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Learning Objectives

Upon completion of this module, participants will be able to:

1. Identify and describe three anxiety specific standardized assessment tools
2. Describe the concept of triangulation as it relates to assessment
3. Identify five questions you should consider during an initial intake for a client who reports anxiety symptoms `
4. Identify two strategies that can be used to assess treatment progress

Introduction

Anxiety is a complex, yet normal, emotional response. Generally speaking, anxiety can, within normal bounds alert a person to potential danger, increase motivation, and instill energy for self-protection. It is when a person experiences chronic and excessive anxiety regarding everyday life/situations, above a normal protective anxiety threshold, that it can be problematic. To identify symptoms, severity, impact on functioning, and type of anxiety, the implementation of effective and reliable assessment is critical to the helping process.

As with other helping professions, gathering client data for the purposes of establishing a diagnosis and treatment planning is important for determining treatment progress. Currently, there are no biological tests to determine the presence of mental illness. According to the work of Dr. Rose and Dr. Devine (2014, p. 197), “As with other mental disorders, patients’ self-reported symptoms are of crucial importance to diagnose anxiety disorders, as well as to monitor treatment success. For evidence-based medicine, a precise, reliable, and valid (i.e., “objective”) assessment of the patient’s reported “subjective” symptoms are essential.”

Before we move ahead, let me address one question I often get from students. “What is the difference between a screening and an assessment?” According to Substance Abuse and Mental Health Services Administration [SMASHA] (2009), Screening is a process for evaluating the possible presence of, or if at risk of a particular problem. The outcome is normally a simple yes or no. Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis. While the two concepts are different, they are often used interchangeably. Assessment can be seen as an overarching concept with screening as a sub-type of assessment. For the purposes of this module, I will use the term assessment as an overarching concept and will clarify which tools are for screening purposes.

This module will introduce the reader to components/questions associated with conducting a general assessment, an overview of anxiety-related standardized assessment tools, and strategies for assessing client treatment progress.

General Intake/Assessment Questions

During a first visit with a client, one of the primary goals beyond establishing rapport is to determine the reason for the visit and develop a preliminary diagnosis. As part of this process, there are a series of questions to be explored. These questions should also assist in obtaining a cultural perspective of the problem.  As with any initial assessment, it is important to engage in the process of differential diagnosis thus assessing substance use, medical history, and cultural components. Symptom expression and views on mental health can vary depending on a person’s race and ethnicity. In addition, always conduct a mental status exam. Initial questions should contain elements associated with symptom duration, severity, impact on functioning, social supports, and coping. Hypothetically, if the reason for the visit is due to symptoms of anxiety, the following questions should be considered.

1. What is the primary problem that is bothering you?
2. When did it start/how long has it been going on?
3. Currently, is there anything new or stressful going on your life? (Prompts: work, school, immigration status, financial, family, or other intimate relationships, health status, and change in life roles).
4. Do you eat or drink anything that contains caffeine?
5. Do you use any type of drugs? Prescribed or illicit?
6. If at all, how has this problem changed over time?
7. When was your last physical exam? Lab results? Diagnoses?
8. In what ways has your life been impacted by this problem? (Prompts: work, school, financial, family, or other intimate relationships)
9. Is there anything you do that helps to make the problem better? And what have you already done to make this problem better?
10. Are there people in your life that provide support when you are experiencing this problem?

Anxiety Assessment

When assessing for anxiety, most clinicians think about using standardized assessment tools. Although useful and important in the assessment process, most standardized tools have gone through rigorous empirical testing, yet they are not 100% reliable nor valid in truly capturing various mental health disorders. As a result, we should think of assessment as multifaceted. That said, it is important to engage in the process of triangulation when gathering assessment data. What does this exactly mean? It means obtaining information from multiple data sources when possible, including the utilization of standardized assessment tools, behavioral checklists, and information from the client/parent/caretaker/teacher when feasible. It is also important to incorporate the clinical expertise of the clinician conducting the assessment. For example, if you have a client who identifies as a Black transgender male and expresses a history of discrimination, consider what additional information might be helpful. In this case, you may want to consider implementing the Perceived Discrimination Scale (Williams et a., 1997).

Assessments specific to anxiety and anxiety disorders fall into two categories: Global and specific assessments. Global assessment tools attempt to capture more general symptoms of anxiety while more specific tools, attempt to capture a specific anxiety diagnosis i.e., social anxiety, panic disorder, agoraphobia. Many tools assess the presence of anxiety symptoms while others assess the severity of symptoms. The delivery of anxiety assessment tools also varies (self-administered vs. clinician administered and/or in person or before/during a virtual appointment). While many of these tools are self-administered, it is also appropriate for clinicians to administer when necessary (i.e., possible vision challenges or problems with literacy). Furthermore, assessment tools are often tailored to specific age groups (i.e., children, adolescents, and/or adults) and are often available in different languages thus making them more accessible. While available in different languages, they lack alignment with different cultures.

When learning about anxiety specific assessment tools, it is critical be aware of the underpinnings of the empirical research.  Specifically, when exploring standardized assessment tools, it is important to use a critical eye in assessing the tools’ reliability (often referred to as internal consistency and test/retest reliability), validity (i.e., face, construct, criterion) and its cross-cultural application. While it is beyond the scope of this module to dig into the psychometrics of standardized assessment tools, reliability, is often described as fair, moderate, high, or strong (there is typically a number between 0-1 associated with reliability. This is known as a Cronbach’s alpha). Reliability is often referred as the consistency factor. The Recovery Village (2021) states it quite simply, “These tools are validated through research exploring validity (such as construct validity – does this tool measure what it claims to measure; content validity- does the content in the cover what you want it to assess?) and reliability (such as test/retest reliability – can a person take the test multiple times and get the same result).” When learning about and/or implementing an anxiety-based assessment tool, you will want to be familiar with its purpose (global or specific), empirical support (reliability and validity), how to interpret reliability, and how to make sense of the tool’s validity. Furthermore, does the tool assist in screening for anxiety risk or does it help making a specific anxiety related diagnosis?

Click the link below to learn more about validity and reliability in research.

https://www.scribbr.com/methodology/reliability-vs-validity/

Common Standardized Anxiety Assessment Tools

Generalized Anxiety Disorder 7 (GAD 7)

The GAD 7 is a seven-item self-administered assessment tool. The primary purpose is the measure the severity of anxiety symptoms (mild, moderate, or severe) that fall within a two-week timeframe. It is suitable for use with adolescents and adults. The GAD 7 is available in multiple languages including Spanish, Arabic, and Chinese. The GAD 7 is known to have high reliability meets criteria for validity (Spitzer, et al., 2006). Please note that while some scales are available in multiple languages, this does not mean they are culturally sensitive to such items as symptom expression across different cultures (i.e., cultural expression).

Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory is a self-report questionnaire which measures 21 common somatic and cognitive symptoms associated with anxiety. It has been researched and supported to be used with those between the ages of 17 and older. One criticism of this inventory is that it does not fully capture other anxiety related symptoms, but rather has a focus on cognitive symptoms (i.e., worry, catastrophizing) (Leyfer et al., 2006). That said, it does a good job capturing possible panic disorder. The BAI is also available in numerous languages (i.e., English, Spanish, German). It is known to have strong reliability and meets criteria for validity (Beck, et al., 1988; Bardhoshi, et al., 2016).

Patient Health Questionnaire 4 (PHQ-4)

The PHQ-4 is a brief assessment tool used to assess both anxiety and depression symptoms among adolescents and adults. This inventory is typically self-administered and scored by the clinician. This tool is used for screening and provides the clinician with data to determine if additional assessment is needed. You can think of it as screening for risk of the possible condition and this case anxiety and depression. The reason behind this comorbid assessment is that both anxiety and depression are known to co-occur in the general population (Kroenke, et al., 2009). The scores range in level of symptom severity (normal, mild, moderate, and severe).  Based on empirical research, this tool has strong reliability meets criteria for validity (Kroenke, et al., 2009; Löwe, et al, 2010). Limited information is available on whether this tool is available in different languages.

Hamilton Anxiety Rating Scale (HARS)

The Hamilton Anxiety Rating Scale contains 14 items that assesses both physical and emotional symptoms (Hamilton, 1959) of anxiety. This scale can be used with children, adolescents, and adults. While this is a self-administered tool, some of the concepts/words in the assessment may be confusing for clients thus may require some interpretation. This scale is typically self-administered and scored by the clinician. The HARS is available in multiple languages. It has been established to have an acceptable level of reliability meets criteria for validity (Hamilton, 1959).

Overall Anxiety Severity and Impairment Scale (OASIS)

The Overall Anxiety Severity and Impairment Scale is a 5- question, self-administered brief assessment that explores frequency and intensity of symptoms, behavioral avoidance, and functional impairment (Norman, et al., 2006). It is unique in that it can be used to assess anxiety across the anxiety disorders and not specific to one specific type. While the OASIS scale has not been thoroughly evaluated, few studies have supported its use in assessing anxiety impairment and severity across multiple settings and populations (Norman, et al., 2006; Campbell-Sills et al., 2009). It has also been shown to have a high degree of reliability meets criteria for validity (Norman, et al., 2006).

Leibowitz Social Anxiety Scale (LSAS)

The Leibowitz social anxiety scale is as specific disorder, 24-item tool used to assess symptom severity as well as measure treatment outcomes (Heimberg, et al., 1999). The 24 items are based on various social situations in which the respondent answers are specific to fear and avoidance vs assessing specific anxiety symptoms. The original tool was developed to be clinician administered, but today, a client self-administered version has been validated and available for use (Fresco et al., 2001; Oakman et al., 2003). It is important to note that there are different versions for children/adolescents (known as LSAS-CA) and adults. This tool is shown to have good validity meets criteria for validity (Heimberg, et al., 1999). The LSAS has been researched and tested using different languages (Bobes, et al., 1999).

Panic Disorder Severity Scale (PDSS)

The Panic disorder severity scale is a specific, self-administered, 7-item tool which measures the severity of panic attacks, panic attack symptoms, and treatment progress (Shear, et al., 1997). More specifically, it assesses such items as panic frequency, phobic avoidance, distress during panic, and impairment in social functioning. This tool is appropriate to use with adolescents and adults and is available in multiple languages. This tool has shown to have adequate reliability meets criteria for validity (Shear, et al., 1997; Houck et al., 2002).

Other Assessment Approaches

While the focus of this module has been on standardized means for screening and assessing anxiety severity and symptoms, it is also important to implement a plan for monitoring treatment progress. For example, you have been providing weekly therapy to an adult 25-year-old male who has been diagnosed with generalized anxiety disorder. How will you determine if the treatment approach is effective in managing client symptoms? That is, how will you assess treatment progress?

In short, there are several strategies that can be used to evaluate and track treatment progress. First is the Subjective Units of Distress Scale (SUDS). The scale ranges from 10-0 and is often referred to as a distress thermometer (10= high; 0= low). Client’s use this scale to track severity of fear, anxiety, and/or distress over time. SUDS is also used in the process of creating a hierarchy in exposure therapy (more on this in module 5). Second, is the use of a 5-point Likert scale which is like SUDS. A unique aspect of the Likert scale is that it can be individualized to the client. That is, what does a 5 represent and what does a 1 represent? Third, is journaling. This is a useful way to expand in narrative form information obtained from using SUDS or a Likert scale. This type of approach leads to increased awareness (i.e., identification of triggers), insight, growth, and a way to externalize strong feelings and emotions. Last, the use of the standardized assessment tools discussed in this module can be useful. For example, clinicians may use information they obtained from an initial anxiety assessment as baseline data (a starting point). Once the treatment protocol has been activated, the use of the same standardized tool can be used to determine if for example, the severity of symptoms have improved.

DSM 5

The DSM 5 TR is a useful tool to assist in both assessment and diagnosis of anxiety disorders. The American Psychiatric Association (APA) has created several cross-cutting assessment tools which are traditionally used during for initial assessments, screenings as well as for monitoring treatment progress/outcomes. These tools have been developed for use across the lifespan (ages 6 and older). Each tool contains a narrative which addresses how to score and interpret the data.

Access the following link and review a minimum of three assessment tools related to anxiety (i.e., distress, social anxiety, specific phobia, agoraphobia etc.).

https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures

Conclusion

          Assessing and screening for anxiety is a crucial step as it assists in guiding the diagnostic and treatment process. There are both global and specific standardized anxiety assessment tools that can assist in this process. While these tools are an important ingredient in the assessment process, it is helpful to engage in the process of triangulation. Beyond the use of standardized assessment tools for initial assessment, they can be used to assess treatment progress.

Learning Activities

1. Identify and critique two standardized anxiety assessment tools. That is, what are the pros and cons of each tool? This may require you to explore the literature (i.e., research).
2. As you prepare for an upcoming therapy session with a client whom during the intake appointment expressed “always feeling anxious”, what assessment questions would be important to consider?
3. You are a social work clinician who just received a referral to work with a 13-year-old, male with cerebral palsy. As part of the intake and information gathering process, you engage in what is known as triangulation. Discuss how you might apply triangulation in this case.

References

Beck, A. T., Epstein, N., Brown, G., Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897.

Bardhoshi, G., Duncan, K., Erford, B.T. (2016). Psychometric meta-analysis of the English version of the beck anxiety inventory. J. Couns. Dev. 94, 356–73.

Bobes, J., Badia, X., Luque, A., Garcia, M., Gonzalez, M. P., Dal-Re, R. (1999) Validation of the Spanish version of the Liebowitz Social Anxiety Scale, social anxiety and distress scale and Sheehan disability inventory for the evaluation of social phobia. Medicina Clinica, 112, 530–538.

Campbell-Sills, L. et al., (2009). Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS). J Affect Disord. 112(1-3): 92-101.

Fresco D. M., Coles, M. E., Heimberg, R. G., Liebowitz, M. R., Hami, S., Stein, M. B., Goetz, D. (2001). The Liebowitz Social Anxiety Scale: A comparison of the psychometric properties of self-report and clinician administered formats. Psychological Medicine, 31, 1025–1035.

Hamilton, M. (1959). The assessment of anxiety states by rating. British journal of medical psychology, 32(1), 50-55.

Heimberg, R. G., Horner, K. J., Juster, H. R., Safren, S. A., Brown, E. J., Schneier, F. R., & Liebowitz, M. R. (1999). Psychometric properties of the Liebowitz Social Anxiety Scale. Psychological medicine, 29(1).

Houck, P. R., Spiegel, D. A., Shear, M. K., Rucci P. (2002). Reliability of the self-report version of the panic disorder severity scale. Depression and Anxiety, 15(4).

Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics, 50(6), 613.

Leyfer, O.T., Ruberg, J.L., & Woodruff-Borden, J. (2006). “Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders”. Journal of Anxiety Disorders. 20 (4): 444–458.

Löwe, B, Wahl I, Rose M, et al. (2010). A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. Journal of Affective Disorders, 122 (1-2): 86-95.

Norman, S. B., Hami Cissell, S., Means‐Christensen, A. J., & Stein, M. B. (2006). Development and validation of an overall anxiety severity and impairment scale (OASIS). Depression and anxiety, 23(4), 245-249.

Oakman, J., van Ameringen, M., Mancini, C., Farvolden, P. (2003). A confirmatory factor analysis of a self-report version of the Liebowitz Social Anxiety Scale. Journal of Clinical Psychology, 59(1), 149– 161.

Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009.

SAMSHA (2009). Treatment Improvement Protocol (TIP) Series, No. 51.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine, 166(10), 1092.

Shear, M.K., Brown, T.A., Barlow, D.H., Money, R., Sholomskas, D.E., Woods, S.W., Gorman, J.M., Papp, L.A. (1997). Multicenter collaborative Panic Disorder Severity Scale. American Journal of Psychiatry, 154, 1571-1575.

The Recovery Village (2021). Screening for anxiety disorders. Edited by Alston. R. https://www.therecoveryvillage.com/mental-health/anxiety/related/anxiety-screening-tools/

Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical and mental health: Socio-economic status, stress and discrimination. Journal of Health Psychology, 2(3