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Articles   |    
Development of the CAT-ANX: A Computerized Adaptive Test for Anxiety
Robert D. Gibbons, Ph.D.; David J. Weiss, Ph.D.; Paul A. Pilkonis, Ph.D.; Ellen Frank, Ph.D.; Tara Moore, M.A., M.P.H.; Jong Bae Kim, Ph.D.; David J. Kupfer, M.D.
Am J Psychiatry 2014;171:187-194. doi:10.1176/appi.ajp.2013.13020178
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Drs. Gibbons, Kupfer, Frank, Weiss, and Pilkonis have financial interests in Adaptive Testing Technologies, through which the CAT-ANX will be made available commercially. Dr. Frank has served as a consultant for Servier International and has received royalties from Guilford Press and American Psychological Association Press. Dr. Kupfer has served as a consultant for the American Psychiatric Association.

Supported by NIMH grant R01-MH66302.

From the Center for Health Statistics, University of Chicago, Chicago; the Department of Psychology, University of Minnesota, Minneapolis; and Western Psychiatric Institute, University of Pittsburgh, Pittsburgh.

Address correspondence to Dr. Gibbons (rdg@uchicago.edu).

Copyright © 2014 by the American Psychiatric Association

Received February 08, 2013; Revised April 03, 2013; Accepted May 06, 2013.


Objective  The authors developed a computerized adaptive test for anxiety that decreases patient and clinician burden and increases measurement precision.

Method  A total of 1,614 individuals with and without generalized anxiety disorder from a psychiatric clinic and community mental health center were recruited. The focus of the present study was the development of the Computerized Adaptive Testing–Anxiety Inventory (CAT-ANX). The Structured Clinical Interview for DSM-IV was used to obtain diagnostic classifications of generalized anxiety disorder and major depressive disorder.

Results  An average of 12 items per subject was required to achieve a 0.3 standard error in the anxiety severity estimate and maintain a correlation of 0.94 with the total 431-item test score. CAT-ANX scores were strongly related to the probability of a generalized anxiety disorder diagnosis. Using both the Computerized Adaptive Testing–Depression Inventory and the CAT-ANX, comorbid major depressive disorder and generalized anxiety disorder can be accurately predicted.

Conclusions  Traditional measurement fixes the number of items but allows measurement uncertainty to vary. Computerized adaptive testing fixes measurement uncertainty and allows the number and content of items to vary, leading to a dramatic decrease in the number of items required for a fixed level of measurement uncertainty. Potential applications for inexpensive, efficient, and accurate screening of anxiety in primary care settings, clinical trials, psychiatric epidemiology, molecular genetics, children, and other cultures are discussed.

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FIGURE 1. Flowchart of Participant Enrollment, Allocation, and Testing for Development of the Computerized Adaptive Testing–Anxiety Inventory

a Treatment-seeking comparison subjects were patients who came in for treatment but did not meet DSM criteria for depression or anxiety.

FIGURE 2. Observed and Expected Proportions of Generalized Anxiety Disorder as a Function of Score on the Computerized Adaptive Testing–Anxiety Inventory (CAT-ANX)

FIGURE 3. Percentile Rank Among Patients With Generalized Anxiety Disorder and Probability of Generalized Anxiety Disorder Diagnosis for the Range of Scores on the Computerized Adaptive Testing–Anxiety Inventorya

a CAT-ANX=Computerized Adaptive Testing–Anxiety Inventory; GAD=generalized anxiety disorder.

FIGURE 4. Receiver Operating Characteristic Curve for the Computerized Adaptive Testing–Anxiety Inventory Compared With DSM-IV Generalized Anxiety Disorder
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TABLE 1.Examples of Items From Each of the Four Domains of the Computerized Adaptive Testing–Anxiety Inventory
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TABLE 2.Demographic Characteristics and Diagnostic Prevalence Rates of the Overall Sample (N=1,614)
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aBased on the Structured Clinical Interview for DSM-IV; percentages based on an N of 387.

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TABLE 3.Item-by-Item Results for the Computerized Adaptive Testing–Anxiety Inventory for Two Illustrative Patients
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aItems apply to the past 2 weeks.

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bScore=44.0, SE=5.2; probability of generalized anxiety disorder, 0.458; percentile among patients with generalized anxiety disorder, 40.6%.

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cScore=96.8, SD=5.5, probability of generalized anxiety disorder, 0.997, percentile among patients with generalized anxiety disorder, 99.0%.



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