Temperament and character dimensions in patients with social phobia: Patterns of change following treatments?

Psychiatry Research 152 (2007) 81 – 90 www.elsevier.com/locate/psychres

Temperament and character dimensions in patients with social phobia: Patterns of change following treatments? Ewa Mörtberg ⁎, Susanne Bejerot, Anna Åberg Wistedt Department of Clinical Neuroscience, Section of Psychiatry St Göran's Hospital, Karolinska Institute, Stockholm, Sweden Received 12 January 2006; received in revised form 2 July 2006; accepted 2 October 2006

Abstract The aim of this study was to examine Temperament and Character Inventory (TCI) profiles in patients with social phobia (DSM-IV) and to outline patterns of change following intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU). One hundred patients recruited by advertisements in local papers were randomized to IGCT, ICT and TAU. Patients (n = 59) who completed diagnostic evaluation and TCI assessments at baseline and 1-year follow-up were examined in this study. Patients differed from healthy controls in novelty seeking (NS), harm avoidance (HA), self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Treatments overall were associated with decrease in HA, while increase in SD was observed after psychotherapy only. Reduced social anxiety was correlated with decrease in HA and increase in SD. High HA at baseline was related to poor treatment outcome in all treatments. To conclude, patients with social phobia show a temperamental vulnerability for developing anxiety and character traits associated with personality disorders. Successful treatment is related to decrease in HA and increase in SD. High HA at baseline may suggest a need for extensive treatment in order to achieve remission. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Temperament and Character Inventory (TCI); Cognitive and behavior therapy; Group and individual treatment; Treatment as usual

1. Introduction Social phobia (American Psychiatric Association, 1994), defined by a marked and persistent fear of embarrassment or negative evaluation while engaged in social interaction or public performance, is a prevalent (Furmark, 2002; Kessler et al., 2005) and disabling ⁎ Corresponding author. The Unit for Psychotherapy in City (Psykoterapienheten City), Karlavägen 53, SE-114 49 Stockholm, Sweden. Tel.: +46 8 6722432; fax: +46 8 6724068. E-mail addresses: [email protected], [email protected] (E. Mörtberg).

disorder that usually runs a chronic course (Bruce et al., 2005). Several studies of social phobia report co-morbid anxiety disorders, depression and alcohol dependence (Lydiard, 2001; Kessler et al., 2005; Bruce et al., 2005) and a consistent elevation of cluster C (fearful) personality disorders, most particularly avoidant personality disorder (Schneier et al., 1991; Fahlén, 1995; Pelissolo et al., 2002; Clark et al., 2003; Marteinsdottir et al., 2003). Trait-based studies of personality patterns in patients with social phobia could provide additional diagnostic information, which would be useful for evaluation and further treatment planning. The Temperament and

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Character Inventory (TCI), based on Cloninger's psychobiological model of personality (Cloninger et al., 1993, 1994) provides a description of seven basic dimensions of temperament and character. The temperament aspects of personality (novelty seeking [NS], harm avoidance [HA], reward dependence [RD] and persistence [P]) are supposed to be highly hereditary, independent, and stable throughout life and mood state. They involve automatic emotional reactions (anger, fear, and attachment) and related automatic behavioral reactions (activation, inhibition, and maintenance of behavior) in response to specific environmental stimuli (novelty, danger, and reward). The character aspects of personality (selfdirectedness [SD], cooperativeness [C] and self-transcendence [ST]) involve individual goals, values, and selfconscious emotions that are supposed to be influenced by maturity and social learning. The TCI is a further development of an earlier version of the instrument, the Tridimensional Personality Questionnaire (TPQ) (Cloninger, 1987), which included only three personality (temperament) dimensions (NS, HA and RD). Previous studies of TCI and TPQ personality characteristics indicate that patients with social phobia compared to controls, have significantly elevated levels of harm avoidance (Kim and Hoover, 1996; Chatterjee et al., 1997; Pelissolo et al., 2002; Marteinsdottir et al., 2003; Hofmann and Loh, 2006), which define individuals who tend to be “cautious, careful, fearful, tense, apprehensive, nervous, timid, doubtful, discouraged, insecure, passive, negativistic, or pessimistic even in situations that do not worry other people” (Cloninger et al., 1994). Overall, elevated harm avoidance is not specific for social phobia but has also been reported in obsessive compulsive disorder, (Bejerot et al., 1998; Lyoo et al., 2003), post-traumatic stress disorder (Richman and Frueh, 1997), panic disorder (Fossey et al., 1989; Perna et al., 1992; Starcevic et al., 1996), generalized anxiety disorder (Fossey et al., 1989; Starcevic et al., 1996), the Asperger syndrome (Soderstrom et al., 2002), eating disorder (Klump et al., 2004), and in depressive states (Kelley Yost Abrams et al., 2004). Other consistent findings in social phobia are decreased levels of SD and C (Chatterjee et al., 1997; Pelissolo et al., 2002; Marteinsdottir et al., 2003), dimensions that are highly correlated with personality disorders in general (Svrakic et al., 1993). One study (Hofmann and Loh, 2006) has examined changes of the TPQ temperament patterns, following two cognitive behavioral group treatment (CBGT) programs, showing that reduced HA is significantly correlated with reduced social anxiety. Despite significantly reduced scores of HA, thus implicating state dependent changes

following treatments, patients remained having significantly higher scores than controls. To date, no study of treatments of social phobia has examined changes of baseline TCI temperament and character patterns following treatments. The aims of the present study were 1) to examine personality patterns in patients with social phobia, thus replicating previous studies and 2) to examine the nature of change following intensive group cognitive treatment (IGCT), individual cognitive therapy (ICT), and treatment as usual (TAU) involving antidepressant medication. Based on previous findings we expected that patients would show high baseline levels of HA and low levels of SD and C. We hypothesized 1) that dysfunctional character and temperament traits, independent of treatment condition, would be significantly improved following treatments and that 2) improved personality traits would be significantly related to reduced social anxiety. 2. Methods 2.1. Patients Patients (n = 59) were involved in a larger randomized controlled trial (n = 100) comparing intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU) of social phobia (Mörtberg et al., in press). All patients (n = 59) who completed diagnostic assessment and TCI measures at baseline and 1-year follow-up (IGCT: 21 patients ICT: 24 patients, TAU: 14 patients) were included in this paper. Patients were recruited through advertisements in a local newspaper, screened on telephone for social phobia, and were invited to diagnostic interviews using the Structured Clinical Interview for DSM-IV (First et al., 1995) for establishing the diagnosis of social phobia and assessing additional psychiatric disorders. Specification of social phobia sub-types was based on a procedure described by Baker et al. (2002). The SCID-II Screener (DSM-IV) was used for diagnoses of personality disorders (PD), with the cut-off level adjusted upwards so that one additional criterion was required for each of the personality disorders. This procedure has shown a high overall kappa agreement (0.78) between the SCID interviews and the SCID-II Screener (Ekselius et al., 1994). Patients were offered inclusion in the treatment trial if they fulfilled the following criteria: (a) had a primary diagnosis of social phobia according to DSM-IV (APA, 1994); (b) were 18 to 65 years, and were without (c) current depressive episode, bipolar disorder, stress disorders, addiction, or psychoses; d) present psychotropic medication; or e) current psychotherapy. Fifteen

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patients did not meet the inclusion criteria and additional two patients declined further participation after the psychiatric interview. The remaining patients (n = 100) fulfilled criteria (a)–(e), gave written consent, and were randomly assigned to the treatments. The Karolinska Hospital Ethics Committee approved the study. Psychiatric assessors who were blind to treatment condition repeated the SCID social phobia module at 1-year follow-up. Non-response to treatment was defined in patients who still fulfilled criteria for social phobia at the 1-year follow-up. 2.2. Control group Patients TCI-scores were compared with normative scores of a sub-group (n = 400, 20–35 years) in a community sample (n = 1300, 20–80 years), used for the validation of the Swedish version of the TCI (Brändström et al., 1998). One thousand of the subjects were randomly drawn from a large health and memory study (n = 2800, 35–80 years) “The Betula Cohort Study”, which is found to be demographically representative for the Swedish normal population (cited in Brändström et al., 1998). An additional group of 300 individuals (aged 20, 25, and 30 years) were randomly recruited from the same area by the Västerbotten County population register. The subjects were consecutively included until each cohort consisted of 100 individuals (50 males and 50 females). The Swedish TCI is representative for the Swedish population and replicates the American version well for the mean scale scores, distribution of scores, and relationships between and within scales and subscales (Brändström et al., 1998). 2.3. Treatments ICT (Clark, 2001; Clark et al., 2003), is based on Clark's, and Wells' model of the maintenance of social phobia (Clark and Wells, 1995) and was guided by a treatment manual (Clark, 1997 unpublished manual). In ICT, patients had up to 16 weekly sessions in 4 months followed by a booster session at 8 and 12 months. IGCT (Mörtberg et al., in press) is a development of the intensive group cognitive behavioral treatment previously used (Mörtberg et al., 2005, 2006) and was manual based. The treatment procedures in ICT were adapted for group administration and incorporated in a program that also included training in applied relaxation. The IGCT contained 16 longer treatment sessions for a period of 3 weeks, 9 sessions in the first week (4.5 days = 23 h) and 7 sessions (3.5 days = 18 h) in the

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third week, followed by a booster session at 4, 8, and 12 months. TAU followed routine psychiatric practice. All patients were prescribed medication that was maintained for 12 months. The medication for 13 patients consisted of an antidepressant with indicated efficacy for social phobia in either randomized controlled trials (fluoxetine, paroxetine, sertraline, moclobemide) (Hood and Nutt, 2001; Blanco et al., 2003a,b) or open trials (citalopram) (Bouwer and Stein, 1998), whereas one patient received a benzodiazepine (oxazepam). Selective serotonin reuptake inhibitors were most common (11 patients). Daily doses were: fluoxetine (20–60 mg), paroxetine (20–40 mg), sertraline (50– 100 mg), moclobemide (600 mg) citalopram (20– 40 mg) and oxazepam (15 mg). Each psychiatrist decided the number of visits. 2.4. Measures 2.4.1. Personality The Temperament and Character Inventory (TCI) (Cloninger et al., 1993, 1994) is a 238-item, selfadministered, true–false questionnaire developed to assess seven dimensions of personality. It includes four basic dimensions of temperament: 1) Novelty Seeking (NS): To respond actively to novel stimuli (NS1 “Exploratory excitability”, NS2 “Impulsivity”, NS3 “Extravagance”, NS4 “Disorderliness”); 2) Harm Avoidance (HA): To respond intensively (behavioral inhibition) to signals of punishment or non-reward. (HA1 “Anticipatory worry”, HA2 “Fear of Uncertainty”, HA3 “Shyness with strangers”, HA4 “Fatigability”); 3) Reward Dependence (RD): To respond intensely to signals of reward and to maintain signals that have previously has been associated with reward is not an RD “Social attachment”, RD4 “Dependence”); 4) Persistence (P): To be persistent and hardworking, despite frustration and fatigue. Three dimensions of character are measured: 1) Self-directedness (SD): Self-determination and willpower, the ability to control, regulate and adapt one's behavior in order to achieve personal goals (SD1 “Responsibility”, SD2 “Purposeful”, SD3 “Resourcefulness”, SD4 “Self-acceptance”, SD5 “Congruent Second Nature”); 2) Cooperativeness (C): The tendency of identification with and acceptance of other individuals (C1 “Social tolerance”, C2 “Empathy”, C3 “Helpfulness”, C4 “Integrated Conscience”); 3) Self-Transcendence (ST): Acceptance of ambiguity and uncertainty, spiritual acceptance and identification with the wider world (ST1 “Self-forgetful”, ST2 “Transpersonal Identification”, ST3 “Spiritual acceptance”).

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2.4.2. Social phobia Patients completed standardized social phobia scales: the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1985; Fresco et al., 2001); the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) (Mattick and Clark, 1998). 2.4.3. Mood measure The Beck Depression Inventory (BDI) (Beck and Steer, 1984, 1995) was used to assess depressive mood. 2.5. Statistical analyses The analyses were based on all patients who completed diagnostic assessment and TCI measures at baseline and 1year follow-up. The TCI-scores were compared to those of healthy controls of the corresponding age group (Brändström et al., 1998). Differences between the groups' average scores were computed by independent sample t-tests. To avoid multiple testing, comparisons of subscales were only conducted if a significant result was obtained on the dimensional score of the TCI. The P-level was set to 0.05. To examine effects of treatments on the TCI scales (NS, HA, RD, P, SD, C, ST), we performed repeated measures ANOVA analyses (Time: pre-test and 1-year follow-up measure by Group: treatment conditions) with scores of the seven TCI scales as the dependent variables. Paired comparisons were conducted if a significant main or interaction effects were observed. One-way ANOVAs of baseline TCI-scores were performed in order to examine possible differences at baseline between treatments. The P-level was set to 0.05. The same procedures were used to compare TCI dimensions in responders and non-responders to treatment, i.e. one-way ANOVA analyses of baseline scores and repeated measures ANOVA (Time: baseline and 1-year follow-up by Group: responders and nonresponders) with scores of the seven TCI-dimensions as the dependent variables. Analyses of covariance (ANCOVA) were conducted with baseline scores as covariate when groups differed in baseline scores. Correlation analyses (Pearson r coefficient) of change scores of social phobia measures and TCI-scales were used to examine associations between reduced levels of social anxiety and scores of TCI-variables at the 1-year follow-up. 3. Results 3.1. Demographic and clinical characteristics Table 1 shows the demographic and clinical characteristics of the sample. The patients had 19.8 years of

duration of social phobia, 66% were suffering from generalized social phobia, 68% had avoidant personality disorder, and 80% had some personality disorder. The Axis-I lifetime co-morbid conditions were depressive disorder (25%), obsessive compulsive disorder (OCD) (10%), panic disorder (5%), anxiety disorder NOS (5%), eating disorder (5%), alcohol or substance abuse (2%), dysthymia (3%), specific phobia (5%), and generalized anxiety disorder (GAD) (5%). There were no differences between completers (59) and non-completers (41) in demographic and clinical characteristics, baseline TCI-scores, social phobia measures, and Beck Depression Inventory (Tables 1 and 2). Due to mistakes in data administration, baseline TCI was only available in 84 patients, 59 completers and 25 non-completers. 3.2. Baseline TCI dimensions in patients compared to a normative control group Patients differed significantly from controls on the temperament dimensions HA and NS and the character dimensions SD, C, and ST (Table 3). The difference between patients and controls was most pronounced in HA. Patients showed traits of pessimistic worry, anticipation of harm and failure, uncertainty in unfamiliar situations, shyness in most situations, and active Table 1 Demographic and clinical characteristics Demographic and clinical Patients characteristics (n = 59)

Noncompleters (n = 41)

Group effect χ2 (1)

Age, mean (S.D.) 34.9 (8.6) 34.2 (9.9) Women, n (%) 34 (58) 28 (68) Married/cohabiting, n (%) 25 (42) 24 (58) Higher education1, n (%) 28 (47) 15 (37) Occupation, n (%) Employed 41 (69) 25 (61) Unemployed 4 (7) 4 (10) Students 10 (17) 9 (22) Sick list 4 (7) 3 (7) Age of onset, mean (S.D.) 15.1 (7.2) 15.9 (7.4) Duration of social phobia 19.8 (10.4) 18.7 (11.9) years, mean (S.D.) Axis I co-morbidity n (%) 24 (41) 21 (51) Generalized social phobia 39 (66) 24 (59) n (%) Avoidant personality 40 (68) 25 (61) disorder, n (%) Any personality disorder, 47 (80) 36 (87) n (%) 1

Higher education = University/University College.

F (1,98) 0.13

1.2 2.5 1.2 0.78 0.29 0.39 0.01 0.30 0.22 1.1 0.59 0.49 1.1

E. Mörtberg et al. / Psychiatry Research 152 (2007) 81–90 Table 2 Baseline scores of TCI-scales, social phobia measures, and Beck Depression Inventory in completers (n = 59) and non-completers (n = 41) Measures

Novelty seeking (NS) Harm avoidance (HA) Reward dependence (RD) Persistence (P) Self-directedness (SD) Cooperativeness (C) Self-transcendence (ST) Liebowitz Social Anxiety Scale (LSAS) Social Performance Scale (SPS) Social Interaction Anxiety Scale (SIAS) Beck Depression Inventory (BDI)

Completers

Noncompleters

Group effect

Mean (S.D.)

Mean (S.D.)

1

20.0 (5.7) 24.9 (4.1) 15.5 (3.1) 4.1 (2.0) 24.6 (7.7) 31.2 (4.3) 7.5 (4.7) 74.8 (22.3)

18.8 (6.1) 24.8 (5.9) 14.2 (3.0) 4.3 (1.8) 24.4 (7.7) 31.2 (4.7) 9.7 (6.3) 72.2 (22.7)

0.75 0.01 2.9 0.12 0.01 0.00 3.2 0.31

37.8 (13.4)

35.3 (14.1)

0.74

48.6 (15.5)

45.8 (15.6)

0.75

11.5 (8.7)

14.2 (8.4)

2.7

F(1,82), F(1,98)

1

Due to mistakes in data administration, baseline TCI was only available in 84 patients, 59 completers, and 25 non-completers.

avoidance of meeting strangers. The differences in NS was significant but moderate (P b 0.05), indicating that patients compared to controls show less need for novel stimulation and tend to be reserved. Patients and controls did not differ in traits of responding intensely to signals of reward and maintaining signals associated with reward (RD) or in the ability of being persistent despite fatigue (P). The low score of the character trait SD reflects less developed personal capacities of self-determination and of the ability to control, regulate and adapt one's behavior. The low score of C indicates less identification with and acceptance of other individuals and the low ST a tendency of not tolerating ambiguity and uncertainty and instead striving for control. 3.3. Effects of treatments Table 4 shows the changes in personality patterns and social phobia and depressive symptoms following treatments. There were no significant baseline differences between treatment conditions (ICT, IGCT, TAU) in any of the baseline TCI-variables or measures of social phobia and depression. The statistical analyses indicated that patients had reduced the levels of HA at the 1-year follow-up (main effect of Time) but there were no effect of treatment group or any interaction effect (Time by Group)

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(Table 4). In addition, analyses of RD revealed a significant but moderate (P b 0.05) interaction effect of Time by Group. Paired comparisons showed a difference between ICT and TAU (P b 0.01) indicating that patients in TAU reduced RD scores, while patients in ICT did not. Moreover, analyses of SD showed a significant effect of Time and a Time by Group interaction effect but no single effect of treatment condition was indicated. Paired comparisons showed that the TAU group differed significantly from the psychotherapy groups (ICT (P = 0.001) and IGCT (P = 0.02)) who both improved SD scores from the baseline to 1 year, which was not the case in the TAU group. There were no significant changes in any other temperament or character dimension. Although patients overall, showed significant changes in HA and SD, they still deviated from the control population (HA: t = 11.7 P b 0.001, SD: t = 3.2 P b 0.01). However, NS was normalized after treatment. Patients' symptoms of social phobia anxiety and avoidance (LSAS, SPS, SIAS) as well as depressive symptoms (BDI) were significantly reduced following treatments (main effect of Time). Planned comparisons of the Time by Group interaction effect indicated by the LSAS scores, showed that ICT was superior to TAU (P = 0.002). In order to examine whether pre-treatment depressive symptoms would have an impact of TCI and social phobia measures, ANCOVA repeated measures of HA, SD, LSAS, SPS (pre- and post-test) were performed with pre-treatment scores of BDI as covariate. These Table 3 The Temperament and Character Inventory (TCI) in patients and controls Group effect 3 t(P)

TCI variables

Patients (n = 59)1

Controls (n =400)2

Novelty seeking (NS) Harm avoidance (HA) Reward dependence (RD) Persistence (P) Self-directedness (SD) Cooperativeness (C) Self-transcendence (ST)

20.0 (5.6)

21.9 (6.0)

2.4 ⁎

24.9 (4.1)

13.4 (6.3)

18.6 ⁎⁎⁎

15.5 (3.1)

15.3 (3.8)

4.1 (2.0) 24.6 (7.7)

4.2 (2.0) 31.1(6.9)

0.4 6.1 ⁎⁎⁎

31.2 (4.3) 7.5 (4.7)

33.1(5.2) 11.7 (5.4)

3.1 ⁎⁎ 6.3 ⁎⁎⁎

1

0.8

There were available TCI baseline measures in 84 patients who showed an almost identical TCI-profile compared to these 59 patients with the exception of NS (t = 3.1 P b 0.01). 2 The normative scores of the age group 20–35 years (n=400) were used for comparison in this study. Comparison with age group 40–55 years yielded essentially similar results. 3 P b 0.05 = ⁎ P b 0.01 = ⁎⁎ P b 0.001 = ⁎⁎⁎.

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Table 4 Changes of temperament and character dimensions and social phobia and depressive symptoms following treatments (n = 59) TCI-dimensions

Baseline

1 year

Repeated measures ANOVA 1

F(1, 56), 2F(2, 56)

Novelty Seeking (NS) Harm avoidance (HA) Reward dependence (RD) Persistence (P) Self-directedness (SD) Cooperativeness (C) Self-transcendence (ST) Liebowitz Social Anxiety Scale (LSAS) Social Phobia Scale (SPS) Social Interaction Anxiety Scale (SIAS) Beck Depression Inventory (BDI)

20.0 (5.6) 24.9 (4.1) 15.5 (3.1) 4.1 (2.0) 24.6 (7.7) 31.2 (4.3) 7.5 (4.7) 74.8 (22.3) 37.8 (13.4) 48.6 (15.5) 11.5 (8.7)

20.5 (6.1) 22.6 (5.4) 15.4 (2.9) 3.7 (1.8) 27.6 (8.0) 31.7 (4.0) 7.2 (4.4) 42.8 (23.0) 20.3 (14.1) 31.3 (16.9) 6.6 (7.1)

Time1

Group2

Time⁎Group2

1.5 17.4 ⁎⁎⁎ 0.8 3.7 20.5⁎⁎⁎ 0.9 0.3 79.2⁎⁎⁎ 86.6⁎⁎⁎ 89.9⁎⁎⁎ 23.3⁎⁎⁎

0.3 0.8 0.1 1.1 0.4 0.3 0.2 0.3 0.3 0.3 1.2

0.3 0.9 3.9⁎ 0.9 5.9⁎⁎ 1.2 0.1 5.3⁎⁎ 2.2 2.2 2.7

One-way ANOVA of baseline TCI-scores indicated no differences between ICT, IGCT and TAU (F(2,56) = 0.1 (NS); 1.4 (HA); 0.4 (RD); 1.1 (P); 0.01 (SD); 0.3 (C); 0.2 (ST); 1.56 (LSAS); 0.18 (SPS); 0.93 (SIAS); 0.16 (BDI). P b 0.05 = ⁎ P b 0.01 = ⁎⁎ P b 0.001 = ⁎⁎⁎.

treatment. The Liebowitz Social Anxiety Scale (LSAS) was reduced by 54% in responders and by 24% in nonresponders at the 1-year follow-up. There was no significant difference (χ2 (2) = 0.1 P = 0.94) between treatment conditions in the distribution of non-responders and responders (ICT: 67%, IGCT: 62%, TAU: 64%). One-way ANOVA of baseline TCI-measures indicated significant differences between responders and non-responders in HA (F(1,57) = 6.6 P b 0.01) and SD (F(1,57) = 4.1 P b 0.05) showing that non-responders had elevated scores of HA and lower scores of SD from the start. The groups did not differ in any other TCIdimensions. The repeated measures of variance analyses (ANOVA) of HA showed significant effects of Time (F(1,57) = 14.9 P b 0.001), Group (F(1,57) = 14.0 P b 0.001) and an interaction effect of Time by Group (F(1,57) = 6.9 P b 0.01). Paired comparisons showed that only responders had decreased in HA (P b 0.001) at 1-year follow-up, while non-responders remained unchanged. Further

analyses did not differ from the results presented in Table 4. 3.4. Correlations of change scores of social phobia measures, BDI and TCI-scales In order to examine to what extent reduction of social anxiety was related to changes of TCI-scales, correlation analyses of the change scores of the social phobia measures and the change score of each of the TCI-scales were performed (Table 5). The results showed that reduced social anxiety as indicated by the LSAS, the SPS, and the SIAS was significantly correlated to decreased scores of HA and increased scores of SD. In addition, the reduction of BDI-scores was significantly correlated to increase in NS, RD, and SD, and reduction in HA. 3.5. Responders and non-responders to treatment Thirty-eight patients were classified as responders and 21 patients were classified as non-responders to

Table 5 Correlations of change scores of social phobia measures, BDI and TCI-scales Measures

NS

HA

RD

P

SD

C

ST

LSAS

SPS

SIAS

LSAS SPS SIAS BDI

0.02 0.06 0.12 − 0.27⁎

0.38⁎⁎ 0.40⁎⁎ 0.44⁎⁎ 0.26⁎

0.00 0.06 0.13 − 0.29⁎

0.13 0.21 0.02 0.06

− 0.42⁎⁎ − 0.34⁎⁎ − 0.25 − 0.46⁎⁎

0.08 − 0.06 − 0.01 − 0.06

0.07 − 0.03 − 0.00 − 0.20

0.68⁎⁎ 0.66⁎⁎ 0.44⁎⁎

0.78⁎⁎ 0.34⁎⁎

0.25

NS = Novelty seeking; HA = Harm avoidance; RD = Reward dependence; P = Persistence; SD = Self-directedness; C = Cooperativeness; ST = Selftranscendence; LSAS = Liebowitz Social Phobia Scale; SPS = Social Performance Scale; SIAS = Social Interaction Anxiety Scale; BDI = Beck Depression Inventory. P b 0.05 = ⁎ P b 0.01 = ⁎⁎.

E. Mörtberg et al. / Psychiatry Research 152 (2007) 81–90

Fig. 1. TCI pattern at 1-year follow-up in responders, non-responders and healthy controls.

analyses of HA subscales showed that the differences were evident in “Anticipatory Worry” (P b 0.05), “Fear of uncertainty” (P b 0.01), and Shyness of strangers” (P b 0.01). Additionally, analyses of SD showed significant effects of Time (F(1,57) = 21.8 P b 0.01) and Group (F(1,57) = P b 0.05) but no interaction effect. Paired comparisons showed that both responders (P b 0.001) and non-responders (P b 0.01) improved in SD during the period.1 The analyses of NS, RD, C, and SD did not show any significant main or interaction effects. When comparing responders to controls, HA remained high (P b 0.001) in contrast to SD, which was in the normal range after treatment. Fig. 1 shows the TCI-patterns in responders and non-responders at the 1year follow-up. The dotted line represents the control group. 4. Discussion The temperament and character patterns in 59 patients were examined before and after treatments with psychotherapy or medication. Although patients were recruited by advertisement they appear representative for a clinical population of social phobia considering the severity and duration of social phobia as well as proportion of comorbid disorders presented. The study replicated previous consistent findings of dysfunctional personality patterns in social phobia i.e. high HA, low SD and C. Elevated HA is associated with the DSM-IV cluster C (fearful) and low SD and C are

1 The results of analyses of HA and SD remained when the baseline differences were controlled in ANCOVA with baseline measure as covariate.

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indicated to be predictors of personality disorders in general (Svrakic et al., 1993), which most likely is reflected in our sample containing 68% of patients with avoidant personality disorder and 80% with some personality disorder. Some inconsistencies between studies might be expected due to differences in sample-size, co-morbidity, and personality disorders. We observed low ST, which is previously reported by Marteinsdottir et al. (2003) and Pelissolo et al. (2002). In addition, we found a moderate but significantly (P b 0.05) low NS, which might be less clinically relevant. Low NS, was previously observed by Chatterjee et al. (1997), who suggested that low NS reflects the patients inherent inability to enjoy exposure to novel social situations. However, an alternative explanation could be that reserved behaviors and avoidance of novel stimulation are safety behaviors, i.e. influenced by state dependent anxiety in social situations, which would be expected to normalize in the course of successful treatment. Consistent with our prediction we found that treatments overall improved HA, however, only psychotherapies were associated with improvement in SD. Svrakic et al. (2002) hypotheses that psychotherapy acts on character dimensions (such as SD), which are expected to change in the course of social learning and maturity, while medication acts to temporarily control extreme temperament traits (such as HA) (Svrakic et al., 2002), was not fully confirmed in this study. We did not find evidence that medication was superior in modifying the temperament trait HA. Our result is, however, consistent with a recent study of social phobia, showing that HA is responsive to psychological interventions, thus indicting a state dependent influence of HA (Hofmann and Loh, 2006). Despite the fact that only patients treated with psychotherapy improved SD, psychotherapy did not result in a higher percentage of responders compared to those treated with medication. Nevertheless, it might be expected that increased abilities to control, regulate and adjust behavior, a likely consequence of normalizing SD, would make the individual more prepared to handle the influence of a high HA and thus preventing future relapse. A follow-up study would be needed to examine this further. RD differed between TAU and ICT after treatment, but the difference was moderate and less clinically relevant in this sample, as patients scored within the range of a normal population at baseline. Moreover, the normalization of NS after treatment might be an unreliable finding, considering the weak difference to healthy controls at baseline. Replication is required.

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As predicted, we found that reduced levels of social anxiety was correlated with improvements in HA (decrease) and SD (increase). The result of HA is consistent with Hofmann et al. who report that HA is associated with self-report measures of social phobia and changes in social anxiety during the course of treatment (Hofmann and Loh, 2006). Moreover, reduced levels of depressive symptoms were related to reduced HA and increased SD, RD, and NS. This might be expected, considering that elevated HA seem to represent a common vulnerability trait in anxiety disorders and depressive states. Decrease in HA, is for example, shown to be a reliable predictor of response to antidepressant treatments in patients with a major depressive disorder and dysthymic disorder and besides HA, also RD and NS are correlated to response (Kelley Yost Abrams et al., 2004). Patients diagnosed with depression in our sample were, however, excluded. The means of BDI at the baseline and 1-year follow-up were, for example, in the non-clinical range. As even minor depressive symptoms may have an impact of TCI- and social phobia scores, data were reanalyzed controlling for pre-treatment depressive scores. The outcome of this procedure did however, not differ from the previous results. It is previously noted that reduced depressive symptoms are correlated to reduced scores in social phobia measures, which might be consistent with the view that the depressive symptoms observed in our patients are secondary to their social phobia (Clark et al., 2003; Mörtberg et al., in press). High baseline HA, and reduction in HA following antidepressant treatment are also demonstrated in patients with obsessive compulsive disorder (Lyoo et al., 2003), panic disorder (Starcevic et al., 1996), and generalized anxiety disorder (Starcevic et al., 1996; Allgulander et al., 1998). Similar to our study, patients remain, however, different from controls in HA after treatment. Additionally, TCI-predictors of personality disorder (SD and C) are shown to decline after medical treatment of generalized anxiety disorder (Allgulander et al., 1998) and in major depression (Black and Sheline, 1997). Lyoo et al. (2003) did however, not found that SD improved in patients with obsessive compulsive disorder (OCD) following a 4-month antidepressant and cognitive behavioral treatment (CBT). This finding could, according to the authors, implicate that psychotherapy in OCD patients must be of longer duration and be more intensive (Lyoo et al., 2003). As we administered TCI at 1-year follow-up it is unknown whether improvement in SD occurred earlier. However, substantial changes in this trait may be detected at follow-up rather than post-treatment, as patients need

time to practice and integrate new behaviors/attitudes in order to develop new adaptive patterns. A state dependent influence of symptoms on personality traits is suggested by the correlations between improvement of anxiety (and depressive symptoms) and improvement of personality traits. However, a reduced symptom level is probably crucial for a substantial/deeper improvement of personality function (e.g. coping skills), which might be necessary for achieving a clinically significant reduction of social anxiety. Independent of treatment condition, the outcome was differentiated only with regard to HA. Interestingly, nonresponders scored higher in HA and lower in SD at baseline, but improved in SD proportionally as much as responders. Nevertheless, as they in SD were more disabled from the start, they consequently were more disabled at the end in contrast to responders, who scored within the range of the normal population after treatment. Non-responders remained unchanged in HA, which might indicate that high baseline HA is a predictor of poor outcome, independent of treatment. Depressive patients (Kelley Yost Abrams et al., 2004) and patients with panic disorder, and obsessive compulsive disorder (Lyoo et al., 2003) who fail to respond to antidepressant treatments are shown to have generally higher HA scores before treatment and this might also be the case in patients suffering from social phobia. However, social phobia is highly related to comorbid conditions making it unclear whether HA, which is regarded as a general vulnerability trait to psychopathology, is uniquely associated with the social phobia syndrome or if it reflects the impact and profile of comorbid disorders presented. Marteinsdottir et al. (2003) found that patients with social phobia and concurrent avoidant personality disorder could only be distinguished on the dimensional level from those without such comorbidity by means of significantly higher scores on HA (Marteinsdottir et al., 2003). Pelissolo et al. (2002) showed that patients with social phobia with or without depressive disorder have a marked profile of TCI traits (high HA, low SD), however, patients with depression had higher HA and lower SD. Only HA was found to be main determinant of social anxiety severity, independent of depression (Pelissolo et al., 2002). Thus, it is probable that social phobia with comorbid conditions will be reflected by worse scores on the TCI (i.e. increased symptom severity), rather than a different basic TCIpattern. Our data indicate higher severity in nonresponders according to TCI, and preliminary data show that significantly more non-responders than responders exhibit lifetime comorbid disorders. According to Svrakic et al. (2002) individuals with high HA are

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at higher risk for personality disorder, however, extreme temperament traits are associated with personality disorder only when accompanied with low character traits (Svrakic et al., 2002). Using the Personality Trait Questionnaire (TPQ), Fahlén (1995) suggests that social phobia is probably characterized both by personality traits that are specific for the disorder, such as increased interpersonal sensitivity and avoidance, and by personality traits, such as depressed mood and general anxiousness, that are less specific and common in many anxiety and mood disorders. Pronounced levels of HA may suggest the presence of a more stable trait and treatment resistant disorder with stronger association, e.g. to comorbid conditions, early shyness, early behavioral inhibition, and an earlier onset of social phobia. Such a sub-group may benefit from individualized treatment approaches, treatments of longer duration and combined approaches of medication and psychotherapy. Further studies are required to examine the influence of elevated HA for treatment outcome in patients with social phobia. A limitation of this study is that the repeated TCI and diagnostic assessments were conducted only at 1-year follow-up. It would have been better if additional assessments had been obtained earlier, for example at an assessment point at 4 months i.e. closer to an end of treatment when fewer patients were lost to follow-up. It would also have permitted analyses of early and delayed patterns of personality changes. A potential bias when interpreting the results is that the analyses are based on a sub-group of 59 patients who completed 1-year followup assessments rather than all randomized patients (n = 100). The comparisons of clinical and demographic characteristics and baseline scores of the various assessments did however, not reveal any differences in severity between completers and non-completers. Acknowledgements This study was supported by grants from the Boethius Foundation, the Söderström-Königska Foundation, the Organon Foundation, the FOU (The Research and Development Centre) of the Stockholm County Council and the St Göran Psychiatric Clinic Foundation. References Abrams, K.Y., Yune, S.K., Kim, S.J., Jeong, H.J., Han, S.J., Hwang, J., Sung, Y.H., Lee, K.Y., Lyoo, K., 2004. Trait and state aspects of harm avoidance and its implication for treatment in major depressive disorder, dysthymic disorder, and depressive personality disorder. Psychiatry and Clinical Neurosciences 58, 240–248.

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