SUPARNA DAS

ASSESSMENT OF ANXIETY

People with anxiety disorders experience persistent fear, worry, or dread, which
is out of proportion to the circumstances, causes them significant distress and/or
interferes with their daily functioning.

Formal systems for the diagnosis of mental illness define a number of different
types of anxiety disorders, including:

 Specific phobia: Significant and excessive fear or anxiety about a specific object or
situation that when faced, provokes intense fear, anxiety, or avoidance
(symptoms last at least 6 months).

 Social anxiety disorder: Significant and excessive avoidance of, and fear or
anxiety about social situation(s) where there is possible scrutiny and negative
evaluation by others (symptoms last at least 6 months).

 Panic disorder: Recurrent, unexpected panic attacks (a sudden, intense fear or

discomfort that peaks within minutes, Includes symptoms like heart palpitations,
trembling, fear of losing control), followed by at least 1 month of persistent worry
about additional panic attacks and/or significant maladaptive behaviour changes
related to panic attacks (e.g. avoidance of situations where they might have a
panic attack).

 Agoraphobia: Significant and excessive avoidance of, and fear or anxiety about
being in situations that might cause panic, helplessness, or embarrassment e.g.
 being outside of the home alone, using public transportation (symptoms last at
least 6 months).

 Generalized anxiety disorder: Significant and excessive anxiety and worry

(apprehension about something in the future) about a number of events or
activities that the person finds difficult to control (symptoms occur more days
than not for at least 6 months)

 *Obsessive-compulsive disorder: recurrent and persistent obsessions (intrusive

and unwanted thoughts, urges, and impulses) and/or compulsions (repetitive and
excessive behaviours or mental acts in response to the obsession, with the aim of
preventing/reducing anxiety or the occurrence of some feared event).

 *Posttraumatic stress disorder: exposure to actual/threatened danger (e.g.

death, serious injury), followed by (1) intrusive symptoms (e.g. recurrent
nightmares, flashbacks), (2) persistent avoidance of stimuli associated with the
traumatic event(s), (3) negative alterations in mood and cognition (e.g. feelings of
detachment or dissociative amnesia), and (4) arousal and reactivity associated
with the traumatic event(s) (e.g. hypervigilance, exaggerated startle response)
(symptoms last at least 1 month).

 Separation anxiety disorder: developmentally inappropriate and excessive fear or

anxiety regarding separation from an attachment figure (symptoms last at least 4
weeks in adolescents and 6 months in adults).
 Selective mutism: persistent failure to speak in social situations where there is an
expectation for speaking (e.g. at school, at work), despite speaking in other
situations (symptoms last at least 1 month outside of the first month of school).

Common to all the disorders is the experience of significant distress or functional

impairment as a result of the symptoms.

In the most recent update to the Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM-5), separation anxiety disorder and selective mutism
were added to anxiety disorders. Obsessive-compulsive disorder (OCD) and
posttraumatic stress disorder (PTSD) were removed from anxiety disorders and
are recognized in the DSM-5 as separate disorders on their own.

Anxiety Assessment Tools:

Professional anxiety assessments include a comprehensive evaluation of the

patient to determine the presence, type, and extent of anxiety disorders. They
can incorporate subjective and objective, formal and informal, and standardized
or non-standardized methods of collecting data, such as interviews, forms, rating
scales, and observations. Assessments may involve only the patient themselves or
can include informants, such as a spouse or parent.

Throughout the process, providers look for signs and symptoms, as well as risk
factors and potential comorbidities. Assessment tools are typically designed for
specific ages and purposes, with clinical validation backing their accuracy and
clinical relevance.
These assessment tools often come in one of the following formats:

 Rating scales: A patient might rate the severity or frequency of a

symptom on a 1 to 10 scale.

 Checklists: The patient can check off symptoms or prompts that apply to
them.

 Questionnaires: Questions or open-ended prompts can provide more

detail on specific topics.

Benefits of Anxiety Assessment Tools for Clinicians:

Assessment tools for anxiety can collect data from many different angles to give
clinicians a better view of the whole picture. Some of the advantages of anxiety
assessment tools include:

 Objectivity: These tools can turn nebulous thoughts into concrete

numbers, simplifying the diagnostic process.

 Standardization: Test results often provide at-a-glance information

about the patient's condition that all clinicians can understand.

 Validation: Assessment tools typically go through rigorous validation

processes, so you can use them and view the results with much more
confidence than, say, a personal interpretation of an informal interview.

 Ease of use: Most assessment tools are easy to administer and flexible.
You can hand out a form, have the patient fill out a digital copy, or read
 the questions aloud. They tend to be fast, simple, and easy to get
reimbursement for.

 Repeatability: Many assessment tools can be reused over and over,

making them a great way to get quick insights into a patient's progress.
For instance, you could have a patient take a test during their weekly
psychotherapy visit and get more data on their progress.

Description of Tools for Screening for Anxiety:

some of the most popular anxiety assessment tools include the following:

 Generalized Anxiety Disorder Scale (GAD-7)

The Generalized Anxiety Disorder-7 was developed by Spitzer et al.(
2006). The seven-item Generalized Anxiety Disorder Scale (GAD-7) is a
self-report questionnaire. patients answer seven questions related to the
frequency of anxiety behaviors they have experienced during the last
two weeks on a 0-3 scale. Scores of 5, 10, and 15 are taken as the cut-off
points for mild, moderate and severe anxiety. A study involving more
than 5000 participants has shown that this questionnaire is internally
consistent. Additionally, it is both reliable and has good construct
validity. Other research supports the GAD-7 as a valid and efficient tool
for screening for generalized anxiety disorder and assessing its severity in
both the clinic and research settings.
 Hamilton Anxiety Rating Scale (HAM-A)
In 1959, Max R Hamilton developed the first version of the Hamilton
Anxiety Rating Scale.The HAM-A was one of the first rating scales
developed to measure the severity of anxiety symptoms, and is still
widely used today in both clinical and research settings. The scale
consists of 14 items, each defined by a series of symptoms, and
measures both psychic anxiety (mental agitation and psychological
distress) and somatic anxiety (physical complaints related to anxiety).
Unlike some of the other scales, the HAM-A measures anxiety globally
and is not meant exclusively for GAD. Each item is scored on a scale of 0
(not present) to 4 (severe), with a total score range of 0–56, where a
score of 17 or less indicates mild anxiety severity, a score from 18 to 24
indicates mild to moderate anxiety severity and a score of 25 to 30
indicates a moderate to severe anxiety severity. Research has also shown
that the HAM-A is a reliable and valid measure for assessing global
anxiety in an adolescent population, as well as adults.

 Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other
colleagues in 1988, is a 21-question multiple-choice self-report
inventory that is used for measuring the severity of anxiety in
adolescents and adults ages 17 and older. The questions used in this
measure ask about common symptoms of anxiety that the subject has
had during the past week (including the day you take it) (such as
numbness and tingling, sweating not due to heat, and fear of the worst
 happening). It is designed for individuals who are of 17 years of age or
older and takes 5 to 10 minutes to complete. Several studies have found
the Beck Anxiety Inventory to be an accurate measure of anxiety
symptoms in children and adults as it has high internal validity and
test/retest reliability. It is also able to discriminate between anxious
populations (people with GAD, post-traumatic stress disorder, etc) and
non-anxious populations (people with major depressive disorder,
dysthymic disorder, etc). The BAI contains 21 questions, each answer
being scored on a scale value of 0 (not at all) to 3 (severely). Higher total
scores indicate more severe anxiety symptoms. The standardized cutoffs
are:
 0–7: Minimal
 8-15: Mild
 16-25: Moderate
 26-63: Severe

 Leibowitz Social Anxiety Scale (LSAS)

The LSAS was developed by psychiatrist and researcher Dr. Michael R. Liebowitz in
1987. This particular scale is, as the name suggests, used for measuring social
anxiety or social phobia. The Leibowitz Social Anxiety Scale (LSAS) is composed of
24 items divided into 2 subscales, 13 concerning performance anxiety, and 11
pertaining to social situations. The 24 items are first rated on a Likert Scale from 0
to 3 on fear felt during the situations, and then the same items are rated
regarding avoidance of the situation. Combining the total scores for the Fear and
Avoidance sections provides an overall score with a maximum of 144 points. .
Below are the suggested interpretations for various score ranges.

 55–65: Moderate social phobia

 65–80: Marked social phobia
 80–95: Severe social phobia
 Greater than 95: Very severe social phobia

This questionnaire also has good reliability and validity. One study showed that it,
in fact, had adequate test/retest reliability, internal consistency, and convergent
and discriminant validity.

 Zung Self-Rating Anxiety Scale (SAS)

The Zung Self-Rating Anxiety Scale (SAS) was designed by William & Zung
in 1971. The Zung SAS is a self-report scale whose 20 items cover a variety
of anxiety symptoms, both psychological (e.g, “I feel afraid for no reason at
all” and “I feel like I’m falling apart and going to pieces”) and somatic
(e.g., “My arms and legs shake and tremble” and “I feel my heart beating
fast.”) in nature. Responses are given on a 4-point scale which range from 1
(none, or a little of the time) to 4 (most, or all of the time). Participants are
instructed to base their answers on their experiences over the last week.
Items include both negative and positive (e.g., “I fall asleep easily and get a
good night’s sleep.”) experiences, with the latter being reverse scored. Raw
scale scores for the SAS range from 20 to 80. The SAS has satisfactory
 psychometric properties. These include: internal consistency (Cronbach’s
alpha = .82), concurrent validity (r = .30 with the Taylor Manifest Anxiety
Scale); and, the capacity to discriminate between clinical and non-clinical
samples and anxiety and other psychiatric disorders.

Overall assessment is done by total score. The total raw scores range from 20 to
80. The raw score then needs to be converted to an "Anxiety Index" score. The
"Anxiety Index" score can then be used on this scale below to determine the
clinical interpretation of one's level of anxiety:

 20–44 -Normal Range

 45–59 -Mild to Moderate Anxiety Levels
 60–74- Marked to Severe Anxiety Levels
 75 and above- Extreme Anxiety Levels

 The State-Trait Anxiety Inventory (STAI)

The State-Trait Anxiety Inventory (STAI) is a commonly used measure of trait and
state anxiety (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). It can be
used in clinical settings to diagnose anxiety and to distinguish it from depressive
syndromes. This inventory is made up of 40 questions, and distinguishes between
a person’s state anxiety and their trait anxiety. The two forms of anxiety are
separated in the inventory, and both are given their own 20 separate questions.
When participants rate themselves on these questions, they are given a 4-point
frequency scale. The frequency scales differ between the two types of anxiety.
The 4-point scale for S-anxiety is as follows: 1.) not at all, 2.) somewhat, 3.)
moderately so, 4.) very much so. The 4-point scale for T-anxiety is as follows: 1.)
almost never, 2.) sometimes, 3.) often, 4.) almost always. There are two main
forms of the Inventory, Form X and Form Y. The State-Trait Anxiety Inventory is
one of the first tests to assess both state and trait anxiety separately. Each type of
anxiety has its own scale of 20 different questions that are scored. Scores range
from 20 to 80, with higher scores correlating with greater anxiety. The creators of
this test separated the different anxieties so both scales would be reliable. This
means the S-anxiety scale would only measure S-anxiety and the T-anxiety scale
would only measure T-anxiety, the ultimate goal in creating this test. Low scores
indicate a mild form of anxiety and high scores indicate a severe form of anxiety.
Both scales have anxiety absent and anxiety present questions. Anxiety absent
questions represent the absence of anxiety in a statement like, “I feel secure.”
Anxiety present questions represent the presence of anxiety in a statement like “I
feel worried.”

 Screen for Child Anxiety Related Emotional Disorders (SCARED)

The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a self-
report screening questionnaire for anxiety disorders developed in 1997. The
SCARED is intended for youth, 9–18 years old (For children ages 8 to 11, it is
recommended that the clinician explain all questions, or have the child answer
the questionnaire sitting with an adult in case they have any questions), and
their parents to complete in about 10 minutes. It can discriminate between
depression and anxiety, as well as among distinct anxiety disorders. The
SCARED is useful for generalized anxiety disorder, social anxiety
disorder, phobic disorders, and school anxiety problems.
SCARED is a child-focused assessment tool that uses a 41-items (child version
and parent version) on a scale of 0-2. A total score of ≥ 25 may indicate the
presence of an Anxiety Disorder. Scores higher than 30 are more specific. A
score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate
Panic Disorder or Significant Somatic Symptoms. A score of 9 for items 5, 7, 14,
21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder. A score of 5
for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder.
A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety
Disorder. A score of 3 for items 2, 11, 17, 36 may indicate Significant School
Avoidance.

Therefore, Anxiety assessments tools provide a wide range of insights to help

providers diagnose and treat disorders accurately and efficiently.

ASSESSMENT OF AGGRESSION
What is aggression?

According to Berkowitz (1993), aggression refers to goal-directed motor behavior

that has a deliberate intent to harm or injure another object or person. Bandura
(1973), on the other hand, did not conceptualize aggression to include intentions,
but instead considered aggression as harmful behavior that violates social norms.
Buss and Perry (1992) defined verbal and physical aggression as the motor
components of behavior that involve hurting or harming others.
However, the commonly used definition in the social sciences and behavioral
sciences, aggression is an action or response by an individual that delivers
something unpleasant to another person.

Types of Aggression:

When we define "aggression," we first break it down into the four major types of
aggression -- physical, mental, emotional, and verbal.

 Physical Aggression - aggressive behavior that physically harms yourself or

someone else, such as hitting, biting, using weapons, and kicking.
 Mental Aggression - aggressive behavior experienced with the intent of
harming someone mentally, such as causing anxiety, stress, or depression
 Emotional Aggression -aggressive behavior that harms someone
emotionally and causes them to struggle with expressing themselves.
 Verbal Aggression - aggressive behavior that is spoken by one person to
make another person feel less confident in their own skin.

Psychologists divide aggression into two main types. Both are damaging to those
who experience them, whether as the target or the aggressor.

Impulsive Aggression

 Also known as affective or reactive aggression, impulsive aggression is

characterized by strong emotions. Impulsive aggression, especially when it's
caused by anger, triggers the acute threat response system in the brain,
involving the amygdala, hypothalamus, and periaqueductal gray.
  This form of aggression is not planned and often takes place in the heat of
the moment. If another car cuts you off in traffic and you begin yelling and
berating the other driver, you're experiencing impulsive aggression.

Instrumental Aggression

 Also known as predatory aggression, instrumental aggression is marked by

behaviors that are intended to achieve a larger goal. Instrumental
aggression is often carefully planned and usually exists as a means to an
end.
 Hurting another person in a robbery is an example of this type of
aggression. The aggressor's goal is to obtain money, and harming another
individual is the means to achieve that aim.

Measurement

How aggression is defined and measured can potentially influence the selection of
measurement instruments, research outcomes, and clinical decisions. There are
numerous measurement methods to consider when selecting an assessment
technique.

 Self-report
 Observer-rated
 Projective tests
 Behavioral laboratory measures
Aggression Assessment Tools:

Aggression assessment measures are tools used to evaluate and quantify various
aspects of aggression in individuals. There are several assessment tools available
to measure aggression. Here are a few commonly used ones:

1. Buss–Perry Aggression Questionnaire

The Buss–Perry Aggression Questionnaire (also known as the Aggression

Questionnaire and sometimes referred to as the AGQ or AQ) was designed
by Arnold H. Buss and Mark Perry in 1992. The 1992 version of the AQ is a 29-
item questionnaire in which participants rank certain statements along a 5-point
continuum from "extremely uncharacteristic of me" to "extremely characteristic
of me". The scores are normalized on a scale of 0 to 1, with 1 being the highest
level of aggression. It measures four factors: physical aggression, verbal
aggression, anger, and hostility.

2. Modified Overt Aggression Scale (MOAS)

A psychometrically upgraded version of the Overt Aggression Scale (Yudofsky et

al., 1986) developed to assess aggression in psychiatric populations. Assesses the
four categories of aggression by psychiatric patients: 1. Verbal aggression 2.
Aggression against property 3. Autoaggression 4. Physical aggression. The MOAS
was upgraded from a behavioral checklist (nominal scale) to a five-point rating
system (ordinal or interval scale) that represents increased levels of severity and
introduced a weighted total score that reflects overall seriousness of aggression.
20 items (5 items under each form of aggression) requires rater to check the
highest applicable rating point to describe the most serious act of aggression
committed by the patient during the specified time period (usually past week).
The MOAS is one of the most widely used measures for violence and aggression.

3. The State-Trait Anger Expression Inventory

The State-Trait Anger Expression Inventory (STAXI; Speilberger, 1996) is a 44-item

instrument designed to measure anger both as an emotional situational response
and a dispositional quality. The STAXI-2 (Spielberger, 1999) which is purported to
measure the experience, expression, and control of anger, consists of 57 items, 6
scales, 5 subscales, and an Anger Expression Index (total anger expression)
(cf. Spielberger & Reheiser, 2009). The State Anger scale (15 items) measures
anger intensity as a momentary emotional state, while the Trait Anger scale (10
items) measures the disposition to experience angry feelings as a personality-like
trait over lengthy time periods (i.e., the individual’s disposition to become angry
or angry temperament). The Anger Expression scale (16 items) and the Anger
Control scale (16 items) measure four anger-related trait dimensions. The Scales
include: State Anger, Trait Anger, Anger Expression-Out, Anger Expression-In,
Anger Control-Out, Anger Control-In, and Anger Expression Index. Ratings of items
are on a 4-point response scales that measure state anger (intensity) as well as
trait anger (frequency).

4. Overt Aggression Scale-Modified for Outpatients (OAS-M)

OAS-M (Coccaro et al. ,1991) was designed to assess various manifestations of

aggressive behavior in outpatients. It includes a rating of the frequency/severity
of overt behaviors during the past week. It examines the following: (1) Verbal
Aggression, (2) Aggression against Objects, (3) Aggression against Others, (4)
Aggression against Self, (5) Global Irritability, (6) Subjective irritability, (7) Suicidal
Tendencies (Ideation and Behavior), (8) Intent of Attempt, and (9) Lethality of
Attempt. It has 25 items and three domains: 1. Aggression ,2. Irritability & 3.
Suicidality.

5. Clinical Anger Scale (CAS)

CAS (Snell, Gum, Shuck, Mosley, and Hite ,1995) is a 21 items self-report Four-
point scale, designed to measure the syndrome of clinical anger. Clinical anger
was conceptualized as syndrome that consists of global, debilitating, and chronic
symptoms of anger and includes cognitive, affective, physiological, behavioral,
and social manifestations. Initial items were discuussed among professional
psychology staff and students; after revision of items they were administered to
several samples. The CAS is intended primarily for use with individuals who are
suffering from major levels of clinical anger.

6. Brief Symptom Inventory (BSI)

BSI (Derogatis,1993) is a 53 items self-report Five-point Likert scale and a

shortened version of SCL-90-R (Derogatis, 1977) that generates three global and
nine primary psychological symptom dimensions including Somatization (SOM),
Obsessive – compulsive (O-C), Interpersonal Sensitivity (I-S), Depression (DEP),
Anxiety (ANX), Hostility (HOS), Phobic Anxiety (PHOB), Paranoid Ideation (PAR),
and Psychoticism (PSY).
 7. Child Behavior Checklist (CBCL)

The Child Behavior Checklist (CBCL) is a component of the Achenbach System of

Empirically Based Assessment (ASEBA). The ASEBA is used to detect behavioural
and emotional problems in children and adolescents. The CBCL is completed by
parents. The other two components are the Teacher’s Report Form (TRF)
(completed by teachers), and the Youth Self-Report (YSR) (completed by the child
or adolescent himself or herself). The CBCL consists of 113 questions, scored on a
three-point Likert scale (0=absent, 1= occurs sometimes, 2=occurs often). The
2001 revision of the CBCL, the CBCL/6-18 (used with children 6 to 18), is made up
of eight syndrome scales:

 anxious/depressed
 depressed
 somatic complaints
 social problems
 thought problems
 attention problems
 rule-breaking behaviour
 aggressive behaviour.

These group into two higher order factors—internalizing and externalizing. The
time frame for item responses is the past six months. The 2001 revision also
added six DSM-oriented scales consistent with DSM diagnostic categories:

 affective problems
 anxiety problems
  somatic problems
 ADHD
 oppositional defiant problems
 conduct problems.

Conclusion: These tools vary in their scope and application, with some focusing
specifically on aggression and others assessing it as a part of a broader
assessment of psychological functioning. It is essential to select the most
appropriate tool based on the research purpose or clinical needs.