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Hamilton Anxiety Rating Scale (HAM-A)
The instrument is freely available here: Hamilton Anxiety Rating Scale
NeuroRehab Supplemental - Highly Recommended

Recommendations for Use: Indicated for studies requiring a measure of psychological status.

Supplemental: Mitochondrial Disease (Mito) and Parkinson's Disease (PD)
Short Description of Instrument
The 14-item version of the Hamilton Anxiety Rating Scale (HAM-A) consists of 13 questions and one observational rating of the patient's behavior during the interview (Hamilton, 1959). The HAM-A was originally developed to assess the severity of anxiety symptoms in patients diagnosed with 'neurotic anxiety states' (Hamilton 1959), and it provides an overall measure of global anxiety that is weighted towards somatic and autonomic features of anxiety, but also includes emotional and cognitive symptoms. The HAM-A assesses a range of symptoms that are frequent in all eight of the DSM-IV Anxiety Disorders but is used most often to assess symptom severity in Generalized Anxiety Disorder (Shear et al. 2001). The HAM-A does not distinguish symptoms of specific anxiety disorders or distinguish anxiety from depression. However, HAM-A items are compatible with DSM-IV criteria for Generalized Anxiety Disorder (A Criterion=Excessive worry; B Criterion= Inability to control Worry; C Criteria = additional symptoms of restlessness/psychic tension, easy fatigability, difficulty concentrating, irritability, muscle tension, and sleep disturbance).
The scale was not intended for measurement of anxiety occurring in the context of other psychiatric or medical conditions, but it is now applied that way.
Comments/Special Instructions
Parkinson's Disease-Specific: The HAM-A is an observer-rated scale which is more difficult to use than self-report scales. It has been validated in PD and widely used but should no longer be considered the standard. The Hospital Anxiety and Depression Scales (HADS) (self-report) or Parkinson's Anxiety Scale (PAS) are preferrable.
Scoring and Psychometric Properties
Scoring: The HAM-A takes approximately 10 to 15 minutes to administer. Each of the 14 items is rated on a 5-point Likert-type scale (0 to 4) with higher scores indicating greater severity. Total scores for the HAM-A range from 0 to 56. A score >16 is consistent with clinically significant anxiety in the general population. Analyses in a PD sample suggest a lower cut-off score of 11/12 to distinguish patients with and without anxiety disorders and an optimal cut-off score of 12/13 on the HAM-A was found to best distinguish patients with a diagnosed anxiety disorder according to the DSM-IV criteria.
Psychometric Properties: The HAM-A displayed good internal consistency (Cronbach's a = 0.86) and inter-rater reliability (r = 0.87). (Leentjens et al., 2011). In another study of 360 patients with PD, The HAM-A displayed high internal consistency (Cronbach's a = 0.91) and satisfactory inter-item correlation (mean r = 0.51) (Stefanova et al., 2013). Mondolo et al. (2007) found that the HAM-A displayed good concurrent validity against the Spielberger State Trait Anxiety (STAI) and the Hospital Anxiety and Depression Scale, anxiety subscale (HADS-A).
There are questions regarding validity in PD (Dissanayaka et al., 2015; Kummer et al., 2010).
Parkinson's Disease-Specific:
Strengths:The scale is in the public domain and has been used in studies in a variety of countries, languages, and neurological disorders (e.g., Espinola-Nadurille et al., 2010; Leentjens et al., 2011). The HAM-A is best used to screen for generalized symptoms of anxiety (Kummer et al., 2010).
Weaknesses: It is not designed to identify specific anxiety disorders, but rather is a global rating of overall anxiety symptoms and can distinguish patients with and without significant anxiety (Leentjens et al., 2011); There is overlap of anxiety symptoms on the HAM-A with symptoms of PD (e.g., akathisia). Overall, the HAM-A may be an adequate screening tool for significant anxiety but cannot discriminate anxiety independent of depression or be used as a diagnostic instrument for anxiety disorders (Kummer et al., 2010).
Mitochondrial Disease-Specific:
Strengths: The HAM-A has been used in other medical disorders than may affect neurological functioning and somatic function. For example, HAM-A scores were correlated with focal loss of grey matter in superior and middle gyri of right frontal lobe in patients with relapsing remitting multiple sclerosis (Lin et al., 2013). This suggests it may be of use in monitoring change in time in response to exacerbations of mitochondrial disease.
Weaknesses: The scale incorporates both emotional and somatic symptoms of anxiety, and therefore may be elevated by the presence of somatic symptoms associated with mitochondrial disorder. Adjustment of cut scores may need to be considered for use in this population (Forjaz et al., 2013).
Key Reference:
Hamilton M. The assessment of anxiety states by rating. Br J Medical Psychology. 1959;32(1):50-5.
Additional References:
Dissanayaka NN, Torbey E, Pachana NA. Anxiety rating scales in Parkinson's disease: a critical review updating recent literature. Int Psychogeriatr. 2015 Nov;27(11):1777-84.
Espinola-Nadurille M, Colin-Piana R, Ramirez-Bermudez J, Lopez-Gomez M, Flores J, Arrambide G, Corona T. Mental disorders in Mexican patients with multiple sclerosis. J Neuropsychiatry Clin Neurosci. 2010 Winter;22(1):63-9.
Forjaz MJ, Martinez-Martin P, Dujardin K, Marsh L, Richard IH, Starkstein SE, Leentjens AF. Rasch analysis of anxiety scales in Parkinson's disease. J Psychosom Res. 2013 May;74(5):414-9.
Kummer A, Cardoso F, Teixeira AL. Generalized anxiety disorder and the Hamilton Anxiety Rating Scale in Parkinson's disease. Arq Neuropsiquiatr. 2010 Aug;68(4):495-501.
Leentjens AF, Dujardin K, Marsh L, Martinez-Martin P, Richard IH, Starkstein SE, Weintraub D, Sampaio C, Poewe W, Rascol O, Stebbins GT, Goetz CG. Anxiety rating scales in Parkinson's disease: critique and recommendations. Mov Disord. 2008 Oct 30;23(14):2015-25.
Leentjens AF, Dujardin K, Marsh L, Richard IH, Starkstein SE, Martinez-Martin P. Anxiety rating scales in Parkinson's disease: a validation study of the Hamilton anxiety rating scale, the Beck anxiety inventory, and the hospital anxiety and depression scale. Mov Disord. 2011 Feb 15;26(3):407-15.
Lin A, Chen F, Liu F, Li Z, Liu Y, Lin S, Wang X, Zhu J. Regional gray matter atrophy and neuropsychologcal problems in relapsing-remitting multiple sclerosis. Neural Regen Res. 2013 Jul 25;8(21):1958-65.;
Mondolo F, Jahanshahi M, Gran? A, Biasutti E, Cacciatori E, Di Benedetto P. Evaluation of anxiety in Parkinson's disease with some commonly used rating scales. Neurol Sci. 2007 Oct;28(5):270-5.
Shear MK, Vander Bilt J, Rucci P, Endicott J, Lydiard B, Otto MW, Pollack MH, Chandler L, Williams J, Ali A, Frank DM. Reliability and validity of a structured interview guide for the Hamilton Anxiety Rating Scale (SIGH-A). Depress Anxiety. 2001;13(4):166-78.
Stefanova E, Ziropadja L, Petrovic M, Stojkovic T, Kostic V. Screening for anxiety symptoms in Parkinson disease: a cross-sectional study. J Geriatr Psychiatry Neurol. 2013 Mar;26(1):34-40.

Document last updated August 2022