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Psychometric Measures of Fear Anxiety and Phobia

Presented by –Deepti Awasthi

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contents

• Introduction• Difference between anxiety, fear & phobia• Methods to measure anxiety• Anxiety rating scales• Conclusion• References

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Introduction

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Difference between anxiety, fear & phobia

• Dental anxiety

• Dental fear

• Dental phobia

Textbook of Pedodontics – Shobha Tandon

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Methods to measure anxiety

• Physiological• Behavioural• Hormonal • Psychometric

Advances in psychology research

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Physiological

• Anxiety leads to change in Vitals

Measures: • Heart Rate• Pulse• Oxygen saturation• B.P.• Palmer Sweating• Respiratory rate• Muscle tone

Advances in psychology research

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Disadvantage• Requires expensive instruments• Instruments itself may introduce

anxiety• Therefore not correct measure of

anxiety• Anxiety may be of instrument only

not of dental T/t• Dentists not trained to use these

instrument ( will require training)• Time consuming

Advances in psychology research

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Hormonal

• Stress activates production of adrenal hormone and salivary cortisol is equal to free cortisol in serum.

• Disadvantage• Time consuming• Special instrument required• Not possible in all set-ups• costly

Advances in psychology research

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Psychometric

• Inexpensive, flexible, easy to administer and results in score ranges that can be easily compiled & processed statistically

Advances in psychology research

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Anxiety rating scales

1. Corah2. Modified Corah’s3. Klienknecht’s Dental fear survey4. Dental Anxiety Question5. Photo Anxiety Questionnaire6. Children’s Fear Survey Schedule7. Venham Picture Scale8. Adolescents’ Fear of Dental

Treatment Cognitive Inventory.9. Behaviour Profile Rating Scale 10.Hamilton anxiety rating scale11.Zung Self-Rating Anxiety Scale (SAS )12.Fear Survey Schedule

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CORAH Dental anxiety scale

• Norman Corah(1969)• 4 item measure• Respondents are asked about 4

dentally related situations and are asked to indicate which of four responses is closest to their likely response to that situation.

ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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• 1.If you had to go to the dentist tomorrow, how would you feel about it?-I would look forward to it as a reasonably enjoyable experience.-I wouldn't care one way or the other.-I would be a little uneasy about it.-I would be afraid that it would be unpleasant and painful.-So anxious that I sometimes break out in a sweat or almost feel physically sick

• 2.When you are waiting in the dentist's office for your turn in the chair, how do you feel?-Relaxed-A little uneasy-Tense-Anxious-So anxious that I sometimes break out in a sweat or almost feel physically sick

Corah DAS , revised

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• .3.When you are in the dentist's chair waiting while he gets his drill ready to begin work on your teeth, how do you feel?-Relaxed-A little uneasy-Tense-Anxious-So anxious that I sometimes break out in a sweat or almost feel physically sick

• 4.You are in the dentist's chair to have your teeth cleaned. While you are waiting and the dentist is getting out the instruments that he will use to scrape your teeth around the gums, how do you feel?-Relaxed-A little uneasy-Tense-Anxious-So anxious that I sometimes break out in a sweat or almost feel physically sick

Corah DAS , revised

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• Total scores ranged from 4 to 20. • Anxiety rating:• 4-5 = No Anxiety• 6-8 = Mild Anxiety• 9 - 12 = moderate anxiety • 13 - 14 = high anxiety• 15 - 20 = severe anxiety or phobia

Corah DAS , revised

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• Advantages :

• Adults & children• Internal consistency & reliability is

high.

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• Disadvantages :• range of total scores is too narrow to

be used effectively in clinical studies.

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Modified Corah’s anxiety Scale• Humphris- 1995• Addition of a fifth item that asks

responses to administration of local anesthetics

• most frequently used dental anxiety questionnaire in the United Kingdom.

• High reliability & validity.Advances in psychology research

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• Each item scored as follows:Not anxious = 1Slightly anxious = 2Fairly anxious = 3Very anxious = 4Extremely anxious = 5

• Total score is a sum of all five items• range 5 to 25: • 19 or above which indicates a highly

dentally anxious patient, possibly dentally phobic .

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Klienknecht’s Dental fear survey

• asks respondents to rate their anxieties about 27 specific situations—such as

• making an appointment or• hearing the dental drillon a five-point Likert scale ranging

from “none” to “great”.

ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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Dental Anxiety Question

• is a single-item construct:• “Are you afraid of going to the dentist?” • It has four possible responses:• “no,”• “a little,”• “yes, quite,”• “yes, very.”• These responses are scored from 1 to 4

in the direction of increasing anxiety. ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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• Useful & brief tool for some purposes – screening people , who are likely to be highly anxious about dental treatment.

• it has a tendency to overestimate the prevalence of severe dental anxiety

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Photo Anxiety Questionnaire

• The response scale is nonverbal, consisting of five photographs with facial expressions of differing anxiety levels.

• There are different versions for men and women.

• Patients indicate which photograph best expresses their feelings.

• The scale is scored by summing the item ratings 1 = relaxed,

5 = very anxiousANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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• Advantages:

• internal consistency of the scale is high

• Does not rely on verbal markers• problems of differences in the

interpretation of words and phrases do not arise

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Children’s Fear Survey Schedule.

• Cuthbert & Malamed (1982)• Commonly used measure of dental

fear among children • Child subjects rate their level of fear

on a 5-point scale covering 15 situations, ranging from “not afraid at all” to “very much afraid”.

ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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The situations are divided into three categories

Fear of highly invasive procedures--drilling and filling

Fear of potential victimisation-- from strangers, taking a choking fit

Fear of less invasive procedures-- opening the mouth and being examined by the dentist.

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• RATING• The possible response to each item

was scored between• 1 - not afraid• 5 - very afraid • Total scores ranged between 15–75. • Children with the scores >38 can be

defined as dentally anxious

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Venham Picture Scale• By venham et al (1977)• scale consists of a series of eight paired

drawings of a child.• Each pair consists of a child in a non-

fearful pose and a fearful pose.• The respondent is asked to indicate which

picture more accurately reflects his / her feelings at the time.

• Scores are determined by summing the number of instances in which the child selects the high-fear stimulus.ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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Crying

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Anger

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Run away

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Anxious

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surprise

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Aloof

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Feeling of cry

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sad

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• The more emotional figure of the pair of cartoons is scored one

• whereas the more emotionally neutral figure is scored zero.

• Scale has a range of 0 – 8• 0- no anxiety• 8- Severe anxiety

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Advantages• quick • Child need not be able to read to

complete the scale. • Scale especially suitable for young

children.Disadvantages• Failure to interpret photograph

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Adolescents’ Fear of DentalTreatment Cognitive Inventory.

• measures the thoughts and ideas an adolescent may have during dental treatment.

• It is unique among the children’s scales in that it focuses solely on the cognitive manifestations of fear.

• It is a 23-item scale, with a five-point response format.

• Scores ranges from • 23 - no fear to• 115 - high fear. ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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• Factor analysis of the scale revealed four components:

• fear of pain• negative perceptions of the dentist• avoidance of the dentist and a• fourth scale that was not interpreted

by the researchers.

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Behaviour Profile Rating Scale.

• By Malamed• 27 uncooperative behaviours

considered to be related to dental anxiety

• overall score is calculated on the basis of the frequency of each behavior, together with a weighing for the severity of the behavior (kicking)

ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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Advantages• The face validity of the scale is high, • distinguish between children referred for

behavioral management of uncooperative behavior in the dental setting and a control group of children

Disadvantages• Time consuming

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HAMILTON ANXIETY RATING SCALE

Classification of symptoms:• 0 - absent;• 1 - mild;• 2 - moderate;• 3 - severe;• 4 - incapacitating.HAM-A score level of anxiety:• < 17 mild;• 18 - 24 mild to moderate;• 25 - 30 moderate to severe.

Psychiatric Associates of Atlanta, LLC

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• 1. Anxious mood 0 1 2 3 4• • worries• 2. Tension 0 1 2 3 4• • startles• • cries easily• • restless• • trembling• 3. Fears 0 1 2 3 4• • fear of the dark• • fear of strangers• • fear of being alone• • fear of animal• 4. Insomnia 0 1 2 3 4• • difficulty falling asleep or staying asleep• • difficulty with nightmares• 5. Intellectual 0 1 2 3 4• • poor concentration• • memory impairment• 6. Depressed Mood 0 1 2 3 4• • decreased interest in activities• • insomnia

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• 7. Somatic complaints - Muscular 0 1 2 3 4• • muscle aches or pains• • bruxism• 8. Somatic complaints - Sensory 0 1 2 3 4• • tinnitus• • blurred vision• 9. Cardiovascular Symptoms 0 1 2 3 4• • tachycardia• • palpitations• • chest pain• • sensory of feeling faint• 10. Respiratory Symptoms 0 1 2 3 4• • chest pressure• • choking sensation• • shortness of breath

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• 11. Gastrointestinal Symptoms 0 1 2 3 4• • dysphagia• • nausea or vomiting• • constipation• • weight loss• 12. Genitourinary Symptoms 0 1 2 3 4• • urinary frequency or urgency• • dysmenorrhea• • impotence• 13. Autonomic Symptoms 0 1 2 3 4• • dry mouth• • flushing• • pallor• • sweating• 14. Behavior at Interview 0 1 2 3 4• .fidgets• • tremor• • paces

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Zung Self-Rating Anxiety Scale (SAS)

• 1 I feel more nervous and anxious than usual.• 2 I feel afraid for no reason at all.• 3 I get upset easily or feel panicky.• 4 I feel like I'm falling apart and going to pieces.• 5 I feel that everything is all right and nothing bad will

happen.• 6 My arms and legs shake and tremble.• 7 I am bothered by headaches neck and back pain.• 8 I feel weak and get tired easily.• 9 I feel calm and can sit still easily.• 10 I can feel my heart beating fast.

William W.K. Zung. A rating instrument for anxiety disorders. Psychosomatics. 1971

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• 11 I am bothered by dizzy spells.• 12 I have fainting spells or feel like it.• 13 I can breathe in and out easily.• 14 I get feelings of numbness and tingling in my

fingers & toes.• 15 I am bothered by stomach aches or indigestion.• 16 I have to empty my bladder often.• 17 My hands are usually dry and warm.• 18 My face gets hot and blushes.• 19 I fall asleep easily and get a good night's rest.• 20 I have nightmares.

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Fear Survey Schedule

• Geer, developed the scale• 51-item scale consisting of a list of

commonly encountered stimuli. • Each stimulus is rated on a seven-

point scale, ranging from • 0 (no fear) to 6 (terrified).• Scores indicate the extent of general

fearfulness

ANXIETY AND PAIN MEASURES IN DENTISTRY: A GUIDE TO THEIR QUALITY AND APPLICATION, JADA, Vol. 131, October 2000

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• Advantages • high levels of internal consistency• and validity• has been used in a number of

European countries

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Conclusion

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References

• Textbook of Pedodontics – Shobha Tandon • Frame H. Columbus.Advances in psychology

research , vol 43• Corah’s Dental Anxiety Scale, Revised (DAS-R)• Anxiety and pain measures in dentistry: a guide

to their quality and application, J.Timoty Newton, Dave buck; Jada, vol. 131, october 2000

• William W.K. Zung. A rating instrument for anxiety disorders. Psychosomatics. 1971

• Psychiatric Associates of Atlanta, LLC