Florida Shock Anxiety Scale Research Articles

The Registry Evaluating Functional Outcomes of Resynchronization Management (REFORM): Quality of Life and Psychological Functioning in Patients Receiving Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) is a treatment for heart failure (HF) that improves cardiac, functional, and quality of life (QoL) outcomes. This study was designed to examine the effect of the addition of CRT (CRTD) to the implantable cardioverter defibrillator (ICD) on psychological functioning. Overall, 99 participants completed batteries before and 9 months after ICD or CRTD implantation in a registry of HF patients receiving device treatment in 3 US centers. Measures included validated indices of mental health (State Trait Anxiety Inventory, Patient Health Questionnaire: Depression) and generic and disease/device-specific QoL (Medical Outcomes Study-Short Form-12, Kansas City Cardiomyopathy Questionnaire, Florida Patient Acceptance Survey, Florida Shock Anxiety Scale). Mixed between-within analyses of covariance were employed to compare device groups on each outcome controlling for cardiac and demographic covariates. Clinically significant anxiety was elevated in both groups at both time points (57% CRTD at baseline, 29% CRTD 9 months, 44% ICD at baseline, 45% ICD 9 months). Clinically significant depressive symptoms were high at baseline (38% CRTD, 31% ICD), but dropped at follow-up (16% CRTD, 7% ICD; P = 0.01). Participants with CRTD had improved mental component and disease-specific QoL following CRT; however, CRTD patients had worse QoL, worse mental component QoL at baseline, and worse device acceptance at 9-month follow-up than patients with ICDs (all P < 0.05). Evidence of low QoL, psychological functioning, and device acceptance provides the impetus to increase research on well-being of HF patients being implanted with CRTD in research and clinical work.

The factors affecting psychological quality of life of implantable cardioverter-defibrillator patients

Purpose: The study aimed to analyze the factors affecting the psychological quality of life of implantable cardioverter-defibrillator (ICD) patients. Methods: We investigated 214 patients from the DEF-Chiba study, which is a multi-center registry in Chiba Prefecture, Japan. All patients completed the Florida Shock Anxiety Scale (FSAS) at the time of registration. The FSAS is a tool designed to provide a quantitative measure of ICD shock-related anxiety. A stepwise multiple linear regression analysis was used to determine the important predictors of the log-transformed FSAS scores. Results: Fifty females (23%) were enrolled in this study and the mean period from implantation to registration (F/U period) was 34±30 months. Ninety-seven patients (45%) underwent an ICD implant for a primary indication and 67 patients (31%) were fllowed by remote monitoring system. Fifty-five patients (26%) had experienced shock therapy. Defibrillation threshold testing (DFT) was performed in 114 patients (53%). A female gender, experience of shock therapy, and a secondary indication were selected as predictors of ICD shock-related anxiety. However, the age, F/U period, remote monitoring system and DFT did not correlate with the FSAS score. ![Figure][1] Figure 1. Forward stepwise regression analysis Conclusions: An experience of a shock therapy is the most important determinant of psychological distress in ICD patients. For female patients who have been implanted for a secondary indication and experienced shock therapy, a fine-tuning of the device programming instead of the nominal settings should be considered after the implantation to reduce the rates of both appropriate and inappropriate shocks. [1]: pending:yes

The relationship between perceived support from healthcare professionals, shock anxiety and device acceptance in implantable cardioverter defibrillator recipients

Purpose: The recipients acceptance of the implantable cardioverter defibrillator (ICD) can be influenced by several factors. One factor is perceived support from healthcare professionals during regular follow-up visits. Another factor is shock anxiety, i.e. the recipients concerns and fear related to possible future shocks. However, little is known about the relationship between perceived support from healthcare professionals, shock anxiety and device acceptance among the recipients. The purpose of this study is 1) to investigate the extent to which shock anxiety and perceived support from healthcare professional support is related to device acceptance and 2) to determine to what degree perceived support from health care professional moderates the relationship between shock anxiety and device acceptance in ICD recipients. Methods: A cross-sectional study comprising recipients (N-167, 80% male, mean age = 64 years) attending an outpatient device clinic completed standardized and validated questionnaires assessing perceived support from healthcare professionals, shock anxiety (the Florida Shock Anxiety Scale) and device acceptance (the Florida Patient Acceptance Survey). Demographic and clinical data were collected by self-report and from medical records in September-October 2010. The statistical analyses included descriptive statistics and multiple regression analyses. Results: The descriptive results indicated that 84.4% of the recipients reported high device acceptance. Regression analysis demonstrated that constructive support from healthcare professionals was positively associated with device acceptance (p<0.05) and moderated the negative relationship between shock anxiety and device acceptance (p<0.05). Non-constructive support and shock anxiety were statistically negatively associated with device acceptance (p<0.01). Conclusions: Healthcare professionals represent a valuable constructive support system that can enhance device acceptance among ICD recipients, partly by preventing shock anxiety from leading to poor device acceptance. On the other hand, the findings suggest that non-constructive communication on the part of healthcare professionals could hinder device acceptance.

Disease-Specific Quality of Life—Patient Acceptance

Despite its established effectiveness, living with an implantable cardioverter defibrillator (ICD) is associated with ongoing physical and psychosocial distress. Little is known about which factors impact the patients' adjustment to living with the device and whether there are racial or gender differences related to these factors. The purpose of this study was to investigate factors (demographic, clinical, psychosocial, and religiosity) related to patients' ICD acceptance and to examine racial and gender differences in ICD acceptance. A total of 101 ICD patients (mean age, 65 ± 12.8 years, 34% female, 42% African American [AA]) seen in a cardiology clinic between January and August 2010 completed the Florida Patient Acceptance Survey (FPAS), Florida shock anxiety scale, ENRICHD social support instrument, hospital anxiety and depression scale, Hoge Religiosity Scale, and a demographic sheet during their clinic visit. All multiple-item scales demonstrated good internal consistency reliability, with Cronbach α values ranging from .77 to .89. Overall patient acceptance of the ICD was high, with an average FPAS acceptance score of 80.9 on the 0-to-100 point scale. The FPAS subscale scores indicated that the group was very positive about the benefits of having the device (mean, 90.3) and had few body image concerns (mean, 10.6), low device-related distress (mean, 15.6), and moderate return to function scores (mean, 63.0). White ICD participants were more accepting of their device than AA ICD patients were, scoring statistically significantly higher than AA patients on total patient acceptance and return to function and significantly lower than AA patients on device-related distress and shock anxiety. Controlling for ethnicity (β = .10, P = .15), age (β = .01, P = .90), and number of comorbidities (β = .19, P = .003) in a hierarchical multiple regression, shock anxiety (β = .31, P < .001), knowledge of the device (β = .23, P = .001), social support (β = .13, P = .08), Hospital Anxiety and Depression Scale anxiety (β = .06, P = .51) and depression (β = .25, P = .01), and importance of religion (β = .17, P = .01) explained 46.8% of the variance in FPAS scores. Although overall patient acceptance was high, AAs in the study had statistically significant lower mean total Florida Patient Acceptance Scale scores and Return to Function scores than whites did and higher Device-Related Distress scores. The strongest predictors of patient acceptance for the total group were shock anxiety, depressive symptoms, and device knowledge. African Americans had significantly lower device knowledge scores and higher shock anxiety scores than whites did. These findings suggest that ICD patients, especially AA ICD patients, may require education and psychosocial measures to enhance acceptance of their device. This study supports a holistic and culturally sensitive approach to focused clinical and psychological assessment and interventions for those living with this life-saving technology.

Shock-related anxiety and sexual function in adults with congenital heart disease and implantable cardioverter-defibrillators

An increasing number of adults with congenital heart disease (CHD) require implantable cardioverter-defibrillators (ICDs), yet little is known about their impact on psychological well-being and sexual function. To assess shock-related anxiety in adults with CHD and its association with depression and sexual function. A prospective, multicenter, cross-sectional study was conducted on adult patients with CHD with (ICD(+)) and without (ICD(-)) ICDs. The Florida Shock Anxiety Scale was administered to patients with ICD(+) and the Beck Depression Inventory-II to all patients. Men completed the Sexual Health Inventory for Men, and women completed the Female Sexual Function Index. A total of 180 adults with CHD (ICD(+): n = 70; ICD(-): n = 110; median age 32 years [interquartile range 27-40 years]; 44% women) were enrolled. The complexity of CHD was classified as mild in 32 (18%), moderate in 93 (52%), and severe in 54 (30%) subjects. In ICD recipients, a high level of shock-related anxiety was identified (Florida Shock Anxiety Scale score 16; interquartile range 12-23.5), which was slightly higher than the median score for ICD recipients in the general population (P = .057). A higher level of shock-related anxiety was associated with poorer sexual function scores in both men (Spearman's ρ =-.480; P<.001) and women (Spearman's ρ =-.512; P<.01). It was also associated with self-reported depressive symptomatology (Spearman's ρ = .536; P< .001). Adults with CHD and ICDs demonstrate a high level of shock-related anxiety, which is associated with lower sexual functioning scores in men and women. These results underscore the need for increased clinical attention related to ICD-related shock anxiety and impaired sexual function in this population.

Shock Anxiety among Implantable Cardioverter Defibrillator Recipients with Recent Tachyarrhythmia

Shock anxiety has been documented irrespective of shock exposure in implantable cardioverter defibrillator (ICD) recipients. The presence of tachyarrhythmia may lead to an anticipation of receiving a shock and thereby give rise to shock anxiety. The aims were to assess: (1) the level of shock anxiety in a sample of ICD recipients, (2) the relationship between such anxiety and shock exposure, and (3) the relationship between recent tachyarrhythmia and shock anxiety. ICD recipients (n = 167) completed the Florida Shock Anxiety Scale measure of shock anxiety. The recipients were divided into three groups: (1) Recipients with no documented tachyarrhythmia over the previous 12 months (n = 56), (2) recipients with documented tachyarrhythmia over the previous twelve months (n = 54), and (3) recipients with any history of shocks (n = 57). Of the recipients, 44% experienced some form of shock anxiety, whereas 15% reported general shock anxiety. Analyses of covariance revealed that recipients with recent tachyarrhythmia (F = 7.675 df = 9/100, P = 0.007) as well as recipients with a shock history (F = 9.976, df = 9/103, P = 0.002) reported higher levels of shock anxiety than recipients with no recent tachyarrhythmia. This study indicates that although a substantial proportion of the ICD recipients experienced some form of shock anxiety, only a relatively small proportion reported general shock anxiety. ICD recipients with recent tachyarrhythmia, in addition to recipients with shock history, appear to be at greater risk for development of shock anxiety. This implies that these recipients may profit from clinical-based strategies and interventions targeting shock anxiety.

The Florida Shock Anxiety Scale (FSAS) for Patients with Implantable Cardioverter Defibrillators: Testing Factor Structure, Reliability, and Validity of a Previously Established Measure

The implantable cardioverter defibrillator (ICD) reduces mortality in patients at risk for life-threatening arrhythmias via high energy shock. The Florida Shock Anxiety Scale (FSAS) was developed to measure ICD patient shock-related anxiety. Initial psychometric evaluation revealed good reliability and validity. The purpose of this study was to examine the psychometrics of the FSAS in a large US sample of ICD patients. Participants were recruited via e-mail and the survey was completed online. Ultimately, 443 ICD patients (359 male and 421 White) completed the 10-item FSAS. Means for FSAS were comparable to previously published data (M = 15.18, SD = 6.5). Interitem reliability was good (Cronbach's α= 0.89). The FSAS was negatively correlated with single-item measures of emotional well-being (r =-0.378, P < 0.01), sense of security (r =-0.365, P < 0.01), perceived general health (r =-0.185, P < 0.01), and quality of life (r =-0.216, P < .01), demonstrating discriminant validity. Convergent validity was supported through significant correlations with number of shocks (r = 0.464, P < 0.01) and reported disruptiveness of shock (r = 0.484, P < 0.01). Confirmatory factor analysis revealed that a single (second-order) factor model (χ(2) [34] = 75.34, P < 0.05, comparative fit index = 0.98, root mean-square error of approximation = 0.05) had the best fit. Shock anxiety as a construct can be measured in a reliable and valid method by the FSAS. These nationally representative data suggest that a single score for shock anxiety is an easy to use and appropriate method of assessment.

General and Disease-Specific Psychosocial Adjustment in Patients With Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy With Implantable Cardioverter Defibrillators: A Large Cohort Study

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is characterized by frequent life-threatening ventricular arrhythmias, diagnosed on average in the teens to mid-50s and commonly treated by implantable cardioverter defibrillators (ICDs). As younger age and high frequency of ICD discharges are risk factors for difficulties in psychosocial adjustment, we developed a study to assess psychosocial adjustment among patients with ARVD/C and to determine risk factors for poor adjustment in this high-risk population. Eighty-six adults enrolled in the Johns Hopkins ARVD Registry (38 male; mean age, 45.4±12.9 years), with an ICD in place for a median 3.2 years (range, 0.2 to 20.1 years), completed a set of questionnaires measuring ICD-specific anxiety (Florida Shock Anxiety Scale), device acceptance (Florida Patient Acceptance Survey), anxiety and depression (Hospital Anxiety and Depression Scale), and functional capacity (Duke Activity Status Index). Although overall device acceptance (Florida Patient Acceptance Survey mean, 76.7±15.3) was normative, patients with ARVD/C had substantially elevated body image concerns (Florida Patient Acceptance Survey subscale mean, 17.9±23.5) and device-related distress (subscale mean, 26.5±19.2), particularly among younger patients (P<0.01). Patients with ARVD/C had elevated ICD-specific (Florida Shock Anxiety Scale mean, 22.9±7.8) and general clinical anxiety (Hospital Anxiety and Depression Scale anxiety subscale mean, 6.2±3.9). Device-specific anxiety (Florida Shock Anxiety Scale) was predicted by younger age (P<0.0001), poorer functional capacity (P=0.016), having an ICD shock (P=0.003), and shorter time since ICD implant (P=0.007). Participants with poor device adjustment had an increased likelihood of clinically significant anxiety (P=0.006) and depression (P=0.008). Patients with ARVD/C are at elevated risk for anxiety, and young patients face challenges with device acceptance. Risk factors for poor device adjustment may be used clinically to identify patients at high-risk of psychological distress.

The Impact of Technology Dependency on Device Acceptance and Quality of Life in Persons with Implantable Cardioverter Defibrillators

BACKGROUND: The impact of implantable cardioverter defibrillator (ICD) technology on the quality of life (QOL) experienced by recipients has been a major focus of recent research. Numerous studies have found psychological distress to be important in determining QOL in persons receiving ICDs, yet the source of psychological distress is not well understood. OBJECTIVE: The aim of this study was to determine the impact of technology dependency on psychological outcomes in ICD recipients. METHODS: With the use of a cross-sectional design, 161 ICD recipients from 1 device clinic were mailed self-administered questionnaires, including the Dependency on Technology Scale, Brief Illness Perception Questionnaire, Florida Shock Anxiety Scale, Florida Patient Acceptance Survey, and Short Form-12 (SF-12). Hierarchical multiple regressions and analyses of variance were performed. RESULTS: The final sample size was 101 participants. Mean (SD) age was 68 (13) years; 72% of the participants were men, 99% were white, and 30% reported receiving a shock(s). A total of 80% reported positive attitudes toward technology dependency; 14%, neutral; and 6%, negative (Dependency on Technology Scale). Illness perceptions were positive (Brief Illness Perception Questionnaire; mean[SD], 34.5 [12.6]), shock anxiety was elevated (Florida Shock Anxiety Scale; mean [SD], 16.5 [6.7]), and device acceptance was good (Florida Patient Acceptance Survey; mean [SD], 74.9 [17.0]). Physical health QOL was low (SF-12; mean [SD], 38.6 [11.3]) and mental health QOL was moderate (SF-12; mean [SD], 50.6 [10.0]). Attitudes toward technology dependency significantly accounted for the variance seen in device acceptance and mental health QOL beyond age, gender, number of shocks, illness perceptions, and shock anxiety by 5.7% (P = .001) and 3.3% (P = .04), respectively. Significant differences were seen in device acceptance between those with negative and neutral attitudes (P = .001) and those with negative and positive attitudes (P < .001) and in shock anxiety and mental health QOL between those with negative and those with positive attitudes (P < .001). CONCLUSIONS: Attitudes toward technology dependency is significantly associated with psychological outcomes and may explain the psychological distress in some ICD recipients. Degree of positivity toward technology dependency influences these outcomes. Research evaluating attitudes toward technology dependency and testing of interventions focusing on these attitudes is warranted.

Longitudinal Investigation of Patient Centric Outcomes: Comparisons between CRT-D vs. ICD Patients

Introduction: The addition of cardiac resynchronization therapy (CRT) to the ICD has demonstrated significant symptomatic, QOL and mortality benefit in heart failure patients. However, comparisons of the psychosocial impact of CRT-D vs ICD alone have not been examined. The purpose of this study was to investigate differences in patient centric outcomes between patients receiving either an ICD or a CRT-D. Methods: 98 ICD patients (49 had CRT-D) were enrolled at 3 centers. QOL (KCCQ and SF-12), depression (PHQ-9), and stress (Spielberger State-Trait Anxiety Inventory) were assessed at baseline and 9 months post-implant while shock anxiety (Florida Shock Anxiety Scale) and device acceptance (Florida Shock Anxiety Scale and Florida Patient Acceptance Survey) were assessed at 3 and 9 months. Results: Defibrillator patient groups (CRT-D vs ICD) were demographically similar at baseline (80 vs 90% Caucasian, 66 vs 64 years old, 51 vs 48% ischemic) with the exception of gender (41 vs 19% female), NYHA class III (87 vs 40%), LVESV (185 vs 44ml), KCCQ (49+25 vs 60+26) and QRS duration (146 vs 111 ms). Comparisons between CRT-D and ICD patient groups on study measures at each time point revealed no significant differences. Within group comparisons over time indicated that CRT patients had significant improvement in KCCQ (21% change from 49 baseline score), SF-12 mental score (12% change from 48), depression (31% change from 8.5) and stress (12% change from 31.5), while ICD patients without CRT did not have any significant changes in psychosocial status (p!.05). Shock anxiety and device acceptance were similar between groups, and there were no significant changes from 3 to 9 months. Conclusions: Patients implanted with defibrillators capable of providing CRT had psychosocial improvement in terms of QOL, depression, and stress, while patients with defibrillators without CRT were unchanged. These results demonstrate potential additional benefit of CRT in patient centric outcomes following CRT-D implantation.

Counting Down Before Blasting Off

Since the first generation of implantable cardioverter-defibrillators (ICDs), technologic advances have markedly enhanced their efficacy and safety and improved the accuracy of arrhythmia detection algorithms. Despite these developments, inappropriate therapies for sinus or supraventricular tachyarrhythmias or lead noise remain a major limitation of contemporary ICDs, with a substantial proportion of patients receiving inappropriate shocks. Psychosocial issues appear to reflect the level of distress related to ICD shocks, with fear of shocks associated with increased anxiety, avoidance behaviors, and perceived functional limitations. 1 Sears Jr., S.E. Conti J.B. Understanding implantable cardioverter defibrillator shocks and storms: medical and psychosocial considerations for research and clinical care. Clin Cardiol. 2003; 26: 107-111 Crossref PubMed Scopus (131) Google Scholar , 2 Irvine J. Dorian P. Baker B. et al. Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Am Heart J. 2002; 144: 282-289 PubMed Google Scholar , 3 Kuhl E.A. Dixit N.K. Walker R.L. Conti J.B. Sears S.F. Measurement of patient fears about implantable cardioverter defibrillator shock: an initial evaluation of the Florida Shock Anxiety Scale. Pacing Clin Electrophysiol. 2006; 29: 614-618 Crossref PubMed Scopus (83) Google Scholar Although all ICD recipients are potentially at risk, reported rates of inappropriate shocks are particularly high in the young, growing, and complex population with congenital heart disease. 4 Khairy P. Harris L. Landzberg M.J. et al. Implantable cardioverter-defibrillators in tetralogy of Fallot. Circulation. 2008; 117: 363-370 Crossref PubMed Scopus (352) Google Scholar , 5 Berul C.I. Van Hare G.F. Kertesz N.J. et al. Results of a multicenter retrospective implantable cardioverter-defibrillator registry of pediatric and congenital heart disease patients. J Am Coll Cardiol. 2008; 51: 1685-1691 Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar , 6 Khairy P. Harris L. Landzberg M.J. et al. Sudden death and defibrillators in transposition of the great arteries with intra-atrial baffles: a multicenter study. Circ Arrhythm Electrophysiol. 2008; 1: 250-257 Crossref PubMed Scopus (182) Google Scholar , 7 Khairy P. Defibrillators and cardiac resynchronisation therapy in congenital heart disease. Exp Rev Med Devices. 2008; 5: 267-271 Crossref PubMed Scopus (11) Google Scholar On the basis of the global literature and ICD interrogation in multicenter cohorts with congenital heart disease, it appeared reasonable to speculate that many inappropriate or unnecessary shocks may potentially be averted by tailored programming. This prompted our succinct “Hands On” article offering 10 programming tips in congenital heart disease. 8 Khairy P. Mansour F. Implantable cardioverter-defibrillators in congenital heart disease: 10 programming tips. Heart Rhythm. 2011; 8: 480-483 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar A more detailed general review of ICD programming beyond nominal settings was subsequently proposed. 9 Mansour F. Khairy P. Programming ICDs in the modern era beyond out-of-the box settings. Pacing Clin Electrophysiol. 2011; 34: 506-520 Crossref PubMed Scopus (26) Google Scholar To the Editor—Programming tips and practical programmingHeart RhythmVol. 8Issue 6PreviewI would like to offer two comments on Khairy and Mansour's well-written article on programming of implantable cardioverter-defibrillators (ICDs) in the March 2011 issue of Heart Rhythm.1 Full-Text PDF

Quality of Life Outcomes in Chinese Patients with Implantable Cardioverter Defibrillators

Patient-centered outcomes for Chinese implantable cardioverter defibrillator (ICD) patients have not been previously studied. This study examined health-related quality of life (HRQL) and its relation with ICD shock-related anxiety, ICD shock, patient acceptance of the ICD, and demographic and clinical characteristics among a sample of Chinese ICD patients. Eighty-five ICD recipients completed the Chinese versions of the Short Form (SF-12) Health Survey, Florida Patient Acceptance Survey (FPAS), and Florida Shock Anxiety Scale (FSAS), and a demographic sheet during their follow-up visit. The mean scores of physical component summary and mental component summary (MCS) of ICD patients (41.7 and 46.6, respectively) were lower than the Hong Kong Chinese normative data. As expected, MCS was negatively correlated with shock anxiety (r =-0.38, P < 0.01) and positively correlated with patient acceptance (r = 0.50, P < 0.01). Shock anxiety was negatively correlated with patient acceptance of the ICD (r =-0.58, P < 0.01). Age was positively associated with FPAS (r = 0.55, P = 0.014) while negatively related with FSAS (r =-0.28, P = 0.003). The experience of ICD shock (yes/no) was not associated with any differences but shock frequency groups (no shocks, 1-2 shocks, and ≥3) and gender were significantly different on shock anxiety but not on general mental functioning. Higher ICD shock anxiety was associated with lower HRQL and lower ICD acceptance. Age, female, and clinical characteristics such as diabetes, coronary heart disease, and ICD shock experience can influence patient-centric outcomes of HRQL, FPAS, and FSAS. These results extend the evidence for increased clinical attention in Chinese patients to specific outcomes such as shock anxiety and its impact on HRQL.

Measurement of Patient Fears About Implantable Cardioverter Defibrillator Shock: An Initial Evaluation of the Florida Shock Anxiety Scale

Psychological distress is both a precipitant and a consequence of ICD shock. Therefore, the assessment of patient anxiety and concerns related to receiving an ICD shock may prompt appropriate psychological referrals and treatment. The purpose of this study is to assess the initial validity and clinical utility of the Florida Shock Anxiety Scale (FSAS). Seventy-two ICD recipients completed the FSAS. Exploratory factor analysis revealed a two-factor structure with items loading such that Factor 1 could be conceptualized as a Consequence Factor (e.g., fearing creating a scene if the device were to fire) and Factor 2 as a Trigger Factor (e.g., fearing sexual activity). Alpha coefficients suggest good reliability (Cronbach's alpha= 0.91, split-half = 0.92), and FSAS Total Score was moderately correlated (r =-0.65) with total score on the Multidimensional Fear of Death Scale. Two subscales, labeled consequence of shock and trigger of shock, were established via factor analysis. Collectively the FSAS demonstrates potential utility to assess shock distress and warrants additional investigation.