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Journal of the Korean Academy of Family Medicine 1996;17(1):31-41.
Published online January 1, 1996.
Devdopment of the White-Coat Anxiety Scale.
Hyun kook Yoon, Seung Ho Jung, Eun Young Choi, Seong Won Kim, Bong Yul Huh, Tae Heon Noh
백의불안척도의 개발
윤현국, 정승호, 최은영, 김성원, 허봉렬, 노태헌
울산의대 서울중앙병원 가정의학교실 한림의대 강동성심병원 가정의학교실
Abstract
Research Background
: It is well-known that there are significant differences in clinic blood pres-sure (CBP) and ambulatory blood pressure (ABP) among many hypertensive patients. These differen-ces are called the "white-coat effect"(WCE). There have been studies to find a method of predicting the WCE and to investigate a correlation between the WCE and anxiety of paients. However, anxiety scales adopted in the former studies were fount to be inadequate to measure the anxiety which patients experience in clinics. In this study we developed a new scale, called the "white-coat anxiety scale"(WCAS), which can effectively measure the anxiety of hypertensive partients in clinics and help to find a method of predicting white-coat hypertension in the future.
Methouds: The WCAS was developed on the basis of te test anxiety scale and the manifest anxiety scale, whose validity and reliability have been proved. First, a test questionnaire was made with professional advices of a psychiatrist, a preventive medicine staff, and a professor of education. Patient anxiety symptoms were classified into three categories : autonomic hyperactivity, motor ten-sion, and cognitive symptom. Twelve questions were made in each category to make the test question-naire of 36 questions. Second, after a pre-test, a final questionnaire was made by rejecting two ques-tion, whose internal consistencies were found to be poor, in each category. The final questionnaire of 30 questions was checked with the test-retest correlation method. Third, a survey was actually done on hypertensive patients whose 24 hours ABP's were monitered either in department of family medicine, a university hospital of in a general hospital. Finally, based on the survey, the correlation between the WCE and WCAS was evaluated. The WCE was determined by subtracting the CBP value with the aerage value of 24 hours ABP.

Results : The study subjects were composed of 15 patients in departiment of family medicine, a university hospital and 25 patients in a general hospital. They consisted of 23 male and 17 female patients, and their average age was 50.6 years. The internal consistency of the WCAS was estimated to be 0.87, and the correlation of the test-retest results was found to be 0.90. The correlation coefficients between the WCAS and the WCE were 0.48 for the daytime systoli lood pressure(SBP), 0.33 for the night-time DBP, and 0.45 for the mean DBP. These values show that the difference of the CBP from daytime blood pressure has a strong correlation with the WCAS. The correlation between the WCE and the WCAS was found to be similar for the SBP and the DBP. Among the patient anxiety symptoms, the cognitive symptom is not correlated wit the WCAS.

Conclusion : The newly developed WCAS has a high reliability and shows a strong correlation with the WCE. In order to introduce the new scale to a clinical use, more studies are required to find a cutoff value of the WCAS and to check the possibilities of predicting white coat hypertension with the WCAS.
초록
연구배경 : 많은 고혈압환자들에서 진료실에서 측정한 혈압과 평상시 혈압에 차이가 있으며, 이 두 혈압간의 차이를 백의효과(white-coat effect)라 한다. 그동안 백의효과를 예측할 수 있는 방법으로 불안과의 연광성을 밝히고자 하는 연구가 있었으나, 그런 연구에서 채택한 불안척도는 진료실에서 느끼는 불안을 측정하는데 부적합하였다. 따라서 이번 연구에서는 고혈압환자들이 진료실에서 느끼는 불안을 효과적으로 측정하는 도구를 개발하여 향후 백의성 고혈압을 예측하는데 도움이 되고자 한다.

방법 : 백의불안척도는 타당도와 신뢰도가 입증된 시험불안지수와 표출불안척도의 항목을 바탕으로 하였다. 우선 불안증상을 자율신경계 항진에 의한 증상과 근육의 긴장에 의한 증상, 불안의 인지에 의한 증상으로 나눈 후 각 범주마다 12개의 항목씩 모두 36개의 항목을 만들어, 정신과 전문의 1명, 예방의학과 전문의 1명, 교육학 교사 1명에게 자문을 구하였다. 시험조사를 실시한 후 각 범주마다 내적일치도가 낮은 항목을 2개씩 제외하여 30문항을 최종적으로 채택하고, 시험 - 재시험법을 시행한 후, 1개 대학병원 가정의학과 1개 종합 병원에서 혈압약 복용에 관계없이 24시간 활동혈압을 측정한 고혈압 환자를 대상으로 백의효과와 백의불안척도와의 상관관계를 구하였다. 백의효과는 진료실혈압에서 24시간 활동혈압의 평균치를 빼서 구하였다.

결과 : 연구대상자는 1개 대학병원 가정의학과에서 15명, 1개 종합병원에서 25명으로 모두 40명을 대상으로 하였다. 남자는 23명, 여자는 17명이었으며, 평균연령은 50.6세였다. 백의 불안척도의 내적일치도는 0.87이었으며, 시험 - 재시험범에 의한 상관계수는 0.90이었다. 백의불안척도와 백의효과간의 상관계수는 주간 수축기혈압과는 0.48, 야간 수축기혈압과는 0.33, 전체 수축기혈압과는 0.44였고, 주간 이완기혈압과는 0.48, 야간 이완기혈압과는 0.34, 전체 이완기혈압과는 0.45로 나왔다. 이를 분석해보면 진료실혈압과 야간혈압간의 차이는 백의 불안척도와 연광성이 약하며, 주간혈압과의 차이를 백의불안척도와 비슷한 연광성을 보였다. 증상별로는 불안의 인지에 의한 증상이 백의효과와 유의한 상관관계가 없는 것으로 나타났다.
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