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versión impresa ISSN 0101-8108
Rev. psiquiatr. Rio Gd. Sul vol.31 no.3 Porto Alegre sept./dic. 2009
Adriana Cardoso de Oliveira e SilvaI; Antonio Egidio NardiII
IPost-doctoral student, Graduate Program
in Psychiatry and Mental Health, Institute of Psychiatry, School of Medicine,
Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, PhD, Psychology,
Institute of Psychology, UFRJ, Researcher, Laboratory of Panic and Respiration,
Institute of Psychiatry, School of Medicine, UFRJ, Instituto Nacional de Ciência
e Tecnologia (INCT) - Translational Medicine, UFRJ, Rio de Janeiro, RJ, Brazil
IIProfessor, Graduate Program in Psychiatry and Mental Health, Institute of Psychiatry, School of Medicine, UFRJ, Associate professor, Graduate Program in Psychiatry and Mental Health, Institute of Psychiatry, School of Medicine, UFRJ, Coordinator, Laboratory of Panic and Respiration, Instituto Nacional de Ciência e Tecnologia (INCT) - Translational Medicine, UFRJ, Rio de Janeiro, RJ, Brazil
Study conducted at the Laboratory of Panic and Respiration, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ and at the Instituto Nacional de Ciência e Tecnologia (INCT) - Translational Medicine, Rio de Janeiro, RJ, Brazil
INTRODUCTION: The Fear of
Negative Evaluation Scale (FNE) is aimed at evaluating the fear of
social evaluations in adults. Its cross-cultural adaptation is the
first step for future comparisons regarding the construct measured by
the instrument in different populations. The objective of the present
study is to semantically adapt the FNE to the Brazilian Portuguese.
METHOD: The process consisted of 1) two translations and back-translations carried out by independent evaluators without any prior knowledge of the scale to be translated; 2) development of a brief version by two different bilingual experts in mental health; 3) subsequent administration to an experimental group to evaluate the items in the brief version, seeking to better match the population to which the scale is intended.
RESULTS: The four stages of the process are shown for each one of the 30 items of the instrument. The use of two translations and back-translations allowed a broader discussion for the design of the brief version. The participation of experts in mental health contributed to the appropriateness of the terms used for the construct measured. The experimental administration of the instrument allowed the identification of potential difficulties regarding the clarity of specific items in some of the population samples and subsequent performance of adjustments.
CONCLUSIONS: We were able to elaborate the Brazilian Portuguese version of the FNE by means of this methodology.
Keywords: Scales, psychometry, anxiety, anxiety disorders.
The Fear of Negative Evaluation Scale (FNE) was designed by Watson & Friend1 and it is aimed at evaluating the fear of social evaluations in adults. It comprises 30 true or false questions. This scale can be administered to individuals, groups or even self-administered.
It is complementary to the Social Avoidance and Distress Scale (SADS), which has already been translated and adapted into Brazilian Portuguese,2 comprising 28 true or false questions. Both scales were developed for joint use in measuring aspects related to social anxiety.
The FNE has reversed items for the construct measured, with items 2, 3, 5, 7, 9, 11, 13, 14, 17, 19, 20, 22, 24, 25, 28, 29, and 30 being considered as standard "true" answers, and items 1, 4, 6, 8, 10, 12, 15, 16, 18, 21, 23, 26, and 27 being "false" answers.
Due to their low cost and short administration time (around 10 minutes each), in addition to the easiness of being self-administered, these scales are interesting options for quick and effective assessment both in the individual's everyday environment, thus adapting well to data collection for social research, and in the clinical and hospital contexts.
The absence of biological markers and other objective measuring parameters for the identification and assessment of psychiatric disorders3 contributes to an increased demand for psychometric instruments that, due to their characteristics, eventually fill the gap, thereby fulfilling an important role.
The increased emphasis on evidence-based methods, including in the mental health field,4-6 has increasingly generated the need for measurements in psychiatry and psychology research, which also boost the search for structured instruments that can provide data obtained from a standardized method assuring the validity and reliability of the results of these studies.
Studies of the psychometric parameters of the original FNE,1 conducted with university students, demonstrate correlation with anxiety measures, fear of social evaluation, and locus of control, internal consistency of 0.94, as measured by Kuder-Richardson coefficient (KR20), and reliability of 0.94, as measured by test-retest with time interval of 1 month.
At the same time, the use of measuring instruments focused on specific sets of signs and symptoms has aided in therapeutic processes that include in their methodological proposals the training of patients so that they are able to recognize these signs and symptoms in themselves allowing for subsequent self-monitoring.
We must consider also that more recent psychotherapeutic approaches, such as cognitive-behavioral therapy, use scales to monitor the patient's progress throughout the therapeutic process, serving in these cases not only to quantify what they are intended to measure, but also as a guide for the therapist as to which procedures are generating better response in terms of therapeutic effectiveness.
In the specific case of anxiety disorders, there has been increasing production, both in terms of development of new instruments7,8 and translation and semantic adaptation into Portuguese of scales already used in other languages,2,9-12 as well as regarding studies focused on the analysis of the psychometric parameters of these scales13-17 seeking to set standards for the Brazilian population13,14
The translation and adaptation of instruments that are widely used internationally have the advantage of allowing the comparison of results obtained from populations of different countries, thereby generating transcultural data.18
Fear of negative evaluation by others, as well as fear of being negatively judged in social situations or publicly humiliated characterize social phobia.19 The anxiety generated, along with its consequent signs and symptoms, may lead to avoidance of environments or situations involving interpersonal relationships, impairing the subject's overall functioning and compromising his/her quality of life. The FNE, focusing on the fear of negative evaluation, is a valuable instrument for studies related to that specific psychiatric disorder.
The objective of the present study is to propose a translation and semantic adaptation of the FNE for the Brazilian population, opening the possibility for future studies to validate and measure the reliability of the instrument developed for this population.
The process of translation and semantic adaptation of the FNE used in the present study, which is similar to that used for the adaptation of the SADS, its complementary scale, was based on the proposal by Herdman et al.20 This model included four steps: translation, back-translation, analysis of semantic equivalence, and experimental administration.
At the beginning of the translation and back-translation process,21,22 an original version of the scale was handed out to two independent Brazilian translators (T1 and T2), who were fluent in the language of the original instrument, with knowledge of psychiatry and mental health, and who had no previous contact with the scale. Later, the questions prepared by T1 and T2 were delivered to other two translators for the preparation of back-translations (B1 and B2).
The material resulting from this process was examined by two specialists in mental health and psychiatry. We compared the sentences generated in the back-translations to the original instrument to check the equivalence between the texts.
Comparisons were made between the proposals of both translations and the original text for each item in order to prepare the synthetic version. While some of them were basically defined by one of the translations submitted, others were designed based on a combination of them, with or without changes made by the experts for more appropriate formulations. The semantic equivalence was emphasized at the expense of the literal equivalence.12
Once the synthetic version was finished, the stage of experimental administration of the instrument was initiated to check its adequacy to the target population. An important point in this phase is the identification of possible difficulties of respondents to understand the items, since the fact that they do not understand the items should not influence their response because this is not the attribute being measured.23
This phase of the process included 27 adult volunteers of both sexes with different educational levels, according to the following distribution: elementary school: six females, one male, seven total; high school: four females, one male, five total; university: nine females, six males, 15 total.
One of the criticisms regarding the studies on measuring instruments for social anxiety disorder is related to the fact that there are few studies conducted with nonclinical samples, which would call into question the effectiveness of these instruments for screening the general population.24 To avoid this problem, we decided to work with participants who met the inclusion criterion of not having mental disorders since the translation and adaptation phase of the instrument.
All volunteers, who initially amounted to 30, were evaluated for psychiatric disorders using the Mini International Neuropsychiatric Interview (MINI) version 5.0.025 after ruling out the presence of mental disorders in 27 subjects who participated in the experimental administration.
The experimental administration included three stages. Participants completed the self-administered scale. Upon completion of this stage, the researcher checked for omissions of answers and recorded the items related to these omissions in order to determine their causes.
Then, a survey was conducted regarding the meaning of the statements according to the respondents' understanding to check their real understanding of the meaning of the sentences. Finally, participants were asked to provide suggestions that could facilitate the understanding of the instrument or improve it.
Based on the data collected using the experimental administration, the statements of the synthetic version were revised, aiming to solve problems present during the administration due to lack of understanding or confusion about the meaning of the items. Then we developed the final version of the FNE in Brazilian Portuguese.
Table 1 shows the questions of the original instrument in English, the translations carried out by two independent translators (T1 and T2) into Brazilian Portuguese, the back-translations (R1 and R2), and the synthetic version developed based on this process by specialists in mental health.
Some items were formed by combining the translations made by T1 and T2, while, in some cases, the suggestion of one of them was chosen. Also, the experts inserted minor changes to the text suggested by the translators in order to maintain the relevance of the construct assessed.
Items 1, 8, 9, 10, 11, 12, 19, 21, 25, and 29 had very similar translations by T1 and T2, thus, in these cases, a combined version of both was achieved. In items 4, 6, 20, and 23, we also used a synthetic version of T1 and T2, but it was slightly adjusted to better comply with the original language standard.
In item 1, the difference between T1 and T2 was only regarding the use of "se pareço" or "em parecer." We decided to use "em parecer" and deleted the word "eu" used by both translators, which was in accordance with the original item since its use is not common in the usual speech of the target language.
In item 8, the text proposed by T1 ("reajo muito pouco") and by T2 ("quase não tenho reação") were converted into "reajo minimamente" in the final version. The last part of the statement was the same for both translators and, therefore, it was not changed.
The texts proposed by T1 and T2 for item 9 were very similar, with the only difference being between "sinto medo" and "tenho medo." We chose to use "tenho medo."
In item 10, the terms "teria um pequeno efeito" and "teria um efeito pequeno" were adapted to "teria pouco efeito" in order to sound more natural. The same happened with "desaprovação de outras pessoas" and "desaprovação vinda dos outros", which were slightly modified to "desaprovação dos outros," however, keeping the original meaning.
Although T1 and T2 suggested very similar statements for item 11, the first translator used "eu tenho a tendência," while the second used "eu tendo." T2's choice prevailed because it sounded more appropriate to the tense expressed in the original version of the item.
Again, translations were quite similar in item 12, the only difference being the use of "passando para" suggested by T1 and "causando em" suggested by T2. Both options are correct and appropriate; however, since we noticed that in the language to which the scale was being adapted, the expression "causando em alguém" is more commonly used, we decided to use this version.
In item 19, the term "usually," which in a literal translation would be "habitualmente," was translated as "frequentemente" by T2 and as "normalmente" by T1. We selected the suggestion of T2 because it sounded closer to the original meaning. The term "tipo de," which was kept by T2 and not used by T1, was also preserved.
A similar situation occurred with item 27, where "usually" was translated as "geralmente" by T1 and "frequentemente" by T2. The same approach was used and we chose to use "frequentemente." The rest of the sentence was used according to T1's translation, using "impressão" instead of "opinião", as suggested by T2, to translate the term "impression."
The translations for item 21 were almost identical, except for the fact that T1 used "tem alguém" while T2 opted for "alguém está," with the meaning being preserved in both proposals. In the final item, we chose to use "someone is."
The difference between T1 and T2 for item 25 was basically regarding the tense used. By trying to properly adapt to the original, for "will say or do," we used "que direi ou farei."
In item 29, the expression "brood about", which could be literally translated as "meditar sobre," was translated into the target language as "ruminar" by both translators. Choosing to respect the term chosen by the translators, the most appropriate tense would be the one used by T2, "eu rumino;" however, culturally, the use of the same expression with a different verb tense is more common, as proposed by T1: "fico ruminando." Due to the objective of semantic adaptation, we used the version suggested by T1 in the final item.
For item 4, T1 opted for using the term "desconcertado" to translate the word "unconcerned", meaning "despreocupado" in a literal translation. Then, we used the suggestion of T2; however, we replaced the term "sobre mim" with "de mim" according to T1's translation.
In item 6, we observed the use of "pessoas que me são importantes" by T1 for the translation of "important people", which would be a major change in the original, since the importance of people in relation to the subject was not mentioned. Therefore, we kept T2's suggestion "pessoas importantes," according to the original statement.
In item 20, we observed the use of "pensam a meu respeito" by T1 and "acharão de mim" by T2. We chose to use a combined version: "pensam de mim." The beginning of the sentence was slightly changed from "eu me preocupo" to "preocupo-me" to adjust to the linguistic patterns.
For item 23, T2's suggestion prevailed, since it proved to be more suitable; however, we made some adjustments to the tense of "pensarão" to "possam pensar."
In item 26, there are two different terms for "often," which in a literal translation would be "frequentemente," and T2's suggestion was "eu fico frequentemente;" however, the expression "eu fico" was not very appropriate. In this sense , we kept the style suggested by T1 using "normalmente sou," and we replaced the first term by "frequentemente," thus defining the final version of the item.
In items 15 and 28, we chose the wording suggested by T1, and in items 2, 16, and 17, we selected the versions proposed by T2. For item 15, the difference between the suggestions of the translators was only regarding the use of "dos outros" and "de outras pessoas." We decided to use the first option. In item 28, T1 used "muito em mim," which was more suitable for "much of me" than "muito sobre mim" proposed by T2.
The tense was decisive for choosing the version of T2 for the translation of item 2, thus we used "pensarão" to translate "will think" instead of the option "pensam" suggested by T1. The phrase "não faz a menor diferença" was changed to "não faz nenhuma diferença" to get more familiar with the usual use in the target language.
In item 16, the use of "chateado" was more appropriate to translate "upset" contained in the original item than "triste" suggested by T1. T2's suggestion was preserved, and we only deleted the pronoun "eu" of "se eu não agrado a alguém" since it was unnecessary.
We observed that in item 17 the phrase "possam estar pensando" suggested by T2 was more adequate to translate "may be thinking." The use of "conversando" instead of "falando" as suggested by T1 to translate "talking" was also a factor for choosing T2's version.
In item 5, we prioritized T2's version, changing only "fico" to "sinto," according to the T1's suggestion. Regarding the term "social error," although we understand that the literal translation would be "erro social," as proposed by T1, we chose the word "gafe," used by T2, which is common in the Brazilian Portuguese, without the term "social" following it. The same adjustment was made in item 18.
In items 3 and 30, both translations were similar using the word "nervoso" as equivalent to "jittery." However, while reviewing the appropriateness of the term for the mental health area, we decided to replace it with "inquieto", because of the higher relevance of the latter, in addition to not compromising the meaning of the wording proposed in the original version.
Still regarding these two items, the use of the phrase "I become," the translation into "eu me torno" proposed by T2 was chosen instead of "eu fico" suggested by T1 because it is closer to a literal translation.
For item 7, the two translations are very similar. We decided to use T2's suggestion, only replacing "tolo" with "bobo," concerning the phrase "make a fool of myself" because it is more frequent in the colloquial language used in the culture of the target population for the administration of the scale.
The word "medo" was chosen to translate "afraid" instead of "me preocupo" suggested by T2 for items 13 and 14. In item 22, we used a synthetic version, but we prioritized the use of "sem valor" suggested by T2 because it is closer to the original text. Finally, in section 24, the suggestion adopted was the one presented by T1. In this case, we chose to keep "estou" instead of "sou," reinforcing the emphasis on the current moment.
Once the synthetic version of the items that formed the first version of the scale into Brazilian Portuguese was prepared, we started the experimental administration of the instrument in order to check the actual adequacy of the items to the population to which the instrument was intended.
With that purpose, we were helped by volunteers with different educational levels, from several areas of knowledge, and of both sexes. These participants were tested by using the MINI to rule out psychiatric disorders. The procedure eliminated three of the initial 30 volunteers, thus 27 individuals effectively participated in the analysis. The profile of the group was as follows: 19 participants were female and eight were male; seven individuals had completed elementary school, five had finished high school, and 15 had a college degree in areas such as humanities, biological and exact sciences.
After answering the FNE during the experimental administration according to the administration standards as specified in the original instrument, the individuals participated in a discussion about the linguistic aspects of the material used.
Such discussion was divided in two stages. During the first stage, the participants were asked to describe in their own words how they understood the statement contained in the preliminary version of the instrument. This was accomplished for all items. In the second phase, the participants were asked to give suggestions of alternative terms that could facilitate the understanding of the item.
First, the administrations were carried out with participants who had completed elementary school, then the instrument was administered to those who finished high school, and finally we completed the process with those who had complete or incomplete higher education; in which case the participant had completed at least 50% of the undergraduate program.
In the group who completed elementary school, we found that three participants did not answer three items. Items 4 and 27 were not answered by two individuals; they explained they did not answer the questions because they did not understand the meaning of the word "favorável." With regard to items 5 and 18, the same omission was found due to the same reason, but this time it was related to the word "gafe," which was not understood by another participant. As for those last two items mentioned above, three other participants reported having difficulty in understanding the term.
Regarding the request for the participants to describe their understanding of the statements, in general the definitions provided were able to grab the meaning proposed by the instrument, showing that it was being well understood. Items 5 and 18 were exceptions because of the difficulty in understanding the aforementioned word "gafe," and also item 29, since the participants were confused about the meaning of the term "ruminante."
Item 28 caused slight confusion over the phrase "que me são." Even though, after briefly analyzing the statement and without interference from the researcher, the participants were able to understand the question. Participants also needed a longer time to understand question 2.
This group did not provide direct suggestions of alternative terms, remaining more passive and restrained than the groups representing other educational levels. However, in item 8, one participant mentioned that the word "pouco" would be more "common" than "minimamente," then another participant declared that it was necessary to read the question twice during the administration of the instrument in order to understand what it "meant."
Among the individuals who had completed high school, we found only one question unanswered regarding item 29 during the experimental administration. The respondent explained later that the question was not answered because it was not possible to understand the meaning of the term "ruminando."
When the participants of this group were requested to explain the meaning of the statements, all of them were able to do it; however, there was some confusion regarding the use of the word "gafe" by one of the respondents, who revealed he chose the answer at random just to avoid leaving it unanswered. The same occurred with the term "ruminante."
This group indicated that item 27 did not seem "natural", but failed to clarify the reason of thinking so. With regard to the word "gafe," one of the participants explained to other individual who mentioned that he could not understand the term that the word would be equivalent to "dar vexame", "pagar mico" or "passar vergonha". The other participants agreed with this explanation.
Due to the difficulty related the term "favorável" in the group that had completed elementary school, we chose to directly ask the high school group about their understanding of the meaning of this word. The subjects showed that they could understand it; therefore the problem with that word was only related to those with lower education.
The members of this second group were more involved in the process and provided some suggestions such as replacing the term "minimamente" in item 8 with "pouco" in order to get closer to the language used by them everyday, as well as changing the use of "sobre mim" to "de mim" in item 17.
After finishing the analysis of the material provided by this group, we started experimental administration to the group holding college degrees. This group comprised professionals who were pursuing their graduate degrees and professionals who had graduated from college in the areas of humanities, exact, and biological sciences. Among the participant of this group, five had knowledge related to the mental health area, but did not know the scale.
There were no unanswered questions in these participant's protocols, and all of them showed perfect understanding of the meaning of the statements when questioned about it. It was the group that participated more actively by offering suggestions for "improvements" of the instrument.
Regarding item 4, the participants suggested the removal of the pronoun "eu" before "sei que," since they considered it to be "unnecessary." For item 14, they suggested replacing "as pessoas" with "os outros" in order to be in agreement with the structure used in items 22, 23, and 24 according to them. Also in relation to those items, they added that the use of "os outros" in these items would be "unnecessary" and it could be deleted.
For item 25, they questioned the possibility of changing "que direi ou farei" to "se direi ou farei." In relation to item 27, they argued that "fico confiante" should be changed to "confio."
The group was also asked about terms that caused difficulties in the administration of the instrument to the previous groups, such as "gafe," "favorável," and "ruminante," and these terms did not cause any confusion among them.
They suggested as an alternative term for "impressão desfavorável" the use of "má impressão" or "impressão ruim." For "gafe", they suggested the term "vexame," as previously suggested by the high school group, although they added "em público" because the word "gafe" refers to an event that occurs socially.
Finally, for the term "ruminante" (in "fico ruminando"), the suggestions were "fico pensando," "fico meditando," and "fico refletindo." One of the participants also suggested adding "sem parar" to the term "pensando" because, according to him, "pensando sem parar" would show the "nature of rumination," that is, "thoughts that come and go." Other individuals agreed with him and another participant suggested using "pensando continuamente."
Once the experimental administrations were carried out, we prepared the synthesis of the material collected in order to design the final version of the statements. Items 1, 2, 3, 6, 7, 9, 10, 11, 12, 13, 15, 16, 19, 20, 21, 26, 28, and 30 remained unchanged in the final version of the scale.
In spite of the suggestions, items 14 and 17 were preserved as originally proposed in order to maintain as much similarity as possible with the original instrument, since they were well understood by all groups. The same occurred in relation to items 22, 23, and 24, which kept the term "os outros."
In item 25, we decided to change "que" to "se" with the purpose of achieving better understanding of the item by the respondents since there was difficulty in one of the groups and the suggested change did not compromised the meaning originally proposed by the instrument. With the same purpose, in items 4 and 27, the term "impressão favorável" was replaced with "boa impressão."
The word "gafe," which caused difficulty in items 5 and 18, was changed to "vexame em público," as suggested by the participants, preserving the original meaning and becoming clearer.
In item 8, where the use of "minimamente" was questioned, with the participants suggesting the use of "pouco" during the experimental administration, we decided to change it to "muito pouco," since it is similar to the one suggested and, at the same time, keeps the relevance regarding the text of the original item: "very little."
The use of "fico confiante," in item 27 was also addressed by the participants, and they suggested to use the alternative option "confio." This change, however, would cause a change in the meaning of the sentence, suggesting a more active than passive attitude as opposed to the text originally presented. Due to this factor, the use of "fico confiante" was kept. As for the term "favorável," we made a change similar to that performed in item 4.
Finally, in item 29, we had difficulty using the original expression "I brood about," which was translated as "Fico ruminando." The issue of tense had already been identified as a problem during the preparation of the synthetic version, and then a change was made to adapt to the use in the target language. But the use of "ruminando" caused difficulties and showed not to be appropriate during the experimental administration, evidencing the need of replacement.
In this sense, among the alternative terms suggested by the participants, the one more closely related to the original meaning was "fico meditando." However, in order to keep coherence with the culture to which the scale is intended to be used, we believe that the use of "meditando" would not evoke the meaning of cyclical and repetitive thought implicit in the term "ruminando," which was chosen by both translators. Therefore, to minimize this problem, we chose to use "penso continuamente."
Thus, we had the final version of the 30 items, which is the version of the FNE for the Brazilian Portuguese.
The importance of the use of structured instruments for the field of psychiatry and mental health with good psychometric properties that, in addition to precision, guarantee that their findings really measure what they claim to measure is evident.
This is partly due to the fact that this field of knowledge does not have resources such as clinical tests or biological markers that are able to provide indisputable basis for a correct identification of mental disorders. Even if this type of diagnostic tool was available, the assessment instruments would still be a fast and low cost resource. And this should be considered especially when thinking in terms of health care facilities with little financial resources.
The correct measurement of signs and symptoms, in turn, cannot stop being carried out, since the non-identification of mental health disorders may cause serious harm to the individuals' lives. A correct diagnosis provides the opportunity for treatment still during the early stages of the disorder development, preventing the emergence of comorbidities and avoiding that, apart from the direct damage that they can cause to individuals, these disorders act as risk factors or contribute to higher morbidity and mortality also in cases of organic illness.
The use of measuring instruments transcends even the assessment area only intended at diagnostic and it fits into the context of clinical care both to evaluate the patient's progress during treatment or even the effectiveness of the procedures adopted and to assist in the psychoeducational process.
With the aim of preparing the translation and semantic adaptation of the FNE, the original items from the FNE were sent to independent translators with no prior knowledge about the scale. Next, the material derived from these translations was sent to two other professionals for back-translations.
The option to work with two translations and two back-translations proved to be fruitful as it allowed extensive discussion when there was disagreement between the versions, allowing thus greater adaptation of the statements to the original scale.
The fact that the translators and reviewers were familiar with the area of mental health made the work of semantic adaptation smoother, because in spite of prior lack of knowledge about the specific instrument, their knowledge about the construct enabled them to make fine adjustments in the terms chosen to represent the original items.
The experimental administration made it possible to carry out a final adjustment of the synthetic version so that it was intelligible for those with elementary educational level, preserving the interest of those who have more years of schooling, preventing impairment of the apparent validity.
Based on the data collected using this procedure, we made the final adjustments to the instrument, thus achieving the final version in Portuguese. Further studies should be conducted to evaluate the validity and reliability and to set up norms for the Brazilian population.
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Correspondence Received May 7, 2009. There are no conflicts of interest associated
with the publication of this manuscript. ANEXO
Adriana Cardoso de Oliveira e Silva
Universidade Federal do Rio de Janeiro, Instituto de Psiquiatria, Laboratório de Pânico e Respiração
Rua Visconde de Pirajá, 407/702
CEP: 22410-003, Rio de Janeiro, RJ, Brazil
Tel.: +55 (21) 2521.6147
Fax: +55 (21) 2523.6839
Accepted July 16, 2009.
Financial support: National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq).
Received May 7, 2009.
There are no conflicts of interest associated
with the publication of this manuscript.