13b
Nicole M. Cain
The chapter by Sanislow and Hector (this volume) provided an excellent overview of Cluster C personality pathology with a particular focus on anxiety, fear, and avoidant behaviors. The authors were comprehensive in describing the evolution of anxious-fearful and avoidant personality pathology throughout the various editions of the DSM, as well as highlighting important changes in how DSM-5 (APA, 2013) Section III, the Alternative Model for Personality Disorders (AMPD), assesses Cluster C pathology. The section on using NIMH RDoC to investigate anxious-fearful-avoidant pathology was particularly relevant to personality disorder (PD) researchers and highlighted several ways that Cluster C pathology fits within the RDoC matrix. One of the unifying themes of the chapter was the emphasis on social processes and the relationship between social functioning and Cluster C pathology. I offer comments intended to extend and elaborate on this theme by arguing that interpersonal theory provides a valuable lens through which to view Cluster C pathology.
Sanislow and Hector (this volume) highlighted that individuals diagnosed with Cluster C PDs are likely to view others as a source of frustration and tend to report significant interpersonal problems and distress. Diagnostic criteria reflect the salience of interpersonal dysfunction across all PD diagnoses and clinicians of all theoretical orientations who treat personality pathology (e.g., Benjamin, 2003; Clarkin, Yeomans, & Kernberg, 2006; Linehan, 1993), including Cluster C, are inevitably faced with threats to the therapeutic alliance, dissolution of important relations, as well as damage to the patient’s life caused by entrenched maladaptive interpersonal behaviors. Thus, it is not surprising that interpersonal difficulties are a critical feature of personality pathology, leading Hopwood and colleagues (Hopwood, Wright, Ansell, & Pincus, 2013) to argue that PDs are fundamentally interpersonal in nature.
Interpersonal theory asserts that the most important expressions of personality and psychopathology occur in phenomena involving more than one person, the interpersonal situation (Sullivan, 1953). Pincus and Ansell (2013) noted that the interpersonal situation is the experience of a pattern of relating self with other associated with varying levels of anxiety (or security) in which learning takes place that significantly influences the development of self-concept and social behavior. The interpersonal situation is intimately tied to the genesis, development, maintenance, and mutability of personality and PD through the continuous patterning and repatterning of interpersonal experience (social learning) in an effort to satisfy fundamental human motives (e.g., agency and communion) in ways that increase security and self-esteem (positively reinforcing) and avoid anxiety (negatively reinforcing). Over time, this social learning leads to the development of mental representations of self and others (Blatt, Auerbach, & Levy, 1997) as well as enduring patterns of adaptive or maladaptive interpersonal behavior (Benjamin, 2003; Hopwood, 2018; Pincus, 2005).
Agency and communion provide helpful dimensions for conceptualizing interpersonal situations and their mental representations (Pincus, 2005; Wiggins, 2003). Agency is manifested in strivings for power and mastery, while communion is found in strivings for intimacy and connection with others. These meta-concepts also form the interpersonal circumplex (IPC; Leary, 1957), with the underlying dimensions of dominance-submission (agency) on the vertical axis and nurturance-coldness (communion) on the horizontal axis. The IPC has been used to describe both adaptive and maladaptive interpersonal behavior and to describe a person’s typical way of relating to others, i.e., their interpersonal style.
Applying the IPC to Cluster C pathology, Cain and colleagues (Cain, Ansell, Simpson, & Pinto, 2015) examined the specific types of interpersonal problems and interpersonal sensitivities associated with obsessive-compulsive PD (OCPD). As noted by Sanislow and Hector (this volume), individuals with OCPD find it difficult to relax and are preoccupied with work to the detriment of social relations. These individuals are often also characterized as rigid and controlling, which can lead to hostility toward others. In a clinical sample of adult outpatients diagnosed with OCPD, Cain et al. found that these individuals reported hostile-dominant interpersonal problems and sensitivity to warm-dominant behavior in others. This interpersonal pattern suggests that individuals with OCPD are overly controlling, vindictive, and cold in their interpersonal relationships, while also being sensitive to or irritated by warm, communal approach behaviors by others. These results suggest that interpersonal warmth in particular is an interpersonal irritant for individuals with OCPD. It is likely that warm, communal behavior in others frustrates the interpersonal motives (Horowitz et al., 2006) of patients with OCPD, which involve being more emotionally restrained, rigid, and controlling in relationships. This interpersonal pattern is consistent with the description of the avoidance behavior commonly observed in OCPD provided by Sanislow and Hector (this volume). These individuals are likely to emphasize work and productivity at the expense of intimacy and connection with others.
Sanislow and Hector (this volume) also note that OCPD is associated with deficits in empathy. Cain and colleagues (2015) used the Interpersonal Reactivity Index (IRI; Davis, 1980) to investigate different facets of empathy in individuals with OCPD. Results showed that individuals with OCPD reported low levels of perspective taking as compared to healthy controls. Perspective taking is the ability to spontaneously adopt the psychological viewpoint of others. In contrast, there were no significant differences between individuals with OCPD and healthy controls on empathic concern. Empathic concern involves sympathy and concern for the unfortunate circumstances of others, a more affective component of empathy. These results suggest that individuals with OCPD may have the capacity to experience sympathy and concern for others and may be able to intuit the appropriate affective response to another person, similar to healthy controls, but are limited in their ability to subsequently demonstrate the appropriate emotional response in a social situation or adopt the other person’s point of view.
Interpersonal theory also allows us to move past static individual differences to investigate more dynamic aspects of personality pathology (Cain & Ansell, 2015; Hopwood, 2018), such as pathoplasticity. As noted by Sanislow and Hector (this volume), pathoplasticity refers to the mutually influencing, non-etiological relationship between psychopathology and another psychological system (Shea et al., 2004). Interpersonal pathoplasticity emphasizes that the expression of certain maladaptive behaviors, symptoms, and mental disorders tend to occur in the larger context of an individual’s interpersonal functioning. In this way, interpersonal style has the potential for influencing the content and focus of symptoms and will likely shape the responses and coping strategies individuals employ when presented with psychological and social stressors (Cain & Ansell, 2015).
Related to Cluster C pathology, Alden and Capreol (1993) examined interpersonal pathoplasticity in a sample of outpatients diagnosed with avoidant personality disorder (AVPD). Results showed that AVPD was associated with two distinct interpersonal subtypes, an exploitable AVPD subtype and a cold AVPD subtype. Patients in the exploitable AVPD subtype reported interpersonal problems with being overly warm and submissive, while patients in the cold AVPD subtype reported problems with being withdrawn and isolated in their relationships. Interestingly, patients in the exploitable AVPD subtype benefited from both graduated exposure and interpersonal skills training interventions targeting their social avoidance, while patients in the cold AVPD subtype only benefited from graduated exposure for their avoidance behaviors. These results suggest the importance of examining interpersonal motivation (Horowitz et al., 2006) to understand social avoidance in AVPD. Those patients in the exploitable AVPD subtype may be more responsive to interpersonal skills training given their motivation for intimacy and connection, while those in the cold AVPD subtype may be using self-protective motives to avoid social rejection and may initially react poorly to interventions aimed at maximizing social closeness. The patients in the cold AVPD group may be more prone to treatment noncompliance or dropout to protect themselves from rejection by others. Treatment may need to use a graduated exposure model to slowly decrease fears about social rejection before a more interpersonally focused skills approach could be useful. These results were subsequently replicated by Cain and colleagues (Cain, Pincus, & Grosse Holtforth, 2010) in a sample of outpatients diagnosed with social phobia, a disorder which shares many clinical features with AVPD as noted by Sanislow and Hector (this volume). Cain et al. found two interpersonal subtypes in social phobia, a friendly-submissive subtype similar to the exploitable AVPD subtype and a cold-submissive subtype similar to the cold AVPD subtype. As expected, the friendly-submissive social phobia subtype reported significantly lower social anxiety and significantly higher well-being and satisfaction at post-treatment than those in the cold-submissive social phobia subtype.
In addition to investigations of pathoplasticity, interpersonal theory also uses agency and communion to model both stability and variability in self–other processes. These self–other patterns are referred to as interpersonal signatures (Fournier, Moskowitz, & Zuroff, 2009; Hopwood, 2018). Research on interpersonal signatures is based on the seminal work of Mischel and Shoda (1995) on the cognitive-affective processing system (CAPS), which argues that individuals encode the psychological features of a given situation through a complex configuration of within-person structures and processes (i.e., cognitive-affective units) that include competencies, expectancies, values, and goals. This complex system of interrelated structures and processes gives rise to stable, but situation-contingent if … then dispositions or behavioral signatures, such that each individual demonstrates stable levels of behavior within situations and stable patterns of behavior across situations. Within interpersonal theory, the situations in which cognitive and affective processing are primarily observed are interpersonal in nature along the dimensions of agency and communion.
Wang and colleagues (2014) investigated the interpersonal signature associated with high dependency by examining intra-individual variability in interpersonal and emotional functioning over a seven-day period in a sample of undergraduate students. They found that for participants with higher dependency, perceiving others as submissive and unfriendly was associated with decreased positive emotion. Wang et al. note that experiencing others as more submissive may run counter to dependency needs, suggesting to the highly dependent individual that they may need to be more autonomous. This likely evokes uncertainty and dysregulation, thus decreasing positive affect. Conversely, a more agentic and communal other would be consistent with dependency needs and likely to contribute to feeling secure and satisfied within the relationship. This interpersonal signature is consistent with the description of dependent personality disorder (DPD) provided by Sanislow and Hector (this volume), highlighting that those with DPD often have difficulty with asserting themselves and desire being taken care of by others.
Wang and colleagues (2014) also found that in those with high dependency, perceiving others as dominant and unfriendly was associated with being more quiet and passive in the interaction. This pattern of becoming less activated by dominant, unfriendly others may serve to help those with high dependency to maintain relationships with these more dominant others. This type of relationship would be consistent with the need to rely on stronger, more competent others, even if the relationship is also unpleasant. Research has shown that higher dependency is associated with perceiving dominance in others as also friendly (Roche, Pincus, Hyde, Conroy, & Ram, 2013), and perhaps this perception serves to help those with high dependency maintain relationships with dominant-unfriendly others. Future research should continue to examine interpersonal signatures in Cluster C pathology.
In sum, Sanislow and Hector (this volume) argue for moving beyond DSM structure to understand Cluster C pathology. I agree, and have offered comments illustrating how interpersonal theory can play a central role in advancing the assessment and treatment of Cluster C pathology. Interpersonal theory provides a useful framework for understanding the complex social processes that signify personality pathology. A thorough assessment of interpersonal functioning in Cluster C pathology will allow us to more specifically target the interpersonal difficulties associated with these anxious-dependent-avoidant pathologies.
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