On the specific depressotypic nature of excessive reassurance-seeking

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1 Personality and Individual Differences 40 (2006) On the specific depressotypic nature of excessive reassurance-seeking Andrea B. Burns, Jessica S. Brown, E. Ashby Plant, Natalie Sachs-Ericsson, Thomas E. Joiner Jr. * Department of Psychology, Florida State University, Tallahassee, FL , United States Received 30 November 2004; received in revised form 1 May 2005; accepted 24 May 2005 Available online 1 September 2005 Abstract Excessive reassurance-seeking has been proposed as a key variable in the development of a depressive spiral in which a dysphoric individual increasingly alienates significant others and thereby compounds his or her own depressive symptoms. Whereas previous research has substantiated an association between reassurance-seeking and depression, this study sought to establish that this relationship is specific to depressive symptoms, rather than generalized psychopathology. One hundred and seventy-eight undergraduate students completed measures assessing reassurance-seeking behavior; current symptoms of depression, anxiety, and eating disorders; and personal and family history of diagnosed mental illness and suicide attempts. Partial correlations between reassurance-seeking and depression and suicide (controlling for other psychopathology) were compared with partial correlations between reassurance-seeking and other disorders (controlling for other psychopathology, including depression). Results generally supported depressotypic specificity of reassurance-seeking behaviors. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Reassurance-seeking; Depression; Suicide; Specificity * Corresponding author. Tel.: ; fax: address: joiner@psy.fsu.edu (T.E. Joiner) /$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi: /j.paid

2 136 A.B. Burns et al. / Personality and Individual Differences 40 (2006) Introduction CoyneÕs (1976) interpersonal theory of depression, often characterized as a depressive spiral, begins with a mildly dysphoric person who, in response to stress, engages the interpersonal environment in such a way as to eventually alienate it. This negative and increasingly bereft environment, in turn, contributes to escalating severity of depressive symptoms. Joiner, Metalsky, and colleagues have argued that excessive reassurance-seeking constitutes the theoryõs main ingredient, in that it serves as a type of interpersonal vehicle which transmits the distress and desperation of depression from one person to another, with untoward consequences for all (e.g., Joiner, Alfano, & Metalsky, 1992, 1993; Joiner & Metalsky, 2001; Joiner, Metalsky, Katz, & Beach, 1999). Excessive reassurance-seeking is defined as the relatively stable tendency to excessively and persistently seek assurances from others that one is lovable and worthy, regardless of whether such assurance has already been provided. It represents a key variable, because when persistent and paired with increasing emotional distress, it exerts a deteriorating influence on the interpersonal environment, with consequences such as interpersonal rejection (e.g., Joiner & Metalsky, 1995), contagious depression (e.g., Joiner, 1994), and increased vulnerability to further depressive symptoms and episodes (Joiner, 2000; Joiner & Metalsky, 2001). Of interest in the present study is the question of whether this deleterious interpersonal behavior demonstrates a unique relationship with depressive symptoms, or whether it is equally associated with other forms of psychopathology. Regarding vulnerability to depression, Joiner and Metalsky (2001) presented a series of studies demonstrating that excessive reassurance-seeking satisfies criteria for a causal contributory risk factor for depression. More specifically, excessive reassurance-seeking covaries with depression in theoretically specified ways, displays temporal antecedence vis-à-vis depression, and constitutes a theoretically plausible, partial explanation for depression vulnerability. A fourth criterion, nonspuriousness (i.e., ruling out as many alternative explanations as possible for the relation between the proposed vulnerability factor and the syndrome in question), was also addressed, in two ways. First, excessive reassurance-seeking was predictive of depressive symptoms even when other interpersonal variables (e.g., general dependency) were controlled. Second, excessive reassuranceseeking displayed diagnostic and symptom specificity to depression. Diagnostic or symptom specificity holds when the relation between a hypothesized causal factor and a psychopathological syndrome is not attributable to the relation of either the hypothesized factor or the syndrome to a distinct clinical phenomenon. For example, the hypothesis that excessive reassurance-seeking is a risk factor for depression would be undermined if it were shown that excessive reassuranceseeking and depression were related merely because both are related to anxiety. Joiner and Metalsky (2001) showed that undergraduates who received a diagnosis of Major Depression based on a structured clinical interview obtained significantly higher reassurance-seeking scores than both undergraduates with other diagnoses (including anxiety disorders), and those with no diagnosis. Three other studies bear on this point as well. Joiner, Metalsky, Gencoz, and Gencoz (2001, Study 1) demonstrated that adult inpatients with a diagnosis of depression obtained higher reassurance-seeking scores than adult inpatients with other diagnoses, including schizophrenia. Similarly, a study of adolescent inpatients (Joiner et al., 2001, Study 2) revealed that depressed youth had higher reassurance-seeking scores than those with externalizing disorders (e.g., Conduct Disorder, Attention Deficit Hyperactivity Disorder). In a study of Air Force cadets in basic training,

3 A.B. Burns et al. / Personality and Individual Differences 40 (2006) Joiner and Schmidt (1998) found that high reassurance-seeking cadets were more vulnerable to prospective increases in depressive symptoms than were their low reassurance-seeking counterparts, and this same result did not apply to increases in anxious symptoms. There is thus growing evidence that excessive reassurance-seeking displays some specificity to depression, especially regarding the comparison condition of anxiety. However, the relatively small number of studies, combined with the possibility raised by Davila (1999) that other symptoms besides depression may be connected to excessive reassurance-seeking, calls for more study of the issue, especially using novel approaches. Accordingly, the purpose of the present study was to extend and deepen the evidence base regarding the specific relation of excessive reassurance-seeking to depression by demonstrating that excessive reassurance-seeking was more strongly associated with depressive symptoms than with anxious or eating disordered symptoms. Eating pathology was considered an important point of comparison along with anxious symptoms in light of the suggested association between disordered eating and dependent features (possibly including reassurance-seeking behavior; Bornstein, 2001). Specifically, consistent with the approach of past work (e.g., Joiner et al., 2001), we intended to show that the magnitude of the relationship between excessive reassurance-seeking and depressive symptoms, controlling for eating disordered and anxious symptoms, exceeded that of the relationship between excessive reassurance-seeking and the other examined symptoms, controlling for depressive symptoms. As an additional demonstration of the specific relationship between excessive reassurance-seeking and depression, we also examined whether excessive reassurance-seeking was associated with a personal or family history of depression, or a personal or family history of attempted suicide. As past studies have not considered these variables, this constitutes an important extension of the literature in this area. We predicted that the association between excessive reassurance-seeking and participantsõ history of both depression and attempted suicide, controlling for history of the other examined conditions, would exceed the associations between excessive reassurance-seeking and history of other conditions, controlling for depression history, attempted suicide history, and other variables. We made parallel predictions regarding family history. We suggest that these tests on current symptoms, personal history, and (perhaps especially) family history, taken together, represent a risky prediction in the Popperian sense, placing the specific depressotypic nature of excessive reassurance-seeking in grave danger of refutation (Popper, 1959). Survival of these tests, on the other hand, would represent a high degree of corroboration for the specific depressotypic nature of excessive reassurance-seeking. 2. Method 2.1. Participants and procedure Two hundred and twenty undergraduates (77% women; mean age = 18.8 years, SD = 2.87 years; 64% Caucasian; 15% African American; 12% Hispanic; 2% Asian American; 7% other) received credit in an introductory psychology course for participating. Data were collected as part of a large study of the relationships between various biological and interpersonal correlates and symptoms of psychopathology. In small groups, participants provided consent and completed

4 138 A.B. Burns et al. / Personality and Individual Differences 40 (2006) measures of excessive reassurance-seeking, depression, anxiety, eating disorder symptoms, and personal and family history of select mental disorders and attempted suicide. Complete data on variables of interest were obtained from 178 participants. The 42 participants who failed to provide complete data on all measures of interest were not found to differ significantly from participants with complete data on any assessed variable, including sex, age, and ethnic distribution as well as symptom and behavior measures. All analyses were accordingly performed on the 178 participants with complete data. Because two of our comparison conditions, bulimia nervosa and anorexia nervosa, are far more common in women, we re-ran all analyses in women alone. The direction and magnitude of the results were unchanged from those in the mixed sample; thus, we report on the mixed sample of men and women (n = 178) Measures Excessive reassurance-seeking scale This 4-item scale measures reassurance-seeking, defined as a tendency to excessively seek reassurance from significant others as to whether they truly care. The scale thus assesses a tendency to repeatedly and persistently seek reassurance, even if such has already been provided. Each item is rated on a 7-point scale; scores thus range from 4 to 28, with higher scores corresponding to increasing reassurance-seeking. Joiner, Metalsky and colleagues have reported criterion and construct validity data for the scale (see Joiner, 1994; Joiner et al., 1992, 1993; Joiner and Metalsky, 1995; Katz and Beach, 1997; Potthoff et al., 1995). In past studies, coefficient alpha has been in the range from.85 to.95; in this study, it was Beck depression inventory (BDI; Beck, Rush, Shaw, & Emery, 1979) Level of depressive symptoms was assessed by the BDI, a 21-item self-report inventory. Possible scores range from 0 to 63, with higher scores indicating more severe depressive symptoms. The BDI is a reliable and well-validated measure of depressive symptomatology (see Beck, Steer, & Garbin, 1988 for a review). A coefficient alpha of.89 was found in the present study Beck anxiety inventory (BAI; Beck & Steer, 1993) The BAI is a 21-item self-report inventory that assesses general symptoms of anxiety. Like the BDI, possible scores range from 0 to 63, with higher scores indicating more significant anxious symptoms. In a variety of clinical and non-clinical populations, the BAIÕs reliability, convergence with other anxiety measures, and discriminant validity with respect to depression measures, have been supported (Beck, Epstein, Brown, & Steer, 1988; Beck & Steer, 1993; Steer, Kumar, Ranieri, & Beck, 1995; Steer, Rissmiller, Ranieri, & Beck, 1993). Coefficient alpha in the present sample was Eating disorders inventory (EDI; Garner, Olmstead, & Polivy, 1983) The Eating Disorders Inventory (EDI) is a frequently used 64-item self-report measure of eating-related attitudes and traits. It has eight subscales: drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, and maturity fears. The subscales have shown adequate internal consistency coefficients and have been well validated (Garner et al., 1983; Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999). For

5 the purposes of this study, only the bulimia and drive for thinness (cf. anorexic symptoms) subscales were used. Each of these subscales comprises seven items, each rated on a scale of 1 6. Possible scores accordingly range from 7 to 42, with higher scores indicating greater bulimic and anorexic symptomatology, respectively. Internal consistency coefficients for the two subscales in this sample were a =.85 and a =.92, for bulimia and drive for thinness, respectively Personal and family history of select mental disorders and attempted suicide Participants completed a questionnaire regarding personal history of depression, anorexia nervosa, bulimia nervosa, and obsessive compulsive disorder, as well as attempted suicide. Because the questionnaire items regarding personal and family history referred only to diagnosed depression, the inclusion of the suicide history items was felt to provide an important alternative indicator of the presence of depressive symptomatology, regardless of any history of formal diagnosis. For each of these conditions, the items read, Have you ever been diagnosed with or... attempted suicide? Responses to these items were coded dichotomously. On the same questionnaire, participants responded to questions about any family history of the same disorders and attempted suicide, with questions reading: Of your first-degree biological relatives, how many have been diagnosed with / have attempted suicide? Participants also reported on their total number of first-degree relatives (biological parents and siblings). Based on this information, we calculated the proportion of first-degree relatives who had been diagnosed with each disorder or had attempted suicide. This brief assessment approach has been validated in past work (Joiner, Johnson, & Soderstrom, 2002; Joiner, Johnson, Soderstrom, & Brown, 2003; Joiner & Perez, 2004) Analytic approach A.B. Burns et al. / Personality and Individual Differences 40 (2006) Because we were interested in the unique associations between excessive reassurance-seeking and depression-related variables, controlling for other variables (e.g., anxiety-related and eating disorder-related variables), we computed partial correlations between excessive reassuranceseeking and depression-related variables, controlling for other variables. These were compared to partial correlations between excessive reassurance-seeking and each of the other variables, controlling for depression-related and the remaining other variables, using an adaptation of Meng, Rosenthal, and RubinÕs (1992) Z test (developed for comparison of zero-order correlations). 3. Results 3.1. Analyses on current symptoms We predicted that the relation between excessive reassurance-seeking and depressive symptoms, controlling for anxious and bulimic symptoms and drive for thinness, would exceed each of the partial correlations between excessive reassurance-seeking and anxious symptoms, bulimic symptoms, and drive for thinness, controlling for remaining variables (e.g., the correlation between excessive reassurance-seeking and anxiety, controlling for depressive and bulimic symptoms and drive for thinness).

6 140 A.B. Burns et al. / Personality and Individual Differences 40 (2006) Table 1 Partial correlations of excessive reassurance-seeking with current symptoms, personal history, and family history of psychopathology BDI BAI Bulimia Drive for Thinness Current symptoms Excessive reassurance-seeking.24 * a Depression Att Suic OCD Bulimia Anorexia Personal history Excessive reassurance-seeking.17 *.25 * b Family history Excessive reassurance-seeking.15 *.17 *.11 b a Note: Bold text represents those correlations predicted to exceed others. In a given row, correlations in bold differ from those not bolded except where superscripted. BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory. * p <.05. a Does not differ significantly from partial correlations of reassurance-seeking with depression. b Does not differ significantly from partial correlation of reassurance-seeking with depression or suicide. Results generally conformed to our expectations (see Table 1). Specifically, the partial correlation between excessive reassurance-seeking and depressive symptoms, controlling for anxious and bulimic symptoms and drive for thinness (pr =.24, p <.01), was the only partial correlation to reach statistical significance. Furthermore, the partial correlations relating anxious and bulimic symptoms to excessive reassurance-seeking were significantly smaller than the partial correlation between depressive symptoms and excessive reassurance-seeking (Z = 3.22 and 2.92, respectively, põs <.01). Although the partial correlation between excessive reassurance-seeking and drive for thinness (pr =.14) did not achieve statistical significance, it was not significantly different from the partial correlation between excessive reassurance-seeking and depressive symptoms (Z = 0.94, p = ns) Analyses on personal history We predicted that the relation between excessive reassurance-seeking and (1) participantsõ history of depression diagnosis and (2) history of suicide attempt, controlling for history of OCD, bulimia, and anorexia, would exceed the partial correlations between excessive reassuranceseeking and history of OCD, bulimia, and anorexia, controlling for remaining variables. Here again, our predictions received some support (see Table 1). Specifically, the partial correlation between excessive reassurance-seeking and history of depression, controlling for history of OCD, bulimia, and anorexia (pr =.17, p <.05) and the partial correlation between excessive reassurance-seeking and history of attempted suicide, controlling for history of OCD, bulimia, and anorexia, (pr =.25, p <.05) were the only correlations to achieve statistical significance. These two partial correlations did not differ significantly from one another in magnitude (Z = 0.94, p = ns). As was the case regarding current symptoms, the partial correlations relating history of OCD and of bulimia to excessive reassurance-seeking (controlling for other variables) were significantly smaller than both the partial correlation between history of depression and excessive

7 reassurance-seeking (Z = 2.39 and 2.93, respectively, põs <.01), and the partial correlation between history of suicide attempt and excessive reassurance-seeking (Z = 3.30 and 3.03, respectively, põs <.01). Again, the partial correlation between excessive reassurance-seeking and history of anorexia (pr =.13), though it did not achieve statistical significance, was not significantly different from the partial correlation between excessive reassurance-seeking and history of depression (Z = 0.41, p = ns), or from the partial correlation between excessive reassurance-seeking and history of suicide attempt (Z = 1.14, p = ns) Analyses on family history A.B. Burns et al. / Personality and Individual Differences 40 (2006) Finally, we expected that the relations between excessive reassurance-seeking and family history of depression and of attempted suicide, controlling for family history of OCD, bulimia, and anorexia, would exceed the correlation between excessive reassurance-seeking and family history of OCD, bulimia, and anorexia, controlling for remaining variables. As with the previous analyses, the findings were generally supportive of our predictions (see Table 1). Specifically, the partial correlation between excessive reassurance-seeking and family history of depression, controlling for family history of OCD, bulimia, and anorexia, (pr =.15, p <.05) and the partial correlation between excessive reassurance-seeking and family history of attempted suicide, controlling for family history of OCD, bulimia, and anorexia (pr =.17, p <.05) were the only two partial correlations to achieve statistical significance. These partial correlations did not differ significantly from one another in magnitude (Z =.24, p = ns). Furthermore, both of these partial correlations were significantly larger than the partial correlation relating excessive reassurance-seeking to family history of bulimia (Z = 2.28, p <.05; and Z = 2.53, p <.01, for family history of depression and suicide attempt, respectively). Although the partial correlation relating family history of excessive reassurance-seeking to OCD was non-significant, it did not significantly differ from either the partial correlation between family history of depression and excessive reassurance-seeking or from the partial correlation between family history of attempted suicide and excessive reassurance-seeking (Z = 0.41 and 0.51, respectively, põs = ns). Similarly, the partial correlation between excessive reassurance-seeking and family history of anorexia did not differ significantly from that between excessive reassurance-seeking and family history of depression (Z = 1.40, p =.08). However, it did differ significantly from the partial correlation between excessive reassurance-seeking and family history of suicide (Z = 1.67, p <.05). 4. Discussion The current study examined the specific depressotypic nature of excessive reassurance-seeking by comparing the relation of excessive reassurance-seeking with some important depressionrelated variables (i.e., current symptoms, personal history, and family history) to the relation of excessive reassurance-seeking with other clinical variables. In one sense, our predictions were borne out in every single case, because all correlations involving excessive reassurance-seeking and depression-related variables exceeded all comparison correlations, without exception, and all correlations involving excessive reassurance-seeking and depression-related variables were

8 142 A.B. Burns et al. / Personality and Individual Differences 40 (2006) statistically significant, whereas all comparison correlations were not. In another sense, however, more guarded conclusions may be in order; the partial correlations of reassurance-seeking with depression and suicide were not large, and not all correlations involving excessive reassuranceseeking and depression- or suicide-related variables exceeded attendant comparison correlations to a statistically significant degree. Three of the four correlations that were not significantly smaller than those involving depression/suicide involved anorexia-related variables. Although it should be recalled that in no case did the relation of excessive reassurance-seeking to anorexia-related variables achieve statistical significance, this topic may deserve future research attention, and to our knowledge, has not been previously explored empirically. Bornstein (2001) reached similar conclusions in his review of the relation of dependent personality symptoms (cf. excessive reassurance-seeking) to eating disorder symptoms. Furthermore, Casper (1982) presented a conceptual model for the treatment of anorexia which, intriguingly, emphasizes anorexic patientsõ need for reassurance, theorizing that anorexic people become obsessed with a newly discovered form of reassurance: the use of food restriction and related behaviors to regulate emotions. It is an interesting speculation that among people prone to anorexic symptoms, the general tendency to seek reassurance (interpersonally or through food restriction, etc.) is pronounced. The other comparison correlation that did not significantly differ from either a depression reassurance-seeking correlation or a suicide reassurance-seeking correlation was that between family history of OCD and excessive reassurance-seeking. Interestingly, previous reports suggest that anxiety disordered patients may be prone to a form of reassurance-seeking (i.e., needing reassurance about safety, as opposed to reassurance of oneõs lovability or worth; Salkovskis & Warwick, 1986), and that this is particularly the case regarding obsessive compulsive disorder (e.g., Abramowitz, Franklin, & Cahill, 2003; Francis, 1988). However, this correlation, like all of the comparison correlations, was not statistically significant. This is now the third study to find that depressive symptoms relate more to excessive reassurance-seeking than does anxiety, either as measured by symptom scale (Joiner & Schmidt, 1998) or by structured clinical interview (Joiner & Metalsky, 2001). Although we did not formulate any a priori hypotheses regarding the potential differences between the correlations of reassurance-seeking with current, personal history, and family history of depressive symptoms, it is intriguing to note that the correlation with the greatest magnitude was found to be that between reassurance-seeking and current symptoms, followed by personal history, with family history demonstrating the weakest of the three relationships with reassuranceseeking. The same pattern was likewise observed in the relationships between reassurance-seeking and personal and family history of suicide attempts. Future research should investigate whether such patterns are consistent across studies. This study was subject to several limitations, which suggest the importance of future work in this area. First, our measurement coverage was not as complete as might ideally be desired. Although we were able to assess current anxiety symptoms using the BAI, our items regarding personal and family history of anxiety were restricted to a diagnosis of OCD. Examination of the relations between reassurance-seeking and a history of other anxiety disorders such as GAD and panic disorder will be necessary to provide greater credence to our conclusions regarding depressotypic specificity. Analogously, our study did not contain a measure to assess the full spectrum of current OCD symptoms (e.g., the MOCI, Hodgson & Rachman, 1977), or of current

9 A.B. Burns et al. / Personality and Individual Differences 40 (2006) suicidal ideation or intent. While our assessment of personal and family history was therefore limited, it nonetheless provided an important starting point to the investigation of the relationships between reassurance-seeking and past psychopathology. A second potential limitation to this study concerns the lower prevalence rates of OCD and the eating disorders relative to Major Depression (Hoek & van Hoeken, 2003; Kessler, 1994), which might reduce the studyõs power and render it more difficult to find significant effects for these conditions. Replication of our findings, in both larger college student samples and clinical samples, will be crucial to the substantiation of the noted effects. Nonetheless, it is noteworthy that while more limited prevalence would necessarily render it less likely that participants would have a personal or family history of formal diagnosis of the full syndromes of OCD, bulimia, or anorexia, their likelihood of experiencing some of the symptoms of these conditions, assessed in this study with the BDI, BAI, and EDI, should not be so low as to significantly limit power. The fact that our analyses of participantsõ reported personal and family diagnostic histories yielded results that mirrored those obtained for current reported symptoms suggests that the more limited prevalence rates of the anxiety and eating disordered conditions assessed likely did not substantially affect our findings. A third limitation concerns the exclusive reliance upon self-report measures of both current symptomatology and personal and family history of psychopathology, as participants may have misrepresented themselves or been unaware of or misinformed about family membersõ diagnostic histories. Future studies might provide greater substantiation for the current findings by utilizing alternative methods of gathering this type of data (e.g., directly surveying family members). This study provides a rigorous examination of the specificity of the relation between excessive reassurance-seeking and depressive symptoms, and demonstrates congruence with an amassing literature that indicates a unique association between these variables (e.g., Joiner & Metalsky, 2001; Joiner et al., 2001; Joiner & Schmidt, 1998). By limiting our examination to the partial correlations between reassurance-seeking and current, past, and family history of depression and suicide, while controlling for other types of psychopathology such as anxious and eating disordered symptoms, we have accounted for multiple potential alternative explanations for the previously demonstrated association between reassurance-seeking and depression and established greater evidence for the non-spuriousness criterion for causality (Haynes, Spain, & Oliveira, 1993). Our results suggest that, as hypothesized by Coyne (1976), reassurance-seeking behaviors do demonstrate a key and specific relationship with depressive symptoms, and thus play an important contributory role in the perpetuation of the depressive spiral. Acknowledgment This research was supported, in part, by the Florida State University Committee on Faculty research Support and the John Simon Guggenheim Memorial Foundation. References Abramowitz, J. S., Franklin, M. E., & Cahill, S. P. (2003). Approaches to common obstacles in the exposure-based treatment of obsessive compulsive disorder. Cognitive and Behavioral Practice, 10,

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