Multi-level prediction of short-term outcome of depression: non-verbal interpersonal processes, cognitions and personality traits
Introduction
Several authors have connected interpersonal theories of depression to cognitive theories of depression and to theories of the connection between personality traits and depression (e.g. Gotlib and Hammen, 1992, Poulton and Andrews, 1992, McCann and Lalonde, 1993, Clark et al., 1994). In the present study we attempt to find an empirical basis for these connections by investigating the interrelationship between variables in the interpersonal domain, the cognitive domain and the personality domain, and their relation with the short-term outcome of depression in severely depressed patients.
From the perspective of an interpersonal approach to depression (e.g. Coyne et al., 1990), substantial empirical evidence exists, indicating that interpersonal difficulties between depressed persons and their social environment, as well as lack of supportive behaviour from this environment, are related to an unfavourable course of depression (Hickie et al., 1991, Brown et al., 1994). Unsatisfactory interactions with fellow-men and rejecting behaviour towards depressed persons by them are considered to be important mechanisms underlying this relationship (Segrin and Dillard, 1992). Approximately 60% of human communication is non-verbal (Burgoon, 1985). It may therefore be expected that an ethological approach toward depressives' interactions with others may provide more insight into the role of interpersonal processes in the course of depression. And indeed, it has been demonstrated that high levels of depressed patients' non-verbal behaviour reflecting `involvement' and `support seeking' predict depression-persistence (Troisi et al., 1989, Bouhuys and Van den Hoofdakker, 1993, Geerts et al., 1995). Moreover, interviewers' non-verbal behaviour manifesting `support giving' is also associated with the course of depression (Bouhuys and Van den Hoofdakker, 1993, Geerts et al., 1995).
Experimental manipulations of the non-verbal `support giving behaviour' displayed by an interviewer have shown that the depressed patients' `non-verbal support seeking behaviour' is causally related to that `support giving behaviour': Patients attune the durations and the frequencies of elements of their non-verbal `support seeking behaviour' to the levels of an interviewer's non-verbal `support giving behaviour' (Geerts et al., 1997). In non-experimental interactions it has been shown that the time course of such attunement can predict the course of depression. The more patients and interviewers got attuned during a clinical interview, the more favourable the course of the depression turned out to be (Geerts et al., 1996Geerts et al., submitted). In normal persons, attunement of non-verbal behaviour during an interaction is related to interpersonal satisfaction (Cappella and Palmer, 1990). Therefore insufficient non-verbal attunement may be an important element in the mechanisms underlying the unsatisfactory interactions in depression and, thus, in the mechanisms underlying its course (Geerts et al., 1996Geerts et al., submitted).
Various studies link aspects of interpersonal processes to cognitive processes. In marital interactions it has been demonstrated that cognitive interpretations of the partner's behaviour determine to a large extent the behavioural responses to the partner's behaviour (Halford and Sanders, 1990). Furthermore, high levels of accurate processing of others' non-verbal behaviour are related to more meaningful and supportive relationships (Hodgins and Zuckerman, 1990). Moreover, people judge persons who are highly accurate in the processing of others' behaviour as more warm and sympathetic than those who are less accurate (Funder and Harris, 1986). With respect to the processing of social stimuli in depression, the cognitive theory of depression proposed by Beck et al. (1979)is of relevance. According to Beck's theory, depression is to be understood by a negative view of the self, of others and of the future (the `negative triad'). These negative distortions manifest themselves in particular in the interpretation of neutral or ambiguous stimuli. Several authors have demonstrated that depressed mood is associated with a tendency to interpret emotional stimuli negatively (see Hokanson et al., 1991, Bouhuys et al., 1995, Mathews and MacLeod, 1994for a review). Such negative interpretations of stimuli are expected to play a causal role in the onset and persistence of a depressive episode (Beck et al., 1979Teasdale and Dent, 1987). Hokanson et al. (1991)demonstrated in non-depressed college students that a relative overestimation of a roommate's hostility predicts the subsequent development of a depression in the roommate's partner. In contrast to Beck's model, Bouhuys et al. (1996)found that in depressed outpatients a negative interpretation of emotions in ambiguous schematic faces predicted a favourable course of depression. The results were interpreted as a sign of hyposensitivity to negative social stimuli in patients who did not improve. Such hyposensitivity to social stimuli in depression has also been observed in other studies (e.g. Gur et al., 1992). Bouhuys et al. (1996)suggested that a hyposensitivity to negative stimuli may have emerged in response to the rejecting behaviour displayed by fellow-men. Both the study by Hokanson et al. (1991)and that by Bouhuys et al. (1996)indicate that cognitions about others' behaviour may be involved in the development and maintenance of depression.
Also personality features are presumed to play a role in the relationship between interpersonal processes and the course of depression (Gotlib and Hammen, 1992). High Neuroticism (N) and low Extraversion (E) are known to be related to depression-persistence (N, see Clark et al., 1994for a review; E, see Clark et al., 1994, Bagby et al., 1995Geerts et al., submitted). It is assumed that N and E exert their effects on the course of depression via interpersonal events; high N subjects have been found to evoke negative interpersonal events and interpersonal distress (Ormel and Wohlfarth, 1991, Poulton and Andrews, 1992, Clark et al., 1994); subjects with low E have less satisfactory interactions (Clark et al., 1994). These relationships between N and E on the one hand and interpersonal processes on the other may be explained by cognitive processing of social stimuli; high N has been found to be related to negative interpretations of social and emotional stimuli (Martin, 1985, Teasdale and Dent, 1987) whereas extraverts are considered to be more sensitive to reward signals (Clark et al., 1994). For both N and E it has been experimentally shown that they are related to a subject's non-verbal responses to an interviewer's non-verbal behaviour (Wiens et al., 1980).
In summary, substantial empirical evidence points to the involvement of factors in different theoretical domains in the course of depression: the interpersonal, the cognitive and the personality domain. As already mentioned, each domain has been linked to each other domain theoretically and empirically. The present study aims to extend the investigation of the linkage between these domains. Specifically, the hypothesis is proposed that non-verbal interpersonal processes (in particular, attunement) and cognitions about non-verbal behaviour represent the link between personality (N, E) and the course of depression. This will be investigated by analysing possible moderating and mediating effects. By moderating effects, it is meant that personality influences the degree to which non-verbal interpersonal processes and cognitions about non-verbal behaviour are related to the short-term outcome of depression. In the case of mediating effects, interpersonal processes and cognitions can explain the way in which personality is related to the course of depression. An alternative possibility is that personality (N, E), cognitions about non-verbal behaviour, and non-verbal behavioural processes contribute independently to the prediction of the short-term outcome of depression.
Section snippets
Subjects and design
Subjects with a primary depression (DSM-IV, American Psychiatric Association, 1994) were recruited from the inpatient ward of the Psychiatric University Clinic of the Academic Hospital Groningen. Patients at age≥18 years were included in the study if they (i) had a score ≥16 on the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967); (ii) had not participated in our previous studies on the relationship between observable behaviour and the course of depression; and (iii) had given
Short-term outcome of depression
Table 2 presents the BDI scores on T1 and T2. The severity of depression significantly decreased over the experimental period (one-way ANOVA with repeated measures on time, F1,25=9.34, P=0.005). The BDI at T1 was not significantly correlated with the BDI at T2 (Pearson's r=0.27, P=0.182). There was no relationship between age and the short-term outcome of depression (partial r=−0.02, P=0.911). Also, the short-term outcome of depression did not differ between sexes (ANOVA, between groups with
Main results
In the present study we attempted to find an empirical link between three important domains that have been found to play a role in the course of depression (the domains of non-verbal interpersonal and cognitive processes and the personality domain). In particular, we investigated the hypothesis that non-verbal interpersonal behavioural processes and cognitions about non-verbal social stimuli link personality to short-term outcome of depression, either via mediating roles (i.e. the relationship
Acknowledgements
The authors are grateful to Louise Dols, Frederique van Nouhuys and Gythe Bulstra for their assistance in the assessment of the data and to Jantje Veen, Marijke Gordijn and Professor Rudy van den Hoofdakker for their valuable remarks on earlier drafts of the manuscript
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