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Construct Overview of Anxiety

Please note that this section is an archive and is no longer being updated.

Background

Anxiety is defined as "a painful or apprehensive uneasiness of mind usually over an impending or anticipated ill, an abnormal and overwhelming sense of apprehension and fear often marked by physiological signs (as sweating, tension, and increased pulse), by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it."¹ Anxiety encompasses a complex set of behavioral, cognitive, and physiological responses to perceived threat. Clinically significant manifestations of anxiety include specific phobia, social phobia, panic disorder, generalized anxiety disorder, acute stress disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder. These diagnoses are defined by criteria described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR²).

Collectively, anxiety disorders are the most prevalent class of mental disorders in the United States. Anxiety disorders are associated with lower quality of life and impaired psychosocial functioning,³ higher utilization of non-psychiatric health care services,⁴ and costs in excess of $4 billion annually due to loss of productive work time⁵.

VA Relevance

Combat and war zone-related stressors are among the most frequently cited etiological factors in PTSD.⁶ Accordingly, a significant proportion of anxiety-related research in veterans has addressed the causes and treatment of PTSD. Less is known about other anxiety disorders in veterans. However, one study concluded that rates of generalized anxiety disorder, panic disorder, and PTSD were approximately twice as high among Gulf War (Operations Desert Shield and Desert Storm) veterans than among non-deployed military personnel.⁷ In addition, combat-related PTSD appears to be a risk factor for comorbid panic disorder and social phobia among veterans.8

Anxiety disorders are likely to be underdiagnosed and undertreated in the veteran population at large. In a prospective study of elderly VA inpatients with no recent records of psychiatric care, 15% were found to have an anxiety disorder diagnosis when assessed after discharge by an interviewer.⁹ Studies conducted in VA primary care outpatients¹⁰ and in soldiers returning from recent combat duty in Iraq and Afghanistan¹¹ suggest that fewer than half of individuals with clinically significant anxiety symptoms in these populations used mental health care services.

Measurement

Anxiety is commonly assessed using clinician- and/or self-administered instruments. A clinician-administered interview based on DSM criteria is widely considered the "gold standard" for diagnostic assessment.¹² However, this approach is time-consuming and requires substantial training on the part of the interviewer. When diagnostic specificity is not required, self-administered questionnaires are effective tools for measuring anxiety symptom severity. Generic anxiety measures may be used as descriptors for heterogeneous clinical populations, as screening tools, or as broad outcome measures in clinical trials.

In some cases, the use of disorder-specific instruments may be helpful, particularly when maintaining factors and mechanisms of change are targets of assessment. Disorder-specific measurements may also facilitate treatment planning. Valid and reliable disorder-specific measures are available for all of the major anxiety disorders; for a thorough guide see Antony et al.¹³

Because anxiety may be conceptualized as both a state and a trait,¹⁴ the time frame of the assessment instrument should be carefully specified (e.g., symptoms within the past 4 weeks versus symptoms in the current moment) and consistent with the goals for measurement. Studies that assess anxiety at multiple time points (e.g., clinical trials) should use instruments that are sensitive to clinically relevant change and reliably discriminate between anxious and non-anxious individuals. However, the experience and expression of anxiety symptoms is influenced by language and culture, and as such some instruments may be more appropriate than others for use in particular cultural groups.¹⁵

Through literature review, METRIC identified four commonly used generic instruments for measuring anxiety. These are ranked according to number of citations, as determined by the ISI Web of Knowledge.¹⁶ Additional recommended instruments have been identified through consultation with researchers with expertise in the assessment of anxiety. What follows is a brief summary of each instrument and three applicable references.

Most Frequently Cited Instruments

1. Hospital Anxiety and Depression Scale (HADS)
   [3393 Citations]
2. Beck Anxiety Inventory (BAI)
   [984 Citations]
3. Anxiety Sensitivity Index (ASI)
   [590 Citations]
4. Anxiety Disorders Interview Schedule (ADIS)
   [244 Citations]

Expert-recommended Instruments

1. State-Trait Anxiety Inventory (STAI)
   
2. Hamilton Anxiety Rating Scale (HARS)
   

1. Merriam-Webster Medical Dictionary. Accessed September 2005. Available: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision). Washington, DC: Author.
3. Mendlowicz MV, Stein MB. Quality of life in individuals with anxiety disorders. Am J Psychiatry 2000;157:669-682. [Abstract]
4. Ford JD, Trestman RL, Steinberg K, Tennen H, Allen S. Prospective association of anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency medical care. Soc Sci Med 2004;58:2145-2148. [Abstract]
5. Greenberg PE, Sisitsky T, Kessler RC, Finkelstein SN, Berndt ER, Davidson JR, Ballenger JC, Fyer AJ. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry 1999;60:427-435. [Abstract]
6. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060. [Abstract]
7. Black DW, Carney CP, Peloso PM, Woolson RF, Schwartz DA, Voelker MD, Barrett DH, Doebbeling BN. Gulf War veterans with anxiety: Prevalence, comorbidity, and risk factors. Epidemiology 2004;15:135-142. [Abstract]
8. Orsillo S, Weathers FW, Litz BT, Steinberg H, Huska J, Keane TM. Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder. J Nerv Ment Dis 1996;184:307-313. [Abstract]
9. Gerson S, Mistry R, Bastani R, Blow F, Gould R, Llorente M, Maxwell A, Moye J, Olsen E, Rohrbaugh R, Rosansky J, Van Stone W, Jarvik L. Symptoms of depression and anxiety (MHI) following acute medical/surgical hospitalization and post-discharge psychiatric diagnoses (DSM) in 839 geritatric US veterans. Int J Geriatr Psychiatry 2004;19:1155-1167. [Abstract]
10. Magruder KM, Frueh BC, Knapp RG, Davis L, Hamner MB, Martin RH, Gold PB, Arana GW. Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics. Gen Hosp Psychiatry 2005;27:169-179. [Abstract]
11. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22. [Abstract]
12. Antony MM, Rowa K. Evidence-based assessment of anxiety disorders in adults. Psychol Assess 2005;17:256-266.
    [Abstract]
13. Antony MM, Orsillo SM, Roemer L (Eds). Practitioner's guide to empirically based measures of anxiety. New York: Kluwer Academic/Plenum Publishers; 2001.
14. Spielberger CD. Theory and research on anxiety. In Spielberger CD (Ed), Anxiety and behavior. New York: Academic Press; 1966.
15. Friedman S. Cultural issues in the assessment of anxiety disorders. In Antony MM, Orsillo SM, Roemer L (Eds), Practitioner's guide to empirically based measures of anxiety. New York: Kluwer Academic/Plenum Publishers; 2001
16. ISI Web of Knowledge. Accessed September 2005. Available: http://isi01.isiknowledge.com/portal.cgi/wos/.