The Global Assessment of Functioning (GAF) instrument measures psychosocial functioning. It comprises a numerical scale ranging from 1 to 100 for symptom level (GAF-S) and another for level of functioning (GAF-F) (12). Lower scores indicate higher degrees of seriousness and increased need for assistance.
A GAF score below 40 indicates very serious symptoms and major functional impairment in multiple areas; a score between 40 and 50 indicates serious symptoms and difficulties in social functioning; a score in the range 51–60 corresponds to moderate problems; a score of 61–70 indicates mild symptoms and social challenges; a score of 71–80 testifies to transient and expectable symptoms of stress and good social functioning; while a score above 80 indicates no symptoms and high levels of functioning.
The scores were determined by consensus between at least two clinicians (doctor, psychologist, nurse, psychiatric nurse) who had been trained in accordance with national procedures (13). For the follow-up data that were based on a review of records, the consensus scores were determined by a doctor or a psychologist in collaboration with a milieu therapist.
Information on regular and pro re nata use of psychotropic drugs was retrieved from patient records or obtained in the follow-up interviews. The data on drug lists in the records are based on information obtained from the patient, collated with written information from a GP and/or referring agency. Interview information was obtained directly from the participants.
Five categories defined by the WHO were investigated: N03A antiepileptics (mood stabilisers), N05A neuroleptics, N05B anxiolytics, N05C hypnotics, and N06A antidepressants. All regular and pro re nata use was converted into defined daily doses (DDD) according to the WHO guidelines (14). For each of these five categories we totalled the use at the time of enrolment to basal exposure therapy and at follow-up, respectively. We also totalled the number of psychotropic drugs for each patient.
We developed a four-point scale to score the degree to which the patients chose to expose themselves to existential catastrophe anxiety during the inpatient treatment, where 0 represented no exposure, 1 intermittent exposure, 2 systematic, gradual exposure and 3 full exposure.
Two clinicians who were familiar with all the patients and their therapeutic processes used the exposure scale independently of each other to rate each patient after discharge. For 24 of the 33 patients (73 %) the two raters gave identical scores, which indicates that the scale has a high inter-rater reliability. As regards the patients that scored differently, the two raters jointly reviewed the observational basis to arrive at a representative score.
For the purposes of this study, we split the scores on the exposure scale into two categories, 'low degree of exposure' (a score of 0 or 1 on the original scale) and 'high degree of exposure' (a score of 2 or 3). For this dichotomised variable, the scores given by the two raters were identical (fell into the same category) for 32 of the 33 patients (97 %) in the study, in other words a high degree of inter-rater reliability.
Since the concept of 'existential catastrophe anxiety' has been developed within the framework of basal exposure therapy, there are no other instruments available for measuring exposure to this condition. The exposure instrument that we have developed therefore cannot be validated against any gold standard, but we have previously shown that scores on this instrument are associated with the patients' degree of recovery from the time of enrolment until discharge from basal exposure therapy, as measured by various validated instruments for symptoms and functioning (8).
We identified the patients' level of education, ability to work and ability to live at home unaided at the time of enrolment to basal exposure therapy and at follow-up.
Level of education was subdivided into: not completed upper secondary, completed upper secondary and completed vocational training. Ability to work was registered as: living exclusively on social welfare, working or studying for less than 50 % of normal working hours (including sporadic assignments, for example holding presentations), working or studying for at least 50 % of normal working hours. The ability to live at home unaided was categorised as: living in assisted housing or hospitalised for more than six months over the last year, living with parents or grandparents, living in their own flat/own house/municipal housing, alone or with co-habitant/spouse.
We registered readmissions (yes/no) during the last year before the basal exposure therapy and the year prior to the follow-up. In addition, we identified types of contacts between the patients and mental healthcare institutions over the last year prior to the follow-up: no contact, contact with municipal mental healthcare services, contact with specialist health services (outpatient contact or inpatient admission to a mental healthcare institution).
Full recovery was defined as simultaneous functional remission (completed vocational training, employment in at least a 50 % position, a GAF-F score above 65 and private housing) and symptomatic remission (no admissions over the last year and a GAF-S score above 65).