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Michael J. Roche and Emily B. Ansell
A central feature of personality disorders is the interpersonal impairment and relationship difficulties with which individuals with these diagnoses often struggle (APA, 2013). As such, interpersonal theory can provide an organizing structure for describing personality pathology. The present chapter reviews contemporary assumptions of interpersonal theory, proposes additional context-driven factors that underlie the assumptions of interpersonal theory, describes the interpersonal circle model, and then examines how static and temporally-dynamic interpersonal data can inform description and treatment approaches for patients with personality disorder diagnoses.
The interpersonal tradition starts with the seminal work of Harry Stack Sullivan (1953a, 1953b, 1954, 1956, 1962, 1964), a psychiatrist who, through his work with patients with schizophrenia, developed a theoretical model that emphasizes the importance of social relationships in the management of psychiatric symptoms (Hooley, 2010). Sullivan defined personality as “the relatively enduring pattern of recurrent interpersonal situations which characterize a human life” (Sullivan, 1953b, pp. 110–111). Subsequent work operationalized his ideas into a model of interpersonal phenomena organized around two interpersonal dimensions, termed the interpersonal circumplex (LaForge, 2004; Leary, 1957). Whereas an overview of the history of interpersonal theory is available elsewhere (e.g., Pincus, 1994; Strack & Horowitz, 2011; Wiggins, 1996), the current chapter focuses on recent theoretical and empirical advances to interpersonal theory (e.g., Pincus, Lukowitsky, & Wright, 2010).
The Interpersonal Paradigm
Decades of interpersonal theorizing and model development have been incorporated into what some describe as an interpersonal paradigm (Wiggins, 2003) or meta-theory (Pincus & Ansell, 2013) for clinical psychological science. Indeed, the interpersonal paradigm articulates both static and temporally-dynamic psychological processes that can be integrated with other existing theories, including attachment (Bartholomew & Horowitz, 1991; Benjamin, 1993; Florsheim & McArthur, 2009), psychodynamic (Lukowitsky & Pincus, 2011; Luyten & Blatt, 2011), social-cognitive (Locke & Sadler, 2007; Safran, 1990a, 1990b), evolutionary (Fournier, Zuroff, & Moskowitz, 2007; Zuroff, Moskowitz, & Côté, 1999), and neurobiological (Depue, 2006; Moskowitz, Zuroff, aan het Rot, & Young, 2011) theories. The interpersonal paradigm has also been applied to the study of psychological assessment (Hopwood et al., 2016; Pincus, 2010; Pincus et al., 2014), psychopathology (Horowitz, 2004; Pincus & Wright, 2011), health (Smith & Cundiff, 2011), and psychotherapy (Anchin & Pincus, 2010; Benjamin, 2003; Cain & Pincus, 2016; Pincus & Cain, 2008). The present chapter focuses on how interpersonal theory, and more specifically the interpersonal paradigm, can inform the description and treatment of personality disorders.
Contemporary Integrative Interpersonal Theory
Contemporary Integrative Interpersonal Theory (CIIT; Pincus, 2005; Pincus & Ansell, 2013) proposes four assumptions that guide the framework of the interpersonal paradigm. The first is that the propaedeutic expressions of personality (and its disorder) are interpersonal in nature. Indeed, most trait models of personality include dimensions that capture interpersonal style (e.g., extraversion, agreeableness; McCrae & Costa, 1989). The alternative model of personality disorders in the DSM-5 also emphasizes interpersonal dysfunction in the definition of core deficits in personality functioning (APA, 2013).
The second assumption is that two bipolar dimensions labeled agency and communion can efficiently organize the description of interpersonal phenomena. These terms serve as meta-constructs for interpersonal theory, as they can be applied to describe several units of analysis such as interpersonal motivations, perceptions/behaviors, strengths, and problems (Bakan, 1966; Wiggins, 1991). Agency can be defined as the condition of differentiation (vs. enmeshment), with more specific descriptions for motivations (to control vs. to give control), perceptions/behaviors (dominance vs. submissiveness), strengths (to lead vs. to cooperate), and problems (domineering vs. nonassertive). Communion can be defined as the condition of affiliation and connectedness with others (vs. isolation), and can similarly be described more specifically for motivations (to affiliate vs. to separate), perceptions/behaviors (friendly vs. unfriendly), strengths (to connect vs. to separate for personal space), and problems (overly nurturant vs. cold).
The third assumption recognizes that interpersonal phenomena (including themes of agency and communion) can describe observable social exchanges, as well as “imagined” social exchanges that exist inside the mind via mental representations of self and others (e.g., Benjamin, 2003; Lukowitsky & Pincus, 2011). These mental representations are formed through the combination of past experiences (e.g., memories of past relationships, distorted memories from the past), present information, and future expectations (e.g., dreams/fantasies about current relationships, (in)accurate expectations about future social exchanges and relationships). As such, personality dysfunction can occur if individuals are so strongly guided by experiences that they discount present evidence and information, have unrealistic expectations about future relationships, or simply fail to perceive an interaction partner’s behavior (or interpersonal intentions) accurately. These distortions may lead to characteristic ways patients see themselves and other people.
The fourth assumption is that there is a normative pattern to how interpersonal exchanges unfold over time. Generally, perceiving an interaction partner as dominant pulls for submission, and vice versa. If both people remain dominant, it is difficult to agree on a decision, and if both remain submissive, no decision can ever be made. This is referred to as agentic complementarity. Along the dimension of communion, there is an expectation that interaction partners will match each other on level of communion. If one person is more communal, she or he may be perceived as intrusive or overly invested in the relationship. If one person is less communal, that individual may be perceived as cold, uncaring, and disconnected from the other person. The research support for complementarity (Carson, 1969) will be reviewed later in the chapter.
A fifth, not previously articulated assumption within CIIT, is that context matters to the expression of these social exchanges, particularly when identifying pathological interpersonal patterns. Although normative, complementary social exchanges may predominate our interpersonal world, specific contexts may evoke non-normative patterns that reflect the characteristic interpersonal problems associated with a given personality disorder. There may be homogeneous non-normative responses that characterize a personality disorder (e.g., responses to dominance in narcissistic personality disorder) or heterogeneous non-normative responses that help explain diversity of interpersonal behavior within a disorder (e.g., borderline personality disorder). These context-driven expressions may best be assessed by temporally-dynamic methods, both at idiographic and nomothetic levels.
In summary, interpersonal phenomena are crucial to understanding the pathology in personality disorder. The dimensions of agency and communion can bring an organizing structure to describing interpersonal exchanges, both real and imagined. Additionally, there are normative patterns to how agency and communion are exchanged within social interactions, and chronic departures from those normative patterns are indicative of psychopathology. In the next sections, we review how agency and communion can be operationalized, and then present research using static and temporally-dynamic methods to capture interpersonal dysfunction in personality disorders.
The Interpersonal Circle
Agency and communion can be organized conceptually and empirically as axes of an interpersonal circle (IPC; see Figure 8.1), where agency is denoted along the Y-axis and communion along the X-axis. The space between these axes represents combinations of agency and communion. IPC self-report measures typically contain 32 or 64 items that organize into eight scales (termed octants). By convention, the communion scale is set at 0˚, and the other scales are separated by 45˚, moving counterclockwise: +C (0˚), +A+C (45˚), +A (90˚), +A‒C (135˚), ‒C (180˚), ‒A‒C (225˚), ‒A (270˚), and ‒A+C (315˚).
Figure 8.1
The interpersonal circle.
The eight scales correlate in a circular pattern, where scales conceptually opposite (e.g., ‒A and +A) will have a strong negative correlation, scales conceptually independent (e.g., +A and +C) will have a near zero correlation, and scales conceptually closer (e.g., +A and +A+C) will have a positive correlation. The circular properties of the eight scales can be tested through various methods (e.g., RANDALL; Tracey, 1997; CIRCUM; Browne, 1992). Numerous studies have demonstrated several interpersonal measures conform to these circumplex properties (e.g., Acton & Revelle, 2002; Alden, Wiggins, & Pincus, 1990; Wilson, Revelle, Stroud, & Durbin, 2013).
Although researchers can examine these eight scales separately, the unique circular structure among the interpersonal scales allow for a more sophisticated approach. The structural summary method (SSM; Gurtman, 1994; Gurtman & Pincus, 2003) was developed to calculate four parameters with substantive interpretation: elevation, prototypicality, amplitude, and angular displacement. Elevation is calculated by averaging the eight scales together, and is simply interpreted as the average scale score (akin to a factor score being the average of the facets). Prototypicality (also termed R2) examines how well the interpersonal profile conforms to a circular structure (e.g., a sinusoidal curve), a necessary step before interpreting the other parameters. An R2 above .8 indicates a good fit to circular structure, and R2 above .7 indicates acceptable fit (Zimmerman & Wright, 2017). The amplitude measures how differentiated or distinct the interpersonal profile is. For instance, how much do octant scales differ from the elevation score? If there is minimal differentiation, then the elevation score is the most efficient score to describe an individual’s profile. In contrast, if the amplitude is .15 or higher, it indicates that some octant scales are higher than others and warrants exploration into which scales are particularly high. This could be done by looking at octant scale values, but the more precise way is to examine the angular displacement, which calculates the angle of the circle where the score peaks (across a 0˚ to 360˚ continuum described earlier). Thus, the angular displacement score is only meaningful if the interpersonal profile is circular and differentiated. A thorough review of circular statistics and calculations can be found in Wright, Pincus, Conroy, and Hilsenroth (2009).
Interpersonal Assessment Instruments
Whereas the eight octants and circular structure are similar across interpersonal circle (IPC) measures, different interpersonal measures can capture different interpersonal phenomena. For instance, the inventory of interpersonal problems circumplex (IIP-C; Alden et al., 1990) is a commonly used IPC self-report measure that captures behaviors that individuals do too much or too little, but that still conform to themes of agency (e.g., I am too aggressive towards other people) and communion (e.g., It’s hard for me to introduce myself to new people). Here, the elevation represents a general factor of interpersonal distress, whereas the angular displacement represents the most characteristic theme of their distress. In contrast, the interpersonal adjective scale (IAS-R; Wiggins, Trapnell, & Phillips, 1988) is captured through a list of adjectives, where the elevation is thought to represent a response style that is not often of substantive interest. Other interpersonal measures exist to capture a person’s values or motivations, goals, traits, efficacies, strengths, impact messages, and sensitivity towards other’s behaviors (see Locke, 2011 for a more extensive review of IPC measures). Whereas each measure captures a different element of interpersonal phenomena, the structure around agentic and communal themes is similar, allowing for easy interpretation across instruments.
Personality Disorder Research Using Static IPC Instruments
At the broadest level, the IPC can serve as a conceptual map to organize constructs such as personality disorders. For instance, researchers can collect an IPC measure along with a measure of personality disorder. Then, researchers can correlate the personality disorder with each of the IPC octants, apply SSM calculations to those correlations, and examine how the personality disorder relates to the IPC in terms of elevation, angular displacement, differentiation, and prototypicality. Interpersonal models are especially appealing to the study of personality disorders because all are characterized by interpersonal dysfunction, and yet each specific personality disorder contains its own specific style of pathology. The elevation parameter can capture this central theme of interpersonal dysfunction, whereas angular displacement scores can capture the individual interpersonal styles characteristic of specific personality disorders.
Several researchers have examined the relationships between interpersonal style and personality disorders over the last several decades. Recently, this research was efficiently summarized in a meta-analysis containing 127 published and unpublished studies between the years of 1994–2013 (Wilson, Stroud, & Durbin, 2017). These researchers reported the correlations between interpersonal octant scales and personality disorders, and then examined the pattern of correlations using the SSM (several different interpersonal measures and personality disorder measures were used). They found that all but two personality disorders (dependent personality disorder, obsessive-compulsive personality disorder) exhibited a prototypical pattern (R2 > 0.8), with adequate differentiation (amplitude > 0.15). Elevation was moderate across the personality disorders (0.17‒0.39), indicating that each personality disorder shares a core of interpersonal dysfunction. Though, some personality disorders evidenced a weaker elevation (schizoid, antisocial), which may reflect the egosyntonic nature of their interpersonal difficulties. Personality disorders also reflected distinct interpersonal themes (see Figure 8.2). Histrionic personality disorder was reflected in friendly-dominance, whereas narcissistic, antisocial, borderline, and paranoid personality disorders had themes of dominance or unfriendly-dominance. Schizotypal and schizoid personality disorders reflected themes of coldness/unfriendliness, whereas avoidant personality disorder contained themes of submissiveness. Though dependent personality disorder did not have adequate structural summary parameters to confidently interpret the interpersonal theme in this study, other studies have found dependent personality disorder to reside in the friendly-submissive area of the circle (Pincus & Wiggins, 1990), which was also the area indicated in the meta-analysis.
Figure 8.2
Interpersonal themes of personality disorder (PD)
Note: Findings summarized from Wilson et al. (2017). Angular displacements are approximate. NPD = Narcissistic PD. ASPD = Antisocial PD. BPD = Borderline PD. PPD = Paranoid PD. SZT = Schizotypal PD. SCZ = Schizoid PD. AVPD = Avoidant PD HPD = Histrionic PD.
The researchers further noted that the correlations between personality disorders and dominant/cold themes were stronger in samples that were predominantly female and non-clinical, and in studies using non self-report methods to assess for personality disorders. In contrast, submissive/warm themes were more strongly related to personality disorders in samples that were predominantly male and clinical, and in studies that used self-report methods to assess for personality disorders. In total, this research suggests that the interpersonal model does a good job of capturing the convergent (interpersonal problems) and discriminant (themes of interpersonal problems) qualities of personality disorders.
The interpersonal circle can also be used to evaluate new models of personality disorder. For instance, the Alternative Model for Personality Disorders (AMPD; APA, 2013; Pincus & Roche, 2019) proposes a severity dimension to describe personality impairment, which includes themes of self and other dysfunction. Dowgwillo, Roche, and Pincus (2018) found that this severity dimension was associated with elevation in interpersonal distress as measured by the inventory of interpersonal problems short circumplex (IIP-SC; Soldz, Budman, Demby, & Merry, 1995). Thus, diagnostic personality models and interpersonal models overlap in their conceptualizations of core interpersonal dysfunction.
The AMPD also includes five pathological personality traits that are meant to capture stylistic differences in how personality disorders are expressed. In a sample of several thousand students, researchers found that the several pathological personality traits exhibited adequate prototypicality and differentiation, suggesting that they capture interpersonal themes of personality dysfunction (Wright et al., 2012). Specifically, dominant problems characterized the antagonism trait, unfriendly-dominant problems characterized the disinhibition and psychoticism traits, unfriendly-submissiveness problems characterized the detachment trait, and overly-friendly problems characterized the negative affectivity trait. Another study of several hundred psychiatric patients found similar results (Williams & Simms, 2016).
Using a more advanced method to contrast interpersonal themes with confidence intervals (Zimmermann & Wright, 2017), researchers examined the associations between the inventory of interpersonal problems circumplex (IIP-C; Alden et al., 1990) and both pathological traits and categorical personality disorders in a large patient sample. This research largely replicated the previously noted meta-analysis findings regarding the elevation and angular displacement of personality disorders and pathological traits. Thus, the IPC provides support for the AMPD model, in that interpersonal distress is significantly associated with the severity measure of AMPD and the pathological traits organize around the circle in theoretically expected ways (antagonism corresponds to dominance problems, detachment corresponds to unfriendly-submissive problems, etc.).
Interpersonal Pathoplasticity
Pathoplasticity research examines the influence personality has on the course of mental health disorders (Boroughs & O’Cleirigh, 2015). Interpersonal pathoplasticity (Pincus & Wright, 2011) recognizes that not everyone with a disorder shares the same interpersonal style, and that different interpersonal styles can suggest different treatment outcomes and experiences. Using a form of cluster analysis, researchers have identified subgroups of patients within a disorder that have different interpersonal styles (e.g., angular displacement) and found that these subgroups are differentially associated with several important factors, such as symptoms and treatment outcomes. These effects have been demonstrated in social phobia (Cain, Pincus, & Grosse Holtforth, 2010; Kachin, Newman, & Pincus, 2001), generalized anxiety disorder (Newman, Jacobson, Erickson, & Fisher, 2017; Przeworski et al., 2011; Salzer et al., 2008; Salzer, Pincus, Winkelbach, Leichsenring, & Leibing, 2011), panic disorder (Zilcha-Mano et al., 2015), depression (Cain et al., 2012; Dawood, Thomas, Wright, & Hopwood, 2013; Simon, Cain, Samstag, Meehan, & Muran, 2015), posttraumatic stress disorder (Thomas, Hopwood, Donnellan, et al., 2014), and eating pathology (Ambwani & Hopwood, 2009; Hopwood, Clarke, & Perez, 2007).
Interpersonal pathoplasticity also extends to personality disorders. Although the previously reviewed meta-analysis suggested that most personality disorders conform to a characteristic interpersonal theme, several studies have found a more nuanced picture. In a sample of avoidant personality disorder patients, friendly-submissive and unfriendly-submissive subtypes exhibited differential responses to interventions emphasizing habituation and intimacy training, respectively (Alden & Capreol, 1993). Leichsenring, Kunst, and Hoyer (2003) found a dominant subtype and friendly subtype in borderline personality disorder patients, where the dominant subtype reported primitive defenses and object relations and the friendly subtype reported identity diffusion. Wright and colleagues (2013) found several subtypes of borderline personality disorder, with certain subtypes endorsing more anger, self-harm, identity disturbance, and emptiness compared to the others. Other researchers have found that the unfriendly-submissive subtype of borderline personality disorder can be associated with a lower therapeutic alliance (Salzer et al., 2013). These studies demonstrate that interpersonal style can be associated with different themes of borderline personality pathology and that this heterogeneity is meaningful when planning for, and conducting, treatment.
Taken together, the value of IPC models for personality disorder description and treatment is in enhancing, integrating, and synthesizing theory with assessment and treatment. Research can articulate similarities (elevation) and distinctions (angular displacement) in personality disorder diagnoses for DSM-IV/5 descriptions, as well as provide support for the alternative model. The observed heterogeneity in pathoplasticity research may be descriptive of the interpersonal situations that characterize the expression of problems. Drilling deeper into groups of patients with a diagnosis can reveal how interpersonal style influences symptom expression, therapeutic alliance, and the success of interventions across several diagnoses, including personality disorder diagnoses. These findings support the potential meaning in idiographic approaches to interpersonal assessment. Indeed, there is even greater nuance available when considering IPC models applied to an individual patient.
IPC Profile at the Individual Level
For a personality disorder patient, an IPC profile (e.g., IIP-C) can describe how much interpersonal distress they are experiencing (elevation), as well as the central theme of that distress (angular displacement) and whether their descriptions of interpersonal problems are conventional or non-prototypical (R2). Another extension of this is to collect collateral reports of an individual’s interpersonal problems and examine discrepancies. This occurred for Madeline G, a well-known case study in Jerry Wiggins’ Paradigms of Personality Assessment book (Wiggins, 2003). Madeline reported her interpersonal problems and her partner gave ratings of her problems as well. Not only were the scores discrepant on the overall problems Madeline G experienced (e.g., elevation), but Madeline described the theme of her problems as friendly-dominant, whereas her partner saw her problems as unfriendly-dominant.
Another application to the individual level is to use multiple interpersonal assessment instruments and examine across-instrument discrepancies. For instance, if a patient’s interpersonal values (elevation) are higher than their interpersonal strengths (elevation), then they may feel ineffective interpersonally. Or, a patient may have the value of being dominant and friendly, but only the strength of being dominant and unfriendly, leading to a specific interpersonal deficit to target in treatment. Moreover, an individual may report a clear theme to their problems (R2), but be puzzled about their strengths, leading to a non-prototypical profile (R2). A case example of such an approach is available in Dawood and Pincus (2016), along with more specific recommendations for how to interpret across multiple interpersonal measures.
Personality Disorder Research Using Temporally-Dynamic IPC Instruments
Recall that the fourth assumption of CIIT is that there is a normative pattern for how interpersonal exchanges unfold over time. This pattern, referred to as complementarity in the interpersonal literature, can be described using the dimensions of agency and communion. Specifically, a normative pattern of reciprocity or “oppositeness” is expected along the dimension of agency, where perceiving another person as dominant invites one to respond with submissiveness (and vice versa). A pattern of correspondence or “sameness” is expected along the dimension of communion, such that perceiving another person as friendly invites one to respond with friendliness (and vice versa).
One method to assess for context and complementarity is the Continuous Assessment of Interpersonal Dynamics (CAID; Sadler, Ethier, Gunn, Duong, & Woody, 2009) approach. Participants arrive at a laboratory and complete a discussion task with another person, and their behavior is coded using a joystick apparatus that captures second-to-second ratings of agency and communion. The discussion task can be with a stranger or person the participant knows, and the topic of the discussion can be unstructured or predetermined (discuss a conflict, recall a pleasant time, etc.). Multiple coders are used to obtain reliability. Although there are sophisticated techniques for modeling this type of data (e.g., Sadler et al., 2009; Thomas, Hopwood, Woody, Ethier, & Sadler, 2014), these results tend to correspond with a basic correlation that is easier to implement and interpret. Similarly, whereas lagged effects may be of interest, research has demonstrated that complementarity was strongest in unlagged data (Sadler et al., 2009). Simply put, in general, people tend to respond rapidly and normatively in interpersonal situations.
The results of several studies confirm that interpersonal complementarity is observed in the second-to-second interactions captured in laboratory settings. Sadler and colleagues (2009) asked 50 dyads to complete a collaborative task, finding evidence for both communal and agentic complementarity. Complementarity was also found in a group of female dyads, with higher communal complementarity being associated with completing tasks more efficiently (Markey, Lowmaster, & Eichler, 2010). Similarly, complementarity on communion and agency was found among mothers and their children, though that complementarity was influenced by gene–environment correlational processes (Klahr, Thomas, Hopwood, Klump, & Burt, 2013). In a study of in-session therapeutic alliance and interpersonal behavior (Altenstein, Krieger, & Grosse Holtforth, 2013), the authors again found evidence for complementarity on communion and agency. They further found that emotional activation was positively associated with decreased complementarity in session for communion and agency, supporting the importance of affect in driving non-normative interpersonal exchanges.
Although we are unaware of any study directly examining the associations among personality disorders and complementarity using this method, other research suggests that attention deficit hyperactivity disorder symptoms can influence complementarity in mother–child exchanges (Nilsen, Lizdek, & Ethier, 2015) and depression symptoms can influence complementarity in married couples (Lizdek, Woody, Sadler, & Rehman, 2016). Given recent conceptualizations that personality pathology relates broadly to meta-constructs of psychopathology (Kotov et al., 2017), these associations fit with interpersonal theory. Although the majority of these studies look mainly at complementarity, there is increasing interest in identifying contexts within and outside laboratory settings that can influence these processes (affect, type of conflict/collaboration task chosen, etc.).
Context Matters: Examining a Fifth Interpersonal Assumption of CIIT
Despite the ubiquitous nature of complementarity, deviations from normative interpersonal patterns happen throughout daily life and across individuals. Non-complementary behavior may even at times be adaptive. For instance, when a boss makes an unfriendly/hostile comment, it is ultimately unwise to complement that behavior with an unfriendly/hostile response. An individual who is hostile (e.g., low communion) may pull for her or his romantic partner to reciprocate that hostility/disconnection. Yet, if the partner explores her or his inner feelings (fondness) and wishes (to maintain the relationship, communion), it may lead to a non-complementary response (meeting hostility with engagement and understanding) in service of preserving the relationship. As therapists, we may wish to challenge the predominant interpersonal exchange with our patients by engaging specifically in a non-complementary pattern. By doing this, we may effectively “move” our patients into new or uncomfortable interpersonal spaces that will prove beneficial for their growth. Taken together, it is clear that complementarity in daily life is influenced by myriad other contextual factors (e.g., the interaction partner, current affect, interpersonal motives).
Our proposed fifth assumption synthesizes personality disorder models with the existing CIIT theory to further articulate what has always been an underlying assumption within CIIT – context-driven, systematic, non-normative interpersonal exchanges disrupt the interpersonal situation in a manner that is characteristic of personality pathology. Interpersonal complementarity is one normative pattern, but other normative patterns (how affect drives behavior, how motives and behaviors connect, etc.) are also relevant for a full understanding of the interpersonal situation. As noted before, interpersonal exchanges associated with personality pathology include those that chronically deviate from the expected normative patterns, or when a given context leads to a rigidly applied non-normative pattern.
These complex processes can be best assessed using temporally-dynamic approaches to better inform assessment and treatment of personality pathology. This method can capture discrepancies that are (a) nomothetic and common across all individuals with a specific personality pathology, or (b) idiographic.
The specific contexts that drive the non-normative behavior may include: (a) the specific interactant (e.g., significant other, parent); (b) the interpersonal behavior in a given exchange (e.g., dominant behavior); (c) the perception of interpersonal behavior in the other (e.g., hostile or low communion behaviors in the other); (d) the motives one has in a situation (e.g., to maintain or dissolve a relationship); or (e) the affect associated with a given exchange (e.g., negative or positive affect). These contexts have long been understood as fundamental to describing and understanding the interpersonal situation in CIIT and have been recently articulated in models of CIIT (Figure 8.3, see Pincus, Hopwood, & Wright, 2017). The benefit in adding this as a separate assumption is to better articulate, define, and test the theoretical basis underlying ongoing efforts (described below) to understand which temporally-dynamic, non-normative responses within specific contexts underlie the interpersonal exchanges that characterize personality pathology. By articulating the how, when, and for whom these non-normative responses occur, we can inform novel treatment approaches that incorporate these data in increasingly personalized ways. Recent advances have moved the assessment of these non-normative interpersonal processes forward in increasingly relevant and informative ways.
Figure 8.3
The expanded interpersonal situation model.
One approach to examining complementarity along with the other context-driven processes is to employ intensive repeated measurements (IRM) in daily life. IRM designs typically ask participants to record information about social exchanges just after they end (e.g., six reports of social interactions per day) across several days. Interpersonally focused IRM designs will typically ask participants to record their own agency and communion as well as their interaction partner’s agency and communion.
Several studies using this approach support the normative pattern for complementarity on communion, with mixed support for complementarity on agency. In a 20-day IRM study of community members, participants rated perceptions of their own behavior and the behavior of their interaction partner in social situations occurring in their daily life. As expected, complementarity on the dimension of communion (e.g., meeting friendliness with friendliness) and agency (e.g., meeting dominance with submission) were confirmed (Fournier, Moskowitz, & Zuroff, 2008). In a similar design of community members, Moskowitz and colleagues (Moskowitz, Ringo Ho, & Turcotte-Tremblay, 2007) found support for communal complementarity. Agentic complementarity was only found in work settings, and the effect was strengthened if the participant was in the higher-status work role (e.g., the boss). This finding supports the relevance of normative interpersonal processes in daily life, with more evidence for communal complementarity.
A few studies have examined how personality dysfunction moderates or mediates complementarity within IRM research designs. In a seven-day IRM study using a student sample, narcissism disrupted agentic complementarity, such that higher narcissism was related to increased dominant behavior when perceiving the other as dominant and friendly (Roche, Pincus, Conroy, Hyde, & Ram, 2013). Wright and colleagues (2017) expanded this research into a clinical sample of psychiatric outpatients, completing a 21-day IRM study of affect, interpersonal perceptions, and behavior. The authors also evaluated the role of narcissism in these relations when controlling for other personality disorder symptoms. First, they found that personality disorder symptoms in general were associated with reporting higher negative affectivity, perceiving others as unfriendly, and behaving with submissiveness and unfriendliness. Narcissism, in contrast, was associated with behaving with more dominance. Examining complementarity across the sample, there was evidence for communal but not agentic complementarity. A unique pattern emerged such that perceiving dominance was associated with responding in an unfriendly manner, and this effect was mediated by negative affect. Narcissism moderated (strengthened) these patterns when controlling for other personality disorder symptoms..
Sadikaj and colleagues (Sadikaj, Moskowitz, Russell, Zuroff, & Paris, 2013) examined the role of interpersonal perceptions, affect, and interpersonal behavior in a sample of community adults and patients with borderline personality disorder who reported on their social interactions over 20 days. Individuals with borderline personality disorder were more likely to respond to perceptions of less communion (quarrelsomeness) with increased negative affect and increased quarrelsomeness (complementarity). This pattern was extended by partners who complement the negative affect and quarrelsomeness with even less communal behavior. This, in turn, led to more negative affect and less communion in the patient, which potentiated the cycle further.
The two examples described above speak to the relevance of non-normative interpersonal patterns that are context-driven and specific to different forms of personality pathology. In the case of narcissism, perceptions of dominance led to negative affect, which led to increasingly hostile interpersonal behaviors, whereas in borderline personality, perceptions of hostility led to negative affect, which led to increasingly hostile interpersonal behaviors. In both cases, the experienced affect and the interpersonal behavior are the same. Importantly, the context (perceptions of others’ behavior) distinguishes the type of personality pathology and the underlying non-normative interpersonal pattern.
Interpersonal studies using IRM designs have been conducted to examine normative patterns of interpersonal perception and affect, generally finding that perceiving lower communion (unfriendly or hostility) is associated with negative affect (Cain, Meehan, Roche, Clarkin, & De Panfilis, 2019). However, personality pathology tends to enhance or alter these associations. For example, dependency moderated this relation, such that perceiving others as submissive and unfriendly was associated with increased negative affect in a sample of student participants (Wang et al., 2014). Similarly, in a community sample, negative affect was associated with lower communal perceptions, and this relation was stronger for those with anxious attachment and weaker for those with avoidant attachment (Sadikaj, Moskowitz, & Zuroff, in press). In a study comparing borderline personality disorder patients with community controls, the borderline personality disorder group had a weaker association between perceiving higher communion and positive affect, but a stronger association between perceiving low communion and negative affect (Sadikaj, Russell, Moskowitz, & Paris, 2010).
Personality pathology also impacts how agentic and communal perceptions are experienced in daily life. In a student sample, perceiving friendliness was positively associated with perceiving dominance, and this relation was strengthened for individuals higher in dependency but weakened for individuals higher in narcissism (Roche, Pincus, Hyde, Conroy, & Ram, 2013). This suggests that the strengthening or decoupling of normative perceptions may drive problematic interpersonal processes in different types of personality pathology.
Taken together, the emerging research using IRM designs suggests that the interpersonal patterns that occur in a person’s daily life are influenced in systematic ways by the presence of personality pathology. Findings from studies using these methods are already proving fruitful in articulating the differential processes underlying different forms of personality pathology. Individuals with borderline personality disorder are more sensitive to low communion, which, in turn, affects their affect and behavioral processes. In contrast, perceptions of agency are disruptive to individuals with narcissism, influencing their affect and behavior. Perceptions of unfriendly-submissiveness are unsettling to individuals with higher dependency, presumably because it thwarts their need for others to be in control and willing to help them. This emerging research highlights the importance of a broader definition of non-normative interpersonal interactions and a broader understanding of how affect influences interpersonal processes.
An expanded model of CIIT has been proposed that incorporates affect and motives along with interpersonal perceptions and behaviors to describe the interpersonal situation (Figure 8.3, see Pincus et al., 2017). It includes a self-system organized by interpersonal motives and affect. Here, affect is also articulated in a two-dimensional circular structure, with the X-axis capturing valence ranging from pleasant to unpleasant, and the Y-axis capturing arousal ranging from alert to fatigued. This same system is also captured for the perceived other. It further includes a section for interpersonal behavior of self and other (organized on agency and communion) as well as perceptions and self-perceptions (how I view my interpersonal qualities, affect, etc.).
This dynamic model captures the contexts of personality dysfunction, and highlights the role of the fifth assumption within CIIT models in articulating these complex processes. For instance, conflicts among motives (e.g., identity integration) or intense emotions are located within the self-system. Engaging in non-complementarity in interpersonal behavior is described as field dysregulation, as the behaviors exist outside of the self. Finally, dysfunction can result by distorting the views of self (e.g., misperceiving one’s own motives of agency and/or communion), the views of others (e.g., perceiving them as focused on agency when they in fact are not), or engaging in interpersonal behaviors that are inconsistent with one’s interpersonal motivations.
Temporally-Dynamic IPC at the Individual Level
Although the majority of research has examined group level differences, theory supports the potential for an idiographic approach that informs personalized treatment. At least one research study has employed an IRM design to articulate the interpersonal and emotional exchanges occurring in daily life at an individual level (Roche, Pincus, Rebar, Conroy, & Ram, 2014). In this study, both husband and wife reported on approximately 130 social interactions, including information about their agentic and communal behavior, their anger and self-esteem, and their perception of the other’s agency and communion. Of the 130 social interactions reported, 85 of them were social interactions where both husband and wife reported on their spouse during the same social exchange, permitting an examination of discrepancy across reports.
From the vantage point of the husband, his field regulation was mostly normative, as he engaged in both agentic and communal complementarity in his social interactions experienced in daily life. However, he would only engage in agentic complementarity when he was in the dominant position relative to his interaction partner (e.g., he is dominant, they are submissive). Engaging in less agentic complementarity was associated with the husband experiencing lower self-esteem, indicating a self-system dysregulation. In other words, he could only feel good about himself when he was dominant and others were submissive.
Regarding his perception accuracy and possible interpersonal distortion, he tended to perceive most people as both dominant and friendly, but perceived his wife consistently as dominant and unfriendly. This demonstrates that his perceptions were not uniformly biased and identifies a specific context for non-normative processes. His wife did not report her own dominant behaviors as being unfriendly, and the couple appeared to agree on her level of agency but not her level of communion (reminiscent of the Madeline G case). As with the Madeline G case, it is not known whether husband or wife is correct in their perceptions, but it does demonstrate how a discrepancy or context can be identified and then targeted for treatment.
Interpersonal Models and Personality Disorder Treatment
Interpersonal models (both static and temporally-dynamic) have conceptual nuances that can enhance personality disorder treatment. A baseline assessment of interpersonal problems may be able to identify which types of treatment approaches will be more (or less) successful. IPC measures can also serve as an outcome measure for treatment, to monitor overall distress (elevation), clarity of problems (R2), and themes of problems (angular displacement). In the session, therapist and patient behaviors can be coded for interpersonal complementarity, identifying treatment ruptures (e.g., therapist talking over patient leading to patient disengagement) or areas for therapist growth (e.g., remaining interpersonally neutral during patient hostile projections). Several studies have recently demonstrated how IPC instruments (cross-sectional, CAID, and IRM methods) can empirically guide treatment planning and patient care, and provide a digestible system for training new clinicians (Blais & Hopwood, 2017; Hopwood et al., 2016; Levendosky & Hopwood, 2017).
Psychodynamic
Interpersonal models can be conceptually incorporated into psychodynamic treatments of personality disorder. Transference focused psychotherapy is an empirically supported treatment for personality disorders (Clarkin, Yeomans, & Kernberg, 2006) based on the assumption that patients form self and other object relations that link with affective experiences. Over time, these self–other relationship patterns form into object relational dyads that individuals use to understand their world. Personality dysfunction occurs when these dyads are used as templates to relate to others, rather than responding to the actual behaviors/intentions of the other person. Thus, the goal is to understand a patient’s typical dyadic conceptualizations and gain insight into how these dyads influence affect and result in maladaptive behaviors and relationship functioning. The IPC models can primarily add to this approach by offering a conceptual map to describe dyads. The dimensions of agency and communion can efficiently describe and organize most dyads, leading to a simpler conceptual framework for both therapist and patient to utilize. Furthermore, the principles of CIIT suggest particular ways in which self and other relate, which can further clarify how the patient is responding to others in a maladaptive fashion.
Interpersonal psychotherapy principles have been articulated that are quite consistent with psychodynamic processing of the therapist–patient relationship (Anchin & Pincus, 2010). This approach recognizes that the therapeutic relationship is fundamentally an interpersonal relationship, with opportunities for patients to develop new social patterns via social learning from therapist–patient exchanges and explicit dialogue about those exchanges. Patients with personality disorders may have difficulty forming an early alliance given their rigid interpersonal style, negative concerns about the therapist, and/or skill at transforming social exchanges into the very relational dysfunctions they purport to disdain and encounter all too often in their daily lives. The therapist’s role is to identify these maladaptive patterns so that they are not remade within the therapeutic relationship.
Generally, within psychodynamic treatments, therapists search their own feelings, action-tendencies, and fantasies to understand what the patient is evoking in them (e.g., impact message, counter-transference, see Kiesler, 1982), and then decide on the most therapeutic response. This will often include facilitating a healthy exchange of dominance within the therapy session, along with some closeness/distance pulls on communion (without occupying the extremes of those pulls, i.e., total enmeshment vs. rejection). Therapists will also connect interpersonal patterns in therapy to similar patterns recalled in the patient’s daily life, highlighting both the costs of maintaining such patterns and the functions that they serve (see Benjamin, 2003).
Consistent with CIIT assumptions and the empirical findings presented earlier, different personality disorders may pull for different maladaptive exchanges in line with their pathology. The patient with narcissistic or obsessive-compulsive personality disorder may provoke unhelpful bids for dominance that prevent learning new information, or prioritize agency at the expense of communion (e.g., Campbell, Brunell, & Finkel, 2006). The therapist is tasked with monitoring these non-normative exchanges and refraining from responding in a complementary pattern in order to facilitate the patient’s acceptance of a relationship with mutual parties contributing and awareness of the merit in attending to communion motives and perceptions. The patient with borderline or histrionic personality disorder may promote non-normative patterns via an intense communal complementarity response in therapy. This will lead to a chaotically deep enmeshment, sudden withdrawal as a more normative process is sought, or both. The therapist will be pulled to engage in these non-normative processes of alternating extremes, but can help shape more normative processes instead by providing consistent and appropriate communal complementarity which will help the patient begin to regulate these disconnections more effectively. This may include educating the patient about varying degrees of communal connection (e.g., what distinguishes a rejection from a small disconnection), and helping the patient form an identity that is understood as unique from how others perceive her or him (i.e., a robust self-system that can maintain a positive and accurate self-image even when others perceive the patient negatively).
Patients with paranoid personality disorder may expect therapists to deceive them, and yet their hostility may provoke vacillations in normative interpersonal exchanges as the therapist tries to elicit more affiliative interpersonal responses. This may result in comments from therapists that are indeed less genuine and thus fit into their narrative of anticipated deception. Instead, therapists can be cautious to not provide an overly-communal (non-complementary) presentation, and avoid mutual disengagement (complementary unfriendly-submissiveness) by instilling a neutral curiosity towards the patient’s concerns. This specific non-complementary process will facilitate alliance within a non-normative interpersonal dynamic. Patients with avoidant and dependent personality disorder may pull for the therapist to be dominant in a way that is ultimately not therapeutic. The therapist will need to seek out ways to engage the patient in his/her own goals and insights.
So, although personality disorder patients share a theme of interpersonal dysfunction, it is clear that the specifics of non-normative patterns are specific to groups and individuals. Thus, therapist actions to facilitate change can be quite complex and driven in part by the flavor of personality pathology present in the room. Interpersonal models provide a basic framework from which to understand these relationship pulls and enactments and enhance normative social exchanges both within and outside the therapeutic relationship.
Cognitive Behavioral
Dialectical behavior therapy (DBT; Linehan, 1993, 2015) is an empirically supported cognitive-behavioral treatment designed to treat patients with suicidality, emotion dysregulation, and borderline personality disorder. It emphasizes both acceptance and change based principles through a combination of group skills training/psychoeducation, individual therapy, and other additional components (e.g., phone coaching, weekly consultation team for therapists). The interpersonal effectiveness skills module of DBT, in particular, can be enhanced by considering interpersonal models. Interpersonal effectiveness comprises effectiveness in three different areas that patients are taught to consider when approaching any interpersonal interaction: namely, their objectives, relationship, and self-respect goals. Each of these sets of goals has a specific set of skills that are described through various acronyms.
The objectives domain of interpersonal effectiveness helps patients ask for what they need (motive) or refuse an unreasonable request. In other words, it is a formula for enacting a dominant social exchange. The formula for doing this follows the acronym DEAR MAN, with the first word describing what to do and the second word describing how to do it. DEAR represents the steps of describing (facts), expressing (emotions, opinions), asserting (specific requests), and reinforcing (explaining consequences). Interpersonal problems may arise when patients start with the assert without building the context for their assertion (e.g., what are the facts that make this request understandable?). Patients also may have difficulty distinguishing a describe statement (e.g., my husband turns on the TV while I am speaking to him) from an express statement (i.e., this makes me feel underappreciated). Finally, patients often fail to include the reinforce statement, make the reinforce ineffective (e.g., I will leave you if you watch the TV when I am speaking), or forget that reinforcement can be positive (e.g., If you turn off the TV in the future it will really mean a lot to me). The acronym MAN ensures that the patient executes the DEAR statement in a mindful way (of one’s objectives), appearing confident (e.g., using a confident tone to promote agentic reciprocity), and being willing to negotiate (e.g., being flexible to alternative solutions, taking a short-term submissive position in service of the overall objective being met).
Thus, the DEAR MAN structure provides the patient with specific instructions on how to enact an agentic request, and provides the clinician with specifics to diagnose where agentic complementarity breaks down. In other words, if both parties in the interpersonal exchange are dominant, the DEAR MAN can help the therapist diagnose aspects of the conversation that may have led to that anti-complementary exchange (e.g., neither party described the facts, one party used reinforcements that amplified the conflict, one party refused to negotiate). When both parties are submissive, the therapist might similarly be able to diagnose the source of the disconnection (e.g., neither party was willing to assert, hoping that their expression of feelings would communicate their unspoken needs).
Goals within self-respect effectiveness focus on building and promoting self-respect by interacting in a way that makes the patient feel competent and balanced in her or his integration of thoughts and emotions (i.e., wise mind). The acronym FAST suggests that the patient be fair (to themselves and others), not apologize, stick to their values, and be truthful. The fair skill guards against unmitigated agency (i.e., pursuing goals with too much dominance), yet also suggests that submissive behaviors enacted at one’s own expense (e.g., over-apologizing, abandoning values) are not an effective way of managing a motivation to be agentic. Here, agentic complementarity adds coherence to what previously appeared to be four disconnected skills (FAST).
Relationship effectiveness goals focus on acting in ways that elicit a positive response from others (e.g., liking, respect) and that balance short- and long-term relationship goals. Importantly, these skills can be used even, and especially, in times of conflict. The acronym GIVE represents the skills of being gentle (courteous, avoiding attacks), interested (acting interested in the other’s perspective), validating (acknowledging the other’s feelings), and acting in an easy manner (smiling, being friendly). Essentially, the GIVE skills are specific ways to increase communion during conflict, and a reminder that communion is an important part of any agentic exchange. In other words, agency and communion are orthogonal, and one can ask for something (higher agency) in a nice way (higher communion). Relatedly, being nice is not the same thing as being weak, nor is being mean necessary to being assertive.
Interpersonal theory adds an important organizing structure to the interpersonal effectiveness skills in DBT. In particular, interpersonal effectiveness skills are sometimes organized around an exchange where the patient needs to be dominant and is hoping for submissive reciprocity in the exchange. The method explicitly articulates how adding a dose of communion to the request is useful in meeting the goals of the exchange. Although not explicit in the DBT theory, providing patients with this simplified two-dimensional structure (agency and communion) may facilitate patients’ engagement, comprehension, monitoring, and implementation in the initial stages. It may also help patients report back and describe specific interpersonal situations that drive affective or behavioral dysregulation.
Conclusion
Diagnostic descriptions of personality disorders and pathology emphasize relationship dysfunction that is relatively pervasive across time and contexts. Interpersonal models have the ability to describe this dysfunction in both static and temporally-dynamic forms, giving greater clarity to the description and treatment of personality disorders. In particular, psychological research has emphasized how interpersonal models can capture both the severity and theme of interpersonal dysfunction, how particular non-normative interpersonal situations may characterize specific forms of personality pathology, and how interpersonal dysfunction can alternatively impact therapeutic alliance and inform personalized and successful treatment techniques. Temporally-dynamic research studies across at least two timescales support the normative patterns of interpersonal complementarity. Moreover, deviations from complementarity do not entirely capture the non-normative interpersonal exchanges that characterize personality pathology. Understanding the contexts of non-normative social exchanges can enhance one’s understanding of specific patterns underlying personality pathology, inform the expected therapeutic exchanges, and identify the key relationship patterns existing in the patient’s daily life. The interpersonal paradigm is pan-theoretical, having broad applications to many theories of psychopathology and treatment; the integration with two approaches to treatment was explicated in the previous pages. In totality, we see the research and clinical potential in tethering the study of personality disorders to interpersonal models in order to better articulate, assess, and treat the non-normative interpersonal patterns that lead to dysfunction in the everyday lives of individuals who struggle with these disorders.
References
Acton, G. S., & Revelle, W. (2002). Interpersonal personality measures show circumplex structure based on new psychometric criteria. Journal of Personality Assessment, 79, 446–471.
Alden, L. E., & Capreol, M. J. (1993). Avoidant personality disorder: Interpersonal problems as predictors of treatment response. Behavior Therapy, 24, 357–376.
Alden, L. E., Wiggins, J. S., & Pincus, A. L. (1990). Construction of circumplex scales for the Inventory of Interpersonal Problems. Journal of Personality Assessment, 55, 521–536.
Altenstein, D., Krieger, T., & Grosse Holtforth, M.G. (2013). Interpersonal microprocesses predict cognitive-emotional processing and the therapeutic alliance in psychotherapy for depression. Journal of Counseling Psychology, 60, 445–452.
Ambwani, S., & Hopwood, C. J. (2009). The utility of considering interpersonal problems in the assessment of bulimic features. Eating Behaviors, 10, 247–253.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Anchin, J. C., & Pincus, A. L. (2010). Evidence-based interpersonal psychotherapy with personality disorders: Theory, components, and strategies. In J. J. Magnavita (Ed.), Evidence-Based Treatment of Personality Dysfunction: Principles, Methods, and Processes (pp. 113–166). Washington, DC: American Psychological Association.
Bakan, D. (1966). The Duality of Human Existence: Isolation and Communion in Western Man. Boston: Beacon Press.
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226–244.
Benjamin, L. S. (1993). Every psychopathology is a gift of love. Psychotherapy Research, 3, 1–24.
Benjamin, L. S. (2003). Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders. New York: Guilford Press.
Blais, M. A., & Hopwood, C. J. (2017). Model-based approaches for teaching and practicing personality assessment. Journal of Personality Assessment, 99, 136–145.
Boroughs, M. S., & O’Cleirigh, C (2015). Pathoplasticity. In The Encyclopedia of Clinical Psychology. Chichester: John Wiley. https://doi.org/10.1002/9781118625392.wbecp296.
Browne, M. W. (1992). Circumplex models for correlation matrices. Psychometrika, 57, 469–497.
Cain, N. M., Ansell, E. B., Wright, A. G. C., Hopwood, C. J., Thomas, K. M., Pinto, A., … Grilo, C. M. (2012). Interpersonal pathoplasticity in the course of major depression. Journal of Consulting and Clinical Psychology, 80, 78–86.
Cain, N. M., Meehan, K. B., Roche, M. J., Clarkin, J. F., & De Panfilis, C. (2019). Effortful control and interpersonal behavior in daily life. Journal of Personality Assessment, 101, 315–325.
Cain, N. M. & Pincus, A. L. (2016). Treating maladaptive interpersonal signatures. In W. J. Livesley, G. S. Dimaggio, & J. F. Clarkin (Eds.), Integrated Treatment of Personality Disorder: A Modular Approach (pp. 305–324). New York: Guilford Press.
Cain, N. M., Pincus, A. L., & Grosse Holtforth, M. (2010). Interpersonal subtypes in social phobia: Diagnostic and treatment implications. Journal of Personality Assessment, 92, 514–527.
Campbell, W. K., Brunell, A. B., & Finkel, E. J. (2006). Narcissism, interpersonal self-regulation, and romantic relationships: An agency model approach. In K. D. Vohs & E. J. Finkel (Eds.), Self and Relationships: Connecting Intrapersonal and Interpersonal Processes (pp. 57–83). New York: Guilford Press.
Carson, R. C. (1969). Interaction Concepts of Personality. Chicago: Aldine.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2006). Psychotherapy of Borderline Personality: Focusing on Object Relations. Arlington, VA: American Psychiatric Publishing.
Dawood, S., & Pincus, A. L. (2016). Multi-surface interpersonal assessment in a cognitive-behavioral therapy context. Journal of Personality Assessment, 98, 449–460.
Dawood, S., Thomas, K. M., Wright, A. G. C., & Hopwood, C. J. (2013). Heterogeneity of interpersonal problems among depressed young adults: Associations with substance abuse and pathological personality traits. Journal of Personality Assessment, 95, 513–522.
Depue, R. A. (2006). Interpersonal behavior and the structure of personality: Neurobehavioral foundation of agentic extraversion and affiliation. In T. Canli (Ed.), Biology of Personality and Individual Differences (pp. 60–92). New York: Guilford Press.
Dowgwillo, E. A., Roche, M. J., & Pincus, A. L. (2018). Examining the interpersonal nature of Criterion A of the DSM-5 Section III Alternative Model for Personality Disorders using bootstrapped circular confidence intervals. Journal of Personality Assessment, 100, 581–592.
Florsheim, P., & McArthur, L. (2009). An interpersonal approach to attachment and change. In J. H. Obegi & E. Berent (Eds.), Attachment Theory and Research in Clinical Work with Adults (pp. 379–409). New York: Guilford Press.
Fournier, M. A., Moskowitz, D. S., & Zuroff, D. C. (2008). Integrating dispositions, signatures, and the interpersonal domain. Journal of Personality and Social Psychology, 94, 531–545.
Fournier, M. A., Zuroff, D. C., & Moskowitz, D. S. (2007). The social competition theory of depression: Gaining from an evolutionary approach to losing. Journal of Social and Clinical Psychology, 26, 786–790.
Gurtman, M. B. (1994). The circumplex as a tool for studying normal and abnormal personality: A methodological primer. In S. Strack & M. Lorr (Eds.), Differentiating Normal and Abnormal Personality (pp. 243–263). New York: Springer.
Gurtman, M. B., & Pincus, A. L. (2003). The circumplex model: Methods and research applications. In J. A. Schnika & W. F. Velicer (Eds.), Comprehensive Handbook of Psychology, Volume 2: Research Methods in Psychology (pp. 407–428). Hoboken, NJ: John Wiley & Sons.
Hooley, J. M. (2010). Social factors in schizophrenia. Current Directions in Psychological Science, 19, 238–242.
Hopwood, C. J., Clarke, A. N., & Perez, M. (2007). Pathoplasticity of bulimic features and interpersonal problems. International Journal of Eating Disorders, 40, 652–658.
Hopwood, C. J., Thomas, K. M., Luo, X., Bernard, N., Lin, Y., & Levendosky, A. A. (2016). Implementing dynamic assessments in psychotherapy. Assessment, 23, 507–517.
Horowitz, L. M. (2004). Interpersonal Foundations of Psychopathology. Washington, DC: American Psychological Association.
Kachin, K. E., Newman, M. G., & Pincus, A. L. (2001). An interpersonal problem approach to the division of social phobia subtypes. Behavior Therapy, 32, 479–501.
Kiesler, D. J. (1982). Confronting the client–therapist relationship in psychotherapy. In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of Interpersonal Psychotherapy (pp. 274–295). New York: Pergamon.
Klahr, A. M., Thomas, K. M., Hopwood, C. J., Klump, K. L., & Burt, S. A. (2013). Evocative gene–environment correlation in the mother–child relationship: A twin study of interpersonal processes. Development and Psychopathology, 25, 105–118.
Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., … & Eaton, N. R. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126, 454–477.
LaForge, R. (2004). The early development of the interpersonal system of personality (ISP). Multivariate Behavioral Research, 39, 359–378.
Leary, T. (1957). Interpersonal Diagnosis of Personality. New York: Ronald Press.
Leichsenring, F., Kunst, H., & Hoyer, J. (2003). Borderline personality organization in violent offenders: Correlations of identity diffusion and primitive defense mechanisms with antisocial features, neuroticism, and interpersonal problems. Bulletin of the Menninger Clinic, 67, 314–327.
Levendosky, A. A., & Hopwood, C. J. (2017). A clinical science approach to training first year clinicians to navigate therapeutic relationships. Journal of Psychotherapy Integration, 27, 153–171.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). New York: Guilford Press.
Lizdek, I., Woody, E., Sadler, P., & Rehman, U. S. (2016). How do depressive symptoms in husbands and wives relate to the interpersonal dynamics of marital interactions? Journal of Counseling Psychology, 63, 721–735.
Locke, K. D. (2011). Circumplex measures of interpersonal constructs. In L. M. Horowitz & S. Strack (Eds.), Handbook of Interpersonal Psychology: Theory, Research, Assessment, and Therapeutic Interventions (pp. 313–324). Hoboken, NJ: John Wiley.
Locke, K. D., & Sadler, P. (2007). Self-efficacy, values, and complementarity in dyadic interactions: Integrating interpersonal and social-cognitive theory. Personality and Social Psychology Bulletin, 33, 94–109.
Lukowitsky, M. R., & Pincus, A. L. (2011). The pantheoretical nature of mental representations and their ability to predict interpersonal adjustment in a nonclinical sample. Psychoanalytic Psychology, 28, 48–74.
Luyten, P., & Blatt, S. J. (2011). Integrating theory-driven and empirically-derived models of personality development and psychopathology: A proposal for DSM V. Clinical Psychology Review, 31, 52–68.
Markey, P., Lowmaster, S., & Eichler, W. (2010). A real‐time assessment of interpersonal complementarity. Personal Relationships, 1, 13–25.
McCrae, R. R., & Costa, P. T. (1989). The structure of interpersonal traits: Wiggins’s circumplex and the five-factor model. Journal of Personality and Social Psychology, 56, 586–595.
Moskowitz, D. S., Ringo Ho, M.-H., & Turcotte-Tremblay, A. (2007). Contextual influences on interpersonal complementarity. Personality and Social Psychology Bulletin, 33, 1051–1063.
Moskowitz, D. S., Zuroff, D. C., aan het Rot, M., & Young, S. N. (2011). Tryptophan and interpersonal spin. Journal of Research in Personality, 45, 692–696.
Newman, M. G., Jacobson, N. C., Erickson, T. M., & Fisher, A. J. (2017). Interpersonal problems predict differential response to cognitive versus behavioral treatment in a randomized controlled trial. Behavior Therapy, 48, 56–68.
Nilsen, E. S., Lizdek, I., & Ethier, N. (2015). Mother–child interpersonal dynamics: The influence of maternal and child ADHD symptoms. Journal of Experimental Psychopathology, 6, 313–329.
Pincus, A. L. (1994). The interpersonal circumplex and the interpersonal theory: Perspectives on personality and its pathology. In S. Strack & M. Lorr (Eds.), Differentiating Normal and Abnormal Personality (pp. 114–136). New York: Springer.
Pincus, A. L. (2005). A contemporary integrative interpersonal theory of personality disorders. In J. Clarkin & M. Lenzenweger (Eds.), Major Theories of Personality Disorder (2nd ed., pp. 282–331). New York: Guilford Press.
Pincus, A. L. (2010). Interpersonal theory of personality. In I. B. Weiner & W. E. Craighead (Eds.), The Corsini Encyclopedia of Psychology (4th ed., pp. 1213–1215). Hoboken, NJ: John Wiley.
Pincus, A. L., & Ansell, E. B. (2013). Interpersonal theory of personality. In J. Suls & H. Tennen (Eds.), Handbook of Psychology, Volume 5: Personality and Social Psychology (2nd ed., pp. 141–159). Hoboken, NJ: John Wiley.
Pincus, A. L., & Cain, N. M. (2008). Interpersonal psychotherapy. In D. C. S. Richard & S. K. Huprich (Eds.), Clinical Psychology: Assessment, Treatment, & Research (pp. 213–245). New York: Academic Press.
Pincus, A. L., Hopwood, C. J., & Wright, A. G. C. (2017). The interpersonal situation: An integrative framework for the study of personality, psychopathology, and psychotherapy. In D. Funder, J. F. Rauthmann, & R. Sherman (Eds.), The Oxford Handbook of Psychological Situations. New York: Oxford University Press.
Pincus, A. L., Lukowitsky, M. R., & Wright, A. G. C. (2010). The interpersonal nexus of personality and psychopathology. In T. Millon, R. F. Krueger, & E. Simonsen (Eds.), Contemporary Directions in Psychopathology: Scientific Foundations of the DSM-5 and ICD-11 (pp. 523–552). New York: Guilford Press.
Pincus, A. L., & Roche, M. J. (2019). Paradigms of personality assessment and level of personality functioning in Criterion A of the AMPD. In C. J. Hopwood, A. L. Mulay, & M. Waugh (Eds.), The DSM-5 Alternative Model for Personality Disorders: Integrating Multiple Paradigms of Personality Assessment (pp. 48–59). Abingdon: Routledge.
Pincus, A. L., Sadler, P., Woody, E., Roche, M. J., Thomas, K. M., & Wright, A. G. C. (2014). Assessing interpersonal dynamics. In C. J. Hopwood & R. F. Bornstein (Eds.), Multimethod Clinical Assessment (pp. 51–91). New York: Guilford Press.
Pincus, A. L., & Wiggins, J. S. (1990). Interpersonal problems and conceptions of personality disorders. Journal of Personality Disorders, 4, 342–352.
Pincus, A. L., & Wright, A. G. C. (2011). Interpersonal diagnosis of psychopathology. In L. M. Horowitz & S. Strack (Eds.), Handbook of Interpersonal Psychology: Theory, Research, Assessment, and Therapeutic Interventions (pp. 359–381). Hoboken, NJ: John Wiley.
Przeworski, A., Newman, M. G., Pincus, A. L., Kasoff, M. B., Yamasaki, A. S., Castonguay, L. G., & Berlin, K. S. (2011). Interpersonal pathoplasticity in individuals with generalized anxiety disorder. Journal of Abnormal Psychology, 120, 286–298.
Roche, M. J., Pincus, A. L., Conroy, D. E., Hyde, A. L., & Ram, N. (2013). Pathological narcissism and interpersonal behavior in daily life. Personality Disorders: Theory, Research, and Treatment, 4, 315–323.
Roche, M. J., Pincus, A. L., Hyde, A. L., Conroy, D. E., & Ram, N. (2013). Within-person covariation of agentic and communal perceptions: Implications for interpersonal theory and assessment. Journal of Research in Personality, 47, 445–452.
Roche, M. J., Pincus, A. L., Rebar, A. L., Conroy, D. E., & Ram, N. (2014). Enriching psychological assessment using a person-specific analysis of interpersonal processes in daily life. Assessment, 21, 515–528.
Sadikaj, G., Moskowitz, D. S., Russell, J. J., Zuroff, D. C., & Paris, J. (2013). Quarrelsome behavior in borderline personality disorder: Influence of behavioral and affective reactivity to perceptions of others. Journal of Abnormal Psychology, 122, 195–207.
Sadikaj, G., Moskowitz, D. S., & Zuroff, D. C. (in press). What’s interpersonal in interpersonal perception? The role of target’s attachment in the accuracy of perception. Journal of Personality.
Sadikaj, G., Russell, J. J., Moskowitz, D. S., & Paris, J. (2010). Affect dysregulation in individuals with borderline personality disorder: Persistence and interpersonal triggers. Journal of Personality Assessment, 92, 490–500.
Sadler, P., Ethier, N., Gunn, G. R., Duong, D., & Woody, E. (2009). Are we on the same wavelength? Interpersonal complementarity as shared cyclical patterns during interactions. Journal of Personality and Social Psychology, 97, 1005–1020.
Safran, J. D. (1990a). Towards a refinement in cognitive therapy in light of interpersonal theory: I. Theory. Clinical Psychology Review, 10, 87–105.
Safran. J. D. (1990b). Towards a refinement of cognitive therapy in light of interpersonal theory: II. Practice. Clinical Psychology Review, 10, 107–121.
Salzer, S., Pincus, A. L., Hoyer, J., Kreische, R., Leichsenring, F., & Leibling, E. (2008). Interpersonal subtypes within generalized anxiety disorder. Journal of Personality Assessment, 90, 292–299.
Salzer, S., Pincus, A. L., Winkelbach, C., Leichsenring, F., & Leibing, E. (2011). Interpersonal subtypes and change of interpersonal problems in the treatment of patients with generalized anxiety disorder: A pilot study. Psychotherapy: Theory, Research, Practice, & Training, 48, 304–310.
Salzer, S., Streeck, U., Jaeger, U., Masuhr, O., Warwas, J., Leichsenring, F., … Leibing, E. (2013). Patterns of interpersonal problems in borderline personality disorder. Journal of Nervous and Mental Disease, 201, 94–98.
Simon, S., Cain, N. M., Samstag, L. W., Meehan, K. B., & Muran, J. C. (2015). Assessing interpersonal subtypes in depression. Journal of Personality Assessment, 97, 364–373.
Smith, T. W., & Cundiff, J. M. (2011). An interpersonal perspective on risk for coronary heart disease. In L. M. Horowitz & S. Strack (Eds.), Handbook of Interpersonal Psychology: Theory, Research, Assessment, and Therapeutic Interventions (pp. 471–490). Hoboken, NJ: John Wiley.
Soldz, S., Budman, S., Demby, A., & Merry, J. (1995). A short form of the inventory of interpersonal problems circumplex scales. Assessment, 2, 53–63.
Strack, S., & Horowitz, L. M. (2011). Introduction. In L. M. Horowitz & S. Strack (Eds.), Handbook of Interpersonal Psychology: Theory, Research, Assessment, and Therapeutic Interventions (pp. 1–13). Hoboken, NJ: John Wiley.
Sullivan, H. S. (1953a). Conceptions of Modern Psychiatry. New York: W. W. Norton.
Sullivan, H. S. (1953b). The Interpersonal Theory of Psychiatry. New York: W. W. Norton.
Sullivan, H. S. (1954). The Psychiatric Interview. New York: W. W. Norton.
Sullivan, H. S. (1956). Clinical Studies in Psychiatry. New York: W. W. Norton.
Sullivan, H. S. (1962). Schizophrenia as a Human Process. New York: W. W. Norton.
Sullivan, H. S. (1964). The Fusion of Psychiatry and Social Science. New York: W. W. Norton.
Thomas, K. M., Hopwood, C. J., Donnellan, M. B., Wright, A. G., Sanislow, C. A., McDevitt-Murphy, M. E., … Morey, L. C. (2014). Personality heterogeneity in PTSD: Distinct temperament and interpersonal typologies. Psychological Assessment, 26, 23–34.
Thomas, K. M., Hopwood, C. J., Woody, E., Ethier, N., & Sadler, P. (2014). Interpersonal processes in psychotherapy: A reanalysis of the Gloria Films. Journal of Counseling Psychology, 61, 1–14.
Tracey, T. J. (1997). RANDALL: A Microsoft FORTRAN program for a randomization test of hypothesized order relations. Educational and Psychological Measurement, 57, 164–168.
Wang, S., Roche, M. J., Pincus, A. L., Conroy, D. E., Rebar, A. L., & Ram, N. (2014). Interpersonal dependency and emotion in everyday life. Journal of Research in Personality, 53, 5–12.
Wiggins, J. S. (1991). Agency and communion as conceptual coordinates for the understanding and measurement of interpersonal behavior. In D. Cicchetti & W. M. Grove (Eds.), Thinking Clearly about Psychology: Essays in Honor of Paul E. Meehl, Volume 2: Personality and Psychopathology (pp. 89–113). Minneapolis, MN: University of Minnesota Press.
Wiggins, J. S. (1996). An informal history of the interpersonal circumplex tradition. Journal of Personality Assessment, 66, 217–233.
Wiggins, J. S. (2003). Paradigms of Personality Assessment. New York: Guilford Press.
Wiggins, J. S., Trapnell, P., & Phillips, N. (1988). Psychometric and geometric characteristics of the revised interpersonal adjective scales (IAS-R). Multivariate Behavioral Research, 23, 517–530.
Williams, T. F., & Simms, L. J. (2016). Personality disorder models and their coverage of interpersonal problems. Personality Disorders: Theory, Research, and Treatment, 7, 15–27.
Wilson, S., Revelle, W., Stroud, C. B., & Durbin, C. E. (2013). A confirmatory bifactor analysis of the Inventory of Interpersonal Problems: Circumplex and associations of interpersonal traits across multiple relationship contexts and measures. Psychological Assessment, 25, 353–365.
Wilson, S., Stroud, C. B., & Durbin, C. E. (2017). Interpersonal dysfunction in personality disorders: A meta-analytic review. Psychological Bulletin, 143, 677–734.
Wright, A. G. C., Hallquist, M. N., Morse, J. Q., Scott, L. N., Stepp, S. D., Nolf, K. A., & Pilkonis, P. A. (2013). Clarifying interpersonal heterogeneity in borderline personality disorder using latent mixture modeling. Journal of Personality Disorder, 27, 125–143.
Wright, A. G. C., Pincus, A. L., Conroy, D. E., & Hilsenroth, M. J. (2009). Integrating methods to optimize circumplex description and comparison of groups. Journal of Personality Assessment, 91, 311–322.
Wright, A. G., Pincus, A. L., Hopwood, C. J., Thomas, K. M., Markon, K. E., & Krueger, R. F. (2012). An interpersonal analysis of pathological personality traits in DSM-5. Assessment, 19, 263–275.
Wright, A. G., Stepp, S. D., Scott, L., Hallquist, M., Beeney, J. E., Lazarus, S. A., & Pilkonis, P. A. (2017). The effect of pathological narcissism on interpersonal and affective processes in social interactions. Journal of Abnormal Psychology, 126, 898–910.
Zilcha-Mano, S., McCarthy, K. S., Dinger, U., Chambless, D. L., Milrod, B. L., Kunik, L., & Barber, J. P. (2015). Are there subtypes of panic disorder? An interpersonal perspective. Journal of Consulting and Clinical Psychology, 83, 938–950.
Zimmermann, J., & Wright, A. G. (2017). Beyond description in interpersonal construct validation: Methodological advances in the circumplex structural summary approach. Assessment, 24, 3–23.
Zuroff, D. C., Moskowitz, D. S., & Côté, S. (1999). Dependency, self-criticism, interpersonal behavior, and affect: Evolutionary perspectives. British Journal of Clinical Psychology, 38, 231–250.