Pre-treatment patient variables as predictors of drop-out and treatment outcome in cognitive behavioural therapy for social phobia: A systematic review

Abstract

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 n≥60 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.

• Cognitive behavioural therapy
• Drop-out
• Patient variables
• Predictive variables
• Prognostic variables
• Social phobia

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Appendix

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 sub-scale 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).