Attachment and Autonomy in Mood and Anxiety Disorders and Personality Disorders. Master Thesis. Beau Dankers ANR Tilburg University

Transcription

1 Attachment and Autonomy 1 Attachment and Autonomy in Mood and Anxiety Disorders and Personality Disorders Master Thesis Beau Dankers ANR Tilburg University Tilburg School of Social and Behavioral Sciences Section Clinical Psychology Assessor: Prof. Dr. M.H.J. Bekker Second assessor: Dr. A. Karreman Word count: 8695

2 Attachment and Autonomy 2 Abstract Problems in attachment and autonomy are associated with mood and anxiety disorders as well as personality disorders. However, it is unknown to what degree both types of disorders differ in terms of these variables. The present study examined attachment styles and level of autonomy in patients with both diagnosis types. Patients with personality disorders were hypothesized to be more insecurely attached and less autonomous than people with mood and anxiety disorders. One hundred and six patients of an ambulatory center participated, 44 had obtained the diagnosis mood and anxiety disorders and 62 were diagnosed with personality disorders. Attachment was measured by means of the Attachment Style Questionnaire, Experiences in Close Relationships Revised, and Parental Bonding Instrument. Autonomy was assessed with the Autonomy-Connectedness Scale. Inventory for Personality Organization was used to measure self reported personality problems. In this study, people with personality disorders were more sensitive to others, less confident, more in need for approval, more preoccupied with relationships in general, and showed more attachmentrelated anxiety in current intimate relationships than patients diagnosed with mood and/or anxiety disorders. After controlling for personality problems, being less confident and more in need for approval were related to having a personality disorder. Patients who are more selfaware, less confident, more in need for approval, more preoccupied with relationships, and who show more attachment-related anxiety in intimate relationships can best be allocated to treatment for personality disorders. Although these results show a practical applicability, more than half of the differences between patients diagnosed with a mood and/or anxiety disorder and patients diagnosed with a personality disorder was left unexplained. Keywords: attachment, autonomy, mood and anxiety disorders, personality disorders, mental health care.

3 Attachment and Autonomy 3 Attachment and Autonomy in Mood and Anxiety Disorders and Personality Disorders Introduction The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) divides mental disorders into two groups: clinical disorders (axis I) and personality disorders (axis II) (APA, 2000). Krueger (2005) found that these axes were more similar than distinct. He suggested that links between the domains may be better understood by focusing on how personality connects clinical and personality disorders. This perspective underlines the need to work toward a more unified model of personality, personality disorders, and clinical disorders in research and in future editions of the DSM. Kupfer, First, and Regier (2002) show important gaps in the current DSM-IV categorical method of diagnosing personality disorders. Excessive co morbidity exists among the DSM-IV-TR personality disorders. Also, there is an arbitrary distinction between normal personality, personality traits, and personality disorders. Lack of empirically documented clinical utility of treatment decisions exists for most of the personality disorders. Finally, there is limited coverage. The most commonly diagnosed personality disorder is the residual diagnosis of personality disorder not otherwise specified. The division of, in particular personality-, disorders in DSM-IV is examined and questioned in several studies. This leaves room for exploring classification of disorders by new concepts. Categorization of Disorders in Mental Health Care Mental health care in many countries, is based on the principle of stepped care, with various care trajectories along the categorization of disorders in DSM-IV. The present study is focused on mood and anxiety disorders and personality disorders (cluster B and C). Based on the five-axes system of DSM-IV, mood and anxiety disorders are categorized on axis I and personality disorders on axis II. Therefore patients in mental health care are often assigned to

4 Attachment and Autonomy 4 either a care trajectory focusing on the treatment of axis I disorders or one targeted at axis II disorders. The aim of the present research is to assess whether there are underlying characteristics of axis I and axis II disorders clearly differentiate both types of disorders. In a study by Flanagan and Blashfield (2006) clinicians were given 67 DSM-IV diagnoses and were asked to discard unfamiliar diagnoses, to make groups of similar diagnoses, to place the most similar groups next to each other, and to describe the overall structure of their taxonomies. Results showed that clinicians were more familiar with the personality disorders than with several of the axis I disorders. Clinicians tended not to keep the personality disorders in one group, although they often kept the cluster groupings together. Cluster groupings were often placed with co morbid axis I disorders. These data suggest that clinicians did not see the personality disorders as qualitatively different from the axis I disorders, thus in practice axis I and axis II are not clearly divided into two different groups. Westen and Arkowitz-Westen (1998) examined if patients treated for enduring, maladaptive personality patterns had an axis II disorder diagnosable by psychiatrics and psychologists. They found a discrepancy between the group of patients treated for a personality disorder and the group of patients that was diagnosed with a personality disorder using the DMS-IV. By applying the DSM-IV criteria for diagnosing personality disorders, most of the patients who were in treatment for a personality disorder, were not actually diagnosed with a personality disorder. There is incongruence between the diagnostic criteria of DSM-IV and the practice. The publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) in May 2013 will mark one the most anticipated events in the mental health field. The development of DSM-V includes reviewing scientific advances and research to develop draft diagnostic criteria in diagnostic categories of psychiatric disorders. With DSM-V on the way, several studies state that the division of disorders on axis I and II is not

5 Attachment and Autonomy 5 as clear as DSM-IV proposes. The aforementioned studies give an indication that the current classification of DSM-IV is outdated. Stepped care in mental health care is based on DSM-IV. Therefore, the care trajectories mood and anxiety disorders and personality disorders may be outdated as well. Factors that contribute to the development of psychological disorders can be considered as differentiation factors for determining best treatment for a patient. The present study will consider differences in attachment style and level of autonomy in patients as new factors to classify diagnoses of patients in and can help allocate patients to the care trajectories in mental health care. Attachment, autonomy and their connection with psychological disorders will be reviewed. Attachment The attachment theory (Bowlby, 1973) states that the style of attachment developed at a young age affects mental health, interpersonal relationships and affect regulation at an older age. Infants are born with a repertoire of behaviors (attachment behaviors) aimed at seeking and maintaining proximity to supportive others (attachment figures). According to Mikulincer, Shaver, and Pereg (2003) proximity seeking is an inborn affect-regulation device (primary attachment strategy) for protecting an individual from physical and psychological threats and to alleviate distress. Bowlby (1988) claimed that the successful accomplishment of these affect-regulation functions results in a sense of attachment security. Based on the theory of Bowlby, Ainsworth and colleagues (1978) observed children between the ages of 12 and 18 months in a Strange Situation, a situation in which they were briefly left alone, and then reunited with their mothers. Ainsworth described the major styles of attachment: secure attachment and insecure attachment divided into ambivalent attachment, avoidant attachment, and disorganized attachment.

6 Attachment and Autonomy 6 For the development of a securely attached child, the caregiver serves as a secure base in anxiety-arousing or stressful situations. An avoidantly attached child is unable to use the caregiver as a source of comfort and to regulate negative affect; it ignores the caregiver. When ambivalently attached, the child makes inconsistent attempts to use the caregiver for comfort in stressful situations. The child does not show a consistent strategy when reacting to separation and reunion with its caregiver (Muris, Meesters, van Melick, & Zwambag, 2001; Rosenstein, & Horowitz, 1996). Attachment style does not only appear in the relationship with caregivers at an early age. Therefore, in this study attachment is divided into three dimensions: attachment style in relationships in general, experienced attachment in childhood, and experienced attachment in current intimate relationships. Research has indicated that people who are insecurely attached have a higher level of anxiety sensitivity. Insecurely attached people develop an anxiety disorder more often (Viana & Rabian, 2008; Watt, McWilliams, & Campbell, 2005). Furthermore, Pacchierottie et al. (2002) found that a dysfunctional relationship between parents and children can influence cognitive and emotional development and can contribute to the development of psychiatric disorders, particularly to panic disorder. Research has also found that people who are insecurely attached are more likely to have a mood disorder. Insecure attachment can lead to depression and anxiety (Muris, Meesters, van Melick, & Zwambag, 2001). There is also a connection between attachment style and personality disorders. Insecure attachment in childhood is a major risk factor for the development of personality disorders. The three subtypes of cluster C personality disorders have been found to be connected to different styles of attachment (Crittenden, 1995, 1997; Millon, 1996; Page, 2001). There is a connection between ambivalent attachment and the obsessive-compulsive personality disorder, between avoidant attachment and the avoidant personality disorder, and

7 Attachment and Autonomy 7 between dependent attachment style and dependent personality disorder. Insecure attachment is also characteristic of the dependent and avoidant personality disorder (Trull, Widiger, & Frances, 1987). Autonomy Autonomy is a psychological condition resulting from the process of individualization and separation. Autonomy can be seen as the result of a healthy development (Bekker & van Assen, 2006). Hmel and Pincus (2002) describe autonomy in three underlying concepts: selfgovernance, agentic separation, and depressogenic vulnerability. Self-governance reflects interpersonal connectedness and dependency. High self-governance means that someone is psychologically well adjusted, at low risk for psychopathology, and well balanced between dependency and independency. The concept agentic separation is related to separation from others and independency. The third concept depressogenic vulnerability is based on Beck s cognitive model of depression. This model states that people with a high level of autonomy appreciate freedom, achievement, and individuality. Autonomy can be seen as self regulation in social functioning (Bekker, 1993; Bekker & van Assen, 2006; Hmel & Pincus, 2002). With autonomy-connectedness, the social element in autonomy is emphasized (Bekker, 2009). Three components can be distinguished within autonomy-connectedness. Self-awareness is the ability to be conscious of your own emotions, needs, and wishes. It also includes the ability to realize interaction with other individuals. Sensitivity to the opinions, wishes, and needs of other people is expressed in the second component of autonomy-connectedness, sensitivity to others. This concept also includes empathy and the capacity and need for intimacy and separation. The attachment theory s secure attachment is inherent to the third component of autonomy connectedness, capacity for managing new situations. This includes the capacity for managing new situations and reflects the drive for exploration (Bekker, 1993; Bekker & van Assen, 2006). There is an important

8 Attachment and Autonomy 8 connection between autonomy and attachment. Without secure attachment, the degree of autonomy will be lower. Research indicates a relationship between autonomy and mental disorders. Autonomyconnectedness can be associated with anxiety and mood disorders (Bekker & Belt, 2006), eating disorders (Bekker & van Assen, 2006), and antisocial behavior (Bekker, Bachrach, & Croon, 2007). The avoidant personality disorder may be associated with aspects of autonomy that include avoiding interpersonal closeness because of fears of rejection. Other personality disorders, including paranoid, schizoid, antisocial, obsessive-compulsive, and passiveaggressive personality disorder, appear to feature concerns about autonomy and achievement (Morse, Robins, & Gittes-Fox, 2002). Connection of Autonomy and Attachment with Mood and Anxiety Disorders and Personality Disorders There is a moderate correlation between anxiety disorders and attachment, and also between depression and attachment (Tasca, 2009; Zuroff & Fitzpatrick, 1995). Patrick (1994) has found that a more evident correlation exists between personality disorders and attachment. People who are securely attached are two times less likely to have a personality disorder than people who are insecurely attached. Insecurely attached people are three to four times more likely to develop a personality disorder (Brennan, 1998). There are several studies that examined the relationship between attachment style and autonomy in mood and anxiety disorders and personality disorders. Little is known of attachment styles and autonomy in mood and anxiety disorders, when controlled for personality problems. People with mood and/or anxiety disorders may have a personality disorder. Insecure attachment and reduced autonomy in people with a mood and/or anxiety disorders can possibly be caused by underlying personality problems.

9 Attachment and Autonomy 9 Aims and Hypotheses of the Present Study Attachment and autonomy are intertwined. Insecurely attached people show more autonomy related problems than securely attached people. The present study was aimed at examining autonomy and attachment style in, on the one hand, patients diagnosed with personality disorders and on the other patient diagnosed with mood and anxiety disorders. Based on prior findings the following three questions and hypotheses were formulated. What is the difference in attachment style and level of autonomy among patients diagnosed with mood and anxiety disorders and patients diagnosed with personality disorders? Our hypothesis was that patients diagnosed with personality disorders are significantly less securely attached and less autonomous than patients diagnosed with mood and anxiety disorders. Will differences in attachment and autonomy disappear after controlling for differences in self reported personality problems? We hypothesized that after controlling for personality disorders patients diagnosed with personality disorders will be similarly insecurely attached and autonomous as patients diagnosed with mood and anxiety disorders. Controlling for personality problems in both groups will make the difference in attachment and autonomy smaller, because the personality problems are hypothesized to be associated with insecure attachment and low autonomy. If a connection of personality disorders with attachment style and autonomy would be found, this link would be further explored. What is the predictive value of attachment style and level of autonomy for personality disorders? Finally, we hypothesized that attachment style and level of autonomy could predict in which diagnosis group of disorders patients would belong.

10 Attachment and Autonomy 10 Method Participants Patients in treatment in the mental health care (Geestelijke Gezondheidszorg, GGz Breburg) in either the care trajectory mood and anxiety disorders or personality disorders were examined in this research. The participants assigned to the group mood and anxiety disorders were in treatment for a mood and/or anxiety disorder and participants allocated to personality disorders were primarily treated for a personality disorder. All participants voluntarily agreed to participate in this study. The inclusion and exclusion criteria for this research were equal to the criteria for treatment allocation into one of the two care trajectories. Patients had to have a diagnosable axis I or axis II DSM-IV disorder. If a patient did not meet these criteria, a patient could not receive treatment in mental health care in the care trajectories mood and anxiety disorders or personality disorders. Through psychological research administered by a trained psychologist, diagnoses were determined. Using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II, First, Gibbon, Spitzer, Williams, & Benjamin, 1997), it was determined if a patient met the criteria of one or more personality disorders and should be treated in the care trajectory personality disorders. Participants had either a mood or anxiety disorder or a personality disorder as primary diagnosis. Participants with mood and anxiety disorders did not primarily have a personality disorder or personality problems emerging. The range of age of the participants was 18 to 65 and participants had an adequate control of the Dutch language. The exclusion criteria were psychotic symptoms and an Intelligence Quotient lower than 80, assessed with the Wechsler Adult Intelligence Scale III (WAIS-III, Wechsler, 1997) or Groninger Intelligentie Test (GIT- 2, Luteijn & Barelds, 2004). Patients treated for psychotic symptoms were not treated in the

11 Attachment and Autonomy 11 care trajectory personality disorders, but in the care trajectory psychosis and therefore not included in this research. An overview of the demographic characteristics of the total group of participants is shown in Table 1. Design A between-groups design was used for this research. It was a cross-sectional, quantitative research. The independent variable was the diagnosis a patient was treated for (Mood and Anxiety Disorders or Personality Disorders). The dependent variables were Attachment Style, measured with the ASQ, PBI and ECR-R; and Autonomy, measured with the ACS-30. Participants were all measured once. The questionnaires were handed out via post or via to patients who were in treatment in for a mood or anxiety disorder, or a personality disorder in mental health care. The system of the Routine Outcome Monitoring (ROM) measurement was used to send the questionnaires via . The ROM is a measurement to evaluate the treatment of patients in mental health care by assessing the nature and severity of the problems at the moment of application of a patient and the course of the problems over time. Measures Autonomy-Connectedness Scale (ACS-30; Bekker & van Assen, 2006). The ACS-30 is a shortened version of the Autonomy list. It measures individual differences in gender-related autonomy and consists of 30 statements, divided into three subscales. The subscales are Self- Awareness, Sensitivity to Others, and Capacity for Managing new Situations. All items are measured on a 5-point Likert scale, running from 1, disagree, to 5, agree. The reliability of the subscales of the ACS-30 is good with Cronbach s alfa, respectively, 89,.83, and.77 (Bekker, & Van Assen, 2006). The test-retest reliability and convergent validity of this shortened

12 Attachment and Autonomy 12 version are reviewed as good (Bekker, 1993; Bekker, & Van Assen, 2006). In the current study, the Cronbach alpha coefficients were respectively.83,.79, and.69. Attachment Style Questionnaire (ASQ; Feeney, Noller & Hanrahan, 1994). The ASQ assesses general attachment style in relationships. The questionnaire is constructed of 40 statements divided into 5 subscales. These scales are Confidence, Preoccupation with Relationships, Relationships as Secondary, Discomfort with Closeness, and Need for Approval. The subscales Confidence, Preoccupation with Relationships and Need for Approval reflect the anxious ambivalent attachment style. The remaining two subscales reflect the avoidant attachment style. All the aspects are rated at a 6-point Likert scale by the participants, ranging from 1, totally disagree, to 6, totally agree. Feeney, Noller, and Hanrahan (1994) state that the subscales have a reliability ranging from.76 to.84. Test-retest reliability ranges from.67 to.78. Stein et al. (2002) found a significant relation between the ASQ and the styles of attachment (secure, avoidant and anxious/ambivalent). Construct and criteria validity are good. In the current study, the Cronbach alpha coefficients were respectively.82,.72,.63,.80, and.68. Parental Bonding Instrument (PBI; Parker, Tupling & Brown, 1979). Assessing the evaluation of parenting styles is the goal of the PBI. Memories of the upbringing that participants received from their parents before the age of 16 were assessed. The questionnaire consists of two times 25 items that are divided into the two subscales Care and Overprotection. It measures the relationship with the mother and father separately. The Care scale consists of 12 items that refer to positive feelings as love, care, and empathy. The Overprotection scale consists of 13 items that refer to overprotecting and reserved behavior of the parents. All items are measured at a 4-point Likert scale, ranging from 1, very much, to 4, not at all. The two scales can be combined so that parents can be assigned to one of the four quadrants: affectionate constraint is high care and high protection, affectionless control, is

13 Attachment and Autonomy 13 high protection and low care, optimal parenting, is high care and low protection, and neglectful parenting, is low care and low protection. Parker (1983) reports a good reliability by Cronbach s alfa coefficients of.87 for Care and.92 for Overprotection. Also, high correlations are found for the test-retest reliability;.77 for maternal care,.73 for maternal protection,.58 for paternal care, and.69 for paternal protection. Construct, - and convergent validity are satisfactory (Parker, 1979; 1983; Gomez- Beneyto, 1993). In the current study, the Cronbach alpha coefficients were.89 (Care) and.82 (Overprotection). The Experiences in Close Relationships Questionnaire Revised (ECR-R; Brennan, Fraley & Waller, 2000) is a revised version of the ECR. The ECR-R assesses how individuals experience intimate relationships in general. It consists of 36 items, divided into the two subscales Attachment-related Anxiety and Attachment-related Avoidance. The subscales both consist of 18 items. The Anxiety scale assesses fear of surrender, concern with a romantic partner, and fear of rejection. The Avoidance scale assesses avoidance of intimacy, discomfort with proximity and self-confidence. All items are measured at a 7-point Likert scale, ranging from 1, strongly disagree, to 7, strongly agree. A study by Brennan, Fraley, and Walley (2000) shows a reliability for the subscales of respectively.91, and.94. The test-retest reliability is.70 for both subscales (Larsson & Zakalik, 2005). Both the convergent and discriminant validity of the ECR-R are good (Sibley, Fischer, & Liu, 2005). In the current study, the Cronbach alpha coefficients were.92 (Attachment-related Anxiety) and.84 (Attachment-related Avoidance). Inventory of Personality Organization (IPO; Clarkin, Foelsch, & Kernberg, 2001). The IPO is used to assess personality problems. The questionnaire consists of 83 items, divided into five subscales with three main scales: Primitive Psychological Defenses, Identity Diffusion, Reality Testing, and two added scales Aggression, and Moral Value. All items are

14 Attachment and Autonomy 14 measured at a 5-point Likert scale, ranging from 1, never right, to 5, always right. Reliability of the subscales varies from.82 to.86. Test-retest reliability of the subscales is considered to be good (Lenzenweger, Clarkin, Foelsch, & Kernberg, 2001). In the current study, the Cronbach alpha coefficients were respectively.91,.92,.92,.78, and.78. Procedure All participants in this research were in treatment at GGz Breburg. Therapists were asked to approach all their patients within a two week period, to ask whether they would like to participate in a research. Participants received an informative letter from their therapists to notify them of the procedure and the goal of the research in which they would be participating. The aim of this letter was to give the participants the possibility to make a well informed choice to participate in the research, before signing the informed consent. Participants had to fill in their name, date of birth, level of education and gender on the participant s information form. They could indicate if they wanted to receive the questionnaires by post or . The therapist returned the informed consent and participant s information to the researcher. Via Psygis (an electronic patient file), the digital questionnaires were sent to participants, or the researcher sent the questionnaires to the participants via post. The ROMsystem Questmanager was used to send the digital questionnaires via . When participants filled in the questionnaires manually, they could return them through a reply envelope. The questionnaires were processed anonymously, by linking each participant to a number. A number was also linked to the questionnaires and the form with the personal information. Participants were not automatically informed about the results of the experiment. There was a possibility for them to receive the results, by indicating this on the informed consent.

15 Attachment and Autonomy 15 Statistical Analysis Via an a-priori power analysis, the sample size was computed using the program G*power. A total group of 111 participants was needed for this research. Before the collected data could be analyzed, a number of preliminary analyses were executed. Several items had to be recoded and items within the same subscale were combined. The total scores of the questionnaires and subscales were computed. The reliability of the subscales was tested and the assumptions of normality and homogeneity of variance were checked. Normality was assessed with the Kolmogorov-Smirnov statistic and homogeneity of variance by applying the Levene s test. The groups Mood and Anxiety Disorders and Personality Disorders were compared on demographic characteristics, to determine if the groups differed on these characteristics. A connection between demographical variables and the research variables could influence the results. In that case, those demographical variables had to be controlled for in further analyses as covariate. Spearman s rho was used to determine the correlation between the demographics and dependent variables. The research question of this study was how people with a mood or anxiety disorder, without a personality disorder, differ from people with a personality disorder as primary diagnosis in terms of attachment style and autonomy. The independent variables were indicator variables for having a mood and anxiety disorder, or having a personality disorder. The dependent variables were attachment and autonomy. Attachment was divided into three dimensions: attachment style in relationships in general, experienced attachment in childhood and experienced attachment in current intimate relationships. Having personality problems as stated by the subscales of the IPO were the covariates.

16 Attachment and Autonomy 16 To test the first hypothesis, a 1oneway multivariate variance analyses (MANOVA) was used per each questionnaire to determine if participants in Mood and Anxiety Disorders would differ from participants in Personality Disorders on attachment and autonomy. For controlling on existing personality problems, as stated by the second hypothesis, a MANCOVA was used. These analyses were all run separately for the subscales of the ACS- 30, ASQ, ECR-R and PBI. Finally, a discriminant function analysis and logistic regression analysis were used to explore the predictive ability of attachment style and level of autonomy, on the categorical dependent measure. The discriminant function analysis was used to analyze which subscales of the questionnaires best predict group membership. A discriminant analysis is used in general to describe major differences among the groups in MANOVA and classifying subjects into groups on the basis of a battery of measurements (Stevens, 2002). The categorical dependent variable is group of treatment (Mood and Anxiety Disorders or Personality Disorders). Direct logistic regression was performed to assess the impact of a number of autonomy and attachmnet on the likelihood that participants would be diagnosed with a personality disorder in addition to the discriminant analysis. In multivariate analyses an alpha level of.05 was retained. In univariate analyses, the Bonferroni adjusted alpha (alfa / number of dependent variables) was used, to reduce the chance of type-1- error. Results The assumption of the Chi-square test of independence between level of education and care trajectory (Mood and Anxiety Disorders or Personality Disorders) concerning minimum expected cell frequency is violated. Forty per cent of the cells have expected frequencies of less than 5. The assumption is not violated for the Chi-square test of independence between gender and care trajectory.

17 Attachment and Autonomy 17 A Chi-square test for independence (with Yates Continuity Correction) indicated a significant association between Gender and care trajectory, χ 2 (1, n = 104) = 4.14, p =.04, phi =.22. The proportion of females in the groups Mood and Anxiety Disorders and Personality Disorders (respectively 70.5% and 88.3%) was larger than the proportion of males within these groups (respectively 29.5% and 11.7%). The Chi-square test for independence indicated no significant association between Education and care trajectory, χ 2 (4, n = 102) = 8.57, p =.07, phi =.29. There was no significant difference in education between Mood and Anxiety Disorders and Personality Disorders. An independent-samples t-test was conducted to compare Age for the groups Mood and Anxiety disorders and Personality disorders. There was no significant difference in age for Mood and Anxiety disorders (M = 39.48, SD = 11.08) and Personality disorders (M = 39.28, SD = 10.42); t (102) =.09, p =.97 (two-tailed). The magnitude of the differences in the means (mean difference =.19, 95% CI: to 4.4) was very small (eta squared =.003). The relationship between the demographical variables (Age, Gender and Education) and attachment (as measured by the subscales Confidence, Discomfort with Closeness, Relationships as Secondary, Need for Approval, Preoccupation with Relationships, Care, Overprotection, Attachment-related Anxiety, and Attachment-related Avoidance) and autonomy (as measured by the subscales Self-Awareness, Sensitivity to Others, and Capacity for Managing new Situations) was investigated using the Pearson product-moment correlation coefficient. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity and homoscedasticity. There was a significant, positive correlation between gender and Sensitivity to Others, r =.33, n = 102, p =.00 and a significant, negative correlation between gender and

18 Attachment and Autonomy 18 Relationships as Secondary r = -.21, n = 102, p =.03. In further analysis Sensitivity to Others and Relationships as Secondary were controlled for Gender. Correlations between the Subscales of the Questionnaires The relationships of all subscales (Self-Awareness, Sensitivity to Others, and Capacity for Managing new Situations, Confidence, Discomfort with Closeness, Relationships as Secondary, Need for Approval, Preoccupation with Relationships, Care, Overprotection, Attachment-related Anxiety, and Attachment-related Avoidance) were investigated for both groups of patients diagnosed with Mood and Anxiety Disorders and patients diagnosed with Personality Disorders, to get a better understanding of the relationships between the subscales. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity and homoscedasticity. Not many differences in correlations among the subscales were found between Mood and Anxiety Disorders and Personality Disorders. Most significant correlations were found among the subscales of the Attachment Style Questionnaire. For Personality Disorders, Confidence was negatively correlated with the Discomfort with Closeness, Relationships as Secondary, Need for Approval, and Preoccupation with Relationships. These correlations did also exist in the group Mood and Anxiety Disorders. For both groups of disorders, positive correlations were found between Discomfort with Closeness and Relationships as Secondary, Need for Approval, and Preoccupation with Relationships. Also a positive correlation was found between Need for Approval and Relationships as Secondary in both groups. These scales (Discomfort with Closeness, Relationships as Secondary, and Need for approval) were positively correlated with Attachment-related Avoidance in both groups too. Between the subscales of the Autonomy-Connectedness Scale (ACS-30) the same negative correlation was found between Self-Awareness and Sensitivity to Others for both groups. The same positive correlation was found between Capacity for Managing new

19 Attachment and Autonomy 19 Situation and Self-Awareness. Only in the group Mood and Anxiety Disorders, Capacity for Managing new Situations was negatively correlated with Sensitivity to Others. Comparing subscales of different questionnaires, Confidence (ASQ) was positively correlated with Self-Awareness and Capacity for Managing New Situations (ACS-30), whereas the other scales of the ASQ were negatively correlated with Capacity for Managing New Situations in both groups of disorders. The same positive correlations in Mood and Anxiety Disorders and Personality Disorders showed between Sensitivity to Others and Need for Approval, and between Sensitivity to Others and Preoccupation with Relationships. Self- Awareness was negatively correlated with Discomfort with Closeness and Need for Approval. Attachment-related Avoidance was negatively correlated with Self-Awareness and Capacity for Managing New Situations in both groups of disorders, Attachment-related Anxiety was positively correlated with Sensitivity to Others. In the group Personality Disorders, Attachment-related Anxiety was also negatively correlated with Self-Awareness. Pointedly, for both Mood and Anxiety Disorders as Personality Disorders no correlations were found between the Parental Bonding Instrument and the scales of the other questionnaires. On a negative correlation between the scales Care and Overprotection of the PBI was found. In table 2 a complete overview of the correlations between the subscales of the questionnaires is displayed for Mood and Anxiety Disorders and Personality Disorders separately. Attachment and Autonomy in Mood and Anxiety Disorders and Personality Disorders. A one-way between groups multivariate analysis of variance (MANOVA) was performed to investigate the group differences in attachment and autonomy. The independent variable was the diagnosis of patients (Mood and Anxiety Disorders and Personality Disorders). The dependent variables were autonomy (in terms of Self-Awareness, Sensitivity

20 Attachment and Autonomy 20 to Others, and Capacity for Managing new Situations) and attachment (in terms of Confidence, Discomfort with Closeness, Relationships as Secondary, Need for Approval, Preoccupation with Relationships, Care, Overprotection, Attachment-related Anxiety, and Attachment-related Avoidance). Preliminary assumption testing was conducted to check for normality, linearity, univariate and multivariate outliers, homogeneity of variance-covariance matrices, and multicollinearity, with no violations noted. There was a statistically significant difference between the groups Mood and Anxiety Disorders and personality Disorders on the combined dependent variables of the Autonomy- Connectedness Scales, F (3, 101) = 5.10, p <.01; Wilk s Lambda =.87, partial eta squared =.13.When the results for the dependent variables were considered separately, Sensitivity to Others reached statistical significant difference between Mood and Anxiety Disorders and Personality Disorders, using a Bonferroni adjusted alpha level of.017, F (1, 103) = 13.70, p <.00, partial eta squared =.12). An inspection of the mean scores indicated that the group Mood and Anxiety Disorders (M = 60.70, SD = 1.46) was less sensitive to others than the group Personality Disorders (M = 67.71, SD = 1.21). There was a statistically significant difference between the groups Mood and Anxiety Disorders and personality Disorders on the combined dependent variables of the Attachment Style Questionnaire, F (5, 99) = 4.08, p <.01; Wilk s Lambda =.83, partial eta squared =.17. When the results for the dependent variables were considered separately, no variables reached statistically significant difference between Mood and Anxiety Disorders and Personality Disorders, using a Bonferroni adjusted alpha level of.001. Using a normal alpha level of.05, Confidence (F (1, 103) = 9.57, p <.01, partial eta squared =.09), Need for Approval (F (1, 103) = 8.10, p <.01, partial eta squared =.07), and Preoccupation with Relationships (F (1, 103) = 4.14, p =.04, partial eta squared =.04) reached statistically significant differences. An inspection of the mean scores of Confidence indicated that the group Mood and Anxiety

21 Attachment and Autonomy 21 Disorders (M = 29.47, SD = 1.25) was more confident than the group Personality Disorders (M = 24.42, SD = 1.04). An inspection of the mean scores of Need for Approval indicated that the group Mood and Anxiety Disorders (M = 26.70, SD = 0.96) was less in need for approval than the group Personality Disorders (M = 30.26, SD =.80). An inspection of the mean scores of Preoccupation with Relationships indicated that the group Mood and Anxiety Disorders (M = 30.70, SD = 1.11) was less preoccupied with relationships than the group Personality Disorders (M = 33.63, SD = 0.92). There was a statistically significant difference between the groups Mood and Anxiety Disorders and Personality Disorders on the combined dependent variables of the Experience in Close Relationships Questionnaire Revised, F (2, 97) = 4.70, p =.01; Wilk s Lambda =.91, partial eta squared =.09. When the results for the dependent variables were considered separately, Attachment-related Anxiety reached statistically significant difference between Mood and Anxiety Disorders and Personality Disorders, using a Bonferroni adjusted alpha level of.025. F (1, 98) = 9.11, p <.01, partial eta squared =.09. An inspection of the mean scores indicated that the group Mood and Anxiety Disorders (M = 61.48, SD = 3.61) showed less Attachment-related Anxiety than the group Personality Disorders (M = 75.55, SD = 2.95). There was not any statistically significant difference between the groups Mood and Anxiety Disorders and Personality Disorders on the combined dependent variables of the Parental Bonding Instrument, F (2, 103) =.71, p =.49; Wilk s Lambda =.99, partial eta squared =.01. Attachment and Autonomy in Mood and Anxiety Disorders and Personality Disorders controlled for Personality Problems. A MANCOVA analysis was conducted to assess the differences between Mood and Anxiety Disorders and Personality Disorders in attachment and autonomy, controlling for personality problems. The dependent variables were autonomy (in terms of Self-Awareness,

22 Attachment and Autonomy 22 Sensitivity to Others, and Capacity for Managing new Situations) and attachment (in terms of Confidence, Discomfort with Closeness, Relationships as Secondary, Need for Approval, Preoccupation with Relationships, Care, Overprotection, Attachment-related Anxiety, and Attachment-related Avoidance), while using personality problems as measured by the IPO as a covariate to control for personality problems. Preliminary assumption testing was conducted to check for normality, linearity, univariate and multivariate outliers, homogeneity of variance-covariance matrices, and multicollinearity, with no serious violations noted. There was a statistically significant difference between the groups Mood and Anxiety Disorders and Personality Disorders on the combined dependent variables of the Inventory of Personality Organization, F (5, 100) = 4.05, p <.01; Wilk s Lambda =.83, partial eta squared =.17. The Levene s Test of Equality of Error Variances is violated for the scales Reality Testing and Aggression of the IPO; therefore an alpha of.01 is used, rather than the conventional.05 level. When the results for the dependent variables were considered separately, Primitive Psychological Defenses, reached statistically significant difference between Mood and Anxiety Disorders and Personality Disorders, using a Bonferroni adjusted alpha level of.01, F (1, 104) = 7.98, p <.01, partial eta squared =.07. Identity Diffusion reached statistically significant difference, F (1, 104) = 13.95, p <.01, partial eta squared =.18, and Aggression also reached statistical significance, F (1, 104) = 13.67, p <.01, partial eta squared =.12. Primitive Psychological Defenses, Identity Diffusion and Aggression were used as covariates in the MANCOVA s. Controlled for Primitive Psychological Defenses, Identity Diffusion and Aggression, there was a statistically significant difference between the groups Mood and Anxiety Disorders and Personality Disorders on the combined dependent variables of the Autonomy Connectedness Scale, F (3, 98) = 3.47, p =.02; Wilk s Lambda =.90, partial eta squared =.10. When the results for the dependent variables were considered separately, Sensitivity to

23 Attachment and Autonomy 23 Others reached statistically significant difference between Mood and Anxiety Disorders and Personality Disorders, using a Bonferroni adjusted alpha level of.017., F (1, 100) = 6.39, p =.01, partial eta squared =.06. An inspection of the mean scores indicated that the group Mood and Anxiety Disorders (M = 61.94, SD = 0.82) were less sensitive to others than the group Personality Disorders (M = SD = 1.91). Controlled for Primitive Psychological Defenses, Identity Diffusion and Aggression, there was a statistically significant difference between the groups Mood and Anxiety Disorders and Personality Disorders on the combined dependent variables of the Attachment Style Questionnaire, F (5, 96) = 3.30, p <.01; Wilk s Lambda =.85, partial eta squared =.15. When the results for the dependent variables were considered separately, Relationships as Secondary reached statistical significant difference between Mood and Anxiety Disorders and Personality Disorders, using a Bonferroni adjusted alpha level of.01, F (1, 100) = 9.35, p <.01, partial eta squared =.09. An inspection of the mean scores indicated that the group Mood and Anxiety Disorders (M = 19.42, SD =.82) had a higher score on Relationships as Secondary, thus show a more avoidant attachment style in general relationships than the group Personality Disorders (M = 16.08, SD =.67). Controlled for Primitive Psychological Defenses, Identity Diffusion and Aggression, there was not a statistically significant difference between the groups Mood and Anxiety Disorders and personality Disorders on the combined dependent variables of the Experience in Close Relationships Questionnaire Revised, F (2, 94) = 1.58, p =.21; Wilk s Lambda =.97, partial eta squared =.03, and the Parental Bonding Instrument, F (2, 100) =.90, p =.41; Wilk s Lambda =.98, partial eta squared =.02. The results of the MANOVA s and MANCOVA s are displayed in Table 3.

24 Attachment and Autonomy 24 Predictive Value of Attachment and Autonomy for Personality Disorders A discriminant analysis was conducted to further investigate the difference of Mood and Anxiety Disorders and Personality Disorders in attachment en autonomy. Predictor variables were Self-awareness, Sensitivity to Others, Capacity for Managing new Situations, Confidence, Discomfort with Closeness, Relationships as Secondary, Need for Approval, Preoccupation with Relationships, Attachment-related Anxiety, Attachment-related Avoidance, Care and Overprotection. This analysis was conducted in order to analyze if these variables of autonomy and attachment could predict whether a patient was diagnosed with either a Mood and Anxiety Disorder or Personality Disorder. Significant mean differences were observed for Confidence and Attachment-related Anxiety using an alpha level of.01, and for Need for Approval and Preoccupation with Relationships using an alpha level of.05. While the log determinants were quite similar, Box s M indicated that the assumption of equality of covariance matrices was violated. However, given the large sample, this problem is not regarded as very serious. The discriminate function revealed a significant association between groups and all predictors, accounting for 29.3% of between group variability, although closer analysis of the structure matrix revealed eight good predictors, namely Confidence (.73), Overprotection (-.68), Need for Approval (-.54), Relationships as Secondary (.53), Attachment-related Avoidance (.49), Attachment-related Anxiety (-.48), Self-awareness (.-45) and Care (.42) with the other variables of autonomy and attachment as poor predictors. The cross validated classification showed that overall 65.7% were correctly classified. For a complete overview of the linear discriminant function analysis see table 4. Direct logistic regression was performed to assess the impact of a number of factors on the likelihood that participants would be diagnosed with a personality disorder. The model contained twelve independent variables (self-awareness, sensitivity to others, capacity for managing new situations, confidence, discomfort with closeness, relationships as secondary,

25 Attachment and Autonomy 25 need for approval, preoccupation with relationships, attachment-related anxiety, attachmentrelated avoidance, care and overprotection). The full model containing all predictors was statistically significant, χ 2 (12, N = 106) = 46.53, p <.001, indicating that the model was able to distinguish between participants who were and were not diagnosed with a personality disorder. The model as a whole explained between 35.8% (Cox & Snell R Square)and 48.3 % (Nagelkerke R Squared) of the variance in diagnosis, and correctly classified 76.2% of cases. As shown in Table 5, eight of the independent variables made a unique statistically significant contribution to the model (self-awareness, capacity for managing new situations, confidence, relationships as secondary, need for approval, attachment-related anxiety, attachment-related avoidance and overprotection). The strongest predictor of having a personality disorder was need for approval, recording an odds ratio of This indicated that participants who were more in need for approval in relationships in general were 1.2 times more likely to be diagnosed with a personality disorder, controlling for all other factors in the model. The odds ratios of the significant variables varied little (.81 to 1.22). Also, Self-Awareness, Confidence, Relationships as Secondary, Attachment-related Anxiety, Attachment-related Avoidance and Overprotection were significant predictors in the logistic regression analysis. Discussion It was hypothesized that differences would be found in attachment and autonomy between patients diagnosed with Mood and/or Anxiety Disorders and patients diagnosed with Personality Disorders. Previous studies have shown that people with mood and anxiety disorders and personality disorders have more problems in attachment and autonomy than people without disorders (Muris, 2001; Viana & Rabian 2008). Studies also found differences in attachment style and level of autonomy between these two groups of disorders. The group of patients diagnosed with Personality Disorders was expected to be less securely attached

26 Attachment and Autonomy 26 and less autonomous than the group of patients diagnosed with Mood and/or Anxiety disorders. Support for Hypothesis 1 It was hypothesized that people in the personality disorders population are significantly less securely attached and less autonomous than people in the mood and anxiety disorders population. In this research patients diagnosed with mood and anxiety disorders and patients diagnosed with personality disorders were compared regarding level of autonomy, and attachment style. Attachment was examined in relationships in general, attachment experiences in childhood and attachment experiences in current intimate relationships. Differences between patients diagnosed with mood and anxiety disorders and patients diagnosed with personality disorders were indeed found in autonomy, attachment in general relationships and attachment in intimate relationships. Our results confirm that patients diagnosed with personality disorders are more sensitive to others in terms of autonomy. They also tended to be less confident, more in need for approval, more preoccupied with relationships in general, and to show more attachment-related anxiety in current intimate relationships than patients diagnosed with mood and anxiety disorders. No significant differences between patients diagnosed with mood and anxiety disorders and patients diagnosed with personality disorders were found in the experienced attachment in childhood. Correlations between the subscales of the questionnaires showed that the Parental Bonding Instrument, that assessed attachment in childhood, was not correlated with the other questionnaires used in this research. This was the only questionnaire on which no differences between patients diagnosed with mood and anxiety disorders and patients diagnosed with personality disorders were found. The nonexistent correlational relationship between the PBI and the other questionnaires (ACS-30, ASQ, and ECR-R) may form an explanation for the