Insomnia and Anxiety (Series in Anxiety and Related Disorders) (7 page)

Structured Interviews for Anxiety

Clinician-Administered Interviews for Anxiety

The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) (Brown, Black, &

Uhde, 1994) is a commonly used semi-structured interview for DSM-IV anxiety

disorders. Within each disorder, users can collect information on specific symptoms,

the intensity of fear and avoidance, the age of onset, and possible causes of the

disorder. There are versions that can be used to collect information on lifetime anxiety

disorders – ADIS-IV-L (Di Nardo, Brown, & Barlow, 1994), children (ADIS-IV-C)

and parental report of their child’s anxiety issues (Silverman & Albano, 1996). The

ADIS-IV is considered a reliable and valid measure for anxiety disorder assessment

(Brown, Di Nardo, Lehman, & Campbell, 2001) with the possible exception of

reliability estimates for GAD. Lowered reliability for GAD may reflect nosologic

issues with the diagnosis itself (i.e., there is high symptom overlap with a number

of other disorders) (Brown et al., 2001). Although the ADIS-IV is a very useful tool

in assessing anxiety and related disorders it can take a few hours to administer.

Clinician-Administered Interviews for Specific Anxiety Disorders

OCD
: The Yale-Brown Obsessive Compulsive Scale (Goodman et al., 1989) is a

10-item, clinician-administered interview. For a variety of reasons, including strong

psychometric performance (Goodman et al., 1989), the Y-BOCS is one of the most

widely used rating scales for OCD. The Y-BOCS is used primary to assess symp-

tom severity across five domains: (1) time spent or occupied; (2) interference with

functioning or relationships; (3) degree of distress; resistance; and control. The

Y-BOCS has been used in those with delayed sleep phase syndrome (Turner et al.,

2007), and was used in an investigation of sleep disturbances among those with

OCD (Kluge, Schussler, Dresler, Yassouridis, & Steiger, 2007).

PTSD
: The Clinician-Administered PTSD Scale (CAPS) (Blake et al., 1990) is a

widely used structured interview for the assessment of PTSD. The CAPS assesses

for the presence of DSM-IV-TR criteria for PTSD. Each symptom is rated on the

basis of frequency and intensity. There is one insomnia item in the interview that

was used to evaluate residual insomnia after the completion of CBT in those who

had PTSD (Zayfert & DeViva, 2004). Zayfert and colleagues employed a >30 min

sleep difficulty cutoff for insomnia and a >90 min cutoff for severe insomnia.

Panic Disorder
: The Panic Disorder Severity Scale (PDSS) (Shear et al., 1992) is a

brief, clinician-administered interview for the assessment of panic attack and asso-

ciated avoidance frequency, severity, and distress. It is not a diagnostic measure, but

provides a quick assessment of panic disorder symptoms consistent with DSM-IV

criteria. There are good demonstrated psychometric properties in those with anxiety

Structured Interviews for Anxiety

23

disorders (Shear et al., 1992); although we are unaware of any use in those with

insomnia.

Self-Report Measures for Anxiety Symptoms

Sleep centers may be most likely to use a general psychiatric symptom instrument

like the Profile of Mood States (POMS) (McNair, Lorr, & Droppleman, 1971),

Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983), or the Symptom

Checklist – SCL-90 (Derogatis, 1992). Such instruments contain a variety of

symptoms, including anxiety symptom scales. However, there are specific mea-

sures that can be used for anxiety as well as specialized scales to assess specific

anxiety problems.

General Measures for Self-Reported Anxiety

The Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown, & Steer, 1988) is a

21-item screening test designed to distinguish anxiety symptoms from depressive

symptoms based on symptoms experienced during the past week. Although the BAI

may be helpful in assessing anxiety symptoms, it has been criticized for its overlap

with panic attack symptoms (Cox, Cohen, Direnfeld, & Swinson, 1996). Because

many individuals with GAD do not experience the range or severity of autonomic

symptoms associated with panic attacks, the BAI may be less appropriate as a mea-

sure of anxiety symptomatology in individuals with GAD. People with breathing

related disorders tend to score in the moderate range on the BAI, which appears to

reflect the increased prevalence of anxiety disorders in those with sleep disordered

breathing (Sharafkhaneh, Giray, Richardson, Young, & Hirshkowitz, 2005) rather

than psychometric shortcomings of the instrument (Sanford, Bush, Stone, Lichstein,

& Aguillard, 2008). The State-Trait Anxiety Inventory (STAI) (Spielberger,

Gorsuch, & Lushene, 1970) is a widely used measure to assess general levels of

anxiety. The STAI has been used across many insomnia studies. However, we are

not aware of any specific psychometric evaluations of the properties of the STAI in

those with insomnia or other sleep disorders.

The Anxiety Sensitivity Index (ASI) (Peterson & Reiss, 1993) is a 16-item scale

measuring fear of anxiety-related symptoms. Endorsement of each item is rated on

a 5-point scale ranging from 0 (very little) to 4 (very much) indicating the strength

of one’s beliefs about the consequences of anxiety, such as fear of embarrassment,

illness, and loss of control. Anxiety sensitivity has been identified as an important

construct in the onset and exacerbation of anxiety disorders (Peterson & Reiss,

1993; Schmidt, Zvolensky, & Maner, 2006) and has recently been identified as a

predictor of sleep-related impairment, but not actual sleep disturbance, in those

with insomnia (Vincent & Walker, 2001).

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2 Considerations for Assessment

Anxiety Disorder-Specific Self-Report Questionnaires

GAD
: The Penn State Worry Questionnaire (PSWQ) (Meyer, Miller, Metzger, &

Borkovec, 1990) is one of the most common tools used to assess pathological worry.

It is a 16-item inventory intended to measure the generality, excessiveness, and

uncontrollability of pathological worry. The PSWQ focuses on the more cognitive

concept of worry, as opposed to the BAI, and does not explicitly address sleep symp-

toms. Total scores range from 0 to 90. The PSWQ has good internal consistency and

test–retest reliability over 8–10 weeks (Meyer et al., 1990). Behar, Alcaine, Zuellig,

and Borkovec (2003) report that ROC cut-off of 45 gives sensitivity of 99% and

specificity of 98% in separating GAD from non anxious controls (the diagnosis was

made by self-report). The same authors looked at a sample of undergrads and

derived a cut-off of 62 (86% sensitivity and 75% specificity). Fresco, Mennin,

Heimberg, and Turk (2003) looked at social phobia vs. GAD and found a cut-off of

65 to be optimal. The PSWQ has been used in sleep populations, including primary

insomnia (Buysse et al., 2008; Harvey & Greenall, 2003); however, no psychometric

properties of the PSWQ among individuals with sleep disorders were found.

OCD
: The Obsessive Compulsive Inventory-Revised (OCI-R) (Foa et al., 2002) is

an 18-item self-report questionnaire that assesses the degree of distress related to

OCD symptoms in the past month. The OCI-R discriminates OCD from other anxi-

ety disorders (Abramowitz & Deacon, 2006) and has sound psychometric proper-

ties (Foa et al., 2002), but its properties in sleep disordered groups are unknown.

PTSD
: The Impact of Events Scale (IES) (Horowitz, Wilner, & Alvarez, 1979) is a

widely used 22-item questionnaire to assess responses to traumatic events. A Likert

rating scale is used to assess the degree of distress produced by each symptom.

The PTSD Diagnostic Scale – PDS (Foa, Cashman, Jaycox, & Perry, 1997) is used

to inquire about the presence and severity of the DSM-IV PTSD symptoms. The

measure asks about the frequency of each of the 49 items in the past month, which

are rated on a 4-point scale. The PSQI Addendum for PTSD – PSQI-A (Germain,

Hall, Krakow, Shear, & Buysse, 2005) is a 7-item scale measuring the frequency of

disruptive nocturnal behaviors such as: hot flashes, general nervousness, memories

or nightmares of traumatic experiences, severe anxiety or panic not related to trau-

matic memories, bad dreams not related to traumatic memories, episodes of terror

of screaming, and episodes or acting out dreams. There are also frequency and tim-

ing ratings of nocturnal anxiety and anger and timing of these events. Preliminary

studies have suggested that this addendum has good internal consistency (
a
= 0.85),

good convergent validity with measures of PTSD and the PSQI, and good sensitivity

and specificity for distinguishing those with PTSD from those without.

Social Phobia
: The Social Phobia Inventory (SPIN) (Connor et al., 2000) is a

17-item self-report measure that assesses multiple facets of social anxiety including

the following: (1) avoidance of feared social situations, (2) feelings of embarrass-

ment, (3) physiological changes (e.g., blushing), and (4) fear of being the center of

attention. The SPIN has good reported psychometric properties and may be useful

Structured Interviews for Anxiety

25

as a brief screen for Social Phobia (Connor et al., 2000). The Social Phobia Scale

(SPS) (Mattick & Clarke, 1998) is a 20-item questionnaire to assess the fear of

scrutiny/evaluation in performances situations. Internal consistency reliability for

the SPS has been shown to be high, with alpha values of 0.94. The Social Interaction

Anxiety Scale (SIAS) (Mattick & Clarke, 1998) is a 19-item questionnaire to assess

fears of specific social interaction situations (e.g., dating and attending parties). As

with the SPS, the internal consistency reliability for the SIAS is excellent (
a
= 0.94).

Internal consistency was also high in a study of social anxiety, depression, and

insomnia (Buckner, Bernert, Cromer, Joiner, & Schmidt, 2008). This study showed

that 18.2% of socially anxious participants had elevations on the ISI suggestive of

clinically significant insomnia.

The Social Phobia and Anxiety Inventory (SPAI) (Turner, Beidel, Dancu, &

Stanley, 1989) is a 45-item self-report questionnaire of the frequency of social phobia

or agoraphobia experiences across a range of social contexts. There is good internal

consistency reliability (Turner et al., 1989) and validity (Peters, 2000). A literature

search using the PSYCInfo database did not yield any results for the searches “Social

Phobia and Anxiety Inventory AND sleep disorder,” “SPAI AND sleep disorder,”

“Social Phobia and Anxiety Inventory AND insomnia,” or “SPAI AND insomnia.”

Panic Disorder and Agoraphobia
: The Agoraphobic Cognitions Questionnaire

(ACG) (Chambless, Caputo, Bright, & Gallagher, 1984) is a 15-item measure of

“fear of fear” in those with panic disorder or agoraphobia. The frequency of spe-

cific catastrophic thoughts about the consequences of experiencing anxiety is rated

on a 5-point scale (1 = the thought never occurs, and 5 = the thought always occurs).

The ACQ has demonstrated adequate psychometric properties for the full scale, as

well as two subscales reflecting the loss of control and the consequences of physi-

cal symptoms, and is able to discriminate anxiety disordered from non-clinical

samples (Chambless & Gracely, 1989). Although some analyses suggest that the

two factor structure lacks validity, the ACQ remains one of the most widely used

instruments in research and clinical practice for patients with agoraphobia. To date,

no research has reviewed the ACQ for use with sleep disordered population; how-

ever, evidence indicates that the catastrophic cognitions measured by the ACQ are

specific to the experience of diurnal panic attacks and relatively unrelated to noc-

turnal panic attacks (O’Mahony & Ward, 2003). The ACG is most typically admin-

istered along with the Body Sensations Questionnaire (BSQ) (Chambless et al.,

1984); a measure of the intensity of fear of the physical sensations of anxious

arousal. Each of the 17 physical symptom/panic sensation items are rated on a scale

of 1–5 that corresponds to the degree to which the sensation is frightening.

Although the BSQ has not been examined in the context of insomnia, there

appears to be no relationship between the fear of interoceptive cues as measured

on the BSQ and sleep disturbances related to nocturnal panic attacks relative to

those whose panic attacks occur exclusively during daytime (Craske, Lang, Tsao,

Mystkowski, & Rowe, 2001).

The Panic Attack Symptoms Questionnaire (PASQ) and Panic Attack Cognitions

Questionnaire (PACQ) (Clum, Broyles, Borden, & Watkins, 1990) can be used to

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2 Considerations for Assessment

assess the severity of panic attacks and the degree to which patients are preoccupied