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The study investigated if the degree of personality pathology among people with
clinical levels of social anxiety disorder was similar to those with personality disor-
ders more generally, if the degree of avoidant personality pathology was correlated
positively with Neuroticism and negatively with Extraversion and facets of
Agreeableness (particularly Trust), and finally if scores on the relevant personality
dimensions improve from pre- to post-treatment. Changes in Neuroticism,
Extraversion, and Agreeableness were examined following group treatment for
social anxiety disorder. The current study employed a within-subjects repeated-
measures design (N = 25) to investigate whether these traits can be changed by
group treatment for social anxiety disorder. A measure of personality disorder
pathology was found to correlate positively with Neuroticism and negatively with
Agreeableness in the absence of significant relationships with other Five-Factor
Model traits. Treatment was associated with significant reductions in Neuroticism
and there was significant improvement of the Trust facet of Agreeableness. These
results are discussed in terms of the way that group treatment for Social Anxiety
Disorder may be enhanced.
Address for correspondence: Andrew Page PhD, School of Psychology, University of Western Australia,
35 Stirling Highway, Crawley WA 6009, Australia. E-mail: andrew@psy.uwa.edu.au
and fear of negative evaluation would be consistent with a preference for solitary
pursuits. More surprisingly, the authors also observed that people with avoidant per-
sonality disorder exhibited low Agreeableness.
Low Agreeableness is less unexpected in the context of the broader literature on
personality disorders. A meta-analysis (Saulsman & Page, 2004) showed that when
personality disorders are mapped onto a two-dimensional space defined by
Neuroticism and Agreeableness, each disorder demonstrates a moderate positive
relationship with Neuroticism and a moderate negative relationship with
Agreeableness. The antagonism, or low end of the Agreeableness continuum, is
characterised by cynicism, rudeness, abrasiveness, suspiciousness, uncooperative-
ness, irritability and manipulative, vengeful and ruthless behaviour (Costa &
Widiger, 2002). Although these traits seem atypical of people with social anxiety
and avoidant personality disorders, there is one facet of Agreeableness that might
explain the covariation. This facet is Trust. Trust is the tendency to attribute benev-
olent intent to others and an absence of the suspicion that others are dishonest or
dangerous, and it is not unreasonable to expect that people with a high fear of nega-
tive evaluation who also lack trust would become particularly anxious in social set-
tings. Consistent with this impression Wilberg, Urnes, Friis, Pedersen, and Karterud
(1999) found that avoidant personality disorder is associated with low Trust.
Likewise, while people with social anxiety disorder possess average levels of
Agreeableness (Bienvenu, Nestadt, Samuels, Costa, Howard, & Eaton, 2001) at the
facet level, Trust is in the low range. Therefore, to the extent that people with social
anxiety disorder show similar profiles to those with personality disorders, it is impor-
tant to determine the extent to which treatment reduces the personality features
because these traits can reflect a vulnerability to future psychopathology (e.g.,
Andrews, Page, & Neilson, 1993).
Neuroticism is modifiable using cognitive behavioural treatment methods.
Reductions in Neuroticism of around 1.25 standard deviation units (Jorm, 1989)
occur following cognitive behaviour therapy. Extraversion also can improve follow-
ing treatment (Santor, Bagby, & Joffe, 1997). Thus, despite personality traits being
defined as stable and enduring in nature, personality assessments do reflect changes
in personality traits following treatment. Given that treatment-related changes in
Neuroticism and Extraversion occur, the next issue is whether change in
Agreeableness can occur in therapy.
Three studies speak to the modifiability of Agreeableness. Trull, Useda, Costa,
and McCrae (1995) observed a reduction in Neuroticism and an increase in
Agreeableness after outpatient treatment for a range of psychological disorders.
Piedmont and Ciarrocchi (1999) found a reduction in Neuroticism and increases in
Extraversion, Openness to experience, Conscientiousness and Agreeableness (par-
ticularly on the facet of Trust) over a 6-week outpatient drug rehabilitation program.
In contrast, Carter et al. (2001) found no change in Agreeableness among opioid-
dependent outpatients and only small but significant decreases in Neuroticism and
43
increases in Extraversion and Conscientiousness. Thus, it remains unclear whether
Agreeableness can be altered by therapy and, more specifically, can these occur in
the context of social anxiety disorder? Cognitive–behavioural group therapy for
social anxiety disorder includes treatment components designed to reduce physical
anxiety symptoms and fear of negative evaluation. Furthermore, although cognitive
behavioural treatments for social anxiety disorder (e.g., Andrews, Creamer, Crino,
Hunt, Lampe, & Page, 2003) do not explicitly address deficits in Agreeableness,
Behaviour Change
Krystyna Glinski and Andrew C. Page
they include explicit training in social skills and assertiveness designed to improve
interpersonal relations. The group context also provides a forum within which trust
may be developed as participants are involved with other people during treatment
and therefore improvements in Agreeableness and Trust seem possible.
Thus, the present study asked first, is degree of personality pathology among
people with clinical levels of social anxiety disorder similar to those with personality
disorders more generally? Second, is degree of avoidant personality pathology corre-
lated positively with Neuroticism and negatively with Extraversion and facets of
Agreeableness (particularly Trust)? Third, do scores on the relevant personality
dimensions improve from pre- to post-treatment?
Method
Participants
Twenty-nine participants were recruited from three social anxiety disorder treat-
ment groups, each lasting 9 weeks (2 hours per week). Participants with comorbid
problems, such as depression, panic disorder, agoraphobia, and alcohol dependence
were included in the treatment groups only if these problems were considered sec-
ondary to the person’s social anxiety disorder and not sufficiently severe to warrant
treatment prior to attending the group. They completed an assessment interview
with one of five clinicians who established that they met DSM-IV (American
Psychiatric Association, 2003) diagnostic criteria for social anxiety disorder (27
were classified as generalised subtype). Seven participants (29%) also met diagnostic
criteria for avoidant personality disorder. Four participants did not complete the
treatment program and thus did not provide post-treatment data (and data from
another participant were excluded due to extreme outlying data points). On aver-
age, the treatment completers attended eight of the nine scheduled therapy sessions.
Of the treatment completers, 40% were female and they had a mean age of 37.2
years (SD = 13.2; range 19 to 62).
Materials
The Social Phobia module of the Anxiety Disorders Interview Schedule for DSM-
IV (ADIS-IV; Brown, Di Nardo, & Barlow, 1994) was used to determine whether
participants met diagnostic criteria for Social Anxiety Disorder. This measure is a
valid and reliable (Brown, Di Nardo, Lehman, & Campbell, 2001) method of deter-
mining the presence of an anxiety disorder.
The Avoidant Personality Disorder Module of the Structured Clinical Interview
for DSM-IV Axis II Personality Disorders (SCID-II; First, Spitzer, Gibbon, &
Williams, 1997), which is recognised for high levels of validity and reliability, was
used to assess the presence of avoidant personality disorder.
The PDQ-4+ (Personality Diagnostic Questionnaire — 4+; Hyler, 2003) is a 99-
item true/false self-report measure that assesses the 10 DSM-IV personality disor-
44 ders. It also provides an index of the overall level of personality disturbance. In spite
of some doubt about the reliability of the PDQ-4+ for diagnosing the 10 DSM-IV
personality disorders in the absence of supplementary clinical information, the
PDQ-4+ is a useful and valid measure of degree of general personality pathology and is
recommended for use in research as a continuous variable (Hyler, 2003). Each par-
ticipant’s degree of avoidance was calculated by summing the seven avoidant person-
ality disorder-related items to which they responded true.
Behaviour Change
Modifiability of Neuroticism, Extraversion, and Agreeableness
Procedure
Participants self-referred to join one of the regular Social Anxiety Disorder treat-
ment groups. Clinicians were postgraduate clinical psychology trainees under super-
vision of the second author. They conducted an individual assessment interview
with each participant. During the interview, the Social Phobia module of the
ADIS-IV and the Avoidant Personality Disorder module of the SCID-II were
administered to ascertain whether each participant met criteria for social phobia
and/or avoidant personality disorder. Assessment outcomes were reviewed in clini-
cal supervision to confirm diagnoses. Following the assessment, each potential par-
45
ticipant was invited to participate in the current research project and given the
questionnaire package to complete prior to the first group treatment session. At the
end of the treatment program the questionnaire package was readministered.
The Social Anxiety Disorder group treatment used a manual-based program
(Andrews et al., 2003). Initially, participants were provided with psychoeducation
about anxiety and taught controlled breathing and relaxation strategies to assist
anxiety management. The cognitive model of social anxiety and the role of think-
Behaviour Change
Krystyna Glinski and Andrew C. Page
ing were then addressed. Participants were taught to monitor and challenge their
unhelpful thinking to reduce anxiety. These strategies were incorporated into
graded exposure to feared interpersonal situations in order to reduce avoidance and
provide effective anxiety management experiences. The final module incorporated
social skills training, development of conversation skills and assertiveness training.
Participants were encouraged to tailor these techniques to their own needs and this
process was facilitated through regular between-session tasks.
Results
Pre-Treatment Analyses
The mean scores on the four Social Anxiety Disorder measures (Table 1) confirmed
that the current participant sample exhibited clinical levels of Social Anxiety
Disorder symptoms. The distributions of scores on the FNE scale and SADS exhib-
ited ceiling effects and therefore a composite Social Phobia Index (SPIndex) was
created by calculating the mean of the z scores for each of the measures. The result-
ing index did not possess a ceiling effect.
Scores on the measure of general personality disorder pathology (PDQ-4+)
ranged from 20 to 63 and had a mean of 39.25 (SD = 12.11). This is in the original
authors’ patients in therapy without a significant personality disturbance range (Hyler,
2003), but is above the cut-off of 28–29 suggested in other studies (e.g., Fossati et
al., 1998) to indicate a substantial likelihood of significant personality disturbance. Thus,
the current sample reported a range of personality disorder pathology characteristics
consistent with what might be expected for a treatment-seeking social anxiety disor-
der sample with some degree (29%) of comorbidity with avoidant personality disor-
TABLE 1
Pre- and Post-Treatment Means (Standard Deviation in parentheses) for Measures
of Social Anxiety and the NEO Personality Scores
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Modifiability of Neuroticism, Extraversion, and Agreeableness
TABLE 2
Intercorrelations Between PDQ-4+, Avoidance, SPIndex, Measures of FFM Personality
Dimensions and the Facet of Trust Among 24 People with Social Anxiety Disorder
Behaviour Change
Krystyna Glinski and Andrew C. Page
a) b)
Correlation
0
(Avoidance Current Study)
0
-0.2 -0.2
-0.4 -0.4
-0.6 -0.6
N E O A C N E O A C
Five Factor Model Personality Traits Five Factor Model Personality Traits
FIGURE 1
Comparison of correlations between FFM traits and (a) general personality disorder and
(b) avoidant personality disorder pathology between the current study and the meta-anal-
ysis by Saulsman and Page (2004).
disorders. It is noteworthy that social anxiety disorder symptoms did not correlate
significantly with the personality disorder pathology measure (Rho = .20, p =.35)
and that the presence of social anxiety disorder symptoms was correlated positively
with Neuroticism and negatively with Extraversion, but not with Agreeableness or
Trust. Thus, the personality factors associated with personality disorder pathology
show a different pattern from those associated with social anxiety disorder symp-
tomatology, even within the same sample.
In Figure 1b the mean correlations between the FFM traits and avoidance (the
measure of avoidant personality disorder pathology) are contrasted with the mean cor-
relations reported by Saulsman and Page (2004). Avoidant personality disorder
pathology has a positive relationship with Neuroticism and a strong negative relation-
ship with Extraversion. A negative relationship with Agreeableness was also present.
To determine the extent to which variability in personality disorder pathology
could be accounted for by the factors of Neuroticism and Agreeableness, but not by
Extraversion, Openness to experience and Conscientiousness, a hierarchical multiple
regression was conducted. In the first step gender, Neuroticism and Agreeableness
were entered as predictors simultaneously as one block and in the second step
Extraversion, Openness to Experience and Conscientiousness were entered simultane-
ously as one block (Pedhazur, 1997). In terms of the prediction of PDQ-4+ scores, step
one accounted for 41% of variance (R = .64, R2 = .41, F(3, 20) = 4.64, p = .01) and
both Neuroticism (β = .46) and Agreeableness (β = –.43) emerged as significant pre-
dictors. Consistent with Saulsman and Page (2004), step two did not account for
additional variance (F change (3,17) = .91, p = .46; ΔR2 = .08).
48
Post-Treatment Analyses
A repeated-measures multivariate analysis of variance (MANOVA) was compared
pre and post treatment scores on the four dependent variables: SPIndex, depression
(BDI), assertiveness discomfort (GRAI-DAI) and assertiveness response probability
(GRAI-RP). Significant differences were found between the two time-points on the
dependent measures, Wilks’s Λ = .20, F(4,17) = 17.51, p < .01. The multivariate η2
Behaviour Change
Modifiability of Neuroticism, Extraversion, and Agreeableness
based on Wilks’s Λ was strong, .81. There were significant improvements in social
anxiety disorder symptoms, F(1,20) = 71.02, p < .001, assertiveness discomfort,
F(1,20 = 42.34, p < .001, assertiveness probability, F(1,20) = 23.51, p < .001, and
depression, F(1,20 = 18.84, p < .001. Significant reductions were observed on the
SPIndex from pre- to post-treatment and an inspection of change on the FNE and
SADS indicated that, on average, participants’ symptoms improved significantly in
treatment. On the FNE, the participants’ mean score reduced from 26.83 to 16.67
which, when compared to norms on the measure, indicates a reduction in symptoms
from the clinical social anxiety disorder range to the range reported by a college stu-
dent sample (Watson & Friend, 1969). Similarly, on the SADS, compared to pub-
lished norms, participants moved from the social anxiety disorder range into the
range reported by college student samples.
On the assertiveness measures, the current sample’s pre-treatment scores indi-
cated that they were less assertive than the college student means reported by
Gambrill and Richey (1975). At post treatment, scores remained elevated com-
pared to college norms but had reduced significantly. However, both pre and post
treatment the mean scores would be classified as unassertive. On the BDI, mean
scores moved from the mild to the minimal depression range.
Change over time on the five NEO personality dimensions was assessed using a
repeated-measures MANOVA with gender as a factor, to control for gender differ-
ences inherent in the NEO scales. Significant differences were found between the two
time-points on the dependent measures, Wilks’s Λ =.33, F(5,18) = 7.44, p < 0.01. The
multivariate η2 based on Wilks’s Λ was strong, .67 (Table 1). There was a reduction in
Neuroticism, F(1,22) = 35.75, p < .001, and an increase in Extraversion, F(1,22) =
19.02, p < .001, but there was no change in Agreeableness, F(1,22) = .07, p = .79,
Openness to Experience, F(1,22) = 3.68, p = .07, or Conscientiousness, F(1,22) =
1.77, p = .20. In all cases the main effect of gender and the interaction between
gender and time did not reach statistical significance. A univariate ANOVA, used to
test the hypothesis that the facet of Trust would change during treatment, showed a
statistically significant increase, F(1, 22) = 6.35, p = .02, in Trust scores over time. No
other facet of Agreeableness changed significantly.
Discussion
Prior to treatment the participants exhibited clinical levels of social anxiety disor-
der and a range of personality disorder pathology. Mean scores on the NEO-PI-R
factors showed that Neuroticism was in the very high range, Agreeableness was in
the average range and Trust was in the low range. There were moderate relationships
between general personality disorder pathology and the FFM dimensions of
Neuroticism (positive) and Agreeableness (negative), which together accounted for
41% of variance in general personality disorder pathology. This finding replicates
the patterns previously reported (Saulsman & Page, 2004). 49
Moving to consider the specific hypotheses, it was predicted that during treat-
ment Neuroticism would decrease, while Extraversion and Agreeableness (and
specifically Trust) would increase. Results showed a reduction in Neuroticism and
an increase in Extraversion and Trust from pre- to post-treatment. However, no sig-
nificant change was observed on the dimension of Agreeableness. Overall, these
findings lend support to the position that facets of the FFM personality dimensions
Behaviour Change
Krystyna Glinski and Andrew C. Page
can change but the treatment could not effect an observable wholesale change on
Agreeableness in the current sample and timeframe.
One consideration when interpreting these results is the difficulty of assessing
whether change in the scores on a personality trait measure reflects change in the
underlying personality construct. First, changes may reflect only superficial alter-
ations in participants’ selection of response options rather than changes in their per-
sonality. Second, changes on the scores may reflect changes in the behavioural
expression of a personality trait. Lastly, they may reflect change in the underlying
personality trait itself. Different theoretical definitions of personality offer various
pragmatic views on whether it is possible to alter a personality trait (Heatherton &
Nichols, 1994). Some researchers suggest that the biological and genetic underpin-
nings of personality traits may not be amenable to change through a behavioural
intervention, which would only influence the way in which the underlying trait is
expressed (Brody, 1994). However, Costa and McCrae’s (1992) define the FFM per-
sonality traits as sets of behaviours. By this definition, a treatment that alters these
behaviours in a way that makes them more adaptive would be considered to have a
clinically useful effect on personality. It seems reasonable in the current study to
infer that changes on the NEO-PI-R scores indicate some degree of behavioural
change. The use of a behavioural measure of Trust and Agreeableness in future
research could clarify the degree of personality change that occurs in treatment.
This study found that scores on the facet of Trust changed from pre- to post-ther-
apy. If this change is attributable to the treatment intervention (group cognitive–
behaviour therapy that addresses interpersonal issues), it could indicate that the
treatment was effective in increasing the tendency to attribute benevolent intent to
others and reducing the suspicion that others are dishonest or dangerous, but was
ineffective in altering the other five facets of Agreeableness. Future research is
required to determine whether the other facets of Agreeableness can be changed,
given that an alternative interpretation is that Trust is the only facet amenable to
change. Additional intervention strategies to target the remaining facets may be
required for the development of an ‘agreeableness therapy’.
Therefore, it is of interest to speculate about other interventions that could
target the remaining five facets of Agreeableness if one were to be treating disorders
where all facets are elevated. One facet is Altruism, on which a low score describes
individuals who are self-centred and reluctant to become involved in helping
others. Guidance for improving Altruism may be drawn from the growing literature
on organisational citizenship, which investigates volunteering, helping and cooper-
ating with others, and team-building (Borman, 2004). The construct of Compliance
is related to interpersonal conflict and it is plausible that low scorers could improve
their conflict resolution skills in interventions that increase cooperation and aware-
ness of one’s role within a system, such as group-based interpersonal psychotherapy
(e.g., Vinogradov, Cox, & Yalom, 2003). Training in empathy skills, which has been
researched in populations of helping professionals (e.g., Barone, Hutchings,
50
Kimmel, Traub, Cooper, & Marshall’s, 2005) may also increase the trait of
Tendermindedness and could potentially influence the frequency of altruistic
behaviours. Suggestions for modifying Modesty come from Seligman’s (1995) work
on learned optimism, which uses principles of cognitive therapy to enable people to
make accurate assessments of their own strengths and weaknesses, so that they are
neither self-effacing nor conceited. Finally, dialectical behaviour therapy (Linehan,
1993) offers an ‘interpersonal effectiveness skills’ module, which contains a number
Behaviour Change
Modifiability of Neuroticism, Extraversion, and Agreeableness
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