Understanding Psychological Disorders-I Practical
Understanding Psychological Disorders-I Practical
Understanding Psychological Disorders-I Practical
DISORDERS-I PRACTICAL
Name: Sanaa Batra
Roll No.: 20/0035
Course & Year: BA Hons Applied Psychology (IIInd Year)
State and Trait Anxiety Inventory (STAI)
Aim: To compare the state & trait anxiety between males and females, age ranging between 19-
22.
Basic Concept:
Anxiety is normal and is often regarded as a healthy emotion . It is the total response of a human
being to threat or danger. Each experience of anxiety involves a perception of danger, thoughts
about harm, and a process of physiological alarm and activation. The accompanying behaviours
display an emergency effort toward "fight or flight." The American Psychological Association
(APA, 2000) defines anxiety as “an emotion characterized by feelings of tension, worried thoughts
and physical changes like increased blood pressure".
Anxiety has three components: the cognitive/ subjective, the physiological and the
behavioural. At the cognitive/subjective level, anxiety involves negative mood, worry about
possible future threats or danger, self-preoccupation, and a sense of being unable to predict the
future threat or to control it if it occurs. At a physiological level, anxiety often creates a state of
tension and chronic overarousal which may reflect risk assessment and readiness for dealing with
danger should it occur. At a behavioural level, anxiety may create a strong tendency to avoid
situations where danger might be encountered.
Symptoms of Anxiety
In addition to motor and visceral effects, anxiety affects thinking, perception, and learning.
It tends to produce confusion and distortions of perception, not only of time and space but also of
persons and the meanings of events. These distortions can interfere with learning by lowering
concentration, reducing recall, and impairing the ability to relate one item to another that is, to
make associations.
Stress is a state of imbalance between demands (from inside or outside sources) and our perceived
abilities to meet those demands Hans Selye (1956). Stress was a term used by engineers. Selye
took the word and used it to describe the difficulties and strains experienced by living organisms
as they struggled to cope with and adapt to changing environmental conditions. His work provided
the foundation for current stress research. Selye also noted that stress could occur not only in
negative situations (such as taking an examination) but also in positive situations (such as a
wedding). Both kinds of stress can tax a person’s resources and coping skills, although bad stress
(distress) typically has the potential to do more damage. Stress can also occur in more than one
form—not just as a simple catastrophe but also as a continuous force that exceeds the person’s
capability of managing it.
Stress is the body’s response to changing stimuli or stressors. This is experienced most
acutely when the expectation is that the consequences of meeting the demand will be quite different
from the consequences of not meeting the demand. When a person encounters a stressor, a chain
reaction is set into motion in the brain and nervous system. This chain reaction begins in the brain
when a problem or potential threat is identified, which cues the sympathetic nervous system. When
the sympathetic nervous system is activated, stress hormones and chemicals like adrenaline and
cortisol are pumped into the bloodstream. This results in the stress response (also called fight or
flight) and involves a quickening of the heart rate and breath, feelings of restless energy and
increased mental alertness. People under stress experience mental and physical symptoms, such as
irritability, anger, fatigue, muscle pain, digestive troubles, and difficulty sleeping.
There is a fine line between stress and anxiety. Both are emotional responses, but stress is
typically caused by an external trigger. The trigger can be short-term, such as a work deadline or
a fight with a loved one or long-term, such as being unable to work, discrimination, or chronic
illness. People under stress experience mental and physical symptoms, such as irritability, anger,
fatigue, muscle pain, digestive troubles, and difficulty sleeping.
Anxiety, on the other hand, is defined by persistent, excessive worries that don’t go away
even in the absence of a stressor. Anxiety leads to a nearly identical set of symptoms as stress:
insomnia, difficulty concentrating, fatigue, muscle tension, and irritability.
Stress tends to be short term and in response to a recognized threat. Anxiety can linger and
can sometimes seem as if nothing is triggering it. Stress and anxiety are often used
interchangeably, and there is overlap between stress and anxiety. Stress is related to the same
‘fight, flight, or freeze’ response as anxiety, and the physical sensations of anxiety and stress may
be very similar.
The cause of stress and anxiety are usually different, however. Stress focuses mainly on
external pressures on us that we’re finding hard to cope with. When we are stressed, we usually
know what we’re stressed about, and the symptoms of stress typically disappear after the stressful
situation is over. Whereas, Anxiety isn’t always as easy to figure out. Anxiety focuses on worries
or fears about things that could threaten us, as well as anxiety about the anxiety itself. Stress and
anxiety are both part of being human, but both can be problems if they last for a long time or have
an impact on our well-being or daily life.
• Specific phobias: DSM-V-TR describes the central element of a specific phobia as an excessive
or unreasonable anxiety or fear related to a specific situation or object (American Psychiatric
Association, 2000). People with a specific phobia know that their fear is excessive or
unreasonable. In contrast, a rational fear of being mugged in a large city park late at night and
avoiding parks after dark would not be considered to be a specific phobia. A person with a
specific phobia works hard to avoid the feared stimulus, often significantly restricting his or
her activity in the process. A person with an elevator phobia, for example, will choose to walk
up many flights of stairs rather than take the elevator. Specific phobias you might recognize
include claustrophobia (fear of small spaces), arachnophobia (spiders), and acrophobia
(heights). DSM-V-TR lists five types or categories of specific phobias: animal, natural
environment, blood-injection-injury, situational, and “other” (American Psychiatric
Association, 2000).
Table 1:
Natural The natural environment type of specific phobia typically focuses on heights, water, or
Environment storms, natural environment typically emerge during childhood.
Type
This category includes any other type of specific phobia that does not fall into the four
categories already discussed. Examples of specific phobias that would be classified as
Other Type
“other” are a fear of falling down when not near a wall or some other type of support,
a fear of costumed characters (such as clowns at a circus), and a phobic avoidance of
situations that may lead to choking, vomiting, or contracting an illness.
Source: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.).Arlington, VA: Author.
• Panic disorders- According to the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), panic disorder is a type of anxiety disorder that is characterized by intense, recurrent,
and unexpected panic attacks. Panic disorder differs from normal fear and anxiety because it
is often extreme, and may seem to strike out of the blue. A person with panic disorder may
experience symptoms such as severe feelings of terror, rapid breathing, and rapid heart rate.
People with panic disorder may experience these attacks unexpectedly and for no apparent
reason, but they can also be preceded by some sort of triggering event or situation.While panic
disorder can strike at any point in life, symptoms most often begin during late adolescence or
early adulthood and affect twice as many women as men. Many people living with panic
disorder describe feeling as though they are having a heart attack or on the verge of dying, and
experience some or all of the following symptoms: Chest pain, Dizziness, Feelings of extreme
terror that occur suddenly without warning, Numbness in the hands and feet, Pounding heart,
Rapid breathing, Sweating, Trembling, Weakness.
• Social anxiety disorders- Social anxiety disorder is a mental health condition that was
previously referred to as social phobia. While it's often assumed that having social anxiety
means you are afraid of other people or are exceptionally shy, the anxiety disorder actually
involves a fear of social situations. Social anxiety disorder can be divided into two main types:
specific, in which one or more situations are feared, and generalized, which encompasses fear
of multiple situations. Whatever specific situations you fear, all forms of social anxiety
disorder share several common characteristics. While it can be a severely disabling mental
health condition, when it's recognized and accurately diagnosed, social anxiety disorder can be
treated. Each person with social anxiety will have slightly different symptoms which are
dependent on their specific fears and the intensity of their phobia. Several symptoms are
characteristics of social anxiety disorder. The most common include (but are not limited to)
o Fear: You may feel a sense of dread or doom beginning in the days leading up to a
scheduled social event. During the event, your dread may become overwhelming.
o Physical Symptoms: You may have a physical reaction similar to a panic attack. Intense
blushing, shaking, palpitations, and stomach distress are particularly common.
o Self-Judgment: Many people with social anxiety disorder feel that they are being intensely
scrutinized by those around them. You may become hyper-aware of the way you walk,
talk, chew, and perform other everyday actions. Becoming very critical of yourself is also
common.
Epidemiological studies show that anxiety disorders are highly prevalent and an important cause
of functional impairment; they constitute the most frequent menial disorders in the community.
The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and
2.9% among adults in the general community of the United States. The mean 12-month prevalence
for the disorder around the world is 1.3%, with a range of 0.2% to 4.3%. The lifetime morbid risk
in the United States is 9.0%. Women and adolescent girls are at least twice as likely as men and
adolescent boys to experience generalized anxiety disorder. The 12-month prevalence in older
adults including individuals age 75 years and older ranges from 2.8% to 3.1% in the United States,
Israel, and European countries.
Individuals of European descent tend to have symptoms that meet criteria for generalized
anxiety disorder more frequently than do individuals of Asian and African descent. Furthermore,
individuals from high-income countries are more likely than individuals from low- and middle-
income countries to report that they have experienced symptoms that meet criteria for generalized
anxiety disorder in their lifetime.
Method
Sample: The sample consisted of one male and one female of age 19-22.
Measures/Tool: For this practical The State- Trait Anxiety Inventory (STAI) which was
developed by Charles D. Spielberger and Richard L. Gorsuch (1997) was used. The State- Trait
Anxiety Inventory (STAI) has been used extensively in research and clinical practice. It comprises
separate self-report scales for measuring state and trait anxiety. The S-Anxiety scale (STAI Form
Y-1) consists of 20 statements that evaluate how respondents feel right now, at this moment. The
T-Anxiety scale (STAI Form Y-2) consists of 20 statements that assess how people generally feel.
The STAI-Y S-Anxiety and T-Anxiety scales are printed on opposite sides of a single page test
form.
The essential qualities evaluated by the STAI S-Anxiety scale are feelings of apprehension,
tension, nervousness and worry. The STAI S-Anxiety scale may also be used to evaluate how
participants felt at a particular time in the recent past and how they anticipate they will feel in the
future or any hypothetical situations. The scale has also been used to assess the level of anxiety
induced by stressful experimental procedures and by unavoidable real-life stressors (such as, job
interviews, tests, etc.)
The STAI T-Anxiety scale has been widely used in assessing clinical anxiety in medical,
surgical, psychosomatic and psychiatric patients. The T-Anxiety scale is also used for evaluating
the immediate and long-term outcome of psychotherapy counselling, behaviour modification and
drug treatment programmes. The STAI T-Anxiety scale has proven useful for identifying persons
with high levels of neurotic anxiety.
Although the STAI was developed for use with high-school and college students and
adults, it has been useful with junior high school students. The STAI has been adapted in more
than 30 languages for cross-cultural research and clinical practice.
Reliability: The stability coefficients for Form Y were based on two groups of high school
students tested in classroom settings. The test-retest correlations for the T-anxiety scale were
reasonably high ranging from 0.65 to 0.75. The median reliability coefficient for the T-Anxiety
scale for high school students was 0.695. While the stability coefficients for the S-anxiety scale
were relatively low, ranging from 0.34 to 0.62, with a median reliability coefficient of only 0.33.
Relatively low stability coefficients were expected for the S-Anxiety scale because a valid measure
of state anxiety should reflect the influence of unique situational factors that exist at the time of
testing.
Validity: The STAI provides operational measures of state and anxiety. Individual STAI items
were required to meet the validity criteria at each stage of the test development process in order to
be retained for further evaluation and validation. Concurrent, convergent, divergent and construct
validity of the STAI scales were calculated. Evidence of the construct validity of the T-Anxiety
scale may be seen in comparing the mean scores of the various neuropsychiatric patients (NP)
groups with those of the normal subjects. One of the NP groups had substantially higher T-Anxiety
scores than the normal subjects, providing evidence that the STAI discriminates between normals
and psychiatric patients for whom anxiety is a major symptom. Evidence for construct validity of
the S-Anxiety scale in which the scores of military recruits, tested shortly after they began highly
stressful training programs, were much higher than those of college and high school students of
about the same age who were tested under relatively non stressful conditions.
Norms: In collecting the data for normative samples, the S-Anxiety scale was always given first,
followed by the T-Anxiety scale. Normative data for Form Y are available for working adults,
college students, high school students and military recruits. The normative sample of college
students consisted of 855 students enrolled in Introductory psychology courses at the University
of South Florida. The inventory was administered either during regular class periods or in special
group-testing sessions. The high school normative sample consisted of 424 tenth-grade students
tested during regular class periods. The mean T-Anxiety scores for working adults were somewhat
lower than those for students and military recruits. Although the mean T-Anxiety scores did not
differ between the sexes for working adults and high-school students, the female college students
and military recruits were slightly higher in T-Anxiety than their male counterparts.
Procedure
Preliminaries
Instruction: “A number of statements which people have used to describe themselves are given
below. Read each statement and then circle the appropriate number to the right of the statement
to indicate how you feel right now, that is, at this moment. There are no right or wrong answers.
Do not spend too much time on any one statement but give the answer which seems to describe
your present feelings best.”
Administration: Both the participants were administered the STAI. They were instructed to fill
the responses according to their feelings at that moment. They were also informed that there
weren't any right or wrong answers. After the form was filled, the participants were thanked for
their participation.
Scoring: The range of possible scores for Form X of the STAI varies from a minimum score of
20 to a maximum score of 80 on both the A-State and A-Trait subscales. Subjects respond to each
STAI item by rating themselves on a four-point scale (see the STAI test form in Appendix A). The
four categories for the A-State scale are: (1) Not at all; (2) Somewhat; (3) Moderately so; and (4)
Very Much So. The categories for the A-Trait scale are: (1) Almost never: (2) Sometimes; (3)
Often; and (4) Almost always. The STAIA-State scale is balanced for acquiescence set, with ten
directly scored and ten reversed items. It was not possible, however, to develop a balanced A-Trait
scale from the original item pool; the STAI A-Trait scale has seven reversed items and thirteen
that are scored directly.
Introspective report
Participant B: “I enjoyed the inventory. It was a little confusing in between, but I did my best.”
Behavioural analysis:
Participant A: While filling the inventory, the participant was very calm and relaxed. He
understood the instructions clearly and was very focused while responding to the items.
Participant B: The participant was fidgeting while the instructions were being presented. Even
while noting down the responses, she kept shaking her leg and playing with the pen. She was
doubtful about some responses but did complete the inventory.
Results
The data collected was scored and analysed. The raw score of Participant A (male) was 37 on state
anxiety (Y1) and 40 on trait anxiety (Y2) and the percentile rank was 62 and 60 respectively. The
raw score of Participant B (female) was 47 on the state anxiety (Y1) and 53 trait anxiety (Y2)
which corresponded to a percentile score of 78 and 89 respectively. (see table 2).
Table 2
Representing the Raw Scores and Percentiles Ranks on State(Y1) and Trait Anxiety(Y2) for the
Male and Female Participant
Participant A Male 37 62 40 60
Participant B Female 47 78 53 89
Interpretation
The aim of the practical was to compare the state & trait anxiety between males and females, age
ranging between 19-22 using State and Trait Anxiety Inventory (STAI) developed by Charles D.
Spielberger and Richard L. Gorsuch (1997). Anxiety, as defined by Diagnostic and Statistical
Manual of Mental Disorders 1980) is “apprehension, tension, or uneasiness that stems from the
anticipation of danger, which may be internal or external”
STAI is a commonly used measure of trait and state anxiety. It can be used in clinical
settings to diagnose anxiety and to distinguish it from depressive syndromes. It also is often used
in research as an indicator of caregiver distress. It is formulated on a four-point Likert scale (STAI
“Form X”). A revised edition was published in 1983 (STAI Form “Y”) which placed emphasis on
better describing state and trait anxiety factors.
There are two subscales within this measure. First, the State Anxiety Scale (S-Anxiety)
which evaluates the current state of anxiety, asking how respondents feel "right now," using items
that measure subjective feelings of apprehension, tension, nervousness, worry, and
activation/arousal of the autonomic nervous system. The Trait Anxiety Scale (T-Anxiety)
evaluates relatively stable aspects of "anxiety proneness," including general states of calmness,
confidence, and security. The STAI has 40 items, 20 items allocated to each of the S-Anxiety and
T-Anxiety subscales. The possible range of the two forms of STAI is 20 - 80. Items are answered
on a 4-point Likert scale ranging from 1 (not at all) to 4 (very much so), with the total score ranging
from 20 to 80, with higher scores indicating higher levels of anxiety symptoms.
For the purpose of conducting this inventory, two participants were chosen. Participant A
(Male) had a raw score of 37 on State Anxiety (Y1) and 40 on Trait Anxiety (Y2). The percentile
scores were 62 and 60 respectively. Participant B (Female) had a raw score of 47 on State Anxiety
(Y1) and 53 on Trait Anxiety (Y2). The percentile scores were 78 and 89 respectively.
The distinction between state and trait anxiety is an important conceptual development in
anxiety assessment. Charles D. Spielberger (1972) defined state anxiety as, “anxiety in response
to a specific situation that is perceived as threatening or dangerous. State anxiety varies in intensity
and fluctuates over time.” Hence, State anxiety reflects the psychological and physiological
transient reactions directly related to adverse situations in a specific moment. Like kinetic energy,
state anxiety refers to the empirical process or reaction taking place at a particular moment in time
and at a given level of intensity. On the other hand, Trait anxiety refers to a trait of personality,
describing individual differences related to a tendency to present state anxiety. Trait anxiety is,
therefore, relatively stable over time and considered an important characteristic of patients with
anxiety disorders, as they present higher trait anxiety in comparison to healthy individuals. People
with high trait anxiety tend to view the world as more dangerous or threatening than those with
low trait anxiety and to respond with state anxiety to situations that would not elicit this response
in people with low trait anxiety.
Participant A’s (Male) score on State Anxiety (Y1= 37,62) indicates that the individual
experiences moderate level of anxiety on specific situations. The percentile rank of 62 indicates
that the participant lies in that 38% of population that experiences moderate anxiety when faced
with specific situations. State anxiety is a more transient intense emotional state, associated with
a temporary increased sympathetic nervous system activity, but with no specific pathological
conditions. The symptoms of state anxiety include rapid heartbeat, difficulty concentrating, intense
feelings of worry and muscle tension. Sympathetic nervous system creates symptoms of anxiety
as the body prepares for a specific situation. State anxiety passes when the threat being faced
fades. The participant thus faces moderate anxiety when he is faced with situations which require
the fight or flight response compared to the average level of anxiety people face in such situations.
The score of Trait Anxiety (Y2= 40,60) indicates that the individual experiences moderate
level of anxiety in everyday situations. The percentile rank of 60 indicates that the participant lies
in 40% of the population that experiences moderate level of anxiety to perceived threats in the
environment. Trait anxiety refers to the stable tendency to attend to, experience, and report
negative emotions such as fears, worries, and anxiety across many situations. Those with trait
anxiety may feel more anxious in everyday situations, such as their partner being distant or concern
over their work or school life. They may catastrophise and think the worst-case scenario will
happen. Unlike state anxiety, there is no apparent cause of trait anxiety. As trait anxiety is
connected with personality, many people turn to personality models to better understand what may
cause it. The percentile rank of the participant on State and Trait Anxiety show that there exists a
relationship between the two, since moderate anxiety in everyday life can lead to high anxiety in
specific situations. A study by Horikawa & Yagi (2012) suggests that people with higher trait
anxiety scores tend to experience increased state anxiety under a pressure-laden condition.
Participant B’s (Female) score on State Anxiety (Y1=47,78) indicates that the individual
experiences moderate to high anxiety on specific situations. The percentile rank of 78 indicates
that the participant lies in that 22% of population that experiences moderate to high anxiety when
faced with specific situations. The score of Trait Anxiety (Y2= 53,89) indicates that the individual
experiences high level of anxiety in everyday situations. The percentile rank of 89 indicates that
the participant lies in 11% of the population that experiences high level of anxiety to perceived
threats in the environment. A higher level of trait anxiety generally means that the participant is
more likely to feel threatened by specific situations, or even the world in general, than someone
with lower levels of trait anxiety. The percentile rank of State and Trait Anxiety reflect that the
individual experiences high anxiety in everyday life as well as under situations of duress.
After looking at the individual participant scores, it can be seen that the female participant
displays higher State and Trait Anxiety than the male participant. State and trait anxiety define
different aspects of anxiety, and may represent environmentally and genetically mediated
components of this phenotype. Furthermore their relationship, where trait anxiety is expressed
through levels of state anxiety under threatening circumstances, may represent a process of
interplay between a genetic vulnerability factor and an environmental stressor. State anxiety is
largely influenced by environmental factors in males and females whereas trait anxiety shows
moderate genetic effects and substantial non-shared environment effects. In a study by Truong,
Hashmi, Banu, & Williams, females can be seen as having higher anxiety. The age of onset of
anxiety disorders is often determined by retrospective methods, which large prospective studies
are lacking. Most of the data on the prevalence of adolescent mental health disorders comes from
one large, nationally representative epidemiological study, the National Comorbidity Survey
Replication Adolescent Supplement, which surveyed 10,148 adolescents age 13 to 17 years. Rates
of anxiety disorders showed a female predominance, with higher rates of treatment in females as
well.
In this practical, the female participant was very disturbed at her workplace and was in
between shifting to a new place. Adding to that fact, she lives alone in the city without any family
members around. With the stress of the move and the burdens of her work, without any support
from family, the high level of anxiety can be justified. A study by Annu (2020) compared the level
of anxiety in male and female students at Ranchi. Results of data analysis suggested that female
students scored higher anxiety level than male student. A significant difference was observed
between males and females. In addition to biological mechanisms, women and men seem to
experience and react to events in their life differently.
Women produce more stress hormone than men, which means they’re more likely to
develop anxiety in response to stressful situations. These can include things like going through a
divorce or suffering a bereavement. Also, when faced with stressful situations, women and men
tend to use different coping strategies. Women faced with life stressors are more likely to ruminate
about them, which can increase their anxiety, while men engage more in active, problem-focused
coping. In today’s modern society, women are under more pressure than ever and are expected to
juggle lots of different demands. This can include working full-time, looking after a home and
caring for children. These multiple demands can lead to anxiety, stress and other mental health
problems.
To cope with high levels of anxiety, individuals can use several techniques. Meditation
techniques, like mindfulness, yoga, and tai chi, all involve non-judgmental awareness of the
present moment. Countless studies have shown that practicing meditation can help decrease
anxiety. Meditation is believed to affect areas of the brain involved in attention and focus and also
stimulate the release of neurotransmitters like serotonin. Additionally, it also allows time for self-
reflection. Grounding oneself is a necessity in life and sometimes the chaos of events around can
make us forget it. When the feeling of anxiety escalates, taking a few deep breaths and moving
through the 5 senses grounding technique can help the mind recognize that one is safe in the here
and now (name 5 things you can see, 4 things you can hear, 3 things you feel, 2 things you smell
and 1 thing you can taste). Many women find listening to podcasts or writing down positive
affirmations as an effective way to overcome high levels of anxiety.
It is evident that one of the most critical psychological disorders which has been of interest
to psychologists is Anxiety. Anxiety is an emotion characterized by apprehension and somatic
symptoms of tension in which an individual anticipates impending danger, catastrophe, or
misfortune. The conceptions of state and trait anxiety that guided the construction of STAI are
considered in great detail by Spielberger (1966). State anxiety conceptualised as a transitory
emotional state or condition of the human organism that is characterised by subjective, consciously
perceived feelings of tension and apprehension, and heightened autonomic nervous system
activity. Trait Anxiety refers to relatively stable individual differences in anxiety proneness, that
is, to differences between people in the tendency to respond to situations perceived as threatening
with elevations in state anxiety.
The literature on State and Trait Anxiety is vast and dispersed across multiple disciplines.
With the onset of the recent pandemic and the upheaval it has caused, the future of research on
anxiety promising. With many studies already underway and more to follow, anxiety as a topic of
research in psychology has a lot to be discovered in the coming years.
Conclusion
The aim of the practical was to compare the state & trait anxiety between males and females, age
ranging between 19-22 using State and Trait Anxiety Inventory (STAI) developed by Charles D.
Spielberger and Richard L. Gorsuch (1997). Anxiety is considered a future-oriented, long-acting
response broadly focused on a diffuse threat. State-anxiety has been defined as a transitory
emotional response involving unpleasant feelings of tension and apprehensive thoughts. Trait-
anxiety, on the other hand, has been defined as a personality trait referring to individual differences
in the likelihood that a person would experience state anxiety in a stressful situation. In this
practical, the female participant displays higher State and Trait Anxiety than the male participant.
In addition to biological mechanisms, women and men seem to experience and react to events in
their life differently. A number of reasons can be attributed to this factor, such as hormones, stress
levels, etc. To cope with high levels of anxiety, individuals can use several techniques like yoga,
meditation, and mindfulness. With the evolving nature of studies on disorder, future research on
anxiety looks promising.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
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Annu, S. (2020). A comparative study of anxiety in male and female students. The International
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Horikawa, M. & Yagi, A. (2012). The relationships among trait anxiety, state anxiety and the
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McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in anxiety
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