"Swallowing Fear: A Holistic, Multidisciplinary Approach to Treating Phagophobia" by Kaitlin Wachter

Swallowing Fear: A Holistic, Multidisciplinary Approach to Treating Phagophobia

Kaitlin Wachter, Frederick Community College



Abstract: Phagophobia, the fear of swallowing, is a psychological condition secondary to an anxiety or depressive disorder and typically triggered by a traumatic incident, such as choking. It is difficult to state with accuracy the prevalence of phagophobia as it is diagnosed through elimination of all mechanic and neurologic causes and its wide spectrum of severity. Also due to its rarity, literature is sparse; the author found less than 10 articles on phagophobia published in the past decade, half of which were case studies. Since phagophobia is a disorder which affects the mind, emotions, and body, this study has designed a standardized, holistic treatment plan to maximize the fullness and speed of recovery, as well as the comfort of the patient.

Keywords: phagophobia, psychogenic dysphagia, holistic treatment



Dysphagia is a disorder in which an individual finds it difficult or impossible to swallow, “a disruption in the ability to move food or liquid from the mouth… into the stomach safely and efficiently” (Boyle, 2018, p.1238). This disorder affects approximately 6% of the general population and is frequently a post-surgery complication (Jain, 2016; Boyle, 2018). Minor or early cases show discomfort or unwillingness to swallow and can progress to either food avoidance or a severely restricted diet (Jain, 2016). Common effects are weight loss, anemia, and anxiety disorders due to malnutrition (Blumenfeld, 2015). Furthermore, the self-imposed restrictions or avoiding eating in public can cause crippling social anxieties and a reduced sense of self-worth (Stoian & Rizeanu, 2017).


Diagnoses are divided into three types, which are named for their root causes (Pramalatha et al., 2015). The first two are of organic origin: mechanical dysphagia is caused by physiological abnormalities or obstructions, while neurologic dysphagia is a dysfunction of the nervous system, bringing about muscular malfunctions and loss of sensory input (Boyle, 2018; Jain, 2016; Pramalatha et al., 2015). The third type, psychogenic dysphagia, is based in psychological causes, more specifically, anxiety and depression disorders (Alic, 2012).


Psychogenic dysphagia is much rarer than, its physiological counterparts (Jain, 2016; Blumenfeld, 2015). In fact, it is so rare, there are no reliable statistics as to its prevalence in the world’s population (Baijens et al., 2013). Still further, the underwhelming numbers of phagophobia diagnoses complicates research, as there are not enough known cases at any one time to carry out studies with statistically significant results (Baijens et al., 2013). Consequently, the majority of current published research papers constitute case studies, of which the author located six, and two literature reviews.


Overview of Phagophobia


Phagophobia, the fear of swallowing or choking, is a relatively common subtype of psychogenic dysphagia, triggered by a traumatic event, typically a choking incident (Acikel & Ak, 2018; Jain, 2016). This type of dysphagia presents as physiological and can only be diagnosed through elimination of those causes (Blumenfeld, 2015; Jain, 2016; Pramalatha et al., 2015). The tests needed to determine a lack of mechanic dysphagia are invasive and uncomfortable, typically including a clinical evaluation, a barium swallow study, and an endoscopy (Blumenfeld, 2015).


If neurologic and mechanic dysphagias are eliminated as causes, then the psychogenic testing can begin (Blumenfeld, 2015). This includes a variety of assessments to evaluate the patient’s psychological state, specifically gauging the incidence and severity of anxiety or depression (Finn & McKernan, 2019; Stoian & Rizeanu, 2017). There is no standardized test for these assessments; selecting an assessment is left to the discretion of the psychiatrist, psychologist, or organization administering the test (Blumenfeld, 2015). In the case studies reviewed by the author, a total of 10 different anxiety, depression, post-traumatic stress disorder, or social phobia assessment tests were implemented (Acikel & Ak, 2017; Finn & McKernan, 2019; Pramalatha et al., 2015; Stoian & Rizeanu, 2017). If an anxiety or depressive disorder is diagnosed in the presence of dysphagic symptoms and absence of neurologic and mechanic causes, a diagnosis of phagophobia is given (Finn & McKernan, 2019).


Once an official diagnosis is recorded, a treatment plan can be designed and implemented. Experts agree treatment plans should be multidisciplinary, including medical, psychiatric, and psychologic therapies (Acikel & Ak, 2017; Pramalatha et al., 2015; Stoian & Rizeanu, 2017). What is not agreed upon is a structured, standardized treatment plan. In some cases, psychoeducation of the patient was employed, teaching the physiology of swallowing (Acikel & Ak, 2017; Jain, 2016; Pramalatha et al., 2015). Most use some form of cognitive behavioral therapy, and others used talk-therapy or counselling (Acikel & Ak, 2017; Jain, 2016; Pramalatha et al., 2015; Stoian & Rizeanu, 2017). Another case study discusses creating a list of food feared and avoided by the patient, ordering the list by swallowing hierarchy, then reintroducing the foods in hierarchal order over an eight-week period (Acikel & Ak, 2017). Still another employed clinical- and self-hypnosis (Finn & McKernan, 2019).


The process of testing, diagnosis, and treatment can only be administered if an individual seeks medical care. As phagophobia ranges in severity from a paralyzing fear of choking to avoidance of specific pills, affected individuals usually attempt to self-treat instead of seeking professional assistance when there is little to no change in their quality of life (Baijens et al., 2013; Stoian & Rizeanu, 2017; Finn & McKernan, 2019). However, when disregarded, the symptoms tend to only crescendo; what started with avoiding certain pills or textures leads to a liquids-only diet resulting in weight loss and malnutrition (Pramalatha et al., 2015). Even in the more severe cases reviewed, it was typical for individuals to wait months to address phagophobia, and for a number of reasons, typically surrounding embarrassment or a sense of shame (Finn & McKernan, 2019).


Method of Study


This research began with locating and reviewing all articles on phagophobia or psychogenic dysphagia published over the past 10 years. After assessing the available information, the case reports were compared to locate similarities in the diagnosis, treatment, and outcome of each case. The procedures deemed most effective by the authors of the articles were considered for inclusion based on ease of implementation and both physical and emotional comfort of the patient. Finally, the selection of treatments was compiled into a proposed standardized treatment plan (STP).


Literature Review


The first step in this research was a review of the available literature. The articles considered were restricted to those published in English, since the year 2010, in peer-reviewed academic publications, and focused on adult patients aged 18 years or older. This search yielded a total of nine documents: One literature review, one report, five case studies, and two encyclopedic entries. The case studies, report, and review will be addressed below. The encyclopedia entries were for the benefit of providing clinical definitions. The author hypothesizes the lack of modern publications is due in part to a dearth of research and part to the underwhelming number of diagnosed cases.


Review

In 2013, Baijens, Koetsenruijter, and Pilz reviewed all literature published in English, German, French, Spanish, or Dutch from all main electronic academic databases. Their search included all known materials, gleaned from as early as 1981 through 2011 (Baijens et al., 2013). They found 12 articles in total on phagophobia, of which nine were case reports, 10 discussed treatments, and two gave diagnostic information (Baijens et al., 2013). Their attempt to perform a qualitative analysis was forsaken as the quantity of available literature was insufficient (Baijens et al., 2013). The conclusion of Baijens and cohorts was that cognitive behavioral therapy seemed to relieve symptoms, multidisciplinary approaches appeared to yield the most effective results, and further research was needed for any conclusions to be reached (Baijens et al., 2013).


Report

Bülow’s report from 2012 discusses the psychiatric aspects of dysphagia. No information is reported which cannot be found in the literature review by Baijen, et al in the following year, 2013, with the exception of medical treatments. According to Bülow, two cases, from 1994 and 2006, reported excellent results with the implementation of pharmacological treatments in some cases, including a variety of “antipanic drugs,” specifically benzodiazepines (2012, p.196). The literature discussed ranges from as early as 1981 to the time of publication in 2012, with a majority of the articles referenced being published in the 1990s.


Both the literature review and report have positive and negative offerings. While they collect and provide the information available, they cannot help but be lacking due to the unstable quantity of literature upon which they base their discussion. Additionally, the articles are nearly outdated, rendering them irrelevant as they rapidly approach the tenth anniversary of their publication. However, they did provide foundational information on the initial research of the 1980s and 1990s.


Case Studies

Five case studies were found in the search for literature on phagophobia. Below, we will address each individually, in chronological order, summarizing their content and providing a short discussion assessing the effectiveness of the treatments and their implementation. The most effective applications will be included in the proposed structured treatment plan.


Pramalatha, Varghese, & Gundelli (2015): Modifying Behavior and Counselling

In 2015, Pramalatha and her team of researchers in Bangalore, India, studied the case of a 40-year old male, who reported swallowing difficulties over the previous three months, which he found correlated to times of fatigue. The patient had no notable weight loss and was still on a diet of solid foods but found the issue worsening as his work hours continued to lengthen. After a series of testing for structural abnormalities, carried out by a speech-language pathologist and a gastroenterologist, the patient’s medical history was reviewed to rule out mechanic and probable neurologic causes. A diagnosis of psychogenic dysphagia was given; one final interview determined which step of the swallowing process the patient found abnormal, which was considered in the curated therapy plan. This plan was not detailed except to state the clinicians found a combination of behavior modification and counselling to result in “considerable improvement.”


Jain (2016): The Multidisciplinary Approach

This short article from Current Psychiatry, an academic magazine published by Springer, examined the treatment of a 72-year-old American male. He had two specific and separate episodes of phagophobia, one which had resolved itself two years prior; another appeared following the death of his wife. Contrasting each other, his desire to swallow decreased while his decision to isolate increased. He showed no mechanic or neurologic abnormalities after testing. Jain recommended psychiatric evaluation using the Eating Disorder Inventory-2 and Symptom Checklist 90-R. After diagnosing phagophobia, Jain presents five parts to treatment including: education and reassurance, behavioral intervention, introspection therapy (CBT), aversion therapy, and psychopharmacotherapeutic intervention. Above all, Jain states “it is… imperative that [the clinician] have an empathetic and understanding approach,” as patients with confidence in their clinicians will respond more effectively to treatment (2016).


Acikel & Ak (2017): Implementing Cognitive Behavioral Therapy

Acikel and Ak (2017), Turkish researchers and medical doctors, documented the case of an 18-year-old female who developed phagophobia after three successive choking incidents, all while eating fish. The patient initially self-treated by dramatically restricting her diet, resulting in notable weight-loss. After ruling out neurologic and mechanic causes through blood tests and an endoscopy, an unspecified psychiatric assessment determined the patient suffered severe anxiety.


The researchers suggested the patient receive medical treatment of her anxiety in addition to cognitive behavioral therapy (CBT) to treat phagophobia. The patent was given Fluoxetine, commonly known as Prozac, at 20 mg daily (“Fluoxetine,” n.d.). The CBT plan created a list of avoided foods and organized them by swallowing hierarchy. Psychoeducation on the physiology of swallowing was followed by eight therapy sessions where the patient was slowly re-introduced to these foods in hierarchal order and given homework to practice. After eight weekly sessions and progression through the hierarchal list, the anxiety of the patient surrounding food was “greatly reduced,” and the patient was able to comfortably eat all foods on the list, excepting fish. Her sessions were stopped to accommodate her college schedule and was planned to resume over summer break.


This case study provides some evidence regarding the effectiveness of CBT in the treatment of phagophobia. Medical intervention helped reduce overall anxiety and educating the patient on the physical aspects of their symptoms gave a base understanding of the issue. However, Ackiel and Ak emphasize how the careful, slow reintroduction to feared foods encouraged progress both physiologically and psychologically in the patient’s recovery. The conclusion of Ackiel and Ak states the multidisciplinary approach seems to be an effective format, standardization is hampered by the general lack of information and in-depth research.


Stoian & Rizeanu (2017): Campaigning the Eclectic Approach

In the same year as Ackiel and Ak, Romanian researchers Stoian and Rizeanu chronicled the case of a 26-year-old male who had self-diagnosed dysphagia from a medical website after a choking incident. He attempted to self-treat over a three-year period and only sought medical help when his symptoms did not begin to subside as expected. He was given an assessment using the fourth and fifth editions of the Diagnostic and Statistical Manual (DSM-IV and DSM-V), the Leahy Scale for anxieties and phobias, the DBI-II for depression, and the SCID-II for personality disorders. The patient’s final diagnoses included phagophobia, severe anxiety, social phobia, as well as obsessive-compulsive, narcissistic, paranoid, and borderline personality disorders.


The researchers employed an “eclectic” approach, employing multiple techniques: Eriksonian hypnosis, CBT, and a course on coping strategies were carried out over 24 weekly sessions. A significant part of the CBT included the patient consciously attempting to swallow then recording his physical and emotional ability and reaction(s). This brought an increased awareness of the phagophobia as a symptom, which allowed him to be more conscious moving forward with his treatment.


Stoian and Rizeanu believe the strong motivation of the patient to change stimulated recovery of his eating abilities, led him to make conscious changes to his work and living conditions, which in turn, significantly increased self-esteem, and reduced his anxiety and depression levels. Overall, treating every aspect of the foundation of the phagophobia, physical, emotional, and psychological, caused it to disappear entirely over the course of six months regardless of the exacerbation caused by the patient’s self-diagnosis and self-treatment.


Finn & McKernan (2019): Implementing Clinical Hypnosis

The final and most recent study reviewed for this research conveys the case of an American woman in her early 60s, who began to struggle with dysphagia months after undergoing spinal surgery. She attempted to self-treat by reducing her diet to liquids and soft foods, causing substantial weight loss and complications to her Type 1 diabetes. Eight months post-surgery, she sought medical attention for her dysphagia. Her symptoms and depression worsened as all test results for mechanic and neurologic causes were negative. The patient believed the worst side effect was the reduction in both her quality of life and her relationship with her husband as she resolved to never eat in public, for sake of embarrassment, or alone, for fear of choking to death.


The ability to treat the patient’s phagophobia with hypnosis first required a series of psychological assessments, including the Short-Form McGill Pain Questionnaire, 2nd edition, the Post-Traumatic Stress Disorder Checklist (5th edition), the Anxiety Sensitivity Index-3, The Hospital Anxiety and Depression Scale, and the Satisfaction with Life Scale. As the patient scored low in pain, PTSD, and life-satisfaction scales but high on the anxiety and depression questionnaires, Finn and McKernan also administered the Stanford Hypnotic Susceptibility Scale- Form C, in which she scored in the high range of susceptibility.


The treatment of clinical hypnosis was co-designed by the researchers and the patient, was carried out in eight sessions over six months, and involved the patient being instructed in the practice of self-hypnosis, sometimes referred to as autogenic training. Also incorporated was a slow reintroduction to foods on a customized swallowing hierarchy, similar to Stoian and Rizeanu (2017), until the patient felt comfortable eating both alone and among others.


The initial assessments were repeated at the end of the six, nine, and 18 months after commencement of treatment. At the end of six months, the patient scored significantly lower in the anxiety and depression tests, and much higher in quality of life. After 18 months, none of her test results were considered clinically significant, showing the effectiveness of clinical and self-hypnosis in treating some cases of phagophobia.


Proposing a Standardized Plan


As phagophobia is diagnosed by eliminating all mechanic and neurologic causes, it is necessary to use several tests in the diagnosis process. In the cases discussed above, many different evaluations were utilized due to a lack of standard protocol. Having no standardized plan may cause a delay in treatment, and may further the stress, anxiety, and discomfort of the patient. According to the literature reviewed, there is no feasible way to further narrow the physiological diagnosis. The tests commonly used to eliminate physiological causes are already standardized, therefore, this research proposes a streamlined standardized plan of the psychological assessment and a present a holistic treatment process.

There are several notable benefits in standardizing the treatment of phagophobia, both for the patient and diagnosing party. For one, streamlining the process reduces the possible ambivalence in deciding upon a treatment strategy, which can, in turn relieve much of the stress and discomfiture of the clinician/doctor and of the patient. Simplifying treatment makes it more accessible. As people gain a greater understanding of the clinical definition of phagophobia, there is greater opportunity for individuals to seek treatment and find relief. Furthermore, an increase in reported cases, increases visibility of the disorder’s prevalence, and clarifies the need for more published research. Thus, by standardizing the treatment plan, we increase the overall quality of life of people struggling with phagophobia.


Some may argue standardizing a plan depletes or removes the element of personalization which an individualized plan allows. To clarify, this proposal does not suggest treatment should be a rigid structure but a standardized guideline for clinicians and doctors to implement. While each plan may vary by patient, it will address the same three aspects which attribute to phagophobia: physiological, psychological/cognitive, and emotional. Below will be discussed the evaluation and treatment of each aspect to form a holistic plan which will not compromise the individual care of each patient.


It was stressed earlier how rare the incidence of phagophobia is. However, it is surmised there may be many cases which do not severely impede life quality, and therefore go unreported, undiagnosed, and undocumented (Baijens et al., 2013). In pediatric cases, for instance, food avoidance may be misinterpreted as obstinacy rather than a reaction to a phobia (Henderson & Miles, 2018). In adults, especially the elderly population, phagophobia regarding pills can lead to patients regularly or consistently skipping doses of medication, which can be dangerous to their health, and possibly life-threatening (Forough et al., 2018). These mild effects frequently unnoticed means phagophobia may be far more prevalent than statistics currently show. With the rising awareness surrounding dysphagia and phagophobia, a standardized treatment plan becomes even more necessary.


Evaluation

Since diagnosis is through elimination, it is suggested the patient provide a full medical history to be discussed in an interview with the doctor/clinician overseeing the diagnosis of their swallowing disorder. This proposal assumes both mechanical and neurologic causes have already been excluded as possibilities. We will discuss each of the three aspects of phagophobia and how they may be best assessed for the purpose of standardizing the treatment plan.


Psychological & Cognitive

Being a psychologically based disorder, phagophobia should be evaluated and treated as such. The case studies reviewed in this research presented a total of eight psychological tests, which assessed the incidence and intensity of several disorders including Posttraumatic Stress Disorder, social and specific phobias, as well as disorders regarding personality, eating, anxiety, and depression. In one instance, a patient was also given a test assessing overall quality of life (Finn & McKernan, 2019). While it is needful to assess the psychological state of a patient with psychogenic dysphagia, the author suggests one test be chosen to determine the direction of the root cause. Further tests could be administered only as needed to provide a full representation of the needs to be addressed in the STP.


After reviewing the case studies, the author determined the Hospital Anxiety and Depression Scale (HADS) to be fully encompassing for the purpose of finding a base understanding of a patient’s psychological well-being (Norton et al., 2013; Appendix). If a high state of anxiety and depression is revealed, the corresponding Beck Inventory can clarify which is the foundational cause and appropriate therapeutic action can be taken (Stultz & Critz, 2010; Appendix). Whether to assess social phobias is left to the discretion of the clinician and should be based upon the patient’s reported history.


Emotional

The emotional stress of living with phagophobia has been seen to seriously hinder quality of life, as many other psychological disorders (Finn & McKernan, 2019). Therefore, assessing the patient’s quality of life give the clinician clarity as to the severity of the phagophobia and may provide insights not shared by the patient, whether due to embarrassment or shame (Finn & McKernan, 2019). Therefore, a quality of life scale is also recommended for inclusion in this STP. The scale used by Finn & McKernan (2019) in their case study on clinical hypnotism (2019), the Satisfaction with Life Scale (SWLS), has been in wide use for nearly 30 years and is still considered a valid assessment an therefore applicable to the current research (Emerson et al., 2017; Diener et al., 1985; Appendix).


A Holistic Approach to Treatment

The human is an intricate machine made of body and mind; both parts influence each other inextricably. This has been demonstrated in research time and again the positive influence of psychological well-being on the immune response to fighting infection (Abdurachman & Herawati, 2018). Therefore, the proposed STP addresses the physiological well-being in addition to the three aspects of phagophobia.


Psychological & Cognitive

Two of the reviewed studies used swallowing psychoeducation as the first step in CBT (Acikel & Ak, 2017; Stoian & Rizeanu, 2017). Several patients delayed seeking professional care as they believed symptoms to be “in their head” (Acikel & Ak, 2017; Stoian & Rizeanu, 2017). Thus, providing education on the issue they are facing may help to validate the patient’s diagnosis and alleviate some of the initial anxieties surrounding clinical testing and assessment.


Three case studies employed CBT, using the same foundational process: they slowly reintroduced foods to the patient in hierarchal order (Acikel & Ak, 2017, Stoian & Rizeanu, 2017, Finn & McKernan, 2019). All three cases showed gradual desensitization to have positive results. For instance, Acikel and Ak (2017) noted the patient could once again eat every food comfortably, excepting fish, the culprit of her initial choking incident. Stoian and Rizeanu (2017) stated their patient was “greatly improved,” and Finn and McKernan (2019) reported “by the end of treatment, the patient at with less conscious effort, comfortably eating a wide variety of foods again.” Based on these success stories, it is recommended a similar process should be utilized in the STP yet tailored to suit the needs of individual cases.


Physiological

Physically and metaphorically, the body is the housing of the mind. As mentioned above, they are intertwined in their functions, either enabling or inhibiting each other. Therefore, care must be taken of the body for the mind to be well (Abdurachman & Herawati, 2018). Aside from a healthy diet and exercise, which would be recommended by any medical doctor, two of the case studies recommend the use of pharmaceutical drugs to treat underlying disorders (Jain, 2016) or prescribed them to their patient (Acikel & Ak, 2017). However, suggesting prescriptions will vary based on the foundation of the patient’s diagnosis. If the patient has a minor food avoidance, then swallowing one pill a day may not be an anxiety-inducing event. However, in more severe cases of phagophobia, oral medications may need to be avoided altogether.

In an instance where medication is not a viable option, there are alternative therapies to treat anxiety which have been shown beneficial. Meditation, especially metta meditation, has been shown especially effective in the treatment of anxiety disorders and social phobias- two root causes of phagophobia (Stefan & Hofmann, 2019). Metta meditation emphasizes positive self-directed thoughts, commonly in direct opposition to the self-loathing thought processes of a person suffering social phobia, anxiety, or depressive disorders (Stefan & Hofmann, 2019). In one literature review from 2019, researchers Stefan and Hofmann found the inclusion of metta meditation bolstered the affects of CBT by creating a fertile environment of healthy self-thought. Therefore, the inclusion of regular meditation practice is placed on STP of this research.


Emotional

Stefan and Hofmann (2019) considered the mental fragility of the anxious mind, and the necessity to include interpersonal compassion in addition to the intrapersonal compassion produced by meditation. It was for similar reason Jain (2016) recommended the clinician demonstrate empathy to the patient. The author suggests the emotional relief of the anxious mind be promoted in the STP. This can be fulfilled in a few different ways, addressing each of the three aspects discussed in this research.


To begin, the psychoeducation of the patient must be thorough but not condescending. People struggling with anxiety, depression, or social phobias host self-deprecating thoughts which need no magnification (Stefan & Hofmann, 2019). Second, the steps of CBT must be carried out at the rate of progression comfortable to the patient, but never stagnant. Lack of progression can be just as discouraging as the anxiety of moving too quickly. Third, a clearly delineated plan for incorporating medication and/or mediation into their CBT should be outlined. Fourth, depending on the circumstances, the clinician or an assigned accountability partner, which may be a spouse, caregiver, friend, adult child, etc.) maintain daily or near-daily contact with the patient during the treatment process. Lastly, ensuring regular check-ins with the clinician and providing accessible literature on phagophobia and the prescribed treatments can reduce the unknown aspects of phagophobia, thus shrinking associated fear.


Conclusion


Phagophobia is a disorder which effects the whole of a person: body, mind, and emotion. Therefore, the treatment implemented should address each of these areas simultaneously for the best outcome of the patient and quality of life after treatments cease. The patient should be assessed to determine incidence and severity of anxiety and depression and overall life-quality in order to appropriately customize treatment. The psychological/cognitive aspect can be addressed with CBT, the physical aspect with diet, exercise, medication, and meditation. Finally, it is recommended the clinician treat the patient with dignity and empathy at all times, provide literature and information as needed, and assign or require an accountability partner for the patient are steps for addressing emotional health.

References

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Baijens, L.W.J., Koetsenruijter, K., & Pilz, W. (2013) Diagnosis and treatment of phagophobia: a review. Dysphagia 28, 260-270. Accessed September 20, 2020.

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Appendix


Listed here are the tests and assessments selected for the proposed standardized treatment plan (STP). We will discuss the origin and validity of each, as well as provide a brief description of the formatting. This appendix discusses only the tests in the final STP, not all the scales mentioned in the body of the text.


Beck Anxiety Inventory (BAI) & Beck Depression Inventory (BDI-II)

The Beck Anxiety Inventory and the Beck Depression Inventory have been implemented since their creation by Aaron Beck and his team in 1961, with reassessments and revisions each decade (Stultz & Crits-Christoph, 2010). The intent of their research and structure of the inventories was to differentiate anxiety and depression diagnosis in a patient (Stultz & Crits-Christoph, 2010). Stultz and Crits-Christoph (2010) carried out the most recent reassessment of these Beck scales, which determined with minor adjustments, the reliability rate was only minimally raised, and not a statistically significant improvement upon the formerly valid and reliable scale, ensuring its continued use.


Each scale consists of a 21-item questionnaire measuring the incidence and severity of symptoms for the respective disorder (Stultz & Crits-Christoph, 2010; “Great Plains Health,” n.d., “BDI-II,” n.d.). The measures of the 4-point Likert scale begin with zero (0), indicating the symptom bother the patient “not at all” through to three (3), which indicates the symptom was “severe, it bothered me a lot” (“Great Plains Health,” n.d.; “BDI-II,” n.d.). In scoring the BAI and the BDI-II, the sum of the answers (ranging 0-63) indicates the severity of anxiety and depression, respectively (“Great Plains Health,” n.d.; “BDI-II,” n.d.; Smarr & Keefer, 2011). The categorization of results varies slightly between the two scales: the BAI scores as “low anxiety” (0-21), “moderate anxiety” (22-35), and “potentially concerning level of anxiety” (>36) whereas the BDI-II, scores “minimal range” (0-13), “mild depression” (14-19), “moderate depression” (20-28), and “severe depression” (29-63) (Smarr & Keefer, 2011; “Great Plains Health,” n.d.).


Hospital Anxiety and Depression Scale (HADS)

The HADS provides the clinician with a simple assessment tool for the incidence of anxiety and/or depressive disorders (Norton et al., 2013; “Hospital anxiety and depression scale,” n.d.). In 2013, Norton et al., completed the most current reassessment of the HADS’ validity. They determined the HADS is best used as an assessment of general distress, as it was not specific enough to distinguish between anxiety and depression incidence (Norton et al., 2013). However, it is recommended for use as a tool to determine if further, more precise assessment is necessary (Norton et al., 2013).


The HADS is a 12-item, Likert-based scale with answers ranging from zero (0) to three (3; “Hospital Anxiety and Depression Scale” n.d.). The response boxes are divided into two columns, one for anxiety and one for depression; the scores are added separately (“Hospital Anxiety and Depression Scale” n.d.). A final sum for either column places the respondent within one of three categories, including “normal” (0-7), “borderline abnormal” (8-10), and “abnormal” (11-21; “Hospital Anxiety and Depression Scale” n.d.).


Satisfaction with Life Scale (SWLS)

The purpose of the SWLS is to provide a quantifiable measure of a participant’s perception of their life quality (Diener et al., 1985; Emerson et al., 2017). The scale was most recently retested by Emerson et al. (2017), the conclusion of which was the scale was reliable with little variance across genders. However, age and culture were notably influential factors of the outcome (Emerson et al., 2017). Emerson et al. (2017), concluded as the scale is measuring generalized statements, it is still considered valid.


Diener et al. (1985) created a five-item scale for assessing overall life satisfaction through statements such as “In most ways my life is close to my ideal” (Chan, 2009). The participant responds using the 7-point Likert responses ranging from one (1), “strongly disagree” to seven (7), “strongly agree” (Chan, 2009). The sum of the final scores places the participant within one of six levels of life satisfaction ranging from “extremely dissatisfied” (5-9), to “neutral” (20), through to “extremely satisfied” (31-35; Chan, 2009).

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