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Lecture 3: Assessment in Behavioral Health Dr. Antoinette Lee The University of Hong Kong Outline I. Assessing Stress II. Assessing Mental Health Problems Depression Anxiety III. Assessment of Patients with Medical Illnesses 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) 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 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: High for frequency score (r = .79) Moderate for severity score (r = .48) Validity 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) 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 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 Advantages: 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 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: updown 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: updown 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