Clinical Anxiety Scale

Clinical Anxiety Scale (CAS) Instructions: The Scale is an instrument for the assessment of the present state of anxiety; therefore the emphasis on eliciting information for the ratings should be on how the patient feels at the present time. However, the interview itself may raise, or lower, the severity of anxiety and the interviewer should inform the patient that he should describe how he has felt during the period of the past two days. Psychic tension (care should be taken to distinguish tension from muscular tension— see next item). Score 4: Very marked and distressing feeling of being ‘on edge’, ‘keyed up’, ‘wound up’ or ‘nervous’ which persists with little change throughout the waking hours. Score 3: As above, but with some fluctuation of severity during the course of the day. Score 2: A definite experience of being tense which is sufficient to cause some, although not severe, distress Score 1: A slight feeling of being tense which does not cause distress. Score 0: No feeling of being tense apart from the normal degree of tension experienced in response to stress and which is acceptable as normal for the population. . Ability to relax (muscular tension) Score 4: The experience of severe tension throughout much of the bodily musculature which may be accompanied by such symptoms as pain, stiffness, spasmodic contractions, and lack of control over movements. The experience is present throughout most of the waking day and there is no ability to produce relaxation at will. Score 3: As above, but the muscular tension may only be experienced in certain groups of muscles and may fluctuate in severity throughout the day Score 2: A definite experience of muscular tension in some part of the musculature sufficient to cause some, but not severe, distress. Score 1: Slight recurrent muscular tension of which the patient is aware but which does not cause distress. Very mild degrees of tension headache or pain in other groups of muscles should be scored here Score 0: No subjective muscular tension or of such degree which, when it occurs, can easily be controlled at will. Startle response (hyperarousability)

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Score 4: Unexpected noise causes severe distress so that the patient may complain in some such phrase as “I jump out of my skin”. Distress is experienced in psychic and somatic modalities so that, in addition to the experience of fright, there is muscular activity and autonomic symptoms such as sweating or palpitation. Score 3: Unexpected noise causes severe distress in psychic or somatic, but not in both modalities. Score 2: Unexpected noise causes definite but not severe distress. Score 1: Patient agrees that he is slightly ‘jumpy’ but is not distressed by this. Score 0: The degree of startle response is entirely acceptable as normal for the population.

Worrying (The assessment must take into account the degree to which worry is out of proportion to actual stress). Score 4: The patient experiences almost continuous preoccupation with painful thoughts which cannot be stopped voluntarily and the distress is quite out of proportion to the subject matter of the thoughts. Score 3: As above, but there is some fluctuation in intensity throughout the waking hours and the distressing thoughts may cease for an hour or two, especially if the patient is distracted by activity requiring his attention. Score 2: Painful thoughts out of proportion to the patient’s situation keep intruding into consciousness but he is able to dispel or dismiss them. Score 1: The patient agrees that he tends to worry a little more than necessary about minor matters but this does not cause much distress. Score 0: The tendency to worry is accepted as being normal for the population; for instance even marked worrying over a severe financial crisis or unexpected illness in a relative should be scored as 0 if it is judged to be entirely in keeping with the degree of stress . Apprehension Score 4: The experience is that of being on the brink of some disaster which cannot be explained. The experience need not be continuous and may occur in short bursts several times a day. Score 3: As above, but the experience does not occur more than once a day. Score 2: The sensation of groundless apprehension of disaster which is not severe although it causes definite distress. The patient may not use strong terms such as “disaster” or “catastrophe” but may express his experience in some such phrase as “I feel as if something bad is about to happen.” Score 1: A slight degree of apprehensiveness of which the patient is aware but which does not cause distress. Score 0: No experience of groundless anticipation of disaster. Restlessness Score 4: The patient is unable to keep still for more than a few minutes and engages in restless pacing or other purposeless activity. Score 3: Same as above, but he is able to keep still for an hour or so at a time. Score 2: There is a feeling of “needing to be on the move” which causes some, but not severe, distress. Score 1: Slight experience of restlessness which causes no distress.

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Score 0: Absence of restlessness. The following item may be rated if required, but should not be added to the CAS Score Panic attacks Score 4: Episodes, occurring several times a day, of the sudden experience of groundless terror accompanied by marked autonomic symptoms, feelings of imminent collapse or loss of control over reason and self-integrity. Score 3: As above, but the episodes do not occur more than once a day. Score 2: The episodes may occur only once or twice a week; they are generally less severe than described above but still cause distress. Score 1: Episodic slight increases in the level of anxiety which are only precipitated by definite events or activities. For instance, the experience of a patient who is recovering from agoraphobia and who experiences a perceptible rise of anxiety on leaving the house would be scored here. Score 0: No episodic sudden increase in the level of anxiety.

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