Interpersonal Problems, Personality Pathology, and Social Adjustment After Cognitive Therapy for Depression

Transcription

1 Psychological Assessment Copyright 2003 by the American Psychological Association, Inc. 2003, Vol. 15, No. 1, /03/$12.00 DOI: / Interpersonal Problems, Personality Pathology, and Social Adjustment After Cognitive Therapy for Depression Jeffrey R. Vittengl Truman State University Lee Anna Clark University of Iowa Robin B. Jarrett University of Texas Southwestern Medical Center at Dallas The authors examined the level and structure of the Inventory of Interpersonal Problems Circumplex version (IIP C; L. M. Horowitz, L. E. Alden, J. S. Wiggins, & A. L. Pincus, 2000) before and after 20 sessions of acute-phase cognitive therapy for depression (N 118), as well as associations with the Schedule for Nonadaptive and Adaptive Personality (L. A. Clark, 1993b) and the Social Adjustment Scale Self-Report version (M. M. Weissman & S. Bothwell, 1976). Interpersonal problems had a 3-factor structure (Interpersonal Distress, Love, and Dominance), with the latter 2 factors approximating a circumplex, both before and after therapy. Interpersonal Distress decreased and social adjustment increased with therapy, but the Love and Dominance dimensions were relatively stable, similar to personality constructs. Social adjustment related negatively to Interpersonal Distress but not to Love or Dominance. Personality pathology related broadly to Interpersonal Distress and discriminantly to Love and Dominance. These findings support the reliability and validity of the IIP C and are discussed in the context of personality theory and measurement. The circumplex model of interpersonal behavior, first popularized over 4 decades ago (Leary, 1957), is reemerging as a popular research and clinical tool (e.g., Gurtman & Balakrishnan, 1998; Horowitz, Alden, Wiggins, & Pincus, 2000; Plutchik & Conte, 1997; Wiggins & Trobst, 1997). In this general model, two bipolar Jeffrey R. Vittengl, Division of Social Science, Truman State University; Lee Anna Clark, Department of Psychology, University of Iowa; Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas. The clinical trial was conducted at the University of Texas Southwestern Medical Center at Dallas, Department of Psychiatry, in the Psychosocial Research and Depression Clinic directed by Robin B. Jarrett and was supported in part by Grants MH and MH from the National Institute of Mental Health. Gratitude is expressed to our colleagues for contributing to this research. Dolores Kraft coordinated this trial and provided clinical support. Jeanette Doyle, Greg Eaves, Paul Silver, Marjorie Woodruff, Bethany Hampton, Catherine Judd, Douglas Lisle, Regina Kinney, Maria Marwill-Magee, Andrew Clifford, Martin Schaffer, and Rodger Kobes also provided clinical support. Research support was provided by Barbara Foster, Michelle White, Edna Christian, Joseph Begue, Julie Lowe, Daisha Cipher, Patricia Green, Demetria Clinton, and Paula Reese. Brian F. Shaw rated the cognitive therapists. We appreciate the administrative support of both Eric J. Nestler and Kenneth Z. Altshuler, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas. Correspondence concerning this article should be addressed to Jeffrey R. Vittengl, Division of Social Science, Truman State University, 100 East Normal Street, Kirksville, Missouri , or to Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, Texas vittengl@truman.edu or robin.jarrett@utsouthwestern.edu axes of interpersonal functioning, love versus hate (or friendliness vs. hostility) and dominance versus submission, define a twodimensional circular space. Progressive blends of these theoretically orthogonal dimensions yield eight scales ( octants ) of functioning arranged in equal increments (i.e., every 45 ) around a circle. When the circumplex model is applied to interpersonal problems (Alden, Wiggins, & Pincus, 1990; Horowitz et al., 2000), the octants reflect overly nurturant, intrusive, domineering, vindictive, cold, socially avoidant, nonassertive, and exploitable problems (see Figure 1). In this model, assessment provides information about both the average and the relative levels of a person s interpersonal problem areas (e.g., more socially avoidant and less domineering). The average level of problems has been conceptualized as a general Distress factor, as discussed later. In addition, the configuration of relative problem areas within individuals defines the predominant quality or theme of interpersonal behavior (e.g., Gurtman & Balakrishnan, 1998), which we refer to in this article as interpersonal style, whereas the interrelations of problem areas between individuals define the circumplex space. Because circumplex measures of interpersonal problems are again seeing frequent use, evaluating their reliability and validity in clinical samples is of great importance. This article focuses on the reliability and validity of one of several promising measures available currently, the Inventory of Interpersonal Problems Circumplex version (IIP C; Horowitz et al., 2000), administered before and after the acute phase of cognitive therapy for depression. We addressed the robustness of the IIP C circumplex structure, its functioning as a measure of both state (i.e., readily changeable distress) and trait (i.e., relatively stable interpersonal style) constructs, and its convergence with measures of personality pathology and social adjustment. 29

2 30 VITTENGL, CLARK, AND JARRETT Figure 1. Theoretical circumplex structure with eight scales of interpersonal problems. Initial examination of the IIP C item set (Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988) suggested the presence of a general Distress factor, on which all items loaded positively and which accounted for substantial positive correlations among scales. To control for this general factor in evaluating circumplex structure defined by independent Love and Dominance dimensions, some researchers (e.g., Alden et al., 1990; Soldz, Budman, Demby, & Merry, 1993) have used ipsatized (person-centered) scores. The general Distress factor also may be controlled by separating it from the Love and Dominance dimensions through factor analysis of the IIP C items or octant scales (e.g., Gurtman, 1995). In addition to evaluation of the IIP C s circumplex structure, identification of theoretically relevant orthogonal factors simplifies interpretation of interpersonal distress and average problem level (captured by the Distress factor) distinct from characteristic interpersonal behavior or style (captured by the Love and Dominance factors). Past research suggests that the general Distress factor may tap a construct broader than interpersonal distress. Tracey, Rounds, and Gurtman (1996) found that the general Distress factor correlated moderately (.46) with self-reported neuroticism/negative affectivity (as measured with the Positive and Negative Affect Schedule; Watson, Clark, & Tellegen, 1988) and correlated highly (.75) with self-reported global psychiatric symptom severity (as measured with the Brief Symptom Inventory; Derogatis & Spencer, 1982) in a sample of undergraduates (N 105). Moreover, Gurtman and Balakrishnan (1998) found that the general Distress factor correlated negatively with several therapist-rated scales (unique to their study) of patient adjustment in social and nonsocial domains (median r.26, range.34 to.16, Ns ). Consequently, in clinical applications, the general Distress factor would seem to provide useful information about clients functioning and would be expected to decrease over therapy. Indeed, recent research has demonstrated a reliable decrease in the average IIP C item score (effect size d 1.08, where values of 0.20, 0.50, and 0.80 may be interpreted as small, medium, and large effects, respectively; Cohen, 1988), nearly identical to the general Distress factor, in a small group of psychiatric patients (N 11) completing individual supportive psychotherapy (Rosenthal, Muran, Pinsker, Hellerstein, & Winston, 1999). Similarly, the average IIP C item score was found to be lower (d 0.35) in responders (n 25) than in nonresponders (n 71) to a day treatment program consisting of analytic and cognitive therapy groups for psychiatric outpatients with personality disorders (Wilberg et al., 1999). These groups of researchers did not, however, address changes or stability in the Love and Dominance dimensions or in circumplex structure. Common to most definitions of personality is the notion of temporal stability, even as Axis I pathology changes with timelimited psychotherapies such as acute-phase cognitive therapy that targets symptom reduction. Whereas past research supports the validity of the IIP C through convergence with personality disorder scales (e.g., Matano & Locke, 1995; Pincus & Wiggins, 1990; Soldz et al., 1993) and with the five-factor model (FFM) of personality (e.g., Digman, 1990; McCrae & John, 1992), as outlined below, little is known about the stability of the Love and Dominance dimensions across the course of psychotherapy. If the major axes of the circumplex truly reflect personality, one would expect relative stability across the course of acute-phase cognitive therapy, which does not attempt to change personality. Some

3 INTERPERSONAL PROBLEMS IN DEPRESSION 31 aspects of personality, however, have been found to change over treatment for depression, including FFM dimensions of neuroticism and extraversion but not agreeableness (Bagby, Joffe, Parker, Kalemba, & Harkness, 1995), sparking debate about the state versus trait components of personality measures (e.g., Clark, Watson, & Mineka, 1994; Santor, Bagby, & Joffe, 1997). Addressing this issue in the present study, we expected the IIP C tobe sensitive to changes in depression through its general Distress factor (a state measure) and to capture enduring aspects of interpersonal style through its Love and Dominance dimensions (trait measures). An instrument with these qualities would be of great potential value in clinical and research settings by offering distinct state and trait information relevant to interpersonal problems (see Clark, Vittengl, Kraft, & Jarrett, in press). In contrast to the Distress factor, the Love and Dominance axes of the IIP C often have been viewed as personality constructs. In clinical samples (Matano & Locke, 1995; Soldz et al., 1993), personality disorder scales have been located in each quadrant of the IIP C circumplex (e.g., schizoid personality disorder reflecting low Love and low Dominance; histrionic personality disorder reflecting high Love and high Dominance), although disorders tended to be better separated along the Dominance axis. For normal-range samples, the FFM currently may be the most popular trait dimensional approach and includes measures of neuroticism, extraversion, agreeableness, conscientiousness, and openness. Concerning the IIP C and FFM traits, in a sample of 102 group psychotherapy patients, Soldz et al. (1993) found that Dominance correlated positively with extraversion (.52) and that Love correlated positively with both agreeableness (.52) and extraversion (.49), as well as to a lesser degree with low neuroticism/emotional stability (.21), as measured by self-ratings on adjectives reflecting the FFM (Goldberg, 1992). Gurtman (1995), however, found that Dominance was predicted well by a linear composite of high extraversion, low agreeableness, and high neuroticism (R 2.90), whereas Love was predicted well by a linear composite of high extraversion, high agreeableness, and high neuroticism (R 2.91) in a large sample of undergraduates (N 1,093) completing a similar FFM measure. The positive associations with neuroticism likely reflect the presence of the general Distress factor in Gurtman s analyses, which used raw item scores compared with Soldz et al. s analyses, which controlled for general distress by using ipsatized scores. The other two FFM traits, openness and conscientiousness, appear to relate less strongly and less consistently to the IIP C s dimensions of Love and Dominance (Gurtman, 1995; Soldz et al., 1993). These investigations of the relations of IIP C and conventional personality assessment systems have yielded valuable information, but the IIP C s overlap with trait-dimensional systems of personality pathology is not yet settled. Examining the convergence of a clinical trait-dimensional personality measure, the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993b), with the IIP C factors may clarify associations with personality pathology. The SNAP, whose scales initially were derived from consensual clusters of personality disorder symptoms (Clark, 1990), assesses 15 temperament and trait dimensions from normative levels through a clinical range of personality pathology. This perspective offers two potential advantages over previous investigations in a clinical sample. First, personality scales formed from Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM IV; American Psychiatric Association, 1994) diagnoses and similar criterion sets may represent multidimensional constructs that make correlations with the IIP C ambiguous. By contrast, the SNAP assesses unidimensional constructs relevant to interpersonal functioning (e.g., mistrust, manipulativeness, aggression, dependency, exhibitionism, and detachment), which can be used to unpack the multidimensionality of personality disorder scales. For example, based on ratings from the Structured Interview for DSM III R Personality (Pfohl, Blum, Zimmerman, & Stangl, 1989) in a psychiatric patient sample (N 89; Clark, 1993b), avoidant personality disorder reflected high mistrust (r.35) and detachment (r.52), whereas antisocial personality disorder reflected high manipulativeness (r.54) and aggression (r.57). Second, FFM instruments, which were developed for use with normal populations, may not capture the full range of personality pathology (Ben-Porath & Waller, 1992), and the SNAP offers incremental validity over the FFM domains in predicting personality pathology (Clark, 1993a; Reynolds & Clark, 2001). For example, in a sample of 94 psychiatric patients (Reynolds & Clark, 2001), a composite of two popular FFM self-report inventories the Revised NEO Personality Inventory (Costa & McCrae, 1992) and the Big Five Inventory (John, Donahue, & Kentle, 1991) predicted significantly 11 of 13 personality disorder ratings (median R 2.27, range.07.51) from the Structured Interview for DSM IV Personality (Pfohl, Blum, & Zimmerman, 1995), but the SNAP scales added significantly to the prediction of 10 of 13 disorders beyond the FFM (median increase in R 2.23, range.11.35). Conversely, the SNAP scales predicted significantly 12 of 13 disorders (median R 2.48, range.25.57), and the FFM instruments added significantly to the prediction of only 2 of 13 disorders beyond the SNAP (median increase in R 2.04, range.02.08). In addition to the IIP C s convergence with trait-dimensional personality pathology, the potentially life-interfering consequences of interpersonal distress or particular interpersonal styles make examining relations of the IIP C with a standard measure of social functioning, the Social Adjustment Scale Self-Report version (SAS SR; Weissman & Bothwell, 1976), both theoretically and clinically relevant. Horowitz et al. (2000) found consistently small to moderate correlations (median r.30, range.16.49, ns ) between the SAS SR scales and raw-score (unipsatized) IIP C octant scales in a normative sample, recognizing that the general Distress factor represented in the raw-score scales likely contributed substantially to these correlations. An alternative, and perhaps more informative, approach would be to examine convergent and divergent relations between independent IIP C factors (general Distress, Love, and Dominance) and the SAS SR scales. The present study used this alternative approach to clarify the relative importance of interpersonal distress versus style (Love and Dominance) in predicting social adjustment in several major domains (e.g., at work, with family, and in one s leisure time). The major goals of this study were (a) to evaluate the level and structure of interpersonal problems (as assessed by the IIP C) before and after acute-phase cognitive therapy; (b) to evaluate the stability of the general Distress, Love, and Dominance dimensions of the IIP C; (c) to clarify the convergence of interpersonal distress and style with social adjustment (as assessed by the SAS SR); and (d) to clarify the convergence of interpersonal distress and style with personality pathology (as assessed by the SNAP). Regarding the first goal, two factors lead one to question the robustness of the IIP C s circumplex structure across the course of

4 32 VITTENGL, CLARK, AND JARRETT acute-phase cognitive therapy: the pattern of convergence of the IIP C with conventional personality measures and changes in some personality measures over treatment for depression. Nevertheless, we hypothesized that the IIP C would demonstrate a circumplex structure similar to Figure 1 both before and after acute-phase cognitive therapy, after accounting for a general Interpersonal Distress factor. Regarding the second goal, we further hypothesized that general interpersonal Distress would decrease from pre- to posttherapy but that interpersonal style, as reflected in Love and Dominance dimensions, would be relatively stable, similar to their common conceptualization as personality constructs. Regarding the third goal, a prior investigation revealed moderate positive correlations for all of the IIP C s nonipsatized octant scales, which likely were loaded heavily with the general Distress factor, with social adjustment. Therefore, in this study, we hypothesized that the general Distress factor, but not Love or Dominance, would correlate strongly (positively) with social adjustment. Regarding the fourth goal, prior research has supported a number of relations of personality trait and disorder scales with the IIP C, but no prior investigation has investigated these relations with the SNAP. Accordingly, we hypothesized that the general Distress dimension would relate broadly to personality pathology and that the Love and Dominance dimensions would show more differentiated relations; however, specific scale-level predictions were not made. Participants Method Participants were adults with acute depression meeting criteria for DSM IV (American Psychiatric Association, 1994) nonpsychotic, recurrent, major depressive disorder with clear interepisode recovery ( 2 months of at least nearly normal functioning) and a score greater than or equal to 16 on the Hamilton Rating Scale for Depression (HRSD-17; Hamilton, 1960). Patients were recruited though media, printed announcements, and self- and practitioner referral and completed a telephone screen. Informed consent was obtained prior to diagnostic interviews and to entering therapy. Exclusionary criteria included concurrent medical disorders potentially accounting for depressive symptoms, organic mental disorders, psychotic disorders, active substance abuse or dependence, primary obsessive compulsive or eating disorders, borderline personality disorder, and inability or unwillingness to complete questionnaires or to comply with the treatment protocol. More detail about recruitment, inclusion, and exclusion criteria are available in Jarrett et al. (2001). 1 Although 156 participants began and 130 completed acute-phase cognitive therapy, this article focuses on the 118 patients who completed the IIP C before and after acute-phase cognitive therapy, although the intersection of this group with those completing other instruments posttherapy yielded slightly smaller samples for some analyses. Similar to the full sample, of these 118 participants, 74.6% were female; the mean age was years (SD 10.21); the mean level of education was years (SD 2.77); 4.2% were African American, 3.4% Hispanic, 0.9% Native American, and 91.5% White. The participants mean age of onset of major depressive disorder was years (SD 9.45), the mean length of the current major depressive episode was months (SD 43.90), and participants had experienced a mean of 3.35 total major depressive episodes (SD 1.22). Treatment exposure data, available for participants first, most recent two (if applicable), and current major depressive episodes, suggested that 2.5% had been treated previously with electroconvulsive therapy, 61.9% with pharmacotherapy, and 62.7% with psychotherapy. Procedure Acute-phase cognitive therapy. Acute-phase cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) was conducted by five experienced therapists within a week protocol, including 20 individual sessions (50 60 min) held twice weekly for the first 8 weeks and once weekly for the last 4 weeks. No pharmacotherapy was provided. Acute-phase cognitive therapy is designed to reduce depressive symptoms by eliciting thoughts associated with negative affect, teaching patients to evaluate the validity of such thoughts through logical and empirical methods, and generating more realistic alternatives when negative thoughts are not supported. Thus, therapists providing acute-phase cognitive therapy focus on changing patients discrete thoughts, behaviors, and their affective consequences rather than on altering more general personality style or traits. From before to after acute-phase cognitive therapy, the present sample s depression symptom levels decreased significantly on several measures, including the Beck Depression Inventory (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961; pretreatment M 27.22, SD 7.47; posttreatment M 7.40, SD 7.40), t(115) 23.54, p.01, two-tailed, d 2.19; and the HRSD-17 completed by an experienced diagnostician (pretreatment M 20.32, SD 2.99; posttreatment M 7.21, SD 6.30), t(117) 21.76, p.01, two-tailed, d The response rate to therapy, defined by absence of DSM IV major depressive disorder and an HRSD-17 score of 9 or less, was 69.5%. These data are consistent with the previous literature showing that acute-phase cognitive therapy reduces the symptoms of major depressive disorder in adults (e.g., Jarrett & Rush, 1994). Additional detail about therapy procedures and outcome is available in Jarrett et al. (2001; see footnote 1). Assessment. Two pretreatment assessments were used to establish eligibility for the study. Assessments were conducted at the Department of Psychiatry at the University of Texas Southwestern Medical Center at Dallas and included the Structured Clinical Interview for DSM III R (SCID Outpatient version; Spitzer, Williams, Gibbon, & First, 1989), supplemental interview questions to assess DSM IV disorders, and the HRSD-17. The second assessment was conducted by a faculty-level diagnostician. Participants completed the measures used in this report before the first (IIP C, SAS SR) or third (SNAP) therapy session and again at a posttherapy assessment (all measures). Measures IIP C. Patients completed the original 127-item IIP (Horowitz et al., 1988). On this instrument, patients rated the extent to which a number of behaviors, thoughts, and feelings had been problematic for them in significant relationships. Responses were scored according to the circumplex system developed by Alden et al. (1990) in which 64 items are summed to score eight 8-item scales to cover the circumplex space marked by orthogonal Love and Dominance dimensions. Alden et al. derived the IIP C item set in an undergraduate sample and found support for the reliability and validity of the instrument in an undergraduate replication sample (N 974). In the replication sample, internal consistency of the octant scales was adequate (median.81, range.72.85); convergent correlations for octant scales (median r.44, range.36.58) were generally greater than divergent correlations (median r.28, range r.01.57) with 1 At various points in the text, readers are referred to Jarrett et al. (2001) and Clark et al. (in press), complementary reports using the same data set, to avoid superfluous presentation of methods and results. In contrast to the present article s focus on the IIP C and its relations to the SNAP and SAS SR, Jarrett et al. focused on preventing relapse in responders to acute-phase cognitive therapy and presented greater detail about the recruitment, selection, and exclusion of participants, therapy, and outcome measures. Clark et al. focused on the psychometric properties of the SNAP and relations between personality scores and both pre- and posttreatment depression levels.

5 INTERPERSONAL PROBLEMS IN DEPRESSION 33 another self-report circumplex measure of interpersonal functioning, the Revised Interpersonal Adjective Scales (IAS R; Wiggins, Trapnell, & Phillips, 1988); and circumplex structure was demonstrated through principal-components analyses of the octant scales of the IIP C alone and with the IAS R. Horowitz et al. (2000) conducted the most comprehensive study of the reliability and validity of the IIP C to date. In a census-stratified sample, the octant scales demonstrated adequate internal consistency (median.81, range.76.88, N 800) and moderate-to-high 1-week retest correlations (median r.73, range.58.84, Ns 60). The octant scales demonstrated moderate convergence with self-report measures of depression (median r.38, range.33.43, N 495; Beck, Steer, & Brown, 1996), anxiety (median r.36, range.31.39, N 495; Beck & Steer, 1990), general mental health functioning (median r.54, range.48.59, N 799; Eisen, Dill, & Grob, 1994), and social adjustment (median r.30, range.16.49, Ns ; Weissman & Bothwell, 1976). Moreover, circumplex structure was supported through a principalcomponents analysis of the IIP C octant scales. SAS SR. The SAS SR (Weissman & Bothwell, 1976) is a 56-item self-report measure of functioning in several important social domains. Participants complete only those sections of the questionnaire reflecting their social roles (e.g., not all participants complete marital or parenting sections). Subscales and a total score are computed by averaging item responses. In past research, internal consistency for the overall adjustment score was moderate (.74), and temporal stability was good (r.80) across 2-week intervals in a sample of 92 nonpatient adults (Edwards, Yarvis, Mueller, Zingale, & Wagman, 1978). In addition to correlations with the IIP C summarized earlier, validity evidence for the SAS SR includes significant correlations with clinical ratings and other self-report measures and sensitivity to change in psychopathology. In a sample of 76 outpatients with depression (Weissman & Bothwell, 1976), the SAS SR subscales correlated moderately to strongly with an interview version of the measure (median r.55, range.40.76), similar to the correlation for the overall adjustment score (r.72), and each of the SAS SR subscales demonstrated decreases (improvements) after 4 weeks of unspecified treatment (median d 0.69, range ), as did the overall adjustment score (d 1.17). Moreover, in a community sample (N 482; Weissman, Prusoff, Thompson, Harding, & Myers, 1978), overall social adjustment was found to correlate with a clinician-rated scale of depression (r.44; Raskin, Schulterbrandt, Reatig, & McKeon, 1969), as well as with self-report scales of depression (r.57; Radloff, 1977) and general psychiatric symptomatology (r.59; Derogatis, Rickels, & Rock, 1976). SNAP. This 375-item, factor-analytically derived self-report inventory uses a true false format to assess dimensions of personality functioning relevant to personality disorder. Reflecting their dual grounding in personality disorder criterion sets and normal-range personality theory, the SNAP scales provide reliable information across the range of personality functioning. The scales have repeatedly demonstrated good internal consistency (median s typically range from.76 to.84; Clark, 1993b) and also have shown good test retest reliability over periods of 1 week and 1 month (median rs.81; Clark, 1993b). The SNAP s 12 lower order trait scales intercorrelate approximately.20 on average. Moreover, the higher order temperament dimensions (positive temperament, negative temperament, and disinhibition), which reflect the factor structure of the instrument, also are largely independent of one another, typically correlating.20 or less (Clark, 1993b; Ready, Clark, Watson, & Westerhouse, 2000; Reynolds & Clark, 2001). The validity of the SNAP scales has been supported in several domains. First, in a sample of 178 college students (Clark, 1993b), negative temperament correlated.31 and.11 with self-reported negative and positive affect, respectively, whereas positive temperament correlated.16 and.40 with negative and positive affect, respectively (as measured with the Positive and Negative Affect Schedule Expanded Form using today as the rating time frame; Watson & Clark, 1994). Second, in 89 psychiatric patients (Clark, 1993b), the SNAP scales correlated mostly as hypothesized with interview ratings of personality disorders (from the Structured Interview for DSM III R Personality; Pfohl et al., 1989). For example, mistrust correlated with paranoid (.49), schizoid (.38), schizotypal (.48), and avoidant (.35) personality disorders, whereas exhibitionism correlated with histrionic (.40) and narcissistic (.30) personality disorders. Third, in a sample of 105 psychiatric patients (Clark, 1993b), self-reported personality on the Five Factor Inventory (Costa & McCrae, 1989) correlated as expected with the SNAP scales. For example, correlations for negative temperament and neuroticism (.79), positive temperament and extraversion (.65), disinhibition and agreeableness (.46), and disinhibition and conscientiousness (.44) were moderate to high, whereas correlations for the other cross-measure pairings of these scales were lower (median r.12, range.30.34). Finally, the SNAP scales have demonstrated convergence with a collateral-report version of the instrument in samples of 189 pairs of well-acquainted undergraduates (median r.47, range.27.62; Ready et al., 2000) and 90 psychiatric patients rated by familiar informants (median r.35, range.02.61; Ready & Clark, 2002). Descriptive statistics for the SNAP scales in the present sample are available in Clark et al. (in press; see footnote 1). Analytic Strategies for Hypothesis Testing Our first hypothesis was that the IIP C would demonstrate a circumplex structure similar to Figure 1 both before and after acute-phase cognitive therapy, after accounting for a general interpersonal Distress factor. We based tests of the first hypothesis on principal-components analysis because the two foundational investigations of the IIP C s circumplex structure (derivation of the IIP C by Alden et al., 1990, and the IIP C s national standardization by Horowitz et al., 2000) also used principal-components analysis. Other analytic approaches, such as confirmatory factor analysis, are viable alternatives to principal-components analysis for evaluating circumplex structure but involve substantially different assumptions and computational strategies (e.g., see Fabrigar, Visser, & Browne, 1997; Gurtman & Pincus, 2000). In the present investigation, we extended examination of the IIP C s circumplex structure to a new population (recurrent major depressive disorder before and after acute-phase cognitive therapy). Consequently, we elected not to also vary the analytic method. We reasoned that, with use of principal-components analysis, if discrepancies with past research were evident, they could be interpreted more clearly in terms of the depressed population. In the principal-components analyses, extracted factors were rotated orthogonally to maximize their alignment with the hypothesized structure of the IIP C (general Distress factor plus Love and Dominance). To evaluate the resulting fit with the theoretical circumplex, we used both graphical and quantitative analyses. The graphical analysis involved plotting the octant scales in circumplex space using the factor loadings as polar coordinates, and the quantitative analysis involved calculating the circular correlation of the octant scales placements with their theoretical placements in the circumplex space, as well as pre- to posttreatment scaleplacement correspondence. Additionally, we evaluated the stability of the factor solutions with linear correlations of factor scores derived by applying pretreatment weights with the posttreatment sample and vice versa. Correlations of factor scores were selected to evaluate factor solutions to facilitate comparison with other correlations reported in this article, as opposed to Tucker s (1951) popular factor congruence coefficient, which is not a true correlation coefficient but typically provides results very similar to factor score correlations (e.g., see Derogatis, Serio, & Cleary, 1972; Everett & Entrekin, 1980). Our second hypothesis was that general interpersonal distress would decrease from pre- to posttherapy but that interpersonal style, as reflected in Love and Dominance dimensions, would be relatively stable. To test the second hypothesis, we computed retest correlations of factor scores, and we compared the magnitude of the general Distress versus Love and Dominance retest correlations using Steiger s (1980) formula to compare elements of a correlation matrix. To test for mean level change with repeated measures analyses, it was necessary to approximate the factor

6 34 VITTENGL, CLARK, AND JARRETT Table 1 Descriptive and Change Statistics for the Inventory of Interpersonal Problems Circumplex Version (IIP C) Scales Pre- and Posttreatment Pretreatment Posttreatment Scale M SD T score M SD T score t(117) d Overly Nurturant Intrusive Domineering Vindictive Cold Socially Avoidant Nonassertive Exploitable Note. N 118. Each IIP C subscale contains eight items. All t values are significant at p.01 (two-tailed) and reflect decreased problems posttreatment. Effect sizes (ds) of 0.20, 0.50, and 0.80 may be interpreted as small, medium, and large effects, respectively (Cohen, 1988). scores (which have means of zero) with highly convergent dimensions of Distress, Love, and Dominance with nonzero means derived in reference to a normative sample (Horowitz et al., 2000). Our third hypothesis was that the general Distress factor, but not Love or Dominance, would correlate strongly with social adjustment, and our fourth hypothesis was that the general Distress dimension would relate broadly to personality pathology but that the Love and Dominance dimensions would show more differentiated relations. We tested the third and fourth hypotheses by computing scale-level correlations of the IIP C factor scores (general Distress, Love, and Dominance) with the SAS SR and the SNAP scales. Interpretation of these correlations is facilitated by the independence of the IIP C factor scores. However, because of calculation of multiple statistical tests for these and the above analyses, we selected a conservative alpha level of.01 for all analyses, and whenever possible, we focus on patterns of results in drawing conclusions. Results Description of Interpersonal Problems Pre- and Posttreatment Descriptive and change statistics for the IIP C octant scales scored using the sum of raw scale items are presented in Table 1. The eight-item scales all demonstrated adequate to good internal consistency pre- and posttreatment ( s.72.88). T scores computed from national norms (Horowitz et al., 2000) suggested mild to moderate elevations in interpersonal problems pretreatment (mean Ts 55 66) and average levels to mild elevations posttreatment (mean Ts 48 59). For example, consistent with depressive symptomatology, nonassertive, socially avoidant, and exploitable problems were somewhat more prominent, whereas intrusive, domineering, and vindictive problems were less prominent both pre- and posttreatment. To describe more precisely the sample s location in normative circumplex space, we computed the vector direction (angle) and vector length for octant scale profiles, as is common practice in the circumplex literature (e.g., see Gurtman & Balakrishnan, 1998; Wiggins, Phillips, & Trapnell, 1989). The angle reflects the most prominent form of interpersonal behavior (i.e., interpersonal style), and vector length reflects the degree to which this interpersonal style is intense, maladaptive, and inflexible. This procedure involved first calculating Love and Dominance scores from the octant scales z scores based on national norms (Horowitz et al., 2000), and from these Love and Dominance scores, calculating the angle and vector length for each individual. 2 Averaging angles and computing their standard deviation across participants required use of standard trigonometric formulas to account for circular scaling (e.g., see Batschelet, 1981, pp. 7 15, 33 36), 3 but the linear scaling of vector length allowed for calculation of a traditional mean and standard deviation. The mean angle pretreatment was (SD 58.9 ) with a vector length (in z-score units) of 1.24 (SD 0.66), and the mean angle posttreatment was (SD 57.8 ) with a vector length of 0.94 (SD 0.64). Comparing these angles with Figure 1 suggests that interpersonal style both pre- and posttreatment involved a blend of nonassertiveness (270 ) and exploitability (315 ), with small change in mean angle from pre- to posttreatment. Further, the relatively long vector lengths suggest that this interpersonal style was moderately problematic, although somewhat less so posttreatment. Hypothesis 1: IIP C Circumplex Structure and Its Stability Across the Course of Acute-Phase Cognitive Therapy We used principal-components analysis of the IIP C octant scales to test our hypothesis that the IIP C would demonstrate 2 For individuals, dominance z i sin,.3 i 1 8 love.3 i 1 8 z i cos, vector length dominance 2 love 2, and angle arctan dominance/love, where z between-subjects z score for octant scale i, and angle of octant scale as shown in Figure 1. 3 Across individuals, the mean angle arctan(x sin /X cos ), and the standard deviation for angles (180/ ) [1 (X sin ) 2 (X cos ) 2 ], where angle for each participant calculated as above.

7 INTERPERSONAL PROBLEMS IN DEPRESSION 35 Table 2 Rotated Factor Loadings of the Inventory of Interpersonal Problems Circumplex Version Pretreatment Posttreatment Scale Factor 1: Distress Factor 2: Love Factor 3: Dominance Factor 1: Distress Factor 2: Love Factor 3: Dominance Overly Nurturant Intrusive Domineering Vindictive Cold Socially Avoidant Nonassertive Exploitable Note. N 118. Loadings.30 are in boldface type. circumplex structure pre- and posttreatment. In a principalcomponents analysis of the pretreatment octant scales, the first four factors had eigenvalues of 3.15, 2.06, 1.45, and Thus, three factors were retained. These factors were rotated orthogonally to minimize the least-squares difference from the theoretical circumplex structure (Love, Dominance) after accounting for a general Distress factor. The theoretical structure was represented by a target loading of.707 on Factor 1 (general Distress) for each octant scale and target loadings of.707,.5, 0,.5, or.707 on Factors 2 (Love) and 3 (Dominance) for each octant scale as depicted in Figure 1. Posttreatment, the first four factors had eigenvalues of 4.37, 1.51, 1.03, and Again, three factors were retained and rotated to minimize discrepancy with theoretical structure. The rotated factor loadings are presented in Table 2. To help visualize the obtained circumplex structure, we plotted the scales loadings on the Love and Dominance factors both pre- and posttreatment and used trigonometric transformations to calculate the placement of the scales in circular degrees (see Figure 2). These plots suggested reasonable coverage of the circumplex space, although the scales did not align perfectly with their theoretical placements (i.e., every 45 beginning with Overly Nurturant at 0 ; see Figure 2). To quantify the convergence of the pre- and posttreatment structures with the theoretical circumplex, we computed circular correlations between the angular placement of octant scales in Figure 2 with Figure 1. The circular correlation coefficient 4 ranges from 0 to 1, with higher values indicating greater consistency in angular placement (e.g., see Batschelet, 1981, pp ). The pre- and posttreatment structures correlated highly with the theoretical structure (.99 and.96, respectively; ps.01). In addition, the convergence of factor solutions pre- and posttreatment was evaluated by applying the scoring weights derived from each principal-components analysis to both data sets and then correlating the factor scores derived with the two sets of scoring weights. The six convergent correlations for the three factors pre- and posttreatment were all above.99 ( ps.01, two-tailed), indicating high convergence. Similarly, the circular correlation of the octant scales angles pre- and posttreatment was.99 ( p.01). These analyses support the hypothesis of circumplex structure both preand posttreatment and the stability of that structure. Hypothesis 2: Stability and Change in General Distress, Love, and Dominance IIP C Factors To test the second hypothesis of change in the general Distress factor and relative stability in interpersonal style (Love and Dominance), we calculated retest and cross-correlations of the factor scores over the two assessments (see Table 3). The retest stabilities were moderate (for the Distress factor, r.55) to very strong (for the Love and Dominance factors, rs.84 and.79, respectively) and significant, whereas the cross-correlations were quite small and nonsignificant. Moreover, the Distress factor was less stable than both the Love (z 4.57, p.01, two-tailed) and Dominance (z 3.44, p.01, two-tailed) factors, indicating greater stability in interpersonal style. Factor scores were not appropriate to evaluate mean level change in these three dimensions because each has a mean of zero. Instead, the octant scale s z scores based on national norms (Horowitz et al., 2000) were used to approximate the factor scores in a form suitable for testing change in means. The general Distress factor score was approximated as the mean z score among octant scales, and the Dominance and Love factor scores were approximated by the normative Love and Dominance scores referenced earlier in calculation of mean angle and vector. The general Distress, Dominance, and Love factor scores converged highly with these approximations both pre- (rs.99) and posttreatment (rs.99,.96, and.96, respectively). Consistent with the second hypothesis, neither Dominance, t(117) 1.86, p.07, two-tailed, nor Love, t(117) 0.03, p.98, two-tailed, changed significantly, further suggesting stability in interpersonal style. In contrast, general Distress decreased significantly, t(117) 11.34, p.01, two-tailed, d Hypothesis 3: Relations of IIP C Factors to Social Adjustment Before testing the third hypothesis, we examined the SAS SR descriptive and change statistics. As shown in Table 4, internal 4 The circular correlation 1 8 cos( n i ), where a b for i 1 octant angle sets a and b (e.g., pre- and posttreatment) and n 8 octant scales.

8 36 VITTENGL, CLARK, AND JARRETT Figure 2. Observed circumplex structures: Inventory of Interpersonal Problems Circumplex scales rotated loadings on Factors 2 (Love vs. Hate) and 3 (Dominance vs. Submission) pre- and posttreatment. consistencies for the SAS SR scales were similar to past research (Edwards et al., 1978; Weissman & Bothwell, 1976). Compared with a sample of community-dwelling adults (Weissman et al., 1978), the present sample demonstrated broadly elevated scores (Ts 67 77) pretreatment (note that higher scores on the SAS SR reflect poor adjustment) and more normative adjustment posttreatment (Ts 53 57). Each of the SAS SR scales demonstrated significant decreases pre- to posttreatment ( ps.01, two-tailed). Our third hypothesis was that the IIP C general Distress factor, but not Love or Dominance, would relate broadly to social adjustment. For these analyses and those using the SNAP, posttreatment data were used because results should be more broadly applicable from a sample not acutely depressed. In support of our hypothesis, the general Distress factor was highly related to the SAS SR total and significantly related to higher scores on all the subscales (again, recall that higher scores on the SAS SR reflect poor adjustment), with the exception of the correlation with the parenting subscale, which fell below the significance threshold, perhaps because of the smaller sample size. In addition, the SAS SR scales were not significantly related to the Love and Dominance dimensions (see Table 5). Hypothesis 4: Relations of IIP C Factors to Personality Pathology Our fourth hypothesis was that the SNAP scales would relate broadly to the IIP C general Distress factor and differentially to Love and Dominance (see Clark et al., in press, for SNAP descriptive statistics). As shown in Table 5, personality pathology was most broadly related to the general Distress factor. The Distress factor was highly positively correlated with negative temperament and several related traits (mistrust, dependency, and self-harm) and also strongly negatively correlated with positive temperament and positively with detachment. Several of the SNAP scales demonstrated readily interpretable relations with the Love and Dominance factors as well, suggesting that these scales are partly interpersonal in nature. Those scoring higher on the Love dimension reported lower levels of aggression and detachment and higher levels of dependency, exhibitionism, and impulsivity, whereas participants scoring higher on Dominance reported greater manipulativeness, aggression, exhibitionism, and disinhibition. Discussion This study tested hypotheses concerning the structure and level of interpersonal problems, as measured by the IIP C, before and after a 20-session trial of cognitive therapy for depression; the IIP C s relations to a standard measure of social adjustment, the SAS SR; and a newer, trait dimensional measure of personality pathology, the SNAP. Descriptively, IIP C profiles were consistent with depressive symptomatology (American Psychiatric Association, 1994) and with previous investigations relating the IIP C to depression (Alden & Bieling, 1996; Alden & Phillips, 1990), including greater problems with nonassertiveness and exploitability, and indicated a reduction in problems from pre- to posttreatment.

9 INTERPERSONAL PROBLEMS IN DEPRESSION 37 Table 3 Pre- to Posttreatment Retest and Cross-Correlations of the Inventory of Interpersonal Problems Circumplex Version Factor Scores Factor score Post Distress Post Love Post Dominance Pre Distress Pre Love Pre Dominance Note. N 118. Correlations in boldface type are significant at p.01 (two-tailed); all other correlations are not significant ( ps.05). The first hypothesis that the IIP C would demonstrate a circumplex structure both pre- and posttreatment, after accounting for a general Distress factor, was supported. The IIP C s stable factor structure included a general Distress factor plus Love and Dominance, with the latter two factors defining a circular space around which the octant scales were arranged similarly to their theoretical placements. Identifying these orthogonal dimensions allowed for separation of interpersonal distress and problem level (captured by the general Distress factor) from characteristic interpersonal behavior or style (captured by the Love and Dominance factors). Based on these independent dimensions, the second hypothesis of change in the general Distress factor (similar to a state measure) as opposed to relative stability in interpersonal style (Love and Dominance as trait measures) was also strongly supported. General Distress decreased significantly and had moderate retest reliability, whereas Love and Dominance did not change in mean level and had significantly higher retest reliabilities. This pattern of results suggests that the IIP C circumplex structure is quite robust, even over a trial of cognitive therapy and associated changes in depression and social adjustment. Moreover, assessment with the IIP C appears to tap both state and trait constructs to inform clinicians about clients current level of interpersonal distress in the context of an enduring interpersonal style. Whereas previous research has supported the validity of the IIP C in predicting therapy process and outcome (e.g., Alden & Capreol, 1993; Gurtman, 1996; Horowitz, Rosenberg, & Bartholomew, 1993), this study supported the stability of the IIP C structure, another important aspect of validity for personality measures and informing underlying theory. In contrast to prior research demonstrating change in the FFM traits of extraversion and neuroticism (Bagby et al., 1995), with which the IIP C dimensions of Love and Dominance correlate moderately (e.g., Soldz et al., 1993), this study suggests that Love and Dominance are largely stable over therapy. One might speculate that changes in extraversion and neuroticism reflect the large affective/intrapersonal components of such traits (e.g., Watson & Clark, 1984, 1997), whereas altering the dimensions of Love and Dominance may require therapy focused specifically on interpersonal behavior and relationships rather than depressive symptom reduction. Our third hypothesis concerned the convergence of the IIP C factor scores with the SAS SR. Because of relatively consistent, positive correlations between the IIP C raw octant scales and the SAS SR scales in a previous investigation (Horowitz et al., 2000), we hypothesized that the IIP C general Distress factor, but not Love or Dominance, would relate to social adjustment. This hypothesis was supported for each SAS SR scale, including overall adjustment, at work, during leisure activities, with immediate family, with extended family, and in marriage, with the exception of parenting activities, for which the sample was smaller and no correlations were significant. This pattern of results suggests that, in this population, many interpersonal styles (e.g., warm vs. reserved, assertive vs. receptive) are compatible with good interpersonal functioning, so long as they are not too extreme. Conversely, a highly elevated interpersonal profile, as reflected in high scores on the general Distress factor, relates to poor adjustment in several major areas of social functioning. As implied by the cognitive model, one interpretation of this finding is that effective and efficient change in social functioning may often involve adapting and improving, rather than fundamentally changing, patients basic interpersonal styles. Our fourth and final hypothesis was that the IIP C factor scores would relate broadly to the SNAP. In support of this hypothesis, 10 of 15 SNAP scales correlated with general interpersonal Distress, and negative temperament demonstrated a quite strong correlation (.70), consistent with past research suggesting that this factor of the IIP C largely reflects neuroticism/negative affectivity (Soldz, 1997). However, the moderately strong negative correlation of the Distress factor with positive temperament suggests that the interpersonal Distress factor also encompasses low levels of engagement, and thus may reflect a very broad view of one s interpersonal functioning, similar to the information gathered by the SAS SR. These results fit well with previous research suggesting that the general Distress factor taps adjustment in both social and Table 4 Descriptive and Change Statistics for the Social Adjustment Scale Self-Report Version Scales Pre- and Posttreatment Pretreatment Posttreatment Scale n M SD T score M SD T score t(n 1) d Overall Adjustment Work Social and Leisure Extended Family Marital Parental Family Unit Note. All t values are significant at p.01 (two-tailed) and reflect increased adjustment posttreatment. Effect sizes (ds) of 0.20, 0.50, and 0.80 may be interpreted as small, medium, and large effects, respectively (Cohen, 1988).