2013 - Hames Et - Al., - Interpersonal Processes in Depression

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ANNUAL
REVIEWS Further Interpersonal Processes
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Annu. Rev. Clin. Psychol. 2013.9:355-377. Downloaded from www.annualreviews.org
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Department of Psychology, Florida State University, Tallahassee, Florida 32306;

email: hames@psy.fsu.edu, hagan@psy.fsu.edu, joiner@psy.fsu.edu
Annu. Rev. Clin. Psychol. 2013. 9:355–77 Keywords

First published online as a Review in Advance on excessive reassurance seeking, negative feedback seeking, depression,
January 3, 2013
interpersonal processes, interpersonal feedback seeking
The Annual Review of Clinical Psychology is online at
http://clinpsy.annualreviews.org Abstract
This article’s doi: Humans have an intrinsic need for social connection; thus, it is crucial to
10.1146/annurev-clinpsy-050212-185553
understand depression in an interpersonal context. Interpersonal theories of
Copyright c 2013 by Annual Reviews. depression posit that depressed individuals tend to interact with others in
All rights reserved
a way that elicits rejection, which increases their risk for future depression.
In this review, we summarize the interpersonal characteristics, risk factors,
and consequences of depression in the context of the relevant theories that
address the role of interpersonal processes in the onset, maintenance, and
chronicity of depression. Topics reviewed include social skills, behavioral
features, communication behaviors, interpersonal feedback seeking, and in-
terpersonal styles as they relate to depression. Treatment implications are
discussed in light of the current research on interpersonal processes in de-
pression, and the following future directions are discussed: developing in-
tegrative models of depression, improving measurement of interpersonal
constructs, examining the association between interpersonal processes in
depression and suicide, and tailoring interventions to target interpersonal
processes in depression.
355
Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
BASIC BEHAVIORAL FEATURES AND COMMUNICATION BEHAVIORS
ASSOCIATED WITH DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
SOCIAL SKILLS AND DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
INTERPERSONAL FEEDBACK SEEKING AND DEPRESSION . . . . . . . . . . . . . . . . 359
Excessive Reassurance Seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Negative Feedback Seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Specificity of ERS and NFS to Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
INTEGRATIVE MODELS OF EXCESSIVE REASSURANCE SEEKING AND
NEGATIVE FEEDBACK SEEKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Cognitive-Affective Crossfire Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Cognitive Processing Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364

Integrative Interpersonal Framework for Depression and its Chronicity . . . . . . . . . . . 364
Global Enhancement and Specific Verification Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
INTERPERSONAL STYLES AND DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Interpersonal Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Interpersonal Dependency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Attachment Style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
INTERPERSONAL CONSEQUENCES OF DEPRESSION . . . . . . . . . . . . . . . . . . . . . . 368
TREATMENT IMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
SUMMARY AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Integrative Models of Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Measurement of Constructs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Links Between Interpersonal Factors in Depression and Suicidality . . . . . . . . . . . . . . . . 372
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
INTRODUCTION
Depression affects millions of individuals each year, making it one of the most common forms of
psychopathology. Each year, approximately 1 out of 10 adults in the United States reports expe-
riencing depression (Cent. Dis. Control Prev. 2010). Additionally, by the year 2020, depression
is projected to be a leading cause of disability worldwide, second only to cardiovascular disease
(Murray & Lopez 1997). Depression is thus a prevalent form of psychopathology that produces a
large global health burden.
Humans are also a gregarious species, as individuals have a powerful, fundamental, and pervasive
need to form and maintain strong, stable interpersonal relationships (Baumeister & Leary 1995).
Given the prevalence of depression and humans’ need to belong, it is crucial to understand how
depression interacts with an individual’s interpersonal context. The goal of the current review
is to review the interpersonal characteristics, risk factors, and consequences of depression in the
context of the relevant theories addressing interpersonal processes in depression.
Major depressive disorder consists of a variety of emotional, cognitive, and behavioral symp-
toms. Therefore, depression not only impacts the way individuals feel and think, but it also impacts
how individuals interact with the people in their environment. Symptoms of depression include the
following: depressed mood, anhedonia, change in appetite, insomnia/hypersomnia, psychomotor
356 Hames · Hagan · Joiner

agitation/retardation, low energy, extreme feelings of worthlessness or guilt, concentration diffi-

culties or indecisiveness, and suicidal ideation. To meet Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR; Am. Psychiatr. Assoc. 2000) criteria for a major depressive episode, at least
five of these symptoms (one symptom must be depressed mood or anhedonia) need to be present
during the same two-week period, and the symptoms must produce distress and impairment in
the individual’s life. Symptoms of depression often cause significant distress and impairment in
an individual’s social or occupational functioning. For instance, an individual may lose interest or
pleasure in social activities and interactions, which may lead to social withdrawal and isolation.
Additionally, individuals who experience significant feelings of worthlessness or guilt might talk
about these feelings frequently in their social interactions and even seek excessive reassurance
about their self-worth. As these examples suggest, some symptoms of depression are inherently
likely to produce interpersonal distress and impairment, which could help maintain the current
major depressive episode and create a troubled interpersonal context that could potentially trigger
future episodes of depression.

Two well-established and important features of depression are that it persists and it recurs.
Among adults, the average length of a major depressive episode is approximately eight months
(Shapiro & Keller 1981), and the mean length of dysthymic episodes may be as much as 30 years
(Shelton et al. 1997). In addition to the long episode duration, major depressive episodes tend to
result in incomplete recovery, with subclinical symptoms of depression often persisting after the
initial episode remits ( Judd et al. 2000). In the DSM-IV Mood Disorders Field Trial (Keller et al.
1995), the most frequent course among several hundred patients with current major depression
was “recurrent, with antecedent dysthymia, without full interepisode recovery.” Depression is also
a highly recurrent disorder. There is evidence that more than 75% of individuals who have expe-
rienced one major depressive episode subsequently experienced at least one more, and recurrence
of the disorder often occurs within two years of recovery from an episode (Boland & Keller 2010).
Depression is thus a persistent disorder within acute episodes, and it is recurrent across substantial
portions of people’s lives. The chronicity of depression suggests that there are specific factors and
characteristics that put some individuals at risk for experiencing repeated episodes of the disorder.
In this review, we focus on one particular type of factor that likely contributes to depression’s
chronicity: interpersonal factors.
BASIC BEHAVIORAL FEATURES AND COMMUNICATION BEHAVIORS

ASSOCIATED WITH DEPRESSION
Some of the interpersonal difficulties that depressed individuals experience may stem from basic
behavioral differences that have been identified between depressed and nondepressed individuals.
Namely, differences have been identified in the amount of facial expression, eye contact, posture,
and nonverbal gestures that depressed versus nondepressed individuals use. Compared to nonde-
pressed individuals, depressed individuals have been found to use more animated facial expressions
to express sadness (Schwartz et al. 1976), engage in less eye contact (e.g., Kazdin et al. 1985), hold
their head downward and engage in more self-touching (e.g., rubbing, scratching; Ranelli & Miller
1981), and use fewer gestures (e.g., Kazdin et al. 1985). The extent to which people demonstrate
these deficits has been linked also to the severity of their depressive state (Gotlib & Meltzer 1987).
Additionally, there is evidence that following treatment or the remission of a major depressive
episode, these behavioral features of depression tend to show improvement (e.g., Ellgring
1986, Ekman & Friesen 1972). While communicating and interacting with others, depressed
individuals have been found to speak more slowly and with less volume and voice modulation
(e.g., Youngren & Lewinsohn 1980), and their voices have been perceived more negatively by
www.annualreviews.org • Interpersonal Processes in Depression 357

others (e.g., Tolkmitt et al. 1982) compared to nondepressed individuals. Depressed individuals
have also been found to produce as few as half the number of social or interpersonal actions
such as initiating conversations or responding to others, leading to far less social interaction
(Libet & Lewinsohn 1973). When depressed individuals do interact, they tend to be much more
negative in their chosen topics and self-disclose negative feelings or events without solicitation,
at potentially socially inappropriate times (Segrin 2000). However, there is some evidence that
negative conversational content is most likely to emerge when a depressed individual is interacting
with a close friend or intimate relationship partner (Segrin & Flora 1998). This tendency to
discuss themes of negative self-evaluation and dysphoric feelings with close others places
depressed individuals at risk of social rejection and loneliness, other factors commonly linked to
depression.
SOCIAL SKILLS AND DEPRESSION

There is considerable consensus that depression is associated with social skills deficits (for a review,
see Segrin 2001). The social skills deficits that have been linked with depression may be a product of
the basic behavioral features and communication behaviors that are also associated with depression.
For instance, when rating the social skills of individuals with depression, an objective observer may
witness the individuals engaging in poor eye contact, using few gestures, speaking more slowly and
softly, responding less frequently to others in conversation, and disclosing negative information
about themselves. An observer may consequently rate individuals with depression as having social
skills deficits because of their associated behavioral and communication styles.
Individuals experiencing depression have been consistently found to negatively evaluate their
social skills (e.g., Lewinsohn et al. 1980, Segrin 2000). There have been mixed findings when
comparing depressed people’s self-reports of their social skills to behavioral indicators and ratings
made by conversational partners and objective observers. Some studies have found that depressed
participants rate themselves lower than conversational partners and objective raters do (e.g.,
Gotlib & Meltzer 1987, Segrin 2000); however, other research has demonstrated that depressed
people’s tendency to evaluate themselves negatively does not completely account for self-reported
deficits associated with depression and that actual deficits are also present (e.g., Dykman et al.
1991). The disparate findings in this literature may be in part due to differences in the oper-
ationalization of social skills and the levels of depression of the participants across studies. A
meta-analysis conducted by Segrin (1990) concluded that depressed-nondepressed differences on
partner or observer ratings of social skills are real but not as strong as depressed-nondepressed
differences on self-reported social skills.
Interestingly, there is some evidence that depressed people are more accurate in their rat-
ings of their own social competence than nondepressed people when compared to neutral raters’
scores (Gotlib 1983). Research has found that both healthy control subjects and psychiatric (nonde-
pressed) inpatients demonstrate an illusory positive bias about their own social competence, rating
their social competence higher than objective observers. Depressed patients, however, evaluated
their social skills accurately compared to the neutral evaluator’s scores. As they received treat-
ment, the depressed patients’ self-ratings remained lower than the others’ ratings, but they too
began to demonstrate a positive bias in their self-ratings, compared to objective observers, as their
depression began to lift (Lewinsohn et al. 1980).
Social skills deficits have often been viewed as a risk factor for depression; however, studies
with strong methodological features such as longitudinal design and structured clinical inter-
views have not supported the model that social skills deficits are antecedents of depression (e.g.,
Eberhart & Hammen 2006, Lewinsohn et al. 1994). Instead, social skills impairments have been

viewed as more statelike than traitlike. Based on the overall weak evidence for a main effect of social
skills deficits predicting later depression, researchers began investigating diathesis-stress models
regarding the relationship between social skills problems and depression. Some researchers have
ERS: excessive
begun to test and find evidence supporting the idea that social skills deficits operate as a vulner- reassurance seeking
ability to depression that only becomes problematic in the presence of a significant stressor such
as going away to college for the first time (e.g., Segrin & Flora 2000). Although this model is in
need of further evaluation, it provides a potential explanation for why social skills are not always
found to have a strong main effect on the development of depression.
More recent research provided evidence that the relationship between social skills deficits and
later depression was fully mediated by the presence of positive relations with others (Segrin &
Rynes 2009). Other work has found shy undergraduates to be more susceptible to increases in
symptoms of depression if social support is absent, but not if it is present ( Joiner 1997). This
evidence, although limited, demonstrates that the particularly pernicious problem with social
skills deficits is their effect of reducing general social well-being through pushing away people and
making it more difficult to pursue and maintain new relationships.
INTERPERSONAL FEEDBACK SEEKING AND DEPRESSION

A more specific type of communication behavior that depressed individuals tend to engage in is
interpersonal feedback seeking (i.e., soliciting enhancing or self-verifying feedback from others).
Such interpersonal feedback-seeking behavior may also contribute to others rating the social skills
of depressed individuals more poorly than the social skills of nondepressed individuals, as such feed-
back seeking can be aversive to conversational partners. According to Coyne’s (1976) interpersonal
theory of depression, the way mildly depressed individuals interact with their environment—and
vice versa—increases the likelihood that they will experience a depressive episode. Coyne posited
that when depressed individuals interact with others, they engage in behaviors that elicit rejection,
which then leads to an increase in their depressive symptoms. More specifically, the theory postu-
lates that mildly depressed individuals frequently seek reassurance from others to ease their doubt
as to whether others truly care about them. Significant others often initially provide support and
reassurance to the depressed individual, but the depressed individual does not find the reassurance
satisfying. Instead, the depressed individual often questions the sincerity of the reassurance, which
compels him or her to seek further reassurance from the significant other. The theory posits that
as the depressed individual’s reassurance seeking becomes more frequent and extreme, others in
the environment become increasingly aggravated by the repeated demands for reassurance. As
this pattern of reassurance seeking and aggravation escalates, it creates a downward spiral that
culminates in the rejection of the depressed individual. This rejection constitutes a stressor that
reduces the depressed individual’s social support and leads to an increase in his or her depressive
symptoms. Conceptual frameworks of depression should account for the well-established findings
in the depression literature; namely, that the disorder persists and recurs. In the interpersonal
theory of depression, Coyne (1976) postulated that depressed individuals behave in ways (i.e.,
reassurance seeking) that foster an interpersonal environment that can both lead to and maintain
depression.
Excessive Reassurance Seeking

Joiner and colleagues (1992) refined Coyne’s interpersonal theory of depression by proposing
that excessive reassurance seeking (ERS) is the behavioral means by which depressed individuals
elicit rejection. ERS is defined as the relatively stable tendency to excessively and persistently seek

assurances from others that one is lovable and worthy, regardless of whether such assurance has
already been provided ( Joiner et al. 1992, 1999). For example, a mildly depressed individual who
engages in ERS may repeatedly ask friends if they truly care about him or her or whether they are
just being friendly out of pity or obligation. The friends may initially provide assurance that they
care about the individual, but the individual doubts the sincerity of the assurance, leading him or
her to repeatedly ask the friends for more reassurance. As the ERS escalates, the friends will likely
become frustrated and annoyed, making it more likely that they will avoid or reject the individual
who is seeking excessive reassurance.
The degree to which an individual tends to engage in ERS is typically measured using a
four-item self-report questionnaire called the Depressive Interpersonal Relationships Inventory-
Reassurance-Seeking Subscale (DIRI-RS; Joiner et al. 1992). The DIRI-RS measures an indi-
vidual’s tendency to engage in ERS (e.g., “Do you find yourself asking the people you feel close
to how they truly feel about you?”) and the individuals’ perception of others’ reactions to their
reassurance seeking (e.g., “Do the people you feel close to sometimes get fed up with you seeking
reassurance from them about whether they really care about you?”). The DIRI-RS has shown
strong psychometric properties ( Joiner & Metalsky 2001).
To date, two main predictions of the refined interpersonal theory of depression ( Joiner et al.
1992) have been tested: (a) that ERS is positively related to depressive symptoms and (b) that ERS
is positively related to interpersonal rejection. Research has provided evidence for the association
between ERS and depression, as individuals with symptoms of depression (Davila 2001, Joiner &
Metalsky 2001, Starr & Davila 2008) and diagnoses of depression ( Joiner & Metalsky 2001, Joiner
et al. 2001, Starr & Davila 2008) have been found to score higher on measures of ERS. Similar
associations between ERS and depression have been found among children as well (Abela et al.
2005, Joiner et al. 2001). These cross-sectional results provide evidence that ERS is a behavioral
characteristic of adults and children who are experiencing depressive symptoms or a depressive
episode.
As ERS has been defined as a fairly stable tendency, research has also been conducted to assess
whether the tendency to engage in ERS predicts the onset of depressive symptoms. In a number
of studies to date, ERS has been found to prospectively predict depressive symptoms, providing
support for ERS as a risk factor for the development of depressive symptoms (Davila 2001, Joiner
& Metalsky 2001, Starr & Davila 2008). Additionally, several studies have provided evidence for a
diathesis-stress model whereby ERS predicts depressive symptoms in the context of life stressors
(e.g., Joiner & Metalsky 2001, Joiner & Schmidt 1998). Abela and colleagues (2006) found that
older children who scored high in ERS and experienced high levels of stress or parental depression
experienced increases in depressive symptoms over the follow-up period.
Research has also supported the interpersonal theory’s prediction that ERS evokes negative
reactions from others. In fact, a meta-analysis found that higher levels of ERS were associated with
higher levels of interpersonal rejection (Starr & Davila 2008). Although only a limited number of
studies have examined the longitudinal relation between ERS and rejection, there is some evidence
that ERS predicts future rejection under certain conditions. While some studies have found that
among men (but not women), ERS and depression interact to predict roommate rejection ( Joiner
et al. 1992, Joiner & Metalsky 1995), other studies have found that ERS has no prospective
relation to relationship satisfaction (Shaver et al. 2005) or peer sociometric ratings (Prinstein
et al. 2005). Of note, Joiner & Metalsky (1995) found that neither depression nor ERS alone was
related to interpersonal rejection; rather, only the combination of ERS and depression predicted
interpersonal rejection. This finding suggests that reassurance seeking alone may be relatively
tolerable to others when it is not linked with the urgency, desperation, and other social skills
deficits commonly associated with depressive symptoms.

Negative Feedback Seeking

In addition to having a strong need to seek reassurance from others that they are worthy, individuals
with depression also tend to engage in an opposite type of feedback-seeking behavior called NFS: negative
negative feedback seeking (NFS). NFS is defined as the tendency to actively solicit criticism and feedback seeking
other negative interpersonal feedback from others; the construct is derived from self-verification
theory (Swann 1990). According to self-verification theory, people desire interpersonal feedback
that is consistent with their self-concept, even if their self-concept is negative, because it enhances
their ability to predict and control their environment (Swann et al. 1992a). Although depressed
individuals seek out negative feedback from others, the receipt of negative feedback is just as likely
to lead to an increase in negative affect as it would among individuals with positive self-concepts
(Swann et al. 1987, 1992b). For those with negative self-concepts, the theory argues that people’s
need for self-verifying feedback is so powerful that it overrides the pain of seeking and receiving
negative feedback from others.
The tendency to engage in NFS is typically measured using the Feedback Seeking Ques-
tionnaire (Swann et al. 1992b). The Feedback Seeking Questionnaire assesses a person’s interest
in receiving positive or negative feedback from close others in five domains: intellectual, social,
musical/artistic, athletic abilities, and physical attractiveness. In each of these five categories,
individuals are presented with a list of six possible questions, and they are asked to choose the
two questions they would most like to have someone close to them answer about them. Potential
questions include, “What is some evidence you have seen that [your name here] doesn’t have
very good social skills?” and “What are some signs you have seen that [your name here] is above
average in overall intellectual ability?” Individuals who select more questions aimed at receiving
negative feedback from close others are thought to have a greater tendency to engage in NFS in
their interpersonal relationships.
Negative self-verification strivings have been identified as a correlate of depression among
adults (e.g., Giesler et al. 1996, Swann et al. 1992a) and children (e.g., Joiner et al. 1997). Giesler
and colleagues (1996) conducted a study of self-verification strivings among individuals with clini-
cal depression and found that when participants were given the option of receiving either negative
or positive feedback, 82% of clinically depressed adults chose to receive negative over positive
feedback, compared to 64% of nondepressed individuals with low self-esteem and 25% of nonde-
pressed individuals with high self-esteem. In addition to being a correlate of depression, NFS has
also been identified as a potential vulnerability factor for depression when such feedback seeking
is combined with a negative life event. Joiner (1995) conducted a study of college roommates and
found that controlling for self-esteem, the interaction of NFS and roommate rejection predicted
increases in depressive symptoms three weeks later. Additionally, Pettit & Joiner (2001) found
that the interaction of NFS and perceived midterm failure predicted increases in depressive symp-
toms following the receipt of their midterm grade. Similar results have been found in a sample of
adolescent girls, as Borelli & Prinstein (2006) found that NFS longitudinally predicted depressive
symptoms 11 months later. The results of these prospective longitudinal studies provide evidence
that among adults and adolescents, endorsing a desire for negative feedback puts individuals at
heightened risk for depressive symptoms. There is also evidence that NFS is a stable tendency,
as Rehman and colleagues (2008) found that even after controlling for current depressive symp-
toms, remitted and currently depressed women engaged in higher levels of NFS compared to
never-depressed women.
Not only has NFS been found to be a correlate and risk factor of depressive symptoms, but
longitudinal studies have also provided evidence that over time, NFS is predictive of peer rejec-
tion (Borelli & Prinstein 2006, Joiner et al. 1997, Swann et al. 1992b). Thus, engaging in the

interpersonal feedback-seeking behavior of NFS has the potential to produce the negative inter-
personal consequence of social rejection. For instance, Swann and colleagues (1992b) found that
participants who reported seeking more negative feedback during the middle of the semester were
more likely to have roommates who reported attitudes of rejection toward the participant, a desire
to terminate the relationship, and a plan to secure a new roommate at the end of the semester.
Among adolescents, Borelli & Prinstein (2006) provided evidence that higher self-reported levels
of NFS at baseline predicted higher levels of perceived criticism from best friends among girls
and lower levels of peer-rated social preference among boys. Similar results have also been found
in a sample of youth psychiatric inpatients. Joiner and colleagues (1997) provided evidence that
among youth psychiatric inpatients, greater interest in receiving negative feedback from others
was predictive of the participant receiving more negative interpersonal evaluations by other youth
psychiatric inpatients. Interest in negative feedback was only found to predict negative interper-
sonal evaluations from other inpatients within relatively longer peer relationships (i.e., at least a
week).
Specificity of ERS and NFS to Depression

Given that ERS and NFS are considered to be risk factors for depression, they should dis-
play relative specificity to depression versus other forms of psychopathology. Both ERS and
NFS have shown relative specificity to depressive symptoms and depression diagnoses, although
the findings have been somewhat mixed. In a sample of Air Force cadets, high levels of ERS
predicted increases in depressive but not anxious symptoms ( Joiner & Schmidt 1998). Ad-
ditionally, Joiner and colleagues (2001) provided evidence that among both adults and chil-
dren, ERS was found to be a relatively specific feature of depression compared to other psy-
chiatric diagnoses such as anxiety disorders, substance abuse, schizophrenia, and externalizing
disorders.
Although ERS has mostly been studied in relation to depression, recent research has been
conducted examining the role of ERS in anxiety disorders. Research has provided evidence that
ERS plays an important role in the maintenance of anxiety disorders (e.g., Cougle et al. 2012,
Parrish & Radomsky 2010); however, ERS has been defined more broadly in these studies as
the repeated solicitation of safety-related information from others about threatening objects,
situations, or interpersonal characteristics, despite having already received this information.
Therefore, although ERS has been found to be implicated in anxiety disorders, the reassurance
seeking is not directed at soliciting feedback about one’s self-worth; rather, the feedback solicited
is more specifically related to perceived threats. Consequently, the construct of ERS as defined
in the anxiety literature appears to be somewhat different from the construct of ERS as defined
in the depression literature, and it will be useful for future research to better evaluate the overlap
and unique features of these constructs.
NFS has also been found to be relatively specific to depressive symptoms. Joiner and colleagues
(1997) found that elevated interest in negative feedback was specifically related to depressive
symptoms but not anxiety symptoms. Additionally, Pettit & Joiner (2001) conducted a prospective
study and found that participants who reported high baseline levels of NFS and performed below
expectations on a midterm exam showed an increase in depressive symptoms at follow-up, and
they did not show an increase in anxiety symptoms. Inconsistent with previous findings, Borelli
& Prinstein (2006) provided evidence that among boys, baseline depressive symptoms did not
predict NFS at follow-up. Rather, symptoms of social anxiety were the only symptoms to predict
NFS during the follow-up period.

INTEGRATIVE MODELS OF EXCESSIVE REASSURANCE SEEKING

AND NEGATIVE FEEDBACK SEEKING
Research has provided evidence that the self-reported tendency to engage in two distinct types
of interpersonal feedback-seeking behavior—ERS and NFS—predicts depressive symptoms and
interpersonal rejection. It is particularly notable that both ERS and NFS have been found to
predict depressive symptoms because the goals of ERS and NFS are different and in conflict
with one another for individuals experiencing depressive symptoms. Namely, the goal of ERS
is for self-enhancement, and the goal of NFS is for self-verification. As there is evidence that
individuals who are experiencing depressive symptoms tend to engage in both ERS and NFS, it is
possible that this pattern of excessive and inconsistent feedback-seeking behavior elicits rejection
from close others. Joiner & Metalsky (1995) tested an integration of Coyne’s (1976) interpersonal
theory of depression with self-verification theory and found that mildly depressed male (but not
female) participants who reported tendencies to engage in both ERS and NFS tended to receive
negative evaluations by their roommates three weeks later. Of note, when mildly depressed male
participants reported engaging in only one type of feedback-seeking behavior (i.e., ERS or NFS),
they did not elicit rejection from their roommates, suggesting that the combined effect of engaging
in ERS and NFS has the potential to elicit interpersonal rejection, particularly among men.
Several interpersonal models of depression have accounted for the fact that both ERS
and NFS have been found to be correlates and risk factors for depressive symptoms. These
models include the cognitive-affective crossfire model ( Joiner et al. 1993), cognitive pro-
cessing approach (Swann 1990, Swann & Schroeder 1995, Swann et al. 1990), integrative
interpersonal framework ( Joiner 2000), and the global enhancement and specific verification
theory (Evraire & Dozois 2011).
Cognitive-Affective Crossfire Model

Research has provided evidence that individuals can have different cognitive and affective re-
sponses to self-relevant feedback, particularly if they are experiencing symptoms of depression
(e.g., Swann et al. 1987). For instance, when individuals experiencing depressive symptoms solicit
negative feedback from others, the negative feedback tends to be affectively displeasing because
of its negative nature, but it also tends to be cognitively satisfying because it is self-verifying (i.e.,
consistent with their already negative self-concept). On the other hand, when individuals experi-
encing depressive symptoms solicit excessive reassurance from others, the feedback they receive
is affectively pleasing because of its self-enhancing nature, but it is also cognitively dissatisfying
because it is incongruent with their negative self-views.
According to the cognitive-affective crossfire model ( Joiner et al. 1993), the inconsistency
between one’s cognitive and affective responses to self-relevant feedback leads to either cogni-
tive or affective discomfort, which contributes to additional feedback-seeking behavior to reduce
this discomfort. For an individual experiencing depressive symptoms, the receipt of positive, self-
enhancing feedback is likely to be both affectively pleasing and cognitively incongruent. As a result
of the discomfort that arises from this cognitive incongruence, the individual may then engage in
NFS to obtain self-verifying feedback that is more cognitively consistent. However, the receipt
of this more cognitively consistent negative feedback is still affectively displeasing to the individ-
ual, which may then lead him or her to engage in ERS to receive more affectively pleasing and
self-enhancing feedback. Thus, the cognitive-affective crossfire model describes how individuals
who are experiencing depressive symptoms can exhibit a pattern of soliciting self-enhancing posi-
tive feedback through ERS and self-confirming negative feedback through NFS. This model also

proposes that individuals who are experiencing depressive symptoms may elicit rejection from
close others in their environment as a result of their persistent yet inconsistent attempts to solicit
self-relevant feedback. In support of this facet of the model, Joiner and colleagues (1993) pro-
vided evidence that the combination of negative feedback seeking, high reassurance seeking, and
depression placed participants at greatest risk of negative evaluation by their roommates.
Cognitive Processing Model

The cognitive processing model (Swann 1990, Swann & Schroeder 1995, Swann et al. 1990)
proposes that self-enhancement and self-verification strivings require different levels of cognitive
processing. Processing self-enhancing feedback is thought to require fewer cognitive resources
than self-verifying feedback. When an individual receives self-enhancing feedback, only one step
of processing is required: determining whether the feedback is favorable or unfavorable. When an
individual receives self-verifying feedback, additional steps of processing are involved, including
accessing one’s self-views and determining whether the feedback is consistent or inconsistent with
his or her self-views (Swann et al. 1990).
Swann and colleagues (1990) conducted a study in which they manipulated the cognitive load
of individuals with negative self-views and then gave them the opportunity to solicit either self-
enhancing or self-verifying feedback. Results provided evidence that the type of feedback partic-
ipants sought depended upon the amount of cognitive resources they had available at the time.
Particularly, among participants with negative self-views, those who were under a high cognitive
load preferred to engage with a self-enhancing evaluator, whereas those who were not deprived of
cognitive resources preferred to engage with a self-verifying evaluator. Thus, these results suggest
that when more cognitive resources are available, an individual with a negative self-view may be
more likely to engage in self-verifying NFS than self-enhancing ERS. However, when cognitive
resources are limited, the individual may be more likely to solicit self-enhancing ERS than self-
verifying NFS because it requires fewer steps of cognitive processing. The cognitive processing
model has not yet been tested in a sample of depressed individuals; thus, it is unclear whether sup-
port for this model would be found in this sample. One instance in which depressed individuals
are under an especially high cognitive load is when they are engaging in rumination (Levens et al.
2009); thus, it would be valuable for future research to test whether depressed individuals who
were randomly assigned to a rumination induction would be more likely to seek out self-enhancing
feedback compared to self-verifying feedback.
Integrative Interpersonal Framework for Depression and its Chronicity

Although both the cognitive-affective crossfire model ( Joiner et al. 1993) and the cognitive pro-
cessing model (Swann 1990, Swann & Schroeder 1995, Swann et al. 1990) propose an explanatory
framework for why depressed individuals tend to engage in both self-enhancing ERS and self-
verifying NFS, these models do not directly account for the chronic nature of depression. In other
words, an important question that previous interpersonal models of depression have not addressed
is why depression tends to be a recurrent and persistent form of mental illness.
To redress this limitation of previous theories, Joiner (2000) proposed the integrative in-
terpersonal framework for depression. This framework argues that a number of interpersonal
self-propagatory processes are involved in generating and maintaining depression. The frame-
work defines a self-propagatory process as a complex of psychological and behavioral factors that
(a) represents depression-related, initiated, and active behaviors that (b) serve to prolong and ex-
acerbate existing symptoms or induce the recurrence of past symptoms. Borrowing heavily from

the stress-generation model of depression (e.g., Hammen 1991), Joiner’s (2000) integrative inter-
personal framework argues that several depression-related mechanisms actively produce a variety
of interpersonal problems and stressors; these problems, in turn, are strong predictors of future
depressive symptoms and/or lengthened current episodes of depression. Among the psychological
and behavioral factors that Joiner (2000) predicts are implicated in this self-propagatory process
are excessive reassurance seeking (e.g., Joiner et al. 1992), negative feedback seeking (Swann et al.
1992b), interpersonal conflict avoidance (e.g., Ball et al. 1994), and blame maintenance (i.e., the
idea that depressed people’s relationship partners develop mental representations of them that
become relatively autonomous and bias subsequent perceptions of the depressed person, regard-
less of whether depression has remitted; Sacco & Dunn 1990). There is evidence that each of
these factors is reciprocally involved with both interpersonal stress and depression, with one often
leading to the other in a serial fashion. In addition to the more proximal self-propagatory processes
described above, the framework also includes the following more distal and traitlike interpersonal
risk factors for depression that contribute to the chronicity of depression via the generation of
stress: poor social skills (e.g., Bos et al. 2007), insecure attachment (e.g., Hankin et al. 2005),
and sociotropy (e.g., Shih 2006). The latter two distal and traitlike interpersonal risk factors are
discussed in more detail later in this review.
Global Enhancement and Specific Verification Theory

The global enhancement and specific verification theory (Evraire & Dozois 2011) provides another
account for why depressed individuals tend to simultaneously engage in both self-enhancing ERS
and self-verifying NFS. This theory is based on the idea that self-views vary on a continuum from
global to specific (Neff & Karney 2002). According to the theory, individuals with depression
tend to desire and seek out self-enhancing feedback about their global traits and self-verifying
feedback about their specific attributes. Therefore, an individual experiencing depression might
seek excessive reassurance from close others that she is a kind person but also seek negative,
self-verifying feedback about her specific ability as a dancer, friend, or artist.
The theory also accounts for the fact that nondepressed individuals who solicit global self-
enhancement and specific verification have not been found to be at increased risk for being eval-
uated negatively and rejected by others (e.g., Joiner et al. 1992, 1993; Joiner & Metalsky 1995).
Therefore, the theory posits that there must be something unique about depression that makes
this feedback-seeking behavior aversive to others. The theory predicts that the tendency to engage
in global self-enhancement and specific self-verification interacts with individuals’ core beliefs to
predict interpersonal stress, rejection, and depression. For instance, individuals who hold early
core beliefs reflecting insecurity in relationships and have an overall negative core belief system
about themselves are more likely to engage in ERS and NFS in a persistent and aversive man-
ner, which increases their risk of interpersonal stress and rejection. This interpersonal stress and
rejection then contribute to an increase in depressive symptoms, which leads to an increased
need for the individual to engage in ERS and NFS, thus maintaining and perpetuating his or
her depressive symptoms. On the other hand, individuals who hold early core beliefs reflecting
security in relationships and have an overall positive core belief system about themselves (i.e.,
nondepressed individuals) are likely to engage in ERS and NFS in a manner that is not aversive to
others. Therefore, their efforts to solicit self-enhancing and self-verifying feedback tend to lead
to positive relationship outcomes, feelings of security, and satisfaction.
Of note, the global enhancement and specific verification theory is heavily based on the rather
limited measures of the constructs of ERS and NFS that are currently available. ERS is measured
using the DIRI-RS ( Joiner et al. 1992), which measures the tendency to seek reassurance about

global self-views (e.g., Do you find yourself often asking people you feel close to how they truly feel
about you?), and NFS is measured using the Feedback Seeking Questionnaire (Swann et al. 1992b),
which measures the tendency to seek negative feedback about specific self-attributes (e.g., intellect,
social functioning, musical/artistic ability, athletic ability, and physical attractiveness). Based on
the current measurement instruments available, the extent to which depressed individuals seek
excessive reassurance about specific self-views and negative feedback about global self-attributes
is unclear. Thus, further research is needed that concurrently assesses both global and specific
aspects of ERS and NFS.
INTERPERSONAL STYLES AND DEPRESSION

In addition to specific behavioral impairments and interpersonal feedback-seeking behaviors,
depression has been linked to broader risk factors associated with interpersonal styles, such as
interpersonal inhibition, dependency, and insecure attachment styles. Recently, research has in-
vestigated new interactional models of these factors’ relationship with depression. An understudied
and potentially fruitful area of research involves assessing the relationship between interpersonal
styles and interpersonal feedback-seeking behaviors among individuals with depression. In partic-
ular, it is possible that interpersonal styles such as dependency and insecure attachment increase
the likelihood of a depressed individual engaging in ERS and NFS, and possessing these interper-
sonal styles may be the ingredient that makes ERS and NFS aversive when enacted by a depressed
individual.
Interpersonal Inhibition
Interpersonal inhibition, which includes avoidance, withdrawal, and shyness, has been found to
be a correlate of depression (e.g., Alfano et al. 1994). In fact, Ball and colleagues (1994) found that
above and beyond prior history of depression, lack of assertiveness was a significant predictor of
depression. Prospective longitudinal studies have found that social withdrawal was a significant
risk factor for the development of depressive symptoms over time among children (Boivin et al.
1995) and adults (Elovainio et al. 2004). Furthermore, Joiner (1997) found that level of shyness
and social support interacted to predict an increase in depressive symptoms five weeks later.
Particularly, compared to participants with low levels of shyness, participants with high levels of
shyness experienced an increase in depressive symptoms over the course of a five-week follow-up
period when social support was absent, but not when it was present. The moderated relationship
between shyness, low social support, and depressive symptoms was found to be mediated by feelings
of loneliness, suggesting that shyness in the presence of low social support predicts increases in
depressive symptoms via increases in loneliness. Murberg (2009) replicated and expanded these
data in a sample of adolescents, finding that there was a significant interaction between shyness
and social support predicting increases in future depressive symptoms while controlling for gender
and extraversion over the course of a one-year follow-up period. Other studies have also provided
evidence that shyness measured as early as 18 months of age was predictive of depression in
adolescence, and this relationship between shyness and depressive symptoms was mediated by low
levels of social support (Karevold et al. 2009).
Interpersonal inhibition may contribute to the social skills deficits that depressed individuals
experience because their inhibition leads them to have less practice at interacting with others.
Additionally, the low levels of social support and loneliness that depressed individuals tend to
experience as a consequence of their interpersonal inhibition may lead them to become interper-
sonally dependent on the few social contacts from which they feel support. Dependency on these

individuals may manifest itself through ERS and NFS behaviors, which ultimately may lead to
interpersonal rejection and increased feelings of loneliness.
Interpersonal Dependency
Interpersonal dependency has long been identified as a risk factor for depression (e.g., Blatt et al.
1982). Beck (1983) also discussed the concept of interpersonal dependency through his concept of
sociotropy. High levels of sociotropy indicate an excessive need for interpersonal attachment and
pleasing others, with an accompanying sense of doubt regarding the strength of interpersonal re-
lationships (for a discussion of the relationship between sociotropy and interpersonal dependency,
see Zuroff et al. 2004). Of note, this sense of doubt that characterizes sociotropy overlaps quite
extensively with the sense of doubt that precedes ERS, suggesting that these two constructs are
likely to be highly correlated. The presence of interpersonal dependency (Mongrain et al. 2004)
and sociotropy (Shih 2006) has been shown to predict increases in symptoms of depression over
time. Both have also been found to be related to the onset of major depressive disorder (Mazure
et al. 2000, Sanathara et al. 2003). Frewen & Dozois (2006), however, did not find that sociotropy
was a significant predictor of depression when controlling for additional personality variables.
These risk factors are often studied as diatheses in a diathesis-stress model positing that having
a tendency for interpersonal dependency will only lead to increases in depressive symptoms in
the context of interpersonal stressors. Although multiple studies have demonstrated that interper-
sonal dependency and stress interact to predict increased depressive symptoms in college students
(Priel & Shahar 2000, Shahar et al. 2004), similar results have not been found when predicting
the development of depressive episodes. In Mazure and colleagues’ (2000) study discussed above,
sociotropy was found to predict the onset of depression; however, sociotropy did not significantly
interact with stress to predict depression. As is discussed in the next section, recent research has
provided evidence that sociotropy may have a complex interactional relationship with depression.
Attachment Style
Research has also provided some evidence for a relationship between attachment styles and the
development of depression. This work has been informed by Bowlby’s (1973) attachment theory,
which proposes that infants’ attachment to primary caregivers strongly influences their future
relationships with others. Although this theory has been the subject of much research and further
development since it was proposed, at its core, it can be summarized as describing secure and
insecure (including anxious, avoidant, and fearful) attachment styles. Securely attached adults
tend to do well, being socially skilled, confident, and able to form stable and close relationships
with others. Insecurely attached adults tend to have a much more difficult time forming and
maintaining close personal relationships (for a review, see Cassidy & Shaver 2008).
Despite a variety of categorizations of attachment style, research has established that there is
a general association between insecure attachment styles and depressive symptoms (Roberts et al.
1996) and diagnoses (Reinecke & Rogers 2001). Additionally, longitudinal studies have found that
insecure attachment styles pose a prospective risk for the development of both depressive symptoms
(Hankin et al. 2005) and diagnosable depression (Eberhart & Hammen 2006). Jan Conradi & de
Jonge (2009) also found that those with a fearful attachment style had a worse course of depression
over three years, more prior depressive episodes and residual symptoms, longer antidepressant use,
and worse social functioning overall than those with secure attachments. Similar to individuals
with high levels of sociotropy, individuals with an insecure attachment style may also tend to

doubt the security of relationships, potentially contributing to an increased likelihood of engaging

in interpersonal feedback seeking.
Hammen and colleagues (1995) provided support for a diathesis-stress model of the relationship
between attachment and depression, as they found that insecure attachment and interpersonal
stress interacted to predict depressive symptoms. Eberhart & Hammen (2010), however, found no
support for a diathesis-stress model in their study of the interaction between romantic relationship
stress and attachment style on depressive symptoms. They did, however, find that the relationship
between anxious attachment and depressive symptoms was mediated by romantic conflict and that
the relationship between both anxious and avoidant attachment and symptoms of depression were
mediated by the presence of daily stressors. In a study of undergraduates, insecure attachment and
perceived life stress independently predicted increases in depressive symptoms three weeks later;
however, no significant interaction between attachment and stress was found (Liu et al. 2009).
Other recent studies have also found a variety of factors that mediate the relationship be-
tween insecure attachment and depression. Two separate studies of college students have found
that the relationship between insecure attachment and depression is mediated by sociotropy
(Cantazaro & Wei 2010, Permuy et al. 2010). This relationship between insecure attachment,
sociotropy, and depression highlights the overlap and link that exists between the constructs
of insecure attachment and sociotropy. Propensity to forgive, dysfunctional attitudes, and low
self-esteem have also been found to mediate the relationship between insecure attachment and
symptoms of depression (Burnette et al. 2009, Lee & Hankin 2009). Thus, having an insecure
attachment style may lead individuals to develop depression because of their increased levels
of sociotropy, dysfunctional attitudes, low self-esteem, or their decreased propensity to forgive.
Although much recent research has demonstrated that the connection between attachment style
and depression is more indirect than initially understood, the exact nature of what mediates
the relationship and under what conditions it does so is in need of further investigation and
clarification.
INTERPERSONAL CONSEQUENCES OF DEPRESSION

Given that depression has been found to be associated with poor social skills, excessive reassur-
ance seeking, negative feedback seeking, interpersonal inhibition, negative verbal and nonverbal
behaviors, and so forth, it is not surprising that depressed individuals tend to experience problems
in their personal relationships. Gotlib & Lee (1989) found that the relationships of depressed indi-
viduals tend to be characterized by rejection, dissatisfaction, low intimacy, and decreased activity
and involvement.
In addition to contributing to relationship difficulties, another interpersonal consequence of
depression is contagious depression (i.e., the spread of depressive symptoms from one person to
another). A meta-analysis on the contagion of depressive symptoms and mood provided substantial
support for the view that depressive symptoms and mood are contagious; however, the contagion
was found to be most pronounced in studies of depressive symptoms (versus depressed mood)
( Joiner & Katz 1999). Also in support of the depression contagion hypothesis, Joiner (1994)
found that the roommates of depressed college students tended to experience increased depressive
symptoms over the course of several weeks, and shared negative life stress was ruled out as an
explanation for the finding. Therefore, depression has the potential not only to contribute to
interpersonal distress for the depressed individual, but also to an increase in depressive symptoms
in others who are in close contact with the depressed individual. If close others begin to notice
that they experience an increase in depressive symptoms when they interact with the depressed
individual, it may lead to relationship problems and even rejection.

TREATMENT IMPLICATIONS
A variety of interpersonal risk factors, correlates, and consequences of depression have been identi-
fied in the literature, and such findings should inform the treatment and prevention of depression.
It is important that the interpersonal processes that have been found to play a role in depression
are adequately targeted in treatments so that the interpersonal distress and impairment that often
accompany depression can be reduced. To date, several treatments have been developed and em-
pirically tested that target the interpersonal processes associated with depression. Among these
treatments are interpersonal psychotherapy (IPT), behavioral activation (BA), and the cognitive
behavioral analysis system of psychotherapy (CBASP).
IPT (Weissman et al. 2000) is based on the premise that depression occurs in the context of an
individual’s relationships (i.e., depression affects an individual’s relationships, and the individual’s
relationships affect his or her mood). The goal of IPT is to identify the general area in which a
person is having relationship difficulties and to build the person’s skills in that area to improve his
or her relationships and thus decrease his or her depressive symptoms. There are four primary
areas on which IPT can focus: grief, role transitions, role disputes, or interpersonal deficits. IPT
has been found to be an effective treatment for depression (de Mello et al. 2005). Specifically, IPT
can target specific deficits in social skills, behavioral interactions, and communication behaviors
that may result from a grief reaction, a major role transition, or an interpersonal dispute and be
harmful to an individual’s current relationships.
Another treatment that can be used to address common interpersonal processes involved in
depression is BA (Lejuez et al. 2011). BA targets inactivity, withdrawal, and avoidance behaviors
that can exacerbate depressive symptoms. In order to counteract these patterns of behavior, be-
havioral activation focuses on increasing exposure to pleasant activities and positive interactions in
the environment. The treatment involves identifying one’s values in a particular life area and using
them to identify, plan, and perform daily activities that are consistent with these values. Behavioral
activation centers on the approach that an increase in positive and enjoyable experiences will result
in improved energy and motivation and a decrease in depression. As an individual becomes more
socially integrated through BA, it is likely that his or her social skills, communication behaviors,
and interpersonal behaviors might also improve. Behavioral activation treatments have been found
to be effective in reducing depressive symptoms (e.g., Mazzucchelli et al. 2009).
Additionally, CBASP (McCullough 2003) operates on the premise that individuals suffering
from chronic depression are disconnected from their environment and, as such, fail to receive
critical information concerning problematic interpersonal patterns that may generate or main-
tain depressive symptoms. In CBASP, the therapist and patient collaboratively and systematically
analyze brief, distressing interpersonal interactions using the following steps: (a) describing the
situation in objective and behavioral terms, (b) identifying the individual’s thoughts and behaviors
during the interaction, (c) identifying a specific and behavioral desired outcome for the interaction
that is only a reflection of the individual’s behavior, (d ) comparing one’s desired outcome to what
actually happened during the interaction, (e) assessing whether each thought and behavior dur-
ing the interaction was helpful or hurtful in the individual achieving his or her desired outcome,
( f ) remediating any thoughts or behaviors deemed to be unhelpful in achieving the desired out-
come, and ( g) generalizing the lessons from this brief interaction to other interactions the individ-
ual has had. A primary aim of CBASP is for individuals to gain new perspectives on how to interact
with others that may result in more satisfying interpersonal interactions. For instance, a situation
during which an individual engaged in ERS or NFS can be addressed in a CBASP framework by
discussing with the patient whether ERS or NFS was helpful or hurtful in achieving his or her
desired outcome, discussing why the behavior might have been harmful, and discussing another

remediated behavior that might have been more helpful for the patient to attain his or her desired
outcome. CBASP has been found to be an effective treatment for chronic depression (e.g., Keller
et al. 2000, Klein et al. 2004).
SUMMARY AND FUTURE DIRECTIONS

To date, a significant amount of progress has been made in identifying and understanding the
interpersonal processes that have been found to be correlates and risk factors for depression. Re-
search has provided consistent and compelling evidence regarding the social skills, basic behavioral
features, and communication behaviors of depressed individuals. Namely, there is considerable
consensus that more animated expressions of sadness, poor eye contact, poor posture, and infre-
quent gesturing tend to characterize depressed individuals. When communicating with others,
depressed individuals have been consistently found to have poor social skills, to speak slowly and
quietly, and to be less likely to initiate social interactions. When compared to their nondepressed
counterparts, depressed individuals also have a tendency to use more negative conversational
content and engage in interpersonal feedback-seeking behavior such as ERS and NFS.
Coyne’s (1976) interactional theory of depression was one of the first to incorporate interper-
sonal processes. The theory proposed that individuals interact with others in their environment
in such a way that increases the likelihood that they will experience interpersonal rejection and a
depressive episode. ERS was later identified as the key behavioral component of Coyne’s model
( Joiner et al. 1992). Given that research provides evidence that depressed individuals tend to en-
gage in both ERS and NFS, several interpersonal models of depression have been proposed to
explain why depressed individuals tend to engage in both self-enhancing ERS and self-verifying
NFS. First, the cognitive-affective crossfire model ( Joiner et al. 1993) proposed that the incon-
sistency between one’s cognitive and affective responses to self-relevant feedback leads to either
cognitive or affective discomfort, which then leads to additional feedback-seeking behavior to re-
duce this discomfort. Second, the cognitive processing model (Swann 1990, Swann & Schroeder
1995, Swann et al. 1990) proposed that self-verification requires more complex cognitive process-
ing than self-enhancement; thus, an individual will choose to engage in ERS or NFS as a function
of his or her cognitive load. Under conditions of high cognitive load, individuals will choose to
engage in the less complex ERS, but when cognitive resources are available, the individual will
be more likely to engage in the more complex NFS. Third, the global enhancement and specific
verification model (Evraire & Dozois 2011) proposed that individuals with depression tend to
prefer receiving negative, self-verifying feedback concerning their specific qualities, while also
engaging in high levels of reassurance seeking around their global self-views of acceptance or re-
jection. Fourth, to address limitations of prior models, which did not account for the chronic and
persistent nature of depression, Joiner (2000) proposed an integrative interpersonal framework
for depression. The framework argues that several self-propagatory processes (i.e., ERS, NFS)
actively produce a variety of interpersonal problems and stressors and that these problems, in
turn, are strong predictors of future depressive symptoms and/or lengthened current episodes of
depression.
In addition to basic behavioral features and interpersonal feedback-seeking behaviors, interper-
sonal styles such as interpersonal inhibition, interpersonal dependency, and insecure attachment
have been found to be associated with depression. Not only is there a significant amount of over-
lap between the constructs of the interpersonal styles that have been found to be associated with
depression, but these interpersonal styles are also likely to be closely linked to the tendency to
engage in interpersonal feedback seeking. Depression has also been found to have a number of
interpersonal consequences, such as interpersonal rejection, social withdrawal, and depression

contagion. Given the interpersonal processes that have been found to be implicated in depression,
several treatments have been developed that address these interpersonal processes; namely, IPT
(Weissman et al. 2000), BA (Lejuez et al. 2011), and the CBASP (McCullough 2003).
Despite the progress that has been made in identifying and understanding the interpersonal
processes involved in depression, there are still several areas that would be fruitful for future
research to pursue. In particular, the literature would greatly benefit from additional research
being conducted in (a) the development of more integrative models of depression that explore the
relationship between interpersonal and noninterpersonal factors involved in the onset, mainte-
nance, and recurrence of depression; (b) improved measurement of the constructs of interpersonal
feedback-seeking behaviors (i.e., ERS, NFS); (c) potential links between the interpersonal factors
involved in depression and suicidality; and (d ) the development of interventions that more directly
target interpersonal processes in depression.
Integrative Models of Depression

A number of interpersonal models of depression have been proposed to explain how interpersonal
factors are involved in the onset, maintenance, and recurrence of depression. However, the models
that have been proposed to date have specifically focused on interpersonal feedback-seeking be-
haviors, and little research has been conducted that links interpersonal feedback seeking to other
interpersonal factors such as social skills, interpersonal inhibition, interpersonal dependency, and
attachment style. Additionally, little research has been conducted to explore the relationship
between interpersonal and noninterpersonal factors (e.g., negative cognitive style, rumination,
biological, genetic) involved in depression. Developing integrative theories of depression to ad-
dress how interpersonal and noninterpersonal factors involved in depression work together would
create a more comprehensive understanding of the factors that contribute to depression’s onset
and chronicity.
Some initial steps have been made looking at integration between cognitive and interpersonal
factors in depression. Specifically, Weinstock & Whisman (2007) conducted a study looking at
the cross-sectional associations between depression, ruminative response style, and ERS. Results
provided evidence that rumination mediated the relationship between depression and ERS. As
rumination (Nolen-Hoeksema 1991) and reassurance seeking are conceptually similar in that
they both involve a perseverative response to depressive symptoms, this was the first study to
date to find a cross-sectional association between the two constructs. It would be fruitful for
future research to conduct studies assessing the longitudinal associations between interpersonal
and noninterpersonal factors so that temporal relationships can be evaluated. For instance, if an
individual is persistently ruminating about self-worth, this rumination might precede and predict
reassurance-seeking behavior in which the individual persistently asks others about his or her
self-worth.
Measurement of Constructs
Both ERS and NFS are assessed using self-report measures that ask individuals how frequently
they tend to engage in ERS and NFS. Although such self-report measures have been shown to be
reasonably reliable and valid, there are several limitations to the current methods of measuring
these constructs. First, the extent to which an individual can accurately report how often he or
she engages in interpersonal feedback-seeking behaviors is unclear. Individuals may have different
levels of insight into their feedback-seeking behavior, and it is possible that some individuals who
are frequently engaging in ERS and NFS are unaware of the extent to which they are doing

so. Additionally, in the context of the interpersonal theories of depression, it is arguably more
important to assess how frequently close others in the individual’s environment report that he
or she is engaging in interpersonal feedback-seeking behavior because engaging in ERS and
NFS is only thought to lead to interpersonal rejection if it becomes bothersome to those in
the environment. Therefore, it would be valuable for future research to develop other-report
measures of interpersonal feedback seeking and compare these other-report measures to self-
report measures of these constructs. Rehman and colleagues (2008) have taken an initial step
forward in this regard by developing a novel behavioral measure of NFS.
Second, very few studies to date have assessed actual interpersonal rejection as an outcome
variable. Instead, many studies have assessed others’ attitudes of rejection toward the participant,
and it is unclear whether these attitudes of rejection lead to actual interpersonal rejection of
the participant in the future. Studies have also frequently measured individuals’ perceptions of
rejection by close others as an outcome variable. Although measuring attitudes of rejection and
perceived rejection is important and useful, it is important for future research to address whether
interpersonal feedback-seeking behaviors predict actual interpersonal rejection.
Links Between Interpersonal Factors in Depression and Suicidality

One of the nine symptoms of a major depressive episode outlined in the DSM-IV-TR
(Am. Psychiatr. Assoc. 2000) is having recurrent suicidal ideation or thoughts of death. Although
this symptom is not a necessary feature of a major depressive episode, when present, it has the po-
tential to have grave consequences. Major depression is the psychiatric diagnosis most commonly
associated with suicide, as roughly two out of three people who die by suicide are depressed at
their time of death (Am. Assoc. Suicidol. 2010), and substantially more than that have subclinical
depressive symptoms in the time frame before death. Importantly, suicidal ideation and behavior
are not exclusive to major depressive disorder and can occur in the context of a variety of other
psychiatric diagnoses.
Regardless of whether suicidal ideation occurs in the context of a major depressive episode or
not, the interpersonal theory of suicide ( Joiner 2005, Van Orden et al. 2010) provides a compelling
framework to explain the factors that contribute to suicidal ideation and behavior. According to
the interpersonal theory of suicide, two interpersonal states must be experienced simultaneously
in order to develop the desire for suicide: thwarted belongingness and perceived burdensomeness.
Thwarted belongingness is characterized by feelings of loneliness, disconnection from others, and
the perceived or actual absence of social relationships. Perceived burdensomeness is characterized
by the misperception that one is a burden on others, and it involves feelings of self-hatred and the
belief that one’s death would be worth more than one’s life. In the context of the theory, emphasis
is placed on the idea that the states of thwarted belongingness and burdensomeness are perceived
by the individual, regardless of their actual level of social connection and burden on others. The
theory predicts that when one simultaneously experiences thwarted belongingness and perceived
burdensomeness, and one perceives these states to be stable and unchanging, active suicidal desire
develops. In fact, both thwarted belongingness (e.g., Timmons et al. 2012, You et al. 2011) and
perceived burdensomeness (e.g., Cukrowicz et al. 2011, Joiner et al. 2006) have been found to be
associated with higher levels of suicidal ideation.
When experienced concurrently, there is evidence that the interpersonal states of thwarted be-
longingness and perceived burdensomeness are proximal and potent predictors of suicidal ideation.
However, despite the strong link that exists between depression and suicidality, to our knowledge,
no research to date has examined the interplay of the interpersonal risk factors for depression and
suicidality. For instance, it is unclear the extent to which individuals experiencing suicidal ideation

engage in interpersonal feedback-seeking behaviors such as ERS and NFS, and it would be useful
for future research to assess whether the content of the feedback-seeking behavior is focused on
themes of thwarted belongingness and perceived burdensomeness in these individuals, as would
be predicted by the interpersonal theory of suicidal behavior ( Joiner 2005, Van Orden et al. 2010).
It is possible that individuals experiencing suicidal ideation are frequently asking others in their
environment whether they belong or are a burden on them. Such feedback seeking might con-
tribute to actual interpersonal rejection, which is likely to strengthen their original beliefs that
they do not belong and are a burden on others. Over time, this pattern of feedback seeking may
result in the suicidal individual becoming increasingly socially isolated and consequently increase
his or her risk for death by suicide.
Interventions
To date, several treatments have been developed that, at least in part, address some of the inter-
personal processes involved in depression. IPT (Weissman et al. 2000), BA (Lejuez et al. 2011),
and the CBASP (McCullough 2003) all include components that have the potential to address in-
terpersonal factors such as social withdrawal, interpersonal conflict, and interpersonal inhibition.
However, none of the interventions include specific techniques to directly target an individual’s
tendency to engage in interpersonal feedback seeking. As ERS and NFS have been found to be
important correlates of and risk factors for depression, an important avenue for future research is
to develop and test the efficacy of treatments and prevention interventions that aim to reduce the
frequency of these interpersonal behaviors that could lead to rejection.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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CP09-FrontMatter ARI 9 March 2013 1:0
Annual Review of
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Neurotoxic Effects of Alcohol in Adolescence
Joanna Jacobus and Susan F. Tapert p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 703
Socioeconomic Status and Health: Mediating and Moderating Factors
Edith Chen and Gregory E. Miller p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 723
Contents ix
School Bullying: Development and Some Important Challenges

Dan Olweus p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 751
The Manufacture of Recovery
Joel Tupper Braslow p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 781
Indexes
Cumulative Index of Contributing Authors, Volumes 1–9 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 811

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Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org
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CP09CH13-Joiner ARI 24 February 2013 13:20

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Department of Psychology, Florida State University, Tallahassee, Florida 32306;

Annu. Rev. Clin. Psychol. 2013. 9:355–77 Keywords

Cognitive Processing Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364

356 Hames · Hagan · Joiner

agitation/retardation, low energy, extreme feelings of worthlessness or guilt, concentration difﬁ-

future episodes of depression.

BASIC BEHAVIORAL FEATURES AND COMMUNICATION BEHAVIORS

www.annualreviews.org • Interpersonal Processes in Depression 357

SOCIAL SKILLS AND DEPRESSION

358 Hames · Hagan · Joiner

making it more difﬁcult to pursue and maintain new relationships.

INTERPERSONAL FEEDBACK SEEKING AND DEPRESSION

Excessive Reassurance Seeking

www.annualreviews.org • Interpersonal Processes in Depression 359

360 Hames · Hagan · Joiner

Negative Feedback Seeking

www.annualreviews.org • Interpersonal Processes in Depression 361

Specificity of ERS and NFS to Depression

362 Hames · Hagan · Joiner

INTEGRATIVE MODELS OF EXCESSIVE REASSURANCE SEEKING

Cognitive-Affective Crossfire Model

www.annualreviews.org • Interpersonal Processes in Depression 363

Cognitive Processing Model

Integrative Interpersonal Framework for Depression and its Chronicity

364 Hames · Hagan · Joiner

Global Enhancement and Specific Verification Theory

www.annualreviews.org • Interpersonal Processes in Depression 365

INTERPERSONAL STYLES AND DEPRESSION

366 Hames · Hagan · Joiner

www.annualreviews.org • Interpersonal Processes in Depression 367

doubt the security of relationships, potentially contributing to an increased likelihood of engaging

INTERPERSONAL CONSEQUENCES OF DEPRESSION

368 Hames · Hagan · Joiner

www.annualreviews.org • Interpersonal Processes in Depression 369

SUMMARY AND FUTURE DIRECTIONS

370 Hames · Hagan · Joiner

Integrative Models of Depression

www.annualreviews.org • Interpersonal Processes in Depression 371

interpersonal feedback-seeking behaviors predict actual interpersonal rejection.

Links Between Interpersonal Factors in Depression and Suicidality

372 Hames · Hagan · Joiner

www.annualreviews.org • Interpersonal Processes in Depression 373

Guilford. 2nd ed. 1,020 pp.

374 Hames · Hagan · Joiner

Clin. Psychol. Sci. Pract. 7:203–18

www.annualreviews.org • Interpersonal Processes in Depression 375

analysis and review. Clin. Psychol. Sci. Pract. 16:383–411

376 Hames · Hagan · Joiner

processes, and depression. Personal. Soc. Psychol. Bull. 31:343–59

www.annualreviews.org • Interpersonal Processes in Depression 377

Evidence-Based Psychological Treatments: An Update

and Amantia A. Ametaj p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

Depression and Cardiovascular Disorders

Melissa Fisher, Rachel Loewy, Kate Hardy, Danielle Schlosser,