This article was downloaded by: [Adelphi University], [J. Christopher Muran] On: 27 March 2015, At: 10:08 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Click for updates Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20 Assessing Interpersonal Subtypes in Depression Sarah Simon a , Nicole M. Cain a , Lisa Wallner Samstag ab , Kevin B. Meehan a & J. Christopher Muran bc a Department of Psychology, Long Island University–Brooklyn Campus b Beth Israel Medical Center, New York, New York c Derner Institute of Advanced Psychological Studies, Adelphi University Published online: 24 Mar 2015. To cite this article: Sarah Simon, Nicole M. Cain, Lisa Wallner Samstag, Kevin B. Meehan & J. Christopher Muran (2015): Assessing Interpersonal Subtypes in Depression, Journal of Personality Assessment, DOI: 10.1080/00223891.2015.1011330 To link to this article: http://dx.doi.org/10.1080/00223891.2015.1011330 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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This article was downloaded by: [Adelphi University], [J. Christopher Muran]On: 27 March 2015, At: 10:08Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Click for updates
Journal of Personality AssessmentPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/hjpa20
Assessing Interpersonal Subtypes in DepressionSarah Simona, Nicole M. Caina, Lisa Wallner Samstagab, Kevin B. Meehana & J. ChristopherMuranbc
a Department of Psychology, Long Island University–Brooklyn Campusb Beth Israel Medical Center, New York, New Yorkc Derner Institute of Advanced Psychological Studies, Adelphi UniversityPublished online: 24 Mar 2015.
To cite this article: Sarah Simon, Nicole M. Cain, Lisa Wallner Samstag, Kevin B. Meehan & J. Christopher Muran (2015):Assessing Interpersonal Subtypes in Depression, Journal of Personality Assessment, DOI: 10.1080/00223891.2015.1011330
To link to this article: http://dx.doi.org/10.1080/00223891.2015.1011330
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
subtypes (vindictive, intrusive, socially avoidant, exploitable, and cold). Apart from gender, the subtypes did not differ significantly on
demographic characteristics, psychiatric comorbidity, or self-report depression severity. Socially avoidant participants were more likely to meet
criteria for a clinical depression diagnosis (MDD or DD), whereas vindictive participants were more likely to have sD. Our results indicate that
interpersonal problems could account for heterogeneity observed in depression.
Major depressive disorder (MDD) has been identified as themost common mental disorder in the United States, with a life-time prevalence rate of 16.6% according to the NationalComorbidity Survey–Replication (NCS–R; Kessler et al.,2005). The assessment and treatment of MDD is complicatedby the wide array of clinical presentations and varying severityassociated with it (Goldberg, 2011; Judd, Akiskal, & Paulus,1997). Goldberg (2011) noted that it is a fallacy to considerMDD a homogeneous construct, given the range of symptomsexperienced by individuals reporting depression. Additionally,severity of presenting symptoms has been shown to influencetreatment outcome within samples diagnosed with MDD(Elkin et al., 1995) and increase the risk for a depression diag-nosis in the future (Forsell, 2007). The Diagnostic and Statisti-cal Manual of Mental Disorders–Fifth Edition (DSM–5;American Psychiatric Association, 2013) organizes depressivepsychopathology based on symptom count and course (i.e.,MDD and persistent depressive disorder, formerly dysthymicdisorder in the fourth edition of the Diagnostic and StatisticalManual of Mental Disorders [DSM–IV; American PsychiatricAssociation, 2000]). However, this nonetiological approachassumes that depressive psychopathology is homogenous,does not explain factors associated with mild or severe presen-tations, and largely ignores the context in which the symptomsof depression manifest. Understanding this context mightenable clinicians to better understand differences in depressivepresentations, including whether or not symptoms reach clini-cal threshold, and make more informed treatment decisions.
Interpersonal assessment provides a clinically useful way ofidentifying qualitatively different groups of individualsexperiencing depressive psychopathology. For example,Joiner and Timmons (2009) noted the importance of
interpersonal functioning in the etiology and maintenance ofdepression. Specifically, excessive reassurance seeking, char-acterized as repeated requests for affirmation, regardless ofwhether it has already been provided, and generally submis-sive behavior, have been associated with more severe, endur-ing depression (Pearson, Watkins, & Mullan, 2010).Therefore, considering the interpersonal context in whichdepressive symptoms are expressed could enhance evaluationof depression in naturalistic treatment settings.One model that has been used to illustrate the impact of
interpersonal functioning on the clinical presentation ofdepression is the interpersonal circumplex (IPC; Leary,1957). The IPC is rooted in interpersonal theory, which positsthat one’s interpersonal style can be described using twoorthogonal dimensions: dominance and affiliation (seeFigure 1 for an example of the IPC and its eight octants).Using the IPC model to define the interpersonal context ofdepression is based on the theory of pathoplasticity, which ischaracterized by a mutually influencing nonetiological rela-tionship between psychopathology and personality. In thisway, psychopathology and personality influence the expres-sion of each other, but neither exclusively causes the other, asmight occur in an etiological or spectrum relationship.Widiger and Smith (2008) provided an example of a patho-plastic relationship between the Five-factor model (McCrae &Costa, 2003) personality trait of conscientiousness and eatingdisorders. They explained that although conscientiousnessdoes not necessarily predispose someone to develop an eatingdisorder, it might inform the manner in which such psychopa-thology is expressed. An individual with high levels of consci-entiousness might be more prone to display the extremeconstraint associated with anorexia nervosa. By contrast, aperson with low levels of conscientiousness might be morelikely to exhibit the impulsive dysregulation present in bingeeating. Individual differences in interpersonal functioninghave been found to exhibit a pathoplastic relationship with arange of psychiatric disorders, such as social phobia (Cain,Pincus, & Grosse Holtforth, 2010; Kachin, Newman, &
Received February 14, 2014; Revised December 6, 2014.
Address correspondence to Sarah Simon, Department of Psychology, Long
Island University–Brooklyn Campus, 1 University Plaza, Brooklyn, NY
Pincus, 2001), generalized anxiety disorder (Przeworski et al.,2011; Salzer et al., 2008), posttraumatic stress disorder(Thomas et al., 2014), and eating pathology (Ambwani &Hopwood, 2009; Hopwood, Clarke, & Perez, 2007). Interper-sonal pathoplasticity has also been used to predict variabilityin response to psychotherapy within a disorder (Cain et al.,2010).
Two prior studies have specifically investigated interper-sonal pathoplasticity in depression. Cain et al. (2012) demon-strated evidence of interpersonal pathoplasticity in a sampleof 312 patients diagnosed with MDD from the CollaborativeLongitudinal Personality Disorders Study. They identified sixdistinct interpersonal subtypes in depression (extraverted,dominant, arrogant, cold, submissive, and unassuming) thatdid not differ on demographic variables or baseline psychiatriccomorbidity. MDD patients in the submissive group reportedsignificantly more depression chronicity and poorer globalfunctioning over a 10-year follow-up period, even after con-trolling for comorbid personality pathology.
Dawood, Thomas, Wright, and Hopwood (2013) also exam-ined interpersonal pathoplasticity in a sample of 172 collegestudents scoring in the moderately to severely depressed rangeon the Patient Health Questionnaire (PHQ–9; Spitzer,Kroenke, & Williams, 1999). They found five distinct inter-personal subtypes (dominant, warm, submissive, cold, andundifferentiated) that did not differ in terms of depressiveseverity. Importantly, the dominant group endorsed moreproblematic alcohol use and the cold group demonstratedgreater personality pathology. However, this study was limitedby its reliance on a college student sample, thus restricting thegeneralizability of their findings to clinical populations.
Both the Cain et al. (2012) and Dawood et al. (2013) stud-ies relied on samples with a restricted range of depressive
severity. Cain and colleagues evaluated patients diagnosedwith MDD using a semistructured diagnostic interview,whereas Dawood and colleagues evaluated self-reporteddepressive symptoms in a nonclinical student sample, limitingtheir focus to the high and low ends of severity, respectively.Differences in depression severity have been shown to haveimportant implications for treatment outcome (Elkin et al.,1995) and risk for continuing to meet depressive symptom cri-teria for clinical disorders in the future (Forsell, 2007). Fur-ther, a range of interpersonal problems and depressiveseverity is expectable in a community clinic context whereclinicians will likely encounter both clinical and subthresholdforms of depression. Therefore, investigations of interpersonalpathoplasticity in depression should include a spectrum ofdepressive conditions, including milder, subthreshold depres-sion as well as clinical disorders such as persistent depressivedisorder (i.e., dysthymia) and MDD.
THIS STUDY
This study used archival data selected from a sample of par-ticipants who sought treatment at an urban psychotherapyresearch program from 1988 to 2011. This sample wasselected based on presentation with a wide range of depressiveconditions of differing intensity, duration, and assignment of“clinical” status.” To demonstrate interpersonal pathoplastic-ity across depression diagnoses of varying severity, three crite-ria must be met: (a) the identification of distinct andhomogeneous interpersonal subtypes of depressed individuals,(b) interpersonal subtype classification that is not accountedfor by demographic variables (e.g., age, ethnicity) or featuresof psychopathology (e.g., symptom severity or psychiatriccomorbidity), and (c) evidence of differential expression ofthe disorder (e.g., symptom chronicity) across interpersonalsubtypes. Thus, we first aimed to replicate studies examiningspecific depressive presentations (Cain et al., 2012; Dawoodet al., 2013) and identify prototypical interpersonal subtypesin patients with a range of depressive psychopathology byapplying latent profile analysis (LPA) to IPC octant scores.Second, we tested for differences between the interpersonalsubtypes on demographic variables, self-report depressionseverity, and psychiatric comorbidity. Third, building on Cainet al. (2012), we hypothesized that patients presenting withsubmissive interpersonal problems would be more likely tomeet DSM criteria for a clinical diagnosis, such as MDD ordysthymic disorder (DD), rather than less severe, subthresholdsymptoms.
METHOD
Participants and Procedure
Participants were drawn from a larger archival data set ofoutpatients seeking treatment at the Brief PsychotherapyResearch Program (Brief Program) at Beth Israel MedicalCenter in New York City. An aim of the Brief Program is toinvestigate the impact of personality, particularly DSM ClusterC personality disorders, and interpersonal problems on psy-chotherapeutic treatment outcome. Brief Program participantswere not selected according to a particular depressive presen-tation and comprise a diversity of depression diagnoses of
FIGURE 1.—Circumplex locations of interpersonal subtypes. Note. An exam-
ple of the eight octants found in the Interpersonal Circumplex (IPC) adapted
from Leary (1957). Octants are labeled with the alphabetical notation origi-
nally provided by Leary (e.g., PA, BC, DE, etc.). Circumplex locations for the
full sample (N D 407) located at 218.86�, Group 1: Vindictive (n D 33)
located at 121.21�, Group 2: Intrusive (n D 71) located at 32.61�, Group 3:
Socially Avoidant (n D 53) located at 239.59�, Group 4: Exploitable (n D112) located at 309.46�, Group 5: Cold (n D 138) located at 196.41�. All cir-cumplex locations are approximate.
varying severity. As a result, the study sample approximates adepressed population treated in a naturalistic setting. Furtherdetails regarding the Brief Program’s participants and treat-ments are described elsewhere (e.g., Muran, 2002).
This study selected 407 participants from a pool of 1,087,each of whom met Brief Program selection criteria. Partici-pants for this investigation were chosen according to the fol-lowing three criteria at intake: (a) diagnosis of MDD, DD, orsubthreshold depression (sD); (b) completion of self-reportassessments; and (c) informed consent. MDD or DD diagnoseswere assessed using the Structured Clinical Interview forDSM–IV–Axis I (SCID–I; First, Spitzer, Gibbon, & Williams,1995) administered at intake. An sD diagnosis was determinedusing the intake SCID and Symptom Checklist–90–RevisedEdition (SCL–90–R; Derogatis, 1983) depression subscalescore (DEP subscale score), also completed at intake. Patientswho did not meet criteria for an MDD or DD diagnosis butwhose DEP subscale score achieved a T score of 70 or greater(Wetzler, Kahn, Strauman, & Dubro, 1989), corresponding tothe 98th percentile of the SCL–90–R nonpatient normativegroup (Derogatis, 1983), were assigned to the sD diagnosticcategory. A T score of 70 was used as a cutoff for significantself-report depressive symptoms, as recommended in the man-ual (Derogatis, 1983).
Of the total sample, 218 participants met criteria for MDD(53%), 112 participants met criteria for DD (28%), and 77 par-ticipants met criteria for sD (19%). In addition, 42 participantshad comorbid MDD and DD, representing 19% of MDD par-ticipants. Mean age was 41.5 years (SD D 11.92) and 52.8%were women. Most participants self-identified as White(78.4%) and were employed at the time of the intake assess-ment (74.9%). The sample was highly educated, with nearlyhalf of participants holding an undergraduate degree (46.2%)and close to a third completing a graduate degree (29.2%; seeTable 1). Additional comorbid Axis I disorders are alsoreported in Table 1. A large proportion of the sample also hadat least one comorbid personality disorder (PD) diagnosis(67.5%), with PD not otherwise specified (24.3%) or a ClusterC PD (30.4%) being the most common.
Measures
Structured Clinical Interview for DSM–IV–Axis I & II.The SCID (First et al., 1995), a semistructured clinical interview,assesses for the presence of symptoms associated with Axis Ipsychiatric disorders listed within the DSM–IV using a clinicalscale ranging from 1 (absent) to 3 (threshold). The SCID hasdemonstrated validity in depression diagnosis, with sensitivity of74.2% and specificity of 81% (Sanchez-Villegas et al., 2008).Fair psychometric properties for the SCID–II have also beenestablished for Axis II PD evaluation (First et al., 1995). In thisstudy, the SCID was used to assign participants to MDD, DD, orsD groups and to identify comorbid psychiatric Axis I as well asAxis II PD diagnoses. Research assistants administering theSCID participated in extensive training that included viewing ademonstration video, practicing administration through role-play-ing activities, and observation of a live interview (see Muran,Safran, Samstag, & Winston, 2005, for a more detailed descrip-tion of SCID training). Prior to conducting interviews, assistantswere required to achieve an intraclass correlation of at least .70on an interrater reliability test in which they rated recorded
SCID–I and SCID–II evaluations administered by experiencedprogram personnel.
Symptom Checklist–90–Revised. The SCL–90–R (Dero-gatis, 1983) is a 90-item, patient-rated, self-report measureassessing general psychiatric symptomology using a Likert-type format based on degree of severity. Included items assesssymptoms within 10 clinical scales (Somatization, Obsessive–Compulsive, Interpersonal Sensitivity, Depression, Anxiety,Hostility, Phobic Anxiety, Paranoid Ideation, Psychoticism, andAdditional Items). Participants rate how distressed they are byeach item, from 0 (not at all) to 4 (extremely). The total meanscore, or General Severity Index (GSI), and the mean score ofthe 13 items evaluating depression (DEP) were used in thisstudy. The SCL–90–R has demonstrated validity and reliabilitywithin clinical as well as nonclinical samples (e.g., Derogatis,1983; Derogatis, Rickels, & Rock, 1976). The 13-item DEPsubscale also has good psychometric properties (Moffett &Radenhausen, 1990). In this sample, Cronbach’s alphas were.96 and .88 for the SCL–90–R GSI and SCL–90–R DEP sub-scale, respectively. The SCL–90–R DEP subscale score wasused in this study to assign participants to the sD group anddetermine severity of depressive symptoms at intake.
TABLE 1.—Demographic and clinical characteristics.
Personality disorder (PD) diagnosis typeNo PD 132 32.4Cluster A PD 12 2.9Cluster B PD 7 1.7Cluster C PD 124 30.4Depressive PD 33 8.1PD not otherwise specified 99 24.3
Note. N D 407. Axis I comorbidity and PD diagnosis type D Cluster A PD (schizoid,schizotypal, paranoid), Cluster B (antisocial, borderline, narcissistic, histrionic) diag-nosed using Structured Clinical Interview for DSM–IV.
Inventory of Interpersonal Problems–Short CircumplexScales. The 32-item Inventory of Interpersonal Problems–Short Circumplex Scales (IIP–SC; Soldz, Budman, Demby, &Merry, 1995) assesses interpersonal functioning across eightsubscales, using the circumplex dimensions of dominance andaffiliation as orthogonal anchoring points. The IIP–SC alsocontains a general factor measuring overall level of interper-sonal distress. Items list various interpersonal behaviors, andparticipants rate how distressed they are by each using a Lik-ert-type scale ranging from 0 (not at all) to 4 (extremely). TheIIP–SC has demonstrated good psychometric properties in anumber of validity studies examining clinical as well as non-clinical samples (e.g., Gurtman, 1996; Hopwood, Pincus,DeMoor, & Koonce, 2008). Cronbach’s alphas for his studysample ranged from .71 (vindictive) to .85 (nonassertive) forthe octant scores. In his study, IIP–SC octant scores were usedto classify participants into interpersonal subtypes.
Data Analysis
LPA was conducted using Mplus 6 (Muth�en & Muth�en,1998–2010) to classify depressed individuals into latentgroupings based on their interpersonal profile. The IIP–SCoctant scales were used as the observed variables for the LPAmodels. Model fit was compared using the Bayesian informa-tion criteria (BIC), smaller values of which indicate better fitto the data.
The structural summary method for analyzing circumplexdata was used to model an interpersonal profile of IIP–SCoctant scores as a cosine-curve function (see Figure 2). AsFigure 2 shows, the parameters of this curve are its (a) angulardisplacement or the predominant interpersonal problem on theIIP–SC; (b) amplitude or a measure of interpersonal profiledifferentiation; and (c) elevation, an index of interpersonaldistress across all types of interpersonal problems on the IIP,with high values (> 1) indicating high overall distress (Gurt-man & Balakrishnan, 1998). The goodness of fit of the
modeled curve to actual scores can be evaluated by calculatingan R2 value, which quantifies the degree to which the interper-sonal profile conforms to prototypical circumplex expecta-tions. To the extent that a group’s interpersonal profileexhibits nontrivial amplitude (i.e., is differentiated) and con-forms well to circumplex expectations (i.e., R2 �.80), thegroup can be distinctively characterized by the prototypicalinterpersonal pattern indicated by the profile’s angular dis-placement. Detailed descriptions of the structural summary,procedures for solving for the various parameters, and inter-pretive guidelines that relate each of these summary featuresto clinical hypotheses have been reported (see Wright, Pincus,Conroy, & Hilsenroth, 2009).
The structural summary method does not allow forbetween-group statistical comparisons of interpersonal data;therefore, circular statistics were also calculated. Followingthe methods and guidelines recommended by Wright et al.(2009), circular means, circular variances, and 95% circularconfidence intervals (CIs) were calculated for each group. Cir-cular CIs are calculated as a way of identifying reliable differ-ences in a group’s circular means, allowing for a statisticalcomparison between each corresponding subtype, with theexpectation that each pair of CIs will not overlap.
Finally, external validation of interpersonal pathoplasticitywas conducted by testing group differences on demographicvariables, intake psychiatric comorbidity, depression severity,and likelihood of meeting criteria for a depression diagnosisof varying degree, ranging from MDD to sD. Interpersonalsubtypes were compared using an analysis of variance(ANOVA) with Bonferroni post-hoc analyses and chi-squareanalyses with adjusted standardized residuals to provide moredetail on emerging group differences.
RESULTS
Four (0.98%) of the 407 participants were missing intakeIIP–SC data and 89 (21.87%) participants were missing intakeSCL–90–R data. For the IIP–SC, mean replacement valueswere generated if the participant was missing fewer than twoof the items required for an IPC octant score. This followsSchafer and Graham’s (2002) recommendation that meanreplacement is appropriate when item intercorrelations arehigh, as in the octants of the IIP–SC. Mean replacements werecalculated for two of the four participants missing IIP–SCdata; the other two participants had more than two items miss-ing on one IPC octant and, therefore, mean replacement wasnot used. These two participants contributed only seven of theeight IPC octant scores to the final analyses.
For the SCL–90–R data, Derogatis (1983) suggested that tobe considered valid, no more than 18 items may be missingand each subscale must be at least 60% complete. The GSIand subscale scores may then be calculated by dividing thesum of their item ratings by the total number of items com-pleted. Of the 89 participants with missing SCL–90–R data, 5(1.23% of the total sample) had invalid DEP scores (missingmore than 8 items) and 2 (0.49% of the total sample) hadinvalid GSI scores (missing more than 18 items). This resultedin a final sample of 400 participants with completed SCL–90–R data. Means and standard deviations were calculated forintake SCL–90–R GSI, SCL–90–R DEP scale, and IIP–SCoctant scores and distress (elevation; see Table 2). All scales
FIGURE 2.—An example of a structural summary profile. Note. X axis D cir-
cumplex angle in degrees; Y axis D standard (z) score on Inventory of Inter-
personal Problems–Short Circumplex Scales Interpersonal Circumplex octant;
angular displacement D angular shift from 0� to reported peak value, indicatesinterpersonal typology; amplitude D measure of profile differentiation, repre-
sents the degree to which the individual or group strongly endorses interper-
sonal behaviors that are like and not like them; An amplitude value of 0
indicates a flat, undifferentiated profile whereas a high amplitude value indi-
cates a profile with a clear interpersonal peak and trough; elevation D mean
level of the profile, reflects the overall degree of interpersonal distress.
4 SIMON ET AL.
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were evaluated for skew and kurtosis and found to be normallydistributed.
Intake PD diagnosis was evaluated as a possible covariate.Chi-square analyses were calculated to assess the relationshipbetween presence of a PD diagnosis and presence of a depres-sion diagnosis, as well as interpersonal subtype classification.Contrary to past studies, presence of a PD diagnosis was notrelated to presence of clinical depression or interpersonal sub-type classification: PD and depression, x2(1, N D 407) D 2.43,p D .12, V D .08; PD and interpersonal subtype, x2(4, N D407) D 3.75, p D .44, V D .10). As a result, PD diagnosis wasnot included as a covariate in this study.
Interpersonal Profiles in Depressive Psychopathology
Interpersonal pathoplasticity was investigated in three steps.First, LPAs evaluated whether interpersonal subtypes existwithin a sample of 407 Brief Program participants meeting cri-teria for a spectrum of depressive psychopathology, rangingfrom MDD to sD. Second, emerging interpersonal groupswere compared on demographic characteristics, baseline psy-chiatric comorbidity, and self-report depression levels toensure group assignment was not influenced by those factors.Third, differences among interpersonal subtypes on clinicaldiagnosis were tested to demonstrate that interpersonal prob-lems influence the presentation of depressive symptoms.
Using the structural summary method and the norms pro-vided by Hopwood et al. (2008), an interpersonal profile wascalculated for all 407 depressed participants at baseline. Theinterpersonal profile for the sample was located in the FGoctant (218.86�), suggesting socially avoidant interpersonalproblems. The sample had an elevation of .06, indicating lowinterpersonal distress, and an amplitude of .29, indicating lowinterpersonal differentiation. The sample also had an R2 of.92, which typically indicates excellent interpersonal prototy-picality and interpersonal homogeneity. However, previousresearch by Cain et al. (2012) and Dawood et al. (2013) sug-gested that depressed individuals might form smaller andmore prototypical interpersonal groups, creating multiple cir-cular distributions with offsetting interpersonal profiles.Therefore, participants’ IIP–SC octant scores were subjected
to LPA to derive further information about the interpersonalmakeup of the sample.Prior to running the LPA, IIP–SC octant scores were ipsat-
ized to prevent the identification of clusters based on level ofinterpersonal distress rather than on specific interpersonaltypology. Models were estimated ranging between 1 and 10interpersonal profiles. Table 3 summarizes model fit andentropy statistics. A five-profile solution was selected, basedon the strength of the BIC fit statistic. The entropy was .75,slightly below the traditional .80 cutoff, yet high enough tosuggest that comparisons between groups would yield reliableresults. The resulting subtypes of the five-profile solution weresubjected to circumplex group comparison techniques usingunipsatized octant scores (Wright et al., 2009; see Table 4).1
Figure 1 plots the typology of interpersonal problems reportedby the sample as well as by the five interpersonal subtypes.This sample of depressed participants included vindictive(121.21�, nD 33), intrusive (32.61�, nD 71), socially avoidant(239.59�, n D 53), exploitable (309.46�, n D 112), and cold(196.41�, n D 138) interpersonal subtypes (see Figure 1).Group elevations ranged from .43 (cold) to .91 (vindictive),suggesting moderate to high interpersonal distress, and ampli-tudes ranged from 0.51 (cold) to 1.32 (socially avoidant), sug-gesting moderate to high interpersonal profile differentiation.Overall, these results indicated that when classified into moredistinct and homogeneous interpersonal subtypes, participantsendorsed more interpersonal distress and more differentiatedinterpersonal problems than was apparent as a generallydepressed group. The R2 value was also greater than .90 for allfive groups, indicating excellent interpersonal prototypicalityfor each interpersonal subtype.Circular statistics were also calculated for the five interper-
sonal subtypes (see Table 4). Importantly, the 95% CIs for thesubtypes did not overlap, supporting the argument that the par-ticipants within each identified subtype endorsed specificinterpersonal problems. Taken together, these results supportthe hypothesis that, like participants reporting specific depres-sive presentations (Cain et al., 2012; Dawood et al., 2013),those diagnosed with a range of depressive disorders may beclassified into subtypes according to distinct interpersonalissues.
Further Evidence for Interpersonal Pathoplasticityin Depressive Psychopathology
Comparisons were made among the five interpersonal sub-types on demographic variables, psychiatric comorbidity, andself-reported severity of depressive symptoms at intake (seeTable 5). These analyses were conducted to demonstrate thatinterpersonal classification was not due to these factors. Theinterpersonal subtypes did not differ significantly in age, F(4,395) D .27, p D .89, h2 D .00; race, x2(32, N D 399) D 30.79,p D .53, V D .14; education, x2(24, N D 401) D 21.44, p D.61, V D .12; employment status, x2(12, N D 401) D 4.61, p D
TABLE 2.—Descriptive characteristics of the intake symptom and interpersonal
Note. SCL–90–RD Symptom Checklist–90–Revised; SCL–90–R GSI D intake SCL–90–R General Severity Index, a measure of overall psychiatric distress; SC–90–R DEPscale D intake SCL–90–R DEP subscale score, a measure of depressive distress; IIP–SCD Inventory of Interpersonal Problems–Short Circumplex Scales; IIP–SC elevation D ameasure of overall interpersonal distress; Intake IIP–SC dominant octant, Intake IIP–SCintrusive octant D intake IIP–SC octant scores, measures of interpersonal distress in eightspecific domains.
1We also applied the structural summary method to a four-profile solution
as part of our preliminary analyses. The groups identified included vindictive
(143.42�, n D 72), intrusive and overly nurturant (16.01�, n D 142), socially
avoidant (233.55�, n D 103), exploitable (315.40�, n D 86). However, we ulti-
mately chose the five-profile solution for all subsequent analyses due to its
.97, V D .06; comorbidity with mood, anxiety, or substanceuse disorders; comorbidity with one or more PDs; or self-reported severity of depressive symptoms at intake. Of note,the interpersonal subtypes differed significantly by gender,x2(4, N D 407) D 12.54, p < .05, V D .18. Examination of theadjusted standardized residuals revealed that the exploitablegroup had a significantly higher proportion of women,whereas the cold group had a significantly smaller proportionthan expected.
Differences Between the Interpersonal Subtypes on Ratesof Clinical Depression
Finally, the five interpersonal subtypes were compared interms of meeting diagnostic criteria at intake for a depressiondiagnosis of varying severity, including severe MDD, mild yetpersisting DD, and sD (see Table 6). As predicted, the inter-personal subtypes were found to differ significantly in termsof clinical diagnosis, x2(8, N D 407) D 17.56, p < .05, V D.15. Notably, the socially avoidant group had a significantlysmaller proportion of participants than expected endorsing sDand therefore, a greater proportion meeting criteria for a clini-cal depression diagnosis of either MDD or DD. We had pre-dicted that a submissive group would have a greaterlikelihood of meeting criteria for a clinical diagnosis; how-ever, we did not find a purely submissive group in our LPA.The socially avoidant group endorsed problems with beingboth cold (e.g., keeping distance from others) and nonassertive(e.g., trouble confronting others) in their relationships, sug-gesting primary difficulties with submissive detachment, in
partial support of our hypothesis. Comparatively, the vindic-tive group had a significantly larger proportion of participantsthan expected endorsing subclinical depression and signifi-cantly smaller proportion meeting criteria for the most severepresentation, MDD.
DISCUSSION
Analyses for this study were completed using archival datacollected from participants who sought treatment at an urbanpsychotherapy research program from 1988 to 2011. The firstaim was to extend previous interpersonal pathoplasticity stud-ies that investigated a single depressive presentation by identi-fying interpersonal subtypes across a range of depressivepresentations, more closely approximating psychopathologyseen in treatment settings. LPA was applied to the IPC octantscores of 407 participants and five distinct interpersonal sub-types (vindictive, cold, socially avoidant, exploitable, intru-sive) emerged. Like depressed individuals evidencing aspecific presentation (Cain et al., 2012; Dawood et al., 2013),participants diagnosed with a range of depressive severitycould be further classified according to their interpersonalbehavior.
The second aim of this study was to confirm that interper-sonal subtype classification could not be better accounted forby demographic or clinical factors. The five subtypes identi-fied in this study did not differ on most demographic variables(age, race, education, and employment status), self-reportdepression severity, and psychiatric comorbidity. There weregender differences however; the cold group had a significantlygreater proportion of men than predicted, and the exploitablegroup had a significantly larger number of women. Althoughunexpected, this result was consistent with research suggestingthat men typically endorse interpersonal problems on the cold-dominant area of the IPC and women report issues related towarm-submission (Gurtman & Lee, 2009). It is possible thatinclusion in cold and exploitable groups might have been par-tially determined by participant gender. That said, gender is acomplex construct, encompassing variables, such as socializa-tion, that might have also contributed to subtype classification.Nevertheless, as hypothesized, depressive symptoms of vary-ing severity and interpersonal behavior reflect mutually influ-encing, nonetiological (i.e., pathoplastic) psychologicalsystems.
The third aim of this study was to demonstrate differentialexpression of depressive psychopathology across interpersonalsubtypes. We found that at intake, the socially avoidant group
TABLE 3.—Latent profile analysis model fit indexes and entropy statistic at
Note. BIC D Bayesian information criterion. Entropy is a measure of classificationcertainty with values > .80 reflecting acceptable certainty. Dashes indicate that noentropy is calculated for a one-profile solution (i.e., classification certainty is perfect bydefinition). Bold type indicates preferred model.
TABLE 4.—Interpersonal characteristics of the sample and its subtypes at intake.
Structural summary parameters Circular statistics
Group N Angle Elevation Amplitude R2 Circular mean Circular variance 95% Circular CI
Note. Angle D circumplex location of the predominant interpersonal trait in degrees; elevation D average octant endorsement; amplitude D a measure of profile differentiation; R2
D interpersonal prototypicality; circular mean D the average of the angular displacements for each individual within the group; circular variance D the dispersion of the angular dis-placements of individuals within a group around the circular mean; 95% circular CIs D 95% circular confidence intervals that identify reliable differences in circular means.
6 SIMON ET AL.
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contained a smaller proportion of participants endorsing sub-clinical depression than expected and thus, a greater propor-tion diagnosed with more severe, clinical depression (MDD orDD). This result is a partial replication of the findings by Cainand colleagues (2012). Individuals with socially avoidantinterpersonal problems report being overly cold, avoidant ofsocial interactions, and unable to assert themselves in theirrelationships with others, thus supporting the premise thatinterpersonally withdrawn, nonassertive behavior predicts lon-ger lasting, more serious depressive psychopathology (Cainet al., 2012; Joiner & Timmons, 2009; Pearson et al., 2010)that will meet criteria for a clinical diagnosis.
This result is also consistent with recent findings by GrosseHoltforth et al. (2014) showing that highly introverted(socially avoidant) patients report the most depressive symp-toms as compared to patients with other types of interpersonalproblems. By contrast, the vindictive group had a larger per-centage of participants than expected reporting only sD symp-toms, and a lower percentage of participants meeting criteriafor MDD, the most severe form of clinical depression. Thissuggested the possibility that vindictive interpersonal prob-lems could serve as a buffer against the development of MDD.
The IPC dimensions of agency and communion can be usedto further understand the observed heterogeneity of depressivepresentations between interpersonal subtypes. Whereas theagency-driven vindictive group was less likely to be diagnosedwith severe depression, the submissive, socially avoidantgroup was more likely to meet criteria for clinical symptoms.However, although the exploitable group also endorsed a highdegree of submissiveness similar to that of the socially avoi-dant group, its included participants were not significantlymore likely to experience clinical depression, suggesting thatcommunion might serve as a buffer against severity of depres-sion in this group. Taken together, these results strongly sup-port the presence of interpersonal pathoplasticity in a range ofdepressive presentations, indicating that specific interpersonalbehavior is associated with depression of greater or lesserdiagnostic severity.In this study, the interpersonal problems associated with
depressive psychopathology were notably diverse (i.e., a sin-gle interpersonal problem does not adequately describe thepotential diversity in clinical presentation of these patients).This is consistent with previous findings by Cain and col-leagues (2012), and Dawood and colleagues (2013), who
TABLE 5.—Comparisons of the interpersonal subtypes on intake diagnostic comorbidity and depressive symptom severity.
Note. Comorbidity D Axis I and II comorbidity diagnosed using Structured Clinical Interview for DSM–IV–Axis I (SCID–I/P) and Axis II (SCID–II), respectively; depressivesymptom severity D intake Symptom Checklist–90–Revised DEP subscale score, a measure of depressive distress; V D Cramer’s V, measure of effect size in chi-square analysis; h2
D measure of effect size in analysis of variance.an D 33. bn D 71. cn D 53. dn D 112. en D 138.
TABLE 6.—Comparison of the interpersonal subtypes on depression diagnosis at intake.
Group ar Variancecsy or only partially? ture and eight octants Note. Depression diagnosis: measured by meeting diagnostic criteria for major depressive disorder (MDD) ordepressive disorder (DD) using Structured Clinical Interview for DSM–IV–Axis I (SCID–I/P), subthreshold depression (sD) using SCID–I/P and Symptom Checklist–90–Revised; VD Cramer’s V, measure of effect size in chi-square analysis. Group Differences: determined by an examination of the standardized residual.
an D 33. bn D 71. cn D 53. dn D 112. en D 138. *p < .05.
INTERPERSONAL SUBTYPES IN DEPRESSION 7
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found six and five interpersonal subtypes in depression,respectively. Taken together, the results of all three studiesinvestigating interpersonal pathoplasticity in depression havefound that interpersonal problems, spanning the entire inter-personal circumplex (dominant, submissive, cold, warm), playa role in the clinical presentation of depression across popula-tions (clinical samples vs. student samples) and assessmentmeasures (structured interviews vs. self-report). In this way,LPA as applied to IPC octants is a valuable tool to parse arange of interpersonal problems into subtypes that allowresearchers and clinicians to better understand the context inwhich psychopathology manifests, which has important impli-cations for psychotherapy process and outcome. The subtypesidentified in this study represent the context of depressive psy-chopathology in our sample and accordingly will differslightly in number and profile across different samples and dif-ferent methods. Future studies should continue to investigateinterpersonal subtypes in depression to examine convergencesand divergences in the number and type of profiles identified.
Clinical Implications
Results from this study could be expanded into clinicalpractice by enabling clinicians to better understand the rangeof interpersonal problems and distress associated with depres-sion. For example, the average interpersonal problem reportedby depressed outpatients in this sample was cold, character-ized primarily by difficulty feeling close in relationships and atendency to keep others at a distance. However, cold interper-sonal problems were associated with low interpersonal distressand were not related to an increased likelihood of meeting cri-teria for a depressive diagnosis of varying severity. Once sub-type classification was considered, it was clear thatparticipants were endorsing higher levels of interpersonal dis-tress and interpersonal profile differentiation than evidencedby averaging across participants. These findings suggest thatan assessment of interpersonal functioning at the start of treat-ment might improve diagnostic clarity by providing a morethorough evaluation of the context of symptoms. For example,socially avoidant depressed participants were less likely thanexpected to endorse only subclinical depression and, therefore,more likely to meet criteria for a clinical diagnosis of depres-sion (MDD or DD). Alternatively, vindictive participantswere more likely to report sD symptoms and less likely tomeet criteria for MDD. The submissive, withdrawn behaviorof a socially avoidant patient appears significantly associatedwith the more intense, prolonged symptoms of a clinical disor-der, whereas the social aggression of the vindictive patient isless so. The combativeness of vindictive patients might actu-ally protect against severe depression, whereas the passivedetachment of socially avoidant patients might exacerbatesymptoms.
Such diagnostic precision could also serve to enhance clin-icians’ capacity to begin tailoring treatment interventions tobetter target the interpersonal characteristics of their depressedpatients. For example, Grosse Holtforth, Pincus, Grawe, andMauler (2007) found that cold submissive interpersonal prob-lems were associated with fears of feeling vulnerable in frontof others. Such concerns could make socially avoidantdepressed patients more prone to treatment noncompliance toprotect themselves from rejection by the therapist. In contrast,
friendly submissive interpersonal problems were related toneeding others and a fear of separation. Therefore, exploitabledepressed patients might require a therapeutic focus on asser-tiveness skills and self-direction before undertaking behav-ioral activation to reduce depressive symptoms.
Similarly, interpersonal problems have been found to influ-ence the development of the therapeutic alliance, with friendlysubmissive patients more easily forming an alliance than colddominant patients (Muran, Segal, Samstag, & Crawford,1994). Specific to depression, Grosse Holtforth et al. (2014)found that patients with cold interpersonal problems reportedlower alliance ratings as compared with highly introverted orhighly unassuming patients. With a thorough understanding ofthe interpersonal subtypes in depression, the therapist cananticipate the effect of interventions, facilitating alliance andimproving outcome.
Limitations and Future Directions
This study was limited by restricted demographic character-istics. Similar to Cain et al. (2012) and Dawood et al. (2013),the racial composition of our sample was primarily White,limiting the generalizability of findings to other racial groups.Future research should incorporate more ethnically diversesamples. Additionally, sD is a relatively new diagnostic con-cept, and there are inconsistencies across studies as to how itis defined. sD was operationalized in this study as being pres-ent when a participant did not meet SCID diagnostic criteriafor MDD or DD but endorsed depression symptoms (SCL–90–R DEP scale score above the 98th percentile). Incorporat-ing a self-report questionnaire into the sD operationalizationwas considered valid because a previous study demonstratedthat sD was well detected using this method (Karsten, Hart-man, Ormel, Nolen, & Penninx, 2010). However, the validityof the sD definition used would have been strengthened by acomparison with an alternative operationalization. An impor-tant direction for future research might be to strengthen thediagnostic conceptualization of sD by comparing symptomsidentified by self-report questionnaire and diagnostic inter-view (Cuijpers & Smit, 2004). Finally, this study was archival,which limited the hypotheses that could be tested. For exam-ple, we were unable to examine differences in psychotherapyprocess or outcome variables among subtypes. Future studiesshould test interpersonal problems as moderators of processand outcome to investigate psychotherapy interventions tar-geting at-risk interpersonal subtypes in depressed patients.
In conclusion, expanding on past studies examining inter-personal pathoplasticity in depression, this study identifiedfive interpersonally distinct subtypes across a range of depres-sive presentations. The interpersonal subtypes identified inthis study varied slightly from previous research in terms ofnumber and interpersonal profile due to sample and methodo-logical differences. Future research should examine conver-gences and divergences in the number or type of interpersonalprofiles identified in depression. The interpersonal subtypesidentified in this study were not better accounted for by othermoderators such as demographic variables, psychiatric comor-bidity, and self-report depression severity. These findings indi-cate that interpersonal problems might account for some of theheterogeneity observed in the clinical presentation ofdepressed patients. Consistent with previous research, we
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found that socially avoidant, submissive interpersonal prob-lems were associated with a lower likelihood of reporting sub-clinical symptoms (sD) and, thus, greater likelihood ofmeeting criteria for a more severe depression diagnosis (MDDor DD). Furthermore, vindictive interpersonal problems wererelated to a greater likelihood of endorsing subclinical formsof depression (sD) and a lower likelihood of meeting criteriafor the most serious presentation, MDD. Accounting for inter-personal subtypes in depression could improve diagnosis,treatment planning, and therapeutic outcome.
FUNDING
This research was supported in part by a grant awarded to J.Christopher Muran from the National Institute for MentalHealth (MH071768, Principal Investigator: J. ChristopherMuran).
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