Anxiety and Depression Symptoms in Athletes

and Their Attitudes Towards These Problems

Bára Fanney Hálfdanardóttir

Lokaverkefni til BS-gráðu

Sálfræðideild

Heilbrigðisvísindasvið

Anxiety and Depression Symptoms in Athletes

and Their Attitudes Towards These Problems

Bára Fanney Hálfdanardóttir

Lokaverkefni til BS-gráðu í sálfræði

Leiðbeinendur: Hallur Hallsson og Ragnar Pétur Ólafsson

Sálfræðideild

Heilbrigðisvísindasvið Háskóla Íslands

Febrúar 2016

Ritgerð þessi er lokaverkefni til BS gráðu í sálfræði og er óheimilt að afrita

ritgerðina á nokkurn hátt nema með leyfi rétthafa.

© Bára Fanney Hálfdanardóttir

Prentun: Háskólaprent

Reykjavík, Ísland 2016

Abstract

This study examined symptoms of general anxiety, sport performance anxiety and

depression among 117 basketball players in the top league in Iceland.

Furthermore, stigma towards anxiety and depression problems was explored. The

Sport Anxiety Scale (SAS-2) was used to measure sport performance anxiety. The

Hospital Anxiety and Depression Scale (HADS) was used to measure symptoms

for general anxiety and depression. The Depression Stigma Scale was used to

measure both personal and perceived stigma towards anxiety and depression. The

results showed that measures of sport performance and general anxiety were

strongly related (r=0.74) but not to the degree that they could be considered to be

redundant of each other. There was a gender difference on SAS-2 and HADS

anxiety subscale with female players scoring significantly higher than male

players. There was no significant difference in scores between injured and non-

injured players on the HADS anxiety and depression subscales. However, within

the group of injured players, those who missed five or more practices scored

significantly higher on the anxiety subscale. Players scored higher on measures of

perceived stigma than personal stigma. The results suggest that when exploring

levels of general anxiety in samples of athletes, it is important to take sport

performance anxiety into account to avoid inflated estimates of symptom severity.

Acknowledgements

I want to give thanks to my advisors, Dr. Ragnar Pétur Ólafsson and Hallur Hallsson, for

important and useful guidance and enjoyable conversation about the subject. Additionally, I

like to thank managers and coaches of the teams for allowing me to attend practices for data

collection as well as all the players that participated in this research. Lastly, I want to give

thanks to my family and close friends that have supported me through this whole process, and

special thanks to my aunt, Ingibjörg Markúsdóttir, who has shown me great patience and

unbelievable support.

4

Table of contents

List of figures and tables ......................................................................................................... 5

Introduction .............................................................................................................................. 6

What is depression? ................................................................................................................ 6

What is anxiety? ..................................................................................................................... 7

Theories on anxiety in sport .................................................................................................. 9

Sources of stress in sport ...................................................................................................... 11

Stigma on mental health in sport .......................................................................................... 12

Prevalence of mental disorders in athletes............................................................................ 13

Hypotheses ............................................................................................................................ 14

Method ..................................................................................................................................... 16

Participants ........................................................................................................................... 16

Instruments and measures ..................................................................................................... 16

Sport Anxiety Scale (SAS-2) ......................................................................................... 16

Hospital Anxiety and Depression Scale (HADS) ........................................................... 17

Depression Stigma Scale (DSS) ..................................................................................... 17

Procedure .............................................................................................................................. 18

Design and data analysis ....................................................................................................... 19

Results ..................................................................................................................................... 20

Symptoms of anxiety and depression ................................................................................... 20

Gender difference ................................................................................................................. 22

Injured versus non-injured .................................................................................................... 22

Anxiety facilitating on performance ..................................................................................... 23

Perceived stigma and personal stigma .................................................................................. 24

Discussion ................................................................................................................................ 26

References ............................................................................................................................... 29

Appendix I – Background questionnaire ............................................................................. 38

Appendix II – Sport Anxiety Scale 2 in Icelandic ............................................................... 40

Appendix III – Hospital Anxiety and Depression Scale in Icelandic ................................. 42

Appendix IV – Depression Stigma Scale for depression and anxiety in Icelandic ........... 43

5

List of Figures

Figure 1. Relationship between total scores on SAS-2 and HADS anxiety subscale……..…21

Figure 2. Relationship between total scores on SAS-2 and HADS depression subscale….....21

Figure 3. The scores variability on the statement: “Anxiety has a positive effect on my

performance” and whether players had played for the national team or not…………………24

List of Tables

Table 1. Prevalence of anxiety and depression symptoms within the players……………….20

Table 2. Mean scores, standard deviation, minimum and maximum scores for HADS anxiety

and depression, and SAS-2 performance anxiety, by gender……………….………….….…22

Table 3. Mean scores and standard deviation on the HADS anxiety and depression subscales

for injured and non-injured players……………………………………...……………………23

Table 4. Mean scores and standard deviation on the personal stigma scale and the perceived

stigma scale for anxiety and depression on the DSS. A greater score indicates greater

stigma……………………………………….………………………………………….……..25

6

Societies often view athletes to be the stereotypes for good physical and mental health. It’s

not uncommon for people to draw the conclusion that being in good physical health makes a

person more likely to be in good mental health. Studies have also shown a positive link

between exercise and psychological well-being (Hassmén, Koivula, & Uutela, 2000), with,

for example, exercise improving self-esteem, and reducing anxiety and negative mood

(Callaghan, 2004). However, it has also been found that being an athlete does not necessarily

protect people from mental disorders (Armstrong & Oomen-Early, 2009; Gulliver, Griffiths,

Mackinnon, Batterham, & Stanimirovic, 2015; Schaal et al., 2011; Yang et al., 2007), and the

most common mental disorders among athletes are depression and anxiety (Schaal et al.,

2011).

What is depression?

Sadness and downturn in mood are symptoms that most people have experienced, and can be

normal reactions to trauma or difficulties in life. The main difference between normal

downturn in mood and depression is the severity of the symptoms, duration, and the gravity of

impairment depression can have on person’s daily functioning (Nolen-Hoeksema, 2014).

Depression falls under mood disorders in The Diagnostic and Statistical Manual of

Mental Disorders or DSM-5, where it is called Major Depressive Disorder (American

Psychiatric Association, 2013). To be diagnosed with MDD an individual must have five of

the following symptoms every day during two weeks: depressed mood most of the day or

markedly diminished interest or pleasure in activities, significant weight loss, insomnia or

hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or

inappropriate guilt, inability to think or concentrate, and recurrent thoughts of death. These

symptoms have to be that severe that they are disturbing the daily life of the individual, and

do not appear as a result of substance use or to another medical condition (American

Psychiatric Association, 2013). Depressive episodes are categorized by the severity of the

symptoms, mild, moderate, or severe. Symptoms of depression can take a variety of forms,

and it is common that they are mild in the beginning and can stay mild for a few months

before they start to disturb the daily life of the individual. Therefore, it is important to detect

these symptoms early to increase the possibility of preventing the development of a serious

7

illness (Nolen-Hoeksema, 2014). People with mental disorders, specifically depression, are at

high risk for suicide attempts (Nock et al., 2008).

According to the World Health Organization (WHO), 350 million people of all ages

suffer from depression, and women are twice more likely than men to develop the disorder

(World Health Organization, 2012). Lifetime prevalence of MDD falls between 8 to 12% in

most countries, with the 30 day to 12 months prevalence between 45% to 65%, and 12 months

to lifetime is in the range from 40 to 55% (Andrade et al., 2003). MDD has been found to co-

morbid with anxiety disorders, chronic diseases like arthritis, asthma, diabetes, and heart

diseases (Jiang, Krishnan, & O'Connor, 2002; Moussavi et al., 2007).

There are effective psychological treatments available for depression. For example,

research on Cognitive Behavior Therapy has shown to be as effective as medications for

MDD (DeRubeis et al., 2005). Physical exercise has also been linked to decreased symptoms

of depression, and research on aerobic exercise indicates that it can be an effective treatment

for MDD of mild to moderate severity (Dunn et al., 2005). In spite of this, the majority of

people with depression are likely to not receive any treatment at all for their disease. A

possible explanation might be stigma towards mental disorders, lack of access to treatments,

and lack of knowledge about the symptoms (World Health Organization, 2012).

What is anxiety?

Fear plays an important role in human nature. When a person faces a threat the body reacts to

it with a physical and psychological response that helps the person to fight the threat or flee

from it, often referred to as the fight or flight response. Normally the fear disappears as soon

as the threat is gone. However, fear can turn into anxiety if the fear is unrealistic, excessive,

and persists long after the threat has gone (Nolen-Hoeksema, 2014). Anxiety is an unpleasant

emotional state or reaction that is characterized by feelings of apprehension, intensity,

preoccupation, and disturbance, and is often associated with biological changes in the body

(Nolen-Hoeksema, 2014).

Anxiety is usually divided into two components; somatic and cognitive anxiety

(Smith, Smoll, & Schutz, 1990). The physical response refers to the somatic part of anxiety

and the psychological response refers to cognitive anxiety. Somatic anxiety is the perception

of a person’s physiological change in the body, for example sweat, tremble, and increased

heart rate, blood pressure, breathing, and muscle tension. Cognitive anxiety is the

8

psychological expression of anxiety and can be emotions/thoughts/feelings of terror, fear,

worries, negative thoughts, frustration, and restlessness (Weinberg & Gould, 2015). It is also

necessary to make a distinction between momentary states and more permanent traits of

anxiety (Spielberger 1966, 1972; Spielberger, Vagg, Barker, Dunham, & Westbury, 1980).

Trait anxiety reflects the personality of the individual. People with high trait anxiety show

signs of stress and anxiety in many situations, and they are more likely than people with low

trait anxiety to notice information related to threats. State anxiety is the individual’s

perception of the changes in cognitive and somatic anxiety in a specific situation (Spielberger,

1966, 1972). People with high trait anxiety usually have high state anxiety (Broadbent &

Broadbent, 1988; Weinberg & Hunt, 1976).

According to DSM-5 (American Psychiatric Association, 2013) anxiety disorders can

be divided into separation anxiety, selective mutism, specific phobia, social anxiety disorder,

panic disorder, agoraphobia, and generalized anxiety disorder. Anxiety disorders have high

comorbidity with other mental disorders such as MDD, substance abuse, and drug addiction

(Leray et al., 2011).

In this research the focus is on symptoms of Generalized Anxiety Disorder (GAD).

People with GAD are anxious in almost all situations, they are usually worried about many

things, and spend a lot of time preparing for, or avoiding situations they fear. They frequently

worry about their performance at work, school, relationships, and health. Symptoms usually

develop slowly and tend to be more serious when a person is experiencing more stress in their

life (Nolen-Hoeksema, 2014). According to the DSM-5 (American Psychiatric Association,

2013), generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry

most days of the week during the last 6 months. The individual finds it difficult to control his

or her worry, and the anxiety and worry are associated with at least three of the following

symptoms; restlessness, being easily fatigued, difficulty concentrating, irritability, muscle

tension, and sleep disturbance. These symptoms have to cause clinically significant distress or

impairment in daily life (American Psychiatric Association, 2013).

Prevalence of mental disorders in Europe is estimated to be as high as 38% and

anxiety disorders are the most prevalent disorders (14%; Wittchen et al., 2011). The 12 month

prevalence of GAD in the general population is estimated to be between 2 to 5% (Lieb,

Becker, & Altamura, 2005; Wittchen, 2002). Females, young adults, and people with low

income are at greater risk of developing GAD (Leray et al., 2011).

9

Both medication and psychological treatments, for example relaxation and cognitive

behavioral therapy, have been shown to be effective treatments for anxiety disorders

(Gorman, 2002), as well as physical exercise (Carek, Laibstain, & Carek, 2011).

Theories on anxiety in sport

During the last decades several theories have been formulated that focus on the relationship

between arousal and anxiety, and how they are linked to performance in sports (Jones, 1995).

These different theories all give an important insight into how arousal and anxiety can have

an effect on athletes’ performances.

Arousal is the person’s physiological and psychological response, and it refers to the

intensity state of action that motivates the person to perform at a specific moment. Arousal

intensity can have a positive or negative consequence on person’s performance (Weinberg &

Gould, 2015). High arousal or anxiety can for example cause an increased muscle tension,

fatigue, and lack of concentration (Landers, Wang, & Courtet, 1985; Nieuwenhuys &

Oudejans, 2012; Pijpers, Oudejans, Holsheimer, & Bakker, 2003).

One of the first theories about arousal and performance, the Drive Theory (Spence &

Spence, 1966), proposed a linear relationship between the two. Thus, an increase in drive (i.e.,

arousal, state anxiety, and stress) is associated with an increase in performance -for example

the more aroused an athlete is before a game the better he will perform. However, it matters

how skilled the athlete is. If an athlete’s skill level is not high the performance will become

progressively worse as arousal increases (Weinberg & Gould, 2015). The theory might

explain why elite athletes perform better under pressure, but it does not explain why elite

athletes often fail when they are highly aroused. The Drive Theory has been criticized for

being too simple and not explaining the relationship between arousal and performance well

enough (Harmison, 2006; Martens 1971; Weinberg 1990).

For an answer to this criticism, sport psychologists turned to the Inverted U hypothesis

(Yerkes & Dodson, 1908) to try to explain the relationship between arousal and performance.

Inverted U hypothesis proposes that the relationship between arousal and performance is in

the form of a symmetrical inverted U. With increased arousal, performance will improve, but

only up to a certain point, which is called the optimal point and is located in the middle of the

arousal continuum. Arousal that goes over the optimal point will result in a gradual decrease

in performance (Arent & Landers, 2003; Sonstroem & Bernardo, 1982). However, this theory

10

has been criticized for the shape of the curve and that it does not take individual differences

into account (Weinberg, 1990). Research has shown that a catastrophic decrease happens in

athletes’ performances when arousal reaches above the optimal level instead of slightly

decreasing like the Inverted U hypothesis assumes (Hardy & Parfitt, 1991). In support of the

criticism on the shape of the Inverted U hypothesis a research on female volleyball players,

showed that the players reported their best performances when their anxiety was either low or

high, but not in the moderate range (Raglin & Morris, 1994).

The theory of Individual Zone of Optimal Functioning (IZOF; Hanin, 1980) proposes

that there are individual differences in the relationship between arousal and performance. The

optimal level of state anxiety is not always at the midpoint of the continuum. Each person has

their own zone of optimal level for their best performance. If the state anxiety lies outside of

the person’s optimal zone, their performance will be impaired. Therefore, athletes with state

anxiety within their zone should perform better than athletes with state anxiety outside of their

zone (Gould & Krane, 1992). This theory also accounts for other emotions that can have an

effect on the performance of athletes such as disappointment, frustration, excitement, and joy.

How an athlete perceives these emotions, negative or positive, is the key to understand the

relationship between arousal and performance. Thus, for some athletes, increased anxiety or

anger can help them improve their performance, but for others it might diminish it (Hanin,

2000, 2007). There is research that supports the theory of IZOF (Gould & Tuffey, 1996;

Raglin, Morgan, & Wise, 1990). A meta-analysis of 19 studies showed a better performance

from athletes that were within their optimal individual zone then those athletes who were

outside of their zone (Jokela & Hanin, 1999).

The Catastrophe Model (Hardy & Fazey, 1987) suggests a three dimensional

relationship between cognitive anxiety, physiological arousal (somatic anxiety) and

performance. The physiological arousal is related to performance in an inverted U under the

condition of low cognitive anxiety. Increased cognitive anxiety will enhance performance

under conditions of low physiological arousal. However, if the cognitive or the physiological

arousal becomes too high it will at some point go over the individual’s threshold and cause a

rapid decline in his or her performance, i.e. catastrophe will occur (Hardy 1990, 1996; Hardy

& Parfitt, 1991). This model predicts that a person will perform better with some level of

anxiety provided that his or her physiological arousal level does not become too high.

11

Therefore, experiencing cognitive anxiety does not always have to impact performance in a

negative way (Weinberg & Gould, 2015).

Athletes, as well as people in general, usually look at anxiety as something that will

affect their performance negatively, but in fact, it can have an opposite effect (Ntoumanis &

Jones, 1998; Swain & Jones, 1996). Two athletes that are experiencing similar anxiety prior

to competition can perceive those symptoms very differently. For some athletes’ anxiety

before a game can facilitate their performance and for others it might debilitate it. The impact

anxiety has on performance depends on the individual interpretation of anxiety, and the

individual’s believes in their ability (Jones, 1995). Research has shown that elite athletes

report their cognitive anxiety as being more facilitative to their performance then non-elite

athletes (Jones, Hanton, & Swain, 1994; Jones, Swain, & Hardy, 1993). Jones and Hanton

(2001) found, for example, that swimmers who reported competitive anxiety to be facilitating

for their performance before competition also reported more positive feelings than athletes

that reported competitive anxiety to be debilitating for the performance.

Sources of stress in sport

Stress can be defined as a substantial imbalance between demands and response capability

under conditions where failure to meet the demands has important consequences (McGrath,

1970). Every athlete can relate to this definition, the demands to do well and the worry that

their skill or talents are not good enough against their opponent.

Sources of stress for athletes have been related to negative aspects of competition,

interpersonal problems with teammates and coaches, financial concerns, injuries, lack of

social support, personal struggles, and traumatic experience (Woodman & Hardy, 2001;

Scanlan, Stein, & Ravizza, 1991). It has also been shown that more attention from the media

and interest from supporters can be percived as an added stressor to perform (Kristiansen,

Halvari, & Roberts, 2012).

Injuries can have a substantial impact on the mental health of athletes. They could

experience uncertainty regarding the severity of the injury, their recovery, and worry about

the possibility of losing their position in the team. Leddy, Lambert, and Ogles (1994)

conducted a research on psychological reactions to injury on collegiate athletes, and found

that injured athletes were experiencing more symptoms of depression and anxiety then non-

injured athletes. They also found that athletes that were still dealing with their injury two

12

months later had more symptoms of depression than athletes that were injured in the

beginning of the research but had returned back to practice. Research has shown that athletes

with injuries are at greater risk then non-injured athletes to develop depression, and are also at

higher risk for suicidal attempt (Appaneal, Levine, Perna, & Roh, 2009; Smith & Milliner,

1994).

Stigma of mental health in sports

Negative attitudes and prejudices can have a negative effect on the lives of individuals with

mental disorders, and prevent individuals from seeking help (Sirey et al. 2001; Wells, Robins,

Bushnell, Jarosz, & Oakley-Browne, 1994). Women are more likely to seek help for mental

health problems than men, and younger people are more reluctant to seek help then older

people (Rickwood, Deane, Wilson, & Ciarrochi, 2005).

Stigma can be defined as the negative attitudes and beliefs towards something or

someone and often leads to discrimination (Corrigan, 2004). A definition can be made

between personal stigma and perceived stigma. Personal stigma is the negative attitudes and

beliefs the individual has, and perceived stigma can be defined as the negative attitudes and

beliefs that the individual thinks the general public has (Griffiths, Christensen, & Jorm, 2008).

Perceived stigma can have an effect on the willingness of the person with mental disorder to

seek help (Vogel, Wade, & Hackler, 2007). Pedersen and Paves (2014) found that people

report higher perceived stigma then personal stigma.

Over the last few decades there has been an awakening regarding attitudes towards

mental disorders in sports, which has resulted in more athletes coming forward and talking

about their experience having a mental illness. However, there is more need for research on

stigma in relation to athletes. Watson (2005) did a research on help seeking behavior of

college students, and found that athletes were less likely to seek help then their peers.

The biggest barrier for athletes to seek help seems to be stigma, other barriers are

denial, lack of mental health literacy, and negative past experience of help seeking. However,

encouragement from others, having an established relationship to the provider of support,

pleasant previous interactions with providers of support, the positive attitude of others, and

access to the internet can all increase the likelihood of athletes seeking support (Gulliver et

al., 2012).

13

Education and opportunities to meet and get to know people with mental disorders

have shown to be effective ways to decrease stigma towards mental illness. Furthermore,

education seems to work better for adolescents, and talking with people with mental disorders

seems to have more influence on decreasing stigma for adults (Corrigan, Morris, Michaels,

Rafacz, & Rüsch, 2012).

Prevalence of mental disorders among athletes

The findings of studies on prevalence of mental disorders in athletes are inconsistent.

Armstrong and Oomen-Early (2009) found that collegiate athletes had fewer symptoms of

depression than non-athletes. Yang et al. (2007) found that 21% of 257 collegiate students

athletes playing in Division I in the USA experienced symptoms of depression (male 19,2%

and female 25,6%), and that freshmen and female athletes were more likely to have symptoms

of depression than men.

On the other hand recent research has shown that the prevalence of mental disorders in

athletes is similar to prevalence rates in the general population. Schaal et al. (2010) found that

the prevalence of mental disorders in a sample of French high-level athletes was similar to the

prevalence rates in the general population. In this study 17% of the athletes met the criteria

for at least one current or recent (i.e. within last six months) mental disorder, and lifetime

prevalence rate was 25%. Women were 1.3 times more likely to have at least one mental

disorder, and 2 times more likely to have two or more disorders. GAD had the highest

prevalence among the athletes or 6%, and major depression was in third place with 4%.

Similar results have been reported in Australia. Gulliver et al. (2015) found prevalence

rates of symptoms of mental disorders in a group of elite Australian athletes, to be similar to

prevalence rates in community studies. In this study, 46% of 224 athletes experienced

symptoms of at least one mental disorder, or 39% of males and 53% of females in the sample.

Symptoms of depression had the highest prevalence (27%), and GAD was number five

(7%). Athletes who were dealing with injuries were more likely to have symptoms of

depression and GAD than non-injured athletes.

A study published in 2015 on current and former professional footballers suggests that

the prevalence of anxiety disorders and depression is higher among athletes than in the

general population (Gouttebarge, Frings-Dresen, & Sluiter, 2015). The prevalence of

depression and anxiety disorders was 26% in current players, and 39% in former players.

14

It is important to distinguish between general anxiety and sport performance anxiety in

studies in athlete samples. Sport performance anxiety is the anxiety that the athlete

experiences in sport situations. It is normal for an athlete to experience anxiety before a

competition, such as feeling nervous and worried about his performance, so it is not unlikely

for athletes to have high state anxiety when they are in an important sport situation (Smith et

al., 1990). These feelings that athletes experience around competition, are similar to

symptoms that are listed in questionnaires on general anxiety. It is possible that around

competition day an athlete could score high for general anxiety when asked to answer the

following statements on Hospital anxiety and depression scale: “I feel tense or wound up,

worrying thoughts go through my head, I feel restless as I have to be on the move” (Zigmund

& Snaith, 1983).

Therefore, it is important to look critically on the methods that are used in the research

on anxiety and mental disorders in athletes. Most studies on the prevalence of mental

disorders in athletes do not distinguish between general anxiety and sport performance

anxiety. This can be seen, for example, in the fact that researchers have not used measurement

tools specifically designed to measure sport performance anxiety.

Furthermore, when using measurements on general anxiety it is important that

athletes are instructed to answer the questions about their well-being while excluding their

feelings that are related to their performance in competition (right before or around

competition day).

It is also unclear in some studies at what time point, in relation to competition day the

subjects answered the questionnaires. If a questionnaire on general anxiety is administered on

the day of competition, the results could possibly indicate greater general anxiety because of

performance anxiety. Thus the general anxiety measurement does, not necessarily reflect the

athlete’s general anxiety but performance anxiety.

The purpose of the current study is to examine the level of anxiety and depression

symptoms among basketball players in the top league in Iceland when distinguishing between

general anxiety and sport performance anxiety. Furthermore, stigma towards these mental

disorders is explored. Five hypotheses are put forth.

Hypothesis 1 proposes a positive correlation between sport performance anxiety and

general anxiety as well as between sport performance anxiety and depression. Those who

score high on sport performance anxiety are expected to report more symptoms of general

15

anxiety and depression. Studies have shown that individuals that have high trait anxiety do

also have high state anxiety (Broadbent & Broadbent, 1988; Weinberg & Hunt 1976).

Hypothesis 2 proposes that female players will report more symptoms of sport

performance anxiety, general anxiety and depression. Studies have shown that females are

more likely than men to develop symptoms of anxiety and depression (Leray et al., 2011;

Schaal et al., 2010; World Health Organization, 2012).

Hypothesis 3 proposes that players that have experienced injury the week before the

data collection will report more symptoms of anxiety and depression than non-injured players.

In addition it is proposed that those players that have missed more practices due to their

injuries will report more symptoms of anxiety and depression. Studies have shown that

players that are injured are at more risk of developing symptoms of anxiety and depression

(Appaneal et al., 2009; Leddy et al., 1994).

Hypothesis 4 proposes that players that have played for the national team will report

anxiety as more facilitating on their performance than players that had not played for the

national team. Studies have shown that experienced players are more likely to perceive

anxiety as facilitative on performance (Jones et al., 1994; Jones et al., 1993).

Hypothesis 5 proposes that players will report significantly higher perceived stigma

than personal stigma. A study has shown that perceived stigma is higher than personal stigma

within the general public (Pedersen & Paves, 2014).

16

Method

Participants

Participants were athletes who played basketball in the top league in Iceland the 2015-2016

season. Players younger than 18 years old and foreign players were excluded from the study.

Data were collected from 117 players, 65 males (55.6%) and 52 females. The athletes’mean

age was 24 years with an age range of 18 to 37. The mean age for women was 23, with the

range from 18 to 36. The mean age for men was 24, with the range from 18 to 37. Participants

were recruited using convenience sampling, in which teams located on the South-West coast

of Iceland were contacted. In Iceland, the top league in basketball has seven women’s teams

and 12 men’s teams. All the women’s teams participated in this study and seven men’s

teams.

Instruments and Measures

The questionnaires used in this study can be found in Appendix 1 to 4.

In the Background questionnaire athletes were asked questions to use as independent

variables (see Appendix 1). For example age, gender, whether they had played for the national

team, and how many practices they had missed last week because of an injury. They were also

asked whether they felt that anxiety had positive effects on their performance, and if they use

any strategies to decrease or increase anxiety before a game. Participants answered on a 6-

point scale: 1=never, 2=very rarely, 3=rarely, 4=neutral, 5=often, 6= very often.

Sport Anxiety

The Sport Anxiety Scale-2 (SAS-2; Smith, Smoll, Gumming, & Grossbard, 2006) measures

cognitive and physical symptoms of anxiety associated with athletic performance (see

Appendix 2). The SAS-2 is a revised version of the original edition of the SAS (Smith, Smoll,

& Schutz, 1990) because, although the SAS showed good reliability and validity (Smith et al.,

1990), it was only suited for adults. However, the SAS-2 has shown good validity and

reliability for both adults and youths (Grossbard, Smith, Smoll, Cumming, 2009; Smith et al.,

2006).

SAS-2 has 15 statements that are divided into three factors: Worry, Somatic Anxiety,

and Concentration Disruption. Athletes are requested to read every statement with the

17

headline “Before or while I compete in sports”. Each factor has five statements which the

participants answer on a 4-point scale: 1 = not at all, 2 = a little bit, 3 = pretty much, 4 = very

much. The highest possible score is 60 and the lowest is 15. Participants that have lower

scores are less likely to have sport competitive anxiety then participants that score high on the

questionnaire. Examples of statements: “Before or while I compete in sports” … “it is hard to

concentrate on the game”, “my body feels tense”, and “I worry that I will not play” (Smith et

al., 2006). The SAS-2 was translated from English to Icelandic with a direct translation

(McKay et al., 1996) and committee translation method (Harkness & Schoua-Glusberg,

1998). The translation was then assessed by three experts in psychology.

Anxiety and Depression

The Hospital Anxiety and Depression Scale (HADS; Zigmund & Snaith, 1983) measures both

symptoms of anxiety and depression (see Appendix 3). The questionnaire consists of 14

statements about the participants’ well-being over the last week and is divided into an anxiety

subscale and a depression subscale. Participants answer the statements on a 4-point scale rated

from zero to three points. The scores are counted separately for each subscale, which makes

the highest score 21 and the lowest zero. Scores below eight are classified as no disorder,

scores from eight to ten are classified as borderline abnormal and scores over 11 points are

classified as abnormal and could indicate a possible diagnoses of depression or anxiety

disorder (Zigmund & Snaith, 1983). Examples of statements on the anxiety subscale are; “I

get a sort of frightened feeling as if something awful is about to happen”, and “I get sudden

feelings of panic.” Examples of statements on the depression subscale are; “I still enjoy the

things I used to enjoy”, and “I have lost interest in my appearance.” The HADS has shown

good psychometric properties in both healthy subjects and patients, and has shown good

validity in use with different languages (Hermann, 1997). The HADS has been translated

from English to Icelandic (Schaaber, Smári, & Óskarsson, 1990) and shown good validity and

reliability (Magnusson, 2000).

Stigma

The Depression Stigma Scale (DSS; Griffiths, Christensen, Jorm, Evans, & Groves, 2004)

measures both personal stigma and perceived stigma associated with depression (see

Appendix 4). Personal stigma, measured by nine statements, is the participants own attitudes

18

towards depression, and perceived stigma, also measured by nine statements, is what

participants think the attitudes of others in the society are. Answers are rated on a 5-point

scale: 0 = strongly disagree to 4 = strongly agree. The total score can range from 0-36 for

each subscale, where higher scores indicate a higher level of stigma towards depression. An

example of a statement on the personal stigma subscale is; “depression is a sign of weakness”

and an example on the perceived stigma subscale is; “Most people think that depression is a

sign of weakness”. The DSS has shown good reability, r = .71 for personal stigma and r = .67

for perceived stigma (Griffiths, Christensen, & Jorm, 2008; Griffiths et al., 2004). The first

author of the DSS gave permission for the use of the scale in this study. The wordings of two

questions were adjusted for the purpose of this study to explore players stigma related to the

sport. The questions from the DSS; “I would not employ someone if I knew they had been

depressed” and “I would not vote for a politician if I knew they had been depressed” were

replaced with “I would not want to play with someone that I knew had depression” and “I

would not want to have a coach who I knew had depression”. A direct translation (McKay,

1996) and committee translation method (Harkness & Schoua-Glusberg, 1998) was used to

translate the DSS from English to Icelandic. To measure attitudes toward anxiety the word

depression was replaced with the word anxiety disorder.

Procedure

When the National Bioethics Committee had approved this study, team coaches in the sample

were contacted to find an appropriate date for the data collection. Collection of the data took

place in November and December. The researcher attended one practice of every team in the

sample where the questionnaires were administered (see Appendix 1-4). The data was not

collected the day before a game or on game day, to minimize the possibility that sports

performance anxiety would inflate scores on a measure of general anxiety. The questionnaires

consisted of 78 items which took participants about 13 to 16 minutes to complete. Participants

were informed that participation was anonymous and they did not have to disclose any

traceable personal information. Participants were also informed that they could discontinue

their participation in the study at any time without explanation. Finally they were offered to

talk to a licensed psychologist would they experience any discomfort during or after they had

answered the questionnaires.

19

Design and data analysis

Three independent variables; gender, injury, and national team experience were used in this

study and three dependent variables; scores on the SAS-2 and the HADS anxiety and

depression subscales. Scores on stigma for both depression and anxiety was used to compare

perceived stigma with personal stigma. All the analysis was processed with IBM SPSS

Statistics.

The frequency of anxiety and depression symptoms in players was calculated, and

Person correlation was used to explore the relationship between the SAS-2 scores and HADS

anxiety and depression scores. Further on, an independent-samples t-test was used to calculate

if there was a gender difference on scores on the SAS-2, HADS anxiety and HADS

depression, and if injured and non-injured players had a significant difference in their score

on the HADS anxiety and depression subscales. A one-way between subjects ANOVA were

executed to test differences between the number of practices missed due to injury and HADS

anxiety and depression. Also, an independent samples t-test was used to compare differences

in views on the effects of anxiety on performance based on national team experience. Finally,

a paired-samples t-test was used to compare differences between scores on perceived stigma

and personal stigma scores on the DSS.

20

Results

The Sport Anxiety Scale-2 was found to be highly reliable (15 items; α = .84). Cronbach’s

alpha coefficients for the 7 items HADS anxiety subscale and 7 items HADS depression

subscale were .84 and .61. Cronbach’s alphas for Depression Stigma scale 9 items Perceived

Stigma subscale was .85 and 9 items Personal Stigma subscale was .57. However, the

Cronbach’s alphas for Depression Stigma scale when the word depression was replaced with

the word anxiety was .89 for the 9 item Perceived Stigma subscale and .68 for the 9 item

Personal Stigma subscale. In the data there was one missing value regarding age and one

participant did not answer the DSS for depression. Data for 117 participants was used in this

study, except for DSS depression, where data from 116 participants was used.

The mean score on the HADS anxiety subscale was 4.93 (SD = 3.53), the maximum

score was 17, and the lowest score was zero. For the HADS depression subscale the mean

score was 3.15 (SD = 2.61), the maximum score was 12 and the lowest was zero. The mean

score on the SAS-2 was 26.96 (SD = 7.45). The maximum score for performance anxiety was

51 and the lowest was 15.

Symptoms of anxiety and depression

Percentages of participants having anxiety and depression symptoms scores within the normal

range, borderline abnormal, or in the abnormal range, are shown in table 1.The percentage of

players with symptom scores in the abnormal range was 8 for anxiety and 2 for depression.

Table 1

Prevalence of anxiety and depression symptoms within the players

The relationship between sport performance anxiety and anxiety and depression

A Person product-moment correlation coefficient was used to evaluate the relationship

between scores on the SAS-2 with scores on the HADS anxiety subscale and the HADS

Anxiety Depression

Percentage Percentage

No disorder (total score: 0-7) 78.6 94.0

Borderline abnormal (total score: 8-10) 13.7 4.3

Abnormal (total score: 11- 21) 7.7 1.7

21

depression subscale (see figure 1 and 2). There was a strong positive correlation between

scores on the SAS-2 and the HADS anxiety subscale, r (115) = 0.74, p < .001. The correlation

between the SAS-2 and the HADS depression subscale was weaker but moderate, r (115) =

0.53, p < .001. Overall, there was a positive relationship between levels of sport related

anxiety, measured with the SAS-2, and symptoms of general anxiety and depression,

measured with the HADS.

Figure 1. Relationship between total scores on SAS-2 and HADS anxiety subscale

Figure 2. Relationship between total scores on SAS-2 and HADS depression subscale

22

Gender difference

Table 2 displays mean scores for HADS anxiety, HADS depression, and the SAS-2, by

gender. Women had higher mean scores on anxiety, depression, and performance anxiety than

men. An independent-samples t-test was conducted to compare scores between genders.

There was a significant difference between scores on the HADS anxiety subscale for women

and men, t (115) = -4.13, p < .001. There was also a significant gender difference on the SAS-

2 scores, t (115) = -3.28, p = .01. However, an independent-samples t-test did not show a

significant gender difference on the HADS depression subscale between genders, t (115) = -

0.35, p = .72.

Table 2

Mean score, standard deviation, minimum and maximum score for the HADS anxiety and

depression subscales, and the SAS-2 performance anxiety, by gender.

Male Female

M SD Min Max M SD Min Max

Depression 3.08 2.18 0 8 3.25 3.07 0 12

Anxiety 3.80 2.56 0 11 6.35 4.06 0 17

Sport Performance Anxiety 25.02 5.86 15 39 29.38 8.50 15 51

Injured versus non-injured

Table 3 shows mean HADS anxiety and depression scores for injured and non-injured

players. There were 33 players (28%) that had experienced injury the week before the data

collection. To compare the scores between injured and non-injured players an independent-

samples t-test was conducted. There was no significant difference in the scores on the anxiety

subscale for injured athletes and non-injured athletes t (115) = -1.74, p = .08. Furthermore

there was not a significant difference between the scores on the depression subscale for

injured athletes and non-injured athletes t (115) = 0.54, p = .58

23

Table 3

Mean scores and standard deviation on the HADS anxiety and depression subscales for

injured and non-injured players.

Anxiety Depression

n M SD M SD

Non-injured 84 5.28 3.59 3.07 2.63

Injured 33 4.03 3.23 3.36 2.57

1-2 practices lost 15 3.00 2.20 2.87 1.92

3-4 practices lost 9 3.11 2.67 2.78 3.49

5 + practices lost 9 6.67 3.94 4.78 2.17

Looking only at the data from the players that had experienced injury, a one-way

between subjects ANOVA was conducted to compare scores on the HADS anxiety and

depression subscales across number of practices the players missed due to their injuries (1-2

practices, 3-4 practices and 5 or more practices). There was a significant difference between

the level of anxiety symptoms in terms of the number of practices missed, F (2.30) = 5.18, p =

.01. A Bonferroni Post Hoc test indicated that the mean score for the 5 or more practices

missed was significantly different than 1-2 practices missed and 3-4 practices missed.

However, 1-2 practices missed did not significantly differ from the 3-4 practices missed.

There was not a significant difference between the level of depression symptoms depending

on the number of practices missed, F (2.30) = 1.99, p = .15.

Anxiety facilitating on performance

Figure 3 shows distribution of the scores with players that had played for the national team

compared to players that had not on the answers to the statement: Anxiety has a positive effect

on my performance. There were 31 players that had played for the national team at some point

during their carrier. An independent-samples t-test was used to compare the groups. There

was a significant difference between the scores for those who had played for the national team

(M = 4.09, SD= 1.42) and those who had not (M = 3.23, SD = 1.13), t (115) = 3.22, p < .01.

24

Figure 3. The scores distribution on the statement: “Anxiety has a positive effect on my

performance” and whether players had played for the national team or not. Score is the

possible answer the participant could give for the statement, 1=never, 2=very rarely, 3=rarely,

4=neutral, 5=often, 6= very often.

Perceived stigma and Personal stigma

Table 4 shows mean scores for both personal stigma and perceived stigma towards anxiety

and depression on the DSS and a modified version of the DSS for anxiety. A paired-samples

t-test was conducted to compare personal stigma and perceived stigma. There was a

significant difference between the scores on the personal stigma scale and the perceived

stigma scale for both anxiety, t (116) = -9.180, p < .001, and depression, t (115) = -11.41, p <

.001. Players had lower mean scores on the personal stigma scale then on the perceived

stigma scale.

25

Table 4

Mean scores and standard deviation on the personal stigma scale and the perceived stigma

scale for anxiety and depression on the DSS. A greater score indicates greater stigma.

Depression Anxiety

M SD M SD

Personal stigma 7.51 4.24 7.11 4.82

Perceived stigma 14.45 6.56 13.44 7.44

26

Discussion

The purpose of the present study was to evaluate anxiety and depression among basketball

players in the top league in Iceland. The key difference between this study and others that

have explored the prevalence of anxiety and depression among athletes is the use of the SAS-

2 questionnaire together with the HADS questionnaire. The aim of using the SAS-2 was to

avoid that anxiety symptoms related to athletes’ sport performance would affect the score on

measurements for general anxiety.

As expected in hypothesis 1, the results showed a positive correlation between

symptoms of sport performance anxiety and general anxiety. Those who had high sport

performance anxiety were more likely to have high general anxiety. This is in line with other

studies on state anxiety and trait anxiety, which have found that those who have high trait

anxiety are more likely to have high state anxiety (Broadbent & Broadbent, 1988; Weinberg

& Hunt, 1976). However, the correlation was not perfect which suggests that some players

could have high sport performance anxiety but low general anxiety. This indicates that

athletes can have symptoms of anxiety that relate to their sport performance, but does not

have to mean that they fall under the criteria of general anxiety. There was also a positive

correlation between sport performance anxiety and depression, but that relationship was much

weaker. These results emphasize the importance of differentiating between sport performance

anxiety and general anxiety to avoid overdiagnosis.

According to the data from the present study, Icelandic athletes are experiencing more

symptoms of anxiety (8%) and less symptoms of depression (2%) than the Icelandic general

public (Smári, Ólason, Arnarson, & Sigurðsson, 2008). Magnusson, Axelsson, Karlsson and

Óskarsson (2000) conducted a study on seasonal mood change in Iceland using The HADS

questionnaire and found that the prevalence of anxiety symptoms was 4% and 3% for

depression. Another study on Icelandic college students found prevalence of 6% for

symptoms of anxiety and 3% for depression (Smári, Erlendsdóttir, Björgvinsdóttir &

Ágústsdóttir, 2003).

The scores for sport performance anxiety and general anxiety were significantly higher

among female than male players, which indicates that women are more likely to have

symptoms of general anxiety as well as symptoms of sport performance anxiety. This is in

line with hypothesis 2. However, the scores for depression did not show any gender

differences. This differs slightly from other studies that have shown that women are more

27

likely to be diagnosed with both anxiety and depression than men (Leray et al., 2011; Schaal

et al., 2010; World Health Organization, 2012). In addition, studies on athletes have shown

that female athletes are more likely to develop symptoms of depression than male athletes

(Schaal et al., 2010; Yang et al., 2007).

When looking at how injuries affect players, injuries did not seem to predict more

symptoms of anxiety or depression. This is interesting since the opposite results were

expected in hypothesis 3. This is not in accordance with other studies which have found

higher prevalence of anxiety and depression among injured athletes than non-injured athletes

(Appaneal et al., 2009; Leddy et al., 1994). However, in the present study non-injured players

reported more anxiety symptoms than injured players, and this difference was nearly

significant. When looking at the number of practices players missed due to their injuries, the

players that missed one to four practices reported fewer symptoms of anxiety than non-injured

players. A possible explanation for this might be that self-handicapping could be influencing

the scores (Prapavessis, Grove, Maddison, & Zillmann, 2003). It could be assumed that some

players perceive their injuries as a relief, that is, there is less pressure on them to perform

because of their injuries and they have a valid excuse if their performance falls short in

competition.

When examining further the results from the injured players, there was a significant

difference between the number of practices missed due to injuries for anxiety, but not

depression. Players who had missed five or more practices the week before data collection

showed more symptoms of anxiety than players who missed one to four practices. This could

indicate that athletes that are absent from their sport for longer periods of time, due to their

injuries, are at greater risk of developing symptoms of anxiety, and possibly depression. Even

though there was not a significant difference on the scores for depression it is possible that it

might with higher number of participants. The difference on the mean score for athletes that

missed five or more practices was a lot higher than athletes that lost one to four practices.

Thus, it is important for coaches to follow up on injured players to ensure that they get

appropriate support to decrease the likelihood of them developing more severe symptoms of

mental disorders.

Players that had played for the national team reported anxiety as more facilitating on

their performance than players that had not played for the national team. This was expected in

hypothesis 4 and is in accordance with other studies (e.g., Jones et al., 1994; Jones et al.,

28

1993). These results suggest that the ability of the players could have an effect on how

athletes perceive anxiety, either as a positive or negative influence on their performance.

Perceived stigma was significantly higher than personal stigma for both anxiety and

depression as was expected in hypothesis 5. These results are similar to a study from Pedersen

& Paves (2014). Although most players reported low personal stigma, their perception of the

attitudes and beliefs of others towards mental disorders, was higher. This could possibly

hinder an athlete dealing with anxiety or depression to inform the coach or teammates about

his or her struggles. Therefore, leaders and managers of sports associations and clubs need to

take responsibility in educating and raising awareness of mental disorders to decrease stigma

of those disorders in sport. Furthermore, it is important for clubs to have a clear policy on

how to react when a player is dealing with mental illness. Coaches can play a critical role in

the early detection of symptoms due to their close relationship with players. Also, it is

important that appropriate support is available for players.

The main limitation of the present study is that the Icelandic versions of the

measurements SAS-2 and DSS have not been used before and, therefore, more psychometric

research is needed. Another limitation can be found in the homogeneity of the sample as all

the participants came from the same sport and participants were all adults.

In future studies on the prevalence of mental disorders among athletes it would be

interesting to look at a more diverse sample, especially adolescence. In some sports in Iceland

it is not uncommon that players start in the top league as early as 14 years old while still

playing with their age group. It would be interesting to explore how this could affect their

mental well-being.

29

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38

Appendix I - Background questionnaire

Vinsamlegast fylltu út eftirfarandi:

1. Kyn: Karl □ Kona □

2. Hvaða ár ertu fædd/ur)? ___________________

3. Hvað varstu gömul/gamall þegar þú byrjaðir að spila með meistaraflokki? _________

4. Hvað varstu að spila með mörgum flokkum þegar þú byrjaðir að spila með meistaraflokki (að meistaraflokki undanskildum)? ______________________

5. Hvað ertu að spila með mörgum flokkum í dag? ________________________

6. Hefur þú spilað með unglingalandsliði í körfubolta? Já □ Nei □

7. Hefur þú spilað með A-landsliði í körfubolta? Já □ Nei □

8. A) Hefur þú verið frá vegna meiðsla síðustu viku? Já □ Nei □

B) Ef þú svaraðir já við spurningunni fyrir ofan þá máttu svara þessari spurningu.

Hversu margar æfingar misstir þú af í síðustu viku vegna meiðsla

1-2 æfingar □ 3-4 æfingar □ 5 eða fleiri æfingar □

9. Merktu við viðeigandi svarmöguleika frá 1 til 6 eftir því hversu mikilvæg ástæðan er. Mikilvægasta ástæðan fær gildið 6, næst mikilvægasta ástæðan fær gildið 5 og svo framvegis (minnst mikilvægasta ástæðan fær gildið 1).

39

Afhverju æfir þú körfubolta?

____ Skemmtilegt

____ Þrýstingur frá öðrum

____ Vil skara fram úr

____ Að halda mér í formi (auka hreysti)

____ Til að ná árangri

____ Annað ______________________

10. Hér eru fyrir neðan eru þrjár fullyrðingar, vinsamlegast lestu þær vel. Gerðu svo kross við þann svarmöguleika sem á best við þig. Það eru engin rétt eða röng svör. Svaraðu eins heiðarlega og þú getur og ekki dvelja of lengi við hverja spurningu.

Aldrei Mjög

Sjaldan

Sjaldan Hlutlaus Oft Mjög

oft

1. Kvíði getur haft jákvæð

áhrif á frammistöðu mína í

leikjum

1 2 3 4 5 6

2. Ég nota aðferðir til að draga

úr kvíða fyrir leiki

1 2 3 4 5 6

3. Ég nota aðferðir til að auka

kvíða fyrir leiki

1 2 3 4 5 6

40

Appendix II – Sport Anxiety Scale 2 in Icelandic

Margt íþróttafólk verður taugaóstyrkt á undan eða á meðan keppni stendur. Þetta á jafnvel

við um atvinnumenn. Vinsamlegast lestu hverja spurningu vel. Gerðu svo kross við þann

svarmöguleika sem lýsir því hvernig þér líður YFIRLEITT fyrir eða á meðan þú ert að keppa.

Það eru engin rétt eða röng svör. Svaraðu eins heiðarlega og þú getur og ekki dvelja of lengi

við hverja spurningu.

Áður en eða á meðan ég keppi… Alls

ekki

Aðeins Frekar

mikið

Mjög

mikið

1. er erfitt að einbeita sér að leiknum 1 2 3 4

2. er líkami minn uppspenntur 1 2 3 4

3. hef ég áhyggjur af því að ég muni

ekki spila vel

1 2 3 4

4. er erfitt fyrir mig að einblína á það

sem ég á að gera

1 2 3 4

5. hef ég áhyggjur af því að bregðast

öðrum

1 2 3 4

Áður en eða á meðan ég keppi… Alls

ekki

Aðeins Frekar

mikið

Mjög

mikið

6. finn ég fyrir spennu í maganum 1 2 3 4

7. missi ég einbeitingu á leikinn 1 2 3 4

8. hef ég áhyggjur af því að eiga ekki

minn besta leik

1 2 3 4

9. hef ég áhyggjur af því að ég muni

spila illa

1 2 3 4

10. finnst mér vöðvarnir vera óstyrkir 1 2 3 4

41

Áður en eða á meðan ég keppi… Alls

ekki

Aðeins Frekar

mikið

Mjög

mikið

11. hef ég áhyggjur af því að ég muni

klúðra í leiknum

1 2 3 4

12. finn ég fyrir ólgu í maganum 1 2 3 4

13. get ég ekki hugsað skýrt 1 2 3 4

14. finnst mér vöðvarnir stífir því ég

er taugaspennt/ur

1 2 3 4

15. á ég erfitt með að einbeita mér að

því sem þjálfarinn segir mér að

gera

1 2 3 4

Þýðing: Hallur Hallsson og Hallur Skúlason

42

Appendix III - Hospital Anxiety and Depression Scale in Icelandic

Vinsamlega krossaðu við það svar sem best á við þína líðan eins og hún var síðastliðna viku.

Að undanskilinni líðan sem tengist frammistöðu í keppni á keppnisdegi og á meðan þú keppir

1. Ég er uppsptennt(ur) og taugatrekkt(ur):

( ) Næstum alltaf

( ) Oft

( ) Öðru hvoru, stundum

( ) Alls ekki

8. Ég er seinni til hugsana og verka:

( ) Næstum alltaf

( ) Mjög oft

( ) Stundum

( ) Alls ekki

2. Ég nýt þess enn, sem ég var vön/vanur að gera:

( ) Ábyggilega eins mikið

( ) Ekki alveg eins mikið

( ) Aðeins að litlu leyti

( ) Varla nokkuð

9. Ég finn til hræðslukenndar, fæ óróleikatilfinningu í magann:

( ) Alls ekki

( ) Öðru hvoru

( ) Nokkuð oft

( ) Mjög oft

3. Ég fæ einhvers konar hræðslutilfinningu eins og

eitthvað hræðilegt sé að fara að gerast:

( ) Alveg örugglega og oft slæma

( ) Já, en ekki svo slæma

( ) Að litlu leyti, en ég hef ekki áhyggjur af því

( ) Alls ekki

10. Ég hef misst áhugann á því hvernig ég lít út:

( ) Alveg örugglega

( ) Ég hirði ekki um mig eins og ég ætti að gera

( ) Kannski hirði ég ekki um mig eins og ég ætti að gera

( ) Ég hirði jafn vel um mig og áður

4. Ég get hlegið og séð það skoplega í kringum mig:

( ) Eins mikið og áður

( ) Ekki alveg eins mikið núna

( ) Ábyggilega ekki eins mikið núna

( ) Alls ekki

11. Ég er óróleg(ur), eins og ég þurfi alltaf að vera að aðhafast eitthvað:

( ) Mjög mikið

( ) Þó nokkuð mikið

( ) Ekki svo mjög

( ) Alls ekki

5. Áhyggjur fara í gegnum hugann:

( ) Svo til stöðugt

( ) Mjög oft

( ) Öðru hvoru, en ekki svo oft

( ) Aðeins stöku sinnum

12. Ég hlakka til þess sem framundan er:

( ) Eins mikið og áður

( ) Eitthvað minna en áður

( ) Örugglega minna en áður

( ) Eiginlega alls ekki

6. Ég er kát(ur):

( ) Alls ekki

( ) Ekki oft

( ) Stundum

( ) Svo til alltaf

13. Ég fæ skyndilega ofsahræsluköst:

( ) Mjög oft

( ) Nokkuð oft

( ) Ekki mjög oft

( ) Alls ekki

7. Ég get setið róleg(ur) og slappað af:

( ) Alltaf

( ) Yfirleitt

( ) Ekki oft

( ) Alls ekki

14. Ég get notið góðrar bókar eða skemmtilegs efnis í útvarpi eða

sjónvarpi:

( ) Oft

( ) Stundum

( ) Ekki oft

( ) Mjög sjaldan

43

Appendix IV - Depression Stigma Scale for depression and anxiety in Icelandic

Spurningar 1 til 18 innihalda fullyrðingar um þunglyndi. Vinsamlegast tilgreindu hversu sterklega þú

persónulega ert sammála eða ósammála hverri fullyrðingu.

Mjög

ósammála

Frekar

ósammála

Hvorki

sammála né

ósammála

Frekar

sammála

Mjög

sammála

1. Fólk með þunglyndi gæti rifið sig upp úr

því ef það vildi

2. Þunglyndi er merki um veikleika

3. Þunglyndi er ekki raunverulegur

sjúkdómur

4. Fólk með þunglyndi er hættulegt

5. Það er best að forðast fólk með þunglyndi

til að verða ekki sjálf(ur) þunglynd(ur)

6. Fólk með þunglyndi er óútreiknanlegt

7. Ef ég væri með þunglyndi þá myndi ég ekki

segja nokkrum manni frá því

8. Ég myndi ekki vilja hafa einhvern í mínu

liði sem ég vissi að hefði verið þunglynd(ur)

9. Ég myndi ekki vilja hafa þjálfara sem ég

vissi að hefði verið þunglynd(ur)

Nú viljum við fá að vita hvernig þú heldur að viðhorf flestra annarra til þunglyndis sé. Vinsamlegast tilgreindu

hversu sammála eða ósammála þú ert eftirfarandi fullyrðingum

Mjög

ósammála

Frekar

ósammála

Hvorki

sammála né

ósammála

Frekar

sammála

Mjög

sammála

10. Flestir halda að fólk með þunglyndi gæti

rifið sig upp úr því ef það vildi

11. Flestir halda að þunglyndi sé merki um

veikleika

12. Flestir halda að þunglyndi sé ekki

44

raunverulegur sjúkdómur

13. Flestir halda að fólk með þunglyndi sé

hættulegt

14. Flestir halda að það sé best að forðast

fólk með þunglyndi til að verða ekki sjálf(ur)

þunglynd(ur)

15. Flestir halda að fólk með þunglyndi sé

óútreiknanlegt

16. Flestir myndu ekki segja frá ef þeir væru

þunglyndir

17. Flestir myndu ekki vilja hafa einhvern

sem þeir vissu að hefði verið þunglynd(ur) í

sínu liði

18. Flestir myndu ekki vilja hafa þjálfara sem

þeir vissu að hefði verið þunglyndur

Spurningar 1 til 18 innihalda fullyrðingar um kvíðaröskun. Vinsamlegast tilgreindu hversu sterklega þú

persónulega ert sammála eða ósammála hverri fullyrðingu.

Mjög

ósammála

Frekar

ósammála

Hvorki

sammála né

ósammála

Frekar

sammála

Mjög

sammála

1. Fólk með kvíðaröskun gæti losað sig við

hana ef það vildi

2. Kvíðaröskun er merki um veikleika

3. Kvíðaröskun er ekki raunverulegur

sjúkdómur

4. Fólk með kvíðaröskun getur verið

hættulegt

5. Það er best að forðast fólk með

kvíðaröskun til að verða ekki sjálf(ur)

kvíðin(n)

6. Fólk með kvíðaröskun er óútreiknanlegt

7. Ef ég væri með kvíðaröskun myndi ég ekki

segja nokkrum manni frá því

45

8. Ég myndi ekki vilja spila með einhverjum

sem ég vissi að hefði kvíðaröskun

9. Ég myndi ekki vilja hafa þjálfara sem ég

vissi að hefði kvíðaröskun

Nú viljum við fá að vita hvernig þú heldur að viðhorf flestra annarra til kvíðaröskunar sé. Vinsamlegast tilgreindu

hversu sammála eða ósammála þú ert eftirfarandi fullyrðingum

Mjög

ósammála

Frekar

ósammála

Hvorki

sammála né

ósammála

Frekar

sammála

Mjög

sammála

10. Flestir halda að fólk með kvíðaröskun

gæti losað sig við hana ef það vildi

11. Flestir halda að kvíðaröskun sé merki um

veikleika

12. Flestir halda að kvíðaröskun sé ekki

raunverulegur sjúkdómur

13. Flestir halda að fólk með kvíðaröskun

geti verið hættulegt

14. Flestir halda að það sé best að forðast

fólk með kvíðaröskun til að verða ekki

sjálf(ur) kvíðin(n)

15. Flestir halda að fólk með kvíðaröskun sé

óútreiknanlegt

16. Flestir myndur ekki segja frá ef þeir væru

með kvíðaröskun

17. Flestir myndu ekki vilja hafa einhvern

sem þeir vissu að hefði kvíðaröskun í sínu liði

18. Flestir myndu ekki vilja hafa þjálfara sem

þeir vissu að hefði kvíðaröskun

Þýðing: Hallur Hallsson og Ragnar P. Ólafsson