How is anxiety measured

Maruish Ed. Mahwah: Lawrence Erlbaum Associates. Eifert, G. The Cardiac Anxiety Questionnaire: Development and preliminary validity. Behaviour Research and Therapy, 38 , — Endler, N.

Los Angeles: Western Psychological Services. Foa, E. The obsessive-compulsive inventory: Development and validation of a short version. Psychological Assessment, 10 , — Fresco, D. The Liebowitz Social Anxiety Scale: A comparison of the psychometric properties of self-report and clinician-administered formats.

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Hamilton, M. The assessment of anxiety states by rating. The British Journal of Medical Psychology, 32 , 50— Hayes, S. Hazlett-Stevens, H. Assessment and treatment of anxiety in primary care. New York: Springer.

Hewitt, P. The Multidimensional Perfectionism Scale: Reliability, validity, and psychometric properties in psychiatric sample. Psychological Assessment, 3 , — Hunter, C. Integrated behavioral health in primary care: Step-by step guidance for assessment and intervention. Kendall, P. Cognitive Therapy and Research, 13 , 81— A self-report measure of somatic, cognitive, behavioral and feeling components. Journal of Personality Assessment, 54 , — Lehrer, P.

Self-report assessment of anxiety: Somatic, cognitive, and behavioral modalities. Behavioral Assessment, 4 , — Lovibond, S. Manual for the Depression Anxiety Stress Scales 2nd ed. Sydney, Australia: Psychological Foundation of Australia. Lucock, M.

The measurement of panic attacks is probably most validly measured in terms of minor versus major attacks, i. The measurement of states of OCD is probably most validly measured by the duration of this state of anxiety, e. The Anxiety-Symptom-Scale ASS is shown in the Appendix as an example of a very short screening questionnaire covering the many subtypes of states of anxiety.

In the following, it is the general state of anxiety as measured archetypically by the HAM-A, and by the corresponding self-rating scales that will be treated.

The psychometric validation of these general anxiety scales became important with reference to the classes of drugs most frequently investigated in trials of anti-anxiety medication, namely tricyclic antidepressants e. Early on, Derogatis et al demonstrated that whereas imipramine was superior to diazepam when using the SCL subscale of depression, no differences were obtained when using the SCL anxiety subscale.

The landmark study in this respect was the study by Rickels et al which demonstrated that when treating patients with generalized anxiety disorder with imipramine versus diazepam in a placebo-controlled, randomised trial, imipramine was superior to benzodiazepine on the psychic factor in the HAM-A but not on the somatic factor in the HAM-A.

However in the ICD diagnostic manual World Health Organization the number of somatic anxiety symptoms outranged the number of psychic anxiety symptoms in the algorithm of generalized anxiety disorder. The following will treat the specific psychometrically valid methods principal components analysis, factor analysis and item response theory analysis in order to indicate how to use HAM-A and SCL in trials of anti-anxiety drugs.

In clinical psychometrics we often describe principal components analysis PCA or factor analysis FA as the classical methods of validation while item response theory analysis IRT is seen as the modern method Bech et al. When modifying a factor analysis with our sophisticated electronic programs, e. IRT analysis is used to evaluate to what extent the total score of a scale is sufficient when measuring the clinical effect of anti-anxiety drugs.

In the following, only Mokken analysis will be referred to. The first version of the HAM-A Hamilton consisted of 13 items, whereas the revised version Hamilton included 14 items see Appendix.

Table 1 shows the results. The first principal component is clearly a general factor in which all the 14 items have positive loadings. The second principal component is a bi-directional, or dual factor with positive loadings on the psychic symptoms of anxiety and negative loadings on the somatic anxiety symptoms. Table 1 also shows the results from the study by Pichot et al on patients from the family doctor setting with a mixture of primary and secondary states of anxiety.

Pichot et al employed both a PCA approach and an exploratory factor analysis FA with varimax rotation. Essentially, Pichot et al found no extra information in the FA with rotation. The first principal component is obviously a general factor while the second principal component is a bi-directional factor. In the original publication by Pichot et al the sign of the second principal component loadings is actually the opposite of the signs published by Hamilton , but this type of loading negative and positive is just a technical or topographical issue Child The second principal component identified by Pichot et al contrasts psychic versus somatic symptoms of anxiety corresponding to Hamilton The usefulness of this two factor model of the HAM-A 14 was demonstrated by Rickels et al in a double-blind, placebo-controlled trial comparing diazepam with imipramine in patients with a DSM-III diagnosis of generalized anxiety disorder.

Imipramine was found superior to diazepam on the psychic anxiety symptoms Table 1 on HAM-A, while both imipramine and diazepam were superior to placebo on the somatic anxiety symptoms Table 1. However, among the psychic anxiety symptoms in HAM-A Table 1 are such items as depressed mood and sleep.

Clinical validity was examined in a trial focussing on a 6-item HAM-A subscale HAM-A 6 comprising five psychic anxiety symptoms anxious mood, psychic tension, fears, intellectual difficulties, and anxious behaviour and one somatic anxiety symptom muscular tension Bech This group of HAM-A symptoms covering the core symptoms of generalized anxiety disorder is in accordance with the study by Snaith et al The analyses performed by Meoni et al revealed that the HAM-A 6 items were among the symptoms in patients with DSM-IV generalized anxiety disorder with the most significant discrimination between venlafaxine and placebo.

In this study the four placebo-controlled trials with fixed doses of pregabalin in patients with generalized anxiety disorder were combined, and Mokken analysis identified a coefficient of homogeneity of 0. A coefficient of homogeneity of 0. The pregabalin dose-response relationship study was performed on six of the available placebo-controlled trials Bech Another trial Montgomery et al. Effect size was used as response criterion in this pooled analysis of the four trials with sufficient homogeneity.

An effect size of 0. A dose of mg pregabalin over four weeks proved to obtain an effect size between 0.

In a dose range between mg and mg daily, the pregabalin effect size was between 0. A dose of mg pregabalin daily did not increase the effect size, as the range on the HAM-A 6 was between 0. The trial excluded from this pooled analysis due to a significantly higher baseline HAM-A 14 and patient age is the study by Montgomery et al Montgomery et al. Table 2 shows the results after 4 weeks of therapy in the Montgomery et al study , using effect size as response criterion.

The HAM-A 6 effect size of both and mg pregabalin was between 0. In Table 2 the effect size for the HAM-A item of sleep is included, here the results show that the effect size was clearly above 0. The placebo-controlled trial by Montgomery et al with two fixed pregabalin doses and the active comparator venlafaxine. The results with effect size according to Bech Lydiard et al have made an analysis of all six placebo-controlled pregabalin trials in generalized anxiety disorder, showing the change from baseline to endpoint on the individual HAM-A items.

This analysis confirmed that no difference was seen between mg and mg pregabalin daily compared to placebo for the HAM-A 6 items. There are still very few instances in which HAM-A 6 and HAM-A 14 have been used in trials with new generation antidepressants in patients with generalized anxiety disorder. For venlafaxine Mitte et al obtained an effect size of 0. For duloxetine we only have one fixed dose trial in a placebo-controlled design in the treatment of generalized anxiety disorder over a 9 week period Koponen et al.

Based on the published results it was not possible to calculate effect size correctly Koponen et al. However, the estimation of sample size in the Koponen et al study was based on the assumption that the pooled standard deviation of the change score on HAM-A 14 from baseline to endpoint was 6.

Hamilton never developed a self-rating scale corresponding to his HAM-A Results A 7-item anxiety scale GAD-7 had good reliability, as well as criterion, construct, factorial, and procedural validity.

Increasing scores on the scale were strongly associated with multiple domains of functional impairment all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days. Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability.

There was good agreement between self-report and interviewer-administered versions of the scale. One of the most common anxiety disorders seen in general medical practice and in the general population is generalized anxiety disorder GAD. The disorder has an estimated current prevalence in general medical practice of 2. In part, this may be because of the paucity of brief validated measures for anxiety compared with the numerous measures for depression, 7 , 8 such as the Primary Care Evaluation of Mental Disorders 9-item Patient Health Questionnaire PHQ.

Measures of anxiety are seldom used in clinical practice because of their length, proprietary nature, lack of usefulness as a diagnostic and severity measure, 14 - 17 and requirement of clinician administration rather than patient self-report. We conducted a study in multiple primary care sites to select the items for the final scale and to evaluate its reliability and validity.

We first selected potential items for a brief GAD scale. A item questionnaire was developed that asked patients how often, during the last 2 weeks, they were bothered by each symptom.

In addition, an item to assess duration of anxiety symptoms was included. Our goal was to determine the number of items necessary to achieve good reliability and procedural, construct, and diagnostic criterion validity.

Patients were enrolled from November through June from a research network of 15 primary care sites located in 12 states 13 family practice, 2 internal medicine administered centrally by Clinvest, Inc Springfield, Mo. In all, subjects were approached and To minimize sampling bias, we approached consecutive patients at each site in clinic sessions until the target quota for that week was achieved. In the first phase, subjects also agreed to a telephone interview, and of these, a random sample of were interviewed within 1 week of their clinic visit by 1 of 2 mental health professionals MHPs —a PhD clinical psychologist and a senior psychiatric social worker.

In the study's second phase, subjects who had completed the research questionnaire were sent a 1-page questionnaire that consisted of the 13 potential GAD scale items. Of these, subjects returned the completed 1-page questionnaire with no or minimal missing data within a week of completing the research questionnaire at the clinic. The mean GAD scale score of subjects returning the questionnaire did not differ from that of subjects who did not return the questionnaire.

Before seeing their physicians, patients completed a 4-page questionnaire that included the 13 items being tested for use in the GAD scale, as well as questions about age, sex, education, ethnicity, and marital status; the Medical Outcomes Study Short-Form General Health Survey SF , 20 , 21 which measures functional status in 6 dimensions; and either the item anxiety subscale from the Symptom Checklist 16 first study phase only or the Beck Anxiety Inventory 14 second study phase only.

Depression was assessed with the PHQ-8, which includes all items from the PHQ-9 except for the item about suicidal ideation; PHQ-8 and PHQ-9 scores are highly correlated and have nearly identical operating characteristics. The 2 MHPs conducted structured psychiatric interviews by telephone, blinded to the results of the self-report research questionnaire.

The interview also included the 13 potential GAD scale items to test agreement between self-report and clinician administration ie, procedural validity. The best items for the GAD scale were selected by rank ordering the correlation of each item with the total item scale score in the sample of patients who did not undergo the MHP interview.

Item-total score correlations were reexamined in 2 independent subsamples of the study population: the patients who underwent the MHP interview and the patients in the second phase of the study. In addition, we conducted receiver operating characteristic analyses with varying numbers of items in these patients by using an MHP diagnosis of GAD as the criterion standard.

Divergent validity of each item was assessed by calculating the difference between the item correlations with the item anxiety score and the PHQ-8 depression score. Convergent validity was assessed by examining correlations of the final version of the GAD scale with the Beck Anxiety Inventory and the anxiety subscale of the Symptom Checklist, even though neither scale is specific for GAD.

To assess construct validity, we used analysis of covariance to examine associations between anxiety severity on the final GAD scale and SF functional status scales, self-reported disability days, and physician visits, controlling for demographic variables.

For criterion validity, we investigated sensitivity, specificity, predictive values, and likelihood ratios for a range of cutoff scores of the final scale with respect to the MHP diagnosis. To investigate whether anxiety as measured by the GAD-7 and depression as measured by the PHQ-8 reflect distinct dimensions, we assessed factorial validity by using confirmatory factor analyses.

Finally, procedural validity and test-retest reliability were assessed by means of intraclass correlation. The mean SD age of the patients was Receiver operating characteristic analysis with this set of items showed an area under the curve 0. A proper diagnosis can lead to interventions to help them manage anxiety at a young age. Focus on managing your anxiety rather than on ending or curing it.

Learning how best to control your anxiety can help you live a more fulfilled life. You can work on stopping your anxiety symptoms from getting in the way of reaching your goals or aspirations. If you or your child is diagnosed with anxiety, your doctor will likely refer you to a psychiatrist who can decide what anxiety medications will work best. Sticking to the recommended treatment plan is crucial for the medications to work effectively. Try not to delay your treatment. The earlier you begin, the more effective it will be.

You might also consider seeing a therapist or joining a support group for people with anxiety so that you can talk openly about your anxiety. This can help you control your worries and get to the bottom of what triggers your anxiety. Find active ways to relieve your stress. This can lessen the impact that anxiety may have on you. Some things you can do include:. Also, avoid alcohol, nicotine, and other similar drugs.

The effects of these substances can make your anxiety worse. Be open with your family and close friends about your diagnosis, if possible. However, the more the people around you understand your anxiety, the easier it becomes to communicate your thoughts and needs to them. Anxiety does go away, but it returns during times of stress. Individuals with anxiety disorders may experience the feeling at unexpected times or may…. Is anxiety genetic?

Yes and no. Does worrying put a damper on your day? Try these techniques to free yourself.