British Journal ofclinical f'sycholo~(1997), 36, 101-1 19 Printed in Great Britain 101

8 1997 The British Psychological Society

On predicting improvement and relapse in

generalized anxiety disorder following
psychotherapy

Robert C. Durham*
Tayside Area Clinical Psychology Department, Dundee Healthcare NHS Trust, Royal Dundee Lff
Hospital,
Dundee DD2 5NE; UK

ThCrhse Man
Department of Psychiatry, Universtlyof Dundee, Ninewells Hospital and Medical School,
Dundee D D l 9 S x UK

Christine A. Hackett
Scottish Agricultural Stattstics Service, Scottish Cmp Research Instttute, Invergowrie,
Dundee OD2 5DA. UK

This paper concerns an investigation of outcome predictors in a clinical trial of

psychological therapies for generalized anxiety disorder. A variety of information of
potential predictive value was obtained at three stages of patient contact: the initial
referral, a screening interview and early sessions of therapy. Three measures of the
clinical sigdicance of change over a 12-month follow-up period were used to
construct a composite measure which categorized outcome in terms of sustained
improvement, relapse and no consistent change. Logistic regression was used to
examine the validity of predictors identified in previous research and the relative
importance of data obtained from the three different stages. Seventy-one per cent
of patients were correctly classified as improved or not from initial data with a
sigtllficant increase in accuracy with information from the screening interview (77
per cent) and early sessions (82 per cent). Patients who relapsed or not were
predicted with considerable accuracy from initial data (90 per cent) and there was
no significant increase in predictive power with additional information. The most
powerful and robust predictors were: type of treatment received, marital
status, marital tension and complexity of clinical presentation in terms of axis 1
co-morbidity.A conceptual framework for prediction is outlined.

Clinical trials of psychological treatment for generalized anxiety disorder (GAD)

indicate a wide variation in response to therapy (Chambless & Gillis, 1993; Durham
& Allan, 1993).About 50 per cent of patients appear to make clinically significant
improvements, with a cognitive-behavioural approach the most efficacious
* Requests for reprints
102 Robert C.Durham, Thhise Allan and ChristineA. Hackett
treatment to date, but generalized anxiety tends to be a chronic and relapsing
condition (cf. Brown, O’Leary & Barlow, 1993; Rickels & Schweizer, 1990) and the
long-term effects of treatment are unknown. Since psychotherapy is expensive in
therapist time, and trained therapists are a relatively scarce resource, it would be of
considerable value to select for treatment only those people who are likely to benefit
and to match the intensity of treatment to patient need. In this paper we report
an investigation of outcome predictors based on data from a clinical trial of
psychological treatments for GAD. Two broad areas of the clinical literature are of
direct relevance to the search for reliable outcome predictors: epidemiological
investigations of the course of anxiety neurosis and studies based on clinical trials of
psychological therapy with common mental disorders. We begin with a brief overview
of these two fields so as to provide a general framework for the empirical analysis that
follows.

Course of anxiety neurosis

A number of studies suggest that a significant proportion of patients with anxiety
neurosis develop a chronic and relapsing condition with approximately half of
patients reporting moderately severe symptoms at follow-up which has ranged from
4-20 years (cf. Anderson, Noyes & Crowe, 1984; Krieg et a!., 1987; Murphy et al.,
1986; Noyes, Clancy, Hue& & Slymen, 1980; Schapira et al., 1972).More than half
of the patients in these studies resorted to either drug or non-drug treatment for their
anxiety during the follow-up period.
Several studies have investigated the factors associated with good and poor
outcomes. Good outcomes have been found to be associated with a supportive
family life, lower initial severity ratings and a younger age by Huxley, Goldberg,
Maguire & Kincey (1979), with lower initial severity ratings and a better quality of
social life by Mann, Jenkins & Belsey (1981) and with a higher social class and a
briefer duration of symptoms by Appenheimer & Noyes (1987). Other factors found
to be associated with a poorer outcome included receipt of psychotropic medication,
chronic physical illness and financial problems.

Psychotherapy outcome predictors

The search for reliable predictors of psychotherapy outcome has engaged the
attention of many investigators over the years but few findings have been replicated
and the overall results have been disappointing (Garfield, 1994). One of the central
methodological problems has been a restricted range within both the outcome and
the predictor variables. For example, Miller & Berman (1983), in a general review of
the efficacy of cognitive-behavioural therapy, concluded that there was little
evidence that treatment outcome was related to either patient characteristics,
therapist experience or length of treatment. Oakley & Padesky ( 1990), however, in
commenting on this review noted that the participants were predominantly young
and well educated, therapists were generally inexperienced and treatment was
relatively brief.
 On predicting improvement and relapse 103

Another methodological issue of importance has been the sensitivity of multiple

regression analyses to even small variations in sample size and patient characteristics
making cross-validation of findings uncommon. Butler & Anastasiades (1988), for
example, found evidence for three reliable predictors from an analysis of the
outcome results of a trial of anxiety management training with GAD (Butler,
Cullington, Hibbert, Klimes & Gelder, 1987).An analysis of the results of their sub-
sequent study, however, with a very similar patient population and type of treatment,
failed to replicate this pattern (Butler, Fennell, Robson & Gelder, 1991).Despite the
inherent difficulties of this research field some signrficant themes have emerged and
in the remainder of this brief review we focus on three predictors that hold promise
and merit further investigation: expectations of improvement, the quality of the
patient-therapist alliance and the presence of a coexisting personality disorder.
There are good theoretical reasons for assuming that patients’ beliefs and
expectations regarding psychotherapy and its value are likely to be important determi-
nants of outcome (Brewin, 1988).In a recent series of clinical trials of cognitive-behav-
ioural and non-directive therapy with GAD strong correlations between expectancy
and outcome were found across both self-report and assessor-rated outcome
measures (Borkovec & Costello, 1993). It should be noted, however, that expectancy
is a complex construct (Duckro, Bed & George, 1979; Willcins, 1973) and the
evidence overall suggests that the relationship between expectancy and outcome is by
no means strdtforward (e.g. Bloch, Bond, Qualis, Mom & Zimmerman, 1976).
There is a growing body of evidence suggesting that patients with coexisting
personality disorders have more severe psychopathology, a greater vulnerability to
relapse and a poorer response to treatment (Reich & Green, 1991; Tyrer, Casey &
Ferguson, 1991).Beck & Freeman (1990) review several outcome studies suggesting
that the majority of individuals with personality disorder diagnoses respond poorly to
well-established cognitive-behavioural treatments although recent research on GAD
patients found no association between axis 2 co-morbidityand outcome (Sanderson,
Beck & McGinn, 1994).There is clearly a need for further information on this issue
since axis 2 co-morbidity in patients meeting DSM-III-R criteria for GAD is rela-
tively high (Gasperini,Battagha, Diaferia & Balladi, 1990).
Finally, measures of the ‘helping alliance’ between patient and therapist, using
both questionnaires and observer ratings, have been shown to yield significantly
higher correlations with the outcome of psychoanalytically based therapy than other
variables (e.g. Alexander & Luborsky, 1984; Morgan, Luborsky, Curtis & Solomon,
1982).Curiously, although the therapist’s ability to deliver the ‘non-specific’qualities
inherent in collaborative therapeutic relationships is frequently cited as an essential
ingredient for effective cognitive-behavioural therapy, especially the cognitive
therapy component (cf. Brown, O’Leary & Barlow, 1993) there has been little
empirical investigation of relationship factors in cognitive-behavioural treatment.

General conclusions from previous studies

Accurate prediction of chcally signhcant changes in GAD following psychological
treatment is likely to require a combination of both general prognostic factors-of
104 Robert C. Durham, ThhkseAlhn and Christine A. Hackett
anxiety neurosis as a whole-and more specific variables related to the context and
demands of the treatment process itself. At the end of this paper we speculate on the
relative importance of these two sets of factors and present a broad conceptual
framework for outcome prediction.
From a research point of view the above considerations do have some clear
implications for an appropriate methodology. While some variables can be measured
simply and accurately on the basis of questionnaires or information from referral
letters, others, such as the quality of social supports or complexity of clinical
problems, may require more complex strategies involving structured interview.
Still others can only be assessed once treatment has started. A comprehensive
investigation of outcome prediction, therefore, will necessitate collecting
dormation of varying degrees of complexity at several stages of contact with the
patient. It is with the relative importance of information collected at these different
stages that the study reported in this paper is principally concerned.

Aims of present study

In this paper we report an investigation of outcome predictors based on data from a
clinical trial of psychological treatments for GAD (Durham et al., 1994).A variety of
information of potential predictive value was obtained at three stages of contact with
the patient: ( I ) initial referral letter and postal questionnaires, (2) screening
interview with an independent assessor, and (3) the early sessions of therapy.
Measures of the clinical significance of outcome over the 12-monthfollow-up period
were used to construct a composite index of outcome status. Two general hypotheses
were examined:

1. Data obtained from the screening interview and the early phase of treatment will
add sigdicantly to the predictive value of information from initial referral
information and postal questionnaires.
2. Good outcomes will be associated with low scores on measures of symptom
severity and chronicity, positive indices of social adjustment, the absence of
personality disorder, high expectations of improvement and a positive
therapeutic alliance.

Method
Only information necessary for understandmg the analyses reported in this paper is provided here.
Details of the clinical trial on which the analyses are based can be found in Durham el ul. (1994).

Overview of clinical tnal

One hundred and ten patients meeting DSM-III-R diagnostic criteria for a primary diagnosis of
generalized anxiety disorder (GAD) were allocated randomly to one of three treatment conditions
(cognitive therapy (CT), analytic psychotherapy (AP)and anxiety management training (AMT)) and to
one of several therapists delivering each treatment. Of the 110 patients offered treatment, 11 failed to
 On predicting improvement and relapse 105
attend and 19 (19 per cent of treatment starters) subsequently dropped out of treatment. This left 80
completers who were the participants in this study All patients were seen at referral and at the end of
treatment by an experienced senior registrar in psychiatry to determine diagnosis, social functioning and
overall severity. This assessor was ‘blind’to the patients’ therapist and treatment condition. A variety of
self-report scales were administered before and after treatment and a more limited assessment was
made at six-month and 12-month follow-up.

Participant characteristics
A comparison of completers, drop-outs and non-attenders was made on all subject variables available
by the end of the screening interview. This revealed only one s&cant difference on the overall rating
of severity made by the independent assessor using a 0-8 scale. Means (SD) for overall severity were:
‘completers’ = 6.1 (0.8), ‘drop-outs’ = 6.5 (0.9) and ‘non-attended = 5.4 (0.7). One-way
ANOVA revealed a sigdcant overall difference (F (2,109) = 5.46, p < .01) with ‘drop-outs’having
ugdicantly higher severity ratings than ‘non-attended.
The characteristicsof the overall sample were as follows: 32 per cent were men and 67 per cent were
women. Mean age was 39 years (range 18-65). Forty per cent were referred from psychiatrists and 60
per cent directly from general practitioners. Sixty-two per cent were married or cohabiting, 18 per cent
separated or divorced, 16 per cent single and 4 per cent widowed. The mean reported duration of
current disorder was 30 months (range 6-360 months). Fky-one per cent had received previous
psychiatric treatment (23 per cent in-patient and 28 per cent out-patient). At the time of the initial
assessment 66 per cent of the sample were talung some form of psychotropic medication (37 per cent
on anxiolytics or hypnotics, 25 per cent on antidepressants and 6 per cent on a combination of the two).
The social class distribution of the sample, derived from the patient’s occupation using the OPCS
(1980) Chjfcatton of Occupations was as follows: 1 (professional) = 2 per cent, 2 (managerial and
technical) = 18 per cent, 3 (skilled) = 33 per cent, 4 (semi-skilled) = 30 per cent, 5 (unskilled and
unemployed) = 14 per cent. There was a s&cant bias in the sample towards lower socio-economic
status in comparison with the social class distribution of the adult UK population as determined by the
1981 census(1 = 5,2 = 23,3 = 48,4 = 18,5 = 6percent;A’ = 9 . 8 , ~< .05).
Patterns of co-morbidity for axis 1 DSM-111-R diagnoses were determined by the independent
assessor using the Anxiety Disorders Interview Schedule (ADIS) (DiNardo & Barlow, 1988). In
s u m m a r y , 80 per cent were assigned at least one additional axis 1 diagnosis (79,77 and 87 per cent for
Al? CT and AMT treatment conditions respectively)with 53,26 and 1 per cent receiving one, hvo and
three additional diagnoses respectively The additional diagnoses assigned were as follows: agoraphobia
without panic disorder (21 per cent), panic disorder with agoraphobia (8 per cent), panic disorder with-
out agoraphobia (18 per cent), social phobia (19 per cent), dysthymia (20 per cent), obsessive-compul-
sive disorder (14 per cent) and hypochondriasis (8 per cent).
Patterns of co-morbidity for axis 2 diagnoses were derived from unstructured clinical assessments
made by each patient’s therapist during initial interviews using DSM-111-R diagnostic criteria. In
s u m m a r y , 46 per cent of the sample overall were diagnosed as having coexisting personality disorders,
predominantly of the dependent or avoidant kind. There was a strong though non-sigtllficant tendency
for personality disorder to be diagnosed much more frequently by therapists in the analytic psychother-
apy condition (62,34 and 37 per cent in CT and AMT respectively).The overall distribution of diag-
noses was as follows: dependent (28 per cent), avoidant (20 per cent), paranoid (4 per cent), borderline
(2 per cent), schizoid (2 per cent), histrionic (2 per cent) and obsessive-compulsive (1 per cent).

Independent uariables used as predictors

A variety of information on patient characteristics and response to therapy was collected over the course
of the clinical trial. In this section we refer to those measures of direct relevance to the analyses
reported in this paper.

(1) Pre-treatmentquestionnaires and rating scales. These consisted of the trait version of the State-Eait
Anxiety Inventory (STAI-TI(Spielberger, Gorsuch, Lushene, Vagg &Jacobs, 19831, the Brief Symptom
106 Robert C.Durham, Tht?rt?seAllan and ChristineA. Hackett
Inventory (BSI) (Derogatis & Melisaratos, 1983), the Beck Anxiety Inventory (BAI), (Beck, Brown,
Epstein & Steer, 1988), the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock &
Erbaugh, 1961), the Self-Esteem Scale (SES) (O’Malley& Bachman, 19791, the Bums (1980) version
of the Dysfunctional Attitude Scale (DAS) and 0-8 point ratings of general tension, panic, irritability
and anger.

(2) Screening interview ussessments. The independent assessor administered the Hamilton Anxiety Scale
(HAS)(Hamilton, 1959), the Social Adjustment Scale (SAS)(Weissman & Paykel, 1974), the Anxiety
Disorders Interview Schedule (ADIS) (DiNardo & Barlow, 1988) and the Schonell Graded Word
Reading Test as a measure of verbal intelligence (Nelson & O’Connell, 1978).

(3) Early sessions of therapy. At the end of the third session of treatment, expectations of improvement
and perceived suitability of treatment were each rated by patients on a 0-8 point scale, and the Penn
Helping Alliance Scales, in questionnaire form, were used to assess the quality of the patient-ther-
apist relationship from both patient and therapist perspective (Alexander & Luborsky, 1984). One-way
ANOVAs revealed sigruficant differences on each of these measures across the three treatment
conditions. Means (SD) for expectations of improvement were: AP = 4.1 (2.01,CT = 5.7 (1.9),AMT
c .01).Means (SD) for suitabilityof treatment were: AP = 4.4 (1.6),CT
= 4.9 (1.8) (F (2,79) = 5 . 3 , ~
= 5.9 ( 1 . 3 , AMT = 5.9 (1.4) ( F (2,79) = 9.7, p < .001). Means (SD) for Penn Helping Alliance
(patient perspective) were AP:52.4 (6.11,CT = 57.2 (7.71,AMT= 58.9 (6.3)( F (2,791 = 6 . 0 , < ~ .01).
Means (SD) for Penn Helping Alliance (therapist perspective) were: AP = 39.7 (44.81, CT = 44.8
(7.1),AMT = 47.4 (7.0) (F (2,791 = 5.7, p c .01). Post hoc Tukey tests revealed higher ratings of
suitabilityof treatment and the quality of the helping alliance in both CT and AMT in comparison with
AP, and higher expectations of improvement in CT than A€?In addition, six-point patient ratings of
overall outcome (PROO) were completed at the end of the third session of treatment using the
following categories: worse, unchanged, slightly improved, moderately improved, markedly improved,
completely better.

Outcome measure
The dependent variable was a composite measure of outcome based on the trait version of the
Spielberger State-Eait Anxiety Inventory (STAI-T) (Spielberger et al., 19831, the general severity
of index of the Brief Symptom Inventory (BSI-GSI) (Derogatis& Melisaratos, 1983) and the &-point
patient ratings of overall outcome (PROO).Each of these measures was administered at post-treatment
and at six-month and 12-month follow-up. The composite measure was designed to provide a
simple but clinically meaningful measure of outcome that would reflect both the durability and the
consistency of improvement over the 12-monthfollow-upperiod.
The measure was derived in the following steps. First, scores on the STAI-T and BSI-GSI were
transformed into the four-fold category of clinically significant outcomes using Jacobson criterion c
(Jacobson, Follette & Revenstorf, 1984). These categories were: (1) significant deterioration, (2) no
reliable change, (3) sigruficant change within the dysfunctional distribution, and (4) sigruficant change
within the functional distribution. Second, scores on the PROO were transformed into a similar
four-fold category with ratings of ‘worse’ assigned to (I), ratings of ‘no change’ and ‘slight improvement’
assigned to (2), ratings of ‘moderate improvement’ assigned to (3), and ratings of ‘marked
improvement’ or ‘better’ assigned to (4).Third, decision rules were devised for converting each set of
transformed ratings into an overall index of outcome by converting the numerical ratings into a
graphical format and analysing the resulting patterns. Four categories of outcome emerged from this
process: sustained improvement at either a marked or moderate level, initial improvement followed by
relapse, or no consistent change.
Operational definitions of these four categories were as follows: (4) marked improvement
sustained-at least two ratings of 4 at 12 months, one of which must be PROO; (3) moderate improve-
ment sustained-at least two ratings of 3 or better at 12 months, one of which must be
PROO; ( 2 ) relapse-at least two ratings of 1 or 2 at 12 months or six months, one of which must be
PROO, and at least two ratings of 3 or 4 at post-treatment or six months, one of which must be PROO;
le 1. Overall pattern of improvement over the 12-monthfollow-upperiod in each treatment condition (Numberof participants in
ntheses)

Treatment condition P
w
AMT(%)(n=16) 3
3
Overall (%) ( N = 80) AP (%) ( N = 29) CT (%) (N=35)
= 27 (22) 34 (10) 14 ( 5 ) 44 (7)
3
09

consistent 22 (18) 34 (10) 14 (5) 19 (3) 3.

ange s3
e
provement 24 (19) 21 (6) 29 (10) 19 (3) 8
stained %
ked 3
provement 26 (21) 10 (3) 43 (15) 19 (3)
s
8
stained

. AP = analytic psychotherapy;CT = cognitive therapy;AMT = anxiety management training.

c
0
4
108 Robert C.Durham, Th&ise Alkan and ChristineA. Hackett
(1) no consistent change-all other patterns. These definitions give rather greater weight to the
patients’ ratings of overall improvement than to the symptom rating scales and require evidence of
clinically significant change in at least two measures. The distribution of these four categories across the
three treatment conditions are shown in Table 1.

Results
Overview of regression analyses
Statistical analysis was carried out with the logistic regression procedure in SPSS for
Windows (Norusis, 1994). The four-category measure of the overall pattern of
improvement over follow-up was used to derive two dichotomized variables reflect-
ing clinical outcome. One variable, labelled ‘sustainedimprovement’, was coded ‘1’
for either marked or moderate levels of sustained improvement and ‘0’ for the
remaining two categories. Another variable, labelled ‘relapse’, was coded ‘1’ for the
category relapse and ‘0’ for the remaining categories. Predictor variables, derived
from information at each of the three stages of assessment (i.e. initial referral and
questionnaires, screening interview, and early sessions) were entered in blocks using
the forward selection procedure with a likelihood ratio test of the signtficance of
coefficients. Prior to the analyses, categorical predictors were transformed into
‘dummy’or ‘indicator’variables. Regression analyses were conducted for each of the
two outcome variables using the whole sample of 80 patients. By entering type of
treatment as a dummy variable in the first block the predictive power of other
variables could be assessed relative to the contribution to outcome of treatment
received.

Predictors of improvement

Table 2 shows the stepwise selection of variables that increased signtficantly the
proportion of patients correctly classified as improved or not at the three stages of
data collection. The first two columns of the table give the regression coefficients and
significance levels for each variable. The exponentiation of the coefficient in the third
column gives the odds of the outcome in question if the variable was present in
comparison with the odds if the variable was not present. For example, the odds of a
sustained improvement were three and a half times greater if the patient had a
higher rather than a lower socio-economic status (I, 2 or 3 vs. 4 or 5). The final
column gives the overall percentage of patients that were correctly predicted by the
model either to have improved or not.
It can be seen from Table 2 that the best predictors of sustained improvement in
the first stage of data collection were marital status, type of treatment and socio-
economic status. These three variables classified 71 per cent of cases correctly. The
predicted probabilities of improvement associated with these variables were calcula-
+
ted (using the formula,p = 1/1 e-‘, where x is a linear combination of the explana-
tory variables) and are listed in Table 3. The highest probabilities of improvement
were associated with receiving cognitive therapy, being married or cohabiting and
 On predicting improvement and relapse 109
Table 2. Stepwise selection of variables in a logistic regression model to maximize the over-
all percentage of patients correctly classified as improved or not (N = 80,overall improve-
ment rate = 50 per cent)

Overall %
B Sig. Exp ( B ) correct
classification

First stage
(initzaldata)
Treatment
1AP -0.27 0.70 0.76
2 CT 1.86 0.01 6.45
Marital status 1.72
1 Married 0.43 0.04 5.60
2 Single 0.63 1.54 71
High socio-economic status 1.25 0.03 3.49

Second stage
+
( screening interview)
Treatment
1AP -0.59 0.44 0.55
2 CT 1.71 0.02 5.53
Marital status
1 Married 2.14 0.02 8.53
2 Single -0.13 0.90 0.88
Co-morbidity axis 1 77
1 None 3.47 0.00 32.25
2 One additional 0.70 0.26 2.01

Third stage
(+ early sessions)
Treatment
1AP 0.07 0.93 1.08
2 CT 2.10 0.01 8.20
Marital status
1 Married 1.69 0.06 5.42
2 Single -0.62 0.55 0.53
Co-morbidity axis 1 82
1 None 3.96 0.00 52.37
2 One additional 1.04 0.13 2.84
Positive helping alliance 0.10 0.03 1.10
(therapist perspective)
110 Robert C. Durham, Th&&e Allan and ChristineA. Hackett
Table 3. Predicted probabilities (%) of improvement associated with first stage of data col-
lection for whole sample
~

Treatment condition

AP CT AMT
HighSES LowSES HighSES LowSES HighSES LowSES

Marital status
Married 53 24 90 73 59 29
Single 23 8 72 43 29 10
Widowedl 16 5 63 32 21 7
divorced

&y.
High SES = high socio-economic status (levels 1,2 or 3); low SES = low socio-economic status
(levels 4 or 5).

having a higher socio-economic status (1,2 or 3 vs. 4 or 5).When data collected at the
screening interview were entered into the analysis socio-economicstatus was dropped
from the equation and axis 1 co-morbiditywas added which resulted in an increase in
overall correct classification to 77 per cent. The odds of improvement were greatly
increased for patientswhose primary diagnosiswas GAD with no co-morbid diagnoses.
Finally, when data collected during the early sessions of treatment were added, a
positive therapeutic alliance, from the therapist’s perspective, was found to make a
small but signhcant contribution and the overall percentage of patients correctly
classified was increased to 82 per cent.
Preliminary descriptive analysis of the marital tension subscale of the Social
Adjustment Scale suggested it might be a signrficant predictor of outcome. Mean
scores on this variable for the 50 married and cohabiting patients were 1.6 for
patients sustaining a marked improvement ( N = 16), 2.1 for patients sustaining
some improvement ( N = 14), 2.3 for patients showing no consistent change
(N = 11) and 2.4 for patients who relapsed (N = 9). Because this variable was only
applicable to a proportion of the sample (62 per cent), it was excluded from the
whole sample analysis reported above and included in a separate analysis limited to
married and cohabiting participants. Sixty per cent of this sample showed some
degree of improvement. In the first stage of the analysis 80 per cent of patients
were correctly classified on the basis of treatment administered (cognitive therapy
increasing probability of improvement) and treatment received in the past (being in
receipt of previous psychiatric treatment reducing probability of improvement). In
the second stage of the analysis 86 per cent of the patients were correctly classified
on the basis of treatment received and degree of marital tension. Increasing levels of
marital tension significantly reduced the probability of a sustained improvement. In
the final stage of the analysis the addition of the variable measuring degree of
 On predicting improvement and relapse 111
Table 4. Stepwise selection of variables in a logistic regression model to maximize the over-
all percentage of cases correctly classified as relapsed or not (N = 80, overall relapse rate =
27 per cent)

Overall %
B Sig. Exp ( B ) correct
classification

First stage
(initial data)
Sex (male) 2.11 0.02 8.3
Marital status
1 Married -2.8 0.01 0.1
2 Single 0.3 0.77 1.4 90
Treatment
1AP -1.24 0.23 0.29
2 CT -3.57 0.00 0.03
Previous psychiatric treatment 2.04 0.02 7.66
Sudden surges of panic (0-8) 0.45 0.06 1.57
Anxiety with other people (0-8) 0.42 0.04 1.53
BSI Psychoticism subscale 1.30 0.05 3.69

Second stage
+
( screening interuiew)
Marital status
1 Married -3.44 0.00 0.03
2 Single 0.13 0.92 1.14
Treatment
1AP -0.76 0.46 0.47
2 CT -3.90 0.00 0.02 91
BSI Psychoticism subscale 2.37 0.00 10.66
Good leisure adjustment -0.99 0.37 0.37
Severity of anxiety rating (0-8) 0.04 0.01 1.05
Co-morbidity axis 1
1 None -5.49 0.00 0.00
2 Oneadditional -2.14 0.02 0.12

Third stage
( + early session )
Marital status
1 Married -2.81 0.02 0.06
2 Single -0.44 0.71 0.64 91
Treatment
1AP -0.60 0.50 0.54
2 CT -2.94 0.01 0.05
112 Robert C.Durham, Th&&seAllan and Christine A. Hackett
Table 4 (cont.)

Overall % Overall %
B Sig. Exp ( B ) correct
classification

BSI Psychoticism subscale 1.79 0.01 6.02

Co-morbidityaxis 1
1 None! 4.16 0.00 0.02 91
2 Oneadditional -1.62 0.05 0.19
Patient expectation of -0.33 0.07 0.72
improvement

improvement by the end of the third session of therapy, as rated by the patient,
increased the percentage of patients correctly classified to 88 per cent.

Predictors of relapse
Table 4 summarizes the logistic regression analyses for the prediction of relapse.
First, it can be seen that the overall percentage of correct classification at each stage
of data collection was high and at about the same level. Second, although somewhat
different combinationsof variables were found to be of predictive significance at the
three stages, four variables were found to be consistently influential once introduced
into the regression equation. These were: marital status, treatment condition, axis 1
co-morbidity and the Psychoticism subscale of the Brief Symptom Inventory The
first three of these were also influential in the prediction of sustained improvement.
The analysis indicated that being single, widowed or divorced increased the
likelihood of relapse, as did not receiving cognitive therapy and having more than
one additional axis 1 diagnosis.
The fourth variable-high scores on the BSI Psychoticism scale-was
consistently found to increase the likelihood of relapse by a factor of between
four and 10. This measure was of greater significance than two other measures of
symptom severity in the first stage-sudden surges of panic and anxiety with other
people-and of much greater significance than one measure of symptom severity in
the second stagepercentage of day spent worrying. None of the other measures of
symptomatic functioning were found to be of significance. Relapse was also found to
be much more likely for males rather than females and for patients with previous
psychiatric treatment, both by a factor of about eight. It was also associated weakly
with a poor leisure adjustment and low expectations of improvement.

Discussion
It must be acknowledged at the outset that the regression analyses used in research
of this kind are acutely sensitive to variations in sample size, order of entry effects,
the nature of the measures used, and so forth. The specific findings of this study
 On predicting improvement and reLapse 113
should, therefore, be treated with some caution in the absence of cross-validation.
Our purpose has been to explore the type of variables that are likely to have a
signrficant influence on treatment response in GAD and to illuminate the relative
contribution of data gathered at various stages of patient contact. In this section we
begin with a discussion of the specific findings, and their implications for clinical
practice, and in conclusion present a broad conceptual framework for outcome
prediction in this field.

Empiricalfindings and clinical implications

The first hypothesis, that data from the screening interview and early sessions would
add signrficantly to the outcome predictors from the initial data, was supported for
the prediction of improvement but not for the prediction of relapse. Seventy-oneper
cent of the sample were correctly classified as having improved or not on the basis of
initial data and the accuracy of this classification was significantlyincreased to 77 per
cent with the addition of information from the screening interview and to 82 per cent
with information derived from the early treatment sessions. A broadly similar pattern
of increased predictive power with information from the second and third stages was
also evident for the prediction of improvement in the subsample of married or
cohabiting patients (80 to 86 to 88 per cent). However, the patients who improved
initially but subsequently relapsed were predicted with an unexpectedly
high degree of accuracy on the basis of the initial data alone (90 per cent or above)
and there was little scope for an increase in power with data from the screening inter-
view and early sessions.
These findings,if replicated, would have potentially important implications for the
costs and effectiveness of standard clinical practice. First, the early identification of
patients who are vulnerable to relapse would enable additional or more intensive
forms of therapy to be targeted on this particular group. Booster sessions, long-term
support and more intensive learning strategies may be of value here. Conversely, the
early identification of patients with a good outcome suggests the possibility that brief
intervention strategies might be as effective with this group as standard treatments.
These issues require systematic investigation. Second, the gain in predictive power
from information derived from the second and third stages suggests the potential
value of incorporating screening interviews and a systematic appraisal of the patient’s
response to early sessions in routine clinical practice.
The second hypothesis, concerning the validity of prognostic and outcome
predictors found to be of significance in previous research, was partially confirmed.
Somewhat surprisingly, overall symptom severity, as measured by a number of
well-known self-ratingscales as well as the interview-based Hamilton Anxiety Scale,
was not found to be s d c a n t in predicting improvement. The prediction of relapse
was related to symptom severity but only consistently in the case of one BSI subscale
measuring psychoticism. This subscale includes items indicative of a withdrawn,
isolated, schizoid lifestyle (e.g. ‘never feeling close to another person’) as well as
first-rank symptoms of schizophrenia (e.g. ‘the idea that something is wrong with
114 Robert C.Durham, Th&t?seAllan and ChristineA. Hackett
your mind’) and was developed to represent psychoticism as a continuous dimension
of human experience. The predictive value of this subscale should alert clinicians to
a possible subgroup of socially isolated and potentially quite disturbed GAD patients
for whom therapy may be an opportunity to feel better but only for as long as
contact with the therapist lasts. This is an intriguing finding that warrants further
investigation.
A very robust finding of the present study is that axis 1co-morbiditywas strongly
related to the prediction of both improvement and relapse. It is the complexity of a
person’s clinical presentation that makes the learning processes in therapy difficult,
from both therapist and patient points of view, rather than the absolute severity of
presenting symptoms. Although axis 2 co-morbidity also introduces complexities, the
present findings do not support a link between personality disorder and outcome.
This is consistent with recent research by Sanderson et al. (1994)mentioned earlier
although it should be noted that personality disorder was not objectively assessed in
the present study. Further research is needed on the characteristics of GAD patients
with and without axis 2 disorders.
Aside from treatment received, which was expected to be a significant predictor
given the favourable results for cognitive therapy in the study on which the analysis
was based, the most consistent and robust predictor of both improvement and
relapse across all stages of the analysis was marital status. Married or cohabiting
patients had a much greater probability of improvement and a much decreased
probability of relapse than patients who were single, widowed or divorced. However,
the benefits conferred on those patients who had a partner were moderated by the
quality of the relationship. Tension and friction in the relationship was strongly
associated with a reduced likelihood of improvement. This is entirely consistent with
epidemiologicalresearch suggesting that social adjustment variables are likely to play
a central role in the medium and long-term recovery from common mental disorders
(cf. Goldberg & Huxley, 1992).This is not an issue that has received much attention
in the clinical literature on GAD although Borkovec (1995)has argued recently that
there is something fundamentally social about excessive worry which may often
reflect an excessive empathy, a tendency to feel the pain of others more intensely. It
is also worth noting that Nisbett & Ross (1980),in their discussion of the fallibility of
human reasoning, argue that one of the important defences against human
irrationality and thinking errors is the collective nature of many inferential tasks, a
point that is discussed further by Rachman (1983).GAD patients who worry
excessively, and who, in addition, are isolated or have insecure attachments, may
have particular difficulty in developing and sustaining a more balanced style of
thinking since they are not only exposed to higher levels of stress than their more
socially integrated peers but also have more limited access to the corrective
influences, advice and information of non-anxious friends and confidantes.
Whatever the underlying mechanism these considerations clearly suggest that the
quality of intimate relationships and close social supports in GAD patients should be
carefully assessed at the beginning of therapy and targeted for intervention if
problems are apparent.
 On predicting impmement and relapse 115

Other sigdicant predictors were previous psychiatric treatment which, as might

be expected, was associated with an increased likelihood of relapse, and lower
socio-economic, status, which was associated with a sighlficantly lower likelihood of
sustained improvement as illustrated in Table 3. This latter finding is consistent with
a good deal of research (e.g. H d e y et al., 1979) exploring the ways in which
material advantage, better housing and higher incomes are associated with less
severe mental disorders, a greater availability of social supports and less severe
psychosocial stressors. It should also be noted that being male rather than female was
associated with a greater likelihood of relapse. Finally, although the quality of the
therapeutic alliance and patient expectations of improvement were of some
predictive significance their overall contribution to prediction was relatively
modest. However, as indicated previously, the type of treatment received was itself
associated with differences in expectation of improvement, perceived suitability of
therapy and quality of therapeutic alliance, these being higher in the cognitive
therapy condition. The influence of these variables on outcome may therefore have
been greater than has been apparent from the methodology adopted in the present
study.

Table 5. Conceptual framework for outcome prediction in GAD

Variables Source of data

( 1) Assess general prognostic factors (‘limitsof change’)

Sex Referral letter + questionnaire
u
Socio-economicstatus
u
Marital status
u
Duration of symptoms
U
Previous treatment
U
Concurrent medication
U
Severity of symptoms Structured interview + self-ratingscales
U
Co-morbidityon axis 1
U
Social adjustment
U
Severity of psychosocial stressors
U
(2)Assess treatment response predictors (‘readiness to engage’)
Attitude to psychological formulation Patiendtherapist rating of early sessions
Expectations of improvement U

Quality of therapeutic alliance ”

Compliance with therapeutic tasks u
116 Robert C. Durham, Th&&seAllan and ChristineA . Hackett
A conceptualhamework for outcome prediction

1. Accurate prediction of clinically sign$cant improvement in response to

psychological therapy will require a combination of two distinct but interacting
sets of variables: general prognostic factors-of anxiety neurosis as a whole-
and more specific treatment response predictors related to participation in the
therapeutic process.
2. General prognostic factors-relating to the severity, chronicity and complexity
of the presenting symptomatology, the quality of social adjustment and the
severity of associated psychosocial s t r e s s o r r d act as indices of the ‘limitsof
change’ and will determine the maximum scope that specific treatment strategies
are likely to have in changing the course of the disorder.
3. Within the limits set by prognostic factors, individual response to psychotherapy
will be determined by a set of specific treatment response predictors reflecting
the patient’s ‘readiness to engage’ in the demands of the therapy offered in a
particular clinical context. These will include expectations of psychotherapy,
attributions concerning presenting problems, the quality of the therapeutic
alliance and degree of compliance with therapeutic tasks.
4. The relative importance of these two sets of variables in clinical trials is likely to
depend primarily on the selection processes by which potential patients are
recruited into the trial. Where a heterogeneous group of patients is recruited, in
respect to both clinical complexity and sociaVpersonal circumstances, general
prognostic factors are likely to be of greatest importance. Specific treatment
response predictors will be relatively more influential in a more homogeneous
sample.
5. The manner and timing of outcome assessments will also have a considerable
influence on the results obtained. General prognostic factors are likely to
grow in importance with broadly based measures and with increasing length of
follow-up, whereas treatment response predictors will be favoured by measures
that are more narrowly defined in terms of the immediate goals of treatment.
6. Finally, on a more speculative note, the importance of measures of the patients’
initial response to treatment and ability to develop a productive therapeutic
relationship is likely to be determined in part by the characteristics and overall
power of the therapeutic approach the patient receives. Good outcomes with
treatments such as analytic psychotherapy may be more sensitive to individual
differences in these variables than in the case with cognitive-behavioural
therapies.

The essence of this framework for prediction, which is summarized in Table 5, is

that individual response to psychotherapy needs to be considered and investigated
within the context of the overall biopsychosocial factors that influence the course of
recovery from common mental disorders (cf. Goldberg & Huxley, 1992).It implies a
sequential process of investigation at several stages of patient contact and a more
comprehensive assessment of the characteristics and circumstances of the person
who has the disorder than has been the case heretofore (Durham & Allan, 1994). It
 On predicting improvement and relapse 117
suggests that the power of psychotherapy to effect sustained improvement is
influenced by a range of factors of which the most s i d c a n t are the social
adjustment of the individual and the complexity of the disorder from which they
suffer. Future investigation of the ways in which standard treatments need to be
modified in order to address these factors is surely a matter of some urgency if
psychological treatment is to be effective with those who are most in need of help.
From a methodological point of view there is a need for a greater consensus than
exists at present on measures of outcome and therapeutic process. From a clinical
perspective it may be more meaningful to define outcomes in terms of simple
categories such as improvecUunimprovedor relapsecUsustainedrecovery In this case
the appropriate methodology is logistic rather than linear regression.

Acknowledgement
The preparation of this article was made possible by a grant to the senior author by the Scottish Hospital
Endowments Research Trust whose support is gratefully acknowledged.

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Received 3 April 1995; revised version received 28 February 1996