Relationship discord and the prevalence,incidence,and treatment of psychopathology

Abstract

This paper provides a selective review of the literature on the association between poor relationship adjustment (i.e., relationship discord) and the prevalence, incidence, and treatment of psychopathology. Relationship discord has been shown to covary with a variety of psychiatric disorders and predict the incidence of mood, anxiety, and substance use disorders and increases in depressive symptoms. The association between relationship discord and psychopathology is moderated by several individual difference variables, including variables that have been shown to increase risk for psychopathology. Relationship discord is associated with poorer outcome to individual-based treatments for several common psychiatric disorders, and couple-based interventions have been shown to reduce depression and substance use as well as improve relationship discord.

Keywords

Alcohol anxiety depression discord distress mental health psychopathology satisfaction

Because a satisfying marriage or intimate relationship has been identified as one of the most important goals in life (Roberts & Robins, 2000), it may be expected that relationship functioning will impact and be impacted by partners’ mental health. In one of the first published studies on relationships and mental health, Travis (1933) conducted a chart review of precipitating factors for 70 people with manic-depressive psychosis and found that “marital maladjustment” was the most common precipitating factor. Since then, a growing body of research has found that relationship discord is associated with the prevalence, incidence, and treatment of psychopathology.

In this paper, I provide a selective review of the research on relationship discord and psychopathology. The first section is devoted to reviewing the associations between relationship discord and the prevalence and incidence of psychopathology, including moderators of these associations. The second section focuses on the impact of relationship discord on the outcome of individual-based treatments and the efficacy of couple-based interventions for psychopathology. Because a comprehensive literature review is beyond the scope of this paper, the review should be viewed as illustrative.

Relationship discord and the prevalence and incidence of psychopathology

The most common relationship variable that has been studied in the context of psychopathology is self-reported relationship adjustment, with low relationship adjustment labeled as relationship discord (or distress). Researchers have found associations between relationship discord and psychiatric disorders in population-based community samples, which suggests that the results are likely to be highly generalizable. In population-based samples conducted with people from Canada and the United States, greater relationship discord was associated with broad categories for mood, anxiety, and substance-use disorders, as well as diagnoses of specific disorders within these broad categories (e.g., Whisman, 1999; Whisman, Sheldon, & Goering, 2000). For example, compared to people without a disorder, relationship discord is higher for people with current diagnoses of anxiety, mood, and substance use disorder, with the strongest associations obtained between marital discord and bipolar disorder, alcohol use disorders, and generalized anxiety disorder (Whisman, 2007).

Researchers have also evaluated the association between relationship discord and broad latent dimensions underlying common mental disorders. For example, Humbad, Donnellan, Iacono, and Burt (2010) found that higher scores on a composite measure of externalizing psychopathology were associated with lower relationship adjustment. In another study, South, Krueger, and Iacono (2011) evaluated whether the association between relationship adjustment and psychopathology was due to the shared variance between disorders within the internalizing and externalizing spectrum, or whether each disorder was also uniquely associated with relationship adjustment. Results indicated that relationship adjustment was negatively associated with both internalizing and externalizing psychopathology factors, and after accounting for the impact of the internalizing and externalizing factors, there were no significant associations between relationship adjustment and specific disorders. These results suggest that the associations observed between relationship adjustment and specific disorders may be due, at least in part, to the shared variance among disorders within these two latent dimensions. South and colleagues (2011) conclude that it may be the temperamental core of the internalizing spectrum (i.e., general inability to regulate emotions) and externalizing spectrum (i.e., tendency to project distress outward) that contributes both to psychopathology and relationship discord.

Researchers have also evaluated the association between relationship discord and other quality of life indicators. For example, in a large population-based sample, relationship discord was associated with social impairment, work impairment, psychological distress, and suicide ideation (Whisman & Uebelacker, 2006). With the exception of suicide ideation, the association between relationship discord and these indices remained significant when controlling for past-year Axis I disorders, suggesting that the association between relationship discord and distress and impairment was incremental to any shared association with common manifestations of psychopathology. Furthermore, higher levels of relationship discord were associated with greater likelihood of using the mental health care system, even controlling for past-year mood, anxiety, and substance use disorders (Schonbrun & Whisman, 2010); treatment seeking is often viewed as another indicator of impairment.

Longitudinal research on the association between relationship discord and psychiatric symptoms has focused primarily on depression symptoms, and results indicate that baseline relationship discord predicts increases in depression symptoms over time (e.g., Beach & O’Leary, 1993; Beach et al., 2003; Whisman & Uebelacker, 2009). More recently, Brock and Lawrence (2011) examined the longitudinal association between relationship adjustment and internalizing (i.e., depression and anxiety) symptoms. Results indicated that husbands’ (but not wives’) level of relationship adjustment at the beginning of marriage was predictive of their own (but not their wives’) level of internalizing symptoms across the first seven years of marriage. Researchers have also examined within-subjects longitudinal effects of relationship adjustment and depression symptoms by measuring both constructs on multiple occasions, which allows testing whether change in one variable accounts for change in the other variable, above and beyond the way each variable is already changing. Results from these studies have shown that decreases in relationship adjustment co-occur with increases in depression symptoms (e.g., Davila, Karney, Hall, & Bradbury, 2003; Kouros, Papp, & Cummings, 2008; Poyner-Del Vento & Cobb, 2011; Whitton, Stanley, Markman, & Baucom, 2008). When time-lagged effects were examined, relationship adjustment was predictive of subsequent depression symptoms in one study (Poyner-Del Vento & Cobb, 2011) but not in another study (Whitton et al., 2008), underscoring the need for additional research in this important area. Finally, results from one recent study suggest that greater fluctuations in relationship adjustment over time (i.e., relationship adjustment instability) was associated with higher levels of depression symptoms, and accounted for additional variance in depression symptoms, over and above that which was accounted for by mean level of relationship adjustment (Whitton & Whisman, 2010).

Although more limited in number, there are several longitudinal studies indicating that relationship discord predates the onset of psychiatric disorders. For example, in a United States population-based sample of married adults who did not meet criteria for the associated disorder at baseline, a categorical measure of relationship discord was associated with a 2.7-fold increased risk for developing a major depressive episode (Whisman & Bruce, 1999) and a 3.7-fold increased risk for developing an alcohol use disorder (Whisman, Uebelacker, & Bruce, 2006) during the following 12 months; these associations remained significant when controlling for demographic variables and prior history of the disorder. The association between relationship discord and incidence of psychiatric disorders was replicated in a population-based sample of people in the Netherlands who completed three waves of data collection: baseline relationship discord was associated with increased risk of incidence of major depressive disorder, dysthymia, alcohol abuse, and social phobia (Overbeek et al., 2006).

Moderators of the association between relationship discord and psychopathology

Because not all individuals in discordant relationships exhibit psychopathology, researchers have sought to identify variables that moderate the association between relationship discord and psychopathology. This research has the potential to have important public health implications in identifying the people who are at greatest risk for co-occurring relationship and mental health problems. Whisman (2007) examined whether gender or age moderated the association between relationship discord and broad diagnoses of anxiety, mood, and substance use disorder and specific diagnoses of 11 disorders. The association between relationship discord and major depressive disorder increased in magnitude with increasing age; the association between relationship discord and other psychiatric disorders was not moderated by gender or age. In a study conducted to evaluate moderators of the association between relationship discord and major depression, Uebelacker and Whisman (2006) found that this association was greater for married individuals (versus cohabiters); there was no evidence that this association was moderated by other demographic variables, personality characteristics, parental depression, or childhood loss. Furthermore, when the analyses were limited only to married individuals, the strength of the association between relationship discord and depression increased with increasing elevations in neuroticism.

Much of the research on moderators of the association between relationship discord and psychopathology has been conducting for depression symptoms. Relationship discord is more strongly associated with current depression symptoms for (a) men with lower levels of self-esteem (Culp & Beach, 1998), (b) people with higher levels of anxious-ambivalent attachment (Scott & Cordova, 2002), and (c) people with higher levels of blame-orientated attributions about their partner’s negative behaviors (Gordon, Friedman, Miller, & Gaertner, 2005). South and Krueger (2008) examined whether the association between relationship adjustment and internalizing psychopathology was moderated by latent genetic risk for internalizing psychopathology. Results indicated that genetic effects on internalizing psychopathology increased with lower reports of relationship adjustment, suggesting that people with a genetic predisposition to internalizing psychopathology may be more likely to experience internalizing symptoms in the context of a discordant relationship. With respect to the longitudinal association between relationship discord and depression symptoms, the strength of this association is stronger for (a) people who are chronically dysphoric (Beach & O’Leary, 1993), (b) women in poverty (Liu & Chen, 2006), (c) people with higher levels of neuroticism (Davila et al., 2003), (d) people who report greater levels of relationship conflict (Kouros et al., 2008), and (e) women with lower levels of masculinity (Whitton et al., 2008). An early study on the longitudinal association between relationship discord and depression symptoms found that this association was stronger for women than for men (Fincham, Beach, Harold, & Osborne, 1997), but gender has not been found to be a significant moderator of the longitudinal association between relationship discord and depression symptoms in more recent studies (e.g., Beach et al., 2003; Davila et al., 2003; Whisman & Uebelacker, 2009). In sum, many of the variables that have been shown to moderate the association between relationship discord and depression symptoms have themselves been shown to increase the risk for depression symptoms. Therefore, relationship discord may act as an interpersonal stressor, increasing the likelihood of psychopathology in vulnerable individuals.

Up to this point, the focus of the discussion has been on variables that might moderate the association between relationship adjustment and psychopathology. An alternative perspective is that relationship adjustment serves as the moderating variable, influencing the magnitude of the association between some other risk factor and psychopathology. One such perspective is that marital adjustment buffers the adverse effects of stress on the risk of psychopathology. The results from the few studies conducted to date on the stress-buffering hypothesis have yielded inconclusive results. On one hand, Wade and Kendler (2000) found no evidence that the association between stressful life events and risk for major depression or levels of depression symptoms was moderated by level of social support, including marital support. On the other hand, a two-year longitudinal study of newlywed couples who were evaluated every three months over a period of two years found that a higher level of chronic marital stress strengthened the contemporaneous association between relationship discord and depression symptoms for wives; chronic stress did not moderate the time-lagged associations between relationship discord and depression symptoms (Poyner-Del Vento & Cobb, 2011). Because the results from these studies have been inconclusive, additional research is needed to evaluate how relationship adjustment may interact with stressors that originate within and outside of intimate relationships in the development of psychopathology.

Relationship discord and the treatment of psychopathology

If relationship discord is associated with the onset or maintenance of psychopathology, then people in discordant relationships may be less likely to respond to individual-based treatments because the relationship is not addressed in treatment. Indeed, research has shown that relationship discord is associated with poorer outcome for individual-based treatments for psychopathology. For example, for depressed outpatients treated by psychotherapy (cognitive therapy, interpersonal psychotherapy) or medication, poorer marital adjustment at baseline was associated with poorer outcome at the end of treatment, and poorer marital adjustment at post-treatment predicted higher relapse rates following treatment (Whisman, 2001); similarly, relationship discord at baseline was associated with a lower remission rate for chronically depressed outpatients treated with Cognitive Behavioral Analysis System of Psychotherapy or medication, singly or in combination (Denton et al., 2010). Furthermore, poorer marital adjustment has been shown to predict increased likelihood of relapse, percent days abstinent, and time to relapse among people with substance use problems in treatment (e.g., Fals-Stewart, O’Farrell, & Hooley, 2001). Likewise, poorer relationship adjustment predicts poorer outcome of exposure treatment for agoraphobia (for a review, see Chambless, 2010) and treatments for generalized anxiety disorder (e.g., Durham, Allan, & Hackett, 1997; Zinbarg, Lee, & Yoon, 2007).

If relationship discord is associated with the onset or maintenance of psychopathology, then interventions focused on improving relationship functioning may be effective in treating psychopathology. Support for this perspective comes from studies showing that couple-based interventions are effective in treating psychopathology (for a review, see Whisman & Baucom, 2012). Couple-based interventions have been most widely studied with respect to substance use disorder and depression. In a meta-analysis of 12 randomized controlled trials for couples who were experiencing relationship discord and in which one partner had a substance use disorder, Powers, Vedel, and Emmelkamp (2008) reported that behavioral couple therapy was more effective than individual therapy with respect to frequency of substance use (d = .36), consequences of use (d = .52), and relationship discord (d = .57). A recent meta-analysis of eight controlled trials provided evidence for the effectiveness of couple-based interventions in the treatment of depression (Barbato & D'Avanzo, 2008). Couple-based interventions appear to be comparable to individual-based treatment in reducing depression symptoms (d = −.12) and more effective than individual-based treatment in improving relationship adjustment (d = −.60).

Conclusions

Relationship discord is associated with the prevalence and incidence of psychopathology, and researchers have begun to identify moderators of these associations. Furthermore, relationship discord predicts poorer outcome to individual-based treatments of psychopathology and couple-based interventions show promise in treating psychopathology, particularly substance use disorders and depression. The research conducted to date provides a solid foundation for continued research in exploring the role of relationship discord and other relationship processes in the onset and course of psychopathology, as well as for developing couple-based interventions for preventing and treating psychopathology.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Barbato

D'Avanzo

(2008). Efficacy of couple therapy as a treatment for depression: A meta-analysis. Psychiatric Quarterly, 79, 121–132.

Beach

S. R. H.

Katz

Kim

Brody

G. H.

(2003). Prospective effects of marital satisfaction on depressive symptoms in established marriages: A dyadic model. Journal of Social and Personal Relationships, 20, 355–371.

Beach

S. R. H.

O’Leary

K. D.

(1993). Marital discord and dysphoria: For whom does the marital relationship predict depressive symptomatology? Journal of Social and Personal Relationships, 10, 405–420.

Brock

R. L.

Lawrence

(2011). Marriage as a risk factor for internalizing disorders: Clarifying scope and specificity. Journal of Consulting and Clinical Psychology, 79, 577–589.

Chambless

D. L.

(2010). Interpersonal aspects of panic disorder and agoraphobia. In Beck

J. G.

(Ed.), Interpersonal processes in the anxiety disorders: Implications for understanding psychopathology and treatment (pp. 209–233). Washington, DC: American Psychological Association.

Culp

L. N.

Beach

S. R. H.

(1998). Marriage and depressive symptoms: The role and bases of self-esteem differ by gender. Psychology of Women Quarterly, 22, 647–663.

Davila

Karney

B. R.

Hall

T. W.

Bradbury

T. N.

(2003). Depressive symptoms and marital satisfaction: Within-subject associations and the moderating effects of gender and neuroticism. Journal of Family Psychology, 17, 557–570.

Denton

W. H.

Carmody

T. J.

Rush

A. J.

Thase

M. E.

Trivedi

M. H.

Arnow

B. A.

Keller

M. B.

(2010). Dyadic discord at baseline is associated with lack of remission in the acute treatment of chronic depression. Psychological Medicine, 40, 415–424.

Durham

R. C.

Allan

Hackett

C. A.

(1997). On predicting improvement and relapse in generalized anxiety disorder following psychotherapy. British Journal of Clinical Psychology, 36, 101–119.

10.

Fals-Stewart

O’Farrell

T. J.

Hooley

J. M.

(2001). Relapse among married or cohabiting substance-abusing patients: The role of perceived criticism. Behavior Therapy, 32, 787–801.

11.

Fincham

F. D.

Beach

S. R. H.

Harold

G. T.

Osborne

L. N.

(1997). Marital satisfaction and depression: Different causal relationships for men and women? Psychological Science, 8, 351–356.

12.

Gordon

K. C.

Friedman

M. A.

Miller

I. W.

Gaertner

(2005). Marital attributions as moderators of the marital discord-depression link. Journal of Social and Clinical Psychology, 24, 876–893.

13.

Humbad

M. N.

Donnellan

M. B.

Iacono

W. G.

Burt

S. A.

(2010). Externalizing psychopathology and marital adjustment in long-term marriages: Results from a large combined sample of married couples. Journal of Abnormal Psychology, 119, 151–162.

14.

Kouros

C. D.

Papp

L. M.

Cummings

E. M.

(2008). Interrelations and moderators of longitudinal links between marital satisfaction and depressive symptoms among couples in established relationships. Journal of Family Psychology, 22, 667–677.

15.

Liu

R. X.

Chen

(2006). The effects of marital conflict and marital disruption on depressive affect: A comparison between women in and out of poverty. Social Science Quarterly, 87, 250–271.

16.

Overbeek

Vollebergh

de Graaf

Scholte

de Kemp

Engels

(2006). Longitudinal associations of marital quality and marital dissolution with the incidence of DSM-III-R disorders. Journal of Family Psychology, 20, 284–291.

17.

Powers

M. B.

Vedel

Emmelkamp

P. M.

(2008). Behavioral couples therapy (BCT) for alcohol and drug use disorders: A meta-analysis. Clinical Psychology Review, 28, 952–962.

18.

Poyner-Del Vento

P. W.

Cobb

R. J.

(2011). Chronic stress as a moderator of the association between depressive symptoms and marital satisfaction. Journal of Social and Clinical Psychology, 30, 905–936.

19.

Roberts

B. W.

Robins

R. W.

(2000). Broad dispositions, broad aspirations: The intersection of personality traits and major life goals. Personality and Social Psychology Bulletin, 26, 1284–1296.

20.

Schonbrun

Y. C.

Whisman

M. A.

(2010). Marital distress and mental health care service utilization. Journal of Consulting and Clinical Psychology, 78, 732–736.

21.

Scott

R. L.

Cordova

J. V.

(2002). The influence of adult attachment styles on the association between marital adjustment and depressive symptoms. Journal of Family Psychology, 16, 199–208.

22.

South

S. C.

Krueger

R. F.

(2008). Marital quality moderates genetic and environmental influences on the internalizing spectrum. Journal of Abnormal Psychology, 117, 826–837.

23.

South

S. C.

Krueger

R. F.

Iacono

W. G.

(2011). Understanding general and specific connections between psychopathology and marital distress: A model based approach. Journal of Abnormal Psychology, 120, 935–947.

24.

Travis

J. H.

(1933). Precipitating factors in manic-depressive psychoses. Psychiatric Quarterly, 7, 411–418.

25.

Uebelacker

L. A.

Whisman

M. A.

(2006). Moderators of the association between relationship discord and major depression in a national population-based sample. Journal of Family Psychology, 20, 40–46.

26.

Wade

T. D.

Kendler

K. S.

(2000). Absence of interactions between social support and stressful life events in the prediction of major depression and depressive symptomatology in women. Psychological Medicine, 30, 965–974.

27.

Whisman

M. A.

(1999). Marital dissatisfaction and psychiatric disorders: Results from the National Comorbidity Survey. Journal of Abnormal Psychology, 108, 701–706.

28.

Whisman

M. A.

(2001). Marital adjustment and outcome following treatments for depression. Journal of Consulting and Clinical Psychology, 69, 125–129.

29.

Whisman

M. A.

(2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116, 638–643.

30.

Whisman

M. A.

Baucom

D. H.

(2012). Intimate relationships and psychopathology. Clinical Child and Family Psychology Review, 15, 4–13.

31.

Whisman

M. A.

Bruce

M. L.

(1999). Marital dissatisfaction and incidence of major depressive episode in a community sample. Journal of Abnormal Psychology, 108, 674–678.

32.

Whisman

M. A.

Sheldon

C. T.

Goering

(2000). Psychiatric disorders and dissatisfaction with social relationships: Does type of relationship matter? Journal of Abnormal Psychology, 109, 803–808.

33.

Whisman

M. A.

Uebelacker

L. A.

(2006). Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults. Journal of Family Psychology, 20, 369–377.

34.

Whisman

M. A.

Uebelacker

L. A.

(2009). Prospective associations between marital discord and depressive symptoms in middle-aged and older adults. Psychology and Aging, 24, 184–189.

35.

Whisman

M. A.

Uebelacker

L. A.

Bruce

M. L.

(2006). Longitudinal association between marital discord and alcohol use disorders. Journal of Family Psychology, 20, 164–167.

36.

Whitton

S. W.

Stanley

S. M.

Markman

H. J.

Baucom

B. R.

(2008). Women's weekly relationship functioning and depressive symptoms. Personal Relationships, 15, 533–550.

37.

Whitton

S. W.

Whisman

M. A.

(2010). Relationship satisfaction instability and depression. Journal of Family Psychology, 24, 791–794.

38.

Zinbarg

R. E.

Lee

J. E.

Yoon

K. L.

(2007). Dyadic predictors of outcome in a cognitive-behavioral program for patients with generalized anxiety disorder in committed relationships: A “spoonful of sugar” and a dose of non-hostile criticism may help. Behaviour Research and Therapy, 45, 699–713.