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The relationship of sociotropy and autonomy to symptoms, cognition and personality in depressed patients
journalof AFFECTIVE
DISORDERS
ELSEVIER
Journal
of Affective
Disorders
32 (1994) 239-245
The relationship of sociotropy and autonomy to symptoms, cognition and personality in depressed patients Richard Department
Received
30 November
G. Moore, of Psychiatr),
Ivy-Marie
Unkersity
1993; revised version
Blackburn
of Edinburgh,
received
8 August
Edinburgh,
1994; accepted
* UK
10 August
1994
Abstract A growing body of research suggests that the two personality characteristics of sociotropy and autonomy confer vulnerability to depression in response to interpersonal or achievement-related events. This study examined the relationships of these characteristics to severity of symptoms, measures of negative cognition, neuroticism and extraversion in a sample of 118 unipolar depressed patients. Sociotropy was found to be associated with self-reported depressive symptoms independently of anxiety level, with frequency of negative automatic thoughts, with dysfunctional attitudes and neuroticism. It was more strongly related to dysfunctional attitudes reflecting a need for social approval than to those reflecting perfectionism. Autonomy was not associated with self-reported symptoms of depression or of anxiety. It was, however, associated with low extraversion and significantly more associated with perfectionism than social approval. The results support the need for further research to examine the precise roles of a number of psychological factors in the vulnerability to interpersonal life events but also suggest limitations in the relevance of the construct of autonomy to depression. Keywords;
Sociotropy;
Autonomy;
Depression;
Anxiety;
The personality characteristics of sociotropy and autonomy have been hypothesized to influence vulnerability to life events, symptom patterns, cognitive biases and response to treatment in depression (Beck, 1983). Sociotropy is characterized by dependency on relationships with others for interpersonal needs, such as acceptance
* Corresponding author. Address: Cognitive Therapy Centre. Collingwood Clinic, St Nicholas Hospital, Newcastleupon-Tyne NE3 3XT, UK. OlhS-0327/94/$07.00 0 1994 Elsevier SSDI 0165-0327~94~00061-1
Science
Attitude;
Vulnerability
and approval. Highly sociotropic people are predieted to be vulnerable to threatened or actual rejection or abandonment by others. Autonomous people value their own independence and achievements and need to master and control their environment. They are predicted to be vulnerable to frustration by others or to personal failure. A measure of these characteristics, the Sociotropy-Autonomy Scale @AS; Beck et al., 1983) has been used extensively in research in this area. This is a 60-item measure, with 30 Sociotropy
B.V. All rights reserved
240
R.G. Moore, I.-M. Blackburn /Journal
items and 30 Autonomy items. Each item is rated on 5-point scale to indicate whether that statement applies 0, 25, 50, 75 or 100% of the time. A typical sociotropy item is ‘I feel I have to be nice to other people’ and a typical autonomy item is ‘It is important to me to be free and independent’. A number of studies using the SAS have investigated vulnerability to different kinds of life events. There has been some overall support for the association of sociotropy with vulnerability to interpersonal life events and of autonomy to achievement-related life events (e.g., Hammen et al., 1989h), although some studies have found significant relationships only for sociotropy (e.g., Robins and Block, 1988; Robins, 1990) and others only for autonomy (e.g., Hammen et al., 1989a). By conferring vulnerability to specific kinds of events, these personality characteristics are of particular aetiological importance. An overall understanding of the role of psychological factors in the aetiology of depression will depend on further elaboration of the relationship of sociotropy and autonomy with other factors of putative aetiological relevance. Information about the relationship of sociotropy and autonomy with states of depression and of anxiety and with personality dimensions implicated in depression will, thus, be of theoretical importance as well as being essential in demonstrating the construct validity of the scale. Most of the information so far available relates to the association between the SAS and measures of the severity and nature of depressive symptoms. In their quantitative review, Nietzel and Harris (1990) found a moderate relationship between sociotropy and depressive symptoms but no relationship between autonomy and symptoms. Robins and his colleagues (Robins et al., 1989; Robins and Luten, 1991; Peselow et al., 1992) have found that depression in sociotropic people seems to revolve around symptoms connected with a theme of loss and may be of a non-endogenous type whereas depression in autonomous persons is manifested in symptoms reflecting a theme of defeat and may be of an endogenous type. Although it now seems clear that sociotropy in particular is associated with depressive symp-
of
AffecticeDisorders 32 (1994) 239-245
toms, the relationships of sociotropy and autonomy with anxiety may be of importance in ascertaining whether the relevance of these characteristics is specific to depression. One aim of this study was, therefore, to confirm the relationship of Sociotropy and Autonomy with severity of depression and to examine the specificity of this relationship with respect to severity of anxiety. Previous work on depression has found the personality traits of neuroticism and extraversion to be associated with vulnerability to depression (see Barnett and Gotlib, 1988). Two studies have examined the relationship of neuroticism and extraversion to the SAS. Gilbert and Reynolds (1990) found that, in a sample of patients with mixed diagnoses, sociotropy was significantly associated with neuroticism but not extraversion and that autonomy was unrelated to both neuroticism and extraversion. Similar findings were reported by Cappeliez (1993) in a student sample. A further aim of this study was to replicate these findings in a sample of depressed patients. The relationship of sociotropy and autonomy to specific cognitive themes is also of interest. It has been shown that dependency-related vs. achievement-related dysfunctional attitudes reported on the Dysfunctional Attitude Scale (DAS; Weissman, 1979) can be distinguished (Imber et al., 1990). These groups of dysfunctional attitudes seem to confer specific vulnerability to interpersonal or achievement-related life events in a fashion similar to sociotropy and autonomy (Segal et al., 1992). It is possible that each personality characteristic is associated with these specific clusters of dysfunctional attitudes. Blaney and Kutcher (1991) examined the relationship between the SAS and subscales from the DAS in a large student sample. They found a substantial relationship between sociotropy and the DASanaclitic subscale (dependency), as predicted, but a negligible association between autonomy and the DAS-introjective subscale (achievement). The associations of these clusters of attitudes with sociotropy and autonomy in depressed patients remains to be established and was another focus for the present study. In summary, this study aimed to examine a large number of patients satisfying criteria for
R.G. Moore, I.-M. Blackburn /Journal
major depression to establish the specificity and concurrent validity of the SAS. (1) It was predicted that the relationship between sociotropy and autonomy and severity of symptoms would be specific to depression rather than anxiety. (2) It was predicted that sociotropy would be associated with neuroticism and not introversion in depressed patients, as has previously been found in mixed neurotic patients and students. However, contrary to previous findings, it was predicted that the characteristics described by the autonomy scale would lead to an association with introversion, and not neuroticism. It was further predicted that sociotropy would be specifically correlated with dysfunctional attitudes reflecting dependency and that autonomy would be associated with dysfunctional attitudes reflecting need for achievement.
1. Methods 1.1. Subjects The subjects were patients referred to a psychiatric hospital as either in- or outpatients for treatment for depression. These patients were recruited to an outcome and maintenance study comparing cognitive therapy with medication in the treatment of recurrent depression. Patients were initially screened using the Schedule for Affective Disorders and Schizophrenia (Endicott and Spitzer, 1978) and recruited to the study only if they met Research Diagnostic Criteria (Spitzer et al., 1978) at the time of assessment for primary unipolar Major Depression, had at least one previous depressive episode which met the same criteria and were aged between 18 and 65. Subjects with a history of schizophrenia or bipolar illness, or with a primary psychiatric diagnosis other than depression were excluded. 127 patients meeting Research Diagnostic Criteria for recurrent Major Depression were recruited to the study. Nine patients either refused or were unable to continue to participate in the study. Of the 118 patients included, 72 were outpatients and 46 were inpatients. 61% of the sample was female and the mean age was 40 (SD = 13) years.
of Affectice Disorders 32 (1994) 239-245
The mean number (SD = 2.2).
of previous
241
episodes
was 3.5
1.2. Procedure After the initial screening and before random allocation to treatment groups, patients completed an assessment, including several state measures, measures of depressive cognitive style and personality questionnaires. In this paper, data relating to two measures of severity of symptoms, two personality measures and a measure of basic attitudes are reported. 1.3. Measures 1.3.1. LeL!el of depression The 20-item Beck Depression Inventory (BDI; Beck et al., 1961) was used. It is a widely used and well-validated self-rated measure of severity of depression (Beck et al., 1988). 1.3.2. LeLlel of anxiety The State-Trait Anxiety Inventory, State Version (STAI-S; Spielberger et al., 1970) was used. This scale is also a widely used and well-validated measure (Spielberger et al., 1983). 1.3.3. Personality The SAS (Beck et al., 1983) is described in the introduction and is the measure of the two concepts of interest in this study. Eysenck Personality Questionnaire (EPQ; Eysenck and Eysenck, 1975) provides well-validated measures of neuroticism and introversion/extraversion which have been extensively studied in depression (Martin, 1985) 1.4. Attitudes The DAS form A (Weissman, 1979) is a 40-item questionnaire that measures the degree of agreement with dysfunctional attitudes in a number of areas. These include the areas of dependency and achievement described above, which have been identified from the DAS by a number of factor analytic studies. The subscales adopted for this study were those developed by Imber et al. (1990)
242
R. G. Moore,
I.-M.
Blackhm
/Journd
because the data used in the factor analysis in that study were obtained from a sample of depressed patients. These subscales, labelled need for social approval and perfectionism, are described in detail in Persons et al. (1991) who report their use in a study examining the relationship of these factors to patterns of depressive symptoms. Due to the difficulties some patients had in completing all the questionnaires, the precise numbers on which different calculations were based varied slightly and are shown for each calculation below.
ofA,ffectwe
Di.wrder.s 32 (1994) 239-245
Table 2 Correlations of sociotropy and autonomy severity. cognition and personality
Severity Attitudea
Personality
* P < 0.05; BDl. Beck Inventory, tionnaire: DAS-need ism scale.
BDI STAI-S DAS DAS-SA DAS-P Neuroticism Extraversion
with
measures
Sociotropy
Autonomy
0.44 ** (j.76 **
0.14 0.06 0.05 -0.10 0.19 * 0.13 ~ 0.20 *
0.38 0.5Y 0.2h 0.22 - 0.03
** ** ** *
of
** P < 0.01. Depression Inventory; STAI-S. State Trait Anxiety State Version: ATQ, Automatic Thoughts QuesDAS, Dysfunctional Attitude Scale; DAS-SA. for social approval scale; DAS-P. DAS-perfection-
2. Results Mean and S.D. values for the SAS and for the measures of severity of symptoms, neuroticism and extraversion and for DAS total scores are shown in Table 1. Scores on the BDI indicate that this sample of patients were suffering from moderately severe depression. 2.1. Reliability
of SAS
As a measure of internal consistency, Cronbath’s (Y was computed for the Sociotropy and Autonomy scales. cy values for both Sociotropy and Autonomy were 0.87 (n = 118). These indicate a highly satisfactory degree of internal reliability for the two scales in this sample. For comparison, the correlation of Sociotropy with Autonomy was 0.23, n = 118, P < 0.05.
Table I Mean and S.D. valves of measures patients (/I = 1 IX)
BDI STAI-S Sociotropy Autonomy DAS Neuroticism Extraversion
for a
sample
Mean
SD
27.4 58.9 78.7 70.6 157.3 IX.6 7.2
0.X 11.6 16.5 15.8 33.8 3.9 5.0
of
depresvxl
BDI, Beck Depression Inventory; STAI-S, State Trait Anxiety Inventory, State Veraion; DA% Dysfunctional Attitude Scale.
2.2. Correlations
of SAS with sel,erity
measures
Pearson’s correlations between the Sociotropy and Autonomy scales and the measures of severity are shown in Table 2. The Sociotropy scale correlated significantly with both the Depression and Anxiety severity measures whereas the Autonomy scale was not significantly associated with either. To clarify the specificity of the relationship of the SAS to depression or anxiety, partial correlations were computed of the SAS scales with the BDI controlling for STAI-S scores and of the SAS scales with the STAI-S, controlling for BDI scores. For Sociotropy scores, the correlation with the BDI remained significant when STAI-S scores were partialled out (r = 0.36, t(115) = 4.12, P < 0.001). However, the correlation of the STAI-S with Sociotropy was not significant once BDI scores were controlled for (r = 0.03, t(llS) = 0.37, rz.s.1. For autonomy scores, partial correlations remained non-significant. 2.3. Correlations
of SAS with other
measures
Correlations of the Sociotropy scale with the attitude and personality measures showed significant associations with DAS total score and both sub-scales and with the neuroticism scale of the EPQ. With increasing sociotropy, patients were more likely to endorse more depressogenic attitudes in general and to show higher needs for
R. G. Moore, 1.-M. Bluckhum / Joumul of Affect&
social approval and for perfectionism and to be more neurotic. In contrast, the Autonomy scale was significantly associated only with perfectionism and negatively so with extraversion, that is more autonomous subjects were less extraverted. The association of sociotropy with the need for social approval scale was stronger than its association with perfectionism, the difference between the correlations being significant (t(l13) = 4.79, P < 0.001). The difference between the correlations of autonomy with perfectionism and with social approval was significant (t(113) = 3.57, P < 0.001).
3. Discussion In this sample of depressed patients, both the Sociotropy and Autonomy scales proved to be highly reliable. The associations of the two scales with other measures and their implications for research into vulnerability will be described for each characteristic in turn. Sociotropy was significantly associated with severity of both depressive and anxiety symptoms. The magnitude of the correlations was as would be expected for a vulnerability marker in a currently depressed sample, in that the associations were significant but of modest size, indicating that the scale was not just tapping depression or anxiety. Further analyses of the partial correlations suggested that the association of sociotropy with self-rated depressive symptoms was independent of anxiety symptoms whereas the association of sociotropy with anxiety was statistically mediated via self-reported depression. In its associations with self-report measures of distress, sociotropy, thus, exhibited some specificity to depression rather than anxiety. Autonomy showed no significant association with either self-rated depression or anxiety. This lack of concurrent validity of the autonomy scale may indicate that our depressed sample consisted primarily of sociotropic individuals who had become depressed as a result of negative interpersonal events. Although the characteristics of life events were not examined in this study, there is no reason to believe that this large sample of depressed pa-
Disorders 32 (1994) 239-24.~
243
tients was not a representative sample. The only specific characteristic of this sample was that it consisted of recurrent depressed patients. The other reasons for the lack of association between autonomy and depression and anxiety may be either the lack of validity of the scale or the lack of validity of autonomy itself as a relevant factor in depression. The relevance of sociotropy in the anxiety disorders and of autonomy to depression needs to be investigated further in differing samples of anxious and depressed patients. Sociotropy was also significantly associated with the general level of dysfunctional attitudes, with need for social approval, need for perfectionism and with Neuroticism. The latter finding confirms those of previous studies by Gilbert and Reynolds (1990) and Cappeliez (1993). Thus, the results of this study confirm the relationship of sociotropy with a number of psychological factors thought to be important in the aetiology and/or maintenance of depression. Prior research on such factors has been impeded by the fact that many of the measures used, including those of neuroticism and dysfunctional attitudes, seem to be so responsive to variations in current depressive symptoms that any influences of underlying vulnerability factors are hard to detect (Barnett and Gotlib, 1988). The specificity of the association of sociotropy with particular kinds of content of depressive thinking may help to limit the operation of depressive response biases and improve our detection of enduring vulnerability rather than current distress. Further research is needed to investigate the mechanisms of vulnerability to interpersonal life events and in particular the respective roles of sociotropy and attitudes reflecting need for social approval in such vulnerability. One possibility is that such attitudes constitute the ‘effective ingredient’ of sociotropy and themselves account for increased vulnerability. Alternatively, sociotropy may tap an affective valuation of social interaction, which confers vulnerability independently of consciously-held dysfunctional attitudes. The significant, though weak, negative correlation between the Autonomy scale and extraversion indicated that more autonomous patients
R.G. Moore, I.-M. Blackburn /Journal
244
were more dicted,
given
introverted. that
the
This is as would
be
pre-
Autonomy
is
com-
scale
posed of items reflecting a preference for solitude or individualism, although this relationship was not previously found by Gilbert and Reynolds (1990) or Cappeliez (1993) perhaps due to differences between the samples or difference in sample sizes. Autonomy was more weakly related than sociotropy to both DAS scales although its correlation with the perfectionism scale was just significant. It exhibited a negative relationship with need for approval, which rendered the difference between the two correlations significant, reflecting a greater degree of positive association with perfectionism. Thus, autonomy also showed some degree of specificity in its association with particular kinds of dysfunctional attitudes, albeit weaker than the association for sociotropy. It should be noted that, although the Autonomy scale showed satisfactory reliability, the evidence for the concurrent validity of the autonomy scale was somewhat weak. This is consistent with some previous studies which have found weaker associations for autonomy than for sociotropy both with life events (Robins, 1990) and with symptom patterns (Robins et al., 1989). The association with introversion, which has been found to be an enduring characteristic of those who have previously been depressed (Barnett and Gotlib, 1988) and the slight specificity to perfectionistic attitudes give some cause for encouragement. Therefore, refinement rather than rejection of the concept of autonomy may be indicated (Clark and Beck, 1991). The Autonomy scale of the SAS may tap relatively healthy aspects of being able to tolerate or enjoy solitude and of striving to improve one’s performance, as well as self-critical perfectionism and the defensive avoidance which may result from it. The latter characteristics would appear to correspond more closely with previous work on introversion and self-criticism and may have wider relevance to the aetiology and manifestation of depression. However, examination of this possibility depends on further refinement of measures of autonomy and further investigations of the relationships between these concepts, life events and depressive symptoms.
of Affectil:e Disorders 32 (1994) 239-245
Acknowledgements We would like to thank A. Wilson and M. Hipwell for their help in collecting the data. This work was supported by a grant from the Scottish Office, Home and Health Department.
References Barnett, P.A. and Gotlib, I.H. (1988) Psychosocial functioning and depression: distinguishing among antecedents, concomitants. and consequences. Psychol. Bull. 104, 97-126. Beck, A.T. (1983) Cognitive therapy of depression: new perspectives. In: P.J. Clayton and J.E. Barrett (Eds.), Treatment of Depression: Old Controversies and New Approaches. Raven Press, New York, NY. Beck, A.T., Epstein, N. and Harrison, R. (1983) Cognitions, attitudes and personality dimensions in depression. Br. J. Cogn. Psychother. I-16. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J. (1961) An inventory for measuring depression. Arch. Gen. Psychiatry 4, 561-571. Blaney. P.H. and Kutcher, G.S. (1991) Measures of depressive dimensions: are they interchangeable? J. Pers. Assess, 56, 502-5 12. Cappeliez, P. (1993) The relationship between Beck’s con cepts of sociotropy and autonomy and the NEO-Personality Inventory. Br. J. Clin. Psychol. 32, 78-80. Clark, D.A. and Beck. A.T. (1991) Personality factors in dysphoria: a psychometric refinement of Beck’s Sociotropy-Autonomy Scale. J. Behav. Assess. 13, 369-388. Endicott, J. and Spitzer, R.L. (1978) A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch. Cert. Psychiatry 25, 8377844. Eysenck, H.J. and Eysenck, S.B.G. (1975) Manual ot the Eysenck Personality Questionnaire. Hodder and Stoughton, London, UK. Gilbert, P. and Reynolds, S. (1990) The relationship between the Eysenck Personality Questionnaire and Beck’s concepts of sociotropy and autonomy. Br. J. Clin. Psychol. 29, 319-325. Hammen, C., Ellicott, A. and Gitlin, M. (1989a) Vulnerability to specific life events and prediction of course of disorder in unipolar depressed patients. Can. J. Behav. Sci. 21, 377-388. Hammen, CL., Ellicott, A., Gitlin, M. and Jamison, K.R. (1989b) Sociotropy/Autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders. J. Abnorm. Psychol. 98, 154-160. Imber, S.D., Pilkonis, P.A., Sotsky, S.M., Elkin, I., Watkins, J.T.. Collins, J.F., Shea, M.T., Leber, W.R. and Glass, D.R. (1990) Mode-specific effects among three treatments for depression. J. Consult Clin. Psychol. 58, 3522359. Nietzel. M.T. and Harris, M.J. (1990) Relationship of depend-
R.G. Moore, I.-M. Blackburn /Journal ency and achievement/autonomy to depression. Clin. Psychol. Rev. 10, 279-297. Persons, J.B., Miranda, J. and Perloff, J.M. (1991) Relationships between depressive symptoms and cognitive vulnerabilities of achievement and dependency. Cogn. Ther. Res. 15, 221-235. Peselow, E.D.. Robins, C.J., Sanfilipo, M.P., Block, P. and Fieve, R.R. (1992) Sociotropy and autonomy: relationship to antidepressant drug treatment response and endogenous-nonendogenous dichotomy. J. Abnorm. Psychol. 101, 479-486. Robins, C.J. (1990) Congruence of personality and life events. J. Abnorm. Psychol. 99, 393-397. Robins, C.J. and Block, P. (1988) Personal vulnerability, life events, and depressive symptoms: a test of a specific interactional model. J. Pers. Sot. Psychol. 54, 847-852. Robins, C.J., Block, P. and Peselow, E.D. (1989) Relations of sociotropic and autonomous personality characteristics to
of Affecti1.e Disorders 32 (1994) 239-245
245
specific symptoms in depressed patients. J. Abnorm. Psychol. 98, 86-88. Robins, C.J. and Luten, A.G. (1991) Sociotropy and autonomy: differential patterns of clinical presentation in unipolar depression. J. Abnorm. Psychol. 100, 74-77. Segal, Z.V., Shaw, B.F., Vella, D.D. and Katz, R. (1992) Cognitive and life stress predictors of relapse in remitted unipolar depressed patients: test of the congruency hypothesis. J. Abnorm. Psycho]. 101, 26-36. Spielberger, CD., Gorsuch, R.L. and Lushene, R.E. (1970) Manual for State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto, CA. Spitzer, R.L., Endicott, J. and Robins, E. (1978) Research diagnostic criteria: rationale and reliability. Arch. Gen. Psychiatry 35, 773-782. Weissman, A.N. (1979) The Dysfunctional Attitude Scale: a validation study. Diss. Abst. Intern. 40, 1389-13990.
DISORDERS
ELSEVIER
Journal
of Affective
Disorders
32 (1994) 239-245
The relationship of sociotropy and autonomy to symptoms, cognition and personality in depressed patients Richard Department
Received
30 November
G. Moore, of Psychiatr),
Ivy-Marie
Unkersity
1993; revised version
Blackburn
of Edinburgh,
received
8 August
Edinburgh,
1994; accepted
* UK
10 August
1994
Abstract A growing body of research suggests that the two personality characteristics of sociotropy and autonomy confer vulnerability to depression in response to interpersonal or achievement-related events. This study examined the relationships of these characteristics to severity of symptoms, measures of negative cognition, neuroticism and extraversion in a sample of 118 unipolar depressed patients. Sociotropy was found to be associated with self-reported depressive symptoms independently of anxiety level, with frequency of negative automatic thoughts, with dysfunctional attitudes and neuroticism. It was more strongly related to dysfunctional attitudes reflecting a need for social approval than to those reflecting perfectionism. Autonomy was not associated with self-reported symptoms of depression or of anxiety. It was, however, associated with low extraversion and significantly more associated with perfectionism than social approval. The results support the need for further research to examine the precise roles of a number of psychological factors in the vulnerability to interpersonal life events but also suggest limitations in the relevance of the construct of autonomy to depression. Keywords;
Sociotropy;
Autonomy;
Depression;
Anxiety;
The personality characteristics of sociotropy and autonomy have been hypothesized to influence vulnerability to life events, symptom patterns, cognitive biases and response to treatment in depression (Beck, 1983). Sociotropy is characterized by dependency on relationships with others for interpersonal needs, such as acceptance
* Corresponding author. Address: Cognitive Therapy Centre. Collingwood Clinic, St Nicholas Hospital, Newcastleupon-Tyne NE3 3XT, UK. OlhS-0327/94/$07.00 0 1994 Elsevier SSDI 0165-0327~94~00061-1
Science
Attitude;
Vulnerability
and approval. Highly sociotropic people are predieted to be vulnerable to threatened or actual rejection or abandonment by others. Autonomous people value their own independence and achievements and need to master and control their environment. They are predicted to be vulnerable to frustration by others or to personal failure. A measure of these characteristics, the Sociotropy-Autonomy Scale @AS; Beck et al., 1983) has been used extensively in research in this area. This is a 60-item measure, with 30 Sociotropy
B.V. All rights reserved
240
R.G. Moore, I.-M. Blackburn /Journal
items and 30 Autonomy items. Each item is rated on 5-point scale to indicate whether that statement applies 0, 25, 50, 75 or 100% of the time. A typical sociotropy item is ‘I feel I have to be nice to other people’ and a typical autonomy item is ‘It is important to me to be free and independent’. A number of studies using the SAS have investigated vulnerability to different kinds of life events. There has been some overall support for the association of sociotropy with vulnerability to interpersonal life events and of autonomy to achievement-related life events (e.g., Hammen et al., 1989h), although some studies have found significant relationships only for sociotropy (e.g., Robins and Block, 1988; Robins, 1990) and others only for autonomy (e.g., Hammen et al., 1989a). By conferring vulnerability to specific kinds of events, these personality characteristics are of particular aetiological importance. An overall understanding of the role of psychological factors in the aetiology of depression will depend on further elaboration of the relationship of sociotropy and autonomy with other factors of putative aetiological relevance. Information about the relationship of sociotropy and autonomy with states of depression and of anxiety and with personality dimensions implicated in depression will, thus, be of theoretical importance as well as being essential in demonstrating the construct validity of the scale. Most of the information so far available relates to the association between the SAS and measures of the severity and nature of depressive symptoms. In their quantitative review, Nietzel and Harris (1990) found a moderate relationship between sociotropy and depressive symptoms but no relationship between autonomy and symptoms. Robins and his colleagues (Robins et al., 1989; Robins and Luten, 1991; Peselow et al., 1992) have found that depression in sociotropic people seems to revolve around symptoms connected with a theme of loss and may be of a non-endogenous type whereas depression in autonomous persons is manifested in symptoms reflecting a theme of defeat and may be of an endogenous type. Although it now seems clear that sociotropy in particular is associated with depressive symp-
of
AffecticeDisorders 32 (1994) 239-245
toms, the relationships of sociotropy and autonomy with anxiety may be of importance in ascertaining whether the relevance of these characteristics is specific to depression. One aim of this study was, therefore, to confirm the relationship of Sociotropy and Autonomy with severity of depression and to examine the specificity of this relationship with respect to severity of anxiety. Previous work on depression has found the personality traits of neuroticism and extraversion to be associated with vulnerability to depression (see Barnett and Gotlib, 1988). Two studies have examined the relationship of neuroticism and extraversion to the SAS. Gilbert and Reynolds (1990) found that, in a sample of patients with mixed diagnoses, sociotropy was significantly associated with neuroticism but not extraversion and that autonomy was unrelated to both neuroticism and extraversion. Similar findings were reported by Cappeliez (1993) in a student sample. A further aim of this study was to replicate these findings in a sample of depressed patients. The relationship of sociotropy and autonomy to specific cognitive themes is also of interest. It has been shown that dependency-related vs. achievement-related dysfunctional attitudes reported on the Dysfunctional Attitude Scale (DAS; Weissman, 1979) can be distinguished (Imber et al., 1990). These groups of dysfunctional attitudes seem to confer specific vulnerability to interpersonal or achievement-related life events in a fashion similar to sociotropy and autonomy (Segal et al., 1992). It is possible that each personality characteristic is associated with these specific clusters of dysfunctional attitudes. Blaney and Kutcher (1991) examined the relationship between the SAS and subscales from the DAS in a large student sample. They found a substantial relationship between sociotropy and the DASanaclitic subscale (dependency), as predicted, but a negligible association between autonomy and the DAS-introjective subscale (achievement). The associations of these clusters of attitudes with sociotropy and autonomy in depressed patients remains to be established and was another focus for the present study. In summary, this study aimed to examine a large number of patients satisfying criteria for
R.G. Moore, I.-M. Blackburn /Journal
major depression to establish the specificity and concurrent validity of the SAS. (1) It was predicted that the relationship between sociotropy and autonomy and severity of symptoms would be specific to depression rather than anxiety. (2) It was predicted that sociotropy would be associated with neuroticism and not introversion in depressed patients, as has previously been found in mixed neurotic patients and students. However, contrary to previous findings, it was predicted that the characteristics described by the autonomy scale would lead to an association with introversion, and not neuroticism. It was further predicted that sociotropy would be specifically correlated with dysfunctional attitudes reflecting dependency and that autonomy would be associated with dysfunctional attitudes reflecting need for achievement.
1. Methods 1.1. Subjects The subjects were patients referred to a psychiatric hospital as either in- or outpatients for treatment for depression. These patients were recruited to an outcome and maintenance study comparing cognitive therapy with medication in the treatment of recurrent depression. Patients were initially screened using the Schedule for Affective Disorders and Schizophrenia (Endicott and Spitzer, 1978) and recruited to the study only if they met Research Diagnostic Criteria (Spitzer et al., 1978) at the time of assessment for primary unipolar Major Depression, had at least one previous depressive episode which met the same criteria and were aged between 18 and 65. Subjects with a history of schizophrenia or bipolar illness, or with a primary psychiatric diagnosis other than depression were excluded. 127 patients meeting Research Diagnostic Criteria for recurrent Major Depression were recruited to the study. Nine patients either refused or were unable to continue to participate in the study. Of the 118 patients included, 72 were outpatients and 46 were inpatients. 61% of the sample was female and the mean age was 40 (SD = 13) years.
of Affectice Disorders 32 (1994) 239-245
The mean number (SD = 2.2).
of previous
241
episodes
was 3.5
1.2. Procedure After the initial screening and before random allocation to treatment groups, patients completed an assessment, including several state measures, measures of depressive cognitive style and personality questionnaires. In this paper, data relating to two measures of severity of symptoms, two personality measures and a measure of basic attitudes are reported. 1.3. Measures 1.3.1. LeL!el of depression The 20-item Beck Depression Inventory (BDI; Beck et al., 1961) was used. It is a widely used and well-validated self-rated measure of severity of depression (Beck et al., 1988). 1.3.2. LeLlel of anxiety The State-Trait Anxiety Inventory, State Version (STAI-S; Spielberger et al., 1970) was used. This scale is also a widely used and well-validated measure (Spielberger et al., 1983). 1.3.3. Personality The SAS (Beck et al., 1983) is described in the introduction and is the measure of the two concepts of interest in this study. Eysenck Personality Questionnaire (EPQ; Eysenck and Eysenck, 1975) provides well-validated measures of neuroticism and introversion/extraversion which have been extensively studied in depression (Martin, 1985) 1.4. Attitudes The DAS form A (Weissman, 1979) is a 40-item questionnaire that measures the degree of agreement with dysfunctional attitudes in a number of areas. These include the areas of dependency and achievement described above, which have been identified from the DAS by a number of factor analytic studies. The subscales adopted for this study were those developed by Imber et al. (1990)
242
R. G. Moore,
I.-M.
Blackhm
/Journd
because the data used in the factor analysis in that study were obtained from a sample of depressed patients. These subscales, labelled need for social approval and perfectionism, are described in detail in Persons et al. (1991) who report their use in a study examining the relationship of these factors to patterns of depressive symptoms. Due to the difficulties some patients had in completing all the questionnaires, the precise numbers on which different calculations were based varied slightly and are shown for each calculation below.
ofA,ffectwe
Di.wrder.s 32 (1994) 239-245
Table 2 Correlations of sociotropy and autonomy severity. cognition and personality
Severity Attitudea
Personality
* P < 0.05; BDl. Beck Inventory, tionnaire: DAS-need ism scale.
BDI STAI-S DAS DAS-SA DAS-P Neuroticism Extraversion
with
measures
Sociotropy
Autonomy
0.44 ** (j.76 **
0.14 0.06 0.05 -0.10 0.19 * 0.13 ~ 0.20 *
0.38 0.5Y 0.2h 0.22 - 0.03
** ** ** *
of
** P < 0.01. Depression Inventory; STAI-S. State Trait Anxiety State Version: ATQ, Automatic Thoughts QuesDAS, Dysfunctional Attitude Scale; DAS-SA. for social approval scale; DAS-P. DAS-perfection-
2. Results Mean and S.D. values for the SAS and for the measures of severity of symptoms, neuroticism and extraversion and for DAS total scores are shown in Table 1. Scores on the BDI indicate that this sample of patients were suffering from moderately severe depression. 2.1. Reliability
of SAS
As a measure of internal consistency, Cronbath’s (Y was computed for the Sociotropy and Autonomy scales. cy values for both Sociotropy and Autonomy were 0.87 (n = 118). These indicate a highly satisfactory degree of internal reliability for the two scales in this sample. For comparison, the correlation of Sociotropy with Autonomy was 0.23, n = 118, P < 0.05.
Table I Mean and S.D. valves of measures patients (/I = 1 IX)
BDI STAI-S Sociotropy Autonomy DAS Neuroticism Extraversion
for a
sample
Mean
SD
27.4 58.9 78.7 70.6 157.3 IX.6 7.2
0.X 11.6 16.5 15.8 33.8 3.9 5.0
of
depresvxl
BDI, Beck Depression Inventory; STAI-S, State Trait Anxiety Inventory, State Veraion; DA% Dysfunctional Attitude Scale.
2.2. Correlations
of SAS with sel,erity
measures
Pearson’s correlations between the Sociotropy and Autonomy scales and the measures of severity are shown in Table 2. The Sociotropy scale correlated significantly with both the Depression and Anxiety severity measures whereas the Autonomy scale was not significantly associated with either. To clarify the specificity of the relationship of the SAS to depression or anxiety, partial correlations were computed of the SAS scales with the BDI controlling for STAI-S scores and of the SAS scales with the STAI-S, controlling for BDI scores. For Sociotropy scores, the correlation with the BDI remained significant when STAI-S scores were partialled out (r = 0.36, t(115) = 4.12, P < 0.001). However, the correlation of the STAI-S with Sociotropy was not significant once BDI scores were controlled for (r = 0.03, t(llS) = 0.37, rz.s.1. For autonomy scores, partial correlations remained non-significant. 2.3. Correlations
of SAS with other
measures
Correlations of the Sociotropy scale with the attitude and personality measures showed significant associations with DAS total score and both sub-scales and with the neuroticism scale of the EPQ. With increasing sociotropy, patients were more likely to endorse more depressogenic attitudes in general and to show higher needs for
R. G. Moore, 1.-M. Bluckhum / Joumul of Affect&
social approval and for perfectionism and to be more neurotic. In contrast, the Autonomy scale was significantly associated only with perfectionism and negatively so with extraversion, that is more autonomous subjects were less extraverted. The association of sociotropy with the need for social approval scale was stronger than its association with perfectionism, the difference between the correlations being significant (t(l13) = 4.79, P < 0.001). The difference between the correlations of autonomy with perfectionism and with social approval was significant (t(113) = 3.57, P < 0.001).
3. Discussion In this sample of depressed patients, both the Sociotropy and Autonomy scales proved to be highly reliable. The associations of the two scales with other measures and their implications for research into vulnerability will be described for each characteristic in turn. Sociotropy was significantly associated with severity of both depressive and anxiety symptoms. The magnitude of the correlations was as would be expected for a vulnerability marker in a currently depressed sample, in that the associations were significant but of modest size, indicating that the scale was not just tapping depression or anxiety. Further analyses of the partial correlations suggested that the association of sociotropy with self-rated depressive symptoms was independent of anxiety symptoms whereas the association of sociotropy with anxiety was statistically mediated via self-reported depression. In its associations with self-report measures of distress, sociotropy, thus, exhibited some specificity to depression rather than anxiety. Autonomy showed no significant association with either self-rated depression or anxiety. This lack of concurrent validity of the autonomy scale may indicate that our depressed sample consisted primarily of sociotropic individuals who had become depressed as a result of negative interpersonal events. Although the characteristics of life events were not examined in this study, there is no reason to believe that this large sample of depressed pa-
Disorders 32 (1994) 239-24.~
243
tients was not a representative sample. The only specific characteristic of this sample was that it consisted of recurrent depressed patients. The other reasons for the lack of association between autonomy and depression and anxiety may be either the lack of validity of the scale or the lack of validity of autonomy itself as a relevant factor in depression. The relevance of sociotropy in the anxiety disorders and of autonomy to depression needs to be investigated further in differing samples of anxious and depressed patients. Sociotropy was also significantly associated with the general level of dysfunctional attitudes, with need for social approval, need for perfectionism and with Neuroticism. The latter finding confirms those of previous studies by Gilbert and Reynolds (1990) and Cappeliez (1993). Thus, the results of this study confirm the relationship of sociotropy with a number of psychological factors thought to be important in the aetiology and/or maintenance of depression. Prior research on such factors has been impeded by the fact that many of the measures used, including those of neuroticism and dysfunctional attitudes, seem to be so responsive to variations in current depressive symptoms that any influences of underlying vulnerability factors are hard to detect (Barnett and Gotlib, 1988). The specificity of the association of sociotropy with particular kinds of content of depressive thinking may help to limit the operation of depressive response biases and improve our detection of enduring vulnerability rather than current distress. Further research is needed to investigate the mechanisms of vulnerability to interpersonal life events and in particular the respective roles of sociotropy and attitudes reflecting need for social approval in such vulnerability. One possibility is that such attitudes constitute the ‘effective ingredient’ of sociotropy and themselves account for increased vulnerability. Alternatively, sociotropy may tap an affective valuation of social interaction, which confers vulnerability independently of consciously-held dysfunctional attitudes. The significant, though weak, negative correlation between the Autonomy scale and extraversion indicated that more autonomous patients
R.G. Moore, I.-M. Blackburn /Journal
244
were more dicted,
given
introverted. that
the
This is as would
be
pre-
Autonomy
is
com-
scale
posed of items reflecting a preference for solitude or individualism, although this relationship was not previously found by Gilbert and Reynolds (1990) or Cappeliez (1993) perhaps due to differences between the samples or difference in sample sizes. Autonomy was more weakly related than sociotropy to both DAS scales although its correlation with the perfectionism scale was just significant. It exhibited a negative relationship with need for approval, which rendered the difference between the two correlations significant, reflecting a greater degree of positive association with perfectionism. Thus, autonomy also showed some degree of specificity in its association with particular kinds of dysfunctional attitudes, albeit weaker than the association for sociotropy. It should be noted that, although the Autonomy scale showed satisfactory reliability, the evidence for the concurrent validity of the autonomy scale was somewhat weak. This is consistent with some previous studies which have found weaker associations for autonomy than for sociotropy both with life events (Robins, 1990) and with symptom patterns (Robins et al., 1989). The association with introversion, which has been found to be an enduring characteristic of those who have previously been depressed (Barnett and Gotlib, 1988) and the slight specificity to perfectionistic attitudes give some cause for encouragement. Therefore, refinement rather than rejection of the concept of autonomy may be indicated (Clark and Beck, 1991). The Autonomy scale of the SAS may tap relatively healthy aspects of being able to tolerate or enjoy solitude and of striving to improve one’s performance, as well as self-critical perfectionism and the defensive avoidance which may result from it. The latter characteristics would appear to correspond more closely with previous work on introversion and self-criticism and may have wider relevance to the aetiology and manifestation of depression. However, examination of this possibility depends on further refinement of measures of autonomy and further investigations of the relationships between these concepts, life events and depressive symptoms.
of Affectil:e Disorders 32 (1994) 239-245
Acknowledgements We would like to thank A. Wilson and M. Hipwell for their help in collecting the data. This work was supported by a grant from the Scottish Office, Home and Health Department.
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