VOLUME XII • NUMBER 6 NOVEMBER·DECEMBER 1971

PSYCHOSOMATICSOFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE

A R.ating Instrument For Anxiety DisordersWILLIAM WK. ZUNG, M.D.

• Diagnosis and diagnostic criteria enableclinicians and researchers alike to com­

municate with one another about their pa­tients and make comparisons of cases anddata meaningful. The fact there is a need forassessing anxiety, whether as an affect, asymptom, or a disorder is obvious by thenumerous rating scales available and in use.However, the need for a standardized methodof evaluating and recording the presence ofanxiety as a clinical disorder has not beenmet by most scales today. We were interestedin having a rating instrument which wouldfulfill the following: it should be inclusive withrespect to symptoms of anxiety as a psychiat­ric disorder, it should quantitate the symp­toms, it should be short and simple, and itshould be available in two formats so that, 1)the patient can indicate his own responses ona self-administered scale, and 2) the observercan indicate his clinical evaluation of the pa­tient's status on the same set of criteria. Thisreport summarizes our efforts at devising arating instrument for anxiety disorders whichwe felt fulfilled our needs and purposes.

METHOD

In the construction of the present ratinginstrument the symptoms of the illness weredelineated by using the descriptive approach,since the basis of definition and classificationin psychiatric nosology continues to be basedupon presenting symptomatologyl.

Anxiety as a disorder is defined in the

Dr. Zung is Associate Professor of Psychiatry,Duke University Medical Center, and VeteransAdministration Hospital, Durham, N.C.

November-December 1971

Diagnostic and Statistical Manual, SecondEdition or DSM-II as a neurosis characterizedby anxious overconcern extending to panicand frequently associated with somatic symp­toms2• More detailed definitions and descrip­tions of anxiety and its characteristic symp­toms are described by the following authorsand summarized in Table I: Kolb in Noyes'Modern Clinical Psychiatry3, Lief in Com­prehensive Textbook of Psychiatry" Portnoyin the American Handbook of Psychiatryl, anda report on anxiety neurosis by Wheeler,White, Reed and Cohen5

•

In devising our rating instrument, diag­nostic criteria used were comprised of the mostcommonly found characteristics of an anxietydisorder, such as those listed in Table I. Fromthis list of criteria, an observer rated AnxietyStatus Inventory (ASI) and a patient Self­rating Anxiety Scale (SAS) were constructed.

Anxiety Status Inventory (ASI)

Table II is the form of the ASI which isthe clinician rated instrument. It contains thediagnostic criteria for anxiety as a psychiat­ric disorder (5 affective and 15 somatic symp­toms) and the interview guide for elicitingeach of the symptoms. The data upon whichthe judgments are based come from the inter­view with the patient. The items in the scaleare to be quantified by using all of the infor­mation available to the rater. This includesboth clinical observations and the materialreported by the patient.

Use of the Interview Guide assures cover­age of all of the areas in which judgments arerequired. However, the rater has the flexibility

371

PSYCHOSOMATICS

of interposing other questions or probing fordetails which allow for a smooth interviewwithout sounding like a question-answer ex­amination. In rating the patient's currentstatus, an arbitrary period of one week priorto the evaluation is adopted in order to stand­ardize the data.

In making the judgment, the following

rules are used:1. Each item should be independently

rated as a unit by itself in order to eliminateany "halo" effect.

2. Each score should be the average ofthe full range of responses observed or elicited,and not necessarily the extreme in severity.

3. The items are judged on a four-point

TABLE I - A comparison of symptoms found in anxiety as reported by various authors.

(*Percentage of each symptom present in patients with anxiety disorder)---- ----------

icOLIl (3)

AFFECTIVE SHlPTOHSApprehension, worried,

inexpressible dread,painful uneasinessof mind

SO~IATIC SY:IPTOMS

Musculoskeletal $vstemTremor,

Tension headache.

h'~akness,

k",stlessgess

I'!!.d.!o~'!.s cUl-,!,--S ys t eml'alpitation,

rapid heartbeat

B-e_,~p.iJ-,,-ton' Sys temHyperv",ntilation:dizziness,fainting,shortne::;s of breatil,f",eling of choking,pressure on tilorax,parestllesias

LIEF (4)

Apprehension, fearful,feeling of impendingdeath, helplessness,mental disintegration

~uscle tightness,tremors, spasms,painful movements,ileadaches, neck andback pains

h'eakness,Restlessness

Palpitation, throbbingpain in chest

Dizziness,

:::;lll.)rtness of ureath)Lvnstriction in chest,

pORno, (1)

Apprehensiol', utlcasincss,anticipation of danger,ilelplessness

Increased tension,tremors, stiffn"ss

Palpitation, rapid pulse,increased Bp

Rapid or irr~gu13r

breathing

\';HEELER eta1.

ApprehensionFear of death>h.-> rvousness

Trel:lblingShakiness

HeadacheTires easil~..WeaknessFatigued all

the time

Palpitation

DizzinessFaintnessllreathlessnessBreathunsatisfactpry

Paresthesias

(5)

60.7*41. 887.6

53.546.5

58.395.056.0

45.1

96.7

78.370.090.0

52.758.2

~~.~_r_l~-_i_~~s_ti na~ _S.Ls_~_\.~~~uus~a and vonlitill~ ~uusea, vonliting,

diarrheu,dllllrt'xia

Xausea, vomiling,diarrhea

\'omiting anddiarrhea

Anorexia14.012.3

~L:n_i_t.9-u_~~.!!...a_~~t ~~~.

Incre3sed desire tourinate

Skinrac,", f 1uSiled,

perspiration

_C_C.!1.t_ r..?_!. __~e [V_OUS S~i.-~

~lind in constant daz~,

:lbsent "'inded

Di fficulty infalling asleep,f":lrful dre:lms

rrillary frequellcy,urgcIH':y

flushing of f:lce,Sensation of heat

1.3ck 0f concentration,J~cr~ased memory,p0rc~ptu:ll defects,irritabilitv

Difficulty in falling:l~l"eJl, fitful sle"p,ul1pl~asant dreams

Urinary frequenc~'

Flushing or ~3llor,

cold, wet extremities

Sleep Jisturhililces

Frequency

FlushingSweating

Insomnia

~ightmares

18.6

36.244.9

52.7

If!. 3

372 Volume XII

RATING INSTRUMENT-ZUNG

system, taking into account Severity in termsof: intensity, duration, and frequency. Theseare defined as follows:

1 = none or insignificant in intensity orduration, present none or a little ofthe time in frequency

2 - mild in intensity or duration, presentsome of the time in frequency

3 - of moderate severity, present a good

part of the time in frequency4 severe in intensity or duration, pre­

sent most or all of the time in fre­quency.

To help establish severity, the followingquestions may be necessary: Intensity ­''How bad was it?" Duration - "How longdid it last?" Frequency - ''How much of thetime did you feel that way?"

TABLE II - The Anxiety Status Inventory (ASI) containing the diagnostic

criteria of an anxiety disorder and their respective interview guide items

AFFECTIVE £:< INTERVIEW GUIDE SEVERITY OF OBSERVEDSDrl<\TIC SYNPTONS FOR OR

OF ANXIETY ANXIETY STATUS INVENTORY (AS!) NONE MILD HOD SEV

I. Anxiousness Do you ever feel nervous and anxious: I 2 J .',

2. Fear Have you ever fe I t afraid? I 2 J .',

J. PanicHow easily do you get upset?

I 2 J .',Ever have panic spe lls or feel likc> it:

.', . Mental disintegratior 00 you ever fee I I ike you1re falling apart? I 2 J .',Going to pieces:

5. Apprehension H~lvc you ever felt uneasy? or that something 1 2 J .',terrible was going to happen?

6. Tremors Have hOU had times when you felt yourself 1 2 J .',trem ling? shaking?

7. Body aches '-. pains Do you have headaches? neck or back pains? I 2 3 .',

8. Easy fatiguability, How easily do you get tired? I 2 J .',weakness Ever have spells of weakness?

9. Rest lessness Do you find yourse If restless and can't I 2 J .',sit still?

10. Palpitation Have you ever felt that your heart 1 2 J .',was running away?

II. Dizziness Do you have dizzy spells? 1 2 J 4

12. Faintness Do you have fainting spells? or feel like it? 1 2 3 4

13. Dyspnea Ever have trouble with your breathing? 1 2 J 4

I.',. ParesthesiasEver have feelings of numbness and t ing ling

I 2 J .',in your fingertips? or around your mouth?

IS. Nausea & vomiting Do you ever feel sick to your stomach or I 2 3 .',

feel like vomiting?

16. Urinary frequency How often do you need to empty your bladder? I 2 3 4

17. Sweating Do you ever get wet, clammy hands? I 2 3 4

18, Face flushing Do you ever feel your face getting hot and 1 2 3 4blushing?

19. Insomnia How have you been sleeping? 1 2 3 4

20. Nightmares 00 you have dreams that scare you? 1 2 3 4

November-December 1971 373

PSYCHOSOMATICS

4. An items is scored positive and presentwhen:

A. Behavior is observedB. Behavior was described by the patient

as having occurred

c. Patient admits that symptom is still aproblem

5. An item is scored negative and not pre­sent when:

A. Symptom has not occurred and not a

TABLE III - The Self-rating Anxiety Scale (SAS)

NAME, AGE, _ SEX: M F

NO. _ DATE _

None OR :A little Some Good part Most OR AlII

of the time of the time of the time of the time

1- I feel more nervous andanxious than usual

2. I fee 1 afraid for no reason at all

3. I get upset easily or feel panicky

4. I feel like I'm falling apart andgoing to pieces

5. I feel that everything is all rightand nothing bad will happen

6. My arms and legs shake and tremble

7. I am bothered by he~daches,neck and ba~k pains

8. I feel weak and get tired easily

9. I feel calm and can sit sti 11 easily

10. I can feel my heart beating fast

ll. I am bothered by diZZy spells

12. I have fainting spe lls or feellike it

13. I can breathe in and out easily

14. I get fee lings of numbness andtingling in my fingers, toes

15. I ~m bothered by stomachachesor indigestion

16. I have to empty my bl~dder often

17. Hy hilnds are usuilily dry and Harm

18. Hy filce gets hot and blushes

19. I filiI asleep easily and get agood night's rest

20. I have nightmares

374 Volume XII

RATING INSTRUMENT-ZUNG

problem or presentB. Patient gives no information relevant

to an itemC. Response is ambiguous even after suit­

able probingA total raw score is obtained by a sum­

mation of the rated responses obtained foreach of the 20 items.Self-rating Anxiety Scale (SAS)

For the purpose of constructing the SAS,

illustrative verbatim records were made frompatient interview and examples were selectedfor inclusion which were most representativefor the particular symptom. Table III is theactual form of the SAS as it is used and to bescored by the patient. The SAS is based onthe same 20 diagnostic criteria as the observerrated Anxiety Status Inventory.

So that the patient is less able to discerna trend in his answers, the scale was devised

TABLE IV - Key for Scoring Self-rating Anxiety Scale (SAS)

None ORA little Some Good part Most OR All

of the time of the time of the time of the time

1- I feel more nervous andanxious than usual I 2 3 :.

2. I feel afr,1id for no reason at all 1 2 J :.

J. I i!et upset e3si Iy or fee 1 pnnicky 1 2 J .:.

4. I fee 1 like I'm fctllin~ apart and 1 :2 J -,going to pieces

5. I fee 1 that everythi ng is all right~ 3 :2 1

and nothing bad wi 11 happen

6. My arms and legs shake and tremble I :2 J .:.

7. I am bothered by headaches, 1 2 3 .:.neck 3nd bilck pilins

8. I feel weak and get tired easily I 2 3 .:.

9. I fee 1 calm 3nd can sit sti 11 easily .:. 3 2 I

10. I C.:10 feel my heart be3ting fast 1 2 3

II. I am bothered by dizzy spe lls I :2 3 .:.

1:2. I have faintin~ spells or feel1 2 3 "like it

13. I can breathe in '1nd out easily .:. 3 2 I

14. I get feelings of numbness and I 2 3 :.tingling in my fingers, toes

IS. I 3m bothered by stom3chaches 1 2 3 :.or indigestion

16. I h3ve to empty my bladder often 1 2 3 .:.

17. My hands are usu31ly dry and warm - J 2 1

18. Ky face gets hot :",d blushes 1 2 3 ~

19. I fall asleep easily "nd get a J 2 1'+good night's rest

20. I have nightm3res 1 2 3 4

November-December 1971 375

PSYCHOSOMATICS

so that of the 20 items used, some of the itemswere worded symptomatically positive, andothers symptomatically negative, dependingupon their suitability and usage. In addition,an even-number of columns were used toeliminate the possibility of a patient checkingmiddle and extreme columns.

In using the scale, the patient was askedto rate each of the 20 items as to how it ap­plied to him within the past week, in thefollowing four quantitative terms: NoneOR A little of the time, Some of the time,Good part of the time, Most OR All of thetime. The SAS is constructed so that the lessanxious patient will have a low score on thescale, and the more anxious patient will have

TABLE V

a higher score. In scoring the SAS, a value of1, 2, 3 and 4 is assigned to a response depend­ing upon whether the item was worded posi­tively or negatively. A key for scoring thisscale can be simply made up, as shown inTable IV.

An index for the SAS (and for the ob­server rated Anxiety Status Inventory orASI) was derived by dividing the sum of thevalues (raw scores) obtained on the 20 itemsby the maximum possible score of 80, con­verted to a decimal and multiplied by 100(see Table V).

In order to prevent confusion between theASI and SAS results, the converted ASI scoreis called a Z score and the converted SAS

TABLE VI

A table for the conversion of raw scores toASI and SAS indices

Distribution of patients tested by their ase,sex, and psychiatric diallnoses at time of

discharse

RawScore

20

21

22

23

24

25

26

27

28

29..30

31

32

33

34

35

36

37

38

39

ASI&

SASIndex

25

26

28

29

30

31

33

34

35

36

38

39

40

41

43

44

45

46

48

49

RawScore

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

ASI&

SASIndex

50

51

53

54

55

56

58

59

60

61

63

64

65

66

68

69

70

71

73

74

Raw

Score

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

ASI&

SASllIdex

75

76

78

79

80

81

83

84

85

86

88

89

90

91

92

94

95

96

98

99

100

AGE

19 & under

20 - 3940 - 6465 & over

SEX

Males

Females

DIAGNOSES

Mental Retardation

Organic Brain Syndrome

Schizophrenia

Anxiety Disorder

Depressive Disorder

Obsessive Compulsive Disordel'

Personality Disorders

Psychophysiologic Disorders

Transient SituationalDisturbances

No Psychiatric Diagnosis

N

897

112

8

225

175

50

225

1

5

25

22

967

54

2

12

1

225

%

3.643.149.73.6

100.0

0.42.2

11.19.8

42.9

3.224.2

0.9

5.3

100.0

376 Volume XII'

RATING INSTRUMENT-ZUNG

score is called an index.

Taylor Manifest Anxiety Scale (TMAS)

The TMAS consists of 50 items drawnfrom the Minnesota Multiphasic PersonalityInventory (MMPI) judged to be indicativeof manifest anxiety.6 Since this is a commonlyused scale in anxiety studies, we included itin our investigation.

The self-rated forms were not looked at norscored until the completion of the study.

The SAS was given on randomly selecteddays to a normal control group of 100 in­dividuals, who were at work at the hospital.They consisted of approximately an equalnumber of professional and non-professionalstaff members.

TABLE VIII

TABLE VII

Anxiety Status Inventory (ASI) Z Scores forthe various diagnostic groups tested

Self-rating Anxiety Scale (SAS) indices forthe various diagnostic groups tested

Subjects Tested

A total of 225 patients were tested duringthe period of study. The inpatient population(N=152) were all men, whose ages rangedfrom 22 to 75 years (m=45). The out-pa­tient population (N=73) had 23 men and50 women, whose ages ranged from 14 to 72years old (m=32). The total mean age forall 225 subjects was 41 years old. Each pa­tient was given a diagnosis at the time of dis­charge by his psychiatrist, and was donewithout any knowledge of the scale results.The distribution of all patients tested by theirage, sex and diagnoses are presented inTable VI.

A total of 100 normal adult subjects weretested. There were 57 men and 43 women.Their ages ranged from 18 to 62 years old(m=34).

RESULTS

Anxiety Status Inventory (ASI)

Results of the ASI for the five largest diag­nostic groups which comprised 93% of thetotal patient population tested are presentedin Table VII. Statistical tests of significanceusing analysis of variance indicated that themean ASI Z score obtained by patients withdiagnoses of anxiety disorders was significant­ly higher than those of the other four diag­nostic groups (P = < 0.05).

Self-rating Anxiety Scale (SAS)

Results of the SAS for the five largest diag­nostic groups are presented in Table VIII.Analysis of variance indicated that the meanSAS index obtained by patients with diag­nosis of anxiety disorders was significantlyhigher than those of the other four diagnosticgroups (P = < 0.05). In addition, the meanSAS index obtained from normal control sub-33.8 ± 5.9

209100Controls6

Data CoIIection

The data for this study were obtained asfollows: all new patients admitted to the psy­chiatric in-patient service of the hospital for15 consecutive months, and all new patientsseen at the out-patient clinic for 4 consecutivemonths were seen and tested. Patients werefirst given the self-rating form of the anxietyscales (SAS and TMAS), after which an in­terview was conducted to complete the inter­view-rating form of the anxiety scale (ASI).

ASI Z ScoreGroup Diagnosis N Mean & S.D.

1 Anxiety Disorder 22 62.0 ± 13.82 Schizophrenia 25 49.4 ± 15.93 Depressive Disorder 96 49.9 ± 12.54 Personality Disorder 54 52.6 ± 13.65 Transient Situational

Disturbances 12 42.0 + 8.1

SAS IndexGrou,p Diagnosis N Mean & S.D.

1 Anxiety Disorder 22 08.7 ± 13.52 Schizophrenia 25 46.4 ± 12.93 Depressive Disorder 96 50.7 ± 13.44 Personality Disorder 54 51.2 ± 13.25 Transient Situational

Disturbances 12 45.8 ± 11.9

November-December 1971 377

PSYCHOSOMATICS

TABLE IX

TABLE X

Severity of Symptoms of Patients withAnxiety Disorders

Taylor Manifest Anxiety Scale (TMAS)Scores for the various diagnostic groups tested

Volume XII

as being the worst (upper third) the follow­ing affective symptoms: feelings of mentaldisintegration, anxiousness and apprehension,and somatically: symptoms referable to themusculoskeletal and gastrointestinal systems.By comparison, Wheeler et al.5 noted in theirstudy that the most frequent complaints bypatients with anxiety neurosis as involvingthe cardiovascular and respiratory systems(see Table I).

Taylor Manifest Anxiety Scale (TMAS)

Results of the TMAS for the five largestdiagnostic groups are presented in Table X.Analysis of variance indicated the meanTMAS scores obtained for these diagnosticgroups were not significantly different fromeach other (P = > 0.05).

Correlation between ASI, SAS and T M AS

Pearson product-moment correlation forcalculation of the coefficient r on data ob­tained from all patients was performed. Allof the coefficients r calculated were statisti­cally significant, with P = < 0.01 in all in­stances.

The correlation between the ASI and SASwas 0.66. Correlation between the ASI andTMAS, and SAS and TMAS were 0.33 and0.30, respectively. Correlation between theASI and SAS scores for patients with a diag­nosis of anxiety disorder was 0.74.

Split half correlations for the ten even­numbered and the ten odd-numbered ASIitems, and similarly, for the even-odd SASitems were 0.83 and 0.71, respectively.

Correlations between items 1 through 20of the ASI with the ASI Z score were as fol­lows: 0.50, 0.56, 0.65, 0.65, 0.64, 0.50, 0.52,0.34, 0.51, 0.65, 0.61, 0.65, 0.42, 0.63, 0.60,0.39, 0.54, 0.49, 0.58, and 0.47, respectively.

Correlations between items 1 through 20of the SAS with the SAS index were as fol­lows: 0.39, 0.53, 0.57, 0.69, 0.50, 0.56, 0.58,0.40, 0.50, 0.64, 0.47, 0.51, 0.27, 0.55, 0.61,0.62,0.42, 0.47, and 0.49, respectively.

DISCUSSION

Anxiety scales available and in use todaycan be divided into those which are generaland measure anxiety as a personality trait or

MeanSAS Item Items: in Decreasing

Score No. Order of Severity

2.8 4 Mental disintegration2.8 6 Tremors

2.6 7 Body aches and pains2.5 1 Anxiousness2.5 5 Apprehension

2.5 15 Nausea and vomiting

2.4 2 Fear

2.4 3 Panic

2.4 10 Palpitation2.4 14 Paresthesias

2.4 16 Urinary frequency2.2 17 Sweating2.1 8 Fatigue

2.1 13 Dyspnea

2.1 20 Nightmares2.0 9 Restlessness2.0 11 Dizziness2.0 12 Faintness

2.0 18 Face Blushing2.0 19 Insomnia

TMASScoreGroup Diagnosis N Mean & S.D.

1 Anxiety Disorder 22 31.0 ± 15.32 Schizophrenia 25 23.0 ± 13.53 Depressive Disorder 96 25.1 ± 13.54 Personality Disorder 54 31.7 ± 10.85 Transient Situational

Disturbances 12 29.3 ± 7.0

378

7

5

6

4

2

3

1

RankOrder

jects was significantly lower than all five ofthe patient diagnostic groups (P = < 0.01).

Table IX rank orders the 20 items of theSAS as quantitated by the patients with anxi­ety disorders, listed in decreasing order ofseverity, and arbitrarily divided into thirds. Itcan be seen that these patients complained

RATING INSTRUMENT-ZUNG

feeling state, and those which are specific andmeasure anxiety as a clinical entity. They mayalso be grouped as those which are self-ad­ministered and those which are given by atrained interviewer. General instruments in­clude those by Costello and Comrey;, whoseanxiety scale was designed to measure a pre­disposition to develop anxious states; Cattell'sanxiety scale" which is used to measure fluc­tuations in level of anxiety over short periodsof time; and Taylor's manifest anxiety scaler,.Use of a general scale for the measurement ofanxiety as a clinical entity may tend to obscureresults more than it would reveal. Thus, in astudy of the TMAS, O'Connor et aP did afactor analysis of their results and showedthat as many as five different dimensions wereinvolved in the items comprising the scale.Aggregate scores of such a scale may confoundby blurring, and analysis by sub-groups ofitems may fail to indicate differences whichmay be present. Examples of specific anxietyscales include those by Hamilton10 and Kell­ner and Sheffield ll

• These are both interview­er-rated scales and require a trained clinicianto complete them.

In developing the presently reported rat­ing instrument for measuring anxiety as aclinical entity, we felt that it would fullfill thepreviously mentioned criteria and that itwould be a useful tool for our purpose. Fromthe results obtained, it did appear to us thatthe two-part instrument, consisting of the self­rated SAS, and the clinician-rated ASI wasuseful in quantitating anxiety as an opera­tionally defined disorder.

SYNOPSIS

A rating instrument for the measurementof anxiety as a clinical entity was devised asan attempt to quantitate the symptoms of thisdisorder, using the most commonly agreedupon diagnostic criteria. As a two-part instru­ment, it can be used as an interviewer-ratedinventory (Anxiety Status Inventory or ASI),

November-December 1971

or as a self-rated scale (Self-rating AnxietyScale or SAS). Data was collected from apopulation of psychiatric patients using thenew instrument and the Taylor ManifestAnxiety Scale (TMAS). Statistical analysesof the results indicated that the new instru­ment was able to differentiate significantlyanxiety patients from patients with other diag­noses, whereas the TMAS did not. Correla­tion between the ASI and SAS, and betweenthe individual items of the two-part instru­ment with their respective total scores wereall significant.

REFERENCES

1. Portnoy, I.: The Anxiety States, in Arieti, S.(Editor): American Handbook of Psychiatry,Vol. I: Basic Books, New York, 1959, p. 308.

2. Diagnostic and Statistical Manual of MentalDisorders, Second Edition, American Psy­chiatric Association, Washington, D.C., 1968,p.39.

3. Kolb, L.: Noyes' Modern Clinical Psychiatry,Seventh Edition, Saunders, Philadelphia, 1968,pp. 464-466.

4. Lief,. H.: Anxiety React;on, in Freedman, A.and Kaplan, H. (Editors): CcmLIJrehensiveTextbook of Psychiatry, Williams and Wil­kins, Baltimore, 1967, pp. 865-866.

5. Wheeler, E., White, P., Reed, E., and Cohen,M.: Neurocirculatory Asthenia (Anxiety Neu­rosis, effort syndrome, neurasthenia), JAMA,142: 878-888, 1950.

6. Taylor, J.: A personality scale of manifestanxiety, J. Abn. & Soc. Psychol. 48:285-290,1953.

7. Costello, C. and Comrey, A.: Scales for mea­suring depression and anxiety, J. Psychol.66 :303-313, 1967.

8. Cattell, R.: Handbook for the IPAT AnxietyScale. Institute for Personality and AbilityTesting, Champaign, Illinois, 1957.

9. O'Connor, J., Lorr, M. and Stafford, J.: Somepatterns of manifest anxiety, J. Clin. Psychol.12: 160-163, 1956.

10. Hamilton, M.: The assessment of anxietystates by rating, Brit. J. M ed. Psychol. 32:50-55, 1959.

11. Kellner, R. and Sheffield, B.F.: Symptom Rat­ing Test scores in neurotics and normals,Brit. J. Psychiat. 113 :525-526, ]967.

37~