[50]

THE ASSESSMENT OF ANXIETY STATES BY RATING

BY MAX HAMILTON*
In the last decade many scales have been and in
a manner which permits of reproduc-
devised for the assessment of psychiatric symp-
tion in another enquiry.
toms. Most have been designed for use with
The present scale was
designed
along
patients in mental hospitals and have therefore different lines. It is intended for use with
concentrated chiefly on behaviour in the ward patients already diagnosed as suffering from
and in hospital activities. Not many of the neurotic anxiety states, not for assessing
items are concerned with symptoms, and these
anxiety in patients suffering from other dis-
are chiefly those of schizophrenia and the
orders. Anxiety in greater or lesser degree is
depressive psychoses. Even less attention is
found in agitated depression and obsessional
paid to neurotic symptoms, especially anxiety states particularly, and also in such states as
states, despite the fact that the scales are
organic dementia, hysteria and schizophrenia,
intended generally to cover the full range of
but it must be clearly emphasized that the
psychiatric syndromes. These scales have been scale is not intended to cope with these
designed to enable the research worker to
conditions.
obtain a quantified measure of the patient's
The usual methods for scale design were
clinical status, e.g. for use in clinical trials of
used. A series of symptoms were assembled
treatment. In them, the separate items are
which were considered to cover the condition
summed in groups and a set of scores or
adequately. These were then grouped together
' profile' is obtained for each patient. This
according to their nature, or where clinical ex-
'profile' is often used as a diagnostic aid,
periences indicated that they were associated.
although this is not the primary purpose of the It was decided that for practical purposes
scale. Users are generally warned not to use
twelve groupings were sumcient. Together
the scale for making a diagnosis.
with the patient's behaviour at interview, these
In practice, these scales have two other
functions of great importance. The first is that formed the thirteen variables of the scale. They
the investigator can describe precisely certain are: anxious mood (a continued state of ap-
prehension), tension (including irritability),
characteristics of his group of patients using
fears (of specific or phobic type), insomnia,
the mean score and standard deviation. The
cognitive changes (diffculty in concentration
description and definition of the population
and forgetfulness), depression, somatic symp-
from which a sample is drawn is of funda-
toms of a general type, cardiovascular, res-
mental importance and is one of the diffcult
piratory, gastro-intestinal, genito-urinary, and
problems that faces research in psychiatry.
general autonomic symptoms, the latter con-
For this purpoe diagnostic categories are
sisting chiefly of headaches and sweating.
notoriously unreliable and rating scales are
Each of the variables was defined in a series of
invaluable. The second function is that they
brief statements, headed by the name of the
help to define syndromes and subsyndromes, variable, printed on a sheet which faced the
interviewer during the interview with the
• Senior Research Fellow, Department of patient (see Appendix l).
Psychiatry, University of Leeds. Based on a paper
Assessments were made on a five-point scale
read at the Annual General Meeting of the British
Psychological Society, April 1957. Manuscript (see Appendix 2). In practice, the last grade
is very rarely used for out-patients, and serves
received 2 August 1958.
more as a marker, a method of delimiting
 ASSESSMENT OF ANXIETY STATES 51
the range, rather than as a grade of practical
use. In order to determine the reliability ofthe on the sum of crude scores for each patient.
scale the patients Product-moment correlations were calculated
were seen by two
interviewers
between each pair of physicians, and since the
simultaneously. The principal interviewer
patients were interviewed on two occasions
conducted the interview and endeavoured to
for purposes of a drug trial, two such correla-
obtain information regarding the patient's
tions between each pair of physicians is
symptoms. The second interviewer made his
available. The results are to be seen in Table l.
ratiny independently of the first and could
The weighted mean of these correlations, using
add his own questions if he thought he had not the z transformation, is 0•89. This is re-
had sumcient information.
Raters markably high and illustrates the reliability of
11 psychiatric assessments under suitable condi-
Table l. Correlation.s and t tests between
I t tet 0-30 0-54 tions. Since the reliability coemcient does not
Correlation raters093 give information on the bias of raters towards
No. of subjæts 8 high or low scores, r tests were calculated
inter- between pairs of raters in the same way (see
II t test 007 0•63 view Table l). The weighted mean of these t tests is
Correlation 0•83 0-91 0•61 and shows that very little bias is to be
found.
No. of subjects 8 10 The relations between the variables were
then examined. Product-moment correlations
111 t test 0•64 1•30 were calculated between the variables and the
Correlation 0-95 0-93 resultant matrix factor-analysed by the method
No. of subjects 8 10 of Simple Summation (the matrix of correla-
tions is available on request). Communalities
were estimated by five iterations of the process.
Second This is very easily done using the shortened
interview method of Burt (1949). A general and one
bipolar factor were extracted. The general
factor is clearly a general factor of anxiety
The initial testing of the scale involved three and the bipolar divides the symptoms into
psychiatrists. two groups: The first contains psychic symp-
Preliminary discussions elimi- toms consisting of tension, fears, insomnia,
nated many anxiety, intellectual (cognitive) changes, de-
of the diffculties in the first pression, and behaviour at interview. This was
version of the contrasted with a group of somatic symptoms
definitions of the variables. The consisting of æstro-intestinal, genito-urinary,
rating scale was then tried on a number of respiratory, cardiovascular, somatic general
patients and the discrepancies and agreements and autonomic symptoms (Table 2).
between psychiatrists carefully considered in
detail, in an endeavour to eliminate diff- When the factor saturations are plotted it
culties. The scale was then tried on a group of may be seen that the vect0N lie almost com-
patients and this paper is concemed with the pletely within a right angle. In other words it
results. An identical procedure was followed is possible to rotate the saturations to give two
throughout. Each patient was assessed by orthogonal poup factors. The variance of the
two raters and the results recorded. After-
wards the results were compared and any general factor constitutes 27 %, of the bipolar
discrepancies noted and discussed. Neverthe- 18 0/0, giving a total of 45 0/0 of the total vari-
less, once a rating had been made it was not ance. This total was probably reduced by
altered. The measure of reliability was based selection.

4.2
52 MAX HAMILTON
to identify the same factors regardless of the
Table 2. Saturations for centroid and
problems introduced by selection. In this
rotated factors
particular case, the group factor analysis has
11
1
Tension 0-60 0-26 0•36 0-54 the advantage of orthogonality as well.
Fears 0-29 0•37 0-46 Despite the apparent advantage ofthe group
0•32 factor approach over the general factor
Insomnia 0•79 0-75 -0-06 0•70
Anxious mood 0-43 0•07 0-48 0-86 approach, it must not be forgotten that mathe-
Cognitive changes 0•56 0-52 -42 0•37 matically, the two have an equivalence, since
Depression 0-38 0-22 002 0-64 the one can be converted into the other by a
Behaviour 0•37 0-00 0•39 simple transformation, in this case, the sim-
Gastro•intestinal 0-41 0•34 0•22 plest of all, an orthogonal rotation. No new
information can appear from such a trans-
symptoms formation. (In fact, factor analysis, except for
Genito-urinary 0-43 -0•34 o.ss -005 the method of principal components with full
symptoms 0•56 -0-27 variance, actually loses information.
Respiratory 0-31 -0•54 yeat advantage is that it makes information
symptoms 0-62 -033 Its
Cardiovascular 0-34 - 0-62 0•57 between general and group factor analysis
symptoms clearer and more comprehensible.) The choice
Somatic (general) 0•48 -0•31 001
In this case, the selection of patients is based
symptoms must depend on other considerations.
Autonomic 0-56 - o, 10 0•52 23
symptoms neurosis, and this condition shows itself as
on the fact that they all suffer from anxiety

Communality 2-93 209

Communality as 23
16
a gener factor, i. . a dimension to which all
percentage
which they all have positive non-zero projec-
DISCUSSION tions. It may be that, in other circumstances,
the division into group factors may be pre•
This particular matrix of correlations can be ferred. For example, theresponsetotreatment,
resolved either into a general factor of anxiety or the effects of some drug, may show as a
and a bipolar factor of psychic versus somatic change in one or other of the group factors.
symptoms, or alternatively, into two ortho- Even if this should be so, it would only mean
gonal group factors of psychic anxiety' and that whereas for such a situation, the group
•somatic anxiety'. Since both factorizations factor is appropriate, for the present situation,
give orthogonal factors, there is no advantage i.e. for diagnosis, the general factor is the
in one over the other. On general grounds, we appropriate one.
know that had there been less selection of It is interesting to compare this rating scale
subjects, so that they extended through the with the factor analysis of the Taylor scale by
full range from those with trivial symptoms to O'Connor, Lorr & Stafford (1956). Although
those severely ill, then in the centroid analysis, the present scale is concerned with general
the general factor would have had a greater symptoms, whereas the Taylor scale deals with
varian% the bipolar factor still being ortho- specific statements, the two factors A and B
gonal to it. In the group factor analysis, the correspond roughly with the present general
two group factors would have been positively and bipolar factors. Factors A and B correlate
correlated, this implying a general second 0•068, so they too are orthogonal.
order factor. The British school of factorists, Both the Taylor scale and the scales of
following Burt, emphasize the value of ortho- Dixon, de Monchaux & Sandler (1957a, b)
gonality. The American school, following differ from the present one in that they are
Thurstone, emphasize the value of being able concemed with the content of the patient's
 ASSESSMENT OF ANXIETY STATES 53
symptoms, rather than the form. This is also suggest that either scale is better than the other.
true of the Taylor scale. Although in the Only practical use will determine which is the
course of treatment the specific nature of a more useful, and it is to be hoped that both
patient's fears and anxieties may change, it will be superseded by something better.
does so much less readily than the intensity.
The scale can by no means be considered to
The assessment of both these kinds of be in its final state. Ideally, each of the items
changes is of practiæl and theoretical im-
listed under the heading of a variable should
portance, and therefore the two kinds of scale
are complementary. be handled separately for purposes of full
The present scale obviously invites compari- item analysis. The sheer labour of doing this in
a rating scale (as opposed to a questionnaire)
son with that designed by Buss, Wiener, Durkee
& Baer (1955). It is important to recognize the will delay this for a long time. Some of the
between the two. The present scale variables are obviously a rag-bag of oddments
is designed for the rating of anxiety neurosis and need further investigation. Further work
as a syndrome, not for the rating of anxiety. is being done in which the general somatic
Until the contrary is proved, it must be symptoms are separated into two variables:
regarded as invalid for the rating of anxiety muscular and sensory.
in any other setting. This limits the range of Experience has shown that grade 2 can be
usefulness of the scale but, within these limits, split up into two g•ades without increasing the
patients can be compared meaningfully. It
dificulty of rating. In practice, grade 4 is
places great emphasis on the patient's sub-
jective state. (This follows from the medical almost never used because the rater is reluctant
to give the maximum score to subjects who
bias of the author, for in treatment the patient's
subjective state takes first place both as a could obviously be much worse. An additional
criterion of illness, which brings the patient grade would probably be rarely or never used,
for treatment, and as a criterion of improve- but would encourage the rater to subdivide
ment.) The various symptoms are rated grade 3, shifting some of his ratings to the
separately, the somatic ones being given equal higher grade.
place with the psychic. This is because in out- SUMMARY
patient practice patients place great emphasis A rating scale for the symptoms of anxiety
on somatic symptoms, and a large number go neurosis has been prepared as an aid to the
first to the general medical departments for quantification of symptoms. It was used on
investigation of these. The scale of Buss et al. thirty-five patients by three physicians working
was used for rating anxiety on all types of in pairs. The reliability of the scale, as shown
patient except those suffering from cerebral by correlations and t tests between raters, is
damage. It therefore has a wider range of high. The correlations between variables nn
application. This is counter-balanced by the be factorized into a general factor of anxiety
fact that the comparison of scores for anxiety,
and a bipolar factor contrasting psychic with
e.g. schizophrenia, depression
somatic symptoms; or into two orthogonal
and anxiety
group factors of 'psychic' and 'somatic'
neuroses, has no clear meaning.
It assembles anxiety.
symptoms into fewer groups. ACKNOWLEDGEMENTS
It gives less I would like to thank Prof. Hargeaves for
weight to somatic symptoms, or alternatively, permission to publish this paper, and par-
gives more weight to psychic symptoms. Both ticularly for his advice and guidance in the
scales group many single items under a limited design of the rating scale. I have to thank him
number of headings, and it would be clearly and Dr Roberts for taking part in the ratings
desirable to investigate the appropriateness of patients. The Research Fellowship is
and usefulness of this procedure. Both show supported in part by a grant from the Mental
high reliability in use. I do not intend to Health Research Fund to whom thanks are due.
54 MAX HAMILTON

APPENDIX 1
Symptoms of anxiety states
General somatic (muscular)
Anxious mod Genito-urinary symptoms
Muscular pains and aches Frequency of micturition
Worries
Anticipation of the worst Muscular stiffness Urgency of micturition
Apprehension (fearful Muscular twitchings Amenorrhea
anticipation) Clonic jerks Menorrhagia
Irritability Grinding of teeth Development of frigidity
Unsteady voice Ejaculatio praecox Loss
of erection Impotence
Tension
General wruric (sensory)
Feelings of tension
Tinnitus
Fatiguability Inability
Blurring of vision
to relax Startle Autonomic symptonts
Hot and cold flust—
response Moved to Dry mouth
Feelings of weakness
tears easily Flushing
Pricking sensations
Trembling Pallor
Feelings of restlessness Tendency to sweat
Cardio vascular symptoms
Giddiness
Tachycardia
Tension headache
Fears Palpitations
Raising of hair
Of Dark Pain in chest
Strangers Throbbing of vessels
Being left alone Fainting feelings maviour at interview (general)
Large animals, etc. Missing beat Tense, not relaxed
Tramc Fidgetting: hands,
Crowds Respiratory symptoms picking fingers,
Pressure or constriction clenching, tics,
in chest handkerchief
Insomnia Choking feelings Restlessness: pacing
Diffculty in falling asleep Sighings Tremor of hands
Broken sleep Unsatisfying Dyspnoea Furrowed brow
sleep and Strained face
fatigue on waking Gastro-intestinal Increased muscular tone
Dreams synptoms Diffculty in Sighing respirations
Nightmares swallowing Wind Facial pallor
Night terrors Dyspepsia :
pain before and after
meals mapiour (Ahysiological)
Intellectual (cognitive) Swallowing
burning ensations
Dificulty in concentration fullness Belching
Poor memory waterbrash High resting pule rate
nausea Respiration rate over
vomiting 20/min.
Depressed
sinking feelings Brisk tendon jerks
Loss of interest Tremor
'Working' in abdomen
L..ack of pleasure in hobbies Dilated pupils
Borborygmi
Depression Looseness of bowels Exophthalmos
Early waking Loss of weight Sweating
Diurnal swing Constipation Eye-lid twitching
 ASSESSMENT OF ANXIETY STATES 55

APPENDIX 2

Date Gra&s
Anxious mood O is none
Tension 1 is mild
Fears 2 is moderate
Insomnia 3 is evere
Intellect 4 is very severe,
Depressed mood grossly
Somatic general (muscular disabling
and setBory)
Cardiovascular system
Respiratory system
Gastro-intestinal system
Genito-urinary system
Autonomic system
Behaviour at interview

General comtents :

REFERENCES
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a shortened mahod of factor analysis. Brit.
(1957b). Patterns of anxiety: an analysis of
J. Psychol. Statist. Sect. 2, 61—6.
social anxieties. Brit. J. Md. Psy&l. 30,
BUSS, A. H., WIENER, M., DURXEE, A. & BAER, M.
107-12.
(1955). Tbe measuren*nt of anxiety in clinical
situations. J. Cons. Psychol. 19, 125—9, no. 2. O'CONM)R, J. P., L.ORR, M. & STAFFORD, J. W.
(1956). patterns of rnanifest anxiety.
DMON, J. J., DE MONCHAUX, C. & SANDLER, J.
J. Clin. Psych'. 12, 160-3.
(1957a). Patterns of anxiety: the phobias.
frit. J. Med. Psychol. 30, 34-40.