Download THE PERSONAL DISTURBANCE SCALE (DSSI/sAD)

Person. individ.Of5 Vol. 22, No. 4, pp. 493-510, 1997
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THE PERSONAL DISTURBANCE SCALE (DSSI/sAD):
DEVELOPMENT,
USE AND STRUCTURE
Alan Bedford’ and Ian J. Deary’,*
‘York Clinical Psychology Services, Monkgate Health Centre, 31-35 Monkgate, York Y03 7PB. England,
*Department of Psychology,
University of Edinburgh,
7 George Square, Edinburgh
EH8 9JZ, Scotland
(Received I5 Ju1.v 1996)
Summary-This
is the second in a series of three articles reviewing and reassessing Foulds’ theoretical
conceptions
of personality
disturbance
and personal illness and the scales that were developed to assess
them. In this report we review the theoretical
development
of DSSI/sAD (Delusions-Symptoms-States
Inventory/states
of Anxiety and Depression,
otherwise known as the Personal Disturbance
Scale) and
describe how it fits into Foulds’ theories. The intended use of SAD is discussed and the many past and
current applications
of the SAD are reviewed. Studies of the SAD’S psychometric
structure are rare and we
present a new analysis, including confirmatory
factor analysis of SAD in 480 psychiatric patients. The SAD
items’ factorial structure fits largely with its authors’ conceptions.
However, the SAD items cover an
anxietydepression
continuum.
rather than distinct states of anxiety and depression.
The SAD’S item
structure may be interpreted within three current conceptualisations
of mood: (I) that of general psychological distress; (2) that ofclinical states of anxiety and depression; and (3) that of ‘normal’ mood dimensions
of hedonic tone and tense arousal. It is argued that the SAD might provide a theoretical bridge for the
integration of these ideas, and help to bring about a unified model of normal and pathological
mood states.
0 1997 Elsevier Science Ltd. All rights reserved.
INTRODUCTION
Foulds (1955, 1965) proposed that it was logically necessary to assess separately personality traits
and the symptoms and signs of personal (psychiatric) illness before any possible interrelationship
could be studied. Such a view, in its employment of Axis 1 and Axis 2 diagnoses, now forms a major
part of official psychiatric nomenclature, e.g. Diagnostic and Statistical Manual of Mental Disorders,
4th Edition (DSM-IV; American Psychiatric Association, 1994). Accordingly, Foulds and his
colleagues devised distinct psychometric measures for such separate assessments. Subsequently, as
he modified his theory of personality and personal illness (Foulds, 1971, 1976) a second generation
of self-report measures was produced. This report is the second in a series of articles, the first being
by Deary, Bedford and Fowkes (1995), which examine the subsequent literature on these measures
and reassess their psychometric properties.
Foulds and Bedford (1975) proposed a hierarchy of classes of personal illness model in which the
relationship between the symptom-classes was inclusive and non-reflexive. Each higher class included
all the lower classes whilst the converse did not hold. Figure 1 shows the models’ four classes ranging
from Dysthymic States up to those of delusions of disintegration which their data supported for
93.3% of 480 psychiatric patients. As persons scoring in the higher classes almost invariably scored
in all of the lower ones it followed that a scale derived from the Dysthymic States class could be
efficient and economical for ‘case’ selection or treatment evaluation. Hence, the Personal Disturbance Scale (DSSI/sAD) is empirically derived from the full Delusions-Symptoms-States Inventory (Bedford & Foulds, 1978a) and logically from the hierarchy of classes of personal illness model
(Foulds & Bedford, 1975; Foulds, 1976). Data on the scale were first reported by Bedford, Foulds
and Sheffield (1976), and were followed by a test manual with updated norms (Bedford & Foulds,
1978b).
The DSSI/sAD is a self-report scale consisting of seven state of anxiety items and seven state of
depression items and is shown in full in Appendix A. All items are prefixed by “Recently” which
can be explained as “During the last month or so”. Testees are first asked whether an item is true
*To whom all correspondence
should be addressed.
493
494
Alan Bedford and Ian J. Deary
Persons
$1
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f4
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Delusions of
*~__~~~~~~_____~~~-~---_~~~----~~~~~--~~Disintegration
Integrated
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Fig. 1. Schematic diagram of the inclusive relationship of the hierarchy of classes of personal illness. Person
5 has symptoms at all class levels. Person 4 at the three lower levels, Person 3 at the two lesser levels, Person
2 has a Dysthymic State and Person 1 is non-personally
ill.
or false for them. Affirmed items-those
circled ‘true’-are
then scored 1, 2 or 3 mostly according
to the degree of distress claimed, e.g. ‘a little, a lot, or unbearably’.
The possible range of scores is,
therefore, CL21 for each state and CL-42 for the combined SAD scale. Scores of 4 and above for a
seven item set mean that at least two items have been affirmed at some level, and are taken as
indicating ‘presence’ of that adverse mood state.
The item content of the SAD was validated
against the judgements
of experienced
clinical
psychologists and psychiatrists with a very high degree of concordance.
Similarly, the psychiatrists’
ratings of their inpatients were statistically significantly
related to the patients’ scores on anxiety,
depression and SAD total (Bedford & Foulds, 1978b). Norms were presented in the manual by the
authors from their database of 200 normal Ss and 480 psychiatric patients and are summarised in
Table 1. Goldberg, in evaluating
his General Health Questionnaire
(GHQ; 1972), states that the
test “missed chronic schizophrenics,
organics and hypomanics”.
Much the same was anticipated
for the SAD, which, however, enquiries about current state and the degree of distress caused,
whereas the GHQ asks about change from ‘usual self.
As opposed to the 3 - vs 4 + dichotomy of anxiety and depression scores, Bedford and Foulds
(1978b) employed a three category classification
for total SAD scores. They adopted the following
rules:
(a) let scores of 0, 1 and 2 be considered non-personally
disturbed (PD);
(b) let scores of 3,4, 5 and 6 be considered personally disturbed (PD);
(c) let scores of 7 and above be considered personally ill (PI).
Table 2 shows the result of so doing.
Other studies by the authors and Edinburgh
co-workers
include the following: Foulds and
Bedford (1977) uses the Personal Disturbance
Scale and the Personality Deviance Scales (Bedford
& Foulds, 1978~) to examine self-esteem in affective and non-affective patient groups. Three hundred
and twenty-five psychiatric patients were allocated to classes within the hierarchy of personal illness
model by means of their Delusions-Symptoms-States
Inventory scores. When each of these classes
were dichotomised,
on the grounds of clinical expectation, into ‘affective’ and ‘non-affective’ groups,
Table 1. Means, standard deviations and percentages scoring 4+ on state of anxiety and state of depression among nornul Ss and patients
Patients (N = 480)
Healthy Ss (h’ = 200)
State of anxiety (sA)
State of depression (SD)
Mea”
SD
0x4 +
Mea”
SD
%4+
0.9
0.6
1.3
1.5
5.5
5.0
7.1
7.5
4.7
5.5
71.3
69.0
Personal Disturbance
Scale (DSSI/sAD)
495
Table 2. Totals and percentages of normal Ss’ and patients’ SAD scale scores falling into the three Personal Illness categories
Healthy .Ss (N = 200)
Patients (N = 480)
Category
SAD scores
N
%
N
%
GE
23.4, 5.6
-I+
162
28
10
81.0
14.0
5.0
57
65
358
11.8
13.5
14.1
PD
PI
it was found that both intropunitiveness of the Personality Deviance Scales and the Personal
Disturbance Scale (DSSI/sAD) discriminated highly significantly. Evidence was adduced, however,
that these two measures were not tapping the same attributes (Foulds & Bedford, 1977). Bedford
and McIver (1978) confirmed, in both a normal and a patient group, Foulds’ (1971) suggestion that,
of the 16 PF (Cattell, Eber & Tatsuoka, 1970) primary traits, C, 0 and 44 were more like states
whereas G, L and 43 were deviant traits. Ingham (1981) conducted epidemiological studies of
normal Ss in the community and found that “about 10 per cent of a general population sample,
excluding any who had consulted their GPs within three months” were classified as personally ill.
This illness threshold he believed to be close to Index of Definition Category 5 of the Present State
Examination (a structured psychiatric interview; Wing, Cooper & Sartorius, 1974). Conversely,
Ingham and Miller (1982) noted that “thirty seven per cent of women who reached the personally
ill criterion score on the SAD had consulted their doctors, whereas for the men the figure was 22%“.
Bedford and Bedford (1985) found similar SAD scores in the general population and in British
social workers and social work trainees. The social workers had a mean of 2.2 with a standard
deviation of 4.3.
The SAD scale was originally intended for use in treatment evaluation and for detecting the
personally disturbed in the community. The following sections present and discuss applied work
with the SAD.
Normative
data and validation
Lyketsos, Blackburn and Mouzaki (1979) translated the SAD and a companion measure, the
Personality Deviance Scales, into Greek and collected data on 220 normal Ss. Women, with means
for anxiety of 3.2 and for depression of 2.2, scored significantly higher than Greek men. By contrast
with the initial British norms (Foulds, 1976), both Greek sexes had the higher SAD mean scores.
The authors believed that the results highlighted the need for local norms in transcultural research.
In an Australian epidemiological study Henderson, Byrne and Duncan-Jones (198 1) introduced
the SAD together with the GHQ, the SDS (Zung, 1965) and his own 4NS scale. Table 3 shows the
SAD results. Again, the women are the higher scorers and more often exceed the depression 4+
threshold. The correlations among the four different tests were all highly significant, ranging from
0.50 to 0.62. The Canberra team again included the SAD in a battery of psychological tests of
psychiatric symptoms and personality where repeated measures were needed to evaluate the “retest artefact in longitudinal studies” (Jorm, Duncan-Jones & Scott, 1989). They found that this
mean change towards less psychopathology is unrelated to the time lag between occasions, ranging
from 4 to 34 weeks, but was confined to measures assessing negative self-characteristics and administered by an interviewer. In a further two-wave community survey, Henderson and Jorm (1990)
Table 3. State of anxiety (sA) and state of depression (SD) means, standard deviations and percentages scoring 4+ for Canberra men and
women
Men (N = 101)
State of Anxiety
(sA)
Women (N = 142)
State of
Depression (SD)
State of Anxiety
(sA)
State of
Depression (SD)
0.7
1.6
7.0
1.9
2.4
16.1
1.1
2.1
12.6
496
Alan Bedford and Ian J. Deary
found that respondents who reported that the interviews had made them feel anxious/depressed
gained significantly higher scores on both state measures on both occasions.
In another article from the Canberra Research Unit, Braithwaite (1987) outlined a newly
developed measure of neuroticism, the Scale of Emotional Arousability (SEA), intended to avoid
“the consistent pattern of negatively worded items that plagues the neuroticism (N) Scale of the
Eysenck Personality Inventory” (Eysenck & Eysenck, 1964). The SAD scales, in common with other
“well-known measures of neurosis” correlated moderately with the SEA, i.e. 0.55 with anxiety and
0.48 with depression.
Economou and Angelopoulos (1989) collected data on 754 Greek high school students, mean age
16.9 years. For the males the mean SAD score was 4.7 (SD 4.8) and for the females was 9.1 (SD
7.1), all considerably in excess of the British adult norms. In a separate Greek translation, involving
also the Personality Deviance Scales, Vaslamatzis, Bazas, Lyketsos and Katsouyanni (1985) compared female nursing, teaching and physiotherapy trainees with Lyketsos et d’s (1979) Greek
female norms. The only significant difference for the SAD scales was that student nurses gained the
highest depression scores. On total SAD the nurses’ mean was 6.9 and the Greek women sample
mean was 5.4 with the other two trainee groups intermediate. Angelopoulos and Economou (1994)
assessed 1080 high school students of a Greek provincial town a few weeks before their June
examinations. The boys’ and girls’ mean anxiety scores were 2.4 (SD 3.0) and 5.0 (SD 4.2) respectively, and for depression were 3.1 (SD 3.3) and 5.2 (SD 4.2). The total SAD means were, therefore,
5.4 for males and 10.2 for females. The authors suggested that their findings should encourage
discussion of gender differences in adolescent mood disorders. Again, it is clear that different norms
from those of the UK are needed for Greek Ss, particularly the young. For Australian research
purposes the evidence of such a need is less compelling. When employing categories, however, as
per Table 2, it is necessary to demonstrate that terms are being employed identically.
In a sample of 604 young convicted male offenders Cookson (1994) found, inter alia, high anxiety
and depression SAD scores among drug users and the highest mean SAD scores of all in children of
problem drinking parents. SAD correlated 0.43 with Neuroticism from the short form of the standard
EPQ-R. In a factor analysis of all six scales SAD loaded highly with Neuroticism and Self-esteem
on one factor; the second was defined by psychoticism and impulsiveness.
Psychosomatic groups
A series of Greek studies has examined the personality characteristics, using the Personality
Deviance Scales, and mood state, employing the SAD, of various psychosomatic hospital inpatient
groups.
In comparison to norms collected by Lyketsos et al. (1979), a study of consecutive hospital
admissions for hypertension and ulcers found the hypertensives to be significantly more anxious
and depressed and both groups to exceed a control group and the norms. The SAD means for the
experimental clinical groups were 12.7 and 6.7 on admission whilst the controls and norms were
both 3.9. At discharge “the state differences persisted” (Lyketsos, Arapakis, Psaras, Photiou &
Blackburn, 1982). Likewise the bronchial asthma inpatients’ SAD mean of 13.4 on admission grossly
exceeded control and norms scores (Lyketsos, Karabetsos, Jordanoglou, Liokis, Armagianidis &
Lyketsos, 1984). Indeed, this is the kind of score found among psychiatric patients under treatment
in the United Kingdom. Three skin disease groups (urticaria, psoriasis and alopecia) also completed
these two questionnaires and obtained SAD means of 11.0, 12.8 and 12.7, respectively, all significantly greater than a control group of patients with other skin diseases (Lyketsos, Stratigos,
Tawil, Psaras & Lyketsos, 1985). Inpatients with ulcerative colitis and irritable bowel syndrome had
means of 7.4 and 8.9 compared to a control group of medical admissions (with neither psychiatric
nor psychosomatic complaints) with a mean score of only 1.5. In all these groups, anxiety was the
much greater element in the total SAD mean (Arapakis, Lyketsos, Gerolymatos, Richardson &
Lyketsos, 1986).
An article summarising the SAD findings “in physical conditions of presumably psychogenic
origin” and controls involved nine and five groups respectively (Lyketsos, Lyketsos, Richardson &
Beis, 1987). The authors concluded that “on the SAD, all the above [physical] groups scored
significantly higher than somatically ill controls in anxiety, and all except the ulcer patients scored
significantly higher in depression”. The authors added that “while all experimental groups showed
Personal Disturbance Scale (DSSI/sAD)
497
similar levels of anxiety, depression varied considerably.” The former tends not to improve with
remission of some ‘psychosomatic’ disturbances whilst depression may lessen with the amelioration
of such symptoms.
Male hypertensives and a control group in a Chicago hospital recorded similar total SAD means
of only 1.2 and 1.0 respectively (Aritzi, Demakis, Demakis, Fareed, Reid, Dunkas, Richardson &
Lyketsos, 1989).
Physical problems
(a) Acquiredhearing loss. Thomas (1984) reported at length on a sample of 211 hearing-impaired
adults of employment age with regard to their social and psychological status. In a series of separate
publications, different aspects of these findings were discussed. For example, Thomas and Gilhome
Herbst (1980a) noted that using the Manual cutting score of 7+ identified 19% of the people as
psychiatrically disturbed compared to 5% of the general population. Such disturbance related
significantly to “unhappiness at work, changing jobs due to deafness, being lonely, having no
friends, deafness adversely affecting marriage, feeling near to a nervous breakdown and overall
dissatisfaction with life”. A significantly greater proportion of such ‘SAD cases’ were found among
those with severe (as contrasted to moderate or mild) pure tone loss (Thomas & Gilhome Herbst,
1980b). Similar results applied to the standard of speech discrimination ability. Thomas (1981)
reviewed descriptive and experimental studies on the relationship between acquired deafness and
psychological disturbance.
In a random sample of 657 patients aged 70 and over from a general practice ‘hearing difficulty’
was associated with both depression and anxiety (Jones, Victor & Vetter, 1984).
(6) Obesity. In a three-month double blind trial of 100 obese women, a significant correlation
between change in mood and change in weight was found. Weight loss was associated with improved
mood state and weight gain with increased disturbance (Weighill & Buglass, 1984). By contrast, a
placebo controlled double-blind trial of fluvoxamine maleate in 40 females showed a significant
improvement in mood for both groups over three months but no “significant relationship between
improved mood and weight change” (Abell, Farquhar, Galloway, Steven, Philip & Munro, 1986).
(c) Lower limb amputation. Stephen (1982) reported that, of 22 patients admitted at a median of
22 weeks post amputation, only one had a significant score for anxiety and only two for depression.
Elderly
The majority of studies under this heading were completed either by the Research Team for the
Care of the Elderly, Welsh National School of Medicine, Cardiff, or the Department of Health,
Care of the Elderly, Nottingham University Medical School with colleagues.
The first reported use of the SAD with old people, however, would appear to be by McNab and
Philip (1980). Health visitors were able to assess 41 elderly people, 85 years or over, and found that
their distribution into SAD categories did not differ significantly from the normative data of younger
adults. Vetter, Jones and Victor (1982) had 1288 people, aged 70 years and above, interviewed
regarding mental and physical disability and the use of services. The SAD results are presented in
terms of “normal, borderline and pathological” categories in relation to these variables as well as
age and sex. The authors concluded that the “relationship between anxiety, depression and the use
of services is a close one” and that anxiety/depression are important predictors of the need for
services. When carers for the elderly at home were assessed they were found to be more often
anxious-“23%
and 13% scored as borderline and pathological”-than
depressed (9% and 6%).
In general “there was a great deal of distress and psychological morbidity among the carers” (Jones
& Vetter, 1984). A report on hearing difficulty and its psychological implications by this team was
cited earlier (Jones et al., 1984). “Both anxiety and depression showed a close relationship and
loneliness” in urban and rural 70 plus year olds, increasingly so with age (Jones, Victor & Vetter,
1985). That the anxiety and depression scores were higher in an urban (than a rural) general practice
and in females, and were closely associated with physical disability in these old people was reported
by Vetter, Jones, Victor and Philip (1986).
The Nottingham team assessed mental health and psychological well-being in 507 (65-74 year
olds) and 535 (75+ years) individuals in the community. Both groups reported similar levels of
anxiety and personal disturbance and showed a similar prevalence of depression. A Cronbach alpha
498
Alan Bedford and Ian J. Deary
coefficient of 0.85 was calculated for the 14 item SAD scale. Employing a higher cut-off score,
clinical and survey ratings of depression showed an overall agreement of 84.6% with a Kappa
coefficient of 0.66 (p < 0.001). Separate tables for the anxiety and depression subscales scores
distributions (O-S+) by age in conjunction with information in the text could provide useful
normative data for those aged 65 + years (Morgan, Dallosso, Arie, Byrne, Jones & Waite, 1987a).
When these persons were classified on SAD score as psychiatrically normal, borderline or ill, those
classified as ill were significantly more likely to report recent GP and social services contact and be
receiving psychotropic drugs. The rank-order correlation between a 1Zitem physical health problems checklist and the SAD was 0.41 (p < 0.001; Morgan, Dallosso, Ebrahim, Arie & Fentem,
1987b). Subjective insomnia at least ‘sometimes’ was reported by 37.9% of this community sample,
it being test predicted by SAD anxiety scores, sex and self-ratings of health (Morgan, Dallosso,
Ehrahim, Arie & Fenten, 1988). To assess relationships between customary physical activity and
mental health, the elderly were divided into two groups on the basis of SAD scale score 2versus 3 + , the latter being regarded as ‘disturbed’. In a stepwise discriminant analysis of variables
predicting group membership, health, social engagement and age achieved significance for both
sexes. For men, home maintenance activities also contributed (Morgan, Dallosso, Bassey, Ebrahim,
Fentem & Arie, 1991).
From the Nottingham database recently widowed women were studied longitudinally with respect
to their psychological and physical health and social functioning. Never-married and still-married
subjects acted as controls. All groups showed an age-related decline in mental and physical health.
While widows showed significantly greater changes in morale and personal disturbance, as assessed
by the SAD, their levels of social functioning remained stable over the four year period (Bennett &
Morgan, 1992). A battery of psychometric measures, including the SAD, was employed by Pearson
and Beech (1990) in illustrating the inter-relationships of personality variables and symptoms in an
elderly patient suffering pain.
Psychiatric disorders of childbirth
Postnatal depression was investigated by the antenatal screening of a sample of 166 women for
factors that might be predictive of later disturbance. SAD anxiety, amongst other measures, was
positively associated with postnatal depression six weeks after birth. It was suggested that, for a
number of women, depression found postnatally might already be present before childbirth (Hayworth, Little, Bonham Carter, Raptopoulos, Priest & Sandler, 1980). Similarly “women with high
anxiety or hostility scores had a more pronounced ante-natal heart response to the sound of a baby
crying than to noise of similar frequency and intensity. This more pronounced heart response
was also related to later post-natal depression” (Little, Hayworth, Bonham Carter, Dewhurst,
Raptopoulos, Sandler & Priest, 1981). As there were no significant differences in either anxiety
(SAD) or hostility over the course of pregnancy it does not seem to matter very much at what point
in pregnancy such questionnaires are administered in terms of the significance of the predictive
power for later depressed mood (Little, Hayworth, Benson, Bridge, Dewhurst & Priest, 1982). Postnatal depression from six weeks to 12 months post-partum was positively associated with first
trimester ante-natal scores on SAD anxiety and other psychometric measures (Bridge, Little,
Hayworth, Dewhurst & Priest, 1985).
Forty-five pregnant women gained a mean SAD anxiety subscale score of 7.29, considerably in
excess of normative score findings (Benson, Little, Talbert, Dewhurst & Priest, 1987). Maternal and
foetal heart rates were recorded while they listened to a tape through headphones. The foetuses of
anxious mothers showed pronounced responses to certain taped stimuli. This series of studies, and
other work, is included in Priest, Tanner, Gandhi and Bhandari (1995).
Of 425 childbearing women, 230 completed the SAD and 10 visual analogue scales on four
occasions pre- and post-pregnancy (Cox, Connor, Henderson, McGuire 8c Kendell, 1983). The
authors concluded that self-report scales, unlike visual analogue scales, have a limited sensitivity to
rapid mood changes and for several reasons may require re-design and revalidation for use during
pregnancy and in the puerperium. Consequently, Cox, Holden and Sagovsky (1987) developed the
Edinburgh Postnatal Depression Scale from an initial pool of 21 items. Some of the items were of
their own devising whilst others were from existing scales including the SAD.
Personal Disturbance
Scale (DSSI/sAD)
499
Bereaved Parents
A series of prospective studies by the Child Health Department of Queensland University has
examined the stress responses and circumstances of 94 parents following sudden infant death (SIDS),
179 after a stillbirth (SB), and 192 with a neonatal death (NND). Among the measures used in the
various research waves were the items of the SAD.
The first report examined the three bereaved groups’ parents and 453 controls two months after
loss. Parents were interviewed separately and each subject family was individually matched with a
control family. The authors concluded that bereaved parents “manifest high levels of anxiety and
depression two months after the death. Mothers have more symptoms than fathers, and parents
affected by SIDS have the most symptoms of anxiety and depression” (Vance, Foster, Najman,
Embelton, Thearle & Hodgen, 1991). They also report reliabilities close to 0.90 (Cronbach’s alpha)
for the two SAD scales.
More detailed “maternal anxiety” and “paternal anxiety” mean scores, based on a five-point
scale are shown for four waves (2-25 months) on the above groups by Vance, Najman, Embelton,
Foster, Thearle and Boyle (1993). Patterns of depressive symptoms are said to be very similar. The
Ss are the same people on all occasions. In summary, bereaved “mothers’ symptoms persist for
longer than the fathers’. For mothers who have lost children from SIDS, these differences persist
for two years. These symptoms persist for 15 months for those mothers who have lost infants from
neonatal death or stillbirth.”
Boyle (1993) concerned herself with the patterns of distress and predictors of recovery in mothers
of SIDS bereavements. “Bereaved mothers who were not distressed at 2 months were unlikely to
become so later. However, those who were still distressed at 8 months tended to remain distressed
subsequently”, i.e. at 15 and 30 months post loss. Boyle, Vance and Najman (1993) looked at the
anxiety and depression rates for all bereaved mothers who did, and did not, become pregnant within
68 months of their loss and also those rates at the later interviews. They “found no evidence to
suggest that an early pregnancy places women at risk for psychological disorder, at least within the
first 25 to 30 months of the loss”. Vance (1994) discussed the relevance of the Department’s work
to research into postnatal depression from the use of the seven-item depression component of the
SAD as an effective way of detecting depression in a group of bereaved and control mothers.
A study including fifth wave interviewers, i.e. 60 months after loss, found that, while distress for
mothers, as assessed by the SAD, may persist for at least 30 months, it appears to subside within
five years. It was suggested that the lower manifestation of psychological symptoms in fathers may
be due to grief expressed in other forms, e.g. increased alcohol use. Having used a marital adjustment
scale (Spanier, 1976), marital status and “Quality of Life” questions, they added that parents “who
experience the death of a baby are also more likely to experience an adverse marital outcome within
five years of the loss” (Vance, Najman, Thearle, Embelton, Boyle & Lutvey, 1995b). When religious
affiliation, church attendance, child loss and anxiety/depression rates were examined in the loss and
control groups of parents at 2 months, the results did not “confirm a traditionally held belief that
religious consolation for the grief of bereavement and the bereaved ‘turn to God’ as reflected in
church attendance” (Thearle, Vance, Najman, Embelton & Foster, 1995). It was suggested, however,
that the finding that “the bereaved who attend church regularly have less anxiety and depression”
compared with the rest warrants further examination.
That bereaved parents have a marked reduction in symptoms (anxiety and depression) over the
first 8 months after the loss was shown by Vance, Najman, Thearle, Embelton, Foster and Boyle
(1995~). Compared with controls, however, these levels were still high for mothers “but far less
evident for fathers”. Finally, Vance, Boyle, Najman and Thearle (1995a) presented a wide range of
findings covering the first four waves including “heavy alcohol ingestion” which was “significantly
more prevalent at 2 and 30 months”. Similarly, Keeping, Najman, Morrison, Western, Andersen
and Williams (1989) introduced the first of four waves in a study of 8556 pregnant women whose
first antenatal visit included completing at 117-item questionnaire that contained the SAD anxiety
and depression scales.
Genetic twin studies
A series of studies involving Australian and American authors has reported on data gathered
from the Australian National Health and Medical Research Council Twin Register. Both members
500
Alan Bedford and Ian J. Deary
of 3810 twin pairs had responded by completing a questionnaire which included the SAD items.
Jardine, Martin and Henderson (1984) found that for men and for women both “anxiety and
depression scales show extreme ‘reverse-J’ shape distributions” unlike the EPQ (Eysenck & Eysenck,
1975). Neuroticism which showed “a reasonably symmetric distribution but.. . with a ‘basementlike’ effect”. The scale means were 2.4 for anxiety in women and 1.8 for men, 1.5 for depression in
women and 1.1 for men. A genetic analysis of the trait of neuroticism and symptoms of anxiety and
depression found that differences between people on these measures could be explained simply by
differences in their genes and differences in their individual environmental experiences. There was
no evidence that shared environmental experiences, i.e. by co-twins, were important.
Kendler, Heath, Martin and Eaves (1986) examined the SAD’S 14 individual items’ responses by
sex and noted that “females scored higher than males on all items”, significantly so on 10 occasions.
Their Table 4 provides normative data in the form of mean, standard deviation and per cent scoring
positive by item. The main analysis again concludes that “the results strongly support the role of
genetic factors in explaining twin resemblance for the large majority of symptoms. Contrary to
prediction, evidence of a role for familial-environmental factors in influencing symptom scores was
either absent or weak”.
Kendler, Heath, Martin and Eaves (1987) carried out four traditional factor analyses on 1978
same sex female and 918 same sex male and 902 opposite sex volunteer twin adult pairs having
subdivided the sample by sex and then into first and second members from each twin pair. One
depression item, relating to suicidal thoughts, was omitted because of its low response rate, and, as
the most extreme response category (“unbearably”) was used infrequently, it was collapsed into a
three-point scale. Using the eigenvalue criterion, three orthogonal factors were extracted. The first
phenotypic factor, accounting for between 45.8% and 50.5% of the total variance was similar across
the four groups, and was termed “depression-distress”. It accounted for two-thirds of the total
variance of the depression subscale. The second factor, accounting for between 6.5% and 10.9% of
the total variation, was also quite similar in the groups. This factor was termed “general anxiety”
and accounted for over five times as much variance in the anxiety as in the depression subscale. A
third factor, accounting for between 5.6% and 5.9% of the total variation, had in all four groups
by far the highest loading on two items-“worrying
kept me awake” and “miserable, difficulty with
sleep”. This factor was termed “insomnia”. The authors then carried out what they believed to be
the first application of multivariate genetic methods to individual psychiatric symptoms. They
concluded that there was “little evidence that genes influenced specifically either symptoms of
depression or symptoms of anxiety. However, certain environments appeared to be specifically
depressogenic and others anxiogenic”.
Female twin responders (1233 monozygotic and 750 dizygotic pairs) to the same six SAD
depression items produced data on the items’ endorsement frequencies and inter correlations (the
highest being +0.59 and the lowest being +0.40). When analysed the first two eigenvalues of the
correlation matrix were found to be 3.36 and 0.67. The loadings for the items ranged only from
+0.69 to +0.81 (Eaves, Martin, Heath & Kendler, 1987). The authors concluded that “there is
strong support for a unidimensional model for the latent space”. For the purpose of genetic analysis
of the liability to depression, the items were recorded dichotomously and led to the resulting
comment that “a model which allows only for polygenic variation in the latent trait is supported as
well as the ‘mixed model’ which also allows for the effects of a major gene. The likelihood is
significantly lower when all genetic effects are ascribed to a single gene”. Silberg, Martin and Heath
(1987) also studied these female twins with regard to genetic and environmental factors in primary
dysmenorrhea and its relationship to anxiety, depression and neuroticism. Covariations between
menstrual symptoms and the symptoms and personality variables of state anxiety (sA) and
depression (SD) and trait neuroticism (N of the EPQ) were shown to be almost entirely genetic in
origin.
Data from 2903 adult same-sex twin pairs were analysed to investigate whether the genetic
determinants for symptoms of panic are different from those underlying the neuroticism personality
trait (Martin, Jardine, Andrews & Heath, 1988). Two SAD anxiety items, numbers 3 and 7, were
taken as the criteria for panic. Their results confirmed that “much of the genetic variation influencing
the physical symptoms associated with panic is nonadditive, perhaps due to dominance or epistasis”.
Mackinnon, Henderson and Andrews (1990), in conducting a five-wave study of 462 twin pairs,
Personal Disturbance
Scale (DSSI/sAD)
501
replicated the findings of previous single-wave twin studies, that trait neuroticism and symptom
levels of anxiety and depression are substantially under genetic control with little influence coming
from the twins’ shared environment. “It has then produced evidence that gene action does not play
a part in determining individual variability in these measures” but rather that this “was related to
recent life events”. Andrews, Stewart, Allen and Henderson (1990) interviewed 446 pairs of adult
twins in respect of lifetime data for six common neuroses. The twins also completed measures of
neuroticism and anxiety and depression symptoms. In agreement with earlier work there was a
genetic contribution to neuroticism and to symptoms but no inheritance of specific disorders.
Morris-Yates, Andrews, Howie and Henderson (1990) recruited a sample of 343 adult, same-sex
pairs of twins from the Australian Twin Registry to test the equal environments assumption. Again
EPQ Neuroticism and the separate anxiety and depression scales of the SAD were employed, and
subjects were asked about the similarity of their social environment during childhood and early
adolescence. Monozygotic twins reported experiencing more similar ‘imposed’ (by parents) and
‘elicited’ (by similar interests and behaviour) environments than dizygotic twins. The extent of
imposed similar treatments was unrelated to current behavioural similarity as indicated by absolute
intrapair differences on the questionnaires. “Therefore, for the purpose of most analyses, the equal
environments assumption is valid.”
Mellors, Boyle and Roberts (1994) investigated the association of personality, stress and lifestyle
with self-reported hypertension in 4870 female and 2746 male twins from the Registry. The SAD
comprised the measure of stress and means were obtained for males of 2.0 anxiety and 1.2 depression
and for females of 2.58 and 1.71 respectively. For both sexes, anxiety was one of the five main
significant predictors for hypertension in a discriminant function analysis.
In summarising these results Eaves, Eysenck and Martin (1989) say that “the same genetic effects
create variation in neuroticism scores, depression scores and anxiety scores. The analysis also shows
that some environmental effects are specific to anxiety and depression.” They add that “there are
distinct and independent environmental influences that increase the chance of expression of symptoms of depression rather than anxiety or vice versa, in individuals of high genetic liability. This
means that two individuals with the same high genetic liability will have a higher chance of endorsing
symptoms of both anxiety and depression, but that environmental experiences will determine
whether they develop the symptoms of anxiety or depression.”
Miscellaneous
Researchers of the Australian National University have included the SAD, as a measure of
disturbed mood, in their investigations of a theoretical model of persistent gambling. In one study
a mean of 7.2 (SD 7.9) for a group of 36 poker machine players is reported. For regular players
(N = 15) the correlation between SAD and persistence was 0.76 (Dickerson & Adcock, 1987). When
10 high frequency players were studied, SAD mean 2.3 (SD 1.8), depression was “the only significant
predictor in the regression equation”, accounting for 36% of the variance, of persistence when
losing. Overall they state that “the effect of dysphoria is to render the onset of a session less
likely and to reduce the duration should a session occur” (Dickerson, Hinchy, England, Fabre &
Cunningham, 1992).
A battery of questionnaires, including the SAD, GHQ and a short form of EPI Form B, was
administered twice to 354 adults drawn from the electoral roll and subjected to principal components
analysis. It was concluded that “neurotic symptoms and well-being scales do largely measure
different ends of a single continuum, but well-being scales seem to have an extraversion component
not shared by neurotic symptoms scales” (Jot-m & Duncan-Jones, 1990).
Smith, Pearce, Pringle and Caplan (1995) evaluated a pilot therapy service for adults with a
history of child sexual abuse. Clients completed three psychological measures-GHQ,
SAD and a
social activity and distress scale. At the start of therapy 72% of 58 clients were personally disturbed
or personally ill, i.e. scored 3 + and/or 7 + , whilst at the end of therapy only 31% did so.
George, Shanks and Westlake (199 1) and Westlake and George (1994) carried out a census of
388 single homeless people over a 12 hour period in Sheffield. Raised SAD anxiety and depression
scores did not differentiate between those with and without a self-reported psychiatric history or
admissions. They suggested that these symptoms are a result rather than a cause of homelessness
502
Alan Bedford and Ian J. Deary
and that a broad social solution to mental illness in homeless people is needed in addition to specific
medical interventions.
Scale Structure
In the Genetic Twin Studies section the series of Australian-American researchers also involved
an investigation of the item structure of the scales. In summary they found: (a) a one factor solution
for the six items used of the seven item depression scale in a normal sample; and (b) a three factor
solution for thirteen items of the SAD, again omitting the same depression item, with a normal
sample. No separate analysis was carried out for the anxiety items. The present report is the first to
conduct a factor analysis of all SAD items in psychiatric patients using the full response range for
each item.
SUBJECTS
AND METHOD
DSSI/sAD responses were collected on 253 psychiatric inpatients (142 women, 111 men), with a
mean age of 33.6 years (SD = 12.1) in English, Scottish and Canadian hospitals within one week of
admission. One hundred and eighteen outpatients (59 men, 59 women), with a mean age of 33.3
years (SD = 12.1) were seen at their first appointment. Similarly, 109 day patients (64 women, 45
men), with a mean age of 34.1 years (SD = 11.6), were assessed within their first week of attendance.
Therefore, in total, 480 adults undergoing outpatient, daypatient and inpatient psychiatric treatment
completed the DSSI/sAD. Some data concerning this group were reported in a series of publications,
e.g. Bedford and Foulds (1978b), Foulds (1976) and Foulds and Bedford (1975).
RESULTS
The means and standard deviations of each of the 14 SAD items are shown in Table 4. Principal
components analysis of the 14 items resulted in three components with an eigenvalue greater than
one: 5.9, 1.4 and 1.O respectively. These components accounted for 42.3%, 9.8% and 7.1% of
total item variance, respectively. Using principal axis factoring, the percentages of variance were,
respectively, 38.9%, 6.5% and 4.1%. Inspection of the scree slope implied that either a two or three
factor solution might be appropriate (Cattell, 1966). As a result, and taking into account the
disproportionately large amount of variance accounted for by the first unrotated factor, one, two
and three factor solutions are shown in Table 4. For the factor solutions shown in Table 4 principal
axis factoring was carried out using squared multiple correlations in the diagonals. Oblique solutions
were sought.
The first unrotated factor had high loadings for all items, with 4 items 20.7 and all save two
Table 4. Means, standard deviations and factor loadings of each Personal Disturbance Scale item for 480 psychiatric patients. 1st PCA is the
first unrotated principal component. Loadings for the two and three factor solutions are for the pattern matrix of the oblique rotations
Item No.
Anxiety
1
3
4
I
9
II
13
Abbreviated item text
Mean
SD
1st
Unrotated
Factor
Worried about every little thing
Been breathless/pounding heart
Worked up/couldn’t sit still
Had feelings of panic
Pain/tense in neck/head
Worry kept me awake
Couldn’t make up my mind
1.21
0.73
I .06
1.18
0.86
1.14
0.98
1.02
0.84
1.00
1.06
0.97
1.03
1.07
0.64
0.37
0.54
0.58
0.44
0.71
0.71
0.62
0.49
0.60
1.06
1.04
1.20
1.00
1.04
1.14
1.08
1.01
0.68
0.59
0.65
0.71
0.68
0.70
0.58
0.62
Depression
2
Difficulty with my sleep
5
Depressed without knowing why
6
Not caring if never woke up
8
Low in spirits,. sat for ages
10
Future seemed hopeless
12
Lost interest in everything
14
Thought of doing away with myself
1.25
0.71
1.17
1.36
1.18
0.82
2 Factor solution
Factor 1
Z
0.73
0.59
-:::
0.28
0.00
0.10
-0.21
Factor 2
3 Factor solution
Factor I
Factor 2
Factor 3
0.07
-0.10
-0.02
0.06
-0.08
-0.00
0.18
0.55
0.58
0.47
0.60
0.48
0.10
0.54
0.15
-0.04
0.04
0.14
-0.03
-0.10
0.26
0.04
-0.11
0.12
-0.08
0.07
0.88
-0.00
0.07
0.24
0.81
0.50
0.75
0.67
0.88
-0.00
0.27
-0.18
0.17
0.00
0.05
-0.34
-0.00
0.30
0.83
0.55
0.80
0.72
0.90
0.84
0.10
0.05
0.06
-0.07
-0.02
0.08
Personal Disturbance Scale (DSSI/sAD)
1.0
1
Anxiety
General
psychoiogical
distress
0.8 -
-0.2
0.0
0.2
0.4
Hedonic
503
0.6
0.8
1.0
tone
Fig. 2. Loadings of the 14 SAD items on two orthogonally
rotated principal components.
Names of axes
and names attached to vectors are hypothetical
(see text). Item numbers are adjacent to each item’s position
in two-dimensional
space. For actual item content see Appendix A.
>0.5 (Table 4). The two which were lower than 0.5 were somatic anxiety symptoms relating to
breathlessness/palpitations
(0.37) and pain/tension in the head and neck (0.44). Therefore, the SAD
scale as a whole has coherence as a general psychological disturbance scale.
The two factor solution shows a clear separation of anxiety and depression items (Table 4). All
of the anxiety subscale items have high loadings (all very near or above 0.5, and going up to 0.73)
on the first obliquely rotated factor. All of the anxiety items have low loadings on factor 2. Two
nominally depression items have their highest loading on the first factor: “Recently I have been so
miserable that I have had difficulty with my sleep” (0.62); and “Recently I have been depressed
without knowing why” (0.40). The second obliquely rotated factor has high to very high loadings
for five of the depression items, and no other item loads aboGe 0.3, with most being below 0.1 (Table
4). The highest loading items relate to suicidal thought and feelings and to feelings of hopelessness
(items 14,6 and 10).
Therefore, the two factor solution appears to discriminate efficiently between anxiety and
depression, with one of the 14 items (number 2) appearing to be misallocated (in this sample, at
least) and one item (number 5) not having a high loading on either of the two factors. However, the
large percentage of variance in the first unrotated factor should caution against necessarily viewing
these two factors as conceptually distinct. In addition, the correlation between the anxiety and
depression factors is 0.70, indicating a substantial amount of shared variance.
Also instructive is to examine the loadings derived from an orthogonal rotation of a principal
components analysis (Fig. 2). This demonstrates clearly the relative continuity and separation of
the items. For example, the five ‘good’ depression items (numbers 8, 12, 10, 6 and 14) do separate
from the nominal anxiety items (numbers 3, 9, 4, 7, 11, 1 and 13), and the two items found to be
‘poor’ depression items in the present study have an intermediate position (numbers 2 and 5).
However, the gap between the two item sets is not large, and another way to view Fig. 2 is that the
items execute an efficient 90” sweep between the two axes. What characterises the anchors of the
quarter circle? The items at one end (numbers 3, 9, 4 and 7) are related to somatic anxiety and at
the other end (numbers 12, 10, 6 and 14) relate to anhedonia. Therefore, the two factor solution of
the 14 SAD items offers at least 3 interpretations, as illustrated in Fig. 2. First, the first unrotated
principal component might be viewed as indicating a construct of ‘general psychological distress’.
Second, the two highly correlated oblique factors might be taken as indicators of ‘anxiety’ and
‘depression’ constructs. Third, the 14 items might be seen as sampling just one quarter of an
orthogonal bivariate space with axes indicating high and low tense arousal and hedonic tone. The
Alan Bedford and Ian J. Deary
504
degree to which this last solution fits with current psychometric models of normal mood will be
addressed in the discussion.
The three factor solution in Table 4 retains the basic division between anxiety and depression
items seen in the two factor solution. The major change is that there are two very high loading items
in factor three, with all other item loadings being near to or below 0.1. In addition, the two items
loading highly on factor 3 have no loadings above 0.1 on the other two factors. The two high
loading items are: item 11, “Recently worrying has kept me awake at night” (0.88); and item 2,
“Recently I have been so miserable that I have had difficulty with my sleep” (0.84). Therefore,
factor 3 is a sleep factor. The former is nominally an anxiety item and the latter a depression item,
though both are in the anxiety group of items in two factor space (Table 4 and Fig. 2). In the three
factor solution, the factor intercorrelations are: anxiety versus depression = 0.40; anxiety versus
sleep = 0.48; and depression versus sleep = 0.44. Again, all three factors show a substantial amount
of shared variance.
Conjirmatory
factor
analysis
To test some of the above alternative models competitively, the 14 SAD items were modelled
using the EQS structural equation modelling programme (Bentler, 1989). All models were essentially
confirmatory factor analyses which tested the hypothesis that a small number of latent variables
underlie most of the SAD inter-item covariance. Test results for the various models are shown in
Table 5 and these will be referred to as each model is described and assessed, and compared with
other models.
Model 1 tested the hypothesis that a single latent trait underlies all of the inter-item covariance.
Therefore, all items were allowed free loadings on a single latent variable and all other item variance
was assumed to be item specific. This is the ‘general psychological distress’ model. The test results
for this model are poor: the fit indices are well below 0.9 (the customary level at which models are
deemed adequate) and the x2 result is highly significant, indicating a poor fitting model. Moreover,
the x2 is much more than twice the number of degrees of freedom, a commonly used rule of thumb
to indicate an acceptable value, especially because x2 statistics are often significant in the presence
of a good model when subject samples are large.
Model 2 tested the hypothesis that there were two correlated factors in the SAD in line with the
nominal item allocations: thus, item numbers 1, 3, 4, 7, 9, 11 and 13 were allowed free loadings on
the first latent variable (the anxiety factor, Fl) but loadings fixed at zero on the second latent
variable (the depression factor, F2); and items 2, 5, 6, 8, 10, 12 and 14 were allowed free loadings
on the second latent variable (depression) and had fixed zero loadings on the first latent variable.
The two latent variables were allowed to correlate. Model 2 fits the data significantly better than
Model 1 (x” difference between the models = 105.1, d.f. = 1, p < O.OOl),and the two latent variables
Table 5. Results of confirmatory factor analyses models on the 14 DSSl/sAD items. In all models factor 1 (FI) is the anxiety factor, factor 2
(F2) is the depression factor, and factor 3 (F3) is the general psychological distress factor. In models 2 and 3 the anxiety and depression latent
traits are allowed to correlate
Model I:
I Factor
Model 2:
2 Factor
Model 3:
2 Factor
with
correlated
sleep items
Average off-diagonal standard&d
residuals
x2
Degrees of freedom
p value
Bentler-Bonnet
normed fit index
Bentler-Bonnet
non-nonned fit index
Comparative fit index
Wald test: non-significant parameters
0.056
603.1
II
<O.OOl
0.785
0.771
0.806
None
0.048
498.0
76
<O.OOl
0.822
0.814
0.844
None
0.047
282.2
75
<O.OOl
0.899
0.907
0.924
None
Lagrange test: parameters
the model
None
Items 2. 5.
8, 14 on
Fl. Item
11 onF2
Items 2, 5,
8. 14 on
Fl
to be added to improve
Model 4:
3 Factor
with
correlated
sleep items
0.022
125.2
62
<O.OOl
0.955
0.966
0.977
Items I.
11. 13 on
Fl
None
Model 5:
Modified 3
Factor
model
0.023
125.6
65
<O.OOl
0.955
0.969
0.978
None
Personal Disturbance Scale (DSSI/sAD)
505
are highly intercorrelated (r = 0.82). However, Table 5 shows that the x2 is still very high with
respect to the number of degrees of freedom, the fit indices are still well below 0.9, and five itemfactor associations have been omitted that, if included, would significantly improve the model fit.
Of these five associations, four are depression items that could be allowed to load on the anxiety
factor and one is an anxiety item that could be freed to load on the depression factor.
Model 3 is comparable to the three factor solution in Table 4. The structure of the model was the
same as that of Model 2 above, except that the item-specific variances of the two sleep-related items
(numbers 2 and 11) were allowed to be correlated. This procedure was allowed for two reasons:
first, two items is small to define a latent trait; and, second, the correlation of the error terms
captures the possibility that the two items might represent a bloated specific, essentially having a
similar item content. This model fitted significantly better than Model 2 (x2 difference between the
models = 215.8, d.f. = 1, p < O.OOl),and the three fit indices were near to or above 0.9. Therefore,
Model 3 is the first of the models to approach acceptability. However, there were still four depression
items (2, 5, 8 and 14) which, if allowed a loading on the anxiety factor, would improve the fit of the
model still further.
Rather than take this empirically-driven route, Model 4 was intended to be a combination of
Models 1 and 3. In Model 4 the item variance was assumed to arise from three sources. First, all
items were assumed to be influenced by general psychiatric disturbance; second, in line with the
item allocations in the SAD, the items were assumed to be influenced by either anxiety- or depressionspecific variance; third, each item contained item-specific variance, though this was allowed to be
correlated in the case of the two sleep items. This model fits significantly better than Model 3 (x2
difference between the models = 157, d.f. = 13, p c O.OOl),and has highly acceptable fit indices, all
well above 0.9 (Table 5). The x2 value is approximately twice the number of degrees of freedom in
the model. However, the model contains three associations that are non-significant, viz. the loadings
of items 1, 11 and 13 on the anxiety factor (Fl).
By omitting the three non-significant associations Model 5 was tested and found to have similar
fit indices to Model 4 while having 3 extra degrees of freedom. Model 5 is shown in Fig. 3. All of
the items had substantial loadings on the general psychological distress factor. Item 3 had the only
large loading on factor l-anxiety-and
was followed by item 9. Both are related to somatic aspects
of anxiety. The items with the highest loadings on factor 2%-depression-were
those related to
suicidal thoughts and feelings and feelings of hopelessness.
DISCUSSION
As the literature review in the Introduction indicates, the Personal Disturbance Scale (DSSI/sAD)
has been widely employed. Contrary to the authors’ expectations, most studies have not been
epidemiological (bar notably Australian-American exceptions), nor of treatment monitoring in the
clinical psychology-psychiatry
fields, but of general medicine. Given that the items were devised
from clinical and research experience in psychiatric settings, this might appear surprising, particularly when item content is considered. For example, an item enquiring about enjoying “a good
book or radio or TV programme”, an item in the Hospital Anxiety and Depression Scale (HAD;
Zigmond & Snaith, 1983), seems of a different order from the SAD’S “I have thought of doing away
with myself ‘. However, validity and statistical considerations apart, perhaps, paradoxically, such
item ‘strength’ is an advantage for non-psychiatric clinicians and non-clinical researchers in addition
to using a self-report questionnaire instead of an interview. Also, the SAD and the forementioned
HAD are the only British produced and standardised measures confined to anxiety and depression.
(A specific comparison of these two scales is in preparation by Bedford, de Pauw & Grant.)
Other measures such as those of Goldberg’s (1978) General Health Questionnaire and Kellner and
Sheffield’s (1970) Symptom Rating Test also include other scales, e.g. assessing somatic and cognitive
symptoms, and/or are scored as unidimensional. A broader scope still is found in measures such as
the Experiential Index of Crown and Crisp (1979), formerly the Middlesex Hospital Questionnaire,
which purports to cover six variables.
Regardless of the reason for choosing the SAD, it is clear that the breadth of studies carried out,
involving associations with other assessments including psychometric ones, interviews, clinical
506
Alan
Bedford
and
Ian J. Deary
Fig. 3. Best fit model of the 14 SAD items using EQS. Parameter estimates for paths in the model are shown
beside the relevant arrows. Not shown are the item-specific variance contributions
or a parameter of 0.60
connecting the error terms of items 2 and 11. For actual item content see Appendix A. Fl is the ‘anxiety’
items’ factor, F2 is the ‘depression’ items’ factor and F3 is a ‘general psychological
distress factor’. For fit
statistics for this model see Table 5.
judgements and demographic factors, has added considerably to our knowledge of the utility,
reliability and validity of the SAD scales. For future intending researchers it should be reassuring
that high compliance has been reported in both nonpsychiatric patient and non-patient groups.
The factor analytic results reported for our psychiatric patients indicate that the SAD scale as a
whole is statistically a highly acceptable measure of general psychological disturbance. Twelve of
the items have factor loadings above 0.53, with three sharing the highest loading of 0.71. Similarly,
a two factor oblique solution produced a clear coherent scale from all of the a priori anxiety items
whilst five of the putative depression items loaded highly (0.50 or above) on what is obviously a
depression factor. Of the two poorest depression items, one (item 2-“difficulty with my sleep”)
joins with item 11 of the anxiety scale in the three factor oblique solution. The other item (number
5-“depressed
without knowing why”) is inconsistent in its loadings between the anxiety and
depression factors. It is also the poorest of the 14 items other than when considered as a part of a
general psychological disturbance scale (see table 4). Hence, the items have apparent credibility at
three levels.
The present results on the SAD may, perhaps, be used to build a theoretical bridge between
clinical and non-clinical mood measures. In addition to the scales mentioned above, and used largely
in clinical settings, there is a number of mood scales, used more typically in experimental settings,
which assess ‘normal’ moods. Many of these scales are based on a theory of mood which has two
Personal
Disturbance
Scale
(DSSI/sAD)
507
orthogonal factors (though a notable exception is the three oblique factor structure of Matthews,
Jones & Chamberlain, 1990). The axes of the two factor mood space have been called energy and
tension (Thayer, 1989), arousal and stress (Cox & Mackay, 1985), arousal and pleasure-displeasure
(Russell, 1980; Russell, Weiss & Mendelsohn, 1989), and arousal and affect (Watson & Tellegen,
1985). Matthews et al. (1990) illustrate these four congruent accounts in a useful circumplex diagram,
and Russell (1980) gives examples of adjectives that appear at different co-ordinates of his circumplex
model of mood. How might the quarter-circle of mood covered by the items in the SAD map onto
such a circumplex? Examining both circumplexes mentioned above in the light of Fig. 2 from the
present study suggests that, in Russell’s (1980) terms, the sADs is covering the region of mood that,
at one extreme, involves high arousal and high displeasure (the state of anxiety items) and, at the
other extreme, involves low arousal and high displeasure (the state of depression items). This
account is also congruent with Thayer’s (1989) views on the bases of anxiety and depression in
terms of basic mood factors. Thus, it might be theoretically possible and clinically useful to bring
together clinical and experimental mood scales which, at present, exist largely in isolation (cf.
Goldberg, 1996).
The more genera1 conclusion from the present study is that apparently contradictory accounts of
mood may be reconciled within a hierarchical structure, much as different facets of cognitive ability
may be so reconciled (Carroll, 1993). The fact that all of the items of the SAD fall within less than
90” in a two-factor model, suggests that it is allowable to refer to genera1 psychological distress, in
the way that the GHQ is often used. Second, the fact that the SAD items congregate into (largely)
two separable, correlated components, allows us to refer to clinical anxiety and depression levels,
as is done with the HAD. Finally, when one imposes an orthogonal structure on the SAD items,
they appear to map out a quarter of the two-factor circumplex mode1 of mood arrived at by several
authors working within a psychometric tradition; thus, the SAD items may also be construed in
terms of basic, uncorrelated mood factors. Therefore, in future, it would be useful to see not only
more clinical investigations with the SAD, but also more theoretical research where the SAD was
used in conjunction with ‘normal’ mood scales in experimental studies of mood structure and mood
change.
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APPENDIX A
Personal Disturbance Scale (DSSI/sAD) Items. (The state of anxiety items are indicated by an asterisk.)
* 1.
2.
*3.
*4.
5.
6.
*7.
8.
*9.
10.
* 1I.
12.
Recently
Recently
Recently
Recently
Recently
Recently
Recently,
Recently,
Recently
Recently
Recently
Recently
* 13. Recently
14. Recently
I have worried about every little thing.
I have been so miserable that I have had difficulty with my sleep.
I have been breathless or had a pounding of my heart.
I have been so ‘worked up’ that I couldn’t sit still.
I have been depressed without knowing why.
I have gone to bed not caring if I never woke up.
for no good reason, I have had feelings of panic.
I have been so low in spirits that I have sat for ages doing absolutely nothing.
I have had a pain or tense feeling in my neck or head.
the future has seemed hopeless.
worrying has kept me awake at night.
I have lost interest in just about everything.
I have been so anxious that I couldn’t make up my mind about the simplest thing.
I have been so depressed that I have thought of doing away with myself.