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Differences in Depression Symptoms
between Adult Attachment Dimensions
Thomas van Sonsbeek - 10383441 - Begeleider: Henk Jan Conradi2
Abstract
The purpose of the current study was to examine the relationships between attachment and individual symptoms of depression. The theory of attachment poses that humans have inborn relational needs, as well as mechanisms for obtaining proximity to a significant other. If the attachment figures were responsive and available, individuals develop a secure attachment style, characterized by the ability to regulate their emotions and positive views of the self and others. If the attachment figures were not responsive and available or inconsistent, individuals can develop insecure attachment styles. These insecure attachment styles can be divided into anxious attachment and avoidant attachment. Anxious attachment is characterized by the intensification of negative emotions, preoccupation with relationships and fears of abandonment and rejection, whereas avoidant attachment is characterized by the denial and suppression of emotions, avoidance of intimacy and negative views of others. Anxious and avoidant attachment seem to be related to different symptoms of psychopathology. To examine this, 145 participants with recurrent depression between 18 and 70 years old were recruited through their general practitioners. The results suggested that avoidant and anxious attachment are related to different symptoms of depression. Avoidant attachment seems to be related to loss of pleasure and interest, irritability, loss of social
interest, indecisiveness, fatigue, changes in appetite, weight loss, loss of interest in sexual activities
and suicidality. Anxious attachment seems to be related to sadness, feelings of guilt, dislike,
self-blame and perceptions of the self as less attractive. Both attachment dimensions seem to be related
to depression symptoms of pessimism (i.e. hopelessness about the future), failure (i.e. seeing the self or one’s past as full of failures) and problems with work and activities. In conclusion, different attachment styles seem to be related to different individual depression symptoms.
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Introduction
The theory of attachment poses that humans have inborn relational needs, as well as mechanisms for obtaining proximity to a significant other. Bowlby (1982) proposed that the attachment system promotes survival for children, since it propels them to seek out a primary caregiver during times of distress, who can provide safety, support and comfort. Attachment is closely related to emotion regulation (e.g. Shaver & Mikulincer, 2008). This is apparent by the way in which attachment has been investigated in children between the age of nine and 18 months: the
strange situation test (Ainsworth & Bell, 1970). The manner in which the child responds to distress
within this test (by being abandoned by the mother and left alone with a stranger) marks the security or insecurity of the child's attachment to the primary caregiver. Secure children signal their distress by crying, but calm down and quickly return to playing once the mother returns to console them. Insecure children on the other hand, show persistent distress despite the mother's attempt to console them, or are seemingly unaffected by the absence of the mother even though they do show the same elevated levels of physiological arousal seen with the distressed children.
Since attachment has such strong links to emotion regulation, it is not surprising that attachment has also been linked to mood disorders. A relationship between insecure adult attachment and a higher severity of depression symptoms has been found consistently by a large number of studies (e.g. Carnelley, Pietromonaco & Jaffe, 1994; Roberts, Gotlib & Kassel, 1996; Wei, Mallinckrodt, Russell & Abraham, 2004). Such a relationship has been found not only for depression, but for several other psychological disorders as well. Since an individual’s attachment is related to the development of psychopathological symptoms, it’s relevant for clinical practice that the relationship between psychopathology and attachment is delineated. The purpose of the current study is to examine the relationships between different forms of attachment and symptoms of depression.
Attachment and emotion regulation
Studies often differentiate between two attachment dimensions: attachment anxiety and attachment avoidance, as identified by the factor analysis study of Brennan, Clark and Shaver (1998). This model has been elaborated by several authors, and will provide the theoretical foundation for the current study. Within the attachment model (Shaver & Mikulincer, 2008), attachment anxiety is characterized by a preoccupation with relationships and a fear of rejection and abandonment, whereas attachment avoidance is characterized by avoidance of intimacy. Individuals with an avoidant attachment style don’t rely on others for support and suppress their attachment related needs and feelings. In an attempt to further delineate this model, Shaver and Mikulincer reviewed the literature and proposed that the two attachment dimensions reflect two different
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problematic strategies to cope with threat or stressful situations (e.g. Shaver & Mikulincer, 2008). According to the model of Shaver and Mikulincer, the initial strategy to deal distress is to seek proximity to attachment figures such as parents, friends or teachers. If the attachment figure is available and responsive, this leads to regulation of distress, due to the support and safety provided by the attachment figure. These individuals will learn that they can rely on others in times of distress and develop positive views or working models regarding both self and others (Bartholomew & Horowitz, 1991). If the attachment figure is not available and responsive, secondary coping strategies can develop: hyperactivating and deactivating strategies.
Anxious attachment is seen as related to a hyperactivating strategy to cope with stress (Shaver & Mikulincer, 2008). Negative emotional responses to threats are intensified and attachment figures are desperately sought for support and protection. These individuals are more sensitive to potential threats and are worried that others may leave them or not be available in times of distress. They are likely to ruminate and worry more about threat related concerns, and have a negative view of the self (Bartholomew & Horowitz, 1991). Hyperactivating strategies have been linked to parents that were inconsistently available and responsive, as well as anxious. These parents were more likely to respond when the child exaggerated (i.e. up-regulated) his calling and clinging behavior or distress (Cassidy & Berlin, 1994; Mikulincer & Shaver, 2008), leading to a particularly strong pattern of intermittent reinforcement of this strategy (Maunder & Hunter, 2001).
Avoidant attachment in contrast, is seen as related to a deactivating strategy to cope with stress (Shaver & Mikulincer, 2008). There is denial of attachment needs while negative emotions and thoughts are suppressed or not attended to. These individuals have a negative view of others (Bartholomew & Horowitz, 1991) and value independence and autonomy. They are less likely to ruminate, worry and react emotionally –both positively and negatively- and may therefore, from outward appearance seem resilient to distress. Deactivating strategies have been linked to consistently unavailable, distant and unresponsive parenting, as well as parents that react to their children’s distress with withdrawal, rejection or hostility. Under these circumstances, children learn that others will not provide support or that signaling distress will lead to rejection. Seeking proximity or signaling distress did not lead to alleviation of this distress, and therefore these children learned to suppress or ignore their distress and attachment needs (Mikulincer & Shaver, 2008).
Different scores on these two attachment dimensions can be used to distinguish four attachment styles: the secure (low anxiety, low avoidance), preoccupied (high anxiety, low avoidance), dismissive (low anxiety, high avoidance) and fearful (high anxiety, high avoidance) attachment styles. Preoccupied individuals are inclined to the use of hyperactivating strategies, and are preoccupied with the relationship and fear abandonment and rejection. In addition, they have difficulty functioning autonomously. Dismissive individuals tend to use of deactivating strategies and deny attachment needs and ignore or suppress negative emotions and thoughts. They find it difficult
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to establish intimate relationships. Secure individuals have a history of available and responsive attachment figures and are less preoccupied with fears of abandonment and rejection, and are comfortable with both autonomy and intimacy and seek support from others in times of distress. Fearful individuals alternate between hyperactivating and deactivating strategies. These individuals are both preoccupied with fears of abandonment and rejection, and avoid intimacy. They do not seek support from others in times of distress, and experience approach-avoidance conflicts.
Attachment and severity of depression
Having a secure attachment style has been repeatedly linked to lower depression severity and number of symptoms (Fraley & Bonanno, 2004). The fearful attachment style, characterized by a combination of high scores on both attachment dimensions, has been linked by several studies to be most vulnerable for developing depression symptoms (Fraley & Bonanno, 2004; Murphy & Bates, 1997). Indeed, these individuals are often described as carrying both problematic emotion-regulation patterns (i.e. hyper- and deactivation), thus being most at risk for developing psychopathological symptoms. The literature is less consistent in the findings on the dismissive and preoccupied attachment styles, with some studies reporting that individuals with a dismissive attachment style are less likely than individuals with a preoccupied attachment style to report feeling depressed (Cooper, Shaver & Collins, 1998; Jinyao et al., 2012; Mikulincer, Florian & Weller, 1993; Murphy & Bates, 1997; Wayment & Vierthaler, 2002), while other studies find that preoccupied and dismissive individuals do not differ significantly in their relationship to depression (Ciechanowski, Walker, Katon & Russo, 2002; Priel & Shamai, 1995). A previous study from Conradi and de Jonge (2009), which used the same data as the current study, confirmed that secure attachment is related to lowest depression symptom severity and fearful attachment to the highest depression symptom severity. Additionally, concerning dismissive and preoccupied attachment, the latter pattern was found: preoccupied and dismissive attachment were not found to be significantly different in their depression symptom severity.
This inconsistency concerning dismissive and preoccupied attachment, provides the field of attachment with a puzzle. Although the answer may partially lie in the different questionnaires used by different studies to measure attachment and depression, it could also be the case that anxious and avoidant attachment are both equally related to depression, but that their expressions of depression differ. This shifts the interest from the question whether insecure attachment is related to psychopathology (which seems to be the case), to the question whether different forms of insecure attachment are related to different forms of psychopathology. Since the aforementioned literature mostly makes use of sumscores on depression inventories, the same score can be obtained through different constellations of items or symptoms.
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Attachment and individual symptoms of depression
There is evidence suggesting that the attachment dimensions relate differently to specific individual symptoms. Anxious attachment seems to be related to symptoms characterized by negative emotions and cognitions (i.e. sadness, rumination, guilt) whereas avoidant attachment seems to be related to symptoms characterized by loss of pleasure and interest and somatic symptoms. The DSM-5 (American Psychiatric Association, 2013) lists nine main symptom clusters for major depressive disorder: sadness, loss of pleasure, weight loss or gain, change in appetite, sleeping
problems, psychomotor agitation, fatigue, feelings of worthlessness and guilt, concentration problems or indecisiveness and suicidal thoughts, plans and attempts.
Regarding sadness, several studies have reported that individuals scoring high on anxious attachment are more likely to report feeling depressed or experience grief, whereas individuals scoring high on attachment avoidance are less likely to do so (Mikulincer, Florian & Weller, 1993; Jinyao et al., 2012; Wayment & Vierthaler, 2002). Confirming a difference in the experience and expression of negative emotions, Shaver, Mikulincer, Lavy and Cassidy (2009) found that anxious attachment was related to more crying and negative emotions in comparison to avoidant attachment. These findings seem to suggest that anxious attachment is related more to sadness than avoidant attachment. Avoidant attachment, on the other hand, seems to be related more to loss of
pleasure and interest (i.e. anhedonia). Adam, Gunnar and Tanaka (2004) found that mothers with a
dismissive attachment style reported higher feelings of joylessness, fatigue, disinterest and disengagement. Confirming a possible relationship between avoidant attachment and disinterest, research by Troisi, Alcini, Coviello, Nanni and Siracusano (2010) found that social anhedonia, the reduced ability to enjoy social affiliation, was related only to avoidant attachment and not anxious attachment. These findings suggest that the deactivating strategy that is characteristic of avoidant attachment may lead to suppression of not just negative emotions, but positive emotions as well, resulting in flattened affect and loss of interest.
As mentioned above, Adam, et al., (2004) found that mothers with a dismissive attachment style (i.e. high on avoidant attachment) reported higher levels of fatigue. Regarding loss of appetite and weight loss, Several studies have found that individuals scoring high on avoidant attachment are overrepresented in the population diagnosed with anorexia nervosa (e.g. Ward et al., 2001; Zachrisson & Kulbotten, 2006). Developing a model to clarify the relationship between attachment and anorexia nervosa, Connan, Campbell, Katzman, Lightman and Treasure (2003) suggested that loss of appetite and weight loss may be symptoms of a dysregulated sympathetic nervous system and that the minimization of emotional expression characteristic of avoidant attachment (i.e. deactivating strategies) may lead to this dysregulation. Such a relationship between deactivating strategies and physiological stress has been suggested by other authors. Alexander (1950, cited in
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Waller & Scheidt, 2006) suggested that there was an inverse relationship between expression of emotions and physiological arousal. According to Alexander’s theory, physiological arousal that was not expressed and put into action, would lead to heightened physiological reaction to stress. Supporting this, studies have found that suppression of negative emotions increased cardiovascular activation (Mauss & Gross, 2004; Richards & Gross, 1999) and lower cellular immune functioning (Esterling, Antoni, Kumar & Schneiderman, 1990;). Furthermore, release of emotional inhibition (through disclosure and expressive writing) may have positive influences on cellular immune-system functions (Pennebaker, Kiecolt-Glaser & Glaser, 1988; Polivy, 1998) and other indications of physical health (see Smyth, 1998 for a review). Habitually coping with emotions by inhibiting its expression is associated with higher blood pressure (Goldstein, Edelberg, Meier & Davis, 1988) and cardiovascular disease (Mauss & Gross, 2004). There is also evidence that these findings are relevant for avoidant attachment. Jain and Labouvie-Vief (2010) found that during discussions of conflicts, dismissive women had the highest initial heart-rate levels and slowest heart-rate recovery in comparison to the other attachment styles. Wayment and Vierthaler (2002) found that individuals with an avoidant attachment were more likely to report somatic symptoms as a reaction to grief in comparison to those with anxious attachment and proposed that the “[s]uppression of emotion may lead to different health-related problems such as headaches, nausea or upset stomach, or pains in the lower back” (p. 130). Waller, Scheidt and Hartmann (2004) found that people with a somatoform disorder (i.e. symptoms of fatigue, heart problems, rheumatic pain, stomach trouble, nausea and pain) had a dismissive attachment style approximately twice as often as a preoccupied and secure attachment style. Taken together, the literature suggests that avoidant attachment is more related to somatic symptoms than anxious attachment, and that this may have to do with the deactivating strategies.
Regarding sleeping problems, the evidence is not conclusive. Sharfe and Eldredge (2001) found a connection between sleeping problems and both anxious and avoidant attachment. Carmichael and Reis (2005) also found both anxious and avoidant attachment to be related to sleeping problems in recurrently depressed individuals, although the relationship was no longer significant for avoidant attachment when controlling for depression. This suggests that –even though anxious attachment has an unique relationship to sleeping problems beyond depression- both attachment dimensions are related to sleeping problems.
Regarding feelings of worthlessness and guilt, Lopez et al., (1997) found that –although the anxious and fearful attachment styles were not related to feelings of guilt- the avoidant attachment scale was negatively related to guilt-proneness. Avoidantly attached individuals thus had a lower chance of feeling guilty than those high on attachment anxiety or low on avoidant attachment.
There is a lack in literature on the connections between attachment and the symptoms of
concentration problems and indecisiveness. There were two studies that found connections between
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attributes this to the higher importance work has for the avoidant individual. According to Ecke, avoidantly attached individuals are more likely to tie their identities to their work. Since work is prioritized, decisions carry more weight, leading to more indecisiveness. Another possible explanation may be that feelings are important factors in attributing value to choices, thus working as an internal compass that guides decision making (e.g. Damasio, 2008; Greenberg, 2002). Since avoidant attachment is characterized by flattened affect and loss of interest, avoidant individuals may find it more difficult to sense what is important, possibly leading to indecisiveness.
There is inconsistency regarding the research on suicidality, with one study finding only anxious attachment to be related to suicidality (Lizardi et al., 2011), three studies finding only avoidant attachment to be related to suicide attempt (Grunebaum et al., 2010; Mandal & Zalewska, 2012; Sheftall, Schoppe-Sullivan, & Bridge, 2014), while yet another study found both anxious and avoidant attachment to be equally related to suicidality (Palitsky, Mota, Afifi, Downs & Sareen, 2013). These differences may be due to the different attachment measures used, with Palitsky and colleagues using a very short measure of attachment (the Attachment Self-report, ASR;) and Grunebaum and colleagues (Adult Attachment Scale, AAS;), Lizardi and colleagues (AAS), Mandal and colleagues (Attachment Style Test) and Sheftall and colleagues (Experiences in Close Relationships; ECR) using more extensive measures of attachment.
Since the Beck Depression Inventory (BDI; Beck, Ward & Mendelson, 1961) is used in the current study, it is relevant to review literature regarding additional symptoms measured by the BDI:
perceptions on physical attractiveness, irritability, loss of sexual interest, worry about health and trouble with work and activities.
As a correlate of self-worth, the BDI contains an item concerning physical attractiveness. Anxious attachment but not avoidant attachment has also been repeatedly related to perceptions of
the self as less attractive (e.g. Bogaert & Sadava, 2002; Bylsma, Cozzarelli & Sumer, 1997; Park,
Crocker & Mickelson, 2004). This may have to do with the negative view of the self that has been related to anxious attachment (Bartholomew & Horowitz, 1991).
There is some evidence suggesting that attachment styles differentiate in their sexual behavior. Previous studies have found that avoidant individuals have more aversive feelings and thoughts about sex (Birnbaum, Reis, Mikulincer, Gillath & Orpaz, 2006), are low in their sex drive and are less sexually active (Tracy, Shaver, Albino & Cooper, 2003) than anxious and secure individuals. Brassard, Shaver and Lussier (2007) found that avoidant but not anxious attachment was related to lower frequency of sex. The relationship between avoidant attachment and less frequency of sex has been found by other studies (Bogaert & Sadava, 2002; Gentzler & Kerns, 2004) which would not be surprising considering the intimate nature of sexuality and the avoidance of intimacy that is characteristic of avoidant attachment. Indeed, several authors found that avoidant individuals have trouble with the intimate nature of sexuality (e.g. Birnbaum, et al., 2006; Tracy et al., 2003). In
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contrast, Davis, Shaver and Vernon (2004) found anxious attachment to be related to the use of sex to cope with stress and insecure feelings, and to obtain reassurance and emotional closeness to their partners. For this reason, avoidant but not anxious attachment is expected to be related to loss of
sexual interest.
A study by Campbell, Simpson, Kashy and Rholes (2001) found that only avoidant attachment was related to more irritation and critical behavior towards romantic partners. Campbell and colleagues reason that this may have to do with the history of rejection that avoidant individuals often have, which leads to the development of negative views of others (Bartholomew & Horowitz, 1991). These negative views of others may be expressed through more critical behavior and
irritability towards others.
Concerning worry about health, avoidant attachment has been repeatedly linked to denial of distress and reluctance to seek help from others (e.g. Vogel & Wei, 2005; Fraley & Shaver, 1997; Kotler, Buzwell, Romeo & Bowland, 1994). Although they may experience similar amounts of physical and psychological problems, they are more likely to deny or suppress this distress (Fraley & Shaver, 1997; Kotler, et al., 1994). In the aforementioned study from Jain and Labouvie-Vief (2010), it was found that, although dismissive-avoidant women had the highest initial heart-rate levels and slowest heart-rate recovery, they reported the highest emotional and physical wellbeing. Jain and Labouvie-Vief interpreted this as a dissociation between reported well-being and physiological reactivity. Indeed, as discussed above, it is the suppression of negative feelings and thoughts (i.e. worry) that is conceptualized to lead to an increased likelihood of somatic symptoms (Kotler, et al., 1994; Mikulincer, et al., 1993; Waller & Scheidt, 2006; Waller, Scheidt & Hartmann, 2004). For this reason, although avoidant attachment is postulated to be related to more somatic symptoms, avoidant attachment is not expected to be related to worry about these symptoms. Since the literature suggests that anxious attachment is not related to somatic symptoms, neither attachment styles are expected to be related to worry about health.
Finally, there is, to my awareness, no literature suggesting that avoidant and anxious attachment would differ in their overall experienced difficulties with work and activities. Two studies (Ecke, 2007; Wolfe & Betz, 2004) found both avoidant and anxious attachment to be related to problems at work. A study by Pines (2004) also found both avoidant and anxious attachment to be related to burn-out. Both attachment dimensions are therefore expected to be related to problems at work.
Taken together, there is ample evidence suggesting that the dimensions and styles of attachment are related to different symptoms of depression. Consistent with the model of Shaver and Mikulincer (2008), the literature suggests that anxious attachment has a relationship with symptoms of depression characterized by negative emotions and thoughts (i.e. sadness, crying,
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a relationship with symptoms of depression characterized by anhedonia and somatic symptoms (i.e.
loss of pleasure and interest, fatigue, loss of social interest, loss of appetite, weight loss, indecisiveness, irritability, loss of sexual interest). The literature suggests that both avoidant and
anxious attachment are related to difficulties with work and activities, sleeping problems and suicidality. A similar division for depression was found through a factor analytic study by Schotte, Maes, Cluydts, Doncker and Cosyns (1997), who reported two subscales within the Beck Depression Inventory (Beck, Ward & Mendelson, 1961). One subscale reflected symptoms of negative emotions and thoughts, whereas the other reflected loss of pleasure and somatic symptoms. The subscales identified by Schotte and colleagues differs from the grouping of individual symptoms concluded above; loss of pleasure and interest, suicidality, irritability and indecisiveness were grouped in the subscale with cognitive affective symptoms, and difficulties with work and activities, sleeping
problems and worry about health were grouped in the subscale with anhedonic and somatic
symptoms.
The current study
The purpose of the current study is to examine the relationships between attachment dimensions and differences in depression symptoms. Based on the literature, (1) anxious attachment is hypothesized to be related to cognitive-affective symptoms of depression, such as sadness, crying,
worthlessness and guilt and perceptions of the self as less attractive. (2) Attachment avoidance is
hypothesized to be related to anhedonic-somatic symptoms of depression, such as loss of pleasure
and interest, fatigue, loss of social interest, loss of appetite, weight loss, indecisiveness, irritability
and loss of sexual interest. Finally, (3) both are hypothesized to be related to sleeping problems,
suicidality and difficulties with work and activities. See figure 1 for a graphic presentation of the
proposed relationship between attachment dimensions and individual symptoms.
INSECURE ATTACHMENT STRATEGIES HYPERACTIVATION STRATEGY (attachment anxiety) DEACTIVATION STRATEGY (attachment avoidance)
COGNITIVE-AFFECTIVE
Sadness, crying, worthlessness and guilt, and perceptions of the self
as less attractive.
ANHEDONIC-SOMATIC
Loss of pleasure and interest, fatigue, loss of social interest, loss of appetite, weight loss, indecisiveness, irritability
and loss of sexual interest.
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Method
Participants
The data used in the current study comes from an earlier study (Conradi & de Jonge, 2009). The participants of that study were patients who had been diagnosed with a depressive disorder, between 18 and 70 years old, and were recruited by nearly 50 general practitioners. Patients who had a life threatening medical condition or comorbid psychotic disorder, bipolar disorder, dementia and alcohol or drug dependency were excluded from the study, as well as participants who were pregnant or were already receiving psychotherapy. All patients who met these inclusion criteria took part in a randomized clinical trial (Conradi et al., 2007) to evaluate the effect of four depression treatments: (1) usual care by the general practitioner, (2) the PsychoEducational Prevention (PEP) program, (3) psychiatric consultation followed by PEP and (4) brief cognitive behavioral therapy together with PEP. The total sample consisted of 267 participants. However, 122 patients had finished their participation before a reliable adult attachment measure was available in the Netherlands. Since the current study requires adult attachment data, these participants were excluded from the analysis, leaving a total of 145 participants.
Study measures
As a measurement of attachment, the Experience in Close Relationships questionnaire (ECR; Brennan, Clark & Shaver, 1998) was used. The ECR is a self-report questionnaire containing 36 items. Each item provides a statement concerning an experience within romantic relationships (e.g. “I
worry about being abandoned”). The respondent rates the extent to which he agrees with each
statement on a 7-point scale, ranging from 1 (disagree strongly) to 7 (agree strongly), 4 being neutral (neutral/mixed). Two subscales can be discerned: one for anxious attachment and one for avoidant attachment. From these two subscale scores, individuals can be categorized as having a secure, preoccupied, dismissive and fearful attachment style. In the current study, the Dutch translation was used, which has two additional questions to explore whether the respondent is currently in a romantic relationship or whether he has ever been in a relationship. According to a study from Conradi, Gerlsma, Duijn, and Jonge (2006), the Dutch translation of the ECR was found to be valid and reliable, with anxiety of rejection and abandonment having a Cronbach's α=0.86 and avoidance of intimacy having a Cronbach's α=0.88.
As a measurement of depression symptoms, the Beck Depression Inventory (BDI; Beck, Ward & Mendelson, 1961; Dutch version, Luteijn & Bouman, 1988) was used. The BDI is a self-report questionnaire containing 21 items, each measuring a different symptom on a 4-point scale from 0 to 3 (e.g. "0 - I don't feel guilty, 1 - I often feel guilty, 2 - I feel guilty most of the time, 3 - I feel guilty
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consistently"). The Dutch translation of the BDI was found to be reliable and valid (Luteijn &
Bouman, 1988). The two subscales identified by Schotte, Maes, Cluydts, Doncker and Cosyns (1997) are used in the current study. One subscale reflects cognitive-affective symptoms and contains the items regarding sadness, pessimism, feelings of failure, loss of pleasure, guilt, feelings of being
punished, self-dislike, self-blame, suicidality, irritability, indecisiveness and perception of the self as less attractive. The other subscale reflects anhedonic-somatic symptoms and contains the items
regarding loss of social interest, problems with work and activities, sleeping problems, fatigue,
changes in appetite, weight loss, worry about health and loss of sexual interest.
Statistical analyses
To test whether anxious attachment was related to cognitive-affective symptoms and whether avoidant attachment was related to anhedonic-somatic symptoms, multiple regression analyses were used with the cognitive-affective and anhedonic-somatic subscales of the BDI identified by Schotte and colleagues (1997) as dependent variables and the avoidant and anxious attachment subscales of the ECR as predictor variables.
The BDI subscales as identified by Schotte and colleagues deviate from the individual symptoms hypothesized to be related to the two attachment dimensions (i.e. avoidant and anxious) based on the literature review. To test the hypotheses regarding individual depression symptoms, regression analyses were used with the individual BDI items as dependent variables and the avoidant and anxious subscales of the ECR as predictor variables.
Finally, regularized partial correlation network analyses (e.g. Friedman, Hastie & Tibshirani, 2011) were used as explorative analyses to examine the relationships between each of the BDI items for the attachment styles (i.e. preoccupied and dismissive). Since the purpose of this study is to examine the relationships for the avoidant and anxious attachment dimensions, only the networks for the preoccupied attachment group (i.e. high on anxious but low on avoidant attachment) and dismissive groups (i.e. high on avoidant but low on anxious attachment) were compared. This way, patterns could be discerned that are unique for the two attachment dimensions (i.e. anxious and avoidant attachment). For both attachment style groups, partial correlations were computed between each of the BDI items, and a g-lasso network was plotted using R-studio and the R-package qgraph (Epskamp, Cramer, Waldorp, Schmittmann & Borsboom, 2012).
Within the network analyses, the items of the BDI are rendered as nodes, and the partial correlations between the BDI items are rendered as lines between these nodes –green or red lines, representing positive or negative correlations, respectively- with thicker lines representing stronger correlations. Additionally, the networks are computed in such a way that the BDI items (i.e. nodes) with stronger correlations are closer to each other, making it possible for clusters to be formed of nodes that are strongly interrelated.
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Additionally, betweenness, closeness and strength (e.g. see McNally et al., 2014) were plotted for each of the four networks. These are measures to determine the centrality for a particular BDI item within the network. Betweenness is the number of time that a BDI item lies on the shortest path between two other items. A score of closeness is the average distance between one symptom and all the other symptoms in the network. The strength is determined by the sum of all the correlation magnitudes for each symptom. For each of the centrality measures, a higher value indicates that the symptom is more central within the network.
Results
Participants
There was a difference in gender within the sample, with about 34.5% (n=50) being male and 64.5% (n=95) being female. Age ranged from 17 to 69 years old, M = 42.6, SD = SD = 11. A t-test determined that males and females didn’t differ significantly in mean scores for both avoidant attachment, t(143) = 1.772, p=.078, and anxious attachment, t(143) = -1.371, p=.173. Overall, the ratio for men and women was not significantly different for the attachment styles, X2 (3) = 5.99,
p=.112, although the number of preoccupied individuals was significantly lower for the male group
and significantly higher for the female group. See table 1 for n, percentage and significant proportion differences for each attachment style.
Table 1: Results of crosstabulation for attachment style and gender ratios.
n and percentage for each attachment style
Gender: Secure Fearful Preoccupied Dismissive
Male 23(46%) a 10(20%) a 4(8%) b 13(26%)a
Female 39(41.1%) a 13(13.7%) a 23(24.2%) b 20(21.1%) a
Total 62(42.8%) 23(15.9%) 27(18.6%) 33(22.8%)
a,b = all significant differences at p<.05
Regression analyses
The regression analyses for the cognitive-affective and anhedonic-somatic subscales of the BDI are presented in table 2, with precise p-values for easier comparison between the two attachment scales. For the cognitive-affective subscale, both avoidant attachment, t(139) = 3.34, p<.01, and anxious attachment, t(139) = 3.43, p<.01, were significant predictors. For the anhedonic-somatic subscale, both avoidant attachment, t(137) = 4.40, p<.001, and anxious attachment, t(137) = 2.12,
p<.05, were significant predictors, although the relationship with avoidant attachment was much
higher judging from the parameter estimate, B = 0.074, which was twice as high as the parameter estimate of anxious attachment, B = 0.036. The hypothesis that anxious but not avoidant attachment
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would be significantly related to cognitive-affective symptoms was not supported when looking at the subscales. The hypothesis that avoidant, but not anxious attachment would be significantly related to anhedonic-somatic symptoms was also not supported when looking at the subscales.
Table 2: Regression analyses for BDI subscale sum-scores. Significant results in bold.
Avoidant Attachment Anxious Attachment
Subscale: B SE B β t p B SE B β t p BDI Cognitive-affective 0.081 0.024 .279** 3.341 .001 0.083 0.024 .286** 3.433 .001 BDI Anhedonic-somatic 0.074 0.017 .369*** 4.403 <.001 0.036 0.017 .178* 2.121 .036 * = p<.05, ** = p<.01, *** = p<.001.
The results of the regression analyses for individual BDI items are presented in table 3, again with precise p-values. Many of the hypotheses regarding individual symptoms of depression as measured by the BDI were supported: as predicted, the regression analyses found significant connections between avoidant attachment and symptoms of loss of pleasure, t(141) = 5.71, p<.001,
irritability, t(141) = 2.51, p<.05, loss of social interest, t(141) = 3.99, p<.001, indecisiveness, t(141) =
3.30, p<.01, fatigue, t(141) = 2.06, p<.05, appetite changes, t(141) = 3.19, p<.01, weight loss, t(141) = 2.28, p<.05, and loss of interest in sexual activities, t(139) = 3.85, p<.001. For anxious attachment, significant relationships were found for sadness, t(141) = 2.95, p<.01, pessimism, t(142) = 2.12,
p<.05, failure, t(142) = 2.27, p<.05, guilt, t(142) = 2.63, p<.05, dislike, t(140) = 2.52, p<.05, self-blame, t(141) = 3.47, p<.01, and perceptions of the self as less attractive, t(141) = 3.28, p<.01. Both
avoidant attachment, t(139) = 3.32, p<.01, and anxious attachment, t(139) = 2.20, p<.05, were related to difficulties with work and activities. Finally, neither avoidant, t(140) = 1.24, p=.216, nor anxious attachment, t(140) = 1.36, p=.178, were found to be significantly related to worry about
health.
There were also several unexpected findings. Significant relationships were found between avoidant attachment and both pessimism, t(142) = 3.62, p<.001, and failure, t(142) = 2.19, p<.05. Only avoidant attachment, t(141) = 3.33, p<.01, but not anxious attachment, t(141) = 1.54, p=.126, was significantly related to suicidality. Neither attachment dimensions were found significantly related to sleeping problems (t(141) = 1.17, p=.243 for avoidant, t(141) = 1.42, p=.158 for anxious),
feeling punished (t(141) = 0.75, p=.455 for avoidant, t(141) = 1.46, p=.147 for anxious) and crying
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Table 3: Regression analyses for individual BDI items. Significant results in bold.
Avoidant Attachment Anxious Attachment
BDI items: B SE B β t p B SE B β t p Sadness 0.003 0.003 .109 1.218 .225 ha ll 0.008 0.003 .263** 2.950 .004 Pessimism 0.012 0.003 .309*** 3.622 <.001 0.007 0.003 .189* 2.212 .029 Failure 0.007 0.003 .194* 2.185 .031 0.007 0.003 .202* 2.272 .025 Loss of pleasure 0.018 0.003 .463*** 5.707 <.001 0.004 0.003 .103 1.265 .208 Guilt 0.004 0.003 .115 1.277 .204 0.008 0.003 .236* 2.629 .010 Feeling Punished 0.002 0.002 .070 0.749 .455 0.003 0.002 .136 1.458 .147 Self-dislike 0.005 0.003 .149 1.664 .098 0.007 0.003 .226* 2.521 .013 Self-blame 0.001 0.003 .030 0.340 .734 0.012 0.003 .311** 3.470 .001 Suicidality 0.008 0.002 .293** 3.334 .001 0.004 0.002 .135 1.540 .126 Crying 0.005 0.004 .108 1.153 .251 0.003 0.004 .075 0.803 .423 Irritability 0.008 0.003 .225* 2.509 .013 0.005 0.003 .151 1.688 .094 Loss of social interest 0.013 0.003 .349*** 3.993 <.001 0.003 0.003 .068 0.774 .440 Indecisiveness 0.013 0.004 .292** 3.303 .001 0.005 0.004 .114 1.291 .199 Attractiveness 0.003 0.004 .065 0.727 .468 0.012 0.004 .293** 3.276 .001 Work and activities 0.012 0.004 .288** 3.316 .001 0.008 0.003 .191* 2.203 .029 Sleeping problems 0.005 0.005 .109 1.172 .243 0.007 0.005 .132 1.419 .158 Fatigue 0.007 0.004 .186* 2.063 .041 0.007 0.004 .166 1.837 .068 Appetite changes 0.008 0.003 .286** 3.191 .002 0.002 0.003 .073 0.818 .415 Weight loss1 0.007 0.003 .212* 2.277 .024 -0.003 0.003 -.088 -0.944 .347 Worry about health 0.003 0.003 .116 1.244 .216 0.004 0.003 .126 1.355 .178 Loss of sexual interest 0.017 0.004 .331*** 3.851 <.001 0.008 0.004 .148 1.726 .087 * = <.05, ** = <.01, *** = <.001 1 = corrected for dieting
Attachment style network analyses
Network analyses for the preoccupied and dismissive groups are depicted at figure 2, and the centrality plots for both group networks are depicted at figure 3. Based on the betweenness centrality measures, different symptoms emerged as more central for the two group networks. For the preoccupied network, the strongest betweenness was found for symptoms reflecting
perceptions of the self as less attractive, suicidality, weight loss and feelings of failure. For the
dismissive network, the strongest betweenness was found for symptoms reflecting appetite
changes, loss of pleasure and interest, suicidality, fatigue and loss of social interest. Below, several
salient differences between the dismissive and preoccupied group networks will be noted.
For both the dismissive and preoccupied group networks, suicidality was highly central as determined by the betweenness score. This finding is interesting, considering that through the regression analyses, only avoidant attachment was found to be significantly related to suicidality. For the dismissive network, suicidality has a particular strong connection to loss of social interest. For
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the preoccupied network, suicidality has connections to feelings of failure, feelings of being punished and changes in appetite. It is interesting that loss of social interest is related to dislike and
blame in the preoccupied network, whereas dislike and blame are related to more
self-directed items in the dismissive network (i.e. loss of pleasure and interest, perception of the self as
less attractive, feeling punished).
Indecisiveness, another symptom through the regression analyses found to be related only to
avoidant attachment, was connected to loss of social interest in the dismissive network, and to
pessimism, sadness and appetite changes for the preoccupied network.
Within the dismissive network, difficulties with work and activities, that were found related to both anxious and avoidant attachment through the regression analyses was related to fatigue. For the preoccupied network, problems with work and activities was connected to fatigue through loss
of pleasure and interest. Finally, the symptom of irritability seems to be connected to somatic
symptoms for both networks (i.e. worry about health through weight-loss in preoccupied, fatigue in dismissive).
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Figure 2: Regularized partial correlation group network analyses, for the preoccupied and dismissive styles.
anh = loss of pleasure, app = appetite changes, att = perception of self as less attractive, blm = self-blame, cry = crying, ftg = fatigue, flr = failure, glt = guilt, ind = indecisiveness, irr = irritability, pns = feeling punished, pss = pessimism, sdn = sadness, scd = suicide, scl = social interest, slf = self-dislike, slp = sleeping problems, smt = worry about health,
sxl = loss of sexual interest, wgh = weight loss, wrk = problems with work and activities.
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Preoccupied group
Dismissive group
Figure 3: Measures of centrality (betweenness, closeness and strength), plotted for the preoccupied and dismissive networks.
anh = loss of pleasure, app = appetite changes, att = perception of self as less attractive, blm = self-blame, cry = crying, ftg = fatigue, flr = failure, glt = guilt, ind = indecisiveness, irr = irritability, pns = feeling punished, pss = pessimism, sdn = sadness, scd = suicide, scl = social interest, slf = self-dislike, slp = sleeping problems, smt = worry about health,
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Discussion
Based on the regression analyses, avoidant and anxious attachment seem to be related to different symptoms of depression. Avoidant attachment seems to be related to anhedonic-somatic depression symptoms reflecting loss of pleasure and interest, irritability, loss of social interest,
indecisiveness, fatigue, changes in appetite, weight loss and loss of interest in sexual activities.
Unexpectedly, but in line with three previous studies (Lizardi et al., 2011; Mandal & Zalewska, 2009; Sheftall, Schoppe-Sullivan, & Bridge, 2014), avoidant attachment was also related to suicidality. Anxious attachment seems to be related to cognitive-affective depression symptoms reflecting
sadness, feelings of guilt, self-dislike, self-blame and perceptions of the self as less attractive. Both
attachment dimensions seem to be related to depression symptoms of pessimism (i.e. hopelessness about the future), failure (i.e. seeing the self or one’s past as full of failures) and problems with work
and activities. That both attachment dimensions are related to pessimism and hopelessness is in line
with cognitive theories on depression, often relating perceptions of the self as worthless, and hopelessness regarding the future as the core cognitive causes of depression (e.g. Beck & Clark, 1988; Beck, 2008).
The finding that neither attachment dimensions were significantly related to sleeping
problems is puzzling considering previous literature that found both attachment dimensions to be
related to sleeping problems (e.g. Carmichael & Reis, 2005; Sharfe & Eldredge, 2001). Also unexpected was the non-significant relationship between crying and anxious attachment. Interestingly, a significant relationship for anxious but not avoidant attachment was found for the crying item of the Symptom Checklist-90 (SCL-90; Derogatis, Rickels & Rock, 1976; Dutch version, Arrindell & Ettema, 2003), a self-report questionnaire with 90 items regarding psychopathological symptoms that was also administered to the sample of the current study (B = 0.009, SE = 0.004, β = .211, t(142) = 2.30, p<.05, for anxious, B = 0.002, SE = 0.004, β = .049, t(142) = 0.53, p = .594 for avoidant). That the SCL-90 but not the BDI finds a significant relationship between anxious attachment and crying may have to do with a difference in encoding between the two scales. A score of four on the BDI represents the statement “I used to cry often, but now I can’t, even if I wanted to”, and reflects a measurement of the quality of crying. A score of four on the SCL-90 represents “I cry a
lot”, and the 90 item measures the quantity (i.e. frequency) of the crying. When taking the
SCL-90 item of crying into account, there does seem to be a relationship between an increased frequency of crying and anxious attachment.
That different attachment dimensions are related to different depression symptoms is highly relevant for clinical practice. Individuals with different attachment styles may seek help for different complaints even if they suffer from the same disorder according to the DSM-5 (American Psychiatric Association, 2013). Avoidant individuals may get treatment for their somatic complaints which will
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not be effective for alleviating a possible depression that goes unnoticed. Also, there is an increasing interest in transdiagnostic factors. In this approach, fundamental processes are believed to underlie several different psychological disorders (e.g. Davidson & Frank, 2014; Mansell, Harvey, Watkins & Shafran, 2008). Indeed, other authors have suggested emotion-regulation strategies such as emotional avoidance to be such a factor (e.g. Davidson & Frank, 2014). The findings of the current study seem to imply that, when looking at symptoms of depression, hyperactivating strategies are uniquely connected to negative thoughts and feelings (e.g. sadness, guilt, self-dislike), whereas deactivating strategies are uniquely connected to a loss of pleasure and interest and somatic symptoms (e.g. fatigue, weight loss, changes in appetite). From a transdiagnostic perspective, assessing attachment may provide more insight into the client’s problems and these attachment strategies may prove fruitful targets for psychotherapy. There are already several forms of psychotherapy making use of attachment as an important theoretical construct for their practice (e.g. Emotionally Focused Therapy; Johnson & Sims, 2000; Mentalization Based Treatment; Allen & Fonagy, 2006; Accelerated Experiential Dynamic Psychotherapy; Fosha, 200; also see Wallin, 2007).
The network analyses suggest that different attachment styles may be related to different symptom dynamics. For the group scoring high on avoidant attachment (i.e. the dismissive group), symptoms that were found to be only related to avoidant attachment (i.e. appetite changes, loss of
pleasure and interest, suicidality, fatigue and loss of social interest) were most central based on their
betweenness. For the group scoring high on anxious attachment (i.e. the preoccupied group), the most central symptoms were a mixture of avoidant-related and anxious-related symptoms (i.e.
perceptions of the self as less attractive, suicidality, weight loss and feelings of failure). Overall, in the
dismissive group, avoidant-related symptoms were mostly related to other avoidant-related symptoms, whereas for the preoccupied group, avoidant- and anxious-related symptoms were related to each other in a more mixed way. For example, suicidality and indecisiveness, symptoms that were found to be only related to avoidant attachment, were connected to loss of social interest (i.e. an anhedonic symptom) for the dismissive group, and more to negative thoughts and feelings (i.e. feeling punished, feelings of failure, pessimism and sadness) as well as appetite changes for the preoccupied group. That loss of social interest had a central place within the dismissive network and had a strong connection to suicidality is intriguing considering literature finding that social support can be a protective factor for psychopathology (e.g. Cobb, 1976), and that social support is related to a lower chance of suicide ideation and attempt (Brausch & Decker, 2014; Kleiman & Liu, 2013). Although more research will be necessary in order to draw causal conclusions, it may be the loss of social support as a protective factor that causes, prolongs or worsens the depression symptoms for avoidant individuals. These findings would also have strong implications for clinical practice. For those with anxious attachment, interventions targeting negative feelings and thoughts may be
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effective in lowering suicidality, whereas for avoidant attachment, interventions focused on the interpersonal problems may be effective for lowering suicidality.
Since the different groups presented different relationships between individual symptoms, it is possible for an individual that scores low on an attachment dimension (i.e. preoccupied; scoring low on avoidance), to regardless suffer from a symptom related to this attachment dimension (i.e.
indecisiveness), but that this symptom follows a different pathway than for other attachment styles
(i.e. through sadness instead of loss of interest as with the dismissive group). This goes beyond the habitual thinking about symptoms and disorders that is implicit in common psychological science, and opens doors for fascinating clinical research that recognizes and takes into consideration a more systemic complexity of the human psyche.
To my knowledge, the current study is the first to examine the relationships between individual symptoms of depression and attachment. The results are promising, and other studies may find such divisions of symptoms for other disorders, for example post-traumatic stress disorder and schizophrenia. It must be noted however, that the current study had limitations. That more participants were female, may have biased the results, although no significant difference was found in their attachment scores. That the number of females is higher in the sample is to be expected, since females are about twice as likely as males to develop depression (Weissman et al., 1996). Only 24 of total 145 participants had a BDI score that indicated more than a minimal depression (BDI sumscore of 15 or higher), and only 14 of these individuals had a BDI score that indicated moderate to severe depression (BDI sumscore of 20 of higher). With the majority of the individuals having a minimal depression, differences in symptoms may be more difficult to find, since the amount of symptoms is lower than within a population with high BDI scores. A replication with a more severely depressed population may lead to different results. Such a study may find stronger connections between anxious attachment and cognitive-affective symptoms and avoidant attachment and anhedonic-somatic symptoms. Higher distress may elicit stronger hyperactivating and deactivating strategies that will further strengthen the gap in symptom presentation for these two dimensions. It may also be the case however, that when the depression becomes more severe, the usual emotion-regulation strategies break down and that the differences between the two attachment dimensions become smaller. A replication of the current study with a more severely depressed population may find different results for individual depression symptoms between the dismissive and preoccupied attachment styles, that were not found in the current study.
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Literature:
Adam, E. K., Gunnar, M. R., & Tanaka, A. (2004). Adult attachment, parent emotion, and observed parenting behavior: Mediator and moderator models. Child development, 75(1), 110-122.
Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child development, 41(1), 49-67.
Allen, J. G., & Fonagy, P. (Eds.). (2006). The handbook of mentalization-based treatment. Chichester: John Wiley & Sons.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (DSM-5®). Arlington: American Psychiatric Publication.
Arrindell, W. A., & Ettema, J. H. M. (2003). Symptom checklist SCL-90: handleiding bij een multidimensionele psychopathologie-indicator. Amsterdam: Swets test publishers.
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: a test of a four-category model. Journal of personality and social psychology, 61(2), 226.
Beck, A. T., Ward, C., & Mendelson, M. (1961). Beck depression inventory (BDI). Arch Gen Psychiatry, 4(6), 561- 571.
Beck, A. T. (1979). Cognitive therapy and the emotional disorders. New York: Penguin.
Beck, A. T., & Clark, D. A. (1988). Anxiety and depression: An information processing perspective. Anxiety Research, 1(1), 23-36.
Birnbaum, G. E., Reis, H. T., Mikulincer, M., Gillath, O., & Orpaz, A. (2006). When sex is more than just sex: attachment orientations, sexual experience, and relationship quality. Journal of personality and social psychology, 91(5), 929.
Blom, D., van Middendorp, H., & Geenen, R. (2012). Anxious attachment may be a vulnerability factor
for developing embitterment. Psychology and Psychotherapy: Theory, Research and Practice, 85(4), 351-355.
Bogaert, A. F., & Sadava, S. (2002). Adult attachment and sexual behavior. Personal Relationships, 9(2), 191- 204.
Bowlby, J. (1982). Attachment and Loss: Vol. 1. Attachment (2nd edn). New York, NY: Basic Books (1st edn pub. in 1969).
Brausch, A. M., & Decker, K. M. (2014). Self-esteem and social support as moderators of depression, body image, and disordered eating for suicidal ideation in adolescents. Journal of abnormal child psychology, 42(5), 779-789.
Brassard, A., Shaver, P. R., & Lussier, Y. (2007). Attachment, sexual experience, and sexual pressure in romantic relationships: A dyadic approach. Personal Relationships, 14(3), 475-493.
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46-76). New York: Guilford Press.
Burnette, J. L., Davis, D. E., Green, J. D., Worthington, E. L., & Bradfield, E. (2009). Insecure attachment and depressive symptoms: The mediating role of rumination, empathy, and forgiveness. Personality and Individual Differences,46(3), 276-280.
23
Bylsma, W. H., Cozzarelli, C., & Sumer, N. (1997). Relation between adult attachment styles and global self- esteem. Basic and Applied Social Psychology, 19(1), 1-16.
Campbell, L., Simpson, J. A., Kashy, D. A., & Rholes, W. S. (2001). Attachment orientations, dependence, and behavior in a stressful situation: An application of the Actor-Partner Interdependence Model. Journal of Social and Personal Relationships, 18(6), 821-843.
Carnelley, K. B., Pietromonaco, P. R., & Jaffe, K. (1994). Depression, working models of others, and relationship functioning. Journal of personality and social psychology, 66(1), 127.
Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E. (2002). Attachment theory: a model for health care utilization and somatization. Psychosomatic Medicine, 64(4), 660-667.
Cobb, S. (1976). Social support as a moderator of life stress. Psychosomatic medicine, 38(5), 300-314. Connan, F., Campbell, I. C., Katzman, M., Lightman, S. L., & Treasure, J. (2003). A neurodevelopmental model
for anorexia nervosa. Physiology & behavior, 79(1), 13-24.
Conradi, H. J., & de Jonge, P. (2009). Recurrent depression and the role of adult attachment: A prospective and a retrospective study. Journal of Affective Disorders, 116(1), 93-99.
Conradi, H. J., de Jonge, P., Kluiter, H., Smit, A., van der Meer, K., Jenner, J. A., van Os, T. W. D. P., Emmelkamp, P. M. G., & Ormel, J. (2007). Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy. Psychological medicine, 37(06), 849-862.
Conradi, H. J., Gerlsma, C., Duijn, M. V., & Jonge, P. D. (2006). Internal and external validity of the experiences in close relationships questionnaire in an American and two Dutch samples. The European journal of psychiatry, 20(4), 258-269.
Cooper, M. L., Shaver, P. R., & Collins, N. L. (1998). Attachment styles, emotion regulation, and adjustment in adolescence. Journal of personality and social psychology, 74(5), 1380.
Damasio, A. (2008). Descartes' error: Emotion, reason and the human brain. London: Random House.
Davidson, J., & Frank, R. I. (2014). The Transdiagnostic Road Map to Case Formulation and Treatment Planning: Practical Guidance for Clinical Decision Making. Oakland: New Harbinger Publications.
Davis, D., Shaver, P. R., & Vernon, M. L. (2004). Attachment style and subjective motivations for sex. Personality and Social Psychology Bulletin,30(8), 1076-1090.
Derogatis, L. R., Rickels, K., & Rock, A. F. (1976). The SCL-90 and the MMPI: a step in the validation of a new self-report scale. The British Journal of Psychiatry, 128(3), 280-289.
Diamond, L. M., Hicks, A. M., & Otter-Henderson, K. (2006). Physiological evidence for repressive coping among avoidantly attached adults. Journal of Social and Personal Relationships, 23(2), 205-229. Ecke, Y. (2007). Attachment style and dysfunctional career thoughts: How attachment style can affect the
career counseling process. The Career Development Quarterly, 55(4), 339-350.
Epskamp, S., Cramer, A. O. J., Waldorp, L. J., Schmittmann, V. D., Borsboom, D. (2012) Qgraph: Network visualizations of relationships in psychometric data. J Stat Softw 48, 1–18.
Esterling, B. A., Antoni, M. H., Kumar, M., & Schneiderman, N. (1990). Emotional repression, stress disclosure responses, and Epstein-Barr viral capsid antigen titers. Psychosomatic Medicine, 52(4), 397-410.
24
Feeney, B. C., & Kirkpatrick, L. A. (1996). Effects of adult attachment and presence of romantic partners on physiological responses to stress. Journal of personality and social psychology, 70(2), 255.
Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books. Fraley, R. C., & Bonanno, G. A. (2004). Attachment and loss: A test of three competing models on the
association between attachment-related avoidance and adaptation to bereavement. Personality and Social Psychology Bulletin,30(7), 878-890.
Fraley, R. C., & Shaver, P. R. (1997). Adult attachment and the suppression of unwanted thoughts. Journal of personality and social psychology, 73(5), 1080.
Friedman, J., Hastie, T. and Tibshirani, R. (2011). Glasso: Graphical lasso-estimation of Gaussian graphical models. R package version 1.7. http://CRAN.R-project.org/package=glasso
Gentzler, A. L., & Kerns, K. A. (2004). Associations between insecure attachment and sexual experiences. Personal relationships, 11(2), 249-265.
Goldstein, H. S., Edelberg, R., Meier, C. F., & Davis, L. (1988). Relationship of resting blood pressure and heart rate to experienced anger and expressed anger. Psychosomatic Medicine, 50(4), 321-329.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington: American Psychological Association.
Grunebaum, M. F., Galfalvy, H. C., Mortenson, L. Y., Burke, A. K., Oquendo, M. A., & Mann, J. J. (2010). Attachment and social adjustment: relationships to suicide attempt and major depressive episode in a prospective study. Journal of affective disorders, 123(1), 123-130.
Jain, E., & Labouvie-Vief, G. (2010). Compensatory effects of emotion avoidance in adult development. Biological psychology, 84(3), 497-513.
Jinyao, Y., Xiongzhao, Z., Auerbach, R. P., Gardiner, C. K., Lin, C., Yuping, W., & Shuqiao, Y. (2012). Insecure attachment as a predictor of depressive and anxious symptomology. Depression and anxiety, 29(9), 789-796.
Johnson, S. M., & Sims, A. (2000). Attachment theory: A map for couples therapy. In T.A. Levy (Eds.), Handbook of attachment interventions, (pp. 167-191). San Diego: Academic Press.
Kim, Y. (2006). Gender, attachment, and relationship duration on cardiovascular reactivity to stress in a laboratory study of dating couples. Personal Relationships, 13(1), 103-114.
Kleiman, E. M., & Liu, R. T. (2013). Social support as a protective factor in suicide: Findings from two nationally representative samples.Journal of affective disorders,150(2), 540-545.
Kotler, T., Buzwell, S., Romeo, Y., & Bowland, J. (1994). Avoidant attachment as a risk factor for health. British Journal of Medical Psychology, 67(3), 237-245.
Lizardi, D., Grunebaum, M. F., Burke, A., Stanley, B., Mann, J. J., Harkavy-Friedman, J., & Oquendo, M. (2011). The effect of social adjustment and attachment style on suicidal behaviour. Acta Psychiatrica Scandinavica,124(4), 295-300.
Lopez, F. G., Gover, M. R., Leskela, J., Sauer, E. M., Schirmer, L., & Wyssmann, J. (1997). Attachment styles, shame, guilt, and collaborative problem-solving orientations. Personal Relationships, 4(2), 187-199.
25
Mandal, E., & Zalewska, K. (2012). Childhood violence, experience of loss and hurt in close relationships at adulthood and emotional rejection as risk factors of suicide attempts among women. Archives of Psychiatry and Psychotherapy, 3, 45-50.
Mansell, W., Harvey, A., Watkins, E. R., & Shafran, R. (2008). Cognitive behavioral processes across
psychological disorders: A review of the utility and validity of the transdiagnostic approach. International Journal of Cognitive Therapy, 1(3), 181-191.
Maunder, R. G., & Hunter, J. J. (2001). Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosomatic medicine, 63(4), 556-567.
Mauss, I. B., & Gross, J. J. (2004). Emotion suppression and cardiovascular disease. In I. Nyklícek, L. Temoshok, & A. Vingerhoets (Eds.), Emotional expression and health: Advances in theory, assessment and clinical applications, (pp. 60-80) New York: Routledge.
McNally, R. J., Robinaugh, D. J., Wu, G. W., Wang, L., Deserno, M. K., & Borsboom, D. (2014). Mental Disorders as Causal Systems A Network Approach to Posttraumatic Stress Disorder. Clinical Psychological Science, 2167702614553230.
Mikulincer, M., Florian, V., & Weller, A. (1993). Attachment styles, coping strategies, and posttraumatic psychological distress: the impact of the Gulf War in Israel. Journal of personality and social psychology, 64(5), 817.
Mikulincer, M., & Shaver, P. R. (2008). Adult attachment and affect regulation. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd Ed., pp. 503-531). New York: Guilford Press.
Murphy, B., & Bates, G. W. (1997). Adult attachment style and vulnerability to depression. Personality and Individual differences, 22(6), 835-844.
Palitsky, D., Mota, N., Afifi, T. O., Downs, A. C., & Sareen, J. (2013). The association between adult attachment style, mental disorders, and suicidality: Findings from a population-based study. The Journal of nervous and mental disease, 201(7), 579-586.
Park, L. E., Crocker, J., & Mickelson, K. D. (2004). Attachment styles and contingencies of self- worth. Personality and Social Psychology Bulletin, 30(10), 1243-1254.
Pennebaker, J. W., Kiecolt-Glaser, J. K., & Glaser, R. (1988). Disclosure of traumas and immune function: health implications for psychotherapy. Journal of consulting and clinical psychology, 56(2), 239.
Pines, A. M. (2004). Adult attachment styles and their relationship to burnout: A preliminary, cross-cultural investigation. Work & Stress, 18(1), 66-80.
Priel, B., & Shamai, D. (1995). Attachment style and perceived social support: Effects on affect regulation. Personality and Individual Differences, 19(2), 235-241.
Roberts, J. E., Gotlib, I. H., & Kassel, J. D. (1996). Adult attachment security and symptoms of depression: the mediating roles of dysfunctional attitudes and low self-esteem. Journal of personality and social psychology, 70(2), 310.
Saffrey, C., & Ehrenberg, M. (2007). When thinking hurts: Attachment, rumination, and postrelationship adjustment. Personal Relationships, 14(3), 351-368.
26
Scharfe, E., & Eldredge, D. (2001). Associations between attachment representations and health behaviors in late adolescence. Journal of Health Psychology, 6(3), 295-307.
Schotte, C. K. W., Maes, M., Cluydts, R., De Doncker, D., & Cosyns, P. (1997). Construct validity of the Beck Depression Inventory in a depressive population. Journal of Affective Disorders, 46(2), 115-125. Shaver, P. R., & Mikulincer, M. (2008). Adult attachment and cognitive and affective reactions to positive and
negative events. Social and Personality Psychology Compass, 2(5), 1844-1865.
Shaver, P. R., Mikulincer, M., Lavy, S., & Cassidy, J. (2009). Understanding and altering hurt feelings: An attachment-theoretical perspective on the generation and regulation of emotions. In A. L. Vangelisti (Eds.), Feeling hurt in close relationships, (pp. 92-119). Cambridge: Cambridge University Press. Sheftall, A. H., Schoppe-Sullivan, S. J., & Bridge, J. A. (2014). Insecure attachment and suicidal behavior in
adolescents. Crisis, 35(6), 426–430.
Smyth, J. M. (1998). Written emotional expression: effect sizes, outcome types, and moderating variables. Journal of consulting and clinical psychology,66(1), 174.
Tracy, J. L., Shaver, P. R., Albino, A. W., & Cooper, M. L. (2003). Attachment styles and adolescent
sexuality. Adolescent romance and sexual behavior: Theory, research, and practical implications 1, 137-159.
Troisi, A., Alcini, S., Coviello, M., Nanni, R. C., & Siracusano, A. (2010). Adult attachment style and social anhedonia in healthy volunteers. Personality and Individual Differences, 48(5), 640-643.
Vogel, D. L., & Wei, M. (2005). Adult Attachment and Help-Seeking Intent: The Mediating Roles of
Psychological Distress and Perceived Social Support. Journal of Counseling Psychology, 52(3), 347. Waller, E., & Scheidt, C. E. (2006). Somatoform disorders as disorders of affect regulation: a development
perspective. International Review of Psychiatry, 18(1), 13-24.
Waller, E., Scheidt, C. E., & Hartmann, A. (2004). Attachment representation and illness behavior in somatoform disorders. The Journal of nervous and mental disease, 192(3), 200-209.
Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford Press.
Wayment, H. A., & Vierthaler, J. (2002). Attachment style and bereavement reactions. Journal of Loss & Trauma, 7(2), 129-149.
Wei, M., Mallinckrodt, B., Russell, D. W., & Abraham, W. T. (2004). Maladaptive Perfectionism as a Mediator and Moderator Between Adult Attachment and Depressive Mood. Journal of Counseling Psychology, 51(2), 201.
Weissman, M.M., Bland, R.C., Canino, G.J., Faravelli, C., Greenwald, S., Hwu, H.-G., Joyce, P.R., Karam, E.G., Lee, C.-K., Lellouch, J., Lepine, J.- P., Newman, S.C., Rubio-Stipc, M., Wells, E., Wickramaratne, P.J., Wittchen, H.-U., & Yeh, E.- K. (1996). Cross-national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association, 276, 293–299.
Wolfe, J. B., & Betz, N. E. (2004). The Relationship of Attachment Variables to Career Decision-Making Self- Efficacy and Fear of Commitment. The Career Development Quarterly, 52(4), 363-369.
Zachrisson, H. D., & Kulbotten, G. R. (2006). Attachment in anorexia nervosa: an exploration of associations with eating disorder psychopathology and psychiatric symptoms. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 11(4), 163-170.
