Anxiety scales tutorial

1. Hamilton Anxiety Rating Scale
State-Trait Anxiety Inventory
Hospital Anxiety Depression Scale
Dr. Amit Chail

2. • Case 1:
– 65 yr m/o serving Nk admitted in MH CTC, a case
of NHL on chemotherapy, h/o fever, nausea and
vomiting x10 days. Called for evaluation of
disturbed sleep, refusal to eat, episodic
restlessness, palpitations, diaphoresis and pacing
around in the ward.
• Q- Which is the most suitable scale to assess
the level of distress of such a patient?

3. • Case 2
– 35 yr serving NCO in LMC (S2 T-24+24) for
moderate depressive episode admitted for recat 2
days back. Reports disturbed sleep, bechaini;
looks anxious and has fine digital tremors.
– Q- Which psychometric scale?
– Q- Which is the best scale for follow up?

4. The Hamilton Anxiety Rating Scale

5. Introduction
– HAM-A, HARS
– Hamilton M, The assessment of anxiety states by
rating. Br J Med Psychol, 1959; 32:50–55
– Affiliation : University of Leeds
– Clinician-rated
– Severity of anxiety symptoms and their progression
– Adults, adolescents and children
– Two domains – psychic and somatic
– Open access
– Not diagnostic

7. History and Evolution
– First intro- April 1957 at Annual General Meeting of
British Psychological Society
– Published article -1959
– 13 Item scale- Item No-07- somatic symptoms of a
general type
– HAM-A (14) (1969, British J Psy)
– Somatic (muscular)
– Somatic (Sensory)
– In already diagnosed cases of Neurotic Anxiety States

8. History and Evolution
• SIGH-A : Structured Interview Guide for the
Hamilton Anxiety Rating scale*
• Manual for HAM-A14 (2011)**
*Shear M. Katherine, et al, Reliability and validity of a Structured Interview Guide for the
Hamilton Anxiety Rating scale (SIGH-A), Depression and anxiety 13:166–178 (2001)
**Per Bech (2011). Measuring States of Anxiety with Clinician-Rated and Patient-Rated Scales,
Different Views of Anxiety Disorders, Dr. Salih Selek (Ed.), ISBN: 978-953-307-560-0, InTech,

9. The Hamilton Anxiety Rating Scale
• Components:
– 14 Items
– 1-6 - psychic components
– 7-14 - Somatic
– To assess the severity of these symptoms

10. Administration
– Clinician rated,
– 10-15 min
– Scoring – (0-4) Five responses / Likert scale
0- Not present
1- Mild
2- Moderate
3- Severe
4- Very severe

28. Statistical Parameters
• Scoring Test-retest reliability- Good
• Scoring Internal consistency - Good -
Cronbach’s alpha=0.77 to 0.92
• Validity Satisfactory,
• compared with clinical assessment and
Covi anxiety scale
http://www.thoracic.org/members/assemblies/assemblies/srn/questionaires/ham-a.php

29. Interpretation of scores
• Range: 0-56
• <17 - Mild
• 18-24 - Mild to moderate
• 25-30 - Moderate to severe
• 30-56 - Very severe
New Norms*
6 to 14 = mild anxiety
15 to 28 = moderate anxiety
29 to 52 = severe anxiety
Per Bech (2011). Measuring States of Anxiety with Clinician-Rated and Patient-Rated Scales,
Different Views of Anxiety Disorders, Dr. Salih Selek (Ed.), ISBN: 978-953-307-560-0, InTech

30. Utility
• Assessment of severity
• Therapeutic decision
– Mild - Relaxation techniques
– Moderate - OPD- Pharmacotherapy +
Relaxation techniques
– Severe - IPD
•Follow-up- response to therapy

31. Limitations
• Skewed towards physical manifestations
• Does not differentiate between anxiety co-morbid
with depressive episode or an independent anxiety
disorder
• Research for therapeutic efficacy of a drug
– anxiolytic or anti-depressant??

32. STATE TRAIT ANXIETY INVENTORY

33. Introduction
– Charles Spielberger, 1968(X), 1977, 1983 (Y)
– Affiliation: Dept of Psychology, University of South
Florida
– Introspective psychological inventory
– 40 self-report items pertaining to anxiety affect.
– Not Open access

35. Applications
• Psychological and health research
• Clinical diagnosis
• Differentiating anxiety from depression
• Assessment of clinical anxiety in medical, surgical,
psychosomatic and psychiatric patients
• Intensity of feelings of anxiety
• Normal adults
• Screen for anxiety disorders
• Follow-up

36. Concept
• State anxiety (Kinetic energy) (cross-sectional)
(situational) (as of now)
Vs
Trait anxiety (potential energy) (propensity or
predisposition) (in general)
If a situation comes, will the person be in a state of
anxiety ?

37. Concept
• Taylor- Taylor’s Manifest Anxiety Scale (TMAS)-1953
– Anxiety – trait = predisposition to react
• Cattell (1960s) – Concept of state vs trait anxiety
• STAI- based on this concept

38. Administration
• Self report
• 10 min
• >16 yrs, with at least a 6th grade level comprehension

39. Description/ Components
• Two categories-
– State Anxiety (A-State)- 1-20 (Y-1)
• “How you feel right now, that is, at this
moment.”
– Trait Anxiety (A- Trait) – 21-40 (Y-2)
• “how you generally feel”
–Likert Scale- 1-4

43. Statistical Parameters
• Test-retest reliability- 0.65 to .75
• Internal consistency – high
– α -- Y1- 0.83 - 0.94
– α-- Y2- 0.90 - 0.91
• Validity-
– Content validity – 5/8 domains of DSM-IV
– Factorial validity - 0.7 to 0.8

44. DSM criteria for GAD
• Excessive anxiety and worry (apprehensive expectation)
• Difficult to control the worry.
• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying asleep, or
restless unsatisfying sleep)

45. Scoring
• Range- 20-80- each sub-scale
• Reversed for anxiety-absent items (19 items of
the total 40)
• Cut off
– S-Anxiety (Y1) - 39-40
– T – Anxiety (Y2 )- ?
– Norms- in the manual for adults, college students,
and psychiatric samples

46. Limitations
• Indian Adaptations?
• Education ?

47. • Hospital Anxiety and Depression Scale

48. Introduction
– AS Zigmond and RP Snaith, 1983
– Acta Psychiatri Scand, 1983 Jun;67(6):361-70
– Affiliation: Dept of Psychiatry, University Of Leeds
– Self-report- IPD/OPD
– The HADS is copyrighted and available from: Nfer Nelson
– Brief, easy to understand and acceptable
– Screening, Not diagnostic

50. Why a separate scale?
• Emotional component of physical illness – sadness/worry
• Anxiety and depression
– somatic symptoms like pain, fatigue, insomnia,
disturbed appetite, weight loss, palpitations, sweating
and GI symptoms
– Increase the distress of physical illness
– Can even confuse the diagnosis
• If diagnosed- respond well to anti-depressant or anxiolytic
treatment

51. History and Evolution
• 1983- Published – 8 items in each sub-scale
• Aim- To avoid effect of somatic complaints of
illnesses like insomnia/fatigue
• 2-factor model-ie -2 diff emotional conditions
– More acceptable
• One factor model (?)- MDD incl Adjustment
disorder with co-morbid anxiety

52. Administration
• Self report
• 2-5 min
• “Fill the form to reflect how you have been
feeling over the last one week”
• Literate
• Verbally by examiner for illiterate

53. 53

54. Anxiety items Depression items
I feel tense or 'wound up' I still enjoy the things I used to
enjoy:
I get a sort of frightened feeling as if
something awful is about to happen
I can laugh and see the funny side
of things
Worrying thoughts go through my mind I feel cheerful
I can sit at ease and feel relaxed I feel as if I am slowed down
I get a sort of frightened feeling like
'butterflies' in the stomach
I have lost interest in my appearance
I feel restless as I have to be on the move I look forward with enjoyment to things
I get sudden feelings of panic I can enjoy a good book or radio or TV
program
54
Scoring:
Total score: Depression (D) ___________ Anxiety (A) ______________
0-7 = Normal
8-10 = Borderline abnormal (borderline case)
11-21 = Abnormal (case)

55. Components
• Two subscales
– A- scale and D-scale
– Each scored separately
• Present state assessment- over the last few days
• Not for immediate stressful state
• Follow-up – weekly intervals- HADS chart

56. Components
• A-scale
• Generalized anxiety, not necessarily focused on any
situation
• Anxious mood, restlessness and anxious thoughts
(psychological)
• Not covering somatic symptoms of anxiety
• D-scale
• Mainly- loss of interest and diminished pleasure response
• Anhedonia (5/7) – 2,4,10,12,14
–Reliable guide to biological origin of mood disorder
–Most likely to respond to anti-depressants

57. Scoring
• Likert scale, four responses, 0-3
• Each sub-scale- 0-21
• Caseness – Cut off- 7/21 (A/D)
– 8-10 – Mild
– 11-14 - Moderate
– 15-21 - Severe
–Composite scale= Emotional Distress Scale
–Total of both subscales
– HADS Manual – NOT TO ADD

58. Statistical Parameters
• Sensitivity and specificity = 0.8 (A & D)
• Internal consistency- α=0.93(A) and 0.90 (D)
• Test-re-test reliability - 0.89(A) and 0.92 (D)
• Face validity- good
• Construct validity- Correlation between both scales =
0.37-0.56
• Concurrent validity (screening)- good

59. Thank you