Lecture 3: Assessment in Behavioral Health

1. Lecture 3: Assessment in Behavioral Health Dr. Antoinette Lee The University of Hong Kong

2. Outline • I. Assessing Stress • Stress • Coping • Social support • II. Assessing Mental Health Problems • Depression • Anxiety • III. Assessment of Patients with Medical Illnesses • Psychosocial factors related to physical illness • Adjustment to illness • Quality of Life • Pain • IV. Lifestyle Assessment • V. Assessing Premenstrual Syndrome

3. Assessing Stress 1.) Physiological measures 2.) Self-Report measures 3.) Interviews 4.) Ecological Momentary Assessment

4. 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

5. Polygraph Calm Tense

6. Assessing Stress • 2.) Self-Report Measures • a. Social Readjustment Rating Scale • b. Life Experiences Survey • c. Daily Hassles • d. Perceived Stress Scale

7. 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

9. SRRS • criticisms: • some items are vague • subjective experience • context • personal values and priorities • whether the event has been resolved • measuring change or negative experience?

10. 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 open-ended questions on recent events that have affected the lives of the respondents • Approximately 10 minutes to complete

11. 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

12. LES

13. 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)

14. 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)

15. LES: Norms

16. LES: Convergent Validity

17. LES • Advantages: • Brief • Easy to administer • Takes into account one’s perceived desirability of life events • Disadvantage: • Norms only available for college-aged population

18. 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).”

19. 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

20. 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)

21. 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 10-item 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

22. PSS: Sample Items

23. 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

24. PSS-14: Convergent Validity Note: Number and impact of life events was measured by a modified version of the College Student Life-Event Scale

25. PSS-14: Convergent Validity • 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

26. PSS-14: Norms 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

27. 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 16.5 • Disabled 19.9 • Separated 16.6 • Divorced 14.7 • Married 12.4

28. 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

29. Assessing Stress • 3.) Interviews • Stress symptoms • Sources of stress • Perceived stress

30. 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 tremblingFoot-tappingFinger-drumming BEHAVIORAL & SOCIAL substance use Withdrawn, reduced social contactsIntoleranceResentmentLashing outDistrustLack of intimacy Symptoms of Stress EMOTIONAL & COGNITIVE Anxiety and tension FrustrationIrritability and bad temper Mood swings Crying spellsDepression Worry Forgetfulness Poor concentration Reduced productivity Confusion Impaired judgment Accident-prone Apathy

31. 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.

32. Assessing Coping • 1.) Ways of Coping Questionnaire • 2.) Brief COPE

33. 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)

34. Ways of Coping Questionnaire

35. 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……..”

36. 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)

37. 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

38. Social Support Questionnaire

39. 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

40. 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

41. 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 • Sleep onset insomnia • Sleep maintenance insomnia • Terminal insomnia

42. Assessing insomnia • Secondary Insomnia • Secondary to / symptom of an underlying medical or psychological condition • Underlying psychopathology or psychological distress

43. Assessing Insomnia • Nature and severity of insomnia • Sleep history • Sleep diary • Epworth Sleepiness Scale • 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)

44. Assessing Patients with Physical Illnesses • Psychosocial context of Physical Illness • Adjustment to Illness • Quality of Life • Pain

45. 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

46. 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

47. Some Useful Self-Report Measures • Mini-Mac • Impact of Events Scale • Post-traumatic Growth Inventory • Measures of depression and anxiety (refer to next section)

48. 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

49. Chinese Mini-Mac

50. Chinese Mini-Mac: Reliability • 115 Hong Kong Chinese cancer patients: