Anxiety disorders and psychological evaluation: Instruments used in

Anxiety disorders are characterized by fear and anxiety disproportionate to the situation that triggers and persists beyond what is foreseen for the event. They cause harm to the individual due to the suﬀering produced, worsen the quality of life and impose social restrictions. Psychological assessment techniques can help an investigation and improve understanding of these disorders. This study aimed to investigate the instruments for anxiety assessment used in Brazil. Thus, a literature review was carried out, searching specialized textbooks, journals and indexed articles (in capes, lilacs, pubmed, mediline, scielo and academic Google) in order to describe the most used ones. At the end of this study, it was found that the instruments for assessing anxiety disorders can be divided into seven categories: The ﬁrst includes instruments that assess anxiety as a global construct; the second evaluates psychiatric disorders; the third comprises instruments that assess speciﬁc anxiety disorders, taking into account symptomatic behaviors and thoughts or feelings; the fourth category covers instruments related to speciﬁc contexts, such as hospital or sports; the ﬁfth category includes instruments for assessing speciﬁc characteristics related to anxiety, such as concern, irritability, among others; the sixth category, covers instruments for mental health assessment in general as complaints related to anxiety seen as screening and need for psychiatric care and; ﬁnally, the seventh category comprises the other instruments that did not fall into the previous categories. It was also veriﬁed that the most used tests in Brazil from 2000 to 2015 were: Anxiety Inventory (BAI), Hospital Anxiety and Depression Scale (HADS); State Trait Anxiety Inventory (IDATE); Hamilton Anxiety Scale; Social Phobia Inventory (SPIN). These instruments are adaptations of international instruments for use in Brazil.


INTRODUCTION
Psychological evaluation is understood as a technical-scientific process, usually complex, where data collection is performed, and the information provided by patients is interpreted as resulting from interactions of various natures between individuals and the social environment. Thus, methods, techniques and psychological instruments of standardized Anxiety disorders and psychological evaluation: Instruments used in Brazil www.nucleodoconhecimento.com.br measurement are used and based on a scientific theory, being necessary to meet the requirements of validity and accuracy (CFP, Resolution No. 6, of March 29, 2019).
Psychological assessment should produce hypotheses, or diagnoses, about a person or group of people. Hypotheses or diagnoses concern intellectual functioning, personality characteristics, ability to perform one, or more tasks, among other possibilities (HUTZ, 2015).
The expression psychological testing is sometimes used as a synonym for psychological evaluation, but it is necessary to be careful with this linkage, because testing is often part of the evaluation, but it is not necessarily psychological evaluation. Although it is a fact that psychological evaluation can be done, in certain specific cases, using only psychological tests, this does not occur as a rule (HUTZ, 2015).
When it comes to the broad term, psychological evaluation, one must first distinguish it from the assessment instruments. Evaluation is a more complex activity and constitutes a systematic search for knowledge about the psychological functioning of individuals, so that it can guide future actions and decisions. On the other hand, evaluation instruments are systematically organized procedures for collecting useful and reliable information in order to serve as the basis for a broader and deeper process of psychological evaluation, in ways that the instruments are part of the broader process of psychological assessment (PRIMI et al., 2004). Testing can be interpreted as part of the psychological evaluation process in many situations.
Instruments in general are standardized means to obtain behavioral samples and indicators in order to reveal individual differences in constructs, latent traits or implicit psychic resources. Thus, the covert traits are the causatis variables of the behaviors that manifest themselves during testing. Therefore, the comprehensive processes of measures, implying in directly, through the observation of indicators, allows interference on the construct to be evaluated (GOTTFREDSON and SAKLOFSKE, 2009). Validity studies seek to prove the causal relationship between variations in the underlying construct and changes in behavioral indicators analyzed by the instrument, thus confirming the meanings associated with construct-related scores (PRIMI, 2010).
It is important to mention that psychological evaluation is one of the oldest areas of   published the book entitled "Tests", with the subtitle "Introduction to the study of scientific means of judging the intelligence and application of students", this was the first book on psychological tests in Brazil (GOMES, 2009;HUTZ and BANDEIRA, 2003). Hutz, (2015) still describes the following text on the importance of psychological evaluation: It is also important to understand that psychological evaluation is a complex area with interfaces and applications in all areas of psychology. In principle, one should not start a procedure, with people or groups, in any area of psychology without a diagnosis or an initial evaluation of that person or group. After the procedure (or even during its performance), it is necessary to evaluate the results. It is, therefore, fundamental a basic training in this area to work efficiently and quality as a psychologist in any other area of application of psychology. How this training should be done is still the subject of discussion. The knowledge of psychological evaluation comes against the current concept of health, and the causes of diseases. Health is not only as an absence of symptoms, since an individual may be severely ill without presenting symptomatology. Diseases, in the current view, do not have a single determination, but on the contrary, they are multidetermined. There are no two psychos, one of health and one related to the disease. In reality, the expression psychology in health involves the experience of a person and also in their process of illness. Thus, every disease has psychological aspects and involves multiple factors to be evaluated, such as lifestyle, habits, culture and family myths (STRAUB, 2005).
Speaking particularly of anxiety disorders, they substantially affect people's lives, compromises everyday activities, social relationships and other aspects of their lives. These disorders have low rates of spontaneous regression and a strong tendency to chronicor even unfold in other psychiatric disorders if not treated (PINE, 1997;VIANNA, 2009). Thus, it is necessary that the diagnosis occurs as soon as possible, taking into account the appropriate evaluations and treatments, so the patients will have better prognoses and lower will be the harms for the individual.
The correct diagnosis of an anxiety disorder, both due to severity and comorbidities, generates expectation of a good prognosis because it provides adequate information about course, prevalence and possibilities of treatment, in addition to other factors. Therefore, it is important that clinicians have at their disposal appropriate instruments for the assessment of anxiety, both for symptom measurements and for screening and diagnosis. Good instruments provide standardized and safe instruments for obtaining indicators for construct evaluation, a latent trait or underlying psychological process (PRIMI, 2010), for example anxiety and fearconstructs that hide symptoms of anxiety disorders (CRASKE et al., 2009  Anxiety involves cognitive, behavioral, affective, physiological and neurological factors that modulate the individual's perception of the environment and provoke specific responses by stimulating some kind of action (CLARK and BECK, 2012;CRASKE et al., 2009). In the face of stimuli or stressful situations, the body's responses arise, such as increased blood pressure, increased frequency of heartbeat, increased sweating and motor activity, agitation, skeletal muscle stiffness and respiratory changes, superficial and rapid type and insomnia, in addition to other physiological changes (LUNDIN, 1977).
According to Tess (1996) anxiety is a warning sign, a warning about immediate dangers, preparing you to create and take measures to face a vague threat, where the situation of danger is not concrete, however it leads to a behavioral and physiological repertoire in a response and has the direction facing the future.
Anxiety is not necessarily a pathological condition, but a natural condition of the organism, Anxiety disorders and psychological evaluation: Instruments used in Brazil www.nucleodoconhecimento.com.br which allows preparing for a response, defense or attack, in the best possible way, in new or unknown situations, or situations already known but interpreted as eminently dangerous (SILVA, 2010). This condition only becomes pathological when it reaches very high and continuous levels, starting to impair performance in daily activities and generate physical and/or emotional imbalance and thus will configure in a state of constant alertness, characterizing the pathologies designated as anxiety disorders (ARAÚJO, 2011).
According to DSM 5, (2014), anxiety disorders include disorders that share excessive fear and anxiety characteristics and related behavioral disorders. Fear is the emotional response to real or perceived imminent threat, while anxiety is anticipating future threat. Obviously, these two states overlap, but also differ, with fear being more often associated with periods of increased autonomic excitability, necessary for fight or flight, thoughts of immediate danger and escape behaviors, and anxiety being more often associated with muscle tension and vigilance in preparation for future danger and behaviors of caution or elusiveness. Sometimes the level of fear or anxiety is reduced by constant antics behaviors. Panic attacks stand out within anxiety disorders as a particular type of response to fear. They are not limited to anxiety disorders and can also be seen in other mental disorders According to Antai-Otong (2003) cognitive (nervousness, apprehension , concern, irritability and distractability) (DSM 5, 2014).
Brazil has very high rates of anxiety disorders, and factors such as socioeconomic, poverty, unemployment, environmental factors, lifestyles in large cities favor this scenario (GONÇALVES and KAPCZINSKI, 2008). On the other hand, Anxiety Disorders are among the most prevalent mental disorders in children and adolescents. According to Asbahr, (2004) loses only to Attention Deficit Hyperactivity Disorder (TDAH) and Conduct Disorder.
Epidemiological studies in American populations indicated that childhood anxiety disorders have an estimated prevalence of 8 to 12% (COSTELLO, 1989;SPENCE, 2001). In Brazil, a population study showed a prevalence rate of 4.6% in children and 5.8% in adolescents (FLEITLICH-BIL and GOODMAN, 2004). Ford et al., (2003) in studies in England, morbidity rates were similar to those found in Brazil, indicating a prevalence of 3.4% in children, and 5.04% in adolescents (FORD et al., 2003).
According to the World Health Organization (WHO) the worldwide prevalence of anxiety disorder (TA) is 3.6% of the population. However, in the American continent, this disorder reaches 5.6%, and in Brazil, TA reaches 9.3% of the population, with the highest number of cases of anxiety among the countries of the world (WHO, 2017).
Anxiety disorders are pointed out as one of the most relevant mental health problems in Brazil and are among the most recurrent psychiatric disorders. It is emotional dysfunction that probably most affects and most interferes with quality of life and are considered the most disabling disorders (RAMOS, 2009). These data point to anxiety disorder as a public health problem, and suggest that further studies be conducted in this regard.

ANXIETY DISORDERS ACCORDING TO DSM 5
The reformulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) removed from the chapter referring to anxiety disorders, the disorders "obsessive compulsive", "acute stress" and "posttraumatic stress", reselecting them in new chapters.
Phobic conditions (agoraphobia, specific phobia and social anxiety disorder) no longer require the minimum age of eighteen years for the recognition of their excessive or irrational fear.
Finally, the minimum duration for diagnosis also became six months without age distinction Children or adolescents fear that something might happen to themselves or their caregivers, as long as they are removed from them. Thus, they assume excessive attachment behavior to their caregivers, preventing the removal or even systematically phoning them. They need company to sleep and can resist sleep for fear of separation or loss of control. They refer to nightmares, about the fears of separation is common secondary school refusal in these patients (CASTILLO, 2000).
It is enough for a child to imagine that his/her parents will be absent so that somatic manifestations of anxiety (abdominal pain, headache, nausea and vomiting) may arise. Some have palpitations, dizziness and an impression of fainting. Retrospective studies have raised the hypothesis that separation anxiety in childhood may constitute a risk factor for the onset of anxiety disorders in adults (CASTILLO, 2000). The essential characteristics of generalized anxiety disorder are excessive anxiety and concern (apprehensive expectation) about various events or activities. The intensity, duration, or frequency of anxiety and worry is disproportionate to the actual probability or impact of the anticipated event. The individual has difficulty controlling the concern and preventing worrying thoughts from intervening in the attention to the tasks in question. Adults with generalized anxiety disorder often worry about daily life routine circumstances, such as possible responsibilities at work, health and finances, the health of family members, misfortunes with their children, or minor issues (e.g., performing household chores or being late for appointments). Children with the disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of concern may shift from one concern to another.

PANIC DISORDER (TP)
In panic disorder there is an abrupt outbreak of fear, or intense discomfort that reaches a peak in minutes and during this time the most common symptoms presented are: palpitations, acceleration of heart rate, sweating, feeling short of breath, or being suffocated, feeling dizzy, fear of losing control or dying, depersonalization, disrealization, in addition to other symptoms. The start is always sudden and the duration of 10 to 30 minutes on average (DSM 5, 2014 Children with this disorder speak at home in the presence of family members, but often do not talk to close friends or second-degree family members. The disorder is often marked by high social anxiety. At school, these children often refuse to speak, and have repercussions on school performance. As for the development and course of this disorder, in general, its onset occurs before the age of 5, but may not be clinically detected until entering the school, where there is an increase in social interaction (DSM 5, 2014).
Risk factors for selective mutism are not well identified. Negative affectivity (neuroticism) or Anxiety disorders and psychological evaluation: Instruments used in Brazil www.nucleodoconhecimento.com.br behavioral inhibition may play a role, as well as parental history of shyness, social isolation and social anxiety. At the environmental level, parents of children with selective mutism were described as overprotective and more controlling than parents of children with other anxiety disorder or without disturbances. Due to the significant overlap between selective mutism and social phobia, there may be genetic factors common to both conditions (DSM 5, 2014).

RESULT AND DISCUSSION
Araújo (2013), conducted a systematic review in search of psychological assessment instruments available in Brazil, with relevance for diagnoses of anxiety disorders and divided the instruments into seven categories. The first category includes instruments that analyze anxiety as a global construct, in this category is the Inventory of State-Trait Anxiety -STAI).
The second category involves instruments to assess psychiatric disorders, such as the Screen for Child Anxiety Related Emotional Disorders (SCARED) or instruments for the evaluation of anxiety disorders and disorders of other psychiatric categories (e.g., Composite International Diagnostic Interview -CIDI).
The third comprises instruments for assessing specific anxiety disorders through behaviors, thoughts and/or feelings symptomatic of the disorder in question (e.g., Social Phobia Inventory -SPIN). The fourth includes instruments for assessing anxiety related to specific contexts (e.g., hospital, where it applies to anxiety and depression scales -HADS); Competitive State Anxiety Inventory-2 -CSAI-2). The fifth category includes instruments for assessing a peculiarity related to anxiety, such as the concern: Penn State Worry Questionnaire -PSWQ; anxiety sensitivity index-3 -ASI-3). The sixth category, involving instruments that assess mental health in general -such as anxiety-related complaints -has value as an indicative screening of the need for psychiatric care, among them is the Self-Reporting Questionnaire-20 -SRQ-20). The seventh category comprises the other instruments included that did not fall into the previous categories.
The studies by Obelar (2016)  Bai was adapted and standardized for the Brazilian population by Cunha (2001). It assesses anxiety symptoms on a scale from zero to four points, and identifies increasing severity levels of each symptom (TAVARES et al., 2012). There are several instruments already described in order to assess anxiety and depression (Hamilton Anxiety Scale, IDATE Anxiety Inventory I and II, Beck Anxiety and Depression Inventories and Hospital Anxiety and Depression Scale (HADS). Most of them were created to be used in patients with psychiatric disorders. However, HADS was initially created to verify symptoms of anxiety and depression in patients in hospitals and non-psychiatric clinics, later started to be used in non-hospitalized patients and in theotically disorder-free individuals.
HADS was limited to 14 items, divided into anxiety and depression subscales. Zigmond and Snaith (1983) recommended two cutoff points in both subscales as follows: possible cases with scores greater than 8 and probable cases, greater than 11 points. They also suggested a third cut-off point: in relation to severe disorders, which received more than 15 points.
This instrument has already been translated into several languages. Botega et al., (1995) produced a hads validation study in Portuguese. HADS differs from other scales by excluding the interference of somatic disorders, so they are not present in the score of this scale, symptoms of anxiety or depression associated with physical diseases.
Therefore, items such as weight loss, anorexia, insomnia, fatigue, pessimism about the future, headache and dizziness, etc. are not included.

TRACE-STATE ANXIETY INVENTORY (IDATE )
This Inventory is one of the most used instruments to quantify subjective components of anxiety (KEEDWELL and SNAITH, 1996). It was prepared by Gorsuch and Lushene (1970) and in Brazil was translated and adapted by Biaggio and Natalício (1979).
IDATE has a scale to assess anxiety as a state (IDATE -E) and another that checks anxiety as a trait (IDATE -T).
The anxious state portrays a transient response related to a situation of adversity that presents itself at a given moment, while the trait refers to a more stable aspect, the propensity of the individual to deal with greater or lesser anxiety throughout life (CATTELL Anxiety disorders and psychological evaluation: Instruments used in Brazil www.nucleodoconhecimento.com.br and SCHEIER, 1961).
The IDATE was initially developed with the purpose of measuring specific latent structures, in which each scale would correspond to a single factor (SPIELBERGER et al., 1970). However, studies were conducted in the 1970s-80s with technical and statistical foundations of factor analysis, which indicated the existence of two factors for IDATE -E and IDATE -T (BARKER; BARKER and WADSWORTH, 1977;GAUDRY and POOLE, 1975;LOO, 1979;SPIELBERGER et al.,1980). This pattern of results generated discussion about the true potential structure of these scales, especially in relation to the IDATE -T that demonstrated a greater problem of interpretation regarding the nature of its factors. Spielberger et al., (1980) showed that the best classification of items related to these two factors was the one that contained contents that manifested the presence or absence of anxiety.
In Brazil, the factorial structure of the IDATE-T has been little studied. Among the studies are those of Pasquali et al., (1994) as well as those of Andrade et al., (2001), who found different factorial structures in relation to IDATE-T. For example, Pasquali and et al. (1994), verified a solution that helped the interpretation of the two factors of IDATE-T in "present anxiety" and "absent anxiety". On the other hand, Andrade and et al. (2001) reported the presence of two factors related to anxiety and depression.
The assessments on the factorial structure of the IDATE found a high consistency index in both scales, and Cronbach's alpha in three samples ranged from 0.82 to 0.89 (LORICCHIO, 2012).

SOCIAL PHOBIA INVENTORY (SPIN)
The Mini-SPIN is composed of three items, which assess the fear of embarrassment and avoidance. For each item in the inventory, the individual is asked to indicate how much the situations bothered him in the last week, and should mark one of the five existing options, which range from "Nothing to extremely". The score for each option ranges from 0 to 4, and the total score of the instrument ranges from 0 to 12. Scores of 6 points or more suggest that the clinician should investigate the presence of generalized social phobia. The original In addition to the instruments described above because they were found to be the most used over 15 years (2000 to 2015) in the Obelar review (2016)

FINAL CONSIDERATIONS
Anxiety is a normal emotion, a warning sign, which warns of imminent dangers and has the function of mediating man's interaction with the environment; being then a natural and necessary reaction for self-preservation. Anxiety symptoms are expected in appropriate situations. Anxiety is considered pathological, when, disproportionate in relation to the Anxiety disorders and psychological evaluation: Instruments used in Brazil www.nucleodoconhecimento.com.br triggering stimulus. Anxiety Disorder is usually identified by repeated and intense occurrence of various physical (aquicardia, sialosquesis, pulmonary hyperventilation and excessive sweating), behavioral (agitation, insomnia, exacerbation of reactions to stimuli and fears) or cognitive (agitation, distress, worry, nervousness and attention deficit) (LOUZÃ et al., 2011).
In the Brazilian population, anxiety disorders have a high prevalence and are very disabling, causing significant functional and social impairment, and high financial cost for the public service. The realization of a more accurate and effective diagnosis is necessary so that the treatment can be performed correctly. (MARCULINO et al., 2007). Psychological evaluation, when performed with valid, reliable and up-to-date instruments can be of great help to diagnostic improvement and treatment guidance and planning.
A psychological assessment instrument must be adequate, and have well-based theoretical bases on empirical evidence, to generate safe diagnoses and prognoses (CUNHA, 2001;PRIMI, 2010).
The Instruments that assess anxiety should ensure confidence to clinicians and researchers to perform screening and diagnosis processes safely, supporting clinical and academic practices in the planning and efficacy of interventions. It is important that professionals know the qualities of the instruments available in Brazil for the evaluation of anxiety disorders and the qualities of the instruments in order to be able to select the best and most appropriate instrument to measure what is desired, according to the objectives in question.
Psychological assessment should be understood as more than simply a field applied to the use of measures and techniques. The evaluation, in general, and the development of instruments, serve to objectiveize and operationalize theories and constructs (PRIMI, 2010).
They involve the relationship of theoretical concepts with observable elements and require the application of the scientific method. Seeking evidence of adequacy of the evaluation instruments, the studies help the development of the constructs evaluated (PRIMI, 2010).
Thus, the advances of studies on anxiety assessment offer theoretical and empirical bases for the development and knowledge of this construct and for the prevention and treatment of anxiety disorders.