Personality and Individual Differences

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1 Personality and Individual Differences 53 (2012) Contents lists available at SciVerse ScienceDirect Personality and Individual Differences journal homepage: Interpersonal problems in anorexia nervosa: Social inhibition as defining and detrimental Jacqueline C. Carter a,b,, Allison C. Kelly a,b, Sarah Jane Norwood c a Eating Disorders Program, Toronto General Hospital, University Health Network, Toronto, Canada b Department of Psychiatry, University of Toronto, Toronto, Canada c Department of Psychology, York University, Toronto, Canada article info abstract Article history: Received 5 August 2011 Received in revised form 24 February 2012 Accepted 28 February 2012 Available online 24 March 2012 Keywords: Interpersonal problems Anorexia nervosa Treatment outcome Interpersonal difficulties are thought to play a central role in both the development and maintenance of anorexia nervosa (AN). The primary aims of this study were to examine the nature of interpersonal problems in AN and to determine whether interpersonal problems are related to AN psychopathology and treatment outcome. The participants were 218 individuals with AN admitted to a specialized treatment program. Overall, in comparison with a normative community sample, a pattern of difficulties with submissiveness, nonassertiveness and social inhibition emerged among patients with AN. Results indicated a positive association between interpersonal problems and eating disorder psychopathology at baseline. The overall level of interpersonal problems decreased from baseline to post-treatment and higher levels of social inhibition at baseline predicted treatment noncompletion. Our findings suggest that AN is associated with a pattern of submissive and socially inhibited interpersonal behavior which contributes to the maintenance of eating disorder pathology and interferes with treatment completion. The theoretical and clinical implications of the findings are discussed. Ó 2012 Elsevier Ltd. All rights reserved. 1. Introduction Anorexia nervosa (AN) is a serious psychiatric disorder characterized by extreme food restriction, maintenance of an abnormally low body weight, intense fear of weight gain, and body image disturbance (American Psychiatric Association, 2000). The focal importance of interpersonal problems in AN has long been recognized in the clinical literature (e.g., Bruch, 1973; Selvini-Palazzoli, 1974). Disturbances in family functioning have been highlighted in models of both the etiology and maintenance of the disorder (e.g., Lock, Le Grange, Agras, & Dare, 2001), and there is a growing evidence base for the effectiveness of family therapy for children and adolescents with AN (e.g., Le Grange, Binford, & Loeb, 2005). Recently, researchers have begun to focus on the role of marital functioning in the maintenance of AN in adults, and the use of couple therapy in the treatment of the disorder (Bulik, Baucom, Kirby, & Pisetsky, 2011). AN is also associated with significant interpersonal dysfunction outside of the family (Schmidt, Tiller, & Morgan, 1995). A number of studies have found high rates of social anxiety disorder (Godart, Flament, Lecrubier, & Jeammet, 2000) and avoidant personality traits (Díaz-Marsá, Carrasco, & Sáiz, 2000; Skodol, Corresponding author at: Eating Disorders Program, Toronto General Hospital, 200 Elizabeth Street, EN8-241, Toronto, Ontario, Canada M5G 2C4. Tel.: ; fax: address: jacqueline.carter@uhn.ca (J.C. Carter). Oldham, Hyler, & Kellman, 1993) among individuals with AN, as well as difficulties with social withdrawal and social isolation (e.g., Beaumont, 2002). To some extent, these interpersonal problems may be a consequence of the illness and, at the same time, they may contribute to the maintenance of the disorder. A growing interest in the role of interpersonal difficulties in the maintenance of AN is reflected by recent research on interpersonal treatment approaches for the disorder. Interpersonal models of AN view eating disorder symptoms as inextricably intertwined within interpersonal relationships and contend that interpersonal difficulties are often the trigger for symptoms (McIntosh, Bulik, McKenzie, Luty, & Jordan, 2000). Thus, interpersonal treatments for AN aim to reduce eating disorder pathology by improving interpersonal functioning. Very little research has been conducted on the effectiveness of interpersonal treatments for AN and the results are mixed. McIntosh et al. (2000) adapted interpersonal psychotherapy (IPT), originally developed as a treatment for depression (Klerman, Weissman, Rounseville, & Chevron, 1984), for the treatment of AN. They found that IPT was less effective than cognitive behavior therapy (CBT) and specific supportive clinical management (SSCM) as a first-line intervention for acute AN in a randomized controlled study. SSCM was designed to mimic outpatient care for AN in usual clinical practice and involved a combination of clinical management and supportive psychotherapy. However, the sample size in this study was small and the effect sizes in all three conditions were relatively trivial /$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi: /j.paid

2 170 J.C. Carter et al. / Personality and Individual Differences 53 (2012) Schmidt et al. (2011) recently evaluated an interpersonal treatment approach for AN (i.e., MANTRA). MANTRA is based on the idea that AN symptoms facilitate the avoidance of emotions, and that individuals with AN tend to be socially avoidant because close interpersonal relationships may trigger the experience and expression of emotions. No difference was found between MANTRA and SSCM for acute AN (Schmidt et al., 2011). However, the sample size in this study was also small and the effect sizes obtained in both conditions were fairly minor. In addition to being a potential mechanism through which AN symptoms can change, there is preliminary evidence that interpersonal problems at the start of therapy might moderate response to treatment. Tasca, Taylor, Bissada, Ritchie, and Balfour (2004) found that attachment avoidance predicted attrition while attachment anxiety predicted treatment completion among patients with the binge purge subtype of AN (AN-BP), but not among patients with the restricting subtype (AN-R) (Tasca et al., 2004). Thus, AN-BP patients high in attachment avoidance may find it difficult to maintain therapeutic bonds and may be more likely to disengage from helping relationships, while those who worry about losing close relationships may be more likely to remain in treatment. According to Horowitz, Rosenberg, and Bartholomew (1993), specific attachment styles are associated with particular patterns of interpersonal problems. The Inventory of Interpersonal Problems (IIP) was developed to measure distress arising from interpersonal difficulties (Horowitz, Alden, Wiggins, & Pincus, 2000). The IIP is based on a two-dimensional circumplex model that views every interpersonal behavior along two dimensions an affiliation dimension ranging from cold (hostile) behavior to overly nurturant (warm) behavior; and a dominance dimension that ranges from nonassertive (submissive) to domineering (controlling) behavior (see Fig. 1). According to this model, interpersonal problems can be defined in terms of different combinations of affiliation or dominance. For example, social avoidance is viewed as a combination of cold and nonassertive, whereas intrusiveness is seen as a combination of overly nurturant and domineering. The IIP appears to be a useful tool for measuring interpersonal problems in AN since, clinically, individuals with AN tend to report difficulties along these two dimensions assertiveness and social avoidance. To date, only one study has examined interpersonal problems in AN using the IIP. Hartmann, Zeeck, and Barrett (2010) found that patients with eating disorders report particularly pronounced interpersonal difficulties with nonassertiveness and with putting others needs before one s own. Patients with AN-BP reported more difficulties with social avoidance and lack of closeness to others than patients with AN-R, and these difficulties did not improve with inpatient or day hospital treatment (Hartmann et al., 2010). Taken together, preliminary studies suggest that interpersonal problems may vary according to AN subtype and may affect treatment outcome. The overall goals of the current study were to characterize interpersonal difficulties in AN and to determine whether certain interpersonal problems are associated with AN psychopathology and treatment outcome. In order to address these goals, the current study had five specific aims. The first aim was to examine whether patients with AN-R and AN-BP differ on IIP subscales. The second aim was to compare the IIP profiles of AN patients to a normative community sample as described in Horowitz et al. (2000). The third aim was to examine the association between interpersonal functioning and eating disorder psychopathology. The fourth aim was to examine whether interpersonal problems in AN would improve with remission of the eating disorder. The final aim was to examine whether interpersonal problems at baseline would predict treatment noncompletion. 2. Methods 2.1. Participants The participants were a consecutive series of 218 individuals who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Revised (DSM-IV-Revised) criteria for AN based on the Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) interview. All were admitted to the hybrid inpatient/day treatment unit of the Eating Disorders Program of the Toronto General Hospital between 2000 and This is a specialized program for severe AN operated by an interdisciplinary team. Program goals include medical stabilization, weight gain to a healthy level, eradication of binge eating and purging symptoms, normalized eating, and intensive group psychotherapy (Olmsted et al., 2010). The program accommodates up to 12 patients in the group at a time who are together for h weekly, which creates an intensive therapeutic milieu. At admission to the inpatient unit, the 218 participants had a mean age of 26.0 years (SD = 7.6) and a mean BMI of 14.8 (SD = 1.8). Three percent were male and 97% were female. The mean duration of AN was 7.1 years (SD = 6.8) and the mean age of onset of AN was 18.9 years (SD = 6.1). The average length of stay was 13.5 weeks (SD = 6.4) and the mean weight gain was 11.5 kg (SD = 6.3). Eighty-three percent were single, 12% were married or living in common-law relationships and 5% were separated or divorced. Most participants were students (42.2%), 38.7% were employed, and 19.1% were unemployed. With regard to racial background, 87% were Caucasian, 3% were Asian, 2% were African-Canadian, and 8% were Jewish or European. 39% of participants met DSM-IV criteria for the binge purge subtype of AN (AN-BP), while the remaining 61% had the restricting subtype of the illness (AN-R) Measures The following measures were administered at pre- and posttreatment: Fig. 1. Diagram of the interpersonal circumplex from Horowitz et al. (2000) Eating Disorder Examination-Questionnaire (EDE-Q; Fairburn & Bèglin, 1994) Eating disorder psychopathology was measured using the fifth edition of the EDE-Q. The EDE-Q produces four subscale scores: shape concern, weight concern, eating concern, and dietary restraint, which can be combined into one Global score. It has been shown to have good internal consistency and test retest reliability (Luce & Crowther, 1999).

3 J.C. Carter et al. / Personality and Individual Differences 53 (2012) Table 1 Means, standard deviations, and Cronbach s alphas for the subscales of the IIP for patients with AN and the Normative Community Sample Comparison Group. Alpha AN Pre-treatment AN Post-treatment Community M SD M SD M SD Domineering Controlling Vindictive/Self-Centered b 4.90 Cold-Distant a 5.60 Socially Inhibited a 5.70 Nonassertive a 6.10 Overly Accommodating a 5.40 Self-Sacrificing a 5.50 Intrusive-Needy b 4.60 a b Significantly lower than AN sample pre-treatment. Significantly higher than AN sample pre-treatment. Table 2 Hierarchical logistic regression demonstrating the association between AN subtype and interpersonal problems with treatment outcome. B SE Wald p OR 95% CI Step 1 AN Subtype Step 2 Domineering/Controlling Vindictive/Self-Centered Cold/Distant Socially Inhibited Nonassertive Overly Accommodating Self-Sacrificing Intrusive/Needy Step 3 AN Domineering/Controlling AN Vindictive/Self-centered AN Cold/Distant AN Socially Inhibited AN Nonassertive AN Overly Accommodating AN Self-Sacrificing AN Intrusive/Needy Note. N = 218. Cox and Snell R 2 for the model =.14. AN = anorexia nervosa; OR = odds ratio; CI = confidence interval Inventory of Interpersonal Problems-32 (IIP-32; Horowitz et al., 2000) This is a 32-item self-report measure that was shortened from the 64-item IIP (Horowitz et al., 2000). Respondents are asked to rate the extent to which they have had difficulty with various interpersonal problems on a 4-point Likert scale from 1 (not at all) to 4(extremely). The IIP-32 is composed of eight 4-item subscales: Domineering/Controlling (problems giving up control of interpersonal situations); Vindictive/Self-Centered (problems caring for and being involved with others); Cold/Distant (problems feeling close to others); Socially Inhibited (problems being sociable); Nonassertive (problems asserting oneself), Overly Accommodating (problems with not standing up for oneself); Self- Sacrificing (problems with placing the needs of others before one s own), and Intrusive/Needy (problems being open with regards to one s personal life). Subscales scores range from 4 to 16, and a total score is obtained by summing the subscale scores. Higher scores on all subscales reflect greater levels of interpersonal difficulties. This measure has demonstrated strong internal consistency for each subscale (Horowitz et al., 2000). For the purposes of the current study, each subscale was used as an individual predictor and demonstrated acceptable reliability (see Table 1) Statistical analyses All statistical analyses were conducted using SPSS version 19 (SPSS, Chicago). First, a series of two-tailed t-tests were conducted to examine mean baseline differences in IIP subscale scores among patients with AN-R (n = 132) and AN-BP (n = 86). Second, IIP scores for AN patients were compared to a normative community sample of females (n = 400) as described in Horowitz et al. (2000). An alpha level of.01 was used to control the Type 1 error rate. The normative community sample consisted of 400 females aged years. Ethnicity, education level, and region were stratified across groups and 100 females from each age range (18 24, 25 44, 45 64, and 65+) were included so that the sample was representative of the United States (Horowitz et al., 2000). Third, zero-order correlations between each of the IIP subscales and the EDE-Q Global score at baseline were calculated to ascertain the association of interpersonal problems with the core psychopathology of AN. Next, a repeated measures multivariate analysis of variance (RM MANOVA) was used to examine changes in interpersonal problems over the course of treatment. AN subtype was employed as the between-group variable (two levels, AN-R and AN-BP), and time (two levels; pre-treatment and post-treatment) as the within-group variable. Pairwise comparisons using the Bonferroni correction were used to ascertain the point of the significant interaction or main effect. An overall alpha level of p <.05 was used. This analysis was performed on only those participants who successfully completed the treatment program. Finally, a hierarchical logistic regression was performed to examine whether interpersonal problems predicted treatment non-completion. The dependent variable in this analysis was whether or not the patient successfully completed the treatment

4 172 J.C. Carter et al. / Personality and Individual Differences 53 (2012) program. Successful treatment completion was defined as achieving a body mass index (BMI) of at least 20 at the end of treatment and remittance of binge eating and purging behavior during the last 4 weeks of treatment. Patients who did not meet these criteria were defined as non-completers. AN subtype was dummy-coded and entered into block one, the eight subscales of the IIP were entered into block two, and finally the interactions between AN subtype and each interpersonal problem were entered as a block into step three. An alpha level of.05 was used. 3. Results 3.1. Baseline comparisons between AN-R and AN-BP Overall, individuals with AN-BP (M = 62.92, SD = 17.09) reported significantly greater levels of total interpersonal problems than individuals with AN-R (M = 56.25, SD = 17.63) [t(216) = 2.76, p =.006]. Baseline comparisons between AN-R and AN-BP on each of the IIP subscales revealed that patients with AN-BP reported significantly higher scores on the Vindictive/Self-Centered subscale only than those with AN-R [t(216) = 2.88, p =.004]. However, it is of note that scores on this subscale were actually quite low for both subtypes (AN-R, M = 2.60, SD = 3.34; AN-BP, M = 4.21, SD = 4.93). No other significant differences on any of the other IIP subscales emerged between the two AN subtypes. Because there were next to no baseline differences on IIP subscale scores between the two subtypes, we conducted subsequent analyses on the sample as a whole Baseline comparisons with normative community sample In comparison with the normative community sample, patients with AN reported significantly lower scores on the Intrusive/Needy subscale [t(616) = 2.51, p =.01] and the Vindictive/Self-Centered subscale [t(616) = 4.03, p <.001)], and significantly higher scores on the Overly Accommodating [t(616) = 4.97, p <.001)], Nonassertive [t(616) = 5.50, p <.001)], Social Inhibition [t(616) = 6.71, p <.001)], Cold/Distant [t(616) = 3.50, p <.001)], and Self-Sacrificing [t(615) = 3.22, p =.001)] subscales (see Table 1) Baseline correlations between IIP subscales and EDE-Q Global score Severity of eating disorder pathology, as measured by the EDE-Q Global score, was positively and significantly correlated with the Domineering/Controlling (r =.24, p <.001), Cold/Distant (r =.33, p <.001), Socially Inhibited (r =.42, p <.001), Nonassertive (r =.34, p <.001), Overly Accommodating (r =.41, p <.001), and Self-Sacrificing (r =.31, p =.003) subscales of the IIP Impact of treatment on interpersonal problems One hundred and twenty-four (57.1%) patients successfully completed the program, 40 (18.4%) dropped out and 53 (24.4%) were discharged prematurely by staff due to insufficient progress or failure to adhere to program norms. Treatment completers remained in treatment for significantly more weeks (M = 16.84, SD = 5.30) than noncompleters (M = 9.03, SD = 4.92), t(216) = 11.11, p <.001). Among treatment completers, there was a significant within-subjects main effect of time (Wilk s K =.75, F (8, 81) = 3.38, p =.002, partial g 2 =.25) indicating that the level of interpersonal problems significantly decreased over time for both subtypes. However, there was no significant effect of AN subtype (p =.67) nor was there a subtype by time interaction (p =.32). In order to further explore the significant main effect of time, univariate tests were conducted. For both subtypes, scores on the Domineering/Controlling (p =.006), Cold/Distant (p =.005), Nonassertive (p =.031), Overly Accommodating (p =.026), Self-Sacrificing (p =.001), and Intrusive/Needy (p =.012) subscales significantly decreased from pre- to post-treatment Interpersonal problems as predictors of treatment outcome Individuals with AN-R were significantly more likely to complete the program than those with AN-BP (70.2% vs. 29.8%; t(216) = 3.41, p <.001). In order to investigate whether certain interpersonal problems predicted treatment success, a hierarchical logistic regression analysis was performed with treatment outcome status of the participants entered as a categorical dependent variable. AN subtype was dummy-coded and entered into block one, the eight subscales of the IIP were entered into block two, and finally the interactions between AN subtype and each interpersonal problem were entered as a block into step 3 (see Table 2). AN subtype significantly predicted treatment outcome, v 2 (1) = 10.84, p =.001. Specifically, AN subtype correctly classified 52.1% of those who did not complete the program and 69.9% of those who did, for an overall success rate of 62.2%. After controlling for AN subtype, the IIP subscales showed a trend approaching significance in predicting treatment outcome, v 2 (8) = 15.11, p =.057. Examination of the individual subscales revealed that only Social Inhibition significantly contributed to the model (see Table 2), indicating that as levels of Social Inhibition increased the odds of successful treatment completion decreased. The model correctly classified 51.1% of those who did not complete treatment and 76.4% of those who did, for an overall success rate of 65.4%. A test of the model on the full dataset (including interaction terms between each IIP subscale and AN subtype) was not statistically significant, v 2 (8) = 6.36, p =.607 (see Table 2), indicating that there was no difference between the two subtypes in terms of how interpersonal problems affected response to treatment. 4. Discussion The primary goals of this study were to examine the nature of interpersonal problems in AN and to determine whether interpersonal problems are related to AN psychopathology and treatment outcome. On average, patients with the binge/purge subtype of AN reported greater overall interpersonal problems than patients with the restricting subtype, and interpersonal problems were associated with AN psychopathology across both subtypes. In comparison to a normative community sample, patients with AN reported lower than normal levels of intrusiveness/neediness, suggesting a lack of closeness in their relationships, and lower than normal levels of vindictiveness/self-centeredness, suggesting great difficulty expressing feelings of anger. AN patients also reported more problems with being unassertive, socially inhibited, cold and distant, overly accommodating, and self-sacrificing in their relationships. We found that those interpersonal problems in which AN patients were high tended to decrease over the course of treatment, with the exception of social inhibition, which not only remained unchanged but also predicted treatment non-completion. Social inhibition therefore seems to be defining, stable, and detrimental in individuals with AN. Our findings are consistent with previous research indicating that people with AN tend to struggle with socially inhibited and submissive traits (e.g., Tasca et al., 2004; Troop, Allan, Treasure, & Katzman, 2003; Westen & Harnden-Fischer, 2001). The findings are compatible with Schmidt and Treasure (2006) cognitive-interpersonal model of AN suggesting that people with AN tend to avoid close relationships, possibly as a way of avoiding the experience

5 J.C. Carter et al. / Personality and Individual Differences 53 (2012) and expression of emotions. Our results also suggest that people with AN often have difficulty asserting their needs, and it is possible that AN symptoms may function to communicate certain needs for example, the need for care and attention without having to communicate these needs directly. The current results indicated that the severity of eating disorder psychopathology was significantly associated with the level of interpersonal problems. Eating disorder severity scores were significantly positively correlated with six out of the eight IIP subscales suggesting that greater interpersonal difficulties in both the affiliation and dominance dimensions are associated with more severe dietary restraint, eating concern, as well as more extreme concerns about eating, shape and weight. Given the cross-sectional nature of the study, it is not possible to establish the direction of this association it may be that more severe eating disorder symptoms produce greater interpersonal dysfunction and it is also possible that greater interpersonal dysfunction contributes to more severe eating disorder symptoms or to the maintenance of eating disorder psychopathology. In terms of treatment outcome, there were significant improvements in interpersonal problems among those who successfully completed the treatment program, and there were no differences between AN-BP and AN-R in terms of improvements on the IIP. Specifically, there were improvements in difficulties with feeling close to others, asserting oneself, and placing the needs of others before one s own. It is possible that the strong group therapy element of the program contributed to improvements in these interpersonal difficulties. Interestingly, we did not detect significant improvements in terms of social inhibition. This may suggest that social avoidance is the interpersonal difficulty that is most intertwined with AN symptoms given that it seems to be resistant to change. It is also possible that difficulties with social inhibition may improve with time. However, a limitation of this study is that we did not collect follow-up data on the IIP. It is intriguing that there were decreases on the Domineering/Controlling subscale (difficulty giving up control of interpersonal situations) and on the Intrusive/Needy subscale (sharing too much about one s personal life) even though these scores were not elevated compared to normal controls at baseline. In terms of the association between IIP scores and treatment outcome, higher levels of social inhibition predicted treatment noncompletion, but AN subtype did not moderate this relationship. Engagement with treatment is a significant challenge in this population. Research by our group and others has shown that attrition from intensive treatment programs is high and tends to occur sooner and at a substantially higher rate among AN-BP patients than AN- R patients (Kahn & Pike, 2001; Woodside, Carter, & Blackmore, 2004). Consistent with previous studies, patients with AN-BP in the current study were significantly more likely to drop-out or be prematurely discharged from the treatment program, but our findings did not uncover any evidence to suggest that interpersonal problems explain this difference in rates of noncompletion. For individuals with an avoidant interpersonal style, it is possible that the level of interpersonal intensity in the program was perceived as progressively threatening as it became associated with the risk of being exposed to conflict, criticism and negative emotions. The current study had certain limitations. First, the sample was recruited from a tertiary care clinic that treats severely ill patients and the findings may not generalize to other AN samples. Second, interpersonal problems were measured using a brief self-report measure and it is possible that responses may have been biased by the effects of starvation or the desire to deny or minimize the level of distress. Third, our analyses rely on only two time points making it impossible to tease apart the temporal relationship between changes in interpersonal problems and changes in AN symptoms. The current findings may have some possible clinical implications. First, patients with AN may benefit from interventions designed to help them identify and express their feelings and needs directly. Second, since social avoidance was associated with premature termination of treatment and did not improve with treatment of the eating disorder, it may be important to specifically target social inhibition within acute treatment programs for AN. Since most programs are group therapy based, it may be useful to include an interpersonal group therapy component that is designed to specifically address problems with social inhibition. Future research should examine the temporal relationship between improvements in eating disorders symptoms and improvement in interpersonal difficulties during treatment. It would also be important for future studies to investigate the mechanisms by which social avoidance leads to early withdrawal from AN treatment. One interesting possible mechanism worth investigating is emotion avoidance, as Schmidt et al. (2011) have suggested that the desire to avoid experiencing intense emotions may explain the social inhibition seen in AN. Finally, future research should examine the course of interpersonal difficulties following acute treatment of AN to determine whether certain problems continue to improve post-discharge. 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