OVER-REPRESENTATION OF MYERS BRIGGS TYPE INDICATOR INTROVERSION IN SOCIAL PHOBIA PATIENTS
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1 DA DEPRESSION AND ANXIETY 11: (2000) OVER-REPRESENTATION OF MYERS BRIGGS TYPE INDICATOR INTROVERSION IN SOCIAL PHOBIA PATIENTS David S. Janowsky, M.D., 1 * Shirley Morter, 1 and Manuel Tancer, M.D. 2 The purpose of this study is to profile the personalities of patients with social phobia. Sixteen patients with social phobia were compared with a normative population of 55,971, and with 24 hospitalized Major Depressive Disorder inpatients, using the Myers Briggs Type Indicator. The Myers Briggs Type Indicator, a popular personality survey, divides individuals into eight categories: Extroverts versus Introverts, Sensors versus Intuitives, Thinkers versus Feelers, and Judgers versus Perceivers. Social phobia patients were significantly more often Introverts (93.7%) than were subjects in the normative population (46.2%). In addition, using continuous scores, the social phobia patients scored as significantly more introverted than did the patients with Major Depressive Disorder, who also scored as Introverted. Introversion is a major component of social phobia, and this observation may have both etiological and therapeutic significance. Depression and Anxiety 11: , Wiley-Liss, Inc. Key words: personality; social phobia; introversion; shyness; MBTI; major depression; psychiatric patients; anxiety disorders INTRODUCTION Social phobia is a disorder characterized by the experience of severe anxiety, occurring in situations in which one or one s performance is subject to the scrutiny of others. Fear of being embarrassed or humiliated generally results in avoidant behavior. When avoidance is impossible, intense distress occurs [American Psychiatric Association, 1987; Marks and Gelder, 1966; Stein et al., 1992]. Much has been written concerning the phenomenology, social disability, prevalence, etiology, assessment, gender distribution and relation to other disorders of social phobia [Stein et al., 1992]. Relatively few investigators have considered the existence of co-existing personality disorders and/or core personality characteristics in patients with social phobia. Most prominently researched has been the relationship between social phobia and avoidant personality disorder. Avoidant personality disorder is over-represented in patient samples with social phobia [Schneier et al., 1991; Turner et al., 1986, 1991], as is, to a lesser degree, obsessive compulsive personality disorder, dependent personality disorder, and schizoid personality disorder [Jansen, 1984]. Furthermore, there are some reports that avoidant personality disorder and social phobia are essentially the same entities. Social phobia has been found linked to certain core or underlying personality and temperamental variables. Using the Tridimensional Personality Questionnaire [Cloninger, 1987], Tancer et al. [1995] observed that patients with social phobia had significantly elevated harm-avoidance scale scores and significantly lower reward-dependence scale scores, as well as having a statistically insignificant trend toward low novelty-seeking scores when compared to healthy normal controls. In addition, social phobia patients have been found to show low Extroversion scores on the Eysenck Personality Questionnaire [Turner et al., 1991]. The purpose of the current study is to profile the underlying personality features of social phobia patients using the Myers Briggs Type Indicator (MBTI), a popular personality test widely used in management, educational, and counseling circles [Keirsey and Bates, 1978; Myers and McCaulley, 1985], which has significant heritability of its factors [Bouchard and Hur, 1998], specific personality profiles in depressed patients [Janowsky et al., 1998, 1999], a non-pathologi- 1 University of North Carolina, Chapel Hill, North Carolina 2 Wayne State University in Detroit, Michigan Contract grant sponsor: the Richard King Mellon Family Foundation. *Correspondence to: David Janowsky, M.D., Department of Psychiatry, CB# 7175, University of North Carolina, Chapel Hill, NC Received for publication 19 April 1999; Accepted 23 December WILEY-LISS, INC.
2 122 Janowsky et al. cal focus, good reliability, and little or no correlation with levels of or changes in depression. We hypothesized that social phobia patients would be more introverted than individuals in a normal (normative) population. We also hypothesized that social phobia patients would be even more introverted than a comparison group of major depressive disorder patients, a group which has been shown previously to be relatively more introverted than normal controls [Akiskal et al., 1983; Janowsky et al., 1998]. MATERIALS AND METHODS SUBJECTS A total of 16 outpatients diagnosed with social phobia participated in the study. All met DSM III-R [American Psychiatric Association, 1987] criteria for social phobia, generalized subtype. All were screened with a structured clinical interview, the DSM III-R SCID-P. The diagnosis was confirmed using the Anxiety Disorder Interview Schedule - Revised [DiNardo, 1993]. The social phobia patient group consisted of seven males and nine females, age 40.2 ± 9.3 (mean ± SD). None had a Major Depressive Disorder, Substance Use Disorder, or Panic Disorder diagnosis. In addition, 24 psychiatric inpatients with a DSM III-R diagnosis of major depressive disorder (age 40.8 ± 17.0; six males, 18 females) were utilized as a psychiatric control group. The Major Depressive Disorder comparison group was drawn from patients currently admitted to the acute psychiatric units of the University of North Carolina Hospitals. Patients in the Major Depressive Disorder group were free of a concurrent diagnosis of an Alcohol/Substance Use Disorder or other Axis I or Axis II disorders. For the Major Depressive Disorder patients, psychiatric diagnosis was determined by retrospective review of the patients charts. DSM III-R diagnosis was made by the patients faculty psychiatrist collaborating with the patients psychiatric resident, and by a careful review of the patients psychiatric records and discharge summaries by one of us (DSJ). The risks and benefits of the study were explained verbally and in writing to all of the patients, and written informed consent was obtained from all who participated. The research was in compliance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) and the standards of the University of North Carolina at Chapel Institutional Review Board. Finally, as described in more detail below, a normative database of 55,971 individuals administered the MBTI, Form F was utilized for comparison purposes. MATERIALS Each of the patients filled out a copy of the 166- item MBTI, Form F. The MBTI divides individuals into eight dichotomous types: Extroverted (E) versus Introverted (I), Sensing (S) versus Intuitive (N), Thinking (T) versus Feeling (F), and Judging (J) versus Perceiving (P) [Myers and McCaulley, 1985]. Extroverts are sociable, interactive, externally oriented, enjoy multiple relationships, and are gregarious, whereas Introverts are internally oriented, intensive, territorial, enjoy limited numbers of relationships, are reflective, and are energy conservative. Sensors tend to rely on experience, are realistic, hard working, actually oriented, down-to-earth, factual, practical and sensible. Intuitives are future oriented, trust hunches, are speculative, inspirational, ingenuous, imaginative, fantasize, and are creative. Thinking individuals are objective, policy oriented, legalistic, firm, impersonal, justice oriented, analytic, and adhere to standards. Feeling individuals are subjective, intimate, use persuasion, are personable, humane, harmony oriented, sympathetic and devoted. Judgers are settled, decided, fixed, like to plan ahead, like closure, are decisive, and believe in deadlines. Perceivers adapt as they go, like to keep their options open, are open-minded, are tentative, dislike deadlines, and have a wait and see attitude [Myers and McCaulley, 1985]. STATISTICAL ANALYSIS The MBTI was scored and the data was analyzed using the Selection Ratio Type Table (SRTT) computer program [Granade et al., 1987]. This program uses chi square analysis and Fisher s exact tests to compare differences between subjects in different groups. The program was compiled by the Center for the Application of Psychological Type [CAPT, Macdaid et al, 1986]. With the SSRT, differences between the percentage composition of different subject groups are analyzed for each of the eight MBTI single factor individual preferences (i.e., the percentage of Extroverts or Introverts, respectively, etc.), 24 two-factor types (i.e., Sensing-Feeling, or Introverted-Intuitive types, etc.), and 16 four-factor types (i.e., Introverted-Sensing-Feeling-Judging or Extroverted-Intuitive-Feeling- Judging types, etc.). For purposes of the current study, individual preference, two-factor and four-factor type differences between the social phobia group and a normative population of 55,971 (32,731 females, 23,240 males) who had been administered the MBTI, Form F as compiled by the Center for Applications of Psychological Type [Macdaid et al., 1986] were compared to yield categorical data. The social phobia group and the major depressive disorder group were also compared using the SSRT. In addition, t-tests were used to compare relative differences between the social phobia group and the major depressive disorder group. In this case, the data was calculated as a continuum measuring the degree of relative preference for a given pole of an MBTI dichotomy (i.e., a continuum from Extroversion to Introversion), as described by Myers and McCaulley [1985]. Calculated continuous scores for Extroversion to Introversion, Sensing to Intuitive, Thinking to Feeling, and Judging to Perceiving dichotomies were compared between the social phobia and the major
3 Research Article: Social Phobia and Personality 123 depressive disorder groups. A score of 100 represented the cut point between the two factors of a given dichotomy. Numbers less than 100 represented the Extroverted, Sensing, Thinking and Judging poles. Numbers greater than 100 represented the Introverted, Intuitive, Feeling and Perceiving poles. We were unable to compare the continuum scores for the social phobia group with normative data, since the Center for Applications of Psychological Type provided only categorical data, and did not have available continuous normative data. All statistical tests were non-directional (two-tailed), with the level of significance set at Alpha = Because of the exploratory nature of the study, a Bonferroni correction for the number of analyses was not applied. RESULTS As shown in Table 1, using chi square and Fisher s exact tests to compare Social Phobia patients with the normative population, social phobia patients were significantly more often found to be Introverts than were subjects in the normative group (93.7% versus 46.2%, Fisher s exact test =.0001, df = 1, P = <.001). Conversely, social phobia patients were significantly less frequently Extroverts when compared to the normative population (6.3% versus 52.5%, Fisher s exact test =.0001, df = 1, P = <.001). No other significant single factor differences (i.e., Sensing, Intuitive, Thinking, Feeling, Judging or Perceiving preferences) were noted between the social phobia patient group and the normative group. In addition, the social phobia patients were significantly more often found to be a combination of Introverted-Judging (62.5% versus 28.1%, χ 2 = 9.32, df = 1, P = <. 01), Introverted-Sensing (50% versus 27.2%, χ 2 = 4.20, df = 1, P = <.05), Introverted-Intuitive (43.7% versus 18.9%, χ 2 = 6.45, df = 1, P = <.05), Introverted-Feeling (50.0% versus 23.8%, χ 2 = 6.10, df = 1, P = <.05), and Introverted-Thinking (43.7% versus 22.3%, χ 2 = 4.21, df = 1, P = <.05) two-factor types, as compared to the normative population. For TABLE 1. Differences in single factor preference percentages of 16 social phobia patients compared to normative data on 55,971 individuals Normative Social phobia Preference population patients Extroversion 54% 6%* Introversion 46% 94%* Sensing 56% 50% Intuitive 44% 50% Thinking 47% 44% Feeling 53% 56% Judging 60% 62% Perceiving 40% 38% * = P <.001 (All data rounded off to the nearest percentage). the Extroverted-Judging (0% versus 31.2%, Fisher s Exact Test =.0122, df = 1, P = <.05), Extroverted-Sensing (0% versus 28.5%, Fisher s Exact Test =.0094, df = 1, P = <.01), and Extroverted-Thinking types (0% versus 24.2%, Fisher s Exact Test =.0178, df = 1, P = <.05), social phobia patients were significantly less frequently represented as two-factor types compared to the normative population. There were no significant four-factor differences noted between the social phobia population and the normative population. No significant differences were noted when the 16 social phobia and 24 major depressive disorder groups were compared using the chi square and Fisher s Exact analyses. However, social phobia patients numerically more often had Introverted (93.7% versus 70.8%), Intuitive (50% versus 29.2%) Thinking (43.7% versus 25%), and Judging (62.5% versus 45.8%) single factor preferences, and were numerically over-represented as being Introverted-Judging (62.5% versus 25%) and Introverted-Thinking (43.8% versus 20.8%) two-factor types. As shown in Table 2, when the social phobia patients were compared with the major depressive disorder patients with respect to their continuous scores for Extroversion to Introversion, Sensing to Intuitive, Thinking to Feeling, and Judging to Perceiving, social phobia patients were significantly more Introverted (t = 2.46, df = 38, P = <.02). No differences between the social phobia patients and the major depressive disorder patients were noted on the Sensing to Intuitive, Thinking to Feeling, and Judging to Perceiving continuums. DISCUSSION This report is the first that we know of evaluating MBTI profiles in social phobia patients. In our study, social phobia patients were found significantly more often to be Introverts when compared to a large normative population. Furthermore, social phobia patients, on average were more Introverted on a continuum ranging from Extroverted to Introverted, even when compared to major depressive disorder patients, who themselves TABLE 2. Differences in MBTI continuum scores of 16 social phobia patients and 24 major depressive disorder patients taking the MBTI, form f Social phobia patients Mean ± SD Major depressive disorder patients Mean ± SD Extroversion to Introversion 132.7± ±25.1* Sensing to Intuitive 96.1± ±18.7 Thinking to Feeling 105.1± ±19.4 Judging to Perceiving 95.1± ±27.5 *P <.02 - All results expressed as means ± standard deviation. Numbers less than 100 represent Extroverted, Sensing, Thinking, and Judging poles. Number of 100 or greater represent Introverted, Intuitive, Feeling, and Perceiving poles. The continuous score range for the Extroversion to Introversion scale is
4 124 Janowsky et al. were significantly more Introverted than normal controls [Akiskal et al., 1983; Hirschfeld et al., 1983, 1989; Janowsky et al., 1998]. Several reservations are worth noting with respect to our study. Our patient sample sizes were relatively small, possibly accounting for some of the differences that were obviously numerically different, but that yielded negative statistical results. Although our normative group and social phobia subject groups were relatively balanced with respect to gender distribution, the normal subject group was somewhat younger. Also, our Major Depressive Disorder group was predominantly female. However, Myers and McCaulley [1985] have noted that Myers Briggs Type Indicator Introversion rates do not differ between men and women. Furthermore, although we will subsequently discuss the possibility that Introversion may cause social phobia, since our study was essentially a cross-sectional one, it is possible that the converse is true. Social phobia as such could lead to Introversion. Considering social phobia patients as highly Introverted on the MBTI allows a rather novel perspective concerning these individuals. Introverts are people who are often territorial, have high powers of concentration, keep thoughts and ideas to themselves, enjoy limited relationships, are reflective, tend to think and then to speak, are energized by ideas but drained by discussions, enjoy listening rather than talking, and may be considered to be shy and reserved [Myers and McCaulley, 1985]. Operationally, at work they like quiet for concentration, are more careful with details, don t mind working on one project for a long time without interruption, dislike telephone interruptions, like to think before they act, and are interested in the ideas behind their jobs [Myers and McCaulley, 1985]. The above characteristics make for a person who tends to live within him or herself. In many ways such people can be cut off from those around them. Furthermore, although it is obvious that the social phobia group s high frequency of being Introverted determined all the significant two factor type differences, our data suggest that social phobia patients are especially over-represented in the two-factor combination of Introversion-Judging, with 62.5% of cases having this combination of preferences compared to 28.1% of a normative population. Individuals with a Judging preference, in contrast to those with a Perceiving preference, tend to be highly structured, orderly, planned and controlled, and to have a right way and a wrong way to do things. Given this personality profile, it would seem logical that Judging individuals would tend to judge themselves harshly, as they do others, and to expect, due to projection, the same opinions of their performances from others. The combination of an individual who judges himself or herself and others harshly, and has difficulty obtaining feedback from others due to Introversion would logically seem to be a strong candidate for being someone who fears judgment, the sine qua non of social phobia patients. Introversion, as measured by the Eysenck Personality Questionnaire [Akiskal et al., 1983; Kendell and DiScipo, 1968; Shea et al., 1996] and more recently as measured in our work using the MBTI [Janowsky et al., 1999] is increased in patients with major depression. Major Depressive Disorder patients as a group are also significantly more often Sensing, Feeling and Perceiving single-factor MBTI types, as well as Introverted-Sensing-Feeling-Judging (ISFJ), Introverted- Sensing-Feeling-Perceiving (ISFP), and Introverted- Intuitive-Feeling-Perceiving (INFP) four-factor types [Janowsky et al., 1998]. Significantly, a frequent concomitant of social phobia is major depression [Dilsaver et al., 1992]. Although it is possible that the Introversion of social phobia and major depressive disorder respectively are caused by the separate conditions of each, it is also possible that Introversion underlies both disorders. Given the fact that Introversion is to a significant extent genetically determined [Pederson et al., 1988; Bouchard and Hur, 1998] and is found quite early in life by manifesting itself as shyness [Kagan et al., 1988; Caspi et al., 1996; Pederson et al., 1988], the probability that it is a risk factor for social phobia and possibly for depression is quite likely [Caspi et al., 1996]. Thus, the personality trait of Introversion may be an important risk factor in determining and predicting the diagnosis of social phobia. Highly introverted children (i.e., inhibited children) may be at risk for developing social phobia, as well as depression and anxiety, and may be candidates for preventative measures, a possibility awaiting definition by future research. 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