Journal of the American Psychoanalytic Association

http://apa.sagepub.com/ Dependent and Self-Critical Depression: Evidence for Subtypes?

Stijn Vanheule, Mattias Desmet and Reitske Meganck J Am Psychoanal Assoc 2008 56: 1352 DOI: 10.1177/00030651080560042205 The online version of this article can be found at: http://apa.sagepub.com/content/56/4/1352

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DEPENDENT AND SELF-CRITICAL DEPRESSION: EVIDENCE FOR SUBTYPES?

Stijn Vanheule, Mattias Desmet, and Reitske Meganck (Ghent University, Belgium)
In psychiatric and clinical psychological literature much attention has been paid to subtyping the heterogeneous group of depressed patients. Perhaps best known are the dependent or sociotropic and the self-critical or autonomous subtypes of depression proposed by Sidney Blatt and Aaron Beck, derived from psychoanalytic and cognitive-behavioral theory. This poster concentrates on Blatts theory. From the 1970s on, Blatt formulated a theory that distinguishes the two subtypes (for an overview, see Blatt 1998, 2004). Dependent depressed patients are characterized by preoccupation with interpersonal issues such as trust, caring, intimacy, and sexuality; their depression is frequently triggered by object loss, and they often make suicidal gestures. Self-critical depressed patients are primarily preoccupied with establishing and maintaining a sense of self, issues of autonomy and control, and other- or self-directed aggression; the latter form of aggression is obvious in their focus on self-worth and failure and in their frequent serious suicide attempts. As Blatt (1998) notes, Introjective patients are more concerned with establishing, protecting and maintaining a viable selfconcept than they are about the quality of their interpersonal relations and achieving feelings of trust, warmth and affection (p. 731). The strengths of this theory are its clinical roots (i.e., psychoanalytic case studies that illustrate the clinical relevance of distinguishing the two subtypes) and the fact that the theory has engendered a line of empirical research. This research provides evidence that documents the validity of the distinction, and has led to insights into depression that are of interest to scholars and clinicians outside of psychoanalysis. The instrument Blatt developed to assess dependency and self-criticism is the Depressive Experiences Questionnaire (DEQ). His theory has also elicited criticisms, one of which we address in this posterthe assertion that Blatts categorical distinction between subtypes of depression is arbitrary (see Coyne and Whiffen 1995, pp. 360361). First we examined whether there is evidence to prefer a categorical distinction between latent clusters of patients with substantially divergent

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POSTER SUMMARIES

scores on the dependency (D-DEQ) and self-criticism (SC-DEQ) subscales of the DEQ over the assumption that the group of depressed patients we study is a homogeneous group in which members differ only in their degree of dependency and self-criticism. This question was studied by means of latent class analysis (LCA). Hypothesis 1: A latent cluster with strong dependency and low self-criticism and another with low dependency and strong self-criticism will be distinguished, and no subgroup with high scores on both dependency and self-criticism will present (such a group would contradict Blatts theory). Given our observation that it makes sense to differentiate between dependent and self-critical depressed patients, we subsequently studied the validity of our latent classes. First we examined whether these patients differ with respect to self-reported interpersonal problems. A second hypothesis is that given self-critical patients other-directed aggression and their lower concerns about the quality of relationships, more interpersonal problems would be reported than in the other cluster. The 64-item Inventory of Interpersonal Problems (IIP-64) was used to assess eight dimensions of interpersonal problems: domineering/controlling, vindictive/self-centered, cold/distant, socially inhibited, non-assertive, overly accommodating, self-sacrificing, and intrusive/needy. Self-critical patients were hypothesized to have elevated scores on the first three subscales, whereas dependent patients were hypothesized to report fewer interpersonal problems. Next we studied transcripts of an unstructured clinical interview with a male dependent patient and with a female self-critical patient, both randomly selected. Hypothesis 3: The dependent patient would be concerned mainly with dependent themes, rather than with self-critical ones; the reverse for the self-critical patient.
Method

Subjects. The sample consisted of 134 adult outpatients (74% females) from thirty Belgian mental health care centers. After written informed consent was obtained, 404 patients filled out questionnaires (response rate: 72%), of whom 134 met our inclusion criteria for this study: their treating psychiatrist gave a DSM-IV diagnosis of Mood Disorder, and they had a score on the Beck Depression Inventory-II that indicates mild to severe depression.

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Data analysis. Latent class cluster analysis (hypothesis 1) was performed by means of Latent Gold 3.0.6. Cluster-solutions were compared based on the Bayesian Information Criterion (BIC) and Akaikes Information Criterion (AIC). The BIC tends to select the most parsimonious model and the AIC the best explanatory model. The lower the values for the AIC and the BIC, the better the model. Hypothesis 2 was tested by means of independent sample t tests. Hypothesis 3 was tested by means of clinical content analysis. Transcripts of both unstructured clinical interviews were presented to two clinical psychologists (blind to the cluster solution) who were asked to judge whether the patient at hand was preoccupied by any of nine themes that refer to either dependent or selfcritical pathology.
Results

First we performed five LCAs with scores on the D-DEQ and the SC-DEQ as our indicators: 1-cluster: BIC = 692.98, AIC = 681.39; 2-cluster: BIC = 701.50, AIC = 675.42; 3-cluster: BIC = 705.87, AIC = 665.30; 4-cluster: BIC = 720.16, AIC = 665.10; 5-cluster: 742.27, AIC = 672.72. The BIC selected the 1-cluster solution, whereas the AIC selected the 4-cluster solution. The 4-cluster solution discerned a substantial group (cluster 1; n = 114) with moderate scores on the D-DEQ (M = .43) and the SC-DEQ (M = .83), a group (cluster 2; n = 7) with low scores on the D-DEQ (M = .83) and the SC-DEQ (M = .47), a group (cluster 3; n = 8) with high D-DEQ scores (M = 1.82) and low SC-DEQ scores (M = .51), and a group (cluster 4; n = 5) with low D-DEQ scores (M = 1.19) and high SC-DEQ scores (M = 2.10) (see Figure 1). All latent clusters differed significantly in their D-DEQ scores (Wald = 130.32, p < .001) and SC-DEQ (Wald = 74.12, p < .001). The clusters in this solution are completely in line with hypothesis 1, but the dependent and self-critical clusters are small compared to the moderately scoring one. Probably this is why the BIC indicated that it is better to make no categorical distinctions between depressed patients. We further concentrated on the 4-cluster solution, which is the best explanatory one, and study its relevance. T tests were performed that compared the latent clusters in their scores on the IIP-64 subscales. Clusters 3 and 4 differed significantly at the .01 level for the subscales domineering/controlling, vindictive/self-centered, and cold/distant, with higher scores for cluster 4. Clusters 3 and 1 differed significantly at the .05 level for the subscales domineering/controlling,

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Figure 1 4-cluster solution of latent class cluster analysis on the D-DEQ and the SC-DEQ
1,0

0,8

0,6

0,4

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0,0 DEPEND 0-1 Mean Cluster1 Cluster3 SC 0-1 Mean Cluster2 Cluster4

vindictive/self-centered, cold/distant, and intrusive/needy, with higher scores for cluster 1. Clusters 3 and 2 differed significantly at the .05 level for the subscales non-assertive, overly accommodating, and self-sacrificing, with higher scores for cluster 2. Clusters 4 and 1 differed significantly at the .05 level for the subscale vindictive/self-centered, and there was a trend ( p = .08) that both groups differed on the cold/distant subscale, each time with higher scores for cluster 4. Clusters 4 and 2 differed significantly at the .05 level on all IIP-64 subscales except intrusive/needy, with higher scores for cluster 4. Table 1 presents the results of the clinical content analysis. Both raters agreed that the self-critical patient (female) was preoccupied by typical self-critical themes such as 4, 5, 7, and 8. In her stories about previous relationships they noticed some concern about theme 2, but this was no longer true for current relationships. The patient told about self-mutilation and suicidal acts (theme 9), but the latter were gestures rather than serious attempts. There were no indications for preoccupation with theme 3. Only in story lines about her history of abuse were concerns about protecting the self obvious. With respect to the dependent patient (male), clear preoccupation with dependent themes such as 1, 2, and 6 was present. Theme 5 was not present in the story lines, nor was a self-critical theme.
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Table 1. Dependent and self-critical themes in an interview with two patients

Theme 1. Concern about quality of relationship 2. Striving for trust, warmth, affection in relationship 3. Establishing, protecting, and maintaining a viable self-concept in relationship 4. Concern about autonomy and control in relationship 5. Suicidal gestures 6. Object loss 7. Other-directed aggression 8. Self-directed aggression: self-worth and failure 9. Self-directed aggression: self-mutilation, suicide attempts Type of theme Dependent Dependent Self-critical Self-critical Dependent Dependent Self-critical Self-critical Self-critical Self-critical Dependent patient patient O O O X X O X X X X X O O O X O O O

Conclusion

Latent class analysis was performed on DEQ data. The AIC selected a 4-cluster solution that is in line with hypothesis 1. Next we hypothesized (hypothesis 2) that the subgroups would differ with respect to selfreported interpersonal problems. We expected that self-critical patients would report more interpersonal problems than any other subgroup, and that they would be more domineering, self-centered, and distant. Dependent patients were expected to report fewer interpersonal problems than any other subgroup. The t tests indicate that these expectations were justified, suggesting that the distinction between the subgroups of depressed patients is valid. In line with hypothesis 3, content analysis of an interview with two patients indicated that the dependent patient is clearly concerned about dependent themes, but not with self-critical themes or suicide; the reverse is true for the self-critical patient. However, this patients suicidal acts were gestures rather than attempts, and preoccupation with the self-concept in relationships was not apparent.
REFERENCES

BLATT, S.J. (1998). Contributions of psychoanalysis to the understanding and treatment of depression. Journal of the American Psychoanalytic Association 46:723752.

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(2004). Experiences of Depression: Theoretical, Clinical, and Research Perspectives. Washington, DC: American Psychological Association. COYNE, J.C., & WHIFFEN, V.E. (1995). Issues in personality as diathesis for depression: The case of sociotropy-dependency and autonomy-self-criticism. Psychological Bulletin 118:358378.
Stijn Vanheule Department of Psychoanalysis and Clinical Consulting Ghent University H. Dunantlan 2 B-9000 Ghent BELGIUM E-mail: stijn.vanheule@ugent.be

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