholar
  46. Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2008). The factor structure and dimensional scoring of the generalized anxiety disorder questionnaire for DSM-IV. Assessment, 15(3), 343–350.PubMedCrossRefGoogle Scholar
  47. Romera, I., Fernández-Pérez, S., Montejo, Á. L., Caballero, F., Caballero, L., Arbesú, J. Á., … Gilaberte, I. (2010). Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status. Journal of Affective Disorders, 127(1–3), 160–168.Google Scholar
  48. Ruiz, F. J., García-Beltrán, D. M., & Suárez-Falcón, J. C. (2017). General Health Questionnaire-12 validity in Colombia and factorial equivalence between clinical and nonclinical participants. Psychiatry Research, 256, 53–58.Google Scholar
  49. Satorra, A., & Bentler, P. M. (2001). A scaled difference chi-square test statistic for moment structure analysis. Psychometrika, 66(4), 507–514.CrossRefGoogle Scholar
  50. Sawaya, H., Atoui, M., Hamadeh, A., Zeinoun, P., & Nahas, Z. (2016). Adaptation and initial validation of the patient health questionnaire–9 (PHQ-9) and the generalized anxiety disorder–7 questionnaire (GAD-7) in an Arabic speaking Lebanese psychiatric outpatient sample. Psychiatry Research, 239, 245–252.PubMedCrossRefGoogle Scholar
  51. Schneider, S., & Stone, A. A. (2014). Distinguishing between frequency and intensity of health-related symptoms from diary assessments. Journal of Psychosomatic Research, 77(3), 205–212.PubMedPubMedCentralCrossRefGoogle Scholar
  52. Seedat, S., Fritelli, V., Oosthuizen, P., Emsley, R. A., & Stein, D. J. (2007). Measuring anxiety in patients with schizophrenia. The Journal of Nervous & Mental Disease, 195(4), 320–324.CrossRefGoogle Scholar
  53. Sousa, T. V., Viveiros, V., Chai, M. V., Vicente, F. L., Jesus, G., Carnot, M. J., ... & Ferreira, P. L. (2015). Reliability and validity of the Portuguese version of the generalized anxiety disorder (GAD-7) scale. Health and Quality of Life Outcomes, 13(1), 50.Google Scholar
  54. Spielberger, C. D. (1989). State-trait anxiety inventory: Bibliography (2nd ed.). Palo Alto: Consulting Psychologists Press.Google Scholar
  55. Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097.CrossRefGoogle Scholar
  56. Stein, D. J., Fincham, D., Seedat, S., de Bodinat, C., & Ahokas, A. (2009). The DSM-IV-based generalized anxiety disorder severity scale: Preliminary validation using data from a trial of agomelatine versus placebo. The Journal of Nervous & Mental Disease, 197(6), 391–394.CrossRefGoogle Scholar
  57. Sugiura, Y., & Sugiura, T. (2015). Emotional intensity reduces later generalized anxiety disorder symptoms when fear of anxiety and negative problem-solving appraisal are low. Behaviour Research and Therapy, 71, 27–33.PubMedCrossRefGoogle Scholar
  58. Toussaint, A., Murray, A. M., Voigt, K., Herzog, A., Gierk, B., Kroenke, K., ... & Löwe, B. (2016). Development and validation of the somatic symptom disorder–b criteria scale (SSD-12). Psychosomatic medicine, 78(1), 5–12.Google Scholar
  59. Toussaint, A., Löwe, B., Brähler, E., & Jordan, P. (2017). The Somatic Symptom Disorder-B Criteria Scale (SSD-12): factorial structure, validity and population-based norms. Journal of Psychosomatic Research, 97, 9–17Google Scholar
  60. Toussaint, A., Riedl, B., Kehrer, S., Schneider, A., Löwe, B., & Linde, K. (2017). Validity of the Somatic Symptom Disorder–b Criteria Scale (ssd-12) in primary care. Family Practice, 35(3), 342–347.Google Scholar
  61. Van Lancker, A., Beeckman, D., Verhaeghe, S., Van Den Noortgate, N., Grypdonck, M., & Van Hecke, A. (2016). An instrument to collect data on frequency and intensity of symptoms in older palliative cancer patients: A development and validation study. European Journal of Oncology Nursing, 21, 38–47.PubMedCrossRefGoogle Scholar
  62. Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-administered PTSD scale: A review of the first ten years of research. Depression and Anxiety, 13, 132–156.PubMedCrossRefGoogle Scholar
  63. Zhong, Q. Y., Gelaye, B., Zaslavsky, A. M., Fann, J. R., Rondon, M. B., Sánchez, S. E., & Williams, M. A. (2015). Diagnostic validity of the generalized anxiety Disorder-7 (GAD-7) among pregnant women. PLoS One, 10(4), e0125096.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Mindanao State University - Iligan Institute of TechnologyIliganPhilippines
  2. 2.The Education University of Hong KongHong KongChina

Personalised recommendations