Assessment Of Preoperative Anxiety Using Visual Facial Anxiety Scale: An Alternative To The Verbal Rating Scale?

Main Article Content

Roya Yumul Julianne Ahdout Ariana Goodman OFELIA Loani Elvir Lazo Antonio Hernandez Conte Galen Cook-Wiens Xuezhao Cao Paul F. White


Background: Evaluating preoperative anxiety level can be a difficult task for physicians. The Visual Facial Anxiety Scale (VFAS) was designed as an alternative to the Verbal Rating Scale (VRS) for assessing the level of preoperative [state] anxiety. We hypothesized that the VFAS would provide a stronger correlation between the patient and anesthesiologist categorical anxiety assessments than the VRS.  


Methods: After obtaining IRB approval, 200 elective surgery patients were evaluated in the preoperative holding area. Patients were asked to evaluate their current anxiety level using the VFAS and the VRS, as well as to categorize their anxiety level as mild, moderate, or severe. The anxiety level was also assessed using the same categorical rating scale by the attending anesthesiologist. The anesthesiologists were also asked if they routinely evaluate the patient’s anxiety level during the preoperative visit.


 Results: A significant correlation was found between the VRS and VFAS for both patients (r=0.79, p<0.0001) and anesthesiologists (r=0.92, p<0.0001), but utilization of the VFAS resulted in 58% concordance of anxiety level between the patient and anesthesiologist (vs. only 35% with the VRS). Interestingly, 70% of anesthesiologists did not routinely evaluate the patients’ preoperative anxiety level.  


Conclusion: The VFAS is a simple tool which could be used for assessing preoperative anxiety. Anesthesiologists do not routinely evaluate patients’ anxiety levels preoperatively.

Article Details

How to Cite
YUMUL, Roya et al. Assessment Of Preoperative Anxiety Using Visual Facial Anxiety Scale: An Alternative To The Verbal Rating Scale?. Medical Research Archives, [S.l.], v. 2, n. 2, july 2015. ISSN 2375-1924. Available at: <>. Date accessed: 25 june 2018.
preoperative (state) anxiety, visual facial anxiety scale (VFAS), verbal rating scale (VRS), categorical anxiety rating scale
Research Articles


1. Hashimoto Y, Baba S, Koh H, Takagi H, Ishihara H, Matsuki A. Anxiolytic effect of pre-operative showing of anesthesia video for surgical patients. Masui.1993; 42: 611-6.

2. Shevde K, Panagopoulos G. A survey of 800 patients’ knowledge, attitudes and concerns regarding anesthesia. Anesth Analg 1991; 73: 190-8.

3. Norris W, Baird WL. Pre-operative anxiety: a study of the incidence and aetiology. Br J Anaesth 1967; 39: 503-9.

4. Scott LE, Clum GA, Peoples JB. Pre-operative predictors of postoperative pain. Pain 1983; 15: 283-93.

5. Mitchell MJ. Psychological preparation for patients undergoing day surgery. Ambul Surg 2000; 8: 19-29.

6. Mitchell M. Patients’ perceptions of pre-operative preparation for day surgery. J Adv Nurs 1997; 26: 356-63.

7. Carr E, Katrina B, Sandra A, Paul S. Patterns and frequency of anxiety in women undergoing gynecological surgery. J Clin Nurs 2006; 15: 341-52.

8. Zeller JM, McCain NL, Swanson B. Psychoneuroimmunology: an emerging framework for nursing research. J Adv Nurs 1996; 23: 657-64.

9. Fell D, Derbyshire DR, Maile CJ, Larsson IM, Ellis R, Achola KJ, Smith G. Measurement of plasma catecholamine concentrations. An assessment of anxiety. Br J Anaesth 1985; 57: 770-4.

10. Weissman C. The metabolic response to stress: an overview and update. Anesthesiology 1990; 73: 308-27.

11.Kim WS, Byeon GJ, Lee HJ. Availability of preoperative anxiety scale as a predictive factor for hemodynamic changes during induction of anesthesia. Korean J Anesthesiol. 2010; 58: 328-33.

12. McFetridge JA, Yarandi HN. Cardiovascular function during cognitive stress in men before and after coronary artery bypass grafts. Nurs Res 1997; 46: 188-94.

13. Camacho A, Dimsdale JE. Platelets and psychiatry: lessons learned from old and new studies. Psychosom Med 2000; 62: 326-36.

14.Quinn AC, Brown JH, Wallace PG, Asbury AJ. Studies in postoperative sequelae: nausea and vomiting- still a problem. Anesthesia 1994; 49: 62-5.

15.Scott Le, Clum GA, Peoples JB. Preoperative predictors of postoperative pain. Pain 1983; 15: 283-93.

16.Goldman L, Ogg TW, Levey AB. Hypnosis and day-case anesthesia: a study to reduce pre-operative anxiety and intraoperative anesthetic requirements. Anesthesia 1988; 43: 466-9.

17. Williams JGI, Jones JR. Psychophysiological responses to anesthesia and operation. JAMA 1968; 203: 415-7.

18. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a "gold standard"? Anesth Analg 1997; 85(4): 783-8.

19. Carroll NV, Miederhoff PA, Cox FM, Hirsch JD. Costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting. Clin Anesth. 1994; 6: 364-9.

20. Hobson JA, Slade P, Wrench IJ, Power L. Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section. Int J Obstet Anesth 2006; 15: 18-23.

21. Julian LJ. Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res 2011; 63: 467-72.

22. Kil HK, Kim WO, Chung WY, Kim GH, Seo H, Hong JY. Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Br J Anaesth 2012; 108: 119-25.

23. Tanasale B, Kits J, Kluin PM, Trip A, Kluin-Nelemans HC. Pain and anxiety during bone marrow biopsy. Pain Manag Nurs 2013; 14: 310-7.

24. Garra G, Singer AJ, Taira BR, Chohan J, Cardoz H, Chisena E, Thode HC Jr. Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients. Acad Emerg Med 2010; 17: 50-4.

25. Shafer A, Fish MP, Gregg KM, Seavello J, Kosek P. Preoperative anxiety and fear: a comparison of assessments by patients and anesthesia and surgery residents. Anesth Analg 1996; 83: 1285-91.

26. Shafer A, White PF, Urquhart ML, Doze VA. Outpatient premedication: use of midazolam and opioid analgesics. Anesthesiology 1989; 71: 495-501.

27. Wansbrough SR, White PF. Sedation scales: measures of calmness or somnolence? Anesth Analg. 1993; 76: 219-21.

28. Ware LJ, Epps CD, Herr K, Packard A. Evaluation of the Revised Faces Pain Scale, Verbal Descriptor Scale, Numeric Rating Scale, and Iowa Pain Thermometer in older minority adults. Pain Manag Nurs 2006; 7: 117-25.

29. Jenkins BN, Fortier MA, Kaplan SH, Mayes LC, Kain ZN. Development of a short version of the modified Yale Preoperative Anxiety Scale. Anesth Analg. 2014; 119: 643-50.

30. Benotsch EG,Lutgendorf SK, Watson D, Fick LJ, Lang EV. Rapid anxiety assessment in medical patients: evidence for the validity of verbal anxiety ratings. Ann Behav Med 2000; 22: 199-203.

Most read articles by the same author(s)

Obs.: This plugin requires at least one statistics/report plugin to be enabled. If your statistics plugins provide more than one metric then please also select a main metric on the admin's site settings page and/or on the journal manager's settings pages.