HOSPITAL ANXIETY AND DEPRESSION SCALE (HADS)

Date: 15/08/2021 Test No:

Anxiety is an emotion characterized by feelings of tension, worried thoughts and

physical changes like increased blood pressure. People with anxiety disorders usually have
recurring intrusive thoughts or concerns. They may avoid certain situations out of worry.
They may also have physical symptoms such as sweating, trembling, dizziness or a rapid
heartbeat. The cognitive feelings of dread in anticipation of some bad outcome, and physical
sensations such as jitteriness and a racing heart are designed for discomfort. Anxiety is meant
to capture attention and stimulate you to make necessary changes to protect what you care
about. Occasional bouts of anxiety are natural and can even be productive. It is closely
related to fear, which is a response to a real or perceived immediate threat; anxiety involves
the expectation of future threat. People facing anxiety may withdraw from situations which
have provoked anxiety in the past. The cognitive component of anxiety which entails
expectation of a diffuse and certain danger. However, anxiety is not always pathological or
maladaptive: it is a common emotion along with fear, anger, sadness, and happiness, and it
has a very important function in relation to survival. Neural circuitry involving the amygdala
and hippocampus is thought to underlie anxiety.

There are two types of anxiety: Trait anxiety and State anxiety.

State Anxiety

State anxiety can be defined as a transitory emotional state consisting of feelings of

apprehension, nervousness, and physiological symptoms such as an increased heart rate or
respiration (Spielberger 1979). Whereas everyone can experience state anxiety occasionally,
there are large differences among individuals in the frequency, duration, and severity. State
anxiety can be determined by several rating instruments developed in the past. This is the
anxiety felt at the present, cross-sectional moment (state) and is expressed as ‘I feel anxious
now’.

Trait Anxiety

Trait anxiety represents a fairly stable characteristic related to personality.

Experiencing more frequently state anxiety combined with a general view of the world as
being
threatening and dangerous is used as marker of trait anxiety. This is a habitual tendency to be
anxious in general (a trait) and is exemplified by ‘I often feel anxious’. Trait anxiety is part of
the personality dimension of neuroticism versus emotional stability. Trait anxiety also
manifests by repeated concerns about and reporting of body symptoms. Trait anxiety is
characterized by a stable perception of environmental stimuli (events, others’ statements) as
threatening. Trait anxious people often experience and express also state anxiety, in situations
in which most people do not experience such responses. This bias is thought to reflect a
cognitive-perceptual bias. At the perceptual level, there is an over-attentional bias to
threatening stimuli. At the cognitive level, there is a distorted negative interpretation of
information congruent with and fostering anxious responses.

All anxiety disorders have unrealistic, irrational fears or anxieties of disabling

intensity as their principal and most obvious manifestation. DSM V recognizes six primary
types of anxiety disorders include specific phobia, social phobia, panic disorder, agoraphobia,
generalized anxiety disorder and obsessive-compulsive disorder.

Theories of Anxiety

Psychodynamic View

Sigmund Freud in his theory of psychoanalysis has explained about three types of
anxiety. According to him, the psyche’s major problem is how to cope with anxiety.

Objective anxiety (reality anxiety) occurs in response to real, fear-inducing, external

threats. The ego fears losing literal control, for example, a hiker who runs from a bear. In
neurotic anxiety, conflict is felt due to a clash between the id and the ego. For example, a
woman fears that her sexual attraction (id) toward her male co-worker will overcome her
conscious control (ego). Finally, in moral anxiety, the ego and superego conflict. For
example, a student’s superego demands that all of his assignments are perfectly error free, a
standard his ego cannot meet. Overall, during each type of anxiety, the ego is faced with the
demanding task of balancing the realities of the world, the impulses of the id, and the
demands of the superego.

Humans attempt to lessen their anxiety in two general ways. The first is to deal with
the situation directly. We overcome obstacles, either confront or run from threats, and resolve
or come to terms with problems in order to minimize their impact. The alternative approach is
defensive: either the situation is distorted, or it is directly denied. The ego protects the whole
personality against the threat by falsifying the nature of the threat. The ways in which we
accomplish the distortions are called defense mechanisms.

Anxiety that cannot be dealt with by effective measures is said to be traumatic. It reduces the
person to a state of infantile helplessness. In fact, prototype of all later anxiety is the birth
trauma.

Neo-Psychodynamic View

Karen Horney in her theory of personality explained about the concept of basic
anxiety. Horney defined basic anxiety as an “insidiously increasing, all-pervading feeling of
being lonely and helpless in a hostile world” (Horney, 1937). In childhood we try to protect
ourselves against basic anxiety in four ways: Securing affection and love, being submissive,
attaining power and withdrawing.

The four self-protective mechanisms Horney proposed have a single goal: to defend
against basic anxiety. These mechanisms may reduce anxiety, but the cost to the individual is
usually an impoverished personality.

Existentialism

According to Rollo May, feelings of anxiety stem from loneliness and emptiness. Like
Freud, he believed that anxiety signals an internal conflict, but May’s theorizing about the
nature and source of the conflict differs from Freud’s. For May, anxiety is not simply an
unpleasant feeling; it is “the human being’s basic reaction to a danger to his existence, or to
some value he identifies with his anxiety” (May, 1953).

According to May, the conflict that generates ontological anxiety is between being
and nonbeing. Anxiety occurs as the individual attempts to realize his or her potentialities.
There is no escape from anxiety according to May. May clarified the meaning of ontological
anxiety further by dividing it into two components:

Normal anxiety is anxiety that is proportionate to the threat to our values. It does not
involve repression and can be confronted constructively on the conscious level. Neurotic
anxiety, in contrast, is a reaction that is disproportionate to the threat and involves repression.
Neurotic anxiety develops when we are unable to address the normal anxiety arising at the
time of the actual crisis in our growth and the threat to our values (May, 1967).

Depressive disorder is a mood disorder in which a person experiences, in the absence of

drugs or another medical condition, two or more weeks with five or more symptoms, at least
one of which must be either (1) depressed mood or (2) loss of interest or pleasure. According
to Kaplan & Sadock (2015) major depressive disorder has an average lifetime prevalence of
12%. The life-time risk of depression in males is 8-12% and in females is 20-26%. Gender
ratio show a predominance for females than males.

In ICD-10, depressive disorder is called as depressive episode. According to ICD-10, there

are three varieties of depressive episodes as illustrated below:

 Mild (F32.0)
 Moderate (F 32.1)
 Severe (F32.2 & F 32.3)

The diagnostic guideline of depressive episode in ICD-10 is that the individual usually suffers
from depressed mood, loss of interest and enjoyment, and reduced energy leading to
increased fatiguability and diminished activity. Marked tiredness after only slight effort is
common. Other common symptoms are:

(a)reduced concentration and attention;

(b)reduced self-esteem and self-confidence;

(c)ideas of guilt and unworthiness (even in a mild type of episode);

(d)bleak and pessimistic views of the future;

(e)ideas or acts of self-harm or suicide;

(f)disturbed sleep

(g)diminished appetite.

Etiology

 Biological Factors
 First degree relatives are 2-3 times vulnerable in developing the disorder. Reduced
dopaminergic activity and dysregulation in the monoamine neurotransmitters can
cause depression. Increased activation of amygdala, decreased volume of
hippocampus and damage to left anterior prefrontal cortex contribute to the etiology
of the disorder. The dysregulation in HPA axis of CRH and ACTH can also cause
depression.
 Psychological Factors
Major life stresses like severe health problems, loss of a loved one, threat to
occupation etc can trigger depression. Similarly, minor life stresses like poverty,
marital discord, medical issues and the like can also cause depression. High levels of
neuroticism, negative affectivity and regression can lead to the disorder. Faulty
cognitive strategies, learned helplessness, internal, stable and global pessimistic
attributional style contribute to the etiology of the disorder.
 Social Factors
Lack of social support, social rejection, social skill deficit can cause depression. There
is a high correlation between marital dissatisfaction and depression for both women
and men.

Theories

Behaviourism

Behaviourists emphasizes the importance of the environment in shaping behavior. The focus
is on observable behavior and the conditions through which individuals learn behavior,
namely classical conditioning, operant conditioning and social learning theory. Therefore,
depression is the result of a person's interaction with their environment. Classical
conditioning proposes depression is learned through associating certain stimuli with negative
emotional states. Social learning theory states behavior is learned through observation,
imitation and reinforcement.

Psychodynamic Approach

Freud (1917) prosed that many cases of depression were due to biological factors. However,
Freud also argued that some cases of depression could be linked to loss or rejection by a
parent. They believed that depression occurred due to the use of immature defense
mechanisms. Freud also stated that that depression is simply due to an excessively severe
super-ego. Thus, the depressive phase occurs when the individual’s super-ego or conscience
is dominant.
Cognitive Theory

Aron Beck (1967) identified three mechanisms that he thought were responsible for
depression:

1. The cognitive triad (of negative automatic thinking)

2. Negative self-schemas

3. Errors in Logic (i.e. faulty information processing)

As these three components interact, they interfere with normal cognitive processing, leading
to impairments in perception, memory and problem solving with the person becoming
obsessed with negative thoughts. Beck believed that depression prone individuals develop a
negative self-schema. They possess a set of beliefs and expectations about themselves that
are essentially negative and pessimistic. Beck claimed that negative schemas may be acquired
in childhood as a result of a traumatic event.

Theory of Learned Helplessness

Martin Seligman (1974) proposed a cognitive explanation of depression called learned

helplessness. According to Seligman’s learned helplessness theory, depression occurs when a
person learns that their attempts to escape negative situations make no difference. As a
consequence, they become passive and will endure aversive stimuli or environments even
when escape is possible. He believed that internal, stable and global pessimistic attributional
style led to depression. Seligman (1973) referred to depression as the ‘common cold’ of
psychiatry because of its frequency of diagnosis.

Humanist Approach

Humanists believe that there are needs that are unique to the human species. According to
Maslow (1962) the most important of these is the need for self-actualization. The self-
actualizing human being has a meaningful life. Anything that blocks our striving to fulfil this
need can be a cause of depression. Moreover, conditions of worth, inflated ideal self and
obstacle to self- actualization can cause depression.

The various treatment methods used in patients with depression are

pharmacotherapy, hospitalization, CBT, interpersonal therapy, behaviour therapy,
transcranial magnetic stimulation (TMS), sleep deprivation and phototherapy.
DESCRIPTION OF THE TEST

The HADS was developed by Dr. Phillip Snaith and Anthony Zigmond in 1983. The
Hospital Anxiety and Depression Scale (HADS) is a self-administered 14 item measure used
to screen for the presence of depression and anxiety. Seven items assess depression, 5 of
which are markers for anhedonia (an inability to experience pleasure), and 2 concern
appearance and feelings of slowing down. Seven items assess anxiety, of which 2 assess
autonomic anxiety (panic and butterflies in the stomach), and the remaining 5 assess tension
and restlessness

The HADS was developed to provide clinicians with an acceptable, reliable, valid and easy to
use practical tool for identifying and quantifying depression and anxiety. The HADS can be
used in a variety of settings (e.g. community, primary care, in-hospital, and psychiatry). The
HADS is not intended as a complete diagnostic tool, but as a means for identifying general
hospital patients who need further psychiatric evaluation and assistance (Herrmann, 1997).
No formal training is required for the HADS.

The HADS has been validated for use with adolescents (White, Leach, Sims, Atkinson, &
Cottrell, 1999); somatic and psychiatric cases; primary care patients (Olsson, Mykletun, &
Dahl, 2005); and the general population.

Completion of the HADS requires that the client have adequate reading comprehension
and visual ability, as it is a self-administered measure. However, in the case of illiteracy or
poor vision, the items and possible responses may be read to the respondent (Snaith, 2003).

METHOD

Aim :To assess the anxiety and depression of an individual using Hospital Anxiety and
Depression Scale (HADS).

Materials Required

1. Hospital Anxiety and Depression Scale (HADS)

2. Writing Materials

Participant:

Name: KK
Age: 22

Gender: Male

Educational Qualification: B.Sc

Experimenter

Name: AB

Procedure

The HADS is a self-administered measure asks the client to reflect on their mood in
the past week. The HADS only takes 2 to 5 minutes to complete. The caution must be
observed; this is that the patient is, in fact, literate and able to read it. Some illiterate people
are ashamed of their defect and will pretend to answer the statements by haphazard
underlining of response options. When administering the HADS it is reasonable practice to
ask the respondent to read out aloud one or other of the phrases of the questionnaire. Also,
provide explanation of the purpose of the questionnaire and assurance on the confidentiality
of the document. Instruction to the subject “Tick the box beside the reply that is closest to
how you have been feeling in the past week. Don’t take too long over you replies: your
immediate is best”.

Precautions

 Ask the respondent to read out aloud one or other of the phrases of the questionnaire

SCORING

Scores for items in each subscale of the HADS are summed to produce an anxiety
score (HADS-A) or a depression score (HADS-D), or can be added to produce a total score
(HADS-T). Each item is rated on a 4-point scale (ranging from 0 = no not at all, to 3 = yes
definitely), for a total score ranging from 0-21 for each subscale. A higher score indicates
higher distress. A number of items are reverse scored (ranging from 3 = no not at all, to 0 =
yes definitely), including two from the HADS-A and four from the HADS-D.
For both scales, scores of less than 7 indicate non-cases

8–10 Mild

11–14 Moderate

15–21 Severe

Note: Score anxiety and depression separately.

RESULT

Table 1. the raw score and its interpretation for depression and anxiety of the participant in
HADS.

TOTAL SCORE DEPRESSION ANXIETY

6 5

INTERPRETATION Normal Normal

Table 1 shows the raw score and the interpretation of anxiety and depression in HADS for the
participant. The participant has a total score of 6 for depression and a total score of 5 for
anxiety.

DISCUSSION

The aim of the experiment was to assess the anxiety and depression of an individual using
Hospital Anxiety and Depression Scale (HADS). This test was conducted with Hospital
Anxiety and Depression Scale (HADS) which measure the level of anxiety and depression
of individuals. It is a self- report measure that provides a clear understanding of the
participant’s level of anxiety and depression. The participant involved in this test is a 22-
year- old male . He was very cooperative and enthusiastic for participating in this test. He
was very attentive and has orientation of place, time and situation. He also had a stable
mood/affect.

The participant obtained a raw score of 6 for the dimension of Depression. This indicate that
the participant has a normal level of depression. Depression is also considered to be a normal
emotional response/ reaction to negative life events. As a result, the participant in this test
also has depression as normal day-to-day emotional response/ reaction. She does not have the
diagnostic depression.

In the dimension of Anxiety, the participant has a raw score of 5. She has a normal level of
anxiety. Anxiety is also considered to be a normal reaction to stressful or negative life
events. It is a common reaction like depression and denial to various adverse life situations.
Normal anxiety is intermittent. It is a factor that help improve the functioning and efficiency
of an individual. Similarly, the anxiety of the participant has a protective and facilitative
function of improving the functioning of the participant.

Thus, the participant in this test tends to have normal levels of anxiety and depression
which facilitate the day- to- day functioning. This could be a major reason for higher
academic and non- academic performance.

CONCLUSION

The participant has normal anxiety and depression in HADS.

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