Download Assessing Health and Illness - Centre on Behavioral Health

Lecture 3: Assessment in
Behavioral Health
Dr. Antoinette Lee
The University of Hong Kong
Outline
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I. Assessing Stress
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II. Assessing Mental Health Problems
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Depression
Anxiety
III. Assessment of Patients with Medical Illnesses
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Stress
Coping
Social support
Psychosocial factors related to physical illness
Adjustment to illness
Quality of Life
Pain
IV. Lifestyle Assessment
V. Assessing Premenstrual Syndrome
Assessing Stress
1.) Physiological measures
2.) Self-Report measures
3.) Interviews
4.) Ecological Momentary Assessment
Assessing Stress
1.) Physiological measures


Polygraph to measure and record heart
rate, blood pressure, respiration rate, and
GSR (galvanic skin response)
Biochemical analyses:

Blood, urine or saliva samples to measure levels
and changes in levels of catecholamines and
cortisol
Polygraph
Calm
Tense
Assessing Stress

2.) Self-Report Measures
a. Social Readjustment Rating Scale
 b. Life Experiences Survey
 c. Daily Hassles
 d. Perceived Stress Scale

The Social Readjustment Rating Scale
(Holmes & Rahe, 1967)

43 major life events
 Life events in the past year
 Numerical value to represent the extent of
required adjustment for each of the life events
 SRRS total score

index of the amount of change-related stress
SRRS

criticisms:
 some items are vague
 subjective experience
 context
 personal values and priorities
 whether the event has been resolved
 measuring change or negative
experience?
Life Experience Survey (LES)
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Sarason, Johnson, & Siegel (1978)
57-item self-report measure of life changes in the past
year
Section 1: 47 specific events for all respondents
Section 2: 10 specific events for students
Desirability of life events/changes affect its impact on the
individual
 changes that are viewed more negatively are likely to
have more adverse effects on health
LES measures the respondent’s desirability for life events
(Marriage, death, new job)
Self-repot questionnaire; 47 specified items and 3 openended questions on recent events that have affected the
lives of the respondents
Approximately 10 minutes to complete
LES

Respondents are asked to score impact of each event on a
7-point scale (-3: extremely negative, 0: no impact, +3:
extremely positive)
 Also asked to indicate whether event has occurred with the
last 0-6 months or last 7-12 months)
 3 scores obtained from self-report:
 Positive change score: summation of positive ratings of
events (+1, +2, +3) which yields score with a range of 1
to 150
 Negative change score: summation of negative ratings of
events (-1, -2, -3) which yields score with a range of -1
to –150
 Total change score: summation of positive and negative
change scores yielding scores from –150 to +150
LES
Listed below are a number of events which sometimes bring about change in the lives of those who experience
them and which necessitate social readjustment. Please check those events which you have experienced in the
recent past and indicate the time period during which you have experienced each event. Be sure that all
checked marks are directly across from the items they correspond to.
Also, for each item checked below, please indicate the extent to which you viewed the event as having either a
positive or negative impact on your life at the time the event occurred. That is, indicate the type and extent of
impact that the event had. A rating of -3 would indicate an extremely negative impact. A rating of 0 suggests no
impact either positive or negative. A rating of +3 would indicate an extremely positive impact.
Slightly
positive
Moderately
positive
Extreme
positive
-3
-3
-2
-2
-1
-1
0
0
+1
+1
+2
+2
+3
+3
-3
-3
-2
-2
-1
-1
0
0
+1
+1
+2
+2
+3
+3
No impact
Somewhat
negative
1. Marriage
2. Detention in jail or comparable
institution
3. Death of spouse
4. Major change in sleeping habits
(much more or much less sleep)
7 mo
to 1
yr
Moderately
negative
0 to 6
mo
Extremely
negative
Section 1
LES

Sample event items:
 1) Marriage
 3) Death of a spouse/ partner
 6) Major change in eating habits
 11) Male: girlfriend's pregnancy
11) Female: pregnancy
 21) Change in residence
 28) Borrowing more than $100 000.00
 38) Son or daughter leaving home
 48) Beginning new school experience at a higher
academic level (for students only)
 54) Failing a course (for students only)
LES

Reliability:

Test-retest studies conducted on college students
with an interval of 5-6 weeks per administration
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Study 1: N = 34; Study 2: N = 58 (all college students)
Positive change score: r = .19 and .53 (p < .001)
Negative change score: r = .56 (p < .001) and .88 (p
< .001)
Total change score: r = .63 (p < .001) and .64 (p < .001)
Validity:

Negative change scores correlated with scores for
the State-Trait Anxiety Inventory (state: r=0.29,
trait: r=0.46)
LES: Norms
Descriptive statistics of male and female respondents
(undergraduate students in USA) on the Life
Experiences Survey
LES score
Males
Females
(n = 174)
(n = 171)
Mean
SD
Mean
SD
Positive
9.74
8.07
9.57
6.66
6.87
5.97
6.71
5.51
Negative
6.22
6.28
7.04
7.90
4.66
4.36
5.64
6.43
Total
15.97
11.08
16.61
10.23
11.53
8.01
12.35
8.82
Note. In each case figures in top rows are derived from
responses to Section 1 and 2 combined. Figures in the bottom
rows are derived from Section only.
LES: Convergent Validity
Correlations between Life Change Scores, anxiety, and academic achievement
LES Life change scores
Positive
Negative
Total
Balance (negative – positive events)
Note. LES = Life Experiences Survey.
*p < .05; **p < .01; **p < .001.
Anxiety
Trait
.04
.29**
.24**
– .21*
State
.03
.46***
.37***
– .36***
Grade point
average
– .21
– .38***
– .40***
.18
LES

Advantages:
Brief
 Easy to administer
 Takes into account one’s perceived
desirability of life events


Disadvantage:

Norms only available for college-aged
population
Hassles Scale (Daily Hassles Scale)

Lazarus & Folkman (1989)
 117-item measure of daily hassles
 Samples of items: misplacing or losing things,
troublesome neighbors, not enough time for family,
social obligations, health of a family member, concerns
about owing money
 Instructions: “Circle the hassles that have happened
to you in the past month, then indicate the severity of
each hassle using a scale of 0 (did not occur) 1
(somewhat severe), 2 (moderately severe), or 3
(extremely severe).”
Hassles Scale

Frequency score and severity score


Frequency score: number of items with rating of 1 or above (possible
range: 0-117)
Severity score: mean of all items endorsed (possible range (1-3)

Norms
 White middle-class adults (aged 45 to 64): mean =
20.5 (SD = 17.7) for frequency score and mean =
1.47 (SD = 0.39) for severity score
 College student sample: mean = 27.6 (SD = 14.3)
for frequency score and mean = 1.65 (SD = 0.38)
for severity score

No clinical cut-off score for hazardous level of
daily hassles
Hassles Scale

Reliability

Test-retest reliability over a 1-month period:

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High for frequency score (r = .79)
Moderate for severity score (r = .48)
Validity

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High correlations with burnout (r = .50) and low
morale (r = .56)
High correlations with depressive symptoms (r =
.58) and psychosomatic symptoms (r = .64)
Perceived Stress Scale (PSS)
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Cohen, Mamarch, & Mermelstein (1983)
Measure of the degree to which situations in one’s life are appraised as
stressful
Based on the concept of “perceived stress”: “the degree to which
individuals perceive their life situations to be stressful (Unpredictable,
uncontrollable, and overloading)” (Cohen et al., 1983)
Assesses a global conceptualization of perceived stress, rather than
rating certain events that trigger stress (as seen in many other scales)
Assumes health is affected when perceived ability to cope with stress
reaches the limit
Original version consists of 14 self-report items. Also available are 10item and 4-item versions
Respondents are asked to indicate the frequency of feelings, thoughts,
or circumstances that occurred over the past month on a 5-point Likert
scale:
 0= never, 1= almost never, 2= sometimes, 3= fairly often, 4= very
often
Higher scores indicate higher perceived stress
PSS: Sample Items
1.
2.
3.
在過去的一星期，你曾因為一些預料之外的事發生而憂傷嗎？
在過去的一星期，你曾感到你不能控制生命中某些重要的事情嗎？
在過去的一星期，你曾感到緊張及有壓力嗎？
從
絕
偶
間
經
不
少
然
中
常
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
PSS-14: Reliability

Internal consistency: Cronbach’s alpha

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College student sample I: .84
College student sample II: .85
Working adults who are volunteers for a smoking
cessation program): .86
Psychiatric patients: .80
General population: .75 (.78 for 10-item version and .60
for 4-item version)
Test-retest reliability


2 days: r = .85
6 weeks: r = .55
PSS-14: Convergent Validity
Correlations between Life-Event Scores and PSS
No. of life events
Impact of life events
College student
sample I
.20*
.35*
College student
sample II
.17
.24*
Smoking-cessation study
Beginning of
End of
treatment
treatment
.38*
.39*
.49*
.33*
*p < .01
Correlations of stress measures with depressive
symptomatology
No. of life events
Impact of life events
Perceived Stress Scale
College student
sample I
.18*
.29*
.76*
College student
sample II
.14
.33*
.65*
*p < .001
Note: Number and impact of life events was measured by a modified version of the College Student Life-Event Scale
PSS-14: Convergent Validity
Correlations of stress measures with physical symptomatology
No. of life events
Impact of life events
Perceived Stress Scale
College student
sample I
.31*
.23*
.52*
College student
sample II
.36*
.32*
.65*
Smoking-cessation
study
.40*
.51*
.70*
*p < .001
Other evidences of convergent and discriminant validity:
• Correlation between PSS and the Maslach Burnout
Inventory (assessing burnout) is high (r=0.65) while
correlation between PSS and life events checklists is low
(r=0.25 to0.35), further indicating PSS measures constructs
of emotional and physical burden rather than severity of life
events
PSS-14: Norms
Cohen et al’s (1983) study:
Male
Female
Total
College student sample I
(N = 332)
Mean
SD
22.38
6.79
23.57
7.55
23.18
7.31
College student sample II
(N = 114)
Mean
SD
21.73
8.42
25.71
6.20
23.67
7.79
Community sample
(N = 64)
Mean
SD
24.0
7.80
25.6
8.24
25.0
8.00
Cohen & Williamson’s (1988) study:
Representative sample of 2387 community residents in USA (mean age = 42.8, SD = 17.2)
Male:
Mean = 18.8, SD = 6.9
Female: Mean = 20.2, SD = 7.8
PSS-10: Norms

Representative sample of 2387 community residents
in USA (mean age = 42.8, SD = 17.2) (Cohen &
Williamson, 1988):



Mean = 12.1, SD = 5.9 (male)
Mean = 13.7, SD = 6.6 (female)
Cohen & Williamson (1980)





Unemployed
Disabled
Separated
Divorced
Married
16.5
19.9
16.6
14.7
12.4
PSS
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Advantages:

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Short
Easy to administer
Perceived stress has higher correlations with
negative health outcomes (when compared to life
events)
Disadvantages:

No documented clinical utility, used much more in
research, although may be beneficial to clinical use
Assessing Stress

3.) Interviews
Stress symptoms
 Sources of stress
 Perceived stress

Symptoms of Stress
PHYSICAL
Insomnia
Appetite changes
Muscle tension and aches
Tension headache
Fatigue
Weight change
Pounding heart
Upset stomach
Indigestion
Dry mouth
Diarrhea
Constipation
Cold hands and feet
Flushing
Sweating
Elevated blood pressure
Frequent urination
Jaw clenching
Teeth grinding
Shakiness and trembling
Foot-tapping
Finger-drumming
EMOTIONAL &
COGNITIVE
Anxiety and tension
Frustration
Irritability and bad temper
Mood swings
Crying spells
Depression
Worry
Forgetfulness
Poor concentration
Reduced productivity
Confusion
Impaired judgment
Accident-prone
Apathy
BEHAVIORAL &
SOCIAL
substance use
Withdrawn, reduced social
contacts
Intolerance
Resentment
Lashing out
Distrust
Lack of intimacy
Assessing Stress

4.) Ecological Momentary Assessment

Use of a monitor or diary to collect real time
data on relevant stress measures (e.g.
blood pressure, pulse rate) or perceived
stress rating, situational variables, mood,
thoughts, pain etc.
Assessing Coping

1.) Ways of Coping Questionnaire

2.) Brief COPE
Ways of Coping Questionnaire
Folkman and Lazarus (1988)
 4-point Likert scale: 0 (does not apply) –
3 (used a great deal)
 Eight subscales consisting of a total of
50 items (Total number of items in the full
scale = 66)

Ways of Coping Questionnaire
Subscale
What it Measures
Sample item
Confrontive
Coping
Aggressive efforts to alter the situation and
46. Stood my ground and fought for
suggests some degree of hostility and risk-taking. what I wanted.
Distancing
Cognitive efforts to detach oneself and to
minimize the significance of the situation.
41. Didn’t let it get to me; refused to
think about it too much.
Self-Controlling
Efforts to regulate one’s feelings and actions.
35. I tried to keep my feelings from
interfering with other things too much.
Seeking Social
Support
Efforts to seek informational support, tangible
support, and emotional support.
42. I asked a relative or friend I
respected for advice.
Accepting
Responsibility
One’s own role in the problem with a
concomitant theme of trying to put things right.
9. Criticized or lectured myself.
EscapeAvoidance
Wishful thinking and behavioral efforts to escape
or avoid the problem.
58. Wished that the situation would
go away or somehow be over with.
Planful Problem
Solving
Deliberate problem-focused efforts to alter the
situation, coupled with an analytic approach to
solving the problem.
52. Came up with a couple of
different solutions to the problem.
Positive
Reappraisal
Efforts to create positive meaning by focusing on
personal growth. It also has a religious
dimension.
30. I came out of the experience
better than when I went in.
Brief COPE
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



Carver, 1997
28-item measure of coping
Fourteen major coping styles, with 2 items measuring
each
Respondent asked to rate on a scale of 0 (“I haven’t
been doing this at all”) to 3 (“I’ve been doing this a lot”)
the extent to which they are using each of the ways in
coping with a stressful event
“Think of a stressful event that you are currently going
through (a problem with your family, problem in a
course) and……..”
Brief COPE

Sample questions:







I’ve been concentrating my efforts on doing something about
the situation I’m in (Active Coping)
I’ve been thinking hard about what steps to take (Planning)
I’ve been trying to see it in a different light, to make it seem
more positive (Positive Reframing)
I’ve been praying or meditating (Religion)
I’ve been getting comfort and understanding from someone
(Using Emotional Support)
I’ve been saying things to let my unpleasant feelings escape
(Venting)
I’ve been using alcohol or other drugs to help me get through
it (Substance Use)
Assessing Social Support


Few measures of social support provide adequate
evidence of reliability and validity
One with best documented reliability and validity is the
Social Support Questionnaire (Sarason et al., 1983)


27 items
For each item, the individual is asked to:



(i) list the people s/he can count on for support in given
circumstances, and
(ii) rate the overall level of satisfaction with these support (1 for
very dissatisfied to 6 for very satisfied)
Two scores:


(i) N (number) score for each item: number of support the
individual lists → mean N score
(ii) S (satisfaction ) score: satisfaction for each of the items →
mean S score
Social Support Questionnaire
The following questions ask about people in your environment who provide you with
help or support. Each question has two parts. For the first part, list all the people you know,
excluding yourself, whom you can count on for help or support in the manner described.
You may either give the person’s initials or their relationship to you.
For the second part, circle how satisfied you are with the overall support you have.
If you have no support for a question, check the word “No one,” but still rate your level
of satisfaction. Do not list more than nine persons per question.
Please answer all questions as best you can. All your responses will be kept
confidential.
1. Whom can you really count on to listen to you when you need to talk?
2. Whom could you really count on to help you out in a crisis situation, even though they
would have to go out of their way to do so?
3. Whom can you really count on to be dependable when you need help?
4. With whom can you totally be yourself?
5. Who do you feel really appreciates you as a person?
6. Whom can you count on to console you when you are very upset?
Assessing Social Support

Psychometric properties

Reliability (based on a normative sample of
602 undergraduates) :
Coefficient alpha N score = .97
 Coefficient alpha for S score = .94
 Test-retest correlation over a four-week period
for N score = .90
 Test-retest correlation over a four-week period =
.83 for S score

Assessing Social Support

Psychometric properties

Validity (based on 277 undergraduates):
Significant negative correlations between both N
and S scores and emotional discomfort as
measured by the Multiple Affect Adjective Check
List (MAACL)
 Significant negative correlations between both N
and S scores and scores on items in the Lack of
Protection Scale that deal with recollections of
separation anxiety in childhood

Assessing Insomnia
What is insomnia?

Primary Insomnia
•
•
•
•

Chief complaint is nonrestorative sleep, difficulty in initiating
sleep, or difficulty in maintaining sleep
Continues for at least one month (For ICD-10, the
disturbance must occur at least 3 times a week for a month)
Independent of any known physical or mental condition
Patients with primary insomnia often preoccupied with getting
enough sleep
Types of insomnia
1.
2.
3.
Sleep onset insomnia
Sleep maintenance insomnia
Terminal insomnia
Assessing insomnia

Secondary Insomnia
•

Secondary to / symptom of an underlying
medical or psychological condition
Underlying psychopathology or
psychological distress
Assessing Insomnia

Nature and severity of insomnia



Sleep diary
Epworth Sleepiness Scale






Sleep history
8-item self-report measure of subjective daytime sleepiness
Rate likelihood of dozing in eight different situations on a
scale of 0-3
Chinese normals (Mean = 7.5, SD = 3.0)
Chinese patients with obstructive sleep apnea syndrome
(Mean = 13.2, SD = 4.7)
Psychiatric problems (e.g. depression, anxiety)
Any attempts at remedy (e.g. hypnotics, Chinese
herbs, exercise, cutting down on caffeine etc)
Assessing Patients with Physical
Illnesses

Psychosocial context of Physical Illness

Adjustment to Illness

Quality of Life

Pain
Assessing Psychosocial Context of
Physical Illnesses

1. Psychosocial factors contributing to the health
problem

Stress, personality….. (refer to previous notes and notes from
Health Psychology module)

2. Psychosocial problems co-existing with the health
problem (and affecting it’s course of illness and
adjustment to illness)

3. Psychosocial consequences and impact of the
health problem
Adjustment to Illness

Areas of assessment



Differs for different illnesses and different specific
situation, and needs of individual patient
Some possible areas of focus: depression, anxiety,
quality of life, specific reactions to illness, relationship
with healthcare professionals, adherence to treatment
Forms


Clinical interviews (refer to Lecture 2 notes)
Observations




Clinical
Ward staff
Family and other significant others
Self-Report measures
Some Useful Self-Report Measures
Mini-Mac
 Impact of Events Scale
 Post-traumatic Growth Inventory
 Measures of depression and anxiety
(refer to next section)

Adjustment to Cancer: Chinese
Mini-Mac
Ho, Fung, Chan, Watson, & Tsui (2003)
 Chinese version of the Mini-Mental
Adjustment to Cancer scale (Watson et
al., 1988, 1994)
 Measures coping responses among
cancer patients
 29 self-reported items, Likert response
format

Chinese Mini-Mac
以下句子形容一般人對患上癌症後的反應，請選擇並圈上最適合形容你現時的情況的
數目字。
絕對 不是 這是 絕對
不是 我的 我的 是我
我的 情況 情況 的情
情況
況
1. 我覺得生命是無希望的
2. 我非常樂觀
3. 我決定要打敗癌症
4. 我正積極嘗試去不想自己的病
5. 我覺得是世界末日一樣
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
Chinese Mini-Mac: Reliability

115 Hong Kong Chinese cancer patients:
Internal consistency of the Chinese Mini-MAC scale (N = 115)
Cronbach’s alpha coefficients
Ho et al. (2003)
Watson et al. (1994)
Helpless-Hopeless (8 items)
Anxious Preoccupation (8 items)
0.83
0.88
0.87
0.88
Fighting Spirit (4 items)
Cognitive Avoidance (4 items)
Fatalism (5 items)
0.65
0.65
0.71
0.76
0.74
0.62
Novel factors
Negative Emotion (16 items)
Positive Attitude (9 items)
0.91
0.77
NA
NA
Cognitive Avoidance (4 items)
0.65
NA
Original factors
Chinese Mini-Mac: Validity
Correlation coefficients between the original Mini-MAC factors and the Chinese
Mini-MAC factors with the HADS anxiety and depression scores (N = 115)
HADS anxiety
HADS depression
Original factors
Helpless-Hopeless
0.67** (0.49**)
0.65** (0.46**)
Anxious Preoccupation
Fighting Spirit
Cognitive Avoidance
0.67** (0.73**)
-0.24* (-0.19**)
-0.02 (0.18**)
Fatalism
-0.00 (0.04)
0.58** (0.47**)
-0.30** (-0.24**)
-0.08 (0.07)
-0.17 (0.01)
Novel factors
Negative Emotion
0.71**
0.66**
Positive Attitude
Cognitive Avoidance
-0.12
-0.02
-0.26**
-0.08
* p < .05; ** p < .01.
Coefficients reported in Watson et al. (1994) are shown in parentheses.
Impact of Event Scale (IES)





Horowitz et al. (1979), revised by Weiss & Marmar (1997)
Assesses the psychological reactions (namely, intrusion and
avoidance) to stressful life events (e.g. serious illness,
bereavement, assault)
Self-report questionnaire with 15 items (20 items for Weiss and
Marmar’s 1997 revised version) rated on a 4-point scale (0= not at
all, 1= rarely, 3= sometimes, 5= often) to indicate frequency of each
circumstance during the past 7 days
Asked to think of a stressful life event and answer the questions
with reference to that event
Two subscales:
 Original version:
 Intrusion scale: 7 items
 Avoidance scale: 8 items
 Revised version: Intrusion (7 items), Avoidance (8 items), and
Hyperarousal subscales (5 items)
IES

Score Ranges:
 Total score: 0 to 75
 Intrusion scale: 0 to 35
 Avoidance scale: 0 to 40
 Suggested scores to identify PTSD (based on total score of
IES):
 Low score: <8.5
 Medium score: 8.6-19.0
 High score: >19.0
 Usual pattern for scores right after trauma (for baseline):
Intrusion score higher than Avoidance score
 Increase in Avoidance score is shown if PTSD continues
IES

Sample items :


Intrusion Subscale:
 I thought about the event when I did not mean to.
 I had dreams about the event.
 Pictured about the event popped into my mind.
Avoidance Subscale:
 I tried to remove thoughts of the event from my
memory
 I stayed away from reminders of the event.
 I felt as if the event hadn’t happened or it wasn’t
real.
IES

Reliability:



Good internal consistency with Cronbach’s alpha
of 0.79 to 0.92 for Intrusion scale and 0.73 to 0.91
for Avoidance scale
Test-retest reliability after lapse of one week is r =
0.93
Validity:

Correlations are moderate but statistically
significant when compared to the PTSD module of
the Structured Clinical Interview for DSM Axis I
Disorders (Intrusion subscale: r=0.48, Avoidance
subscale: r=0.32, total score: r= 0.48)
IES

Advantages:
Brief
 Applicable to wide variety of subjects (not
event specific)
 Likely to identify individuals prone to PTSD
when assessed few weeks or month after a
traumatic event

Chinese Impact of Event Scale

Wu & Chan (2003):


Validation study on 116 patients (aged 16-78 yrs) from the
Accident and Emergency Department of a Hong Kong hospital
Correlation with GHQ



Intrusion: r = .54 (p < .001)
Avoidance: r = .53 (p < .001)
Hyperarousal: r = .64 (p < .001)
Normative data of the Chinese Impact of Event Scale-Revised subscale scores
Subscale
Intrusion
Avoidance
Hyperarousal
Within 1 week (N = 116)
Mean
SD
Range
Skewness
0.8
0.7
0-3.2
0.9
0.7
0.6
0-2.6
0.6
0.8
0.8
0-3.5
1.1
After 1 month (N = 60)
Mean
SD
Range
Skewness
0.7
0.7
0-3.3
1.8
0.7
0.6
0-2.5
0.9
0.6
0.6
0-2.5
1.3
Chinese Post-Traumatic Growth
Inventory (PTGI)



Ho, Chan, & Ho (2004)
Chinese version of the Posttraumatic Growth Inventory
(Tedeschi & Calhoun, 1996)
Originally 21 self-reported items, with response
choices from 0-5




0 = I did not experience this change as a result of my crisis
3 = I experienced this change to a moderate degree as a
result of my crisis
5 = I experienced this change to a very great degree as a
result of my crisis
After validation with 188 HK Chinese cancer patients,
reduced to 15 items
下列句子描述某種危機／創傷對您的生命可能帶來的轉變(包括癌症)。請仔細閱讀每一句
子，然後根據以下的標準，選擇一個最接近您的感覺的答案。
評分標準: 這個創傷，令我經歷這個轉變的程度是
0 = 完全沒有 1 = 非常少
2 = 少 3 = 有些
4= 多
5 = 非常多
轉變的程度
完 非 少 有 多 非
全 常
些
常
沒 少
多
有
1.
我生命中重要事物的先後次序。
0
1
2
3
4
5
2.
對於須要改變的事物，我更傾向於去改變它。
0
1
2
3
4
5
3.
一種對自己生命的價值的欣賞。
0
1
2
3
4
5
4.
一種「依賴自己」的感覺。
0
1
2
3
4
5
5.
對於心靈上的物質有更佳的瞭解。
0
1
2
3
4
5
Factor
Analysis
Exploratory Factor Analysis results of the Chinese PTGI
Factor
I
Self (25.11% of variance)
7. I established a new path for my life.
12. Being able to accept the way things work out.
10. Knowing I can handle difficulties.
3. I developed new interests.
13. Appreciating each day.
11. I’m able to do better things with my life.
9. A willingness to express my emotions.
Interpersonal (12.29% of variance)
6. Knowing that I can count on people in times of trouble.
8. A sense of closeness with others.
15. Having compassion for others.
Life Orientation (11.25% of variance)
1. My priorities about what is important in life.
17. I’m more likely to try to change things which need
changing.
Spiritual (11.28% of variance)
18. I have a stronger religious faith.
5. A better understanding of spiritual matters.
4. A feeling of self-reliance.
(NP)a
(PS)
(PS)
(NP)
(AL)
(NP)
(RO)
(RO)
(RO)
(RO)
II
III
0.784
0.726
0.726
0.680
0.675
0.648
0.615
0.773
0.752
0.549
(AL)
(NP)
(SC)
(SC)
(PS)
IV
0.837
0.813
0.653
0.631
0.610
a. Abbreviations for the original PTGI subscales: NP = new possibility; PS = personal strength; AL =
appreciate life; RO = relate to others; and SC = spiritual change.
Chinese PTGI: Reliability

Internal reliability


Whole scale (15 items):  = .825
Subscales




Self:  = .856
Spiritual:  = .619
Life Orientation:  = .428
Interpersonal:  = .693
Intrapersonal:  = .803
Chinese PTGI: Validity
Intercorrelations of subscales of PTGI, Mini-MAC, HADS, and GHQ
1. Self
2. Spiritual
3. Life orientation
4. Interpersonal
5. Intrapersonal
6. Negative Emotion
7. Positive Attitude
8. Cognitive Avoidance
9. HADS anxiety
10. HADS depression
11. GHQ
*p < .05; **p < .01.
1
--
2
.40 **
--
3
4
5
.34 ** .43 ** .90 **
.18 * .36 ** .69 **
-- .25 ** .56 **
-- .48 **
--
6
7
-.51 ** .61 **
-.23 ** .35 **
-.02
.19 *
-.17 * .30 **
-.43 ** .59 **
-- -.33 **
--
8
.10
.03
.02
.01
.08
.27 **
.30 **
--
9
-.42 **
-.06
-.03
-.13
-.31 **
.62 **
-.25 **
.11
--
10
-.43
-.12
-.05
-.20 **
-.34 **
.54 **
-.30 **
.11
.69 **
--
11
-.53 **
-.16 *
-.05
-.18 *
-.42 **
.56 **
-.33 **
.10
.69 **
.64 **
--
Chinese PTGI: Norms
Means and SDs for 115 cancer patients in Hong Kong
Total
Male
Female
t-value
Mean
SD
Mean
SD
Mean
SD
25.02
5.02
24.81
5.13
25.06
5.02
-0.26
Spiritual
9.02
2.91
8.90
3.27
9.04
2.84
-0.24
Life orientation
5.84
2.06
6.06
2.02
5.80
2.07
0.66
Interpersonal dimension
9.74
2.31
9.68
2.17
9.76
2.34
-0.18
Intrapersonal dimension
39.88
7.68
39.77
8.01
39.90
7.64
-0.08
Post cancer growth
Self
*p < .05; **p < .01.
Adjustment to Illness
Some other issues to note:
 Psychosocial context

The whole life circumstances of the
patient

Impact on family members
Quality of Life Assessment

Health:



Length of life (vs mortality)
Quality of life (vs morbidity – disease and disability)
Assessments of the quality of life are therefore
crucial:


Evaluate how diseases impact quality of life
Evaluate the extent to which treatments of diseases
influence the quality of life (improve or deteriorate?)
Psychometric Approach vs
Decision Theory

The two major approaches in assessing
quality of life:
Psychometric Approach: separate measures
for the different dimensions of quality of life
 Decision Theory Approach: weighting the
different dimensions of health to provide a
single expression of health status

Psychometric Approach
Concerns
Problem with this approach: fails to reflect

the overall picture e.g. enhanced quality of
life in one area may be associated with
decreased quality of life in another area
 E.g. side effects of medication: it may
improve the dominant physical discomfort
but increases the likelihood of problems
and discomfort
Despite its limitations, it is still very useful
both clinically and in research
Decision Theory Approach



Aims at an overall measure of quality of life that
integrates subjective function states, preferences
for these states, morbidity, and mortality
Quality of life data are increasingly used to
evaluate the cost-effectiveness of health programs
Cost-effectiveness analysis quantifies the benefits
of health-care interventions in terms of years of
life, or quality-adjusted life years (QALYs) –
integrating mortality and quality of life impact in
providing an overall estimate of the benefit of a
treatment
Measurements for Quality of Life
(Psychometric Approach):

SF-36 (Ware, Kosinski, Bayliss,
McHorney, Rogers, & Raczek, 1995)

Sickness Impact Profile (Bergner,
Babbitt, Carter, & Gilson, 1981

Nottingham Health Profile (McEwen,
1992)
SF-36





Ware et al. (1993) and Ware & Gandek (1998)
Medical Outcome Study Short Form-36
Most commonly used measure of quality of
life
Self-administered or administered by a trained
interviewer
36 items under eight scales to measure
different health concepts:
SF-36

Subscales are grouped into two categories:
Physical Health
Physical
functioning
Role-physical
Bodily pain
General health
perceptions
Mental Health
Vitality
Social
functioning
Role-emotional
Mental health
SF-36
Scoring according to an algorithm
 Higher score indicates better health
states
 Normative data available from extensive
studies and sampling
 Clinically used to identify and assess
decreased capacity in function, monitor
functioning over time, and deciding on
the most appropriate treatments

SF-36

Sample items (answered in yes-no, 5- or 6point formats):



During the past 4 weeks, to what extent have your
physical health or emotional problems interfered
with your normal social activities with family,
friends, neighbors, or groups?
How much bodily pain have you had during the
past 4 weeks?
Does your health now limit you in lifting or carrying
groceries?
SF-36

Reliability:
Internal Consistency: Cronbach’s alphas
range from 0.62 to 0.94
 Test-retest reliability: Correlations of 0.43
to 0.90 over 6-month lapse, and 0.60 to
0.81 for a 2-week lapse


Validity: Correlates “moderately well”
with the Sickness Impact Profile and
Duke Health Profile
SF-36

Advantages:
Brief
 Can be machine scored


Disadvantages
No age-specific questions
 Not certain if it is applicable to people
across different age groups

SF-12


Short version of the SF-36
Two subscales





Physical component subscale (PCS)
Mental component subscale (MCS)
The PCS and MCS scores have a range of 0 to 100 and were
designed to have a mean score of 50 and a standard deviation of
10 in a representative sample of the US population.
Scoring of the SF-12 is by the use of a scoring algorithm syntax
Norms: SF-12 Mean Scores for a representative sample of US
general population above the age of 45:




45-54: 50 for PCS and 50 for MCS
55-64: 47 for PCS and 51 for MCS
65-74: 44 for PCS and for 52 for MCS
75 and above: 39 for PCS and 50 for MCS
Items extracted from the full 36-item version:
Sickness Impact Profile (SIP)
Measures an individual’s perception on the
impact of sickness on daily behaviors
 136 statements in 12 categories:

Sleep
and rest
Eating
Work
Home
management
Recreation and pastimes
Ambulation (walking
about)
Mobility
Body
care and movement
Social interaction
Communication
Alertness
Emotion
Sickness Impact Profile (SIP)

Respondents are asked whether they agree
with each of the 136 statements
 If so, they are asked whether the
statements are true because of their health
 Each item has a weighted score that
reflects the severity of the impact in daily
behaviors
 Self-administered or by trained interviewer
Sickness Impact Profile (SIP)

Examples of items:

Body care and movement items:
“18) I only stand up with someone’s help.” Score
(093)
 “20) I am in a restricted position all the time.”
Score (124)
 “34) I dress myself, but do so very slowly.” Score
(043)


Mobility items
“37) I stay in one room.” Score (101)
 “40) I do not use public transport now.” Score (052)

Sickness Impact Profile (SIP)

Emotion items:
“84) I say how bad or useless I am; for example,
that I am a burden to others” Score (089)
 “87) I have attempted suicide.” Score (141)
 “91) I talk hopelessly about the future.” Score
(096)

Sickness Impact Profile (SIP)

Advantages:
Good reliability (α= 0.81 to 0.97) and validity
(compared with clinical assessments of
functioning; correlation from 0.79 to 0.97)
 Well documented and useful in the clinical
settings


Disadvantages:

Long time to complete (~20-30 minutes)
Nottingham Health Profile (NHP)
More commonly used in Europe
 Divided into two parts:

1st part: 38 items divided into 6 categories
(sleep, physical mobility, energy, pain,
emotional reactions, social isolation)
 2nd part: 7 statements related to areas of life
most affected by health (i.e. social life,
employment, household activities, home life,
sex life, hobbies and interests, and
holidays)

NHP

Advantages:
Good reliability and validity
 Language in measure easily understood by
laypersons


Disadvantages:

No relative-importance weightings across
dimensions, therefore hard to compare one
dimension with another
Pain Assessment

Methods of assessment





Clinical interviews
Self-report and pain inventories
Observations
Physiological measures
Areas of assessment:
 The pain: nature, intensity, location, frequency, duration, time of the day…
 Pain behaviors
 Grimacing, limping, postural changes
 Avoidance of activity
 Treatment-seeking
 Self-medication
 Impact
 Daily life
 Emotional functioning
 Occupational functioning
 Social functioning
Assessing Pain: Clinical Interview

Main areas to probe into:

Nature







Frequency
Intensity
Duration
Time of day
Exacerbating and relieving factors
Thoughts





Burning, throbbing, prickling…..
E.g. catastrophic thinking, perceived loss of control / external locus of
control
“This is dreadful”, “I can’t stand this any longer’ “Here we go again,
another day of suffering”, “There is nothing I can do to reduce the pain”,
“If I am in pain, my performance will be impaired”
Pain behaviors and their consequences
Affect / Emotional response
Impairment
Assessing Pain: Self-Report /
Pain Inventories
Visual analogue scale, pain severity
rating (e.g. 0 to 10)
 McGill Pain Questionnaire (MPQ)

Developed by Melzack (1975)
 Allows patients to give sensory and affective
details of pain
 Good validity and reliability

MPQ

Four parts in questionnaire:




Part 1: Use drawing of human figure to pinpoint
location of pain and whether it is external, internal, or
both
Part 2: List of 78 adjectives divided into 20 groups
describing sensory, emotional, and evaluative
aspects of pain; patient is asked to identify at most
one word from each group to define their pain
Part 3: Three groups of adjectives given to patient to
describe how the pain changes over time; at most
one word is chosen from each group
Part 4: Ratings of intensity in pain under different
circumstances
Sample Items of MPQ

Part 2: What does your pain feel like?
 Group 1: Flickering, Quivering, Pulsing,
Throbbing, Beating, Pounding
(Sensory)
 Group 7: Hot, Burning, Scalding, Searing
(Sensory)
 Group 13: Fearful, Frightful, Terrifying
(Emotional)
 Group 16: Annoying, Troublesome,
Miserable, Intense, Unbearable
(Evaluative)
Sample Items of MPQ

Part 3: How does your pain change with
time?

Which word or words would you use to
describe the pattern of your pain?
Group 1: Continuous, Steady, Constant
 Group 2: Rhythmic, Periodic, Intermittent
 Group 3: Brief, Momentary, Transient

Sample Items of MPQ

Part 4: How strong is your pain?

Write the number of the most appropriate
word to describe pain intensity:
(1=Mild, 2=Discomforting, 3=Distressing,
4=Horrible, 5=Excruciating)
1) Which word describe your pain right now?
 2) Which word describes it at its worst?
 4) Which word describes the worst toothache you
ever had?
 6) Which word describes the worst stomach-ache
you ever had?

Assessing Pain: Observation
Pain behaviors are behaviors that arise
from pain
 By observing how different patients deal
with different types of pain, disruption of life
by pain can be assessed
 Provides a more objective way to analyze
pain, since self reports are somtimes
unreliable

Examples of Pain Behaviors









Limping
Complaining
Sighing
Irregular gait
Rubbing affected areas
Expressions of distress
Negative affect
Inactivity
Request for medication / amount of medication
use
Pain Behaviors

Besides the pain, what other reasons are
there for pain behaviors?
Positive reinforcement: sympathy, care and
attention from others, compensation, food,
physical contact
 Negative reinforcement: avoidance in
having to do something (e.g. someone
offering to help lift a box at work)

Pain Diary

Crucial for assessment of pain
 Allows therapists to analyze patterns for the
trigger of pain
 Information to be included:






Intensity of pain
Location of pain
Triggers for pain
Medication dosage
Emotional reactions
Coping strategies
Sample Pain Diary
Time
Activity Pain Severity
(0-10)
Irritability
(0-10)
What did you
do to cope?
Effectiveness?
(0-10)
Pain Severity Ratings
At times, patients may rate their pain as
most severe (10) every time they record
on their diary
 Therapists should help patients
designate a standard for the severity of
pain by helping them think of examples
for each number (e.g. 0 = knocking hand
against something, 6= toothache, 10=
dislocating knee)

Pain Diary
From the diary, therapists can help
patients identify variables which trigger
pain, and pinpoint certain behaviors that
may exacerbate pain
 Therapists can therefore assign
techniques to help lessen such paincausing behaviors
 Diary can also serve as a baseline for
monitoring progress of treatment

Pain Assessment - Physiological
Objective approach to pain assessment
 Measures physiological changes such
as sweating, heart rate, body
temperature, swellings, inflammation,
etc.

Mental Health Problems

Its relevance to Behavioural Health

Its assessment

Clinical assessment



Clinical interview and the DSM system
Structured clinical interview: SCID
Self-Report Measures





Beck Depression Inventory (BDI)
Beck Anxiety Inventory (BAI)
State-Trait Anxiety Inventory (STAI)
Hospital Anxiety and Depression Scale (HADS)
General Health Questionnaire (GHQ)
Assessing Mental Health Problems

What is normal and what is pathological?

Where do we draw the line?
----------------------------------------------------------
Normal
Pathological
What Constitutes Psychopathology?
Multiple criteria:

Psychological / Psychiatric dysfunction



Breakdown of cognitive, emotional, and behavioral
functioning
Along a continuum: where to draw the line?
Clinically significant distress


E.g. time specifier for major depression
Not an adequate criterion on its own (e.g. grief,
mania)
What Constitutes Psychopathology?

Impairment or disability


Is shyness pathological?
Atypical/Not culturally expected
response
E.g. grief reactions
 Homosexuality
 Subculture

Criteria for Defining Psychopathology
According to the DSM-IV (American Psychiatric Association):

a clinically significant behavioural, or psychological syndrome
or pattern that occurs in an individual

and that is associated with
 present distress (e.g. a painful symptom) or
 disability (i.e. impairment in one or more important areas
of functioning) or
 with a significantly increased risk of suffering death, pain,
disability, or
 an important loss of freedom.
Criteria for Defining Psychopathology

Must not be merely an expectable and culturally
sanctioned response

Must be currently considered a manifestation of a
behavioural, psychological, or biological dysfunction in
the individual

Neither deviant behaviour (e.g. political, religious, or
sexual) nor conflicts that are primarily between the
individual and society are mental disorders unless the
deviance or conflict is a symptom of a dysfunction in the
individual
Assessing Psychopathology

Clinical Interview - Getting information about:







Symptoms and nature of the problem
Onset and course
Duration and severity
ABC of symptoms
Predisposing, Precipitating, Perpetuating factors
Aggravating and alleviating factors
Impact


Disability and impairment
Relevant contextual information
Assessing Psychopathology

A hypothesis-testing process


Generate a possible diagnosis and several differential
diagnoses
Allow patients to tell you his/her problems and concerns
 But do it in a systematic and focused manner
 Importance of clarification and perception checking
 Avoid leading questions
 + all the ingredients of good clinical interpersonal and
interviewing skills (empathy, rapport, attentive listening,
attention to verbal and non-verbal cues, reflection of
feelings, control of interview……)
DSM-IV Criteria for Major Depressive
Episode
A. Five (or more) of the following symoptoms have been
present during the same 2-week period and repesent a change
from previous functioning; at least one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a
general medical condition, or mood-incogruent delusion or
hallucinations.
(1) depressed mood most of the day, nearly every day, as
indicated by either subjective report (e.g., feels sad or empty) or
observation made by other (e.g., appears tearful). Note: In
children and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by
either subjective account or observation made by others)
DSM-IV Criteria for Major
Depressive Episode
3) significant weight loss when not dieting, or weight gain
(e.g., a change of more than 5% of body weight in a
month), or decrease or increase in appetite nearly every
day. Note: In children, consider failure to make expected
weight gains.
(4) insomnia or hypersomnia nearly every day (sleep
problem)
(5) psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of
restlessness or being slowed down)
DSM-IV Criteria for Major
Depressive Episode
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate
guilt (which may be delusional) nearly every day (not
merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisivness,
nearly every day (either by subjective account or as
observed by others)
(9) recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide
DSM-IV Criteria for Major
Depressive Episode
B. The symptoms do not meet criteria for a Mixed Episode
C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important ares of
functioning.
D. The symptoms are not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by Bereavement,
i.e., after the loss of a loved one, the symptoms persist for
longer than 2 months or are characterized by marked functional
impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation.
Anxiety Disorders









Generalized Anxiety Disorder
Panic Disorder without Agoraphobia
Panic Disorder with Agoraphobia
Agoraphobia without History of Panic Disorder
Specific Phobia
Social Phobia
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
DSM-IV Criteria for Generalized
Anxiety Disorder
A.
B.
C.
Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least 6 months, about a number of events or
activities (such as work or school performance).
The person finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms present for
more days than not for the past six months). Note: Only one item is
required in children.
(1)
(2)
(3)
(4)
(5)
(6)
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty in concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or restless
unsatisfying sleep)
DSM-IV Criteria for Generalized
Anxiety Disorder
D.
E.
F.
The focus of the anxiety if not confined to features of an Axis I
disorder, e.g. the anxiety or worry is not about having a Panic Attack
(as in Panic Disorder), being embarrassed in public (as in Social
Phobia)…………
The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas
of functioning
The disturbance is not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a general medical
condition (e.g. hyperthyroidism) and does not occur exclusively during
a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental
Disorder
Self Report Measures

Beck Depression Inventory (BDI)

Beck Anxiety Inventory (BAI)

State-Trait Anxiety Inventory (STAI)

Hospital Anxiety and Depression Scale
(HADS)

General Health Questionnaire (GHQ)
Beck Depression Inventory (BDI)



Beck et al. (1961) and (1996)
21 items, each including four statements that describe
the different manifestations of depression among
adolescents and adults
 The four statements range from low to high in severity
and a numerical value is designated to each statement
Measures different areas of depressive symptomatology
 Affective
 Cognitive
 Motivational
 Physiological
BDI

2 versions of the BDI:



BDI-IA (1978): Ask the respondent to choose the
best statement describing what they have been
feeling for the past week, including today
BDI-II (1996): time frame changed to past two
weeks including today, also modified statements to
emulate the DSM-IV criteria, and some modification
in syntax
BDI-IA takes around 5-10 minutes to complete;
oral administration may take up to 15 minutes
BDI Sample Items

Sadness (BDI-II):
1) 0 I do not feel sad.
1 I feel sad much of the time.
2 I am sad all the time.
3 I am so sad or unhappy that I can’t stand it.

Suicidal Thoughts or Wishes (BDI-IA & BDI-II):
9) 0 I don’t have any thought of killing myself.
1 I have thoughts of killing myself, but I would not
carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
BDI Sample Items

Loss of interest (BDI-IA):
12) 0 I have not lost interest in other people.
1 I am less interested in other people.
2 I have lost most of my interest in other people.
3 I have lost all of my interest in other people.

Tiredness or Fatigue (BDI-II)
20) 0 I am no more tired or fatigued than usual.
1 I get more tired or fatigued more easily than usual.
2 I am too tired or fatigued to do a lot of the things I used
to do.
3 I am too tired or fatigued to do most of the things I
used to do.
BDI Scoring

Total score calculated by summing scores from
the items endorsed from each item set
 With each statement given a value of 0-3, total
score range from 0-63:
 0-9 Minimal
 10-16 Mild
 17-29 Moderate
 30-63 Severe
 Not meant to be a sole screening instrument

Needs to be followed up with a diagnostic instrument
or a clinician interview
BDI

Reliability:



Internal consistency: High Cronbach alphas for different
populations (psychiatric patients: 0.76-0.95, students:
0.82-0.92, normal population: 0.73-0.90)
Test-retest reliability:
Validity:

Correlations with the following scales is good:




Hamilton Rating Scale in non-psychiatric patients is between
0.73 and 0.80
Symptom Checklist-90 (SCL-90) Depression subscale is 0.76
Minnesota Multiphasic Personality Inventory Depression Scale
(MMPI-D) is 0.60
Beck Hopelessness Scale is 0.60
BDI

Advantages:
Good scale to assess symptom change
over time and screening tool for depression
 Good reliability and validity evidence


Disadvantages:
Some evidence of bias for women,
adolescents, the elderly, and minorities
(higher scores were found)
 Not meant to substitute clinical diagnosis

Chinese BDI

Shek (1990)
 Chinese version of Beck Depression Inventory (Beck
et al., 1961, 1979)
 Validation sample: 2,150 secondary school students
(13 – 20 yrs) in HK
 Internal consistency




Item-total correlations range from .27 to .56
Cronbach’s alpha = .86
Split-half = .78
Factor structure


General Depression (items 1-11, 13-15)
Somatic Disturbance (items 12, 16-21)
這份問卷共有 21 組的句子，每一組都有幾個選項。請你仔細閱讀每一組的句子後，從中選
出一個最能夠表達你最近兩個星期來（包括今天）所感受的句子，並將此選項左邊的數字圈
起來。
如果你覺得同一組中有好幾個句子都同樣符合你最近的感受，則請圈選在這一組中，數字
最高的那一個句子。請注意任何一組，包括第 16 組（睡眠習慣的改變）
，或第 18 組（食慾改變），
都只能圈選一個句子。
1.
2.
悲傷
0
1
2
3
悲觀
0
1
2
3
我並不覺得悲傷。
我大部份的時間都覺得悲傷。
我時時刻刻都覺得悲傷。
我悲傷或不快樂已到我不能忍受的程度。
我對於自己的將來並不氣餒。
和以往比起來，我現在對於自己的將來覺得較沮喪。
我並不期望自己將來會有任何作為。
我覺得自己的將來是沒有希望的，而且只會愈來愈糟。
Chinese BDI


Validation sample: 2,150 secondary school students
(13 – 20 yrs) in HK
Internal consistency




Item-total correlations range from .27 to .56
Cronbach’s alpha = .86
Split-half = .78
Factor structure


General Depression (items 1-11, 13-15)
Somatic Disturbance (items 12, 16-21)
Beck Anxiety Inventory

Beck, Brown, Epstein, & Steer (1988)
 A 21-item self-report inventory for measuring
the severity of anxiety
 Used to distinguish anxiety from depression,
with some focus on somatic symptoms
 Assesses symptoms of anxiety including:




Dizziness or light-headedness
Inability to relax
Nervousness
Heart pounding or racing
BAI
4-point Likert scale (0= not at all, 1= Mildly
but it didn’t bother me much, 2=
Moderately, it wasn’t pleasant at times, 3=
severely, I could barely stand it)
 Total score ranges from 0 to 63 with the
following cut-off scores:

0-9 normal or no anxiety
 10-18 mild to moderate anxiety
 19-29 moderate to severe anxiety
 30-63 severe anxiety

BAI

Sample Items:

How much have you been bothered by the following
symptoms during the past month, including today:
Feeling
hot
Wobbliness in legs
Unable to relax
Fear of worst
happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Nervous
Hands
trembling
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Hot/cold sweats
BAI
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have
been bothered by that symptom during the past month, including today, by circling the number in the corresponding
space in the column next to each symptom.
Not At All
Mildly but it
Moderately – it
Severely – it
didn’t bother me
wasn’t pleasant at
bothered me a
much
times
lot
Numbness or tingling
0
1
2
3
Feeling hot
0
1
2
3
Wobbliness in legs
0
1
2
3
BAI: Reliability

Reliability:


Internal consistency: high, with Cronbach’s alpha
ranging from 0.90 to 0.94 across five studies (college
students, psychiatric in- and outpatients, adults from
community)
Test-retest Reliability: after one week lapse, studies
show correlations ranging from 0.67 to 0.93
BAI: Validity
Means, standard deviations, and correlations of the BAI and other instruments
Measure
Mean
SD
BAI
BDI
HRSD-R
BAI
22.35
12.36
BDI
19.32
11.38
.48*
HRSD-R
8.93
6.12
.25*
.61*
HARS-R
13.97
8.73
.51*
.24*
.46*
CCL-D
2.59
11.45
.22*
.64*
.53*
CCL-A
19.41
9.47
.51*
.38*
.28*
HS
9.11
5.47
.15
.59*
.51*
Note. BAI = Beck Anxiety Inventory
BDI = Beck Depression Inventory
HRSD-R = Hamilton Rating Scale for Depression-Revised
HARS-R = Hamilton Anxiety Rating Scale-Revised
CCL-D = Cognition Checklist-Depression subscale
CCL-A = Cognition Checklist-Anxiety subscale
HS = Hopelessness Scale
*p < .05
HARS-R
CCL-D
CCL-A
-.01
.45*
.10
.32*
.61*
.22*
Means, standard deviations, and corrected item-total correlations for BAI items
Item
M
SD
r
Numbness or tingling
.68
.80
.30
Feeling hot
.86
.87
.63
Wobbliness in legs
.61
.83
.54
Unable to relax
1.89
.78
.61
Fear of the worst happening
1.74
1.03
.59
Dizzy or lightheaded
1.00
.95
.63
Heart pounding or racing
1.18
.98
.55
Unsteady
.96
.99
.71
Terrified
1.15
1.14
.63
Nervous
1.89
.84
.60
Feelings of choking
.39
.80
.46
Hands trembling
.77
.85
.55
Shaky
1.01
.94
.67
Fear of losing control
1.54
1.07
.64
Difficulty breathing
.87
1.05
.53
Fear of dying
.90
1.11
.50
Scared
1.66
.97
.68
Indigestion or discomfort in abdomen
1.10
.98
.42
Faint
.68
.91
.67
Face flushed
.69
.85
.59
Sweating (not due to heat)
.80
.97
.60
Note. Eigenvalues are 7.87 for Factor 1 and 1.38 for Factor 2.
Interfactor correlation = .56.
Factor loading
1
2
.24
.65
.44
.60
.87
.62
.42
.65
.68
.61
.32
.71
.82
.75
.41
.41
.76
.29
.67
.67
.68
BAI


Advantages:
 Brief (takes around 5 minutes to complete), easy to
administer
 Good for monitoring change during treatment
 Possible screening tool used on individuals in medical
settings
Disadvantages:
 Does not focus on symptoms specified in DSM-IV for
generalized anxiety disorder (irritability, sleep
disturbance, worry)
 Does not discriminate between types of anxiety
disorders
State-Trait Anxiety Inventory
(STAI)


Spielberger et al. (1983)
State Anxiety: emotional reaction that varies from
situation to situation


Measures how a person will react to a stressful
situation (differences in intensity) based on their innate
trait anxiety
Trait Anxiety: a personality characteristic

Measures individual differences in perceiving a
stressful or threatening situation, for screening
individuals prone to anxiety problems
STAI Sample Questions

STAI comprises of two scales


State anxiety (A-State or S-Anxiety; Form Y-1): 20 statements
Trait anxiety (A-Trait or T-Anxiety; Form Y-2): 20 statements

Statements are rated: 1= almost never, 2=sometimes,
3=often, 4=almost always
 STAI Form Y-1 (S-Anxiety Scale):






1) I feel calm.
4) I feel strained.
9) I feel frightened.
13) I am jittery.
16) I feel content.
20) I feel pleasant.
STAI Sample Questions

STAI Form Y-2 (T-Anxiety Scale):
22) I feel nervous and restless.
 27) I am “calm, cool, and collected”.
 31) I have disturbing thoughts.
 35) I feel inadequate.
 37) Some unimportant thought runs through
my mind and bothers me.
 40) I get in a state of tension or turmoil as I
think over my recent concerns and interests.

STAI

Scores for each statement range from 1 to 4, with
total subscale scores ranging from 20-80:
 Norms:
 S-Anxiety:
Working
Adults
College
Students
High School
Students
Male
35.72
36.47
39.45
Female
35.20
38.76
40.54
STAI

Norms:

T-Anxiety:
Working
Adults
College
Students
High School
Students
Male
34.89
38.30
40.17
Female
34.79
40.40
40.97
STAI: Reliability

Reliability:

Internal consistency:
S-Anxiety: High Cronbach’s alpha for female
working adults, college and high school students
(0.93, 0.93, 0.94 respectively) and male working
adults, college and high school students (0.93,
0.91, 0.86 respectively)
 T-Anxiety: High Cronbach’s alpha for female
working adults, college and high school students
(0.91, 0.91, 0.90 respectively) and male working
adults, college and high school students (0.91,
0.90, 0.90 respectively)

STAI: Reliability

Test-retest reliability:


T-anxiety: High for college students with
correlations ranging from 0.73 to 0.86; lower for
high school students, correlations ranging from
0.65 to 0.75
S-anxiety: Somewhat low correlations for both
college and high school students ranging from 0.16
to 0.62

Low correlations are expected because the S-anxiety
scale should measure the unique situational influences
affecting the subject at the moment of testing
STAI: Validity

Concurrent validity:

High correlations of STAI with other trait anxiety measures
with college students and psychiatric patients:


IPAT Anxiety Scale and Taylor Manifest Anxiety Scale: (0.75 to
0.85)
Construct validity
Patients who had undergone major surgery had lower state
anxiety scores after they had been told they were recovering
well compare to before surgery; their trait anxiety scores
remained the same
 Those with high trait anxiety continued to respond in an
anxious way, even in situations that evoke little or no anxiety
among those with low trait anxiety
 Various factor analytic studies have confirmed the two-factor
structure
 the two scales measure distinct aspects of anxiety

Hospital Anxiety and Anxiety
(HADS)





Zigmond & Snaith (1983)
Detect mood disorders in medical patients
Questions focus on subjective disturbances of
mood
Two subscales: depression and anxiety
The depression subscale focuses on tapping signs
of anhedonia (inability to experience pleasure)


Anhedonia is believed to be a good indicator of
depression with the medically ill
Omits physical symptoms (e.g. dizziness and
headache) which may overlap with physical
disorders
HADS

Self report scale with 14 items, 7 items each
for depression and anxiety
 All items are rated on a 4-point Likert scale (0
to 3)
 Score for each of the subscales range from 0
to 21, in which:




0-7 Normal
8-10 Mild Mood Disturbance
11-14 Moderate Mood Disturbance
12-21 Severe Mood Disturbance
HADS

Sample items (Depression subscale):

2) I still enjoy the things I used to enjoy:
A. Definitely as much
B. Not quite so much
C. Only a little
D. Hardly at all

10) I have lost interest in my appearance:
A. Definitely
B. I don’t take so much care as I should
C. I may not take quite as much care
D. I take just as much care as ever
HADS

Sample items (Anxiety subscale):
 5) Worrying thoughts go through my mind:
A. A great deal of the time
B. A lot of the time
C. From time to time but not too often
D. Only occasionally

13) I get sudden feelings of panic:
A. Very often indeed
B. Quite often
C. Not very often
D. Not at all
請閱讀下列每題，並「」出最接近你過去一星期的情緒狀況。請不要花太多時間考慮你的答案，你對
問題的立刻反應，往往比反覆思量來得更準確。
1. 我感到神經緊張：
□ 大部份時候感到
□ 很多時候感到
□ 有時候、間中感到
□ 完全不感到
2. 我依然享受我以前享受的事物：
□ 肯定和以前一樣
□ 有點不及以前
□ 只及以前小許
□ 和以前差得極遠
HADS

Reliability:



Internal consistency: High Cronbach’s alpha (0.90)
for the Depression subscale
Test-retest reliability: r=0.92 in healthy individuals
Validity:


Correlation with the Montgomery-Asberg Depression
Rating Scale is high (0.70) in a sample with cancer
patients
Scores on HADS also converge with psychiatrist
ratings of severity of depression and anxiety (r = 0.70
for depression subscale and r = 0.74 for anxiety
subscale)
HADS

Advantages:
Short (only few minutes to complete), easy
to screen patients
 Questions are not “threatening”: content of
questions do not lead patients to think they
will be stigmatized with psychiatric illness

General Health Questionnaire
(GHQ)
Goldberg, 1972
 Screening tool to detect psychiatric
distress (not meant to be used for
diagnosis of psychiatric illness)
 Identify changes in daily functions and
presence of any new psychological
disorders


Detects recent psychological changes
GHQ
Self-administered questionnaire which takes
3-15 minutes to complete, depending on the
version of GHQ
 Four different versions varying in length:

60-item
 30-item
 28-item
 12-item

GHQ





Sample questions from GHQ-12 (Asked with reference to health
during past few weeks):
 Have you recently:
1)…been able to concentrate on whatever you’re doing?
(Better than usual, Same as usual, Less than usual, Much less
usual)
5)…felt constantly under strain?
(Not at all, No more than usual, Rather more than usual, Much
more than usual)
9)…been feeling unhappy and depressed?
(Not at all, No more than usual, Rather more than usual, Much
more than usual)
11)…been thinking of yourself as a worthless person?
(Not at all, No more than usual, Rather more than usual, Much
more than usual)
GHQ Scoring

Three ways to score GHQ:
1.
2.
GHQ scoring (Binary method): Items on the 4-point Likert scales
are scored 0-0-1-1 (Most commonly used method)
Not at all = 0
No more than usual = 0
Rather more than usual = 1
Much more than usual = 1
Traditional method: different weights for items in 4-point Likert
scale format (1-2-3-4)
Not at all = 0
Same as usual = 1
Rather more than usual = 2
Much more than usual = 3
GHQ Scoring
3.
C-GHQ Scoring Method (Goodchild & Duncan-Jones, 1985)

More useful in the detection of chronic illnesses compared
to the other two methods

Distinction between positive and negative items for scoring

Positive items are scored with the binary method while the
negative items are scored as the following:
More so than usual = 0
Same as usual = 1
Rather more than usual = 1
Much more than usual = 1

Because the response of “Same as usual” have a score of
1, it accounts for the chronic characteristic of the illness
GHQ

Suggested threshold scores (based on
GHQ scoring method):
GHQ-12: 1/2 or 2/3
 GHQ-28: 4/5
 GHQ-30: 4/5
 GHQ-60: 11/12


However, it is recommended to adjust for
the threshold scores depending on the
population of the subjects
GHQ


Reliability:
 Internal consistency: Good Cronbach’s alpha for GHQ60, GHQ-30, and GHQ-12 (0.82 to 0.93)
 Test-retest reliability: good reliability for GHQ-28
version with r= 0.90; other versions range from 0.500.90
Validity:
 Correlations with the Present State Examination and
the Clinical Interview Schedule are between 0.65-0.70
 Sensitivity of 80-84% is found for all versions,
specificity similar or slightly higher
 GHQ-60 showed best specificity (89%)
GHQ

Advantages:
Brief, easy to complete by subject
 Appropriate for all ages
 Sensitive to affective disorder, but probably not
some anxiety disorders


Disadvantages:

Psychometric data not demographically
specified
Lifestyle Assessment

Exercise:
What are the areas you have to assess
as part of a lifestyle assessment?
Health-impairing behaviors
 Health-enhancing behaviors
 General lifestyle factors

Assessing Premenstrual Syndrome?

What is Premenstrual Syndrome (PMS)?

“the cyclic recurrence in the luteal phase of
the menstrual cycle of a combination of
distressing physical, psychological, and/or
behavioral changes of a sufficient severity
to result in deterioration of interpersonal
relationships and/or interference with
normal activities”

Reid and Yen (1981)
Assessing Premenstrual Syndrome?

Distinguish from:
Other physical (e.g. mastalgia) or
psychological (e.g. depression bulimia)
problems
 Premenstrual exacerbation of pre-existing
conditions

Symptoms of PMS
More than 150 symptoms associated
with PMS
 No “hallmark symptom”
 Variable constellation of symptoms


Across individuals and over time
Diagnosis of PMS (Ling, 2000)



A. Does not meet DSM-IV criteria for PMDD but
does meet ICD-10 criteria for PMS
B. Symptoms occur only in the luteal phase, peak
shortly before menses, and cease with
menstrual flow or soon after
C. Presence of 1 or more of the following
symptoms:








Mild psychological discomfort
Bloating and weight gain
Breast tenderness
Swelling of hands and feet
Aches and pains
Poor concentration
Sleep disturbance
Change in appetite
Assessing PMS
Related Conditions
 1.) Premenstrual Dysphoric Disorder (PMDD)

In Diagnostic and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV) (APA, 1994)

Under “mood disorders not otherwise classified

Mood symptoms as the primary complaint
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder

A. In most menstrual cycles during the past
year, five (or more) of the following symptoms
were present most of the time during the last
week of the luteal phase, began to remit within a
few days after the onset of the follicular phase,
and were absent in the week postmenses, with at
least one of the symptoms being either (1), (2),
(3), or (4).
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder

1.

2.

3.

4.

5.

6.
markedly depressed mood, feelings of hopelessness,
or self-deprecating thoughts affective
marked anxiety, tension, or feeling of being “keyed
up,” or “on edge”
marked affective lability (e.g. feeling suddenly sad
or tearful or increased sensitivity to rejection)
persistent and marked anger or irritability or
increased interpersonal conflicts
decreased interest in usual activities (e.g. work,
school, friends, hobbies)
subjective sense of difficulty in concentrating
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder

7. lethargy, easy fatigability, or marked lack of
energy
 8. marked change in appetite, overeating, or
specific food cravings
 9. hypersomnia or insomnia.
 10. a subjective sense of being overwhelmed or out
of control
 11. other physical symptoms, such as breast
tenderness or swelling, headaches, joint or
muscle pain, a sensation of “bloating”, weight
gain
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder

B. The disturbance markedly interferes with work
or school or with usual social activities or
relationships with others (e.g., avoidance of social
activities, decreased productivity and efficiency at
work or school).

C. The disturbance is not merely the
exacerbation of the symptoms of another disorder,
such as major depressive disorder, panic disorder,
dysthymic disorder, or a personality disorder
(although it may be superimposed on any of these
disorders).
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder

D. Criteria A, B, and C must be confirmed by
prospective daily ratings during at least two
consecutive symptomatic cycles. (The
diagnosis may be made provisionally prior to
this confirmation.)

(APA, 1994)
Assessing PMS

1.) Clinical Diagnosis
Diagnostic criteria of PMS and PMDD
 Differential diagnoses
 Lack of a biological marker

Assessment of PMS
2.) Self-report measures
 Prospective daily rating
 At least 2 menstrual cycles
 Moos Menstrual Distress Questionnaire
(MDQ): Moos (1968)



47 items
8 subscales
Retrospective rating for premenstrual, menstrual,
and intermenstrual phases
Symptoms of PMS

Moos (1968): 7 clusters of symptoms
Pain
 Concentration
 Behavioral change
 Autonomic reactions
 Water retention
 Negative affect
 Arousal
 + control scale to detect response bias

Diagnosis and Assessment of PMS

Premenstrual Assessment Form (PAF):
Endicott and Halbreich (1982)


95 item retrospective self-report questionnaire (last
3 menstrual cycles)
6-point Likert scale (no change → extreme change)

Calendar of Premenstrual Experiences (COPE)

Prospective Record of Impact and Severity of
Menstrual Symptoms (PRISM)
Calendar of Premenstrual Experiences











Begin our calendar on the first day of your menstrual cycle. Enter the calendar date below
the cycle day.
Day 1 is your first day of bleeding. Shade the box above the cycle day if you have bleeding
(). Put an X for spotting ().
If more than one symptom is listed in a category, i.e., nausea, diarrhea, constipation, you do
not need to experience all of these.
Rate the most disturbing of the symptoms on the 1-3 scale.
Weight: Weigh yourself before breakfast. Record weight in the box below date.
Symptoms: Indicate the severity of your symptoms by using the scale below.
Rate each symptom at about the same time each evening.
0 = None (symptom not present)
2 = Moderate (interferes with normal activities)
1 = Mild (noticeable but not troublesome) 3 = Severe (intolerable, unable to perform normal
activities)
Other Symptoms: If there are other symptoms you experience, list and indicate severity.
Medications: List any medications taken. Put an X on the corresponding day(s).
Calendar of Premenstrual Experiences
Bleeding
Cycle day
Date
Weight
SYMPTOMS
Acne
Bloatedness
Brest tenderness
Dizziness
Fatigue
Headache
Hot flashes
Nausea,
diarrhea,
constipation
Palpitations
Swellings
(hands, ankles,
breast)
Angry outburst,
arguments,
violent tendencies
Anxiety,
tension,
nervousness
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Calendar of Premenstrual Experiences
Bleeding
Cycle day
Date
Weight
SYMPTOMS
Confusion,
Difficulty concentrating
Crying easily
Depression
Food cravings (sweets,
salts)
Forgetfulness
Irritability
Increased appetite
Mood swings
Overly sensitive
Wish to be alone
Other symptoms
1.__________
2.__________
Medications
1.__________
2.__________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Calendar of Premenstrual Experiences

The COPE Calendar is scored by adding the total number of
points from days 3-9 of the menstrual cycle (The follicular phase
score) and the total number of points from the last 7 days of the
cycle (luteal phase score).

PMS: follicular phase score < 40 and luteal phase score > 42

Follicular phase scores > 40(regardless of luteal phase scores)
suggest the possibility of underlying psychiatric disorder

Although not strictly required for the diagnosis, almost all
patients with PMS will have at least a 30% increase in scores
from follicular to luteal phase. If this is not observed, the
diagnosis should be reconsidered.
Typical PRISM Calendar Record Indicating Depression
BleedinggХ Х Х Х Х
Х Х Х Х Х
Menstrual Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Date:
SYMPTOMS
Irritable
2 3 1 1 2 2 2 2
Fatigue 2 2 1 2 2
1 2 2
Inward Anger 2 3 2 2 2 2 2 1
Labile Mood (crying) 3 3 1 1 2 2
Depressed 3 1 1 2 1 2
Restless
1 1 1 1
Anxious 3 2 3 3 3
1
Insomnia
Lack of Control
2 2 2 1 2 2 2
1 2 2 2 2 3 2
1 2 2 1
3 1 2 2
1 1 1
2 3 3
2 2 1
1
3 2 1
2
2 2 3
2 2 1 2
1 1 2
2 2 3 2
1
Appetite: updown   
 


2
1 2 2
C C C

   
 
2 2 3
1 1 2
2 2
C
3 3 2 2
1 2 1 1
Abdominal Bloating
C
1 1 1
1
2
Bowels: const. (c ) loose (l)
1 2
1 2 2
2 2 2 2 2
Brest Tenderness
Drive: up  down 
2 1 2 2 1 2 2
1 1
2 1 1
2
1 1 2 1 2
2 2 1 2 2
2 1 1 1
2 1 2 2 3
1
2 2
2 2 2
1 2 1 1
1 2 2 1
1 1 2 2 3 2
1 2 2 1 2 3 1 1 2 2 1
2
1 2 2
Edema or Rings Tight
3 2 2 1 2
C
 
     
1
1 1 2
C C

 


 
Chills (C ) / Sweats (S)
Headaches
1 2 2 2
2 2 2 3 2 2
2 2 2 2
Crave: sweets, salt
1 2 2 2 2 2
Feel Unattractive 2 2 2 2 2 3 1 2 2 1 1 2 2
2 2 2 2 2 2 2 2
Guilty 2 2 2 2 2 2 2 2 2 2 2
Unreasonable behavior
Low Self=Image 2 2
Nausea 1
1
2
2 2
Menstrual Cramps 2 2 2 1 2
1 2 2
1 2 2
2 2 2 1
2 2 2
2 2 2 2
2
2 2 2 1 2 2 3 3 2 2
2 2 2
2 2 2
1
1 2
Typical PRISM Calendar Record Indicating PMS
BleedinggХ Х Х Х Х
Х Х Х Х Х
Menstrual Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Date:
SYMPTOMS
Irritable 3 2
Fatigue 2 2 2 2
1 1 2 1 1 2 3 2 3 3
1 1 1 1 2 2 2 3 2 2 2
Inward Anger 1
1
Labile Mood (crying) 2 2
Depressed 2 1 1
2
Restless 3 1
Anxious 2 1
Insomnia 2 1
2 1 1 2 2 2 2
2
2
Abdominal Bloating 3 2 1
Bowels: const. (c ) loose (l) L L C
Appetite: updown 
1 2 2
2 3 2 2 2
3 2
2
Brest Tenderness 2 2 1
1
2
C C C
2
3 3
1 1
1
2
3 3 3 2 3
1
1
2
3 3 3 3 3
1 2 2 2
2 2 2 2
L L
  
Drive: up  down  
2 2 2
1
Lack of Control 1
Edema or Rings Tight
1 2 1
2 2 3 3
2
1
2
C C
 
 

 
  
Chills (C ) / Sweats (S)
Headaches 3 2 2 1
1 2 2 3 1 2 2
Crave: sweets, salt
Feel Unattractive 2
Guilty 1
Unreasonable behavior 2 2
Low Self=Image 2
Nausea 1 2
Menstrual Cramps 1 2 2
2 3 2 1 2 2 3 3 2
1
1
2
3
2 2 1
2
3 2 2
1 2 2
1 2 2 2 1
2 2