Article summary with Interpersonal subtypes in social phobia: Diagnostic and treatment implications by Cain a.o. - 2010

Social phobia has been reported to be the most common anxiety disorder in the United States, with a lifetime prevalence rate of 13.3%. It’s characterized by a “marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others”. It often follows a chronic course, resulting in substantial impairments in vocational and social functioning and causing these individuals to engage in avoidance behaviours allowing them to stay away from feared social situations.

A common critique of the social phobia diagnosis is the inclusion of a generalized subtype. The DSM-IV says the generalized specifier should be ‘when the individual’s fears are related to most social situations’.

Though research has consistently shown that generalized social phobia presents the more severe manifestation of the disorder, there’s a number of problems with the current DSM-IV criteria for subtyping social phobia. Particularly it doesn’t explicitly define the number/type of social situations that comprise the generalized subtype. This results in research groups having developed different operational definitions for generalized social phobia making comparison across empirical studies difficult. DSM-IV symptom-based classification criticized for failing to create qualitatively different subgroups.

Interpersonal assessment may provide a more clinically useful way to identify qualitatively different subgroups of socially phobic individuals by identifying patients based on their distinct ways of responding to social situations. Form an interpersonal perspective, could be argued that the DSM-IV criteria doesn’t fully capture the range of maladaptive responses to social situations that could be exhibited by socially phobic people.

Interpersonal Classification of Social Phobia

Applying interpersonal theory to diagnosis, it’s been argued that interpersonal functioning is an essential component of the diagnostic process in addition to the assessment of symptoms. It’s been pointed out that often the most useful aspects of diagnoses are psychosocial in nature and that most diagnoses are made on the basis of observed interpersonal behaviour.

One method for deriving an interpersonal classification is to use the Inventory of Interpersonal Problems – Circumplex Scales (IIP-C). It’s based on interpersonal theory, providing a nomological framework for articulating both adaptive and maladaptive dynamic interpersonal processes.

The original IIP was revised using a Circumplex model that can be conceptually organized in a circular manner along the dimensions of dominance and affiliation. It contains 64 items divided into eight subscales. These dimensions provided the basis for Leary’s interpersonal Circumplex (see figure 1) and are considered to be the basic elements of interpersonal behaviour. Circumplex quadrants are useful summary descriptors of interpersonal behaviour. Computing scores on each axis can give coordinates to define the location of the predominant interpersonal problem pattern. It also contains a general factor equivalent to mean level of reported interpersonal distress.

Pathoplasticity

Using the IIP-C to form interpersonally based subtypes of socially phobic individuals is based on a theory of pathoplasticity. Pathoplasticity is characterized by a mutually influencing, nonetiological relationship between psychopathology and another psychological system. Psychopathology and another psychological system influence the expression each other, but neither one is the exclusive direct causal agent of the other, which may be the case in an etiological or spectrum relationship. Pathoplasticity recognizes that the expression of certain maladaptive behaviours, symptoms, and mental disorders all occur in the larger context of an individual’s personality.

The interpersonal paradigm asserts that maladaptive self-concepts and disturbed interpersonal relations are key elements of the phenotypic presentation of all psychopathology. It’s been suggested that using an interpersonal paradigm to systematically account for these elements provides additional and valuable information beyond diagnosis itself for both treatment planning and developing testable hypothesis regarding the etiology and maintenance of psychopathology. Differences in interpersonal diagnosis will affect the manner in which patients express their distress. It’ll also influence the type of interpersonal situation they feel is needed to regulate their self, affect, and relationships.

Kachin et al. (2001) (among others) have described procedures to determine the presence of a pathoplastic relationship using the IIP-C. If patients with a particular disorder aren’t defined by a uniform interpersonal profile, and they’re not defined by a complete lack of systematic interpersonal expression, then it’s necessary to examine if a pathoplastic relationship exists. Individuals with a certain disorder are subjected to cluster analyses based on their responses to the IIP-C to confirm the existence of distinct groups with characteristic interpersonal problem profiles. If data supports the clusters -> necessary but not sufficient evidence for pathoplastic relationship.

A number of investigations found that individual differences in interpersonal problems exhibit pathoplastic relationships with mental disorders, pathological symptoms, and maladaptive traits. Using the IIP-C, a study found two distinct subtypes of socially phobic undergraduates with distinct interpersonal features suggesting qualitatively different responses to feared interpersonal situations. The first subtype: reported difficulties with anger, hostility, and mistrustfulness (cold dominant group). Second subtype: reported difficulties with unassertiveness, exploitability, and overnurturance (friendly-submissive group). No significantly differences between the two subtypes on level of interpersonal distress, and they weren’t significantly different on depression or other disorders comorbid to social phobia, providing evidence for pathoplasticity.

This Study

Three main goals. First, to replicate the results of Kachin et al. (2001) by using an interpersonally based approach to subtype socially phobic people using the IIP-C in a clinical sample at an outpatient psychotherapy clinic. Second, to provide evidence for the pathoplasticity of social phobia. Third, examine subtype differences on posttreatment measures of general symptom severity, level of social anxiety, psychological well-being, level of optimism, and satisfaction with social functioning. Extensive research using the IIP-C has shown that friendly-submissive interpersonal problems are positively related to psychotherapy outcome, whereas hostile-dominant problems are negatively related to outcome.

Method

Patients and Therapists

Data was collected for this naturalistic study at the University of Bern, Switzerland, in their outpatient psychotherapy clinic. Clinic accepts patients suffering from wide range of problems and disorders, except psychotic disorders and substance use disorders. This study used data from 20 different therapists.

Analyzed the data of 77 patients diagnosed with DSM-IV social phobia. Assessors at the clinic didn’t specify generalized social phobia, meaning they were unable to analyze data on the diagnostic-based subgroups of social phobia.

In this sample, 100% of the patients met criteria for at least one Axis I disorder, and 55.8% met criteria for more than one Axis I disorder. These diagnoses included social phobia, major depressive disorder, specific phobia, and many others. There was no systematic assessment of Axis II pathology in this sample.

Treatment

Treatment model at the University of Bern outpatient clinic draws on empirical findings from basic psychology, neuropsychology, and various theoretical models as the basis for an integrative framework for empirically supported psychotherapy. Grawe (1997) articulated five change mechanisms necessary for psychotherapy: a) the therapeutic bond, b) problem activation, c) resource activation, d) mastery, and e) motivational clarification.

Interpersonal Measures

Interpersonal problems were assessed using the German version of the IIP-C. the IIP-C assesses interpersonal problems across eight scales emerging around the dimensions of dominance and love: domineering, vindictive, cold, socially avoidant, nonassertive, exploitable, overly0nurturant, and intrusive.

Symptom and Outcome Measures

• Bern Subjective WellBeing Inventory
• Brief Symptom Inventory
• Taylor Manifest Anxiety Scale
• Insecurity Questionnaire

Retrospective Outcome Measures

• Changes in Life Domains Questionnaire
• Revised Questionnaire of Changes in Experiencing and Behaviour

Results & Discussion

The study addressed three major aims.

1. First aim was to replicate results of Kachin et al. (2001) in a clinical sample. Two distinct subgroups of socially phobic patients were found: a friendly-submissive cluster and cold-submissive cluster. The two subgroups exhibited highly protypical circumplex profiles and nonoverlapping circular confidence intervals, suggesting that patients within each of the clusters were reporting distinct interpersonal problems. This study also found a cold-submissive cluster, suggesting that social phobia patients in this sample reported more submissive interpersonal problems overall rather than problems associated with dominance.
2. A second aim was to provide evidence for the interpersonal pathoplasticity in social phobia. The formation of two interpersonally distinct subtypes provides necessary but not sufficient evidence of interpersonal pathoplasticity. Additional analyses show no significant differences between the two subtypes on gender, comorbidity, interpersonal distress, and pretreatment symptom measures. Results provide sufficient evidence for interpersonal subtypes in social phobia in this sample.
3. Third aim was to compare the two interpersonally based subtypes at posttreatment on several outcome measures. Posttreatment comparisons indicated that friendly-submissive social phobia patients exhibited lower levels of social anxiety ad higher levels of well-being/satisfaction at posttreatment than cold-submissive social phobia patients. Friendly-submissive patients showed lower levels of fear of failure/critique, and fear of contact with others and were better able to assert themselves through making demands and being able to say ‘no’ than cold-submissive patients. Friendly-submissive also reported higher levels of optimism than cold-submissive.

On a measure of general psychopathology, though, there were nog significant difference between the two subtypes at posttreatment, suggesting that what might matter most in the treatment of social phobia is targeting social fears and maladaptive interpersonal behaviours instead of overall level of psychopathology.

Interpersonal Complementarity and Interpersonal Motives

The posttreatment differences demonstrated by the two subtypes of socially phobic patients may be attributed to interpersonal complementarity and differences in interpersonal motivation. Interpersonal complementarity is defined as: “a person’s interpersonal actions tend to initiate, invite, or evoke from an interactant complementary responses,” – Kiesler (1983). Kiesler suggested that in a self-fulfilling manner, certain types of rigid, maladaptive interpersonal behaviours actually increase the probability that an individual will elicit the type of response from others that reinforces their fears and maladaptive behaviours.

Empirical studies of complementarity have found that people often don’t exhibit the expected behavioural complementarity. Horowitz et al. (2006) noted that reactions to behaviour are not only guided by the interactional quality of the person’s behaviour but also by the suspected motives of the person. Important to note that interpersonal behaviour can be ambiguous, and one behaviour can have different underlying motives, making it difficult to understand what’s behind the hostile behaviour.

To address the motivational dimension of interpersonal behaviour, Horowitz (2004) expanded the principle of complementarity by describing that individuals have interpersonal motives influencing their behaviour during interpersonal situations and that these motives are also organized around the dimensions of agency and communion. Agentic motive is related to a need for autonomy, communal motive related to a need for intimacy. He argued that people develop strategies to satisfy their motives, but the chronic frustration of interpersonal motives leads to the development of interpersonal problems and distress.

Grosse Holtforth, Pincus, Grawe, and Mauler (2007) aimed to clarify the relationship between interpersonal problems and underlying interpersonal motivations. They found that high scores on friendly-submissive interpersonal problems were associated with highly valuing interpersonal recognition and dreading separations from others, accusations from others, and being hostile. They also found that cold-submissive interpersonal problems were associated with dreading to make oneself vulnerable. Friendly-submissive patients may be seeking more interpersonal recognition from others by employing rigid and maladaptive interpersonal strategies that focus on being excessively compliant and overly friendly. They seem to fear displeasing others and being ignored or disliked and therefore strive to be excessively pleasing. Cold-submissive patients fear being hurt in social situations and may therefore try to minimize social contact and avoid intimacy and relationships with others as a way of protecting themselves from rejection.

Clinical Implications

Results of this study suggest that using the IIP-C to assess interpersonal functioning could provide additional information to the current DSM-IV approach and that traditional psychotherapy may need to modified to better address specific interpersonal problems and interpersonal motives. But they also suggest that an interpersonal classification for social phobia may help improve diagnostic clarity and inform treatment conceptualization and planning.

Incorporating an interpersonal problem component in the diagnostic assessment process could lead to better assessment of interpersonal distress and maladaptive behaviours. Several research studies have shown that friendly-submissive interpersonal problems are positively related to psychotherapy outcome, whereas cold-dominant interpersonal problems are negatively related to outcome in both cognitive-behavioural and psychodynamic therapy.

Based on interpersonal traditional, specific interventions could be tailored to target the therapeutic relationship, the patient’s interpersonal problem areas, and the patient’s interpersonal motivations more effectively.  Therapists might need to avoid responding to patients in complementary ways to avoid reinforcing their maladaptive relational patterns and to stimulate new social learning opportunities within the therapeutic transaction.

Modifications to traditional cognitive behavioural treatment for social phobia may be needed to target specific interpersonal problem areas. Research by Newman et al. has shown the importance of modifications to traditional CBT for anxiety disorders, they examined the efficacy of an integrative psychotherapy for generalized anxiety disorder. They found that their integrative treatment resulted in clinically significant change in GAD symptomatology. These findings highlight the importance of designing treatment modifications addressing interpersonal problems to improve treatment outcome for all patients.

It’s likely that both friendly-submissive and cold-submissive patients would benefit from exposure to feared social situations. But more attention should be given to how each subgroup of socially phobic patients would respond to other CBT interventions like social skills and intimacy skills training. Friendly-submissive patients may be more responsive to relational skills training than cold-submissive who may need to initially focus more on interventions that increase treatment compliance and decrease fears of social rejection.

Limitations and Future Directions

• One limitation of this study was the use of a naturalistic design, limiting the available data and the conclusions that can be drawn about psychotherapy outcome between two clusters of socially phobic patients.
• A second limitation was the small sample size and the reduction of patients from pretreatment to posttreatment, limiting the statistical power and external validity. However, the fact that they were able to examine clinical data from an outpatient psychotherapy clinic allowed for maximization of generalizability of the results to other clinics treating socially phobic patients.
• Third possible limitation is using an exclusively German and Swizz population, may restrict generalizability to other cultures given the use of interpersonal constructs. But it seems that the clinical presentation of social phobia is often consistent between Germanspeaking cultures and the United States, and other European countries.
• Finally, although this study was limited to selfreport data, future research on interpersonal pathoplasticity should employ methods that code for interpersonal processes during psychotherapy to assess how the two subtypes may respond to their therapist and the therapy over the course of treatment.
• In conclusion, results suggest that the two distinct subgroups of socially phobic patients differentially responded to the same treatment – future research should investigate techniques that will effectively target maladaptive interpersonal behaviour of both subtypes. Accounting for distinct interpersonal motives underlying maladaptive behaviour patterns could improve diagnosis, treatment planning, and therapeutic outcome.