Dependentpersonalitydisorderarticle.pdf

An Examination of Dependent Personality Disorderin the Alternative DSM-5 Model for Personality Disorders

Andrew S. McClintock1,2 & Shannon M. McCarrick1

Published online: 5 August 2017# Springer Science+Business Media, LLC 2017

Abstract Although the diagnosis of dependent personalitydisorder (DPD) has demonstrated construct validity and clin-ical utility, little is known about how best to model DPD in theDSM-5’s new, alternative model for diagnosing personalitydisorders. The current research aimed to represent DPD usingthe 25 pathological personality traits of the alternative model.Self-report measures of the 25 pathological personality traits,DPD, avoidant personality disorder, borderline personalitydisorder, and maladaptive interpersonal dependency were ad-ministered to an undergraduate sample (N = 194). Resultsindicated that— as consistent with extant theory— anxious-ness, submissiveness, and separation insecurity were the threetraits most strongly related to DPD symptoms. As agroup, anxiousness, submissiveness, and separation inse-curity were more strongly related to DPD symptoms(r = 0.55) than were the remaining 22 personality traits(r = 0.34). This group of three traits was strongly asso-ciated, however, with avoidant personality disordersymptoms (r = 0.55), suggesting that additional scrutinyof DPD and avoidant personality disorder in the alter-native model may be needed. Limitations and directionsfor future research are presented.

Keywords Dependent personality disorder . Avoidantpersonality disorder . DSM . Alternative model

In light of frequent criticism of the personality disorder diag-nostic system in the DSM-IV (American PsychiatricAssociation 2000; for criticisms, see Widiger et al. 2009),the Personality and Personality Disorders Work Group pro-posed a novel approach to the diagnosis of personality disor-ders. This approach, titled the alternative DSM model for per-sonality disorders (AMPD), was not accepted as the officialdiagnostic system for the DSM-5 (American PsychiatricAssociation 2013) but rather was published in DSM-5’s Section III (Bemerging measures and models^ p.729). If the AMPD holds up to empirical scrutiny, andeven outperforms established diagnostic criteria, then theAMPD may become the official system in future edi-tions of the DSM (Few et al. 2013).

In contrast to previous models, the AMPD is a dimensionaltrait model that represents personality disorders as combina-tions of core personality-related impairments and various con-figurations of 25 pathological personality traits (AmericanPsychiatric Association 2013; Krueger et al. 2012; Moreyand Skodol 2013; Skodol 2012). The pathological personalitytraits are organized into five higher-order domains (i.e., nega-tive affect, detachment, antagonism, disinhibition, andpsychoticism) that align with the extensively validatedfive-factor model of general personality (McCrae andCosta 2003; see Gore and Widiger 2015). That is, theAMPD models personality disorders as extreme, mal-adaptive variants of the same traits that describe normalpersonality (Samuel et al. 2013).

Four personality disorders were excluded from the AMPD:paranoid personality disorder, schizoid personality disorder,histrionic personality disorder, and— as most relevant to the

* Andrew S. [email protected]

Shannon M. [email protected]

1 Department of Psychology, Ohio University, 264 Porter Hall,Athens, OH 45701, USA

2 Department of Family Medicine and Community Health, Universityof Wisconsin School of Medicine and Public Health, Madison, WI,USA

J Psychopathol Behav Assess (2017) 39:635–641DOI 10.1007/s10862-017-9621-y

current research— dependent personality disorder (DPD).According to developers of the AMPD (Skodol 2012), DPDwas excluded because of lower prevalence estimates, relative-ly weak associations with functional impairment, and littleevidence for discriminant validity. Consequently, individualswho exhibit the signs of DPD would be diagnosed in theAMPD as personality disorder- trait specified and would bedescribed with the three pathological traits of anxiousness,submissiveness, and separation insecurity (AmericanPsychiatric Association 2013; Skodol et al. 2011).

Some scholars, however, have disputed the decision to ex-clude DPD from the AMPD. Bornstein (2011) noted, for in-stance, that DPD prevalence rates are comparable to the prev-alence rates of personality disorders included in the AMPD.There is also evidence that the DPD diagnosis is clinicallyuseful, as DPD symptoms are associated with suicidality, part-ner and child abuse, important elements of treatment processand outcome, and high levels of functional impairment(Bornstein 2012a, b). Indeed, Soeteman et al. (2008) reportedthat health care costs associated with DPD were higher thanthe costs associated with obsessive-compulsive, antisocial,and avoidant personality disorders (all included in theAMPD). Furthermore, although DPD overlaps with other per-sonality disorders, particularly avoidant personality disorderand borderline personality disorder (Bastiaansen et al. 2012;Disney 2013; Miller et al. 2015), DPD seems to have comor-bidity rates that are similar to those of personality disordersincluded in the AMPD (Bornstein 2011, 2012a, b; Disney2013; Zimmermann et al. 2005).

Because DPD might be at least as valid and clinically usefulas personality disorders retained in the AMPD (Bornstein2011), empirical research is needed to model DPD withAMPD’s pathological personality traits. While theory impli-cates three pathological traits in DPD (i.e., anxiousness,submissiveness, and separation insecurity; Skodol et al. 2011),empirical support for this configuration is mixed. Bornstein(2011) astutely noted that much of the research in this areafocuses on personality disorders retained in the AMPD, andthus the evidence base for these personality disorders tends tobe larger than the evidence base for excluded personality disor-ders (e.g., DPD). Nevertheless, the data that do exist suggestthat anxiousness and separation insecurity are integral to DPD(Anderson et al. 2014; Bornstein 2012b; Hopwood et al. 2012;Morey et al. 2016; Gore and Widiger 2015), whereas submis-siveness may (Bach et al. 2016a, b; Gore and Widiger 2015;Morey et al. 2016; Smith et al. 2009) or may not (Andersonet al. 2014; Bornstein 2012b; Fossati et al. 2013) be integral toDPD. Bornstein (2012b) reported that individuals with DPDcan be quite assertive in certain contexts (e.g., when importantrelationships are threatened), and thus submissiveness shouldnot be regarded as a core trait of DPD.

Even if the Personality and Personality Disorders WorkGroup is correct in their assertion that DPD is best

characterized by anxiousness, submissiveness, and separationinsecurity (Skodol et al. 2011), it remains to be seen if thisconfiguration is distinct from the configurations of other per-sonality disorders. There is evidence that anxiousness, sub-missiveness, and/or separation insecurity are elevated inavoidant personality disorder (APD) and borderline personal-ity disorder (BPD) (Anderson et al. 2014; Disney 2013;Fossati et al. 2013; Gude et al. 2004, 2006; Hopwood et al.2012; Leising et al. 2006; Morey et al. 2016; Yam and Simms2014), suggesting that the proposed configuration of DPDmay lack discriminant validity.

The present research aimed to model DPD using AMPD’spathological personality traits and to determine if this config-uration of personality traits is distinct from the configurationsof APD and BPD. APD and BPD were selected because, of all10 personality disorders, these two seem to be moststrongly related to DPD (Bastiaansen et al. 2012;Disney 2013; Miller et al. 2015). In addition to theDPD measure, we included a measure of maladaptiveinterpersonal dependency to compare the DPD configu-ration with the maladaptive dependency configuration.

Method

Participants

Participants in the present study were 200 undergraduates at alarge Midwestern university who received course credit fortheir participation. Six students were excluded for invalidresponding, resulting in a final sample of 194 participants.The majority identified as female (66.0%), heterosexual(84.0%), and never married (98.5%). In addition, 84.0% ofparticipants identified as Caucasian, 4.6% identified asAfrican American, 3.6% identified as Asian American, 3.6%identified as Hispanic, 3.6% identified as multiracial, and0.5% identified as American Indian. Participants had a meanage of 18.7 years (SD = 2.9).

Measures

The Personality Inventory for DSM-5 (PID-5; Krueger et al.2012) is a 220-item, self-report questionnaire that assesses the25 pathological personality traits (and five higher-order do-mains) of the AMPD. This measure asks participants to ratestatements on a 4-point Likert scale from 0 (very false or oftenfalse) to 3 (very true or often true). A sample item is BI usuallydo things on impulse without thinking about what might hap-pen as a result.^ The PID-5 has demonstrated construct valid-ity, convergent validity, and discriminant validity in past re-search (e.g., Quilty et al. 2013; Wright et al. 2012). In thecurrent research, the PID-5 scales exhibited acceptable to

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good levels of internal consistency (Cronbach αs ranged from0.75 [PID-5-Grandiosity] to 0.96 [PID-5-Eccentricity]).

The Personality Diagnostic Questionnaire 4+ (PDQ-4+;Hyler 1994) is a 99-item, self-report instrument used to screenfor each of the DSM-IV personality disorders. In the presentstudy, only the DPD (8 items), APD (7 items), and BPD (9items) scales were administered. All items use a true-falseresponse format. Representative items for each scale includeBI prefer that other people assume responsibility for me,^(DPD), BI avoid working with others who may criticize me,^(APD), and BI’ll go to extremes to prevent those who I lovefrom ever leaving me^ (BPD). In the present study, we choseto measure symptoms dimensionally as opposed to assessingpersonality disorders categorically, as dimensional scales tendto be more reliable and valid (Hopwood et al. 2012; Markonet al. 2011). Because PDQ-4+ response options are binary(i.e., true/false), we calculated Kuder-Richardson 20 coeffi-cients for the PDQ-4 + −DPD (0.58), PDQ-4 + −APD(0.71), and PDQ-4 + −BPD (0.54).

The Relationship Profile Test (RPT; Bornstein et al. 2003)is a 30-item, self-report measure of three interpersonal styles:healthy dependency, detachment, and overdependence. In thepresent study, only the Destructive Overdependence (DO)subscale (10 items) was administered. Each item is rated ona 7-point scale, ranging from 1 (not at all true of me) to 7 (verytrue of me). A representative item from the DO subscale is,BBeing responsible for things makes me nervous.^ The itemswere constructed based on the dependency literature and aimto assess the cognitive, emotional, motivational, and behav-ioral features of maladaptive dependency (Bornstein et al.2003). The RPT has exhibited good construct validity in priorresearch (Bornstein et al. 2003; Haggerty et al. 2010). In thecurrent study, the RPT-DO had acceptable internal consisten-cy (Cronbach α= 0.89).

Procedure

This study was conducted at a large Midwestern universityduring the 2015–2016 academic year. IRB approval was ob-tained, and all ethical standards were followed. Participants

completed the above measures online in partial fulfillment ofresearch requirements for psychology courses.

Plan of Analysis

Correlational analyses were first employed to assess the rela-tionships between DPD, APD, BPD, and maladaptive inter-personal dependency. Next, correlations were used to deter-mine how DPD, APD, BPD, and maladaptive dependency arerelated to the 25 pathological personality traits. Given thelarge number of analyses, coupled with our goal of identifyingthe core traits of these conditions, we regarded correlations >.40 (and p values < .001) as meaningful (see Hopwood et al.2012). Finally, we used correlations to examine the relation-ships between personality disorder symptoms, proposed traitconfigurations, and the remaining non-proposed traits. Forthese analyses, the following variables were created: DPDProposed Traits (M of anxiousness, submissiveness, and sep-aration insecurity), DPD Non-Proposed Traits (M of 23 traits;all but anxiousness, submissiveness, and separation insecuri-ty), APD Proposed Traits (M of anhedonia, anxiousness, inti-macy avoidance, and withdrawal), APD Non-Proposed Traits(M of 21 traits; all but anhedonia, anxiousness, intimacyavoidance, and withdrawal),

BPD Proposed Traits (M of anxiousness, depressivity,emotional lability, hostility, impulsivity, risk taking, separa-tion insecurity), BPD Non-Proposed Traits (M of 18 traits;all but anxiousness, depressivity, emotional lability, hostility,impulsivity, risk taking, separation insecurity). For each per-sonality disorder (DPD, APD, BPD), we evaluated whetherthe correlation of the personality disorder and the proposedconfiguration is significantly larger than the correlation of thepersonality disorder and the non-proposed traits.

Results

Correlations between PDQ-4 + −DPD, PDQ-4 + −APD,PDQ-4 + −BPD, and RPT-DO are presented in Table 1. Ofnote, PDQ-4 + −DPD was highly correlated with PDQ-4 +−APD (r = 0.56) and PDQ-4 + −BPD (r = 0.50). Surprisingly,

Table 1 Correlations between measures of DPD, APD, BPD, and maladaptive dependency (N = 194)

M (SD) PDQ-4 + − DPD PDQ-4 + − APD PDQ-4 + − BPD RPT- DO

PDQ-4 + −DPD 1.55 (1.56) − .56* .50* .56*PDQ-4 + −APD 2.61 (2.00) − .47* .63*PDQ-4 + −BPD 2.73 (1.80) − .32*RPT-DO 26.77 (8.14) −

PDQ-4+ Personality Diagnostic Questionnaire 4+, DPD Dependent Personality Disorder, APD Avoidant Personality Disorder, BPD BorderlinePersonality Disorder, RPT-DO Relationship Profile Test-Destructive Overdependence

*p < .001

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RPT-DO was at least as strongly related to the PDQ-4 + −APD(r = 0.63) as it was to PDQ-4 + −DPD (r = 0.56).

Correlations of PDQ-4 + −DPD, PDQ-4 + −APD, PDQ-4 + −BPD, and RPT-DO with PID-5 traits/domains are pre-sented in Table 2. The three PID-5 scales most strongly cor-related with PDQ-4 + −DPD were PID-5-Anxiousness,(r = 0.41), PID-5-Submissiveness (r = 0.42), and PID-5-Separation Insecurity (r = 0.52). This configuration was gen-erally replicated with RPT-DO, as PID-5-Anxiousness andPID-5-Submissiveness were the two scales most strongly

correlated with RPT-DO, and PID-5-Separation Insecuritywas the fifth scale most strongly correlated with RPT-DO.Importantly, PID-5-Anxiousness, PID-5-Submissiveness,and PID-5-Separation Insecurity were also strongly correlatedwith PDQ-4 + −APD (all rs > 0.40).

Next, correlations were conducted to examine the relation-ships between personality disorder symptoms, proposed traitconfigurations, and the remaining non-proposed traits (seeTable 3). The proposed configuration of DPD (i.e., PID-5-Anxiousness, PID-5-Submissiveness, and PID-5-Separation

Table 2 Correlations betweenPID-5 traits/domains andmeasures of DPD, APD, BPD,and maladaptive dependency(N = 194)

M (SD) PDQ-4 + −DPD

PDQ-4 + −APD

PDQ-4 + −BPD

RPT-DO

PID-5 Traits

Emotional Lability 0.98 (0.70) .39 .44 .58 .44

Anxiousness 1.45 (0.72) .41 .49 .46 .54

Separation Insecurity 0.84 (0.65) .52 .41 .36 .42

Submissiveness 1.03 (0.70) .42 .46 .32 .57

Hostility 0.91 (0.52) .26 .24 .55 .12

Perseveration 0.86 (0.59) .36 .32 .46 .36

Depressivity 0.59 (0.61) .36 .48 .56 .38

Suspiciousness 1.03 (0.45) .29 .34 .47 .18

Restricted Affectivity 0.89 (0.66) .07 .07 .10 −.06Withdrawal 0.79 (0.59) .21 .42 .40 .26

Intimacy Avoidance 0.68 (0.64) .09 .15 .23 .10

Anhedonia 0.85 (0.61) .29 .41 .50 .27

Manipulativeness 0.85 (0.66) .11 −.02 .22 −.10Deceitfulness 0.67 (0.56) .23 .14 .33 .08

Grandiosity 0.63 (0.54) .16 −.07 .15 −.05Attention Seeking 0.93 (0.64) .23 .06 .23 .11

Callousness 0.50 (0.49) .12 −.04 .29 .16Irresponsibility 0.53 (0.51) .35 .24 .43 .22

Impulsivity 0.83 (0.62) .18 .07 .34 .08

Distractibility 1.03 (0.66) .38 .39 .47 .44

Risk Taking 1.43 (0.50) −.14 −.23 .01 −.29Rigid Perfectionism 1.01 (0.66) .19 .15 .22 .11

Unusual Beliefs &Experiences

0.68 (0.59) .18 .13 .32 .12

Eccentricity 0.93 (0.76) .22 .15 .37 .23

Perceptual Dysregulation 0.64 (0.53) .33 .28 .47 .28

PID-5 Domains

Negative Affect 1.09 (0.58) .52 .53 .56 .56

Detachment 0.77 (0.50) .24 .40 .47 .26

Antagonism 0.72 (0.51) .19 .02 .27 −.03Disinhibition 0.80 (0.49) .37 .29 .50 .31

Psychoticism 0.75 (0.56) .26 .20 .42 .24

Traits that are used to describe each personality disorder in the alternative model are bolded. Correlations >0.4were regarded as meaningful

PID-5 Personality Inventory for DSM-5, PDQ-4+ Personality Diagnostic Questionnaire 4+, DPD DependentPersonality Disorder, APD Avoidant Personality Disorder, BPD Borderline Personality Disorder, RPT-DORelationship Profile Test-Destructive Overdependence

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Insecurity) accounted for 30% of the variability in PDQ-4 +−DPD scores (r = 0.55). The non-proposed traits (i.e., all butPID-5-Anxiousness, PID-5-Submissiveness, and PID-5-Separation Insecurity) collectively accounted for 12% of thevariability in PDQ-4 + −DPD scores (r = 0.34). These corre-lation coefficients were significantly different (p < 0.05). Ofnote, the proposed configuration of DPD was as strongly re-lated to PDQ-4 + −APD (r = 0.55) as it was to PDQ-4 +−DPD (r = 0.55).

The proposed configuration of APD (i.e., PID-5-Anhedonia,PID-5-Anxiousness, PID-5-Intimacy Avoidance, and PID-5-Withdrawal) accounted for 25% of the variability in PDQ-4 + −APD scores (r = 0.50). The non-proposed traits (i.e., allbut PID-5-Anhedonia, PID-5-Anxiousness, PID-5-IntimacyAvoidance, and PID-5-Withdrawal) collectively accounted for9% of the variability in PDQ-4 + −APD scores (r = 0.30).These correlation coefficients were significantly different(p < 0.05).

The proposed configuration of BPD (i.e., PID-5-Anxiousness, PID-5-Depressivity, PID-5-EmotionalLability, PID-5-Hostility, PID-5-Impulsivity, PID-5-RiskTaking, and PID-5-Separation Insecurity) accounted for40% of the variability in PDQ-4 + −BPD scores(r = 0.63). The non-proposed traits (i.e., all but PID-5-Anxiousness, PID-5-Depressivity, PID-5-EmotionalLability, PID-5-Hostility, PID-5-Impulsivity, PID-5-RiskTaking, and PID-5-Separation Insecurity) collectivelyaccounted for 27% of the variability in in PDQ-4 +−BPD scores (r = 0.52). These correlation coefficientswere not significantly different.

Discussion

We found that— of all personality traits included in theAMPD— anxiousness, submissiveness, and separation inse-curity were most strongly associated with DPD symptoms.These are the same traits used to describe DPD symptomatol-ogy in the current edition of the AMPD (e.g., see Skodol et al.2011). Past research has consistently linked anxiousness andseparation insecurity to DPD symptoms (Anderson et al.2014; Hopwood et al. 2012; Morey et al. 2016; Gore andWidiger 2015), though the link between submissiveness andDPD symptoms has received somewhat mixed results(Anderson et al. 2014; Bornstein 2012b; Fossati et al. 2013;Gore and Widiger 2015; Leising et al. 2006; Morey et al.2016; Smith et al. 2009).

Correlation analyses revealed that anxiousness, submis-siveness, and separation insecurity collectively accounted for30% of the variability in DPD symptoms, which is compara-ble to figs. (28–36%) reported in prior research (Andersonet al. 2014; Few et al. 2013). We also found that DPD symp-toms were more strongly related to anxiousness, submissive-ness, and separation insecurity as a group (r = 0.55) than to theremaining 22 personality traits (r = 0.34). Taken together,these results suggest that DPD can be well-modeled with anx-iousness, submissiveness, and separation insecurity (seeSkodol et al. 2011).

Substantial overlap was observed, however, between DPDand APD. Specifically, APD was strongly associated withboth DPD (r = 0.56) and maladaptive interpersonal dependen-cy (r = 0.63). Furthermore, and as consistent with extant

Table 3 Correlations (N = 194)between DPD, APD, BPD,proposed traits, and non-proposedtraits (N = 194)

1 2 3 4 5 6 7 8 9

PDQ-4 + −DPD (1) – 0.55 0.34 0.56 0.35 0.39 0.50 0.45 0.31DPD Proposed Traits (2) – 0.56 0.55 0.64 0.64 0.47 0.78 0.52

DPD Non-Proposed Traits (3) – 0.29 0.76 0.99 0.53 0.84 0.89

PDQ-4 + −APD (4) – 0.50 0.30 0.47 0.44 0.40APD Proposed Traits (5) – 0.69 0.55 0.71 0.92

APD Non-Proposed Traits (6) – 0.53 0.88 0.83

PDQ-4 + −BPD (7) – 0.63 0.52APD Proposed Traits (8) – 0.70

APD Non-Proposed Traits (9) –

DPD Proposed Traits (anxiousness, submissiveness, and separation insecurity), DPD Non-Proposed Traits (23traits; all but anxiousness, submissiveness, and separation insecurity). APD Proposed Traits (anhedonia, anxious-ness, intimacy avoidance, and withdrawal), APD Non-Proposed Traits (21 traits; all but anhedonia, anxiousness,intimacy avoidance, and withdrawal). BPD Proposed Traits (anxiousness, depressivity, emotional lability, hostil-ity, impulsivity, risk taking, separation insecurity), BPD Non-Proposed Traits (18 traits; all but anxiousness,depressivity, emotional lability, hostility, impulsivity, risk taking, separation insecurity). All correlations coeffi-cients were significant at p < 0.001. Bold values indicate a significant difference between correlation coefficientsfor the proposed and non-proposed traits for that personality disorder

PDQ-4+ Personality Diagnostic Questionnaire 4+, DPD Dependent Personality Disorder, APD AvoidantPersonality Disorder, BPD Borderline Personality Disorder

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literature (e.g., Anderson et al. 2014; Hopwood et al. 2012;Morey et al. 2016), APD symptoms were strongly correlated(all rs > 0.40) with the traits representing DPD (i.e., anxious-ness, submissiveness, and separation insecurity), and thesecorrelations were as strong or stronger than the correlationsbetween APD symptoms and the APD’s proposed traits (i.e.,anhedonia, anxiousness, intimacy avoidance, and withdraw-al). It stands to reason, from these results, that anxiousness,submissiveness, and separation insecurity may be integral toboth DPD and APD.

For decades, scholars have expressed doubt aboutwhether DPD and APD are truly distinct (Grant et al.2005; Trull et al. 1987). Large correlations (e.g.,r = 0.66) have been documented between DPD andAPD symptoms, regardless of whether symptoms areassessed via self-report (Bachrach et al. 2012) or struc-tured interview (Leising et al. 2006). In a large, nationallyrepresentative survey of the U.S. population, Grant et al.(2005) found that the comorbidity of DPD and APD wasexceedingly high (odds ratio = 118.6). The high degree ofoverlap between DPD and APD raises concerns abouttheir validity as independent disorders (Disney 2013).On the other hand, we found that detachment was corre-lated with APD symptoms at 0.40 and DPD symptoms at0.24, which may suggest that while DPD and APD arehighly similar in the negative affect domain (i.e., anxious-ness, submissiveness, and separation insecurity), APDmay include additional features belonging to the detach-ment domain (e.g., withdrawal and anhedonia). This in-terpretation should be regarded as speculative; future re-search is needed to examine how and to what degree DPDand APD are distinct.

This research has several shortcomings. The use of a non-clinical (undergraduate) sample, comprised mostly of young,White females, limits the generalizability of our results toclinical populations, males, people of color, and members ofother age groups. Additionally, our reliance on self-report datamay have led to shared method variance, potentially inflatingthe size of the associations. This concern is somewhat miti-gated by our focus on correlations >0.40. Nevertheless, giventhat some participants may have been unaware of their ownbehavior and symptoms, future research should attempt toreplicate these findings with structured interviews andinformant-based assessments (e.g., see Bach et al. 2016b).

In sum, the present research corroborates the idea that DPDcan be well-modeled with anxiousness, submissiveness, andseparation insecurity in the AMPD. At the same time, each ofthese traits was robustly associated with APD symptoms, sug-gesting that additional work is needed to understand the dis-tinction between DPD and APD in the AMPD. We are hopefulthat the current study will spur efforts to verify DPD and APDand to determine how these diagnoses best fit into our ever-evolving diagnostic systems.

Compliance with Ethical Standards

Funding This study was not funded.

Ethical Approval All procedures performed in studies involving hu-man participants were in accordance with the ethical standards of theinstitutional and/or national research committee and with the 1964Helsinki declaration and its later amendments or comparable ethicalstandards.

Informed Consent Informed consent was obtained from all individualparticipants included in the study.

Conflict of Interest Andrew S. McClintock and Shannon M.McCarrick declare that they have no conflict of interest.

Experiment Participants This study received approval by theuniversity's Institutional Review Board.

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