GENERAL ARTICLES

The Amsterdam
Scale (APAIS)
Nelly Moerman,
Hans Oosting,

MD*,

Preoperative

Anxiety

Frits S. A. M. van Dam, rhq, Martin

and Information
J. Muller,

MA&

and

PhDt

* Department
of Anesthesiology
and t Department
of Clinical Epidemiology
and Biostatistics, Academic Medical
University of Amsterdam;
$ Department
of Clinical Psychology, Faculty of Psychology, University of Amsterdam;
+j Netherlands
Cancer Institute, Amsterdam,
The Netherlands

The purpose of the present study was to assess patients

anxiety level and information
requirement
in the preoperative phase. During routine preoperative
screening, 320 patients were asked to assess their anxiety and
information
requirement
on a six-item questionnaire,
the Amsterdam
Preoperative Anxiety and Information
Scale (APAIS). Two hundred patients also completed
Spielbergers
State-Trait
Anxiety
Inventory
(STAIState). Patients were able to complete the questionnaire
in less than 2 min. On factor analysis, two factors emerged
clearly: anxiety and the need for information. The anxiety
scale correlated highly (0.74) with the STAIState.
It

nxious patients respond differently than nonanxious patients to anesthesia. The insertion of
an intravenous catheter in the preoperative
phase can be a difficult task as a result of anxietyrelated vasoconstriction (1,2). In anxious patients,
larger doses of anesthetics are required to induce anesthesia (3,4) and the anesthesia itself may be associated with autonomic fluctuations (5,6). Although the
exact percentage of patients who are anxious preoperatively is not known, the literature suggests an incidence between 60% and 80% (7-10). Although a sedative drug is often given as premeditation to relieve
fear and anxiety, anxious patients might also benefit
from more attention and information from the anesthesiologist. In clinical practice, however, the anesthesiologist has very little time for preoperative consultation to identify the patients who are anxious and
may benefit from extra attention.
There are many instruments for measuring the patients level of preoperative anxiety (11,12). The instrument most commonly used is Spielbergers State-Trait

Accepted for publication

Address correspondence
Anesthesiology, Academic
dam, PO Box 22700,llOO
01996 by the International
0003-2999/96/$5.00

September 15, 1995.

to Nelly Moerman, MD, Department of
Medical Centre, University of AmsterDE Amsterdam, The Netherlands.

Anesthesia

Research

Centre,
and

emerged that 32% of the patients could be considered as

anxiety cases and over 80% of patients have a positive
attitude toward receiving information. Moreover, the results demonstrated
that 1) women were more anxious
than men; 2) patients with a high information requirement
also had a high level of anxiety; 3) patients who had never
undergone
an operation had a higher information
requirement than those who had. The APAIS can provide
anesthesiologists with a valid, reliable, and easily applicable instrument for assessing the level of patients preoperative anxiety and their need for information.
(Anesth Analg 1996;82:445-51)

Anxiety Inventory (STAI) (13), which has been translated into Dutch and validated by van der Ploeg et al.
(14). He also obtained norms for the Dutch population.
The questionnaire consists of two separate, 20-item,
self-report rating scales for measuring trait and state
anxiety. The trait anxiety is a relatively stable personality disposition, while state anxiety is the situationrelated anxiety and this may differ depending on the
stress of the particular moment. The state scale is
recommended for measuring patient anxiety in the
preoperative phase (15) and has been used in several
anesthesiologic studies (16-19). Although this questionnaire is fairly short, it is still too long for use in
busy outpatient clinics. Moreover, the questions are
not related to the specific situation with which the
patient is confronted.
A second aspect of preoperative care is the patients
need for information. Several studies (20-22) have
shown that information given to patients before surgery may facilitate recovery. However, some patients
like to shut themselves off from information, whereas
others want to be informed as fully as possible (23).
These different coping styles are almost never honored, as it is practically impossible for the anesthesiologist to discriminate between patients who would
like to be informed as fully as possible from those who
want to know as little as possible. It would be greatly

Society
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INFORMATION

beneficial to clinical practice if anesthesiologists knew

whether they were dealing with a patient who wanted
more than basic information which is routinely given,
or a patient who would rather not be given any extra
information.
As we could not find a clinically applicable instrument in the literature which fulfilled all our requirements, i.e., short, specifically attuned to the preoperative situation, and easy to interpret, we decided to
develop a new instrument. Our point of reference was
the work of Miller and Mangan (24,25), who studied
the way patients cope with the stress of a threatening
situation. They differentiated between monitors and
blunters, defining monitors as people who want to
know as much as possible and search actively for
information and blunters as those who have no need
for information and even try to avoid it. This instrument should make it possible to distinguish anxious
from nonanxious patients and patients who want information from those who do not.

Methods
A six-item questionnaire, the Amsterdam Preoperative Anxiety and Information Scale (APAIS) (Table 1)
was developed in a previous studyi, covering both the
monitor and blunting aspects. Four items represented fear of anesthesia and fear of the surgical procedure (Cronbachs cx0.86). Two items represented the
need for information (Cronbachs (Y0.72). The internal
consistencies of both scales were sufficient for group
comparison.
During a period of 3 mo, 320 consecutive patients
visiting the anesthesiology outpatient department (patients who could not speak Dutch were excluded)
were asked by the nursing staff to fill out this questionnaire (Table 1). We noted the age and sex of the
patients and whether they had had surgery previously. To ascertain that our instrument really measured anxiety, the last 200 patients were also asked to
fill out the State version of Spielbergers STAI. This
questionnaire consists of a 20-item self-report rating
scale for measuring state anxiety. In the latter group
we also examined the kind of procedure involved and
the duration of the operation. We classified the operations as minor, intermediate, or major. Minor was
defined as less invasive surgery of limited duration
(minor orthopedic surgery, diagnostic procedures, arthroscopies, laparoscopies, inguinal hernia). Operations classified as intermediate had more impact for
the patient (cholecystectomy, hysterectomy), and major were extensive operations with a high impact
1 Moerman N, Dam van F, Boulogne-Abraham
T, Hooff van M.
The patients need for information in the preoperative period. Proceedings of the 9th European Congress of Anaesthesiology. Jerusalem, Israel, 1994:257.

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(APAIS)

Table 1. The Amsterdam

Preoperative
Information
Scale (APAIS)
1. I am worried
2. The anesthetic
3. I would like
the anesthetic.
4. I am worried
5. The procedure
6. I would like
the procedure.
The measure
five-point
Likert

Anxiety

about the anesthetic.

is on my mind continually.
to know as much as possible

about

about the procedure.

is on my mind continually.
to know as much as possible

about

of agreement
with these statements
should
scale from 1 = not at all to 5 = extremely.

(laryngectomy,
surgery).

and

reconstructive

be graded

on a

and transplantation

Statistical Analysis
Validity. To evaluate the validity of the APAIS (Table 11, we performed several analyses. Attention was
devoted to some aspects of construct (content) validity
and criterion validity, too.
Construct validity was evaluated by factor analysis.
Factor analysis is a statistical approach to reduce data
by determining the relationships among variables and
to determine the underlying structure which is formed
by latent variables known as factors. The relation between variables and a certain factor is given by the
so-called factor loadings, which indicate how much
weight is assigned to each factor. Variables with high
loadings for a factor are closely related to that particular factor. Rotation is the procedure used to make the
factor solution more interpretable (26). The results of
the factor analysis should reflect the concepts we put
into our scales and should thus concur with the results
of our previous study, i.e., two factors should emerge:
anxiety and a need for information.
As a measure of concurrent validity we determined
the correlation of the APAIS with the STAI. We hypothesized that the State version of the STAI should
correlate highly (>0.60) with the anxiety scale of the
APAIS and should have a low correlation (<0.30) with
the need-for-information scale.
For clinical use it is important to be able to identify
those patients who can be considered as anxiety cases. For this purpose we used Spielbergers STAI as
the gold standard. Auerbach (27) divided a group of
surgical patients on the basis of their preoperative
score on Spielbergers trait anxiety scale into a hightrait-anxiety group and a low-trait-anxiety
group. The
mean state anxiety score of the high-trait-anxiety
group was 46. We used this score on the state scale as
a reference point and considered patients with a score
~46 on the STAI-State as anxiety cases. Furthermore,
this point concurs 2 the 9th decile of a Dutch male
reference group and 2 the 8th decile of a Dutch female
reference group (14). We determined for different cutoff points on the APAIS anxiety scale the sensitivity

ANESTH
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THE AMSTERDAM

(proportion
of correctly identified cases), the specificity (proportion
of correctly identified noncases), and
the positive predictive
value (probability
of a high
scale score being a case) in relation to the STAI.
The validity was further evaluated by known-group
comparison
in three different ways. 1) We hypothesized that women should have a higher score than
men on the APAIS anxiety scale. This hypothesis
was
based on data from the literature, where women are
usually regarded as being more anxious than men
(7,10,14,19,28). 2) From the work of Miller and Mangan (24,25) it is known,
that high monitors
are also
anxious people. In other words, in a threatening situation monitoring is mostly associated with higher anxiety and arousal than blunting (29). We therefore hypothesized
that, in our instrument,
patients with a
high information
requirement
should have a higher
score on the anxiety scale than patients with a low
information
requirement. 3) The effect of preanesthetic
information
is less valuable for patients who have
previous anesthetic experience than for those who do
not (30). We therefore hypothesized
that patients with
previous experience of anesthesia and surgery should
have a lower information
requirement than those who
had never had surgery. No specific hypothesis
was
formulated regarding the difference between men and
women with respect to their information
requirement.
Data were analyzed using the SPSS version 4.0. An
analysis of variance (ANOVA)
was used for group
comparison.
Students t-tests were used to compare
the mean scale scores for the subgroups
at baseline.
Statistical significance was considered at P < 0.05.
Cronbachs os were calculated as a measReliability.
ure for internal consistency
of the scales. Reliability
was considered acceptable when Cronbachs
(YS were
270

(26).

Results
Of the 322 patients who were asked to participate, 2
patients refused. Patient characteristics are presented
in Table 2. Patients had no problem completing the
APAIS and usually did so in less than 2 min. As was
predicted, we found in a factor analysis with oblique
rotation (see Table 3) two factors, which explained
72% of the variance: anxiety (questions 1, 2, 4, and 5,
Table 1) and the need for information (questions 3 and
6, Table 1). The correlation between both factors was
0.31. The following step was to convert the two factors
to scales and calculate Cronbachs (Yfor the two scales
separately. Cronbachs (Y for the four anxiety items
(questions 1, 2, 4, 5) was 0.86. Cronbachs cx for the
need-for-information
items (questions 3 and 6) was
somewhat lower (0.68), as was to be expected with a
scale consisting of only two items, but still sufficient
for group comparisons.

PREOPERATIVE

ANXIETY

AND

INFORMATION

MOERMAN
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ET AL.
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447

2. Patient Characteristicsby Whole Group and

Subgroup
Table

Sex
Male
Female
Mean k SD a e
(yr) (range
$
Previous
surgery
Yes
No
Kind of
operation
Minor
Intermediate
Major

APAIS

APAIS + STAI

(n = 320)

(n = 200)

121 (37.8%)
199 (62.2%)
38.3 IL 13.6 (18-87)

85 (42.5%)
115 (57.5%)
38.8 2 13.9 (18-87)

242 (75.6%)
78 (24.4%)

156 (78%)
44 (22%)

145 (72.5%)
42 (21.0%)
7 (3.5%)

AIAIS
= Amsterdam
Preoperative
Anxiety
and Information
Scale;
= Spielbergers
State-Trait
Anxiety
Inventory.
a Operations
were classified
for the last 200 patients
only; 6 patients
not operated
on.

STAI
were

3. Factor Loadings in a Two-Factor Solution (After

Oblique Rotation)
Table

Factor
1
Anesthesia
1. Worried about
2. Thinks about it continually
3. Wishes to know as much as
possible
Surgery
4. Worried about
5. Thinks about it continually
6. Wishes to know as much as
possible
Eigenvalue
Percent of variance

0.83

0.03

0.86

-0.04
0.87

0.01
0.81
0.85

-0.01
3.07

51.1

0.03
-0.02
0.87
1.25
20.8

Concurrent validity was determined by the correlation with the STAI. The correlation between the anxiety items of the APAIS and the STAI-State was high
(0.74) and the correlation between the information
items and the STAI-State was low (0.16).

Anxiety Scale
The anxiety scale consists of four items (questions 1,2,
4, 5), each of which could be scored from 1 to 5. The
score of the anxiety scale is the sum of these four
questions, with a scoring range from 4 to 20. There
was a highly significant difference (P = <O.OOl) between men and women. The mean score of men was
7.5 (SD 3.5) and the mean score of women was 9.9
(SD 4.5). But an ANOVA
indicated an interaction effect
between previous experience of surgery and gender
(P = 0.02); t-test for differences between means
showed that men who had been operated on before

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Table 4. The Scores on the Anxiety

Surgery (n = 320)

ANESTH
ANXIETY

AND

INFORMATION

Scale (Questions

SCALE

1, 2, 4, 5) for Male and Female Related

surgery

Mean

SD

II

6.8
10.4

2.9
4.5

98
23

Yes
No
a t-test

for differences

*I' 5 0.001; tP

between

to Experience

of Previous

Femalet

Male*
Previous

ANALG

1996;82:445-51

(AIAIS)

Meana
9.7
10.6

SD

4.4
4.5

144
55

<O.OOl
0.91

means.

= 0.23.

had a lower score on the anxiety scale than those

without previous experience of surgery. In women
there was no such difference between those who had
previous experience of surgery and those who had not
(Table 4).
There were no statistically significant relationships
between age, type of operation, and the scores on the
anxiety scale. As the number of patients who underwent major surgery was low, the results regarding the
type of operation has to be interpreted with caution.

Need-for-Information

Scale

The need-for-information scale consists of two items

(questions 3 and 6), each of which could be scored
from 1 to 5. The sum of the need-for-information scale
is the sum of these two questions, with a scoring range
from 2 to 10. ANOVA indicated no interaction effect
between type of operation and gender; only a statistically significant main effect for previous experience of
surgery existed (P = 0.002). Patients with previous
experience had a lower score (mean 6.6, SD 2.3) on the
information scale, than those who had not been operated on before (mean 7.5, SD 2.2). There were no statistically significant relationships between age, type of
operation, and the scores on the information scale.
In order to investigate whether there was a relationship between the patients need for information and
the level of anxiety, we divided patients according to
their score on the information scale into three groups.
Patients with a score of 2-4 on the information scale
can be classified as having no or little information
requirement and can be considered as blunters. Patients with a score of 5-7 can be classified as having an
average information requirement, and those with a
score of 8-10 as having a high information requirement. The latter can therefore be considered monitors. Using this three-group classification for the information scale, it turned out that in the population of
320 patients the percentages of patients with low, medium, and high information requirements were 16.9%,
39.7%, and 43.4%, respectively. After correction for sex
and experience with previous operations, patients
with a high information requirement turned out to be
the ones who were most anxious (Table 5).
We also investigated whether we could use the APAIS
for detecting anxiety cases. We wanted to know at

Table 5. The Relationship

Between the Score on the
Information
Scale (Questions 3 and 6) and the Score on
the Anxiety Scale (Questions 1, 2, 4, 5) (n = 320)
Score,
anxiety scale
Score, information

scale

n Mean

24, no/little
information
requirement
5-7, average information
requirement
8-10, high information
requirement
Significant

difference

with

both

other

groups

SD

54 7.1 3.6
127 8.4 3.5
139 10.3 4.8
(Tukey

HSD

procedure

[P < 0.051).

what score on the APAIS anxiety scale patients could be

considered anxious and would therefore benefit from
more attention. As mentioned in Methods, we used the
STAI-State as a gold standard and chose the score of 46
as a reference point. Using this reference point, the sensitivity, specificity, and the predictive value were calculated at different cutoff points on the anxiety scale
(APAIS). Table 6 shows that the cutoff point of 11 leads
to a good balance. Sensitivity and specificity are good
and the predictive value is 71%. At the score of 11, 37
patients are misclassified (18 false-positives and 19 falsenegatives). This means that 9% (n = 18) of the patients
are anxious on the anxiety scale (APAIS) but not on the
STAI-State, and 9.5% (n = 19) are not anxious on the
APAIS although they are on the STAI-State. At the cutoff
score of 10 sensitivity increasesbut, becauseof the lower
specificity, the predictive value is lower, resulting in a
higher number of false-positive patients (anxious on the
APAIS but not on the STAI) than at the score of 11. At the
scores> 11 sensitivity decreasesand specificity increases.
The cutoff scores11-13 produce approximately the same
amount of misclassified patients (false-positives and
false-negatives together), varying from 34 to 39. However, an increasing predictive value reduces the number
of false-positive patients.
Using the score of 46 on the STAI-State as a reference point, the prevalence of anxiety cases in the population (n = 200) was 32%.

Discussion
The purpose of the study was to develop a screening
instrument for use in the preoperative period. For this

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449

6. Characteristicsof the Anxiety Scale(APAIS) at Different Cutoff Points with a Score of 46 on the STAI-State as a
ReferencePoint (n = 200)
Table

Cutoff scoreon the anxiety scale

Sensitivity
Specificity
Positive predictive value
Patients, n (o/o)
a. True-positive
b. False-positive
c. False-negative
d. True-negative
APAIS

= Amsterdam

Preoperative

10

11

12

13

75.0%
78.7%
62.3%

70.3%
86.8%
71.4%

59.4%
90.4%
74.5%

53.1%
97.1%
89.5%

48 (24)

45 (22.5)
18 (9)

38 (19)
13 (6.5)
26 (13)

29 (14.5)

16 (8)
107(53.5)
Anxiety

and

Information

Scale;

19 (9.5)
118(59)
STAI

reason, a six-item questionnaire was developed: the

Amsterdam Preoperative Anxiety and Information
Scale (APAIS). The APAIS was easily and very quickly
completed by patients. Two clear factors emerged:
anxiety and information requirements. The anxiety
scale correlated highly with the standard questionnaire for measuring anxiety: Spielbergers STAI-State
(0.74). Both the anxiety and the need-for-information
scale showed good psychometric properties and were
feasible in clinical practice. According to the literature
we found that 1) women have a higher score on the
anxiety items than men, and 2) there is a positive
relationship between anxiety and information requirement. Patients with a greater need for information
were patients with a higher anxiety level than those
with a low information demand. 3) Patients without
previous experience of surgery had a higher information requirement than those who had been operated
on before.
As already mentioned, there was a difference in
anxiety levels between men and women. Women
scored higher on the anxiety scale than men. It was,
however, striking that men who had not been operated on before were just as anxious as women. However, men who had undergone previous surgery
scored lower on the anxiety scale than men who had
not. In other words men who have been operated on
before cope differently with their fear of anesthesia
and surgery than women. This finding warrants further research.
In contrast to our expectations, it emerged that the
questionnaire did not distinguish well between fear of
anesthesia and fear related to surgery, which means
that feelings of anxiety in the preoperative period are
diffuse and are not really focused on either surgery or
anesthesia. In this respect, the STAI-State should be a
good method for measuring preoperative anxiety, as
noted by Spielberger et al. (15). A great advantage of
our questionnaire, however, is that it is much shorter.
The anxiety scale of the APAIS consists of only four
questions, while in the STAI-State 20 questions must

= Spielbergers

State-Trait

123(61.5)
Anxiety

34
4
30
132

(17)
(2)
(15)
(66)

Inventory.

be answered. Because the APAIS is specifically attuned to the preoperative situation, patients can complete it without further explanation.
The APAIS can be used for clinical practice and for
research purposes. The scores on the anxiety scale of
the APAIS range from 4 (not anxious) to 20 (highly
anxious). The cutoff points chosen depend on the purpose for which the scale is to be used, i.e., clinical use
or research purpose. Based on a comparison with the
STAI as a gold standard, it is clear from the results that
for clinical practice the cutoff score of 11 produces a
good predictive value with an acceptable balance between false-positive and false-negative patients. So
far, the score of 11 seems a useful and efficient score
for identifying anxious patients in clinical practice. A
score of 10 would result in a lower predictive value
and a higher number of false-positive patients (anxious on the APAIS but not on the STAI) than the score
of 11 (14.5% vs 9%). Whether the anesthesiologist will
accept a score of 10 as an indication for anxiety cases
and accept a relatively high number of false-positive
patients, or prefers a score of 11 with a relatively low
number of false-positive patients depends on the
amount of time the anesthesiologist wants to devote to
a patients preoperative stress and anxiety. With
scores higher than 11 the predictive value increases
but because of the higher percentage of specificity the
number of false-negative patients (not anxious on the
APAIS, but anxious on the STAI) also increases. For
the purposes of clinical practice, it is important to
identify the patients who are anxious, and a high
number of false-negative patients is not acceptable. On
the basis of these results, we recommend for the purposes of clinical practice that patients with a score of
211 on the anxiety scale should be considered as
anxiety cases.Future research should be conducted to
clarify whether it is useful to distinguish between
anxiety casesand nonanxiety cases.
When the list is used for research purposes, the
number of false-positive patients is more important.
The score of 11 produces 9% false-positives, that is to

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say, 18 patients have a high score on the APAIS, but

not on the STAI. With a score of 13 the number of
false-positives
decreases to 4. If the list is used for
research purposes, where anxiety reduction is an important outcome criterion, we recommend
a score of
13. At the score of 13 there are hardly any falsepositives (2%) and thus the database is less polluted.
The scores on the information
scale of the APAIS
range from 2 (no need for information)
to 10 (high
need for information).
The results of our study show
that over 80% of patients have a positive attitude
toward receiving information
(score 2 5). This figure
concurs with data from other countries (31,32). Given
the implications
for daily medical practice, this is an
important
point of which
every anesthesiologist
should be aware. It also emerged that the patients
with an extremely
high information
requirement
(score 2 8) are anxious patients. The relationship
between anxiety and information
requirement
has already been underlined by Janis (33), who was the first
to conduct systematic research on preoperative
anxiety. It is important
to realize that anxious patients
might derive great benefit from more attention and
information.
However,
extensive information
is not
always useful and may even induce anxiety (34). Particularly patients with a blunting
coping style may
become anxious when confronted
with extensive information.
By contrast,
patients with a monitoring
coping style become anxious when they are not provided with as much information
as they want (24,35).
In our population
almost 17% of the patients had a
negative or uninterested
attitude toward information
(score I 4). The law requires that patients be given
information
but, as mentioned above, it is important
to realize that not everyone wants to be fully informed. We therefore advise that patients with a score
of 5 and higher should be given information
on the
topics about which they wish to be informed and in
accordance to their score. A score below 5 should be a
signal for providing
no more information
than is legally required.
Consideration
of patients preoperative
fears and
anxieties is of paramount importance in the quality of
anesthesiologic
care. However,
devoting attention to a
patients fear takes time, and time is in short supply.
Fortunately, not all patients are equally anxious and in
need of additional
support.
We have developed a
simple screening instrument
which, if used during
preoperative
assessment, may facilitate the identification of those patients who are in need of extra support.
The extent to which the APAIS will be useful in clinical practice has to be verified in future research.

SCALE

Academic
Medical
Centre for their assistance,
research
nurse, for collecting
the data about
Marion
Alhadeff
for her expertise
and support

ANESTH
ANALG
1996;82:445-51

Marjolein
Porsius,
the operations,
and
as a translator.

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1. Thyer

2.
3.
4.

5.

6.

7.
8.
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10.

11.
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13.

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18.
19.
20.

The authors
wish to thank
Benno
Bonke,
PhD, and Kommer
Sneeuw,
MA, for their valuable
and constructive
comments,
the
nursing
staff of the anesthesiologic
outpatient
department
of the

(APAIS)

21.

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