Bibliography, the Test-Anxiety Instrument and the test-taking strategies. Istration of the Test AnxietyInventory (TAI), (Spielberger. 1980) to the. The view of test anxiety as. Instructions provided in the test manual (Spielberger.
INTRODUCTION This review covers commonly used measures of anxiety. For this review, the author included measures that were 1) measures of general measures of anxiety and severity of anxiety symptoms, 2) administered by self-report, 3) used in rheumatologic populations, and 4) has evidence of adequate psychometric data. To maintain brevity, the majority of the measures reviewed here were selected to provide broad coverage of general symptoms of anxiety, and measures were excluded if they are intended to identify or characterize a specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorder. Specifically, this author excluded measures typically used to evaluate diagnostic criteria or features of specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and others. In addition, broader measures of psychiatric distress, including the Symptom Checklist-90, the General Health Questionnaire, and the Medical Outcomes Study Short Form 36 are not included in this review since they are included elsewhere in this special issue.
However, subscales that have been used frequently in rheumatology as “stand-alone” measures, such as the anxiety scale of the Hospital Anxiety and Depression Scale, are included in this review. Importantly, the measures included in this review should not be interpreted as diagnostically significant for an anxiety disorder, even generalized anxiety disorder, but should be used to measure the presence of symptoms and to calibrate the severity of general symptoms of anxiety commonly occurring in rheumatic disease.
The measures reviewed below include the State Trait Anxiety Index, the Beck Anxiety Inventory, and the anxiety subscale of the Hospital Anxiety and Depression Scale. In this review, the content and structure of each measure is presented (number of items, recall period, response options, presence of translations, and adaptations), the use in rheumatic disease when possible is discussed, and the psychometric properties of each measure, particularly when validated in any of the rheumatic diseases, is detailed.
In addition, information regarding responsiveness of each measure to longitudinal change is presented, including responsiveness to change in rheumatology when available. Finally, a summary of the strengths and weaknesses specific to rheumatology is presented. Score interpretation Range of scores for each subtest is 20–80, the higher score indicating greater anxiety. A cut point of 39–40 has been suggested to detect clinically significant symptoms for the S-Anxiety scale (,); however, other studies have suggested a higher cut score of 54–55 for older adults. Normative values are available in the manual for adults, college students, and psychiatric samples.
To this author's knowledge, no cut scores have been validated for rheumatic disease populations. Validity During test development, more than 10,000 adults and adolescents were tested.
To optimize content validity, most items were selected from other anxiety measures on the basis of strong associations with the Taylor Manifest Anxiety Scale and Cattell and Scheier's Anxiety Scale Questionnaire ; overall correlations between the STAI and these 2 measures were 0.73 and 0.85, respectively. In general, construct validity of the STAI was somewhat limited in discriminating anxiety from depression, with some studies observing higher correlations between the T-Anxiety scale and measures of depression, as compared to other measures of anxiety (,). S-Anxiety validity was originally derived from testing in situations characterized by high state stress including classroom examinations, military training programs, etc.
Like other measures of anxiety, the STAI is also highly correlated with depression and, in some studies, the STAI did not differentiate anxious from depressed patients. Similarly, while the STAI has not been formally validated in rheumatic disease, studies in rheumatology have similarly observed very high correlations among the STAI and measures of depression (e.g., r = 0.83). In some populations (elderly), the STAI has shown poor discriminant validity and did not differentiate persons with and without anxiety disorders. Caveats and cautions Limitations include the limited availability of validation data specific to rheumatic disease. Additionally, there exists relatively poor validity of the scale, particularly the T-Anxiety subscale for differentiation anxious from depressed states.
Further, because the intent of the T-Anxiety scale is to characterize a longstanding trait, clinicians and researchers should be mindful of this if seeking scales to detect change over a relatively short period of time. In general, for these purposes, many have opted to solely use the S-Anxiety subscale for the detection of longitudinal change. Validity Construct validity studies show good convergence of the BAI with other measures of anxiety including the Hamilton Anxiety Rating Scale (r = 0.51), the STAI (r = 0.47–0.58), and the anxiety scale of the Symptom Checklist-90 (r = 0.81). Although the BAI appears to be less correlated with depression scales than the STAI, correlations with depression scales remain substantial (e.g., correlation with Beck Depression Inventory r = 0.61).
While to this author's knowledge, the BAI has not been validated in rheumatology populations, studies among other populations with medical comorbidities (e.g., older adults) suggest that due to the emphasis on somatic symptoms, the BAI did not perform similarly to younger populations (yielded somatic factors in older adults), and therefore the discriminant validity may be less robust than in younger or healthy populations. Caveats and cautions The primary limitations for the BAI are the relatively limited scope of symptoms evaluated and the lack of validation studies specific to rheumatology populations.
The BAI was developed in an attempt to reduce overlap with depressive symptoms, and as a result tends to focus more exclusively on somatic (e.g., heart racing, dizziness) symptoms. In medical conditions, these symptoms have the propensity to overlap with some physical aspects of medical conditions and, therefore, cautious interpretation would be warranted. The BAI does not assess other primary symptoms of anxiety, most notably worry and other cognitive aspects of anxiety. In summary, for rheumatology, unless accompanied by other measures that include cognitive (ruminative) aspects of anxiety, the BAI may provide a limited assessment of anxiety. Validity The majority of psychometric studies observed a 2-factor solution, supporting the use of the anxiety subscale as a “stand alone” measure (11 of 19 studies in a recent review of this measure; however a few studies did find more than 2 factors (see review by Bjelland et al ). Using a cut score of 8 overall provided sensitivities and specificities at 80% and reaching 90% in a community cohort for the HADS-A for detecting anxiety disorders. In primary care populations, cut scores of ≥9 for the HADS-A yielded moderate sensitivity (0.66) and high specificity (0.93).
An additional study in the elderly yielded high misclassification rates and suggested that the HADS-A possessed limited sensitivity and specificity to detect anxiety disorders in this population. One study comparing the HADS to diagnoses of anxiety and depression in a cohort of patients with osteoarthritis observed greater concordance among the HADS-A and diagnoses of anxiety compared to the concordance among the HADS depression scale and diagnoses of depressive disorders. In this study, the HADS-A had a sensitivity and specificity of 88% and 81%, respectively, for a diagnosis of an anxiety disorder (,).
Overall, concurrent validity of the HADS was deemed “good” to “very good” in a comprehensive review , with comparable sensitivity and specificity of longer scales including the General Health Questionnaire, the STAI, and the Symptom Checklist-90 anxiety scales. DISCUSSION Three measures were reviewed above: the STAI, the BAI, and the HADS-A.
These 3 measures were selected for review based on the previous use in rheumatology, sound psychometric properties, and detection of generalized symptoms of anxiety. As mentioned above, measures targeted towards the assessment of specific anxiety disorders including other DSM-IV anxiety disorders (including post-traumatic stress disorder, obsessive-compulsive disorder, etc.) are not included in this review. While assessment of some of these features may be beneficial in rheumatology, for example, some studies in other populations have observed posttraumatic stress type reactions to receiving specific medical diagnoses (,), these instances are more unique considerations and, therefore, such measures are not included in this review. It becomes evident, based on the brevity of this review, that few stand-alone measures of anxiety are currently used in rheumatology.
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Reasons for the decreased emphasis on the assessment of anxiety in these populations may be multifaceted and include a relative increased emphasis on depression in comparison to anxiety, use of larger scale measures detecting a range of features related to psychological distress (e.g., Symptom Checklist-90), or an under-appreciation of the prevalence and severity of anxiety in many rheumatic conditions. Moving forward, it may be warranted to explore these factors more fully and determine if the current measures in use are adequately detecting the presence and severity of symptoms of anxiety that are important to patients or that need to be addressed in the course of medical care.
Nonetheless, based on this review, there currently exist measures that have good psychometric properties and adequate responsiveness to change that would warrant use in rheumatology. Psychometric properties Scale Content No.
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As Seymour Sarason (1959), a major early contributor to theory and research on test anxiety, observed, “We live in a test‐conscious, test‐giving culture in which the lives of people are in part determined by their test performance” (p. Consequently, it is not surprising that test anxiety is a pervasive problem for many students who are so disturbed by the stress associated with taking tests that they experience substantial decrements in performance in evaluative situations. During examinations, individuals high in test anxiety are more likely to experience frequent and intense elevations in anxiety as an emotional state (S‐Anxiety), greater activation of the autonomic nervous system, and more self‐centered worry and task‐irrelevant thoughts that interfere with attention and performance. Given these characteristics, test anxiety can be viewed as a situation‐specific personality trait (Spielberger, Gonzalez, Taylor, Algaze, & Anton, 1978).