Clinically Useful Anxiety Outcome Scale (CUXOS)

Abstract

The Clinically Useful Anxiety Outcome Scale (CUXOS) is a concise, 20-item self-report measure developed to quantify the severity of anxiety symptoms in adult populations, particularly those diagnosed with anxiety disorders or comorbid depression. Developed in 2010, the CUXOS is highly efficient, allowing for rapid administration and scoring, making it ideal for use as a clinical screening tool or for robustly monitoring symptom change and treatment outcomes over time (Zimmerman et al., 2010). Its psychometric properties, including strong internal consistency and reliability, support its utility in diverse clinical settings.

Keywords

CUXOS, anxiety measurement, outcome assessment, anxiety symptoms, depression comorbidity, psychic anxiety, somatic anxiety, self-report measure, clinical monitoring.

Authors

Mark Zimmerman, Ivan Chelminski, Diane Young, Kristy Dalrymple.

Purpose

The primary purpose of the CUXOS is twofold: first, to serve as an efficient screening instrument for the presence and severity of anxiety in clinical settings; and second, to provide a sensitive tool for monitoring therapeutic efficacy. Its brevity and ease of use ensure that it can be incorporated seamlessly into busy clinical workflows, allowing clinicians to track changes in patient status quickly and reliably throughout the course of treatment (Beidas et al., 2015).

The scale is particularly valuable for assessing symptom severity in adults presenting with a diagnosed anxiety disorder or those experiencing significant anxiety symptoms alongside depression. The structure allows for rapid completion by clients (averaging two minutes) and rapid scoring by clinicians (approximately 15 seconds), emphasizing its utility as a practical, clinically focused outcome measure.

Construct

The CUXOS measures the psychological construct of anxiety severity, differentiating it into two primary components: psychic anxiety and somatic anxiety. The development of the item content was grounded in the established diagnostic criteria outlined in the DSM-III-R and DSM-IV, specifically focusing on descriptions of Generalised Anxiety Disorder (GAD) and Panic Disorder (Zimmerman et al., 2010).

The scale is structurally based on the Clinically Useful Depression Outcome Scale (CUDOS, 2008), while its items were derived from the classic Hamilton Rating Scale for Anxiety (HAMA, 1959). This integration results in a measure that captures both the cognitive/emotional aspects (psychic) and the physical manifestations (somatic) of anxiety distress.

Validity

Initial studies demonstrated robust evidence for the validity of the CUXOS. In the original validation study involving 963 patients, the scale exhibited strong convergent validity, showing higher correlations with other established measures of anxiety (median r=0.54) compared to scales measuring unrelated symptom domains (median r=0.32). This confirms that the CUXOS measures the intended construct of anxiety rather than general distress or other psychopathology.

Furthermore, the scale demonstrated excellent discriminatory ability regarding severity levels. An analysis of variance showed that CUXOS severity ratings significantly correlated with ratings from the Social Avoidance and Distress Scale (SADS). A subsequent validation study using a Korean adaptation of the CUXOS (Jeon et al., 2017) confirmed these findings, reporting a strong correlation with other anxiety measures (mean r=0.74) and weaker correlations with other symptom domains (mean r=0.53).

Reliability

The CUXOS exhibits strong evidence of internal consistency and test-retest reliability, supporting its use as a reliable outcome measure. The original study (Zimmerman et al., 2010) reported exceptionally high internal consistency for the total scale, with a Cronbach α of 0.95. Both subscales also maintained high internal consistency: the Psychic Anxiety subscale reported α = 0.90, and the Somatic Anxiety subscale reported α = 0.93.

The test-retest reliability of the total scale was also found to be strong (r=0.90). The Korean validation study (Jeon et al., 2017) replicated these findings, reporting a high internal consistency (α = 0.90) and a substantial test-retest reliability of r=0.74, suggesting reliability across different cultural and linguistic contexts.

Factor Analysis

The CUXOS is designed around a two-factor structure, differentiating between the components of anxiety. This structure includes the Psychic Anxiety Subscale and the Somatic Anxiety Subscale. This factorial composition is supported by the item derivation process, which sought to capture both the cognitive/affective symptoms and the physical manifestations common in anxiety disorders.

The two subscales are delineated as follows: the Psychic Anxiety subscale consists of 6 items focusing on worry, fear, and apprehension (e.g., “I felt scared”), while the Somatic Anxiety subscale contains 14 items addressing physical symptoms such as tension, autonomic arousal, and restlessness (e.g., “I was sweating”). The strong internal consistency observed in both subscales (α ≥ 0.90) supports the coherence of these distinct factors within the overall measure.

Instrument

Test Type: Self-report scale; outcome measure; screening tool.

Format: 20 items rated on a 5-point Likert-type scale (0 to 4).

Language Available: English; Korean adaptation available (Jeon et al., 2017).

Population Group: Clinical population (psychiatric outpatients).

Age Group: Adults.

Population Details: Primarily developed and validated using psychiatric outpatients diagnosed with anxiety disorders, depression, or non-anxious controls. Research regarding diverse demographic features remains limited.

Test Methodology: Patients rate items based on how true they were for them over a specified period. Scores range from 0 to 80. Scoring thresholds are established for severity:

• <10: non-anxious
• 11-20: minimal anxiety
• 21-30: mild anxiety
• 31-40: moderate anxiety
• 41+: severe anxiety

Keywords

Clinical assessment, psychometrics, GAD, panic disorder, outcome monitoring, depression comorbidity, validity, reliability, treatment response.

Authors

Author ORCID Identifier: Information not provided in source content.

Affiliation Email addresses: Information not provided in source content.

Correspondence Address: Information not provided in source content.

Permissions & Fee and Test Year

The CUXOS was developed and published in 2010 (Zimmerman et al.). It is noted in academic literature (Beidas et al., 2015) as being a validated, brief, and free instrument suitable for low-resource mental health settings, suggesting broad accessibility for clinical use.

Reference’s

The following references were cited in the development and validation of the Clinically Useful Anxiety Outcome Scale (CUXOS):

• Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., . . .Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive and Behavioral Practice, 22, 5–19.
• D’Avanzato, C., Martinez, J., Attiullah, N., Friedman, M., Toba, C., Boerescu, D. A., Zimmerman, M. (2013). Anxiety symptoms among remitted depressed outpatients: Prevalence and association with quality of life and psychosocial functioning. Journal of Affective Disorders, 151(1), 401-404. The original PDF can be downloaded here: http://dx.doi.org/10.1016/j.jad.2013.06.040
• Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 50-55.
• Jeon, S. W., Han, C., Ko, Y.-H., Yoon, S., Pae, C.-U., Choi, J., . . . Zimmerman, M. (2017). A Korean validation study of the Clinically Useful Anxiety Outcome Scale: Comorbidity and differentiation of anxiety and depressive disorders. PLoS ONE, 12(6), e0179247. doi:10.1371/journal.pone.0179247
• Zimmerman, M., Chelminski, I., McGlinchey, J. B., & Posternak, M. A. (2008). A clinically useful depression outcome scale. Comprehensive Psychiatry, 49(2), 131-140. The original PDF can be downloaded here: http://dx.doi.org/10.1016/j.comppsych.2007.10.006
• Zimmerman, M., Chelminski, I., Young, D., & Dalrymple, K. (2010). A Clinically Useful Anxiety Outcome Scale. The Journal of Clinical Psychiatry, 71, 534– 542.

Items of the Clinically Useful Anxiety Outcome Scale (CUXOS)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The CUXOS consists of 20 items divided into two subscales:

Psychic Anxiety Subscale (6 items): Example item: “I felt scared”

Somatic Anxiety Subscale (14 items): Example item: “I was sweating”