Standardized Tests For Anxiety

This post is a quick link to information from, a well regarded British newspaper. They provide the questions and rating scales for the Hamilton Anxiety Scale, the State-Trait Anxiety Inventory, the Beck Anxiety Inventory and the Penn State Worry Questionnaire. These rating scales are widely used in the profession.

You can view them at this link.

A word of caution. Diagnoses are not made by these tests. They reflect a level of anxiety at a given point in time. They are certainly not meant to replace a thorough evaluation by a trained medical professional. If you are concerned that you may have an anxiety disorder, please seek out professional counseling and care. These ratings scales do not offer any treatment or medical advice. I offer this link for educational purposes only.

Anxiety, Self-Esteem and Self-Soothing

If you have been following these posts, perhaps you will recall one entitled “The Experience of Anxiety and Panic.” In that essay, I briefly noted some of the thoughts people with anxiety disorders sometimes have about themselves. The self-attributions or labels that they attach to themselves relevant to today’s discussion include:

•a sense of personal failing
•being sure that one is flawed
•believing that you are inferior to others
•being harshly self-critical
•having low self-confidence

These are powerful, negative beliefs that some anxiety-ridden people have about themselves. They hold them to be as true as the sun rises in the East. These thoughts stem from the anxiety disorder. These anxiety-provoking thoughts are incessantly repeated, both verbally and sub-vocally, until they are soaked in apparent truth. Beliefs such as these can strongly influence a person’s behavior and interactions with others.
For instance, a person with social anxiety may repeat the phrase “I suck at meeting new people” over and over again. They practice this belief dozens of times a day. Socially anxious people may even imagine how horrible meeting someone new at school (or elsewhere) today will be. Practice, in this as in many other areas of life, makes perfect. Therefore, our socially anxious person believes that s/he “sucks at meeting new people.” S/he has visually imagined or practiced how poorly the next interaction will be.

This linking of an anxious presumption (I suck at meeting new people) with imagined interactions and outcomes leads someone to become successful at being unsuccessful in meeting new people.

Let me make an aside. When I was young, I played golf. I remember reading an article by the golfing hero of the day, Jack Nicholas. He described the technique he used to prepare for his next shot as he walked up to his ball. He visualized, from a first person point of view, making the back swing, exploding downward and striking the ball, following through and only then looking up to follow the ball on a perfect arch and direction to the exact point where he wanted the ball to land and then roll to.

At the time, I thought that was just something he came up with for the article. I tried doing it and had little success. Only later did I realize that I have a hard time visualizing such things. For me, verbal or auditory cues work much better. Years later, when I read books about NLP, I came to have a much better understanding of why Jack’s visualizations did not work for me, but talking myself through something did work.

Before getting too far afield, let me return to erroneous belief systems and self-soothing. Our socially anxious friend now has a rigid belief that they suck at meeting new people and have practiced poor outcomes in their imaginations. They have become as prepared for that bad interaction as Jack Nicholas was prepared for his birdie. In all probability, the socially anxious person will have a very upsetting encounter with the next new person.

This seems to prove the assumption that “I suck at meeting new people.” So, if anyone should ask why a person thinks she or he have difficulty meeting people, there is fresh, concrete proof. That is a fallacious line of argument.

The socially anxious person, in this case, would better be described as, due to the anxiety disorder, being successful at preparing and planning a disastrous first meeting with someone. It is not that they prepared and practiced to have a successful outcome. We do not know how the meeting would have turned out if the person had been at ease, comfortable in the setting, and had practiced a successful outcome to the meeting.

One way to try to combat negative, self-fulfilling beliefs involves my asking what seems to be a question dreaded by some of my patients.

Let me explain that a bit. Anxious and depressed persons often come to the first session well-versed and ready to discuss what is wrong with them. The descriptions of their purported flaws, shortcomings, self-criticisms flow easily.

At some point in the session, I ask them to “tell me three good things about you.”

There is usually a silence. Sometimes there are looks back at me that seem to say that I have asked a most impolite, hideous and foul question. It would seem easier to return to the lengthy list of negatives.

One of the reasons behind asking this question is to find traits that a person likes about him or herself for use in self-soothing and self-esteem. Another is to assess the constancy and quality of the person’s self-representation. The latter is relevant to this discussion but would take us into object relations theory and psychodynamic/analytic theory and is beyond the scope of this post.

With three good things about oneself in hand, many techniques become available. A simple one is to say to yourself something like the following:
“I’m a good person who is (fill in the blank with three self-positives). I am going through a difficult time (fill in the situation, e.g., meeting this new person). But I have gone through bad times before and made it through. And I’ll be able to make it through now because I’m a good person and (fill in the three self-positives). I’ll still have those good qualities even if this (meeting or whatever) goes poorly.”

In the above, I have suggested three initial strategies on building self-soothing strategies and positive self-esteem.

First, notice when you are practicing negative thoughts about yourself and preparing for self-fulfilling bad outcomes. Then attribute those thoughts and previous outcomes to the anxiety disorder. Stop those ruminations by getting up and doing a different activity, even if it is only getting up from the couch and going into the kitchen and washing dishes; if you are alone you can say “Stop those thoughts” out loud and switching your thoughts to any positive memory you might have; and similar techniques.
Second, try to picture a successful outcome to your next project, like Jack Nicholas. Alternatively, if visualization is not for you, talk yourself through the steps of the project. Imagine how one successful step will lead to the next.

Third, remind yourself of your good traits, at least as often as you rehearse the negative ones. In addition, in times of trouble, remind yourself that you will still have all your positive attributes with you through the difficult task and even afterwards.

I will return to these topics in later posts.

Follow-up on PTSD and The Pentagon

I’d like to subtitle this post “Waiting for Martians,” for reasons that I hope will become clear as we go along.

The Army Times yesterday posted an article about the Pentagon’s decision to withhold the Purple Heart from soldiers who are inflicted with Post-Traumatic Stress Disorder.

The article notes that about 20% of the soldiers in Iraq meet the criteria for PTSD.  The article cites Department of Veterans Affairs findings that nearly 76,000 soldiers were given a provisional diagnosis of Post-Traumatic Stress Disorder between 2003 and 2007.  Obviously, this is a prevalent problem for our soldiers.

The article repeats the Pentagon’s reasons for disqualifying PTSD as an injury meriting the Purple Heart.

To further explain the Pentagon’s decision, the article quotes Charles Figley, professor of disaster mental health at Tulane University.  Figley is quoted as saying “There’s no blood test…no neurological map that clearly identifies” PTSD.

That’s true enough. But Figley goes on to say that PTSD is:

“an anxiety disorder, and all anxiety disorders are extraordinarily subjective. They’re difficult to treat through medication for precisely that reason.” However, “ongoing research could someday lead to a blood test…for the disorder…Figley said.”

Now I must admit that I am lost in this tangled trail of thought.  Let’s pull out the highlights of this argument.

“There’s no blood test…”
“All anxiety disorders are extraordinarily subjective…”
Anxiety disorders are “difficult to treat” because they are “extraordinarily subjective.”
Some day there may be a blood test to diagnose PTSD and anxiety disorder.
And a Pentagon spokesperson added “predictable and quantifiable physiologic injuries associated with specific psychological injuries is less robust now than it may be in the future”

I take this to mean that PTSD is difficult to diagnose by standardized tests like a blood screening or a CAT scan or an MRI.

That point is granted. Like the disorders Major Depression, Schizophrenia, Bipolar and many more, diagnosis is made largely by evaluation of a patient’s reports of their symptoms and levels of functioning. There are no lab tests to confirm the diagnosis of these conditions.

But here comes the point where I become confused. “Anxiety disorders are extraordinarily subjective” which makes them “difficult to treat.”  But someday there may be blood tests to verify the diagnosis.  And at some point in the future we may be able to specify the physical injury behind the disorder.

Only three interpretations of these statements come to me.

I am going to assume this first possible interpretation is not what they meant. They could be saying that since there is no external lab test to confirm the diagnosis, then there is no way to tell if the soldier is lying about his/her injury.  The Purple Heart could then be mistakenly awarded to persons malingering and conjuring up the illness.  So, 20% of the returning soldiers from the current wars could be faking the illness and not deserving of the Purple Heart.

I also assume that this second possible interpretation is false.  They could be saying that since there is no objective lab test for PTSD, then it may not be a real “illness” at all.  That would also imply that nearly all psychiatric disorders are not true illnesses or disorders.

The last intepretation that I can come up with is that unless there is proof of physical injury (in this case damage to the organ of the brain), then the assumption is that there is no injury.

So, for a soldier suffering from PTSD, there would have to be physical, independently verifiable proof of physical injury.

Allow me to make an aside for a moment.  One of the most intelligent persons I have ever met is a neurologist.  Several years ago, he allowed me to follow him around on his morning hospital rounds for a year or so as a volunteer.  I was and remain fascinated by the brain and neurology and he was kind enough to share his time and knowledge.  One day I asked him a fairly detailed question about the neurological pathways and neurotransmitters involved in a particular task and the set of related emotions.  His candid answer to me was: “Mike, we are going to have to wait for Martians to land and have them explain the brain to us in that kind of detail.  So far, we humans haven’t been smart enough.”

Back to the point at hand: objective physical trauma to verify the diagnosis of PTSD.  PTSD is not traumatic brain injury, it is not a closed head injury, it is not a lesion in the frontal or any other lobe.  It is not something that you can identify in a brain scan, picture or even by autopsy. Post-traumatic stress disorder is a psychiatric disorder whose specific mechanisms are unknown to us at this time. Never mind figuring out a way to distinguish those mechanisms in a fashion that would be suitable for a blood test. Like it or not, there is no way to send off a blood sample or a biopsy specimen and confirm the diagnosis.

That certainly does not imply that the psychiatric disorders are not true illnesses.  It does say that we simply do not have a complete understanding of the brain at this point in time.

May I suggest that if Professor Charles Figley and the Pentagon are, in earnest, waiting for the “neurological map that clearly identifies (PTSD)”, then perhaps they are waiting for the martians to land as well.

In the meantime, it seems cruel to me to deny the Purple Heart to soldiers who are suffering from PTSD as a result of their service to their country.

Why deprive them of such recognition simply because our science has not advanced sufficiently to provide absolute diagnostic confirmation?

Of PTSD, Purple Hearts and the Pentagon’s Shame

It seems clear that one of the goals of warfare is to render your opponent’s warriors incapable of fighting. If that’s not one of the goals, then why would you try to kill their soldiers? Therefore, inflicting enough psychological damage to keep them off the battlefield would logically seem to be a weapon of choice.

PSYOPS (psychological operations), according to Wikipedia, have “been used by military institutions throughout history.”

I am not declaring that PsyOps either does or does not calculate the quantity or quality of injuries and death inflicted on the enemy to maximize post-traumatic stress disorder casualties. I have no way of knowing if that is covered by their mission. Although there must have been some reason that the initial assault in the current war with Iraq was called Shock and Awe. Wikipedia’s entry for Shock and Awe reads, in part, as follows: “the use of overwhelming power, dominant battlefield awareness, dominant maneuvers, and spectacular displays of force to paralyze an adversary’s perception of the battlefield and destroy its will to fight (emphasis mine).”

Here is a link to’s links to sites devoted to psychological operations and warfare. I present that as a reminder that psychological operations and the resultant damage inflicted on soldiers and civilians is a well-known and long-standing art of warfare (if such practices can be called an art).

What has this to do with anxiety? Let’s recall that post-traumatic stress disorder falls under the anxiety disorder classification.

In that vein, the Pentagon has determined that soldiers returning from battle with post-traumatic stress disorder do not qualify for Purple Hearts. Their reasoning, as reported by the Army Times, is that PTSD does not meet the criteria of a Purple Heart:

“The Purple Heart recognizes those individuals wounded to a degree that requires treatment by a medical officer, in action with the enemy or as the result of enemy action where the intended effect of a specific enemy action is to kill or injure the service member.”

If one side launches a fiercely violent and brutal assault, at least part of the casualities will be soldiers who have witnessed their fellow service personnel and friends die, get injured or maimed in ways that are highly likely to traumatize the witnesses. Any armed force, whether aggressor or victim, who failed to take that into their calculations would be foolish indeed.

In its wisdom the Pentagon, again according to the Army Times, goes further to say that “PTSD is an anxiety disorder caused by witnessing or experiencing a traumatic event.” It is not “a wound intentionally caused by the enemy from an outside force or agent…”

What possible line of reasoning could they be using? It would seem that they are ignoring their own PsyOps division.

So much for logic, reason and parity between “physical” and “mental” injury and illness.

And shame on the Pentagon.