Pre-treatment patient variables as predictors
of drop-out and treatment outcome in
cognitive behavioural therapy for social
phobia: A systematic review
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ANITA ESKILDSEN, ESBEN HOUGAARD, NICOLE K. ROSENBERG
Eskildsen A, Hougaard E, Rosenberg NK. Pre-treatment patient variables as predictors of dropout and treatment outcome in cognitive behavioural therapy for social phobia: A systematic
review. Nord J Psychiatry 2009;63:000.
Background: Although cognitive behavioural therapy (CBT) has been shown to be an efficacious
treatment for social phobia (SP), many patients drop out or achieve little or no benefit from
treatment. This fact is generally considered an argument for the importance of studies of predictor variables. Aims: This paper systematically reviews pre-treatment patient variables as predictors
of drop-out from and outcome of CBT for SP. Method: A structured literature search was conducted in PsycINFO, Embase and PubMed. Results: 28 published studies with nr60 were
located. No pre-treatment patient variables were found to predict drop-out. Consistently across
studies, higher levels of pre-treatment symptomatic severity predicted higher levels of end-state
symptomatic severity, but not degree of improvement. There was some evidence that comorbid
depression and avoidant personality disorder before treatment negatively influenced post-treatment
end-state functioning, but not consistently improvement. No other patient variables consistently
predicted outcome across studies. Conclusions: Generally, the results are in line with the conclusion that more disturbed patients with SP both begin and end treatment at a higher symptomatic
level but with a similar degree of improvement. There is, however, little clinically or theoretically
relevant knowledge to be gained from existing studies of pre-treatment patient variables as predictors of drop-out and treatment outcome in CBT for patients with SP. The field is in need of
conceptual and methodological improvements if more solid findings should be hoped for.
u Cognitive behavioural therapy, Drop-out, Patient variables, Predictive variables, Prognostic
variables, Social phobia
Anita Eskildsen, Cand.psych., Institute of Psychology, Clinic of OCD, Aarhus University
Hospital, Risskov Nobelparken, Jens Chr. Skous Vej 4, 8000 Aarhus C, Denmark,
E-mail: [email protected]; Accepted 7 October 2009.
S
ocial phobia (SP) or social anxiety disorder is characterized by a marked and persistent fear of social or
performance situations in which embarrassment may
occur (1). Epidemiological studies suggest lifetime prevalence rates between 7% and 13% in most western countries based on DSM-III-R or DSM-IV (2). However, the
figures vary considerably in different studies; probably
mainly because of different cut-off lines for clinical
cases, since the required degree of distress or functional
impairment is not specified in the diagnostic systems. A
new, very large epidemiological study in six different
European countries found a lifetime prevalence estimate
for SP of only 2.4% (3).
© 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)
If untreated, the disorder tends to run a chronic
course and to be associated with lower work productivity,
impaired functioning in social and romantic relationships,
financial dependency, comorbid psychiatric disorders
and poor quality of life (4–6). Mental disorders comorbid with SP especially include major depression, generalized anxiety disorder, personality disorders and alcohol
abuse.
Cognitive behavioural therapy (CBT) is the most
widely used psychological treatment for SP (7, 8). CBT
for SP is often administered in a group format and usually combines exposure exercises with cognitive restructuring, although other methods such as applied relaxation,
DOI: 10.3109/08039480903426929
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A ESKILDSEN ET AL.
rational emotive therapy and social skills training are
also included under the CBT heading.
CBT has been shown to be an efficacious treatment
for SP. Effect sizes of outcome for CBT derived from
meta-analyses are high (9, 10), e.g. Cohen’s (11) d1.27
(pre- to post-treatment) in a meta-analysis of randomized
studies (9), although the effect sizes reported in metaanalyses including non-randomized studies comparing
with placebo control conditions or using intentionto-treat analyses have been considerably lower (5, 12).
The outcome of CBT has been found to be comparable
with pharmacological interventions, but with more durable effects of CBT (4, 13). Many patients with SP,
however, do not respond to CBT, and the proportion of
patients who drop out during treatment is high (10–20%)
(9, 10, 14). When drop-out rates are included, clinical
trials suggest that 40–50% of patients with SP show
little or no improvement after CBT (8, 9, 15). Because
of this, there has been an upsurge of interest in prognostic patient variables in CBT for SP. Empirical studies
on patient variables relevant for prediction of risk of dropout or low benefit from treatment seem to be both theoretically and clinically informative. Knowledge about
which clients are likely to fail in therapy, and why they
would do so, might help in modifying treatment strategies and in delineating critical variables for matching
clients to the most suitable treatment programme (16).
In their declaration on evidence-based practice in psychology, the American Psychological Association (17)
suggests that studies of patient characteristics as moderators of treatment response should be among future
research priorities. Predictive patient variables associated
with outcome in a specific treatment might imply that
the variables are functioning as moderators even though
no formal test of patient×treatment interaction (e.g. 18)
has been performed.
Zaider & Heimberg (19), Rodebaugh et al. (10) and
Lincoln et al. (20) have reviewed the literature on predictors of response to CBT for SP, although neither of
these are systematic reviews with comprehensive literature search reported in the articles.
The aim of this study is to conduct a systematic literature review of pre-treatment patient variables associated
with the outcome of and drop-out from CBT in the treatment of SP.
Method
Search strategies
Journal articles were located in PsycINFO, Embase and
PubMed from the beginning of the databases to November
2008. Meta-analyses and literature reviews were excluded
in the search in PsychINFO. The keywords were (SP or
social anxiety disorder) and (cognitive behaviour therapy
or patient drop-outs or predictor variables or prognosis or
2
treatment outcomes). The databases descriptors were used
when possible. In addition, the articles located were
inspected for further relevant references.
Inclusion criteria
Studies included in the review examined pre-treatment
patient variables as predictors of drop-out rate and/or
treatment outcome in CBT. The inclusion criteria were:
(a) published studies (b) in English, German or French
language (c) that examined pre-treatment patient variables
as predictors of outcome and/or drop-out in (d) CBT, e.g.
cognitive therapy, social skills training, exposure therapy,
or applied relaxation with (e) adult patients (r18 years)
with (f) a formal diagnosis of SP (DSM-III or later version) and (g) a sample size of at least 60. With a sample
size of 60 and a moderate effect size (r0.30), the power
of a study conducting correlation analysis is 0.65
(A0.05, two-tailed) (11).
Excluded were dissertation abstracts, and studies
where different treatment conditions other than CBTs
(e.g. medication) were aggregated in the analyses, unless
controlling for differential effects of the predictors in the
respective conditions.
Data analysis
The varied statistical procedures used in the studies do
not allow for the calculation of a pooled effect size for
the degree of association between variables. Therefore,
the box-score method with counts of statistical significant results is used. Most of the studies predicting outcome used several dependent variables and/or performed
several statistical analyses on the same variable without
statistical correction. In these cases, it was decided to
count a result as substantial supportive evidence if at
least half of the investigated associations were significant. The results are also expressed as the means of the
percentages of the examined associations within each
study that were statistical significant. Associations in the
opposite direction of the general trend in the studies
were subtracted in these calculations. Data are analysed
separately for prediction of drop-out and for prediction
of treatment outcome. With regard to treatment outcome,
a distinction is made between prediction of 1) end-state
functioning or responder status on outcome measures
after treatment or at follow-up (if the authors only
reported a group effect in an ANOVA analysis without a
post hoc analysis regarding post-treatment differences,
the result was not incorporated in the analysis of endstate functioning), and 2) degree of change or improvement from pre- to post-treatment or from pre-treatment
to follow-up. Decline in symptom level measured over
the course of treatment by statistical growth trajectories
(e.g. hierarchical linear modelling) is categorized as
degree of improvement.
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PREDICTIVE VARIABLES
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Results
The three literature searches in PsycINFO, Embase and
PubMed yielded 268, 715 (627 further hits not located in
the PsycINFO search) and 580 (355 further hits not
located in the PsychINFO or Embase searches) hits,
respectively. After inspection of abstracts, 46 articles were
retrieved for more detailed evaluation from PsycINFO,
30 additional articles from Embase, 16 additional articles
from PubMed and three articles were located from reference lists. Of these 95 references, 67 were excluded and
28 included in the review, with 16 studies examining predictors of drop-out (Table 1) and 25 predictors of treatment outcome (Table 2). Tables 1 and 2 are only published
in the online version of the journal at URL: http://www.
informahealthcare.com/10.3109/08039480903426929. A list
of excluded studies is also available online.
Altogether, the studies included 2927 patients. In most
of the studies reviewed, at least one of the treatment formats administered was group CBT using the protocol of
Heimberg and colleagues (e.g. 21) or a similar protocol
(e.g. comprehensive CBT which includes social skills
training; 22, 23). Almost half of the studies used more
than one treatment condition, e.g. including both individual and group therapy. All studies but one (24) incorporated some form of exposure exercises in the treatment.
All studies used DSM-III-R or a later edition of DSM.
Comorbidity
DEPRESSION AND DEPRESSIVE SYMPTOMS
Drop-out. Three studies in Table 1 examined if a diagnosis
of major depressive disorder (MDD) predicted drop-out
Table 1. Studies examining pre-treatment patient variables as predictors of treatment drop-out.
Study
n
Mersch et al. 1989 (44)
74 Severity (PAS, SIB, SCL-90, FQ, Clinician rated avoidance); Rational cognition (RBI
and self-statements test); Behavioral test (SSIT)
Brown et al., 1995 (36)
Safren et al., 1997 (35)
van Velzen et al.,
1997 (27)
63 APD (PDE); Subtype (GSP vs. NGSP)
113 Treatment expectancy after the first session (RTC)
93 APD; Number of PD diagnosis r2; Severity (social anxiety and depressive symptoms
); Additional anxiety or mood disorders; Treatment expectations (the scale is not
reported); Demographic variables (Age, Gender, Marital status, Education,
Employment Status, Duration of complaints, Previous treatment received);
Psychotropic medication use
113 Pattern of anxious arousal in anticipation of and during exposure (BAT)
Coles & Heimberg,
2000 (48)
Mennin et al., 2000 (41)
Erwin et al., 2002 (30)
Erwin et al., 2003 (25)
Rosser et al., 2003 (28)
Rosser et al., 2004 (46)
Herbert et al., 2005 (45)
Ledley et al., 2005 (22)
Lincoln et al., 2005 (20)*; ;
Hofmann & Suvak,
2006 (26)
McEvoy, 2007 (29)
Huppert et al., 2008 (23)
Predictor variables tested (measures)
75 Comorbid GAD
118 Baseline severity (outcome measures); Comorbid mood disorder (DSM-III-R/DSM-IV);
Comorbid anxiety disorder (DSM-III-R/DSM-IV)
68 Anger experience and expression (STAXI): State anger, Trait anger, Angry
temperament, Angry reaction, Anger-In, Anger-Out, Anger control.; Demographic
variables (gender, marital status, education, race and age); Baseline severity (SIAS,
SPS, BFNE); Trust (RAAS-DEPEND); Quality of life (QOLI); Depressive symp.
(BDI)
61 Age; Neuroticism (EPQ-N); Depressive symp. (DASS-D); Severity (SPS, SIAS)
133 Antidepressants medication
65 Demographic characteristics (Marital status, Race, Education, Gender, Age)
279 Depressive symptoms (BDI, HRSD); Severity (BSPS)
217 Demographic characteristics (Age,, Age of onset, Prior treatment experience, Gender,
Marital status, Educational level); Severity (patient rated impairment, CSR,
SCL-GSI, SCL-IS, BSQ, BAI, Number of feared situations, Total anxiety on the
ADIS-R); Comorbid disorders (ADIS-R, BDI, HZI, ACQ, MI-A, WI); Chronic
health problems; Alcohol use (MALT-S); Use of benzodiazepines
133 Demographic characteristics (Age, Sex, Years of education, Family income, Ethnicity
and Marital status); Severity (SPAI-SP and CSR); Subtype (GSP vs. NGSP);
Depressive symptoms (BDI ); Depression (DSM-IV criteria); Number of additional
Axis I diagnoses; Personality disorder traits (PDQ-4); Attitudes towards treatment
(three Likert-type ratings)
153 Severity (SPS, SIAS), depressive symptoms (BDI), medication use, education,
employment status, marital status, age, sex,
252 APD (DSM-IV)
Predictors of drop-out
−RBI; SCL-90; FQ;
Clinician rated
avoidance
NSF
NSF
NSF
NSF
NSF
NSF
Trait anger, Anger
reaction and Angry
temperament
−Severity (SPS, SIAS)
NSF
Gender (female); −Age
BDI, HRSD
MI-A
1 of 3 ratings of attitudes
towards treatment−
Gender (females); −Age
NSF
Note. See Appendix for the denotations of the abbreviations of measures. For the denotations of the other abbreviations, see note for Table 2. If treatment
duration is not reported, it is estimated on the basis of number of sessions. Drop-outs are associated with a higher score on the predictor variable if the
opposite is not indicated by a minus. *Used Bonferroni adjustment (P v0.002).
NORD J PSYCHIATRY· EARLY ONLINE· 2009
3
A ESKILDSEN ET AL.
(25–27) and seven studies (20, 22, 25–29) examined pretreatment level of depressive symptoms as a predictor of
drop-out. Only one of the seven studies (22), a large (n279)
and well-conducted study, found a significant difference
with drop-outs reporting more depressive symptoms.
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Outcome. Three studies in Table 2 examined MDD as a
predictor of outcome (29–31) and nine examined level of
depressive symptoms (15, 20, 22, 28, 29, 32–35). Only one
(30) of two studies (+31) specifically focusing on MDD
found a substantial, negative association with end-state
functioning at post-treatment, and no such associations were
found at follow-up (45% and 0% significant findings,
respectively). No associations were found with regard to
improvement at post-treatment or at follow-up in the three
studies (12% significant findings for the two data points
combined—NB, in the positive direction, i.e. more
improvement among patients with MDD).
For degree of depressive symptoms four (15, 22, 33,
35) of six (+28, 32) studies found an association with
lower end-state functioning at post-treatment (60% significant findings), and none of two (32, 33) at follow-up
(10% significant findings). With regard to degree of
improvement, depressive symptomatology predicted less
improvement in four (15, 20, 22, 33) of seven studies
(+29, 32, 34) at post-treatment, and in two (20, 33) of
four (+15, 32) at follow-up (34% and 48% significant
findings, respectively). In summary, there is some evidence that an MDD diagnosis or the degree of depressive symptoms is negatively influencing post-treatment
end-state functioning after therapy. The association
between depression and improvement is less consistent
with some studies (29–31) even finding MDD or depressive symptomatology associated with more improvement.
AVOIDANT PERSONALITY DISORDER
Drop-out. Three studies in Table 1 examined if avoidant
personality disorder (APD) predicted drop-out from CBT
(27, 36, 37), and one (26) examined APD traits. None of the
four studies found that APD or APD traits had any influence
on drop-out.
Outcome. Six studies in Table 2 examined APD (24, 27,
33, 36–38) and two APD traits (15, 32) as predictors of
treatment outcome. APD/APD traits predicted lower endstate functioning at post-treatment in two (24, 33) of six
studies (+(15, 27, 32, 36), and in two (24, 33) of five studies
(+15, 27, 32) at follow-up (37% and 45% significant findings,
respectively). APD/APD traits predicted less improvement
in two (24, 33) of the eight studies at post-treatment, and in
none of six studies (15, 24, 27, 32, 33, 38) at follow-up (12%
and 0% significant findings, respectively). Thus, although
some studies suggest that APD/APD traits predict lower
end-state functioning at post-treatment and follow-up, there
is no evidence that it has any influence on improvement.
4
OTHER PERSONALITY DISORDERS AND MALADAPTIVE
PERSONALITY TRAITS
Drop-out. One study in Table 1 (27) examined multiple
(more than one) personality disorder (PD) diagnoses, and
one (26) PD traits as predictors of drop-out. None of the two
studies found any association between PD/PD traits and
drop-out.
Outcome. Four studies in Table 2 investigated PD or PD
traits, other than APD, as predictive variables (15, 27, 32,
39), three studies investigated perfectionist personality traits
(28, 34, 40), one (34) dependent personality traits, and one
(28) neuroticism; in all cases with no substantial findings.
COMORBID ANXIETY DISORDERS
Drop-out. Four studies in Table 1 examined comorbid
anxiety disorders as predictors of drop-out (26, 27, 30, 41)
with no statistical significant results.
Outcome. Two studies in Table 2 (29, 30) examined the
influence of comorbid anxiety disorders on outcome, one
study (41) the influence of generalized anxiety disorder, and
one study (27) the influence of both anxiety and mood
disorder diagnoses. None of the studies found any substantial
associations.
OTHER COMORBID DIAGNOSES
Drop-out. Two studies in Table 1 (20, 26) examined the
relationship between the number of comorbid Axis I diagnoses and drop-out with no statistical significant results.
Outcome. Two studies in Table 2 examined alcohol
problems (20, 29) and one substance abuse (42) with no
significant findings. One study (20) examined the influence
of miscellaneous comorbid diagnoses (measured on different
scales) on degree of improvement with only four of 28
significant findings (including depressive symptomatology
[covered in the analysis above]; agoraphobic cognition;
hypocondriasis).
Symptomatic severity
GENERAL SYMPTOMATIC SEVERITY
Symptomatic severity covers somewhat different concepts
and scales in the different studies, e.g. level of social
anxiety and avoidance; clinician rated global severity; or
scores on general symptom scales like the General Symptom Index of the SCL-90 (43).
Drop-out. Nine studies in Table 1 (20, 22, 25–30, 44)
examined if baseline symptomatic severity predicted drop-out.
Seven studies did not find a significant difference in severity
between drop-outs and completers, and two found opposing
results, i.e. in one study (44) drop-outs were more impaired at
baseline, while in the other (28) they were less impaired. Thus,
NORD J PSYCHIATRY· EARLY ONLINE· 2009
NORD J PSYCHIATRY· EARLY ONLINE· 2009
Van Velzen et al., EXP (93, SP)
1997 (27)
CBGT (113, SP)
12 weeks
(6 months)
CBGT (62, SP)
Safren et al.,
1997 (35)
12 weeks
CBGT (91, SP)
Leung &
Heimberg,
1996 (49)
Chambless et al.,
1997 (32)
10 weeks
(3 months)
12 weeks
4 days or
8 weeks
(3-months)
BGT (60, GSP)
Feske et al.,
1996 (33)
12 weeks
CBGT (63, SP)
Duration of trial*
(Follow-up)
Brown et al.,
1995 (36)
Study
Type of treatment
(n, patients)
Number of PD diagnosesr2 (SCID-II);
APD; Additional anxiety or mood
disorders (ADIS-R)
Treatment expectancy after the first
session (RTQ); Severity (outcome
measures): Depressive symptoms
(BDI, HRSD)
Depressive symptoms (BDI);
Expectancy (TES); Personality
disorder traits (MCMI); Social
impairment (GISDS); Medication
use
Locus of control (LOCS)
APD (SCID-II); Depressive symptoms
(BDI)
APD (PDE); Subtype: GSP vs. NGSP
(ADIS-R)
Predictor variables (Measures)
Predictors of improvement
Three composite variables
(1. Avoidance; 2. Cognition;
3. Target situations). BDI
[MANOVA; C2 ]
Factor-analytical derived
variables: 1. Anxious
apprehension; 2. Dyad
anxiety and skill; 3. Speech
anxiety; 4. Speech skill; 5.
Observed rated anxiety and
skill [CorRes; Mregress:
Expectancy, Medication,
APD traits OR Depressive
symptoms]
CSR; SIAS; SPS; LSAS-I;
LSAS-P; FQ-SP; BDI;
HRSD [8 Mregress:
1. Pre-treatment severity; 2.
RTQ]
Pre/post: NSF. Pre/follow-up:
NSF
Pre/post: NR
Pre/post: −Depressive symptoms
(1/5); +Expectancy (1/5);
−APD-traits (1/5); −OCDtraits (1/5); −Medication use
(1/5). Pre/follow-up:
−Depressive symptoms (2/5);
+Expectancy (1/5); −Histrionic
PD traits (1/5)
(Continued)
Post: +Expectancy (6/8);
−Severity (6/6);
−Depressive symp (2/2)/
pre-treatment level of
depressive symptoms
predicted post-treatment
level of depressive
symptoms
Post: −PDr2 (1/4; BDI).
Follow-up: −APD (1/4)
Post: −APD traits (1/5).
Follow-up: −Medication
use (1/5); +Expectancy
(1/5); −Depressive
symptoms (1/5)
Post NSF
Post: −APD (2/2).
Follow-up: −APD 2/2
Post: −Subtype (4/4)
Predictors of end-state
Results (Quotients of significant associations)/Comments
3 sets of dependent variables: 1. Pre/post: NSF
Questionnaires (SADS; FNE;
FQ-SP; SIAS; SPS; CSAQ;
and BDI); 2. Behavioral test
measures (SUDS ratings and
STAI-S); 3. Independent
assessor measures (LSAS).
Responder status (CGI)
[MANOVA; ANOVA; C2]
STAI-T; BD;, SAS-SR; GRAI; Pre/post: −APD (1/2);
and PSS. SPAI [in a separate
−Depressive symptoms (1/2).
analysis] [MANOVA;
Follow-up: −Depressive
ANOVA; (M)ANCOVA with
symptoms (2/2)
BDI as the covariate]
SIAS [Mregress: 1. Prior SIAS; Pre/post: NR
2. LOCS]
Criterion variables [Statistical
methods]
Table 2. Studies examining pre-treatment patient variables as predictors of treatment outcome.
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PREDICTIVE VARIABLES
5
6
CBGT (75, SP)
CBT/CBGT (71,
SP)
CBGT (84, GSP)
Mennin et al.,
2000 (41)
Stangier et al.,
2001 (38)
Cox et al., 2002
(34)
12 weeks
(6 and
12 months)
NR
15 weeks
(6 months)
12 weeks
12 weeks
Duration of trial*
(Follow-up)
24 weeks
MDD
CBGT/EXPG/
Waiting list
(90, SF)
CBT (70, SP)
Joormann et al.,
2005 (31)
Age
CBGT (133, SP)
Rosser et al.,
2004 (46)
Hofmann, 2004
(61)
12 weeks
(6 months)
Antidepressant medication
CBGT (61, SP)
Predictors of improvement
Pre/post: NSR. Pre/follow-up:
NSR
Pre/post: NSF
MI-Alone; MI-Acc.; FNE;
Pre/post: +MDD (1/10)
PERI-D; BDI [ANOVA; HLM]
DASS-depression; SPS; SIAS;
FNE; SF-12 [ANOVA]
SPAI, SCQ, speech length on
a BAT [MANOVA]
Post: −MDD (4/10)
Post: NR. Follow-up:
NR
Post: NSF
Post: −Severity (1/1)
Post: −State anger (3/4);
−Anger-in (3/4); −Angry
reaction (3/4); −Trait
anger (1/4)
Pre/post: NR
Pre/post: NR
Post: −APD (2/2)
Follow-up: −APD (4/4)
Post: −Comorbid mood
disorders (2/4). Follow-up:
−Comorbid anxiety
disorders (1/4)
Post: NR
Pre/post: −APD (1/2). Pre/
follow-up: NSF
Pre/post: +Comorbid mood
disorders (1/4 /Larger change
on BDI). Pre/follow-up:
+Comorbid mood
disorders(1/4) /Larger change
on BDI
Pre/post: +Baseline severity/
social phobia composite (1/1)
Post NSF
Post: NSF
Post: −Patterns of anxious
arousal (2/4) /lower
end-state functioning in
the high anxiety groups
Predictors of end-state
Results (Quotients of significant associations)/Comments
SIAS; SPS; LSAS-FI; LSAS-FP; Pre/post: +Patterns of anxious
LSAS-A; LSAS-AP; CRC;
arousal (2/9)/Higher degree of
Thought Listing (pos. and
change in the high anxiety
neg.); BDI; Responder status;
groups
Proportion of patients no
longer meeting diagnostic
criteria. [ANOVA; C2]
CSR; SPS; SIAS; LSAS-P;
Pre/post: +GAD (1/5)
LSAS-I; Responder status
(CGI) [ANOVA; C2]
SPAI; SCL-GSI [ANCOVA]
Pre/post: NSF
Criterion variables [Statistical
methods]
Baseline severity (a composite of FNE, A composite of FNE; SADS;
SADS, SPS, SIAS, SPAI);
SPS: SIAS; SPAI-SP; FQ-SP
Interpersonal dependency (DEQ);
[Mregress: BDI; DEQ; Social
Perfectionism/self-criticism (DEQ);
phobia composite]
Depressive symptons (BDI)
Comorbid mood disorder (ADIS-III3 sets of dependent variables: 1.
R/-IV); Comorbid anxiety disorder
Independent assessor
(ADIS-III-R/-IV)
measures on ADIS(CSR) and
LSAS; 2. Self-report measures
SIAS,;SPS; FQ-SP; FNE; and
3) 4 SUDS ratings in BATs.
BDI [MANOVA, C2]
APD (SCID-II)
LSAS-AX; LSAS-AV
[Residualized] [2 Mregress: 1.
treatment condition; 2. APD]
Anger experience and expression
BFNE; SIAS; SPS; BDI [4
(STAXI): State anger; Trait anger;
Mregress: 1. pre-score on
Angry temperament; Angry
outcome measure;
reaction; Anger-In; Anger-Out;
2. STAXI-subscales]
Anger control
Neuroticism (EPQ-N); Depressive
The mean standardized score on
symptoms (DASS-D); Severity
the SPS and SIAS [Mregress:
(SPS, SIAS); Perfectionism:
1. severity; 2. DASS_D;
Concern over mistakes (MPS-F-C)
EPQ-N; 3. MPS-F-C]
APD (SCID-II)
Comorbid GAD (ADIS-R)
Patterns of anxious arousal in
anticipation of and during exposure
in a BAT (4 groups based on
hierarchical cluster analysis)
Predictor variables (Measures)
Rosser et al.,
2003 (28)
7 weeks
CT, moclobe-mide 15 weeks
or placebo
(2 and
(82, SP)
15 months)
Erwin et al., 2003 CBGT (68, SP)
12 weeks
(25)
Oosterbaan et al.,
2002 (24)
Erwin et al., 2002 CBGT (118, SP)
(30)
CBGT (90, SP)
Coles &
Heimberg,
2000 (48)
Study
Type of treatment
(n, patients)
Table 2. (Continued)
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CBGT (153, SP)
CCBT and/or
fluoxetine/
placebo.
(252, GSP)
CBT/CBGT (200,
anxiety
disorders; 82,
SP)
McEvoy, 2007
(29)
Huppert et al.,
2008 (37)
NR
14 weeks
7 weeks
12 weeks
16 weeks
Predictors of improvement
SPS; SIAS [Mregress: 1.
Prescores on outcome
measures; 2. DASS-21; 3.
FMPS subscales]
SPS; SIAS; BDI [t-test]
Substance abuse
DASS [MANOVA]
Depression (BDI 17); Age (49
years); Comorbid anxiety; Comorbid
depression; Alcohol problems;
Being a student
APD (SCID-II)
BSPS; CGI [ANOVA; ITT and
completer analyses]
Perfectionism (FMPS); Negative affect
(DASS-21); Severity (SPS; SIAS)
Post: NR
Post: −Severity (2/2);
−Negative affect (2/2)
Pre/post: NSF
Post: NR
Pre/post: NSF/Patients with APD
Post: NR
improved more from weeks 0–4
Pre/post:+BDI17 (1/3)/Larger
change on BDI
Pre/post: NR
Follow-up: NR
Post: NR; Follow-up: NR
Post: −Depressive
symptoms (3/4)
Predictors of end-state
Results (Quotients of significant associations)/Comments
BSPS; CGI (ITT and
Pre/post: −Depressive symptoms
completer analyses) [ANOVA; (1/2)/BDI but not HSRD
t-test]
Demographic data (Age; Age of onset;
SCL-IS [Residualized]; RGI
Pre/post: −Severity (2/10);
Prior treatment experience; Gender;
[Cor]
−Number of feared situations
Marital status; Educational level);
(1/2); −Total anxiety (1/2);
Severity (degree of impairment
−Comorbidity (2/14; BDI:
[patient rated and clinician rated];
1/2). Pre/follow-up:
SCL-GSI, BSQ, BAI); Number of
+Demographic variables
feared situations; Total anxiety
(3/14)/Female, marriage,
(ADIS); Comorbid disorders (ADIS-R,
education; −Severity (2/10);
BDI, HZI, ACQ, MI-A, WI); Chronic
−Number of feared situations
health problems; Alcohol use
(2/2); −Total anxiety (2/2));
(MALT-S); Use of benzodiazepines
−Comorbidity (2/14; BDI: 1/2)
Erythrophobia vs. tremophobia; PD
BTSQ; SPAI, FQ; SCL-90-IS;
Pre/post: NSF
(SCID-II); Prior treatment
FNE-short version; SFA;
CCM [MANOVA]
Depressive symptoms (HRSD,
BDI); Severity (BSPS)
Predictor variables (Measures)
Criterion variables
[Statistical methods]
Notes. General: A “−” denotes that a higher score on the predictor variable is associated with less improvement or lower end-state functioning, and a “+” denotes an association in the opposite direction;
NR denotes that no data are reported; BAT, Behavioral Activation Test; CRC, Clinician rated change; NSF, No significant findings.
Diagnoses: APD, avoidant personality disorder; PD, personality disorders; GAD, generalized anxiety disorder; MDD, major depressive disorder; OCD, obsessive–compulsive disorder; SP, social phobia.
Treatments: AR, applied relaxation; BT, behaviour therapy; BGT, behaviour group therapy; CBT, cognitive behavioural therapy; CBGT, cognitive behavioural group therapy; CCBT, comprehensive
cognitive–behavioural therapy; CT, cognitive therapy (without behavioural methods); EXP, exposure; EXPG, exposure treatment in groups; TCT, task concentrations training.
Measures: Abbreviations of measures are explained in Appendix A.
McEvoy &
Shand,
2008 (42)
Duration of trial*
(Follow-up)
CCBT and/or
14 weeks
fluoxetine/placebo
(279, GSP)
Intensive CBT
7 days; post(217, SP)
assessment
conducted
6 weeks after
treatment began
(1 year)
Bögels, 2006 (39) TCT+CBT or
AR+CBT
(65, SP with
fear of bodily
symptoms)
Ashbaugh et al.,
CBGT (107, SP)
2007 (40)
Lincoln et al.,
2005 (20)
Ledley et al.,
2005 (22)
Study
Type of treatment
(n, patients)
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PREDICTIVE VARIABLES
7
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A ESKILDSEN ET AL.
the existing studies seem to imply that baseline symptomatic
severity does not influence drop-out rate.
Expectancy
Drop-out. Three studies in Table 1 (26, 27, 35) examined
Outcome. Seven studies in Table 2 examined the role of
treatment expectancy or patients’ attitudes toward treatment
as predictors of drop-out, but only one (26) found statistical
significant results for one of three variables.
symptomatic severity in predicting treatment outcome (15,
20, 22, 28, 34, 35, 40). All four studies (15, 28, 35, 40)
examining severity’s role in predicting end-state functioning
after treatment found that higher severity before treatment
predicted higher severity after treatment on all outcome
measures; and the same result was found for one study (15)
with regard to follow-up (only one study (15) controlled for
baseline scores on the dependent variables). Four studies
(15, 20, 22, 34) investigated severity’s role in predicting less
improvement with two studies finding significant associations
in opposite directions, one positive (34) and one negative
(15), at post-treatment, and no association in two studies
(15, 20) at follow-up (7% and 21% significant findings,
respectively). In summary, there is consistent evidence that
pre-treatment symptomatic severity predicts symptomatic
severity after therapy, but no evidence that it predicts degree
of improvement.
SP SUBTYPES
Drop-out. Only one study in Table 1 (36) compared
generalized SP with non-generalized SP and found no
significant differences in drop-out rate between the groups.
One study (20) categorized clinician rated degree of anxiety
and number of feared situations under the heading of
“Subtypes”, but in this review, the two variables are
considered measures of symptomatic severity.
Outcome. The same study was also the only one to examine
SP subtypes as predictors of treatment outcome. Patients
with generalized SP were more severely disturbed on all
outcome measures before and after therapy and more
patients with non-generalized SP were classified as treatment
responders (clinician rated) compared with the group of
generalized SP. No differences were found with regard to
improvement on outcome measures, however.
Demographic variables
Drop-out. Six studies in Table 1 (20, 26, 27, 29, 30, 45)
examined the role of demographic variables (age, age of
onset, prior treatment experience, gender, marital status,
educational level, family income, ethnicity, and employment
status) in the prediction of drop-out. Two studies (29, 45)
found significant associations in that younger and female
patients were more likely to drop out.
Outcome. The one study in Table 2 (20) examining demographic variables as predictors of outcome found no significant associations between such variables and improvement
from pre- to post-treatment. At 1-year follow-up, females,
married patients and patients with higher education were
more improved on one of two outcome measures.
8
Outcome. Two studies in Table 2 (32, 35) investigated the
role of expectancy. One study (32) found that expectancy
positively predicted improvement (pre/post-treatment and
pre-treatment/follow-up) in one of five outcome measures,
and the other (35) found that it positively predicted end-state
functioning in six of eight outcome measures (altogether,
i.e. covering end-state and improvement, at post-treatment
and follow-up, 38% significant findings).
Medication use before and during therapy
Drop-out. Three studies in Table 1 (20, 27, 46) examined
if medication use before and during therapy predicted dropout with no significant findings.
Outcome. Three studies in Table 2 (20, 32, 46) examined
the impact of medication use on treatment outcome with no
substantial associations.
Social anxiety-related cognition
Drop-out. One study in Table 1 (44) found that social
anxiety-related cognition in relation to a behavioural activation test (BAT) predicted drop-out on one of two measures.
Outcome. One study in Table 2 (15) found no associations
between the frequency of positive and negative cognition in
social situations at pre-treatment and end-state functioning
or improvement from pre- to post-treatment or from pretreatment to follow-up.
Anger
Drop-out. One study in Table 1 (25) found that drop-outs
endorsed a greater disposition to experience and express
anger on three of seven scales of the State–Trait Anger
Expression Inventory (47).
Outcome. The same study found that three of seven
measures of anger predicted three of four measures of endstate functioning, while one additional measure of anger
predicted one measure at post-treatment.
Patterns of anxious arousal
Drop-out. One study in Table 1 (48) examined patterns of
anxious arousal during a BAT and classified patients into
four groups: “high anxiety”, “increasing/high anxiety”,
“moderate anxiety” and “mild anxiety”, according to their
responses to eight SUDS probes during the BAT. No
association was found between patterns of anxious arousal
and drop-out during treatment.
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PREDICTIVE VARIABLES
Outcome. The same study also examined the predictive
value of patterns of anxious arousal on treatment outcome.
A significant association was found between lower anxious
arousal before treatment and higher responder rate after
treatment on two of four measures and between higher
anxious arousal before treatment and more improvement
during therapy on two of nine measures.
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Miscellaneous variables
Studies have examined several other pre-treatment patient
variables as predictors of drop-out or treatment outcome,
but failed to find significant results: Social impairment
(Table 2; 32); trust and quality of life (Table 1; 25);
chronic health problems (Tables 1 and 2; 20); negative
affect (Table 2; 40) and locus of control (Table 2; 49)
(see Tables for information on the studies).
Discussion
More than 15 years after Steketee & Chambless (16,
p. 390) declared prediction research “a stepchild to
behavioural outcome research”, the field has witnessed an
increased attention with more than 60% of the studies in
this sample being from 2000 or later. There are, however,
still rather few studies, and their divergent variables and
methods limit any conclusions to be drawn from them.
Almost no pre-treatment patient variables predicted
drop-out from CBT for SP in the reviewed studies. This
result is in line with conclusions from other reviews that
the psychotherapy termination literature in general is
considered inconclusive (50).
Only a few variables predicted outcome. MDD or
depressive symptoms prior to therapy were associated
with lower end-state functioning after therapy, but only
inconsistently with less improvement during therapy.
Correspondingly, APD or APD symptomatology was in
some studies associated with lower end-state functioning,
but not with less improvement. Comorbidity with other
disorders, e.g. other anxiety disorders, substance abuse,
PD or PD traits was not found to be associated with outcome in the studies. Treatment expectancy and anger
expression showed promising results in a few studies.
The only consistent finding in this review was that prior
symptomatic severity predicted lower end-state functioning
after therapy and at follow-up, although it was not associated with degree of improvement. This finding is in line
with Rodebaugh et al.’s (10) conclusion, that more disturbed patients with SP (including patients with generalized
SP and APD) both begin and end treatment at a higher
symptomatic level, but with a similar degree of improvement as less disturbed patients; as well as with conclusions
on predictor variables in CBT for other anxiety disorders
(e.g. 51, 52). This conclusion might also cover the findings
regarding depression and APD in this review.
From a positive point of view, the few prognostic factors in CBT for SP might be interpreted as indicating
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that even severely disturbed SP patients could profit from
short time CBT, although severely disturbed patients
might not achieve end-state functioning close to normality.
The finding of few prognostic factors should, however,
be interpreted on the background of the restricted range
of severity/comorbidity in most studies. Few clinicians
doubt that e.g. severe depression, severe substance abuse
or severe personality disorders, would highly impede
treatment for patients with SP.
Research on predictor variables in psychotherapy is a
challenging field, conceptually and methodological. Conceptually, many of the relevant variables of predictors, as
well as of outcome, could be supposed to load highly on
negative affect(ivity). Thus, the dependent variables might
be contaminated by the independent. It should come as
little surprise that symptomatic severity before treatment is
associated with severity after treatment. The association
between pre-treatment severity and improvement or degree
of change might be influenced by regression towards the
mean. This is taken into account in most studies by using
residual change scores or firstly entering pre-treatment
scores in the regression analysis but in case of predictor
variables loading on negative affect, residual change
scores partly correct for the predictors of interest. Besides,
if there is no association between pre-treatment variables
loading on negative affect and improvement, this might be
related to a combination of two forces drawing in different directions, namely regression towards the mean and
less responsiveness among severely disturbed patients. The
problem is a common one in psychological research with
variables characterized by loose boundaries and conceptual
and/or measurement overlap (cf. 53).
Optimally, the study should try to disentangle the specific contribution of the predictor variable after taking negative affect into account, which was only attempted in a few
of the studies. Thus, in two studies on perfectionism with
a similar design (28, 40), pre-treatment scores on the outcome variable was firstly entered in the regression analysis,
secondly measures of negative affect, and then, thirdly, the
perfectionism dimensions of interest. Perfectionism was not
found to be a specific predictor in these studies.
As in all psychotherapy research, the power problem is
a serious one. The correlations between predictors and
outcome are mostly small to moderate demanding large
samples to achieve acceptable power (nr200 if r0.2, and
power0.8 in a correlation analysis). Only three studies
in the sample had n200. Exclusion of severe cases in
controlled studies will narrow the range in many relevant
predictor variables (e.g. severity and comorbidity) thus
lowering the chance of significant findings. Comparing
groups of unequal size further reduces power, which is a
highly relevant concern with studies of drop-outs, and
with dichotomous predictors, e.g. comorbid diagnoses. If
e.g. the expected drop-out rate is 20% (a high percentage
according to prior studies), a sample of at least 200 is
9
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A ESKILDSEN ET AL.
needed for an 80% chance of finding a difference between
drop-outs and completers if the population difference is
moderate (d0.50; A0.05, two-tailed) (11). Consequently, it is not surprising that a high proportion of the
studies had statistically insignificant findings.
Further research would profit from large, naturalistic
studies with a high degree of variability in the relevant
predictor variables. Study samples could be enlarged by
cooperation between research centres. Some strategies,
now widely recommended for outcome research (54, 55),
might also help to promote the field, namely to use one
primary measure of outcome, and always report effect
sizes for an association (e.g. correlations with end-state
and residual gain score, or d-values). Reporting effect
sizes (or relevant variables for calculating them) would
highly facilitate research syntheses.
Preferably, future studies should include more theoretically derived variables, e.g. related to the proposed subtypes of SP by Hofmann et al. (56). Ultimately, the most
interesting question is, of course, about the relationship
between differentially moderating variables in different
forms of treatments, so-called aptitude–treatment interactions (57). The problems inherent in the much less complex study of predictive variables within one form of
treatment, as exemplified in the present review, might
help in understanding why little progress has been made
in answering this question.
Most probably, prognostic patient variables interact in
complex patterns of causal relationships. With large samples (nc. 300) structural equation modelling (58) could
be used to test specific models of the associations between
different pre-treatment variables and outcome. From quite
another corner of the research landscape, multiple intensive case studies have been suggested as a method suited
for investigation of the complex, idiographic patterns of
patient prognostic variables (59, 60). At present there are,
however, no studies in the field using structural equation
modelling, and few systematic case studies.
The review has some limitations. Thus, only published
studies were included, but most well performed large studies will be published. Because of characteristics of the
studies, it was not possible to use meta-analytic data-synthesis, which is better suited than the box-score method to
take small associations in underpowered studies into
account. By excluding studies with n60, and by using
the criteria for counting results mentioned in the section on
data analysis the review might compensate for one of the
main problems of box score reviews, namely to give undue
weight to findings from small studies. The nature of the
results with very few significant findings, furthermore,
makes it implausible, that more sophisticated data synthesis
methods (if they had been possible) would have resulted
in substantially different conclusions. Anyhow, the review
should be considered an improvement over former, more
impressionistic box score or narrative reviews (10, 20).
10
The most important conclusion from the review is that
there is little clinically or theoretically relevant knowledge to be gained from existing studies of pre-treatment
patient variables as predictors of drop-out and treatment
outcome in CBT for patients with SP. It seems unlikely
that more studies of the same kind would result in a
markedly different conclusion. The field is in need of
conceptual and methodological improvements if more
solid findings should be hoped for.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for
the content and writing of the paper.
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Anita Eskildsen, Cand.psych., Institute of Psychology, Aarhus University,
Nobelparken, Aarhus C, and Clinic of OCD, Aarhus University Hospital,
Risskov, Denmark.
Esben Hougaard, Professor at Institute of Psychology, Aarhus University,
Nobelparken, Aarhus C, Denmark.
Nicole K. Rosenberg, Chief psychologist of Clinic of Anxiety, Aarhus
University Hospital, Risskov, Denmark.
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A ESKILDSEN ET AL.
Appendix
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For personal use only.
Abbreviations of scales
ACQ, the Agoraphobia Cognition Questionnaire; ADIS-R, Anxiety Disorders Interview Schedule-Revised; BAI,
Beck Anxiety Inventory; BAT, Behavioral Assessment Test; BDI, Beck Depression Inventory; BFNE, Brief Fear of
Negative Evaluation; BSPS, the Brief Social Phobia Scale; BSQ, Body Sensation Questionnaire; CGI, the Clinical
Global Impression Scale; CSR, Clinician Severity Rating (ADIS-R or ADIS-IV); CSAQ, the Cognitive–Somatic
Anxiety Questionnaire; DASS-D, the Depression subscale of the Depression Anxiety and Stress Scale; DEQ, the
Depressive Experiences Questionnaire; EPQ-N, Eysenck Personality Questionnaire—Neuroticism Scale; FNE, the
Fear of Negative Evaluation Scale; FQ-SP, the Social Phobia subscale of the Fear Questionnaire; GISDS, the Global
Impairment of Social Domains; GRAI, the Gambrill and Richey Assertion Inventory; HRSD, Hamilton Rating Scale
for Depression; HZI, the Hamburg Obsessive-Compulsive Inventory; LOCS, The Levenson Locus of Control Scale;
LSAS, the Liebowitz Social Anxiety Scale; LSAS-AX, Anxiety subscale of the LSAS; LSAS-AV, Avoidance subscale of the LSAS; LSAS-I, LSAS social interaction subscale; LSAS-P, LSAS performance subscale; LWASQ-B, the
Behavior subscale of the Lehrer-Woolfolk Anxiety Symptom Questionnaire; MALT-S, the Self-evaluation scale of
the Munich Alcoholism Test; MCMI, the Millon Clinical Multiaxial Inventory; MI, the Mobility Inventory; MI-A,
the Alone subscale of the MI; MPS-F, the Multidimensional Perfectionism Scale; PAS, The phobic anxiety scale;
PDE, The Personality Disorders Examination; PDQ-4, the Personality Diagnostic Questionnaire for DSM-IV; PERI-D,
the Demoralization scale of the Psychiatric Epidemiology Research Interview; PSS, the Personal Self Scale of the
Tennessee Self-Concept Scale; QOLI, the Quality of Life Inventory; RAAS-DEPEND, The DEPEND subscale of the
Revised Adult Attachment Scale; RBI, the Rational Behavior Inventory; RGI, The rating of global improvement;
RTQ, Reaction to Treatment Questionnaire; SADS, the Social Avoidance and Distress Scale; SAS-SR, the Social
Adjustment Scale, Self-Report version; SASSI, the Social Anxiety Self-Statements Inventory; SCL-90, The Symptom
Checklist; SCL-D, the Depression subscale of the SCL-90; SCL-GSI, The global severity index of the SCL-90;
SCL-IS, the Interpersonal sensitivity subscale of the SCL-90; SIAS, the Social Interaction Anxiety Scale; SIB, Scale
for Interpersonal Behavior; SPAI-SP, the Social Phobia scale of the Social Phobia and Anxiety Inventory; SPS, the
Social Phobia Scale; SSIT, This test consists of 8 brief social interactions and was used to assess behavioral skills;
STAI-S, the State section of the State–Trait Anxiety Inventory; STAI-T, the Trait section of the State–Trait Anxiety
Inventory; STAXI, the State–Trait Anger Expression Inventory; SUDS, patients provided 0 to 100 anxiety ratings
during a BAT; TES, the 4-item Treatment Expectancy Scale; WI, The Whiteley Index (Hypochondriasis).
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NORD J PSYCHIATRY· EARLY ONLINE· 2009