Modifiability of Neuroticism, Extraversion, and Agreeableness by Group Cognitive Behaviour Therapy for Social Anxiety Disorder

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1 Modifiability of Neuroticism, Extraversion, and Agreeableness by Group Cognitive Behaviour Therapy for Social Anxiety Disorder Krystyna Glinski and Andrew C. Page The University of Western Australia, Australia The study investigated if the degree of personality pathology among people with clinical levels of social anxiety disorder was similar to those with personality disorders more generally, if the degree of avoidant personality pathology was correlated positively with Neuroticism and negatively with Extraversion and facets of Agreeableness (particularly Trust), and finally if scores on the relevant personality dimensions improve from pre- to post-treatment. Changes in Neuroticism, Extraversion, and Agreeableness were examined following group treatment for social anxiety disorder. The current study employed a within-subjects repeatedmeasures design (N = 25) to investigate whether these traits can be changed by group treatment for social anxiety disorder. A measure of personality disorder pathology was found to correlate positively with Neuroticism and negatively with Agreeableness in the absence of significant relationships with other Five-Factor Model traits. Treatment was associated with significant reductions in Neuroticism and there was significant improvement of the Trust facet of Agreeableness. These results are discussed in terms of the way that group treatment for Social Anxiety Disorder may be enhanced. Keywords: social phobia, personality disorders, Five Factors model, neuroticism, agreeableness, avoidant personality disorder. 42 Social anxiety disorder is comorbid with avoidant personality disorder (Widiger, 1992). To the extent that this relationship exists because avoidant personality disorder is at the extreme end of a continuum of social anxiety, the personality profile of patients presenting for treatment with social anxiety disorder will exhibit characteristics of individuals with personality disorders and therefore treatment should address these features. The Five-Factor Model offers a dimensional description of personality in terms of Neuroticism (N), Extraversion (E), Openness to experience (O), Agreeableness (A) and Conscientiousness (C; Costa & McCrae, 1992), and Morey et al. (2002) showed that avoidant personality disorder involves high Neuroticism, low Extraversion, and low Agreeableness. The elevated Neuroticism and the suppressed Extraversion are not unexpected given the symptoms of social anxiety disorder. Anxiety in social situations would be associated with elevated arousal under stress Address for correspondence: Andrew Page PhD, School of Psychology, University of Western Australia, 35 Stirling Highway, Crawley WA 6009, Australia. andrew@psy.uwa.edu.au Volume 27 Number pp

2 Modifiability of Neuroticism, Extraversion, and Agreeableness and fear of negative evaluation would be consistent with a preference for solitary pursuits. More surprisingly, the authors also observed that people with avoidant personality disorder exhibited low Agreeableness. Low Agreeableness is less unexpected in the context of the broader literature on personality disorders. A meta-analysis (Saulsman & Page, 2004) showed that when personality disorders are mapped onto a two-dimensional space defined by Neuroticism and Agreeableness, each disorder demonstrates a moderate positive relationship with Neuroticism and a moderate negative relationship with Agreeableness. The antagonism, or low end of the Agreeableness continuum, is characterised by cynicism, rudeness, abrasiveness, suspiciousness, uncooperativeness, irritability and manipulative, vengeful and ruthless behaviour (Costa & Widiger, 2002). Although these traits seem atypical of people with social anxiety and avoidant personality disorders, there is one facet of Agreeableness that might explain the covariation. This facet is Trust. Trust is the tendency to attribute benevolent intent to others and an absence of the suspicion that others are dishonest or dangerous, and it is not unreasonable to expect that people with a high fear of negative evaluation who also lack trust would become particularly anxious in social settings. Consistent with this impression Wilberg, Urnes, Friis, Pedersen, and Karterud (1999) found that avoidant personality disorder is associated with low Trust. Likewise, while people with social anxiety disorder possess average levels of Agreeableness (Bienvenu, Nestadt, Samuels, Costa, Howard, & Eaton, 2001) at the facet level, Trust is in the low range. Therefore, to the extent that people with social anxiety disorder show similar profiles to those with personality disorders, it is important to determine the extent to which treatment reduces the personality features because these traits can reflect a vulnerability to future psychopathology (e.g., Andrews, Page, & Neilson, 1993). Neuroticism is modifiable using cognitive behavioural treatment methods. Reductions in Neuroticism of around 1.25 standard deviation units (Jorm, 1989) occur following cognitive behaviour therapy. Extraversion also can improve following treatment (Santor, Bagby, & Joffe, 1997). Thus, despite personality traits being defined as stable and enduring in nature, personality assessments do reflect changes in personality traits following treatment. Given that treatment-related changes in Neuroticism and Extraversion occur, the next issue is whether change in Agreeableness can occur in therapy. Three studies speak to the modifiability of Agreeableness. Trull, Useda, Costa, and McCrae (1995) observed a reduction in Neuroticism and an increase in Agreeableness after outpatient treatment for a range of psychological disorders. Piedmont and Ciarrocchi (1999) found a reduction in Neuroticism and increases in Extraversion, Openness to experience, Conscientiousness and Agreeableness (particularly on the facet of Trust) over a 6-week outpatient drug rehabilitation program. In contrast, Carter et al. (2001) found no change in Agreeableness among opioiddependent outpatients and only small but significant decreases in Neuroticism and increases in Extraversion and Conscientiousness. Thus, it remains unclear whether Agreeableness can be altered by therapy and, more specifically, can these occur in the context of social anxiety disorder? Cognitive behavioural group therapy for social anxiety disorder includes treatment components designed to reduce physical anxiety symptoms and fear of negative evaluation. Furthermore, although cognitive behavioural treatments for social anxiety disorder (e.g., Andrews, Creamer, Crino, Hunt, Lampe, & Page, 2003) do not explicitly address deficits in Agreeableness, 43

3 Krystyna Glinski and Andrew C. Page they include explicit training in social skills and assertiveness designed to improve interpersonal relations. The group context also provides a forum within which trust may be developed as participants are involved with other people during treatment and therefore improvements in Agreeableness and Trust seem possible. Thus, the present study asked first, is degree of personality pathology among people with clinical levels of social anxiety disorder similar to those with personality disorders more generally? Second, is degree of avoidant personality pathology correlated positively with Neuroticism and negatively with Extraversion and facets of Agreeableness (particularly Trust)? Third, do scores on the relevant personality dimensions improve from pre- to post-treatment? Method Participants Twenty-nine participants were recruited from three social anxiety disorder treatment groups, each lasting 9 weeks (2 hours per week). Participants with comorbid problems, such as depression, panic disorder, agoraphobia, and alcohol dependence were included in the treatment groups only if these problems were considered secondary to the person s social anxiety disorder and not sufficiently severe to warrant treatment prior to attending the group. They completed an assessment interview with one of five clinicians who established that they met DSM-IV (American Psychiatric Association, 2003) diagnostic criteria for social anxiety disorder (27 were classified as generalised subtype). Seven participants (29%) also met diagnostic criteria for avoidant personality disorder. Four participants did not complete the treatment program and thus did not provide post-treatment data (and data from another participant were excluded due to extreme outlying data points). On average, the treatment completers attended eight of the nine scheduled therapy sessions. Of the treatment completers, 40% were female and they had a mean age of 37.2 years (SD = 13.2; range 19 to 62). 44 Materials The Social Phobia module of the Anxiety Disorders Interview Schedule for DSM- IV (ADIS-IV; Brown, Di Nardo, & Barlow, 1994) was used to determine whether participants met diagnostic criteria for Social Anxiety Disorder. This measure is a valid and reliable (Brown, Di Nardo, Lehman, & Campbell, 2001) method of determining the presence of an anxiety disorder. The Avoidant Personality Disorder Module of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Spitzer, Gibbon, & Williams, 1997), which is recognised for high levels of validity and reliability, was used to assess the presence of avoidant personality disorder. The PDQ-4+ (Personality Diagnostic Questionnaire 4+; Hyler, 2003) is a 99- item true/false self-report measure that assesses the 10 DSM-IV personality disorders. It also provides an index of the overall level of personality disturbance. In spite of some doubt about the reliability of the PDQ-4+ for diagnosing the 10 DSM-IV personality disorders in the absence of supplementary clinical information, the PDQ-4+ is a useful and valid measure of degree of general personality pathology and is recommended for use in research as a continuous variable (Hyler, 2003). Each participant s degree of avoidance was calculated by summing the seven avoidant personality disorder-related items to which they responded true.

4 Modifiability of Neuroticism, Extraversion, and Agreeableness The following measures were administered prior to and following treatment. The dimensions of Neuroticism, Agreeableness, Extraversion, Openness to experience, Conscientiousness and the facet of Trust were measured on the NEO-PI-R (Costa & McCrae, 1992). Internal consistency for the dimension scales ranges from.86 to.92, and from.56 to.81 for the facet scales (Costa & McCrae, 1992). Appropriate factor structure and convergent and discriminant validity has been established for the NEO-PI-R (Costa & McCrae, 1992). In the current study, participants scores were evaluated against male and female adult norms to derive T-scores for the purpose of interpreting levels of personality traits. However, statistical analyses were conducted on raw scores, to preserve the range of scores on each scale. The Fear of Negative Evaluation scale (FNE-30 items) and Social Avoidance and Distress Scale (SADS-28 items) measure expectation and distress related to negative evaluation from others as well as distress in, and avoidance of, social situations (Watson & Friend, 1969). Internal consistency is for the FNE scale and.94 for the SADS (Watson & Friend, 1969). The Social Phobia Scale (SPS-20 items) and the Social Interaction Anxiety Scale (SIAS-20 items; Mattick & Clarke, 1998) assessed fear of being scrutinised during routine activities and more general social interactions. Individuals with Social Anxiety Disorder are reported to have a mean score of 32.8 (SD = 14.9) on the SPS and 49.0 (SD = 15.6) on the SIAS (Heimberg, Mueller, Holt, Hope, & Liebowitz, 1992). Both scales are reported to have high internal consistency (SPS;.87 to.94, SIAS;.86 to.94), good construct and discriminant validity, and sensitivity to change in treatment (Orsillo, 2001). The Gambrill and Richey Assertion Inventory (GRAI: Gambrill & Richey 1975), measures discomfort with assertion (DAI) and probability of engaging in assertive behaviour (RP). The GRAI has good test retest reliability, has been shown to be effective in discriminating between clinical and normal samples, and is sensitive to treatment change. The Beck Depression Inventory (BDI-II: Beck, Steer, & Brown, 1996) assessed the severity of depressive symptoms. The reliability (coefficient alpha estimates are.92 to.93) and validity of the BDI-II have been well established and the measure is sensitive to change (Nezu, Ronan, Meadows, & McClure, 2000). Procedure Participants self-referred to join one of the regular Social Anxiety Disorder treatment groups. Clinicians were postgraduate clinical psychology trainees under supervision of the second author. They conducted an individual assessment interview with each participant. During the interview, the Social Phobia module of the ADIS-IV and the Avoidant Personality Disorder module of the SCID-II were administered to ascertain whether each participant met criteria for social phobia and/or avoidant personality disorder. Assessment outcomes were reviewed in clinical supervision to confirm diagnoses. Following the assessment, each potential participant was invited to participate in the current research project and given the questionnaire package to complete prior to the first group treatment session. At the end of the treatment program the questionnaire package was readministered. The Social Anxiety Disorder group treatment used a manual-based program (Andrews et al., 2003). Initially, participants were provided with psychoeducation about anxiety and taught controlled breathing and relaxation strategies to assist anxiety management. The cognitive model of social anxiety and the role of think- 45

5 Krystyna Glinski and Andrew C. Page ing were then addressed. Participants were taught to monitor and challenge their unhelpful thinking to reduce anxiety. These strategies were incorporated into graded exposure to feared interpersonal situations in order to reduce avoidance and provide effective anxiety management experiences. The final module incorporated social skills training, development of conversation skills and assertiveness training. Participants were encouraged to tailor these techniques to their own needs and this process was facilitated through regular between-session tasks. Results Pre-Treatment Analyses The mean scores on the four Social Anxiety Disorder measures (Table 1) confirmed that the current participant sample exhibited clinical levels of Social Anxiety Disorder symptoms. The distributions of scores on the FNE scale and SADS exhibited ceiling effects and therefore a composite Social Phobia Index (SPIndex) was created by calculating the mean of the z scores for each of the measures. The resulting index did not possess a ceiling effect. Scores on the measure of general personality disorder pathology (PDQ-4+) ranged from 20 to 63 and had a mean of (SD = 12.11). This is in the original authors patients in therapy without a significant personality disturbance range (Hyler, 2003), but is above the cut-off of suggested in other studies (e.g., Fossati et al., 1998) to indicate a substantial likelihood of significant personality disturbance. Thus, the current sample reported a range of personality disorder pathology characteristics consistent with what might be expected for a treatment-seeking social anxiety disorder sample with some degree (29%) of comorbidity with avoidant personality disor- TABLE 1 Pre- and Post-Treatment Means (Standard Deviation in parentheses) for Measures of Social Anxiety and the NEO Personality Scores Measure Pre Treatment Post Treatment M (SD) M (SD) 46 FNE (3.70) (9.10) SADS (4.77) (7.45) SIAS (10.12) (13.28) SPS (14.38) (14.41) SPIndex.00 (.70) 1.86 (1.25) GRAI-DAI (15.98) (22.23) GRAI-RP (10.37) (20.97) BDI (10.25) 9.82 (8.19) Neuroticism (22.66) (27.90) Extraversion (19.96) (23.22) Openness (16.75) (15.92) Agreeableness (14.02) (9.70) Trust (5.30) (5.01) Conscientiousness (19.81) (20.60)

6 Modifiability of Neuroticism, Extraversion, and Agreeableness der. The degree of avoidant personality pathology (avoidance) was calculated by summing the number of avoidant personality disorder-related items to which they responded true on the PDQ-4+ (M = 6.04, SD =1.27). T scores on the NEO-PI-R personality dimensions were used for the purpose of comparison with the norms reported for the NEO-PI-R (Costa & McCrae, 1992). The mean Neuroticism score of (SD = 7.98) was in the very high range. Extraversion score of (SD = 10.09) was in the low range. The mean Openness to Experience score of (SD = 9.58) was in the average range. The mean Agreeableness score of (SD = 9.98) was in the average range (Bienvenu et al., 2001). On the facet of Trust, the mean was in the low range (M = 39.58, SD = 12.25). Mean Conscientiousness score of (SD = 9.82) was in the low range. The correlations between the five personality factors and the two measures of personality disorder pathology were examined to determine whether they follow the same patterns as those found in previous research with personality disorders (Saulsman & Page, 2003; 2004). Spearman s Rho correlations were used on account of the non-normal distribution of the avoidance and Neuroticism variables. Given that raw scores on the NEO-PI-R show a systematic gender difference (Costa & McCrae, 1992), partial correlations were used to portion out the effect of gender in this analysis. Table 2 shows moderate correlations between the general measure of personality disorder pathology (PDQ-4+) and the FFM traits of Neuroticism and Agreeableness. The positive correlation with Neuroticism and negative correlation with Agreeableness, in the absence of significant correlations with the other FFM traits, is consistent with previous research findings about the common factors in personality disorder pathology. Saulsman and Page s (2004) meta-analysis also reported the mean correlations between the FFM traits and avoidant personality disorder, and the mean for all personality disorders combined. These means represent a comparison point for the current research. In Figure 1a the mean correlations between the FFM traits and the general measure of personality disorder pathology in this study are contrasted with the mean correlations reported by Saulsman and Page (2004). The correlations in the current research show a similar pattern, in that the strongest correlations present are a positive correlation with Neuroticism and a negative relationship with Agreeableness, the proposed common factors in personality TABLE 2 Intercorrelations Between PDQ-4+, Avoidance, SPIndex, Measures of FFM Personality Dimensions and the Facet of Trust Among 24 People with Social Anxiety Disorder Measure Avoidance N E O A Trust C SPIndex PDQ * *.55* Avoidance.23.48* * N * E * O A.75* Trust C Note: * p <.05

7 Krystyna Glinski and Andrew C. Page a) b) Correlation Combined Personality Disorders (Saulsman & Page, 2004) General Personality Pathology (PDQ4+ Current Study) Correlation Avoidant Personality Disorder (Saulsman & Page, 2004) Avoidant Personality Pathology (Avoidance Current Study) N E O A C N E O A C Five Factor Model Personality Traits Five Factor Model Personality Traits FIGURE 1 Comparison of correlations between FFM traits and (a) general personality disorder and (b) avoidant personality disorder pathology between the current study and the meta-analysis by Saulsman and Page (2004). 48 disorders. It is noteworthy that social anxiety disorder symptoms did not correlate significantly with the personality disorder pathology measure (Rho =.20, p =.35) and that the presence of social anxiety disorder symptoms was correlated positively with Neuroticism and negatively with Extraversion, but not with Agreeableness or Trust. Thus, the personality factors associated with personality disorder pathology show a different pattern from those associated with social anxiety disorder symptomatology, even within the same sample. In Figure 1b the mean correlations between the FFM traits and avoidance (the measure of avoidant personality disorder pathology) are contrasted with the mean correlations reported by Saulsman and Page (2004). Avoidant personality disorder pathology has a positive relationship with Neuroticism and a strong negative relationship with Extraversion. A negative relationship with Agreeableness was also present. To determine the extent to which variability in personality disorder pathology could be accounted for by the factors of Neuroticism and Agreeableness, but not by Extraversion, Openness to experience and Conscientiousness, a hierarchical multiple regression was conducted. In the first step gender, Neuroticism and Agreeableness were entered as predictors simultaneously as one block and in the second step Extraversion, Openness to Experience and Conscientiousness were entered simultaneously as one block (Pedhazur, 1997). In terms of the prediction of PDQ-4+ scores, step one accounted for 41% of variance (R =.64, R 2 =.41, F(3, 20) = 4.64, p =.01) and both Neuroticism (β =.46) and Agreeableness (β =.43) emerged as significant predictors. Consistent with Saulsman and Page (2004), step two did not account for additional variance (F change (3,17) =.91, p =.46; ΔR 2 =.08). Post-Treatment Analyses A repeated-measures multivariate analysis of variance (MANOVA) was compared pre and post treatment scores on the four dependent variables: SPIndex, depression (BDI), assertiveness discomfort (GRAI-DAI) and assertiveness response probability (GRAI-RP). Significant differences were found between the two time-points on the dependent measures, Wilks s Λ =.20, F(4,17) = 17.51, p <.01. The multivariate η 2

8 Modifiability of Neuroticism, Extraversion, and Agreeableness based on Wilks s Λ was strong,.81. There were significant improvements in social anxiety disorder symptoms, F(1,20) = 71.02, p <.001, assertiveness discomfort, F(1,20 = 42.34, p <.001, assertiveness probability, F(1,20) = 23.51, p <.001, and depression, F(1,20 = 18.84, p <.001. Significant reductions were observed on the SPIndex from pre- to post-treatment and an inspection of change on the FNE and SADS indicated that, on average, participants symptoms improved significantly in treatment. On the FNE, the participants mean score reduced from to which, when compared to norms on the measure, indicates a reduction in symptoms from the clinical social anxiety disorder range to the range reported by a college student sample (Watson & Friend, 1969). Similarly, on the SADS, compared to published norms, participants moved from the social anxiety disorder range into the range reported by college student samples. On the assertiveness measures, the current sample s pre-treatment scores indicated that they were less assertive than the college student means reported by Gambrill and Richey (1975). At post treatment, scores remained elevated compared to college norms but had reduced significantly. However, both pre and post treatment the mean scores would be classified as unassertive. On the BDI, mean scores moved from the mild to the minimal depression range. Change over time on the five NEO personality dimensions was assessed using a repeated-measures MANOVA with gender as a factor, to control for gender differences inherent in the NEO scales. Significant differences were found between the two time-points on the dependent measures, Wilks s Λ =.33, F(5,18) = 7.44, p < The multivariate η 2 based on Wilks s Λ was strong,.67 (Table 1). There was a reduction in Neuroticism, F(1,22) = 35.75, p <.001, and an increase in Extraversion, F(1,22) = 19.02, p <.001, but there was no change in Agreeableness, F(1,22) =.07, p =.79, Openness to Experience, F(1,22) = 3.68, p =.07, or Conscientiousness, F(1,22) = 1.77, p =.20. In all cases the main effect of gender and the interaction between gender and time did not reach statistical significance. A univariate ANOVA, used to test the hypothesis that the facet of Trust would change during treatment, showed a statistically significant increase, F(1, 22) = 6.35, p =.02, in Trust scores over time. No other facet of Agreeableness changed significantly. Discussion Prior to treatment the participants exhibited clinical levels of social anxiety disorder and a range of personality disorder pathology. Mean scores on the NEO-PI-R factors showed that Neuroticism was in the very high range, Agreeableness was in the average range and Trust was in the low range. There were moderate relationships between general personality disorder pathology and the FFM dimensions of Neuroticism (positive) and Agreeableness (negative), which together accounted for 41% of variance in general personality disorder pathology. This finding replicates the patterns previously reported (Saulsman & Page, 2004). Moving to consider the specific hypotheses, it was predicted that during treatment Neuroticism would decrease, while Extraversion and Agreeableness (and specifically Trust) would increase. Results showed a reduction in Neuroticism and an increase in Extraversion and Trust from pre- to post-treatment. However, no significant change was observed on the dimension of Agreeableness. Overall, these findings lend support to the position that facets of the FFM personality dimensions 49

9 Krystyna Glinski and Andrew C. Page 50 can change but the treatment could not effect an observable wholesale change on Agreeableness in the current sample and timeframe. One consideration when interpreting these results is the difficulty of assessing whether change in the scores on a personality trait measure reflects change in the underlying personality construct. First, changes may reflect only superficial alterations in participants selection of response options rather than changes in their personality. Second, changes on the scores may reflect changes in the behavioural expression of a personality trait. Lastly, they may reflect change in the underlying personality trait itself. Different theoretical definitions of personality offer various pragmatic views on whether it is possible to alter a personality trait (Heatherton & Nichols, 1994). Some researchers suggest that the biological and genetic underpinnings of personality traits may not be amenable to change through a behavioural intervention, which would only influence the way in which the underlying trait is expressed (Brody, 1994). However, Costa and McCrae s (1992) define the FFM personality traits as sets of behaviours. By this definition, a treatment that alters these behaviours in a way that makes them more adaptive would be considered to have a clinically useful effect on personality. It seems reasonable in the current study to infer that changes on the NEO-PI-R scores indicate some degree of behavioural change. The use of a behavioural measure of Trust and Agreeableness in future research could clarify the degree of personality change that occurs in treatment. This study found that scores on the facet of Trust changed from pre- to post-therapy. If this change is attributable to the treatment intervention (group cognitive behaviour therapy that addresses interpersonal issues), it could indicate that the treatment was effective in increasing the tendency to attribute benevolent intent to others and reducing the suspicion that others are dishonest or dangerous, but was ineffective in altering the other five facets of Agreeableness. Future research is required to determine whether the other facets of Agreeableness can be changed, given that an alternative interpretation is that Trust is the only facet amenable to change. Additional intervention strategies to target the remaining facets may be required for the development of an agreeableness therapy. Therefore, it is of interest to speculate about other interventions that could target the remaining five facets of Agreeableness if one were to be treating disorders where all facets are elevated. One facet is Altruism, on which a low score describes individuals who are self-centred and reluctant to become involved in helping others. Guidance for improving Altruism may be drawn from the growing literature on organisational citizenship, which investigates volunteering, helping and cooperating with others, and team-building (Borman, 2004). The construct of Compliance is related to interpersonal conflict and it is plausible that low scorers could improve their conflict resolution skills in interventions that increase cooperation and awareness of one s role within a system, such as group-based interpersonal psychotherapy (e.g., Vinogradov, Cox, & Yalom, 2003). Training in empathy skills, which has been researched in populations of helping professionals (e.g., Barone, Hutchings, Kimmel, Traub, Cooper, & Marshall s, 2005) may also increase the trait of Tendermindedness and could potentially influence the frequency of altruistic behaviours. Suggestions for modifying Modesty come from Seligman s (1995) work on learned optimism, which uses principles of cognitive therapy to enable people to make accurate assessments of their own strengths and weaknesses, so that they are neither self-effacing nor conceited. Finally, dialectical behaviour therapy (Linehan, 1993) offers an interpersonal effectiveness skills module, which contains a number

10 Modifiability of Neuroticism, Extraversion, and Agreeableness of components likely to improve Agreeableness by facilitating assertive, validating and respectful communication. It is clear from this discussion of the array of alternative treatment options for low Agreeableness that considerable research will be required before the nature of an effective agreeableness therapy is established. What can be concluded from this study is that Neuroticism and at least one of the facets of Agreeableness change from pre- to post-treatment. This replicates previous research on change in Neuroticism and provides preliminary evidence that a specific treatment intervention targeting interpersonal concerns may be able to change Trust. The findings suggest that other treatment elements may further enhance the degree to which therapy may change agreeableness; a development that may be particular useful for people social anxiety disorder and avoidant personality disorder. References American Psychiatric Association. (2003). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L., & Page, A. (2003). The treatment of anxiety disorders: Clinician guides and patient manuals (2nd ed.). New York: Cambridge University Press. Andrews, G., Page, A.C., & Neilson, M.D. (1993). Sending your children away: Controlled stress decreases neurotic vulnerability. Archives of General Psychiatry, 50, Barone, D.F., Hutchings, P.S., Kimmel, H.J., Traub, H.L., Cooper, J.I., & Marshall, C.M. (2005). Increasing empathic accuracy through practice and feedback in a clinical interviewing course. Journal of Social and Clinical Psychology, 24, Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the BDI-II. San Antonio, TX: The Psychological Corporation. Bienvenu, O.J., Nestadt, G., Samuels, J.F., Costa, P.T., Howard, W.T., & Eaton, W. W. (2001). Phobic, panic, and major depressive disorders and the five-factor model of personality. The Journal of Nervous and Mental Disease, 189, Borman, W.C. (2004). The concept of organizational citizenship. Current Directions in Psychological Science, 13, Brody, M. (1994)..5 + or.5: Continuity and change in personal dispositions. In T.T. Heatherton & J.L. Weinberger (Eds.), Can personality change? (pp ). Washington DC: American Psychological Association. Brown, T.A., Di Nardo, P., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV. San Antonio TX: The Psychological Corporation. Brown, T.A., Di Nardo, P.A., Lehman, C.L., & Campbell, L.A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, Carter, J.A., Herbst, J.H., Stoller, K.B., King, V.L., Kidorf, M.S., Costa, P.T., Jr. et al. (2001). Short-term stability of NEO-PI-R personality trait scores in opioid-dependent outpatients. Psychology of Addictive Behaviours, 15, Costa, P.T., Jr., & McCrae, R.R. (1992). Revised NEO personality inventory (NEO-PI-R) and NEO five-factor inventory (NEO-FFI) [Professional manual]. Odessa, FL: Psychological Assessment Resources. Costa, P.T., Jr., & Widiger, T.A. (2002). Introduction: Personality disorders and the five-factor model of personality. In P.T. Costa, Jr & T.A. Widiger (Eds.), Personality disorders and the fivefactor model of personality (2nd ed., pp. 3 14). Washington, DC: American Psychological Association. First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1997). Structured clinical interview for DSM-IV personality disorders (SCID-II). Washington, DC: American Psychiatric Press Inc. Fossati, A., Maffei, C., Bagnato, M., Donati, D., Donini, M., Fiorilli, M., et al. (1998). Brief com- 51

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