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Instrument Summary for Anxiety

Please note that this section is an archive and is no longer being updated.

Development: In response to a need for a brief but reliable assessment tool for psychiatric symptoms in medical (non-psychiatric) inpatients, the Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and Snaith in 1983 to provide an efficient screening questionnaire for use in this population. The HADS contains 14 items that generate separate scores for depressive (7 items) and anxious (7 items) symptoms.

Purpose: The HADS was developed to measure symptoms of anxiety and depression among medical (non-psychiatric) inpatients.

Useful Facts: The HADS is a self-report questionnaire that can be administered in 5 minutes. Items are rated on a 4-point scale; to score, the 7 items on each scale (anxiety and depression) are summed separately. The original development article discusses recommended cutoff scores for classifying patients as depressed or anxious; a later study validated these classification guidelines2. Translations of the HADS are available in Arabic, Cantonese, Danish, Dutch, French, German, Hebrew, Italian, Norwegian, Swedish, and Spanish.

VA Relevance: The HADS has been used among the veteran population.

Availability: This instrument can be found online at the Scottish Intercollegiate Guidelines Network website and also from the University of Hawaii Department of Psychiatry as a Word document.

References:

1. Zigmond A, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361-370. [Abstract ]
2. Aylard PR, Gooding JH, McKenna PL, Snaith RP. A validation study of three anxiety and depression self-assessment scales. J Psychosom Res 1987;31:261-268. [Abstract ]
3. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res 2002;52:69-77. [Abstract ]

Development: The Beck Anxiety Inventory (BAI) was developed by Beck and colleagues and originally published in 1988. Because of high correlations between many measures of anxiety and depression, items on the BAI were developed with the goal of creating a measure that is better able to differentiate anxiety from depression. The scale consists of 21 items that represent different symptoms of anxiety. The BAI was developed using a sample of psychiatric outpatients.

Purpose: The BAI measures the severity of anxiety symptoms, particularly those that distinguish anxiety from depression.

Useful Facts: The BAI is self-administered and can be completed in 5 to 10 minutes. Items are scored on a scale of 0 to 4 and are summed to generate a total score. Alternative forms include interviewer- and computer-administered versions. The literature has described translations of the BAI in Arabic, Chinese, French, Korean, Spanish, and Turkish. Research has suggested that the BAI may be especially effective for measuring anxiety associated with panic disorder.

VA Relevance: The BAI has been used among the veteran population.

Availability: This instrument can be found online at the Butler University website as a Word document provided by David Luechauer, PhD. The instrument can also be purchased from Harcourt Assessments.

References:

1. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol 1988;56:893-897. [Abstract ]
2. Fydrich T, Dowdall D, Chambless DL. Reliability and validity of the Beck Anxiety Inventory. J Anxiety Disord 1992;6:55-61.
3. Leyfer OT, Ruberg JL, Woodrff-Borden J. Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders. J Anxiety Disord, in press. [Abstract ]

Development: The Anxiety Sensitivity Index (ASI) was first published as a 16-item scale in 1986 by Reiss and colleagues. In contrast to typical generic measures of anxiety, the ASI measures "fear of fear", or the extent to which the respondent believes that anxiety symptoms (such as nervousness, shakiness, and increased heart rate) have negative consequences. Previous scales purported to measure "fear of fear" had failed to show adequate divergence from measures of general anxiety. The ASI was developed in part to provide a scale that measures something distinct from, albeit conceptually related to, anxiety itself. Although several factor structures have been discussed in the literature, the original measure is typically scored as a whole without subscale scores.

Purpose: The ASI measures the severity of the respondent's concerns about psychological, physiological, and socially relevant symptoms of anxiety.

Useful Facts: The ASI is a written self-report questionnaire that can be administered in 5 minutes or less. Items are scored from 0 to 4 and the total score is obtained by summing all item scores (higher scores indicate greater anxiety sensitivity). A 4-item version has also been reported. Ten of the original ASI items were subsumed by the expanded 36-item Anxiety Sensitivity Index-Revised (ASI-R-363). The ASI and ASI-R-36 have been translated into multiple languages.

VA Relevance: The ASI has been used among the veteran population.

Availability: This instrument can be obtained from IDS Publishing.

References:

1. Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 1986;24:1-8. [Abstract ]
2. Schmidt NB, Joiner TE. Structure of the Anxiety Sensitivity Index psychometrics and factor structure in a community sample. J Anxiety Disord 2002;16:33-49. [Abstract ]
3. Taylor S, Cox BJ. An expanded Anxiety Sensitivity Index: evidence for a hierarchic structure in a clinical sample. J Anxiety Disord 1998;12:463-483. [Abstract ]

Development: Di Nardo and colleagues published the original Anxiety Disorders Interview Schedule (ADIS) in 1983 to provide a comprehensive structured interview for diagnosis of anxiety disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). The ADIS incorporates original items as well as items drawn from other anxiety assessment instruments, including the Hamilton Anxiety Rating Scale (reviewed below).

Purpose: The ADIS is used to identify the presence of anxiety disorders and provide differential diagnosis among anxiety disorders. The ADIS also provides sufficient information to rule out psychosis, substance use disorders, and mood disorders in the assessment of anxiety disorders.

Useful Facts: The ADIS is a structured interview that requires significant training and familiarity with DSM criteria to administer. Average completion time has not been reported, but the scope of the interview suggests it is somewhat lengthy. The ADIS was originally written according to DSM-III criteria and has been revised twice to reflect updated criteria for DSM-III-R and DSM-IV anxiety disorders. Copies of the interview are available through Oxford University Press.

VA Relevance: The ADIS has been used among the veteran population.

Availability: The ADIS is available from Oxford University Press.

References:

1. DiNardo PA, O'Brien GT, Barlow DH, Waddell MT, Blanchard EB. Reliability of DSM-III anxiety disorder categories using a new structured interview. Arch Gen Psychiatry 1983;40:1070-1074. [Abstract ]
2. Chorpita BF, Brown TA, Barlow DH. Diagnostic reliability of the DSM-III-R anxiety disorders: mediating effects of patient and diagnostician characteristics. Behav Modif 1998;22:207-320. [Abstract ]
3. Brown TA, DiNardo PA, Lehman CL, Campbell LA. Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders. J Abnorm Psychol 2001;110:49-58. [Abstract ]

Expert-recommended Instruments

Development: Spielberger and colleagues developed the State-Trait Anxiety Inventory (STAI) in 1970 to measure anxiety both as a transitory state and as a stable (personality) trait. According to Spielberger, state anxiety is an emotional response to a perceived threat, whereas trait anxiety represents an individual's tendency to experience anxiety states. The scale consists of 40 items, 20 for state anxiety and 20 for trait anxiety.

Purpose: The STAI was developed to assess state and trait anxiety in adults.

Useful Facts: A revised form of the original STAI (Form Y)2 is typically used today. Items are worded in the first person and rated on a 4-point scale; some items refer to positive states (e.g., "I feel calm") and are reverse-scored. Total scores for the state (A-State) and trait (A-Trait) scales are generated by summing the corresponding item scores. The STAI has been translated into numerous languages and is also available in an abbreviated 6-item version. Age and gender norms are published in the STAI manual.

VA Relevance: The STAI has been used among the veteran population.

Availability: The STAI is available from Mind Garden.

References:

1. Kendall PC, Finch AJ, Auerbach AM, Hooke JF, Mikulka PJ. The State-Trait Anxiety Inventory: A Systematic Evaluation. J Consult Clin Psychol 1976;44:406-412. [Abstract ]
2. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Mind Garden; 1983.
3. Okun A, Stein RE, Bauman LJ, Silver EJ. Content validity of the Psychiatric Symptom Index, CES-Depression Scale, and State-Trait Anxiety Inventory from the perspective of DSM-IV. Psychol Rep 1996;79:1059-1069. [Abstract ]

Development: Hamilton developed the Anxiety Rating Scale (HARS) in 1959 as a measure of symptom severity among individuals diagnosed with anxiety disorders. The scale was originally developed using a sample of psychiatric patients diagnosed with "neurotic anxiety" conditions and was subsequently revised in 1969. The HARS consists of 14 items that each correspond to a set of symptoms (e.g., tension, insomnia, fears, cardiovascular symptoms).

Purpose: The HARS was designed to measure anxiety symptoms among patients diagnosed with anxiety disorders.

Useful Facts: The HARS is a clinician-administered scale. Estimated completion time is 15-30 minutes. Items are rated on a scale of 0 (symptom not present) to 4 (severe) and summed for a total score. At least two standardized interview guides have been recently proposed to improve inter-rater reliability. Alternative forms include a computer-administered version. The HARS has been widely used as an indicator of clinical efficacy in treatment outcome research. A revision published in 1987 was reported to improve the specificity of the HARS to better differentiate anxiety from depression.

VA Relevance: The HARS has been used among the veteran population.

Availability: An online version is available from The Anxiety Community website. A PDF version is available from University of Massachusetts Medical School Department of Psychiatry.

References:

1. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50-55. [Abstract ]
2. Hamilton M. Diagnosis and rating of anxiety. Br J Psychiatry 1969;Special Pub 3:76-79.
3. Riskind JH, Beck AT, Brown G, Steer RA. Taking the measure of anxiety and depression: validity of the reconstructed Hamilton scales. J Nerv Ment Dis 1987;175:474-479. [Abstract ]