Psychological Reports, 1992, 71, 579-586. O Psychological Reports 1992
MENTAL HEALTH LOCUS O F CONTROL IN FIRST-DEGREE RELATIVES O F AGORAPHOBIC AND DEPRESSED INPATIENTS ' ASLE HOFFART Research Institute Modum Badr Nervesanatorium
AND
SVENN TORGERSEN Center for Research in Clinical Psychology Oslo University
Summary.-Mental health locus of control in 77 first-degree relatives of agoraphobic, agoraphobic and major depressed (comorbid), and depressed inpatients were studied. Relatives of comorbid patients externalized locus of control more to chance than did relatives of agoraphobic and of depressed patients. These results suggest that a tendency to externalize to chance is familially transmitted and may be a vulnerability factor for the development of the comorbid condition of agoraphobia and major depression.
A tendency to externalize locus of control has been hypothesized as a predisposing personality trait for the development of agoraphobia. Emmelkamp (1982) suggested that persons with external control orientation who experience anxiety attacks in a stressful period tend to misattribute anxiety to external sources (e.g., crowded areas) or to internal sources beyond their control (e.g., heart attack). Research has indicated that external locus of control and phobic anxiety are correlated (Emmelkamp & Cohen-Kettenis, 1975). Compared to normals, agoraphobics seem to externalize locus of control more (Brodbeck & Michelson, 1987), to internalize health locus of control less, and to externalize health locus of control to chance more (Adler & Price, 1985). Agoraphobic inpatients and comorbid inpatients with both agoraphobia and depression score higher than nonanxious depressed inpatients with respect to attributing mental health externally to. chance (Hoffart & Martinsen, 1990a). These patientswere also assessed at discharge from hospital and at one-year follow-up. Mental health locus of control scores exhibited moderate to high stabhty over time, and the group differences regarding externality to chance tended to become even more marked across posttest and one-year follow-up (Hoffart & Martinsen, 1991b). Examining the subgroup of agoraphobic and comorbid patients who received a specialized behavioral-psychodynamic.treatment,program for agoraphobia, we found that externality to chance tended to decrease more during and after treatment in these patients than in agoraphobic (and comorbid) patients who received psychodynamic treatment only (Hoffart & Martinsen, 1990b). On the other hand, agoraphobic symptoms declined to a similar extent in both groups during treatment. In the group of agoraphobic patients attending the specidzed
'Address correspondence to Asle Hoffart, Research Institute, Modum Bads Nervesanatorium, N-3370 Viersund, Norway.
5 80
A. HOtFAKT & S. TORGERSEN
program, mental health locus of control variables predicted both treatment effectiveness and relapse after treatment (Hoffart & Martinsen, 1991a). These results suggest that an external locus of control orientation is a vulnerability factor for the recurrence of agoraphobia after exposure-based treatment and not just a correlate or a consequence of the agoraphobic state. The purpose of the present study was to examine whether locus of control could be a vulnerability factor for the initial development of agoraphobia by assessing mental health locus of control in first-degree relatives of the patients studied previously. Were we to find that (a) externality of chance ratings of relatives correlated with those of their patient probands and that (b) relatives of agoraphobic and comorbid (agoraphobic and major depressed) patients provided higher ratings than relatives of depressed patients, the external control orientation could be considered farnilially related to agoraphobia. I n another paper (Hoffart & Torgersen, 1991) we reported results with regard to the relation between causal attributions and depression in the same sample of relatives. We chose to report the results in two separate papers because the research questions asked and the consequent diagnostic classifications were quite different in the two cases. I n the other paper, the relatives were divided into four groups: those of major depressed patients, those of agoraphobic patients, those of major depressed and agoraphobic patients, and those of dysthymic patients.
Subjects The subjects were adult first-degree relatives of probands who had been inpatients at a Norwegian psychiatric institution admitting patients with severe neuroses and personality disorders. During a 14-month period, admitted patients with suspected anxiety or depressive disorder were offered diagnostic interviews. A DSM-111-R diagnosis (American Psychiatric Association, 1987) was made on each patient based on the Structured Clinical Interview for DSM-I11 (SCID; Spitzer & Williams, 1984). Those who met the criteria for at least one anxiety disorder or one of the unipolar depressive disorders, 87 female and 5 9 male patients, were included in a follow-up study of cognitive variables. I n May 1988, about a year after the last of these patients had been discharged from the hospital, those who had not dropped out of the longitudinal study (n = 136) were sent a letter requesting permission to contact their parents, siblings, and adult children for a study of cognitive variables. Seven patients were not located, nine informed us that they had no relatives meeting inclusion criteria, seven refused to participate, and 65 did not respond to our letter. Forty-eight patients granted permission. They had 103 relatives within the specified age range (70 >age > 18), including 18 parents, 49 siblings, and 36 children. I n April 1989, these 103 relatives were
RELATIVES OF AGORAPHOBICS, DEPRESSIVES: LOCUS O F CONTROL
581
mailed questionnaires to complete. Five informed us that they were not able or willing to complete the questionnaires, and 2 1 did not respond to our letter, leaving 77 compliers (75%). These 77 complying relatives had 38 patient probands and were divided in three groups: (1) those related to agoraphobic probands without major depression, (2) those related to comorbid, that is, major depressed and agoraphobic probands, and (3) those related to nonagoraphobic depressed probands. Of the 38 nondepressed agoraphobic patients in the original sample, 12 patients permitted us to contact their relatives and had complying relatives. The respective numbers were 3 1 and 9 for the comorbid patients, and 67 and 17 for the nonagoraphobic depressed patients. To assess whether the extent to which the probands having complying relatives were representative of the original patient sample, these probands in each diagnostic group were compared with the rest of the patients in the group on the depression and anxiety indices of the Comprehensive Psychopathological Rating Scale (see Instruments section below) at pre- and posttreatment. No significant differences occurred between probands with complying relatives and remaining patients in any of the three diagnostic groups. personality disorder The proportions of patients having a DSM-111-R among the probands with complying relatives and among the remaining patients in the three groups-agoraphobic, comorbid, and depressed-were, respectively, 55% and 53%, 89% and 90%, and 57% and 56%. Fisher's exact test yielded no significant differences between probands with complying relatives and remaining patients. In general, the data indicate that the probands having complying relatives were representative of the total sample from which these probands came. The descriptive characteristics of the complying relatives are given in Table 1. Statistical tests indicated no significant group differences for age (F2,74 = 0.50, ns), sex (x2= 2.88, ns), or social class (x2= 3.66, ns). The figures in Table 1 also show that there were no parents among the relatives of comorbid patients, whereas siblings and children were more evenly distributed among the three groups. Instruments Locus of control in relation to mental health was measured by the Multidimensional Health Locus of Control scales (Wallston & Wallston, 1981). In this procedure, the subjects are asked to rate their agreement (scale of 1 to 6) with 18 assertions relating to health and disease. Six of these express internahty, six externality to chance, and six externality to powerful others. Subscale scores are computed by taking the sum of appropriate items. In the present version, subjects were instructed to consider illness as psychic problems like anxiety and depression. The Norwegian version of these scales seem to have acceptable psychometric properties (Hoffart & Martinsen, 1990a). I n the present sample of relatives, values of Cronbach's alpha were
A. HOFFART & S. TORGERSEN
582
TABLE 1
D E S C ~ U P ~CHARACTERISTICS ~VE OF RELATIVES OF AGORAPHOBIC, MAJOR DEPRESSED AND AGORAPHOBIC, AND DEPRESSED PROBANDS Characteristics Agoraphobic Patients
Relatives of Major DepressedAgoraphobic Patients
Depressed Patients
No. of Probands No. of Parents No. of Siblings No. of Children No. of Relatives Female Age M
SD Lower Social Classf 9 9 'Unemployed, skilled and unskilled worker, uneducated functionaries.
.74, .71, and .59 for the internality, externality to chance, and externality to powerful others subscales, respectively. Both probands and relatives completed the locus of control subscales and the Beck Depression Inventory (Beck, Rush, Shaw, & Emery, 1979), a widely used and wen-validated self-report instrument. The alpha value was .89 for the present sample. The probands were assessed on the interviewbased Comprehensive Psychopathological Rating Scale (Aasberg, Montgomery, Perris, Schalling, & Sedvall, 1978), which includes a depression and an anxiety index with acceptable psychometric properties (Martinsen, Friis, & Hoffart, 1989). I n the sample of relatives, anxiety symptoms were measured by an extended version of the Anxiety Symptom Questionnaire (Cameron, Thyer, Nesse, & Curtis, 1986). To the original 26 items were added 11 items from the Acute Panic Inventory (Liebowitz, Fyer, Gorman, Dillon, Appleby, Levy, Anderson, Levitt, Palij, Davies, & Klein, 1984). The items are rated on a scale of 0 to 4 and were averaged to provide a total score for anxiety symptoms (a= .97). Phobic symptoms among the relatives were measured by the Phobic Fear Questionnaire (Torgersen, 1979), the items of which are rated on a scale of O to 4 (a= .95).
RESULTS As expected, the externality to chance scores of the relatives correlated significantly with those of their patient probands, Pearson's r = .23 ( p < 0.05). Scores for intern&ty and externality to, powerful others did not correlate across relatives and probands. For the relatives of the agoraphobic, the comorbid, and the depressed patients, respectively, the mean extended scores on the Anxiety Symptom Questionnaire were 0.69 (SD = 0.69), 0.41 (SD= 0.29), and 0.74 (SD = 0.58);
RELATIVES OFAGORAPHOBICS, DEPRESSIVES: LOCUS O F CONTROL
583
the mean scores on the Phobic Fear Questionnaire were 0.65 (SD = 0.621, 0.41 (SD = 0.34), and 0.62 (SD = 0.56); and the mean Beck Depression scores were 2.7 (SD = 1.7), 3.0 (SD = 2.0), and 3.0 (SD = 2.3). Because the distributions on the symptom variables were skewed, the nonparametric Kruskal-Wallis test was used for group comparisons. The three groups of relatives did not differ with regard to extended scores on the Anxiety Symptom Questionnaire ( T =3.65, ns). Also they did not differ on phobic fear scores ( T = 1.35, ns) or Beck Depression scores ( T =0.48, ns). Correlations between the three locus of control subscales in the sample of relatives were computed as Pearson's r. No significant (p
MENTAL HEALTH LOCUS O F CONTROL IN FIRST-DEGREE RELATIVES O F AGORAPHOBIC AND DEPRESSED INPATIENTS ' ASLE HOFFART Research Institute Modum Badr Nervesanatorium
AND
SVENN TORGERSEN Center for Research in Clinical Psychology Oslo University
Summary.-Mental health locus of control in 77 first-degree relatives of agoraphobic, agoraphobic and major depressed (comorbid), and depressed inpatients were studied. Relatives of comorbid patients externalized locus of control more to chance than did relatives of agoraphobic and of depressed patients. These results suggest that a tendency to externalize to chance is familially transmitted and may be a vulnerability factor for the development of the comorbid condition of agoraphobia and major depression.
A tendency to externalize locus of control has been hypothesized as a predisposing personality trait for the development of agoraphobia. Emmelkamp (1982) suggested that persons with external control orientation who experience anxiety attacks in a stressful period tend to misattribute anxiety to external sources (e.g., crowded areas) or to internal sources beyond their control (e.g., heart attack). Research has indicated that external locus of control and phobic anxiety are correlated (Emmelkamp & Cohen-Kettenis, 1975). Compared to normals, agoraphobics seem to externalize locus of control more (Brodbeck & Michelson, 1987), to internalize health locus of control less, and to externalize health locus of control to chance more (Adler & Price, 1985). Agoraphobic inpatients and comorbid inpatients with both agoraphobia and depression score higher than nonanxious depressed inpatients with respect to attributing mental health externally to. chance (Hoffart & Martinsen, 1990a). These patientswere also assessed at discharge from hospital and at one-year follow-up. Mental health locus of control scores exhibited moderate to high stabhty over time, and the group differences regarding externality to chance tended to become even more marked across posttest and one-year follow-up (Hoffart & Martinsen, 1991b). Examining the subgroup of agoraphobic and comorbid patients who received a specialized behavioral-psychodynamic.treatment,program for agoraphobia, we found that externality to chance tended to decrease more during and after treatment in these patients than in agoraphobic (and comorbid) patients who received psychodynamic treatment only (Hoffart & Martinsen, 1990b). On the other hand, agoraphobic symptoms declined to a similar extent in both groups during treatment. In the group of agoraphobic patients attending the specidzed
'Address correspondence to Asle Hoffart, Research Institute, Modum Bads Nervesanatorium, N-3370 Viersund, Norway.
5 80
A. HOtFAKT & S. TORGERSEN
program, mental health locus of control variables predicted both treatment effectiveness and relapse after treatment (Hoffart & Martinsen, 1991a). These results suggest that an external locus of control orientation is a vulnerability factor for the recurrence of agoraphobia after exposure-based treatment and not just a correlate or a consequence of the agoraphobic state. The purpose of the present study was to examine whether locus of control could be a vulnerability factor for the initial development of agoraphobia by assessing mental health locus of control in first-degree relatives of the patients studied previously. Were we to find that (a) externality of chance ratings of relatives correlated with those of their patient probands and that (b) relatives of agoraphobic and comorbid (agoraphobic and major depressed) patients provided higher ratings than relatives of depressed patients, the external control orientation could be considered farnilially related to agoraphobia. I n another paper (Hoffart & Torgersen, 1991) we reported results with regard to the relation between causal attributions and depression in the same sample of relatives. We chose to report the results in two separate papers because the research questions asked and the consequent diagnostic classifications were quite different in the two cases. I n the other paper, the relatives were divided into four groups: those of major depressed patients, those of agoraphobic patients, those of major depressed and agoraphobic patients, and those of dysthymic patients.
Subjects The subjects were adult first-degree relatives of probands who had been inpatients at a Norwegian psychiatric institution admitting patients with severe neuroses and personality disorders. During a 14-month period, admitted patients with suspected anxiety or depressive disorder were offered diagnostic interviews. A DSM-111-R diagnosis (American Psychiatric Association, 1987) was made on each patient based on the Structured Clinical Interview for DSM-I11 (SCID; Spitzer & Williams, 1984). Those who met the criteria for at least one anxiety disorder or one of the unipolar depressive disorders, 87 female and 5 9 male patients, were included in a follow-up study of cognitive variables. I n May 1988, about a year after the last of these patients had been discharged from the hospital, those who had not dropped out of the longitudinal study (n = 136) were sent a letter requesting permission to contact their parents, siblings, and adult children for a study of cognitive variables. Seven patients were not located, nine informed us that they had no relatives meeting inclusion criteria, seven refused to participate, and 65 did not respond to our letter. Forty-eight patients granted permission. They had 103 relatives within the specified age range (70 >age > 18), including 18 parents, 49 siblings, and 36 children. I n April 1989, these 103 relatives were
RELATIVES OF AGORAPHOBICS, DEPRESSIVES: LOCUS O F CONTROL
581
mailed questionnaires to complete. Five informed us that they were not able or willing to complete the questionnaires, and 2 1 did not respond to our letter, leaving 77 compliers (75%). These 77 complying relatives had 38 patient probands and were divided in three groups: (1) those related to agoraphobic probands without major depression, (2) those related to comorbid, that is, major depressed and agoraphobic probands, and (3) those related to nonagoraphobic depressed probands. Of the 38 nondepressed agoraphobic patients in the original sample, 12 patients permitted us to contact their relatives and had complying relatives. The respective numbers were 3 1 and 9 for the comorbid patients, and 67 and 17 for the nonagoraphobic depressed patients. To assess whether the extent to which the probands having complying relatives were representative of the original patient sample, these probands in each diagnostic group were compared with the rest of the patients in the group on the depression and anxiety indices of the Comprehensive Psychopathological Rating Scale (see Instruments section below) at pre- and posttreatment. No significant differences occurred between probands with complying relatives and remaining patients in any of the three diagnostic groups. personality disorder The proportions of patients having a DSM-111-R among the probands with complying relatives and among the remaining patients in the three groups-agoraphobic, comorbid, and depressed-were, respectively, 55% and 53%, 89% and 90%, and 57% and 56%. Fisher's exact test yielded no significant differences between probands with complying relatives and remaining patients. In general, the data indicate that the probands having complying relatives were representative of the total sample from which these probands came. The descriptive characteristics of the complying relatives are given in Table 1. Statistical tests indicated no significant group differences for age (F2,74 = 0.50, ns), sex (x2= 2.88, ns), or social class (x2= 3.66, ns). The figures in Table 1 also show that there were no parents among the relatives of comorbid patients, whereas siblings and children were more evenly distributed among the three groups. Instruments Locus of control in relation to mental health was measured by the Multidimensional Health Locus of Control scales (Wallston & Wallston, 1981). In this procedure, the subjects are asked to rate their agreement (scale of 1 to 6) with 18 assertions relating to health and disease. Six of these express internahty, six externality to chance, and six externality to powerful others. Subscale scores are computed by taking the sum of appropriate items. In the present version, subjects were instructed to consider illness as psychic problems like anxiety and depression. The Norwegian version of these scales seem to have acceptable psychometric properties (Hoffart & Martinsen, 1990a). I n the present sample of relatives, values of Cronbach's alpha were
A. HOFFART & S. TORGERSEN
582
TABLE 1
D E S C ~ U P ~CHARACTERISTICS ~VE OF RELATIVES OF AGORAPHOBIC, MAJOR DEPRESSED AND AGORAPHOBIC, AND DEPRESSED PROBANDS Characteristics Agoraphobic Patients
Relatives of Major DepressedAgoraphobic Patients
Depressed Patients
No. of Probands No. of Parents No. of Siblings No. of Children No. of Relatives Female Age M
SD Lower Social Classf 9 9 'Unemployed, skilled and unskilled worker, uneducated functionaries.
.74, .71, and .59 for the internality, externality to chance, and externality to powerful others subscales, respectively. Both probands and relatives completed the locus of control subscales and the Beck Depression Inventory (Beck, Rush, Shaw, & Emery, 1979), a widely used and wen-validated self-report instrument. The alpha value was .89 for the present sample. The probands were assessed on the interviewbased Comprehensive Psychopathological Rating Scale (Aasberg, Montgomery, Perris, Schalling, & Sedvall, 1978), which includes a depression and an anxiety index with acceptable psychometric properties (Martinsen, Friis, & Hoffart, 1989). I n the sample of relatives, anxiety symptoms were measured by an extended version of the Anxiety Symptom Questionnaire (Cameron, Thyer, Nesse, & Curtis, 1986). To the original 26 items were added 11 items from the Acute Panic Inventory (Liebowitz, Fyer, Gorman, Dillon, Appleby, Levy, Anderson, Levitt, Palij, Davies, & Klein, 1984). The items are rated on a scale of 0 to 4 and were averaged to provide a total score for anxiety symptoms (a= .97). Phobic symptoms among the relatives were measured by the Phobic Fear Questionnaire (Torgersen, 1979), the items of which are rated on a scale of O to 4 (a= .95).
RESULTS As expected, the externality to chance scores of the relatives correlated significantly with those of their patient probands, Pearson's r = .23 ( p < 0.05). Scores for intern&ty and externality to, powerful others did not correlate across relatives and probands. For the relatives of the agoraphobic, the comorbid, and the depressed patients, respectively, the mean extended scores on the Anxiety Symptom Questionnaire were 0.69 (SD = 0.69), 0.41 (SD= 0.29), and 0.74 (SD = 0.58);
RELATIVES OFAGORAPHOBICS, DEPRESSIVES: LOCUS O F CONTROL
583
the mean scores on the Phobic Fear Questionnaire were 0.65 (SD = 0.621, 0.41 (SD = 0.34), and 0.62 (SD = 0.56); and the mean Beck Depression scores were 2.7 (SD = 1.7), 3.0 (SD = 2.0), and 3.0 (SD = 2.3). Because the distributions on the symptom variables were skewed, the nonparametric Kruskal-Wallis test was used for group comparisons. The three groups of relatives did not differ with regard to extended scores on the Anxiety Symptom Questionnaire ( T =3.65, ns). Also they did not differ on phobic fear scores ( T = 1.35, ns) or Beck Depression scores ( T =0.48, ns). Correlations between the three locus of control subscales in the sample of relatives were computed as Pearson's r. No significant (p
