A researcher was interested in exploring the influence of stress on cognitive functioning, specifically memory performance. Upon reading about the topic, she learned that long-term stress in humans can lead to elevated stress hormone (cortisol) levels via activation of the hypothalamic–pituitary–adrenal (HPA) axis. Increased cortisol level has shown to damage neurons in the hippocampus, which, in turn, could impair memory performance. However, she also learned that most studies examined the effects of stress on memory primarily in clinical population (e.g., post traumatic stress disorder, generalised anxiety disorder, depression), and only few studies involved testing healthy populations. Moreover, studies involving healthy populations assessed the effect of experimentally induced stress on memory, rather than self-reported or perceived stress. Thus, to address this literature gap, the researcher wanted to examine the effect of self-reported or perceived stress on memory in undergraduate psychology students. Specifically, the researcher wanted to know if stress was associated with the salivary cortisol level, and secondly, whether stress affected the memory performance. The researcher believed that further understanding of this stress/memory relationship could help designing strategies to reduce stress in student population, which could potentially improve their academic performance.
A Guide to the Depression, Anxiety and Stress Scale (DASS 21) By Fernando Gomez- Consultant Clinical Psychologist Introduction The DASS 21 is a 21 item self report questionnaire designed to measure the severity of a range of symptoms common to both Depression and Anxiety. In completing the DASS, the individual is required to indicate the presence of a symptom over the previous week. Each item is scored from 0 (did not apply to me at all over the last week) to 3 (applied to me very much or most of the time over the past week). The essential function of the DASS is to assess the severity of the core symptoms of Depression, Anxiety and Stress. Accordingly, the DASS allows not only a way to measure the severity of a patient’s symptoms but a means by which a patient’s response to treatment can also be measured. The DASS and Diagnosis Although the DASS may contribute to the diagnosis of Anxiety or Depression, it is not designed as a diagnostic tool. Indeed, a number of symptoms typical of Depression such as sleep, appetite and sexual disturbances, are not covered by the DASS and will need to be assessed independently. The DASS is not meant to replace a comprehensive clinical interview. Suicide Suicidality is not assessed by the DASS. Accordingly, the clinician will need to address directly this important symptom of Depression in their clinical interview. How often to use the DASS? Although the DASS can provide a comparison of symptoms from week to week, it is best given on first presentation and again after a period of time has lapsed long enough for the chosen treatment to have effect. In the case of antidepressant medication, the second administration should be between the 2-4 week period after the individual has commenced taking the medication. This period is long enough for most antidepressants to be expected to show some change in the patient. Scoring the DASS The scale to which each item belongs is indicated by the letters D (Depression), A (Anxiety) and S (Stress). For each scale (D, A & S) sum the scores for identified items. Because the DASS 21 is a short form version of the DASS (the Long Form has 42 items), the final score of each item groups (Depression, Anxiety and Stress) needs to be multiplied by two (x2). Interpreting the DASS Once multiplied by 2, each score can now be transferred to the DASS profile sheet, enabling comparisons to be made between the three scales and also giving percentile rankings and severity labels. DASS Severity Ratings (Don’t forget to multiply summed scores by x 2) Severity Depression Anxiety Stress Normal 0-9 0-7 0-14 Mild 10-13 8-9 15-18 Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely Severe 28+ 20+ 34+ As previously mentioned, the DASS should not be used on its own to assess the presence or absence of Depression or Anxiety. High scores on the DASS would certainly alert the clinician to a high level of distress in the patient and this would need to be explored further within the interview process. Similarly, low scores on the DASS should not be a substitute for a comprehensive clinical interview. High DASS scores which are not changing, may prompt the clinician to look for explanations and perhaps augment dosages or change medication. Here again, the DASS should be interpreted along side the clinical interview. Changes in scores in one scale (EG: Depression), with consistently high and unchanging scores in another scale (Anxiety) may alert the clinician to pay particular attention to the presence of a co- existing anxiety disorder which may need specific treatment in its own right. Similarly, decreasing Depression scores alongside unchanging Stress scores may alert the clinician to the presence of some life event or problem, which may need to be addressed directly. DASS 21 NAME DATE Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 Did not apply to me at all - NEVER 1 Applied to me to some degree, or some of the time - SOMETIMES 2 Applied to me to a considerable degree, or a good part of time - OFTEN 3 Applied to me very much, or most of the time - ALMOST ALWAYS FOR OFFICE USE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 N S O AA D A S I find it hard to wind down 0 1 2 3 I am aware of dryness of my mouth 0 1 2 3 I cannot seem to experience any positive feeling at all 0 1 2 3 I experience breathing difficulty (eg, excessively rapid breathing, 0 1 2 3 breathlessness in the absence of physical exertion) I find it difficult to work up the initiative to do things 0 1 2 3 I tend to over-react to situations 0 1 2 3 I experience trembling (eg, in the hands) 0 1 2 3 I feel that I was using a lot of nervous energy 0 1 2 3 I am worried about situations in which I might panic and make a fool of 0 1 2 3 myself I feel that I had nothing to look forward to 0 1 2 3 I find myself getting agitated 0 1 2 3 I find it difficult to relax 0 1 2 3 I feel down-hearted and blue 0 1 2 3 I am intolerant of anything that kept me from getting on with what I was 0 1 2 3 doing I feel I am close to panic 0 1 2 3 I am unable to become enthusiastic about anything 0 1 2 3 I feel I am worth much as a person 0 1 2 3 I feel that I am rather touchy 0 1 2 3 I am aware of the action of my heart in the absence of physicalexertion (eg, 0 1 2 3 sense of heart rate increase, heart missing a beat) I feel scared without any good reason 0 1 2 3 I feel that life is meaningless 0 1 2 3 TOTALS DASS Severity Ratings The DASS is a quantitative measure of distress along the 3 axes of depression, anxiety1 and stress2. It is not a categorical measure of clinical diagnoses. Emotional syndromes like depression and anxiety are intrinsically dimensional - they vary along a continuum of severity (independent of the specific diagnosis). Hence the selection of a single cut-off score to represent clinical severity is necessarily arbitrary. A scale such as the DASS can lead to a useful assessment of disturbance, for example individuals who may fall short of a clinical cut-off for a specific diagnosis can be correctly recognised as experiencing considerable symptoms and as being at high risk of further problems. However for clinical purposes it can be helpful to have ‘labels’ to characterise degree of severity relative to the population. Thus the following cut-off scores have been developed for defining mild/moderate/severe/ extremely severe scores for each DASS scale. Note: the severity labels are used to describe the full range of scores in the population, so ‘mild’ for example means that the person is above the population mean but probably still way below the typical severity of someone seeking help (ie it does not mean a mild level of disorder. The individual DASS scores do not define appropriate interventions. They should be used in conjunction with all clinical information available to you in determining appropriate treatment for any individual