Subjective Memory Complaints in Relation to
Anxiety and Test Performance of Patients Recovering from Severe Acute
Respiratory Syndrome in Hong Kong.
Chan Yiu Han 2
1 Department of Applied Social Science, Hong Kong Polytechnic University, Hong Kong, China.
Medicine, Queen Elizabeth Hospital, Hong Kong, China.
Au A., Chan, I,.,
Li P, Han C.Y., & Chan, J.
(2006). Subjective Memory
Complaints in Relation to Anxiety and Test Performance of Patients
Recovering from Severe Acute Respiratory Syndrome in Hong Kong.
Rehabilitation. 10 (1)
Reprint requests and correspondence should
be sent to
Alma Au. Ph.D.
Department of Applied Social Science
Hong Kong Polytechnic University
Memory problems have been
reported during steroid administration. The
existing literature suggests that many of these effects are transient
reversible. The purpose of the study was to explore the associations of
subjective memory complaint with objective test performance and
in recovering SARS patients.
patients aged between 20 to 34 were divided into 2 groups:
those who reported trouble with their memory and those who did not.
functioning including general intelligence and memory was assessed
subtests of the Wechsler Adult Intelligence and Memory Scales and the
List Learning Test. Mood was assessed using the Hospital Anxiety and
difference was identified between the two groups in
cognitive test performance. Furthermore, results obtained did not
presence of any systematic cognitive impairment in both groups.
group reporting memory trouble was found to significantly score higher
suggested the possibility of a relationship between anxiety and
subjective memory complaint. Results also suggest that subjective
complaints need to be assessed and treated in the context of the
adjustment in individuals trying to recover from a sudden and severe
Specifically, psychological intervention may be needed to help patients
overcome their anxiety about their functional competence in the process
Key Words: SARS, memory, subjective
Severe Acute Respiratory Syndrome (SARS) is
an acute atypical pneumonia believed to be caused by a previously
coronavirus and is responsible for the first pandemic of the 21st
century (Peiris et al., 2003). Hong Kong, China,
remains one of the most severely affected areas. With the infectious
this new disease, SARS can have many behavioral and emotional
recovering patients. After recovering initially in the physical sense,
challenges begin to surface. These include uncertainties about side
effects of medication,
longer-term effects of the illness, the ability to return to previous
occupation and to handle interpersonal relationships. Uncertainty and
stigmatization are prominent themes in the longer-term emotional
SARS (Maunder et al., 2003; Gorodzinsky, 2003, Au et al., 2004).
A treatment protocol including a
combination of ribavirin and systemic steroids was adopted from the
of the epidemic and the protocol is currently being reviewed (Chan et
2003; So et al., 2003; Yuji, 2003). Memory problems have been reported
steroid administration. This ranges from mild problems in verbal memory
severe dementia. The existing literature suggests that many of these
are transient and reversible (Brown & Chandler, 2003; Newcomer et
1999). However, some recovering SARS patients receiving outpatient
care in our specialist clinic have continued to report a subjective
memory difficulties. So far, there is no published data on the
functioning of recovering Severe Acute Respiratory Syndrome (SARS)
have received steroid therapy in Hong
Kong. Thus, the purpose of the
study was to explore the relationships
between subjective memory complaint, objective cognitive test
emotional state for these patients.
Twenty-three discharged SARS patients (aged
between 20-34) were recruited from the Outpatient Clinic of Queen
Hospital. The age group chosen was based primarily on the availability
test norms for that particular age group which is also the primary
group of the established Wechsler scales (Wechsler, 1981). At the time
regularly scheduled appointments at the clinic, all patients of this
were invited to an interview with the clinical psychologist. After
outlining the purpose of the assessment and obtaining written consent,
were invited to complete self-administered questionnaires. All
patients were seen about 1 to 2 months after discharge from hospital.
patient did not turn up for the scheduled appointment stating that
there was no
need for assessment.
Demographic characteristics were collected
through the questionnaire. Illness and treatment related information
medication was obtained from the medical record. For the subjective
complaint, each subject was asked “Do you have trouble with your
answer “yes” or “no” was recorded. This one question has been
to be a sensitive and valid method to assess memory complaint in
Chinese-speaking population (Wang et al., 2000). Based on the response
question, 12 patients were allocated to the group with subjective
complaint (SMC+) and 11 were allocated to the group without subjective
The Chinese translation of the Wechsler
Adult Intelligence Scale-Revised (WAIS-R) was used to assess general
intellectual functioning (Wechsler, 1981; Chan et al., 2000). As for
memory, the Hong Kong List Learning Test (HKLTT) was used to assess
memory (Chan & Kwok, 1999; Au et al., 2003) and the Visual
(VR) subtest of the Wechsler Memory Scale-Revised (WMS-R) was used to
visual memory (Wechsler, 1987).
The WAIS-R subtests administered included
Digit Span, Arithmetic, Similarities, Picture Completion, Block Design
Digit Symbol. The selection of subtests was based on the seven-subtest
form version of WAIS-R that has generally been found to be a
accurate method to estimate overall intellectual functioning (Axelrod
Paolo, 1998). However, the Information
subtest was omitted as the questions in the original American version
judged to be not representative enough for the local culture. In terms
dimensions of the underlying abilities measured, Similarities has been
load on the “verbal” factor. Block Design, Picture Completion and Digit
loaded on the “perceptual” factor. Finally, Digit Span and Arithmetic
the third factor termed “freedom-from-distractibility” of
“attention/concentration” (Leckliter et al., 1986). The HKLTT yields
of immediate recall of the auditory-verbal learning of a 16-word list
three trials. It also involves a delayed recall of the list after 30
Local norms are available for the chosen WAIS-R subtests and the HKLTT.
Requiring the drawing from memory simple geometric designs that are
exposed for ten seconds, the WMS-R (VR) produced a score for immediate
a score for delayed recall after 30 minutes. There are no local norms
WMS-R (VR). However, with its primarily non-verbal content, the culture
is considered minimized.
Emotional state was monitored using the
14-item Hospital Anxiety and Depression Scale (HADS) to provide
anxiety and depression (Zigmond & Snaith, 1983). Each item is
scored from 0
to 3. Total scores range from 0 to 21 for the Anxiety subscale and also
Depression subscale. The HADS has been widely used to monitor mood
medical and neurological patients in Hong Kong (Au et al., 2002).
The WAIS-R yielded six raw scores, one for
each subtest. The VR of the WMS-R yielded two measures: immediate
recall and 30-minute
delayed recall. For the HKLTT, learning over three trials was added up
a total learning score. The HKLTT delayed recall was based on the
words recalled after 30 minutes. The raw scores of the WAIS-R and the
were converted into percentiles according to the available Hong Kong
norms (Chan et al., 2000, Chan & Kwok, 1999). The
scores for the WMS-R (VR) were converted
into percentiles according to the norms given in the manual. The HADS
scores for 14-items from which two independent subscale scores was
for Anxiety and Depression. Subjects were divided into two subgroups
to the presence or absence of subjective memory complaint. T-tests were
performed to investigate group differences on emotional state and
measures of cognitive functioning. The SPSS programs for Windows,
was used for all analysis.
Demographic characteristics and medical
information of the two groups are summarized in Table 1. The 2 groups
comparable in the variables described. However, the age was higher in
with subjective memory complaint than the group without [t(22) = -2.80, p < 0.05]. Results
on the WAIS-R, HKLTT and WMS-R (VR) are summarized in Table 2. Results
HADS are summarized in Table 3. No significant differences between the
were identified in the objective test performance. Furthermore, the
for both groups are all in the normal range.
As for the HADS, there were also no significant in terms of the
and Depression subscale scores. Again, the scores for both groups are
normal range. However, the group with subjective memory complaint was
score significantly higher in Item 3 [t(22) =
-2.35, p < 0.05]. For this item, patients
were asked to
rate in what degree they “got a sort of frightened feeling as if
awful is about to happen”. Higher scores on the item indicated greater
characteristics and medical information of the two groups: patients
subjective memory complaint (SMC+) versus those without (SMC-)
Time since onset (days)
Time since discharge (days)
Period of hospitalization
Need for Admission into
Intensive Care Unit
Need for Intubation
Prenisolone equivalence (mg)
*p < 0.05
2. Objective test performance of the two groups: patients with
memory complaint (SMC+) versus those without (SMC-)
Group (n=12) SMC- Group (n=11)
<>Wechsler Adult Intelligence Scale-Revised
List Learning Test
Scale-Revised (Visual Reproduction)
<>Table 3. Emotional state profile of
the two groups: patients with subjective memory complaint (SMC+) versus
those without (SMC-)
Group (n=12) SMC- Group
Hospital Anxiety and Depression Scale
*p < 0.05
The study explored the relationships of
subjective memory complaint with objective test performance and
in 23 recovering SARS patients aged between 20 to 34. Comparing a group
subjective memory complaint and a group without the complaint, results
reveal any significant differences in the objective test performance in
of intellectual functioning and memory. The cognitive test scores and
scores for both groups are all in the normal range. However, the group
subjective memory complaint scored significantly higher on an anxiety
described “a sort of frightened feeling as if something awful is about
happen.” This is a rather interesting finding as apprehensive
the cardinal feature of anxiety according to the Diagnostic and
Manual of Mental Disorders. These results would suggest the subjective
complaint could be related to anxiety (APA, 1994).
Discrepancies between subjective memory
complaint and cognitive test performance in neurological patients have
frequently reported (Piazzini et al., 2001). The present study is
first to document this discrepancy in recovering SARS patients.
suggest that subjective memory complaint in these patients may be
anxiety. However, the present study has certain limitations. The
was relatively small and the age group was confined to younger
choice of the age range was initially based on the availability of
norms and the relative lack of other possible neurological
To conclude, the present study highlighted
the possibility of the relationship between emotional factors and the
subjective sense of memory competence. A severe illness like SARS can
major disruptions to activities in daily living. Furthermore SARS
also faced with social prejudice causing them difficulties in getting
support when they need them most. The subjective sense of frailty and
can lower the sense of personal control to return to the previous
and lifestyle. Levels of anxiety and depression have been found to
with the subjective sense of mastery in local epilepsy patients (Au et
2002). Although future studies need to
clarify the relationship between emotions and subjective memory, the
of the present study reinforced the need to take into account the
state in the recovery in SARS patients. Results of the present study
that subjective memory complaints need to be assessed and treated in
of the overall adjustment in individuals trying to recover from a
severe illness. Specifically, psychological intervention may be needed
patients to overcome their anxiety about their functional competence in
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