Attachment, Autonomy-Connectedness, and Internalizing and Externalizing Personality Disorder Symptoms

Research Article

J Psychiatry Mental Disord. 2022; 7(1): 1060.

Attachment, Autonomy-Connectedness, and Internalizing and Externalizing Personality Disorder Symptoms

Bachrach N1,2*, Bekker MHJ2 and Croon MA2

1GGZ Oost Brabant, Helmond, The Netherlands

2Tilburg University, The Netherlands

*Corresponding author: Nathan Bachrach, GGZ Oost Brabant, 5708HA Helmond, The Netherlands

Received: July 15, 2022; Accepted: August 18, 2022; Published: August 25, 2022

Abstract

The aim of this study was to analyze the higher order factor structure of Personality Disorders Symptoms (PDS), and to investigate sex differences in levels of PDS, attachment styles and autonomy-connectedness. Secondly we aimed to test a mediational path model, based upon attachment theory together with neo-analytical object relation theory, with internalizing and externalizing PDS as dependent variables and sex, attachment styles and autonomyconnectedness as explanatory variables.

Our sample consisted of 202 psychology students. We used self-report questionnaires, independent t-tests, and factor- and regression analyses.

Conform expectations a common two-factor solution of internalizing and externalizing was found for PDS. Men were, compared to women, less sensitive to others, more capable of managing new situation, less anxiously attached, more avoidant attached and more externalizing. Conform expectations attachment styles were related to autonomy in a specific way. The analyses of our path model showed that especially anxious attachment predicted internalizing PDS. When leaving out attachment styles in the regression analyses, the autonomy scales also predicted internalizing PDS, indicating spurious correlation effects. Sex and anxious attachment were significant predictors of externalizing pathology.

Our results confirmed the existence of a two-order structure of internalizing and externalizing, sex-differences in levels of autonomy, attachment styles and internalizing and externalizing PDS. In addition, we think our theoretical model gives a good explanation of the specific relationships between sex, attachment, autonomy and internalizing and externalizing PDS.

Keywords: Attachment styles; Autonomy-connectedness; Personality disorders; Internalizing-externalizing; Factor analysis; Sex-differences; and Higher order factors of DSM-IV personality disorders

Introduction

Various authors such as Young, Fonagy and Westen [4,48,49] suggest a major role of disturbed working models of attachment schemata in the development of Personality Disorders (PD). In line with these theoretical frameworks, adult attachment styles can indeed discriminate patients with avoidant, dependent and schizoid PD from those with other PD [46,47]. Regarding cluster C personality disorders anxious attachment and anxious temperament traits appear to be explanatory variables [42]. Far more studies in this area however have been performed on the relationship between attachment and Borderline Personality Disorder (BPD) [1]. Agrawal and colleagues conclude, in their review, that there is a strong association between BPD and insecure attachment. The attachment styles that are most characteristic of BPD subjects are unresolved, preoccupied, and fearful. We conclude in line with other authors that there is ample evidence that PD in general are strongly related to insecure attachment styles [1,41,46].

The studies performed so far regarding this subject were aimed at investigating the relationship between single PD and the various attachment styles that are mentioned in the literature, such as secure, avoidant, ambivalent, and disorganized attachment style [2,3]. Recently though, interesting findings were obtained regarding the higher order categories of PD and attachment styles. Concerning attachment styles, recent studies revealed that adult attachment styles are best conceptualized as regions in a higher order two-dimensional space, called anxious attachment and avoidant attachment [8,12,18,25,44]. Secondly regarding personality psychopathology, various factor analytical studies also showed a two-factor higher order structure namely: internalizing and externalizing [5,34,36,39,43]. We expected to confirm this structure in the current study.

Furthermore there is evidence that sex differences exist in all variables mentioned. To start with clinical disorders, women compared to men higher rates of mood-, eating-, and anxiety disorders and men had higher rates of substance abuse and antisocial behavior [21,27,30,32]. Regarding personality pathology a male-tofemale ratioof 3:1 for the antisocial personality disorder is given, and the DSM-5 states that the borderline personality disorder is “diagnosed predominantly (about 75%) in females” (APA, 2013). Secondly, sex-differences have also been found in levels of the higher order categories of attachment and internalizing-externalizing. In a recent meta-analysis [28], regarding sex differences in attachment style, men were found to have higher levels of avoidant attachment –congruent with detachment and/or denial of attachment, and women were found to have higher levels of anxious attachment. Moreover, regarding sex differences in internalizing and externalizing women had higher mean levels of internalizing psychopathology and lower mean levels of externalizing psychopathology than men [6,33]. In the present study, we again investigated sex-differences in personality pathology and attachment styles, and, in addition, also the relationships between these various sets of sex differences.

We hypothesized that besides disturbed working models of attachment schemata, autonomy problems might also play a role in internalizing and externalizing Personality Disorder Symptoms (PDS). Bowlby’s theory namely states that early insecure attachment experiences lead to insecure attachment schemata, which generate autonomy problems at later age. Autonomy problems will especially be apparent in developmental periods in which individuals normally engage in autonomous behavior, such as in adolescence and adulthood [16,17]. In other words, attachment schemata can be seen as the underlying base from which individuals develop autonomy. Furthermore personality disorders are usually classified from the age of 18 years, a crucial period in which adolescents separate and individuate, a period in which autonomy plays a crucial role. We therefore presume that autonomy might play a crucial role in the development of personality pathology. Our concept of autonomy refers to self-governance including during social interactions, i.e., to the need and capacity for self-reliance and independence, as well as for intimacy and functioning in close relationships [10]. More specifically, consistent with sex differences in mental representations of the self, poor autonomy, particularly high sensitivity combined with low self-awareness, is associated with internalizing PDS, which are more prevalent in women such as women with dependent PD and borderline PD; whereas low sensitivity to others coinciding with high self-awareness is associated with PDS more prevalent in men, such as antisocial PD [6,12]. In line with aforementioned personality disorders, also internalizing clinical disorders, more prevalent in women, such as eating disorders, anxiety disorders and depression are strongly associated to poor autonomy [10,11]. It is therefore assumed that there is a U-shaped relationship between optimal sensitivity to others and psychological health [14]. For these reasons, we aimed to, in the current study, also investigate the role of autonomy in personality pathology.

To our awareness there are hardly any theoretical models that clarify the sex-specific relationship between sex and internalizing and externalizing personality disorder symptoms. We therefore investigated the role of anxious and avoidant attachment and autonomy-connectedness in internalizing-externalizing PDS. We hypothesized that these variables have direct as well as indirect effects on internalizing and externalizing PDS. Our model elaborates on the theoretical model of Dozier, Stovall and Albus (1999) who stated that, as a result of sex specific attachment styles, internalizing psychopathology and anxious attachment styles are more common among women and externalizing psychopathology and avoidant attachment styles are more common among men. In line with this theoretical reasoning, authors such as [7,9-11,19,20] explain these sex specific differences by the fact that the primary attachment person in children’s lives is usually a woman. According to these authors this is crucial for sex differences in attachment schemata and autonomy development (for a full description see: [9,20,45].

In summary, we conclude first, that PDS are strongly related to insecure attachment styles. Secondly a two-factor higher order of internalizing and externalizing exists in personality psychopathology. Thirdly, internalizing psychopathology appears to be more prevalent in women and externalizing psychopathology more prevalent in men. Fourthly a two-factor higher order of anxious and avoidant attachment exists in attachment styles, and women have higher levels of anxious attachment and men have higher levels of avoidant attachment. Finally, poor autonomy, more in particular, high sensitivity to others combined with low self-awareness, is associated with internalizing psychopathology, and low sensitivity to others coinciding with high self -awareness is associated with externalizing psychopathology.

This lead us to formulate the following mediational model (Figure 1). In the model internalizing and externalizing were causally treated as dependent variables. Sex, autonomy (self-awareness, sensitivity to others, and capacity to manage new situations) and attachment (anxious and avoidant) were treated as explanatory variables. Moreover, the attachment styles were seen as more early in a temporal and/or causal chain than the autonomy variables. We expected all variables to have direct effects as well as indirect mediational effects on internalizing and externalizing PDS.