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

  

    

    
Internalizing
    

  
  

    

    
B
    
SE
    
b
    
t
    
p
  
  

    
Sex    through Anxious attachment
    
.32
    
.11
    
0.14
    
2.91
    
.00
  
  

    

    
Externalizing
    

  
  

    

    
B
    
SE
    
b
    
t
    
p
  
  

    
Sex through    Anxious attachment
    
.05
    
.03
    
.12
    
2.05
    
.04
  
  

    
Sex    through Avoidant attachment
    
-04
    
.02
    
-0.10
    
-2.07
    
.04
  

Table 6: Results of the Indirect Effects of the Regression Analyses.

Sex had a significant positive total indirect effect on Internalizing (B = .35, SE = .13, t = 2.70). The direct effect of Sex on Internalizing however was negative (B = -.14, SE = .11, t = -1,34) whereby the positive total effect was annihilated(B = .20, SE = .16, t = 1.29). Significant indirect effects of sex to Internalizing were found through Anxious attachment (B = .32, SE = .11, t = 2.90) as well as through Avoidant attachment (B = -.08, SE = .04, t = -2.18).

The total negative indirect and negative direct effects of Sex on Externalizing both did not reach significance. The total effect of sex on Externalizing however did reach significance (B = -1.16, SE = .15, t = -8.03). No significant indirect effects were found for Externalizing, although the effect of sex through Anxious attachment on Externalizing (B = .10, SE = .05, t = 1.86) almost reached significance.

Discussion

The present study was aimed at examining if the higher order factor structure of internalizing and externalizing in PDS would exist in our sample as well. Secondly we wanted to investigate sex differences in levels of internalizing and externalizing PDS, anxious and avoidant attachment, and levels of autonomy-connectedness. Thirdly we aimed to test a mediational model in which internalizing and externalizing PDS were dependent variables, and sex, attachment styles and autonomy- connectedness explanatory variables. We expected all variables to have direct effects as well as indirect mediational effects on internalizing and externalizing PDS.

Our factor analysis of personality disorders revealed a two-factor higher order solution, of Internalizing and Externalizing. This finding is in line with previous findings of [6,29,34-36,39]. We think that these higher order categories should be used more often in empirical research and clinical practice, because this will enhance the insight into underlying explanatory variables of common mental disorders among practitioners and researchers. The higher order categories give a good overall indication of the behavioral, emotional and cognitive functioning of individuals to clinicians and secondly the higher order categories are repeatedly found to give a valid structural model of psychopathology, which could be used in our scientific knowledge about psychopathology and the DSM system [29]. Moreover these higher order factors explain comorbidity patterns in common personality psychopathhology [29]. The internalizing and externalizing factors were moderately but significantly correlated (.30). By using the factors comorbidity can be reduced, because a correlation coefficient of .30 is much lower compared to the correlation coefficients, which are found between single personality disorders, which rose up to .65 for passive aggressive and borderline in this study. However a correlation of .30 indicates that internalizing and externalizing PDS can co-occur; and future research is needed to investigate the underlying mechanisms involved in the co-occurrence of internalizing and externalizing PDS. Future DSM task forces might take these findings into account in their search of a structural model of psychopathology and maladaptive personality [29,36,37].

We noticed that borderline PD loaded high on both factors. We therefore conclude that borderline PD includes both internalizing as well as externalizing aspects, which is in line with previous findings of various other studies (see for an overview [5]. Contrary to the findings of [29,39], we did not find evidence for a third higher order category, characterized by thought disorders. The personality disorders paranoid, schizoid and schizotypal namely showed factor loadings around .30 on both factors. Because of the differences between the results of various studies more research with various populations and measures is needed to investigate the higher order structure of single personality disorders and all personality disorders together.

Regarding sex differences in levels of the variables under study, we indeed found, in accordance with our hypothesis, sex differences in levels of autonomy, attachment styles and internalizing and externalizing personality pathology. Men compared to women were less sensitive to others, more capable of managing new situation, less anxiously and more avoidantly attached, and had higher levels of externalizing PDS. The sex differences in levels of autonomy are in line with previous studies [10,11]. In particular, the sex difference in sensitivity to others appears to be a very robust as well as large sex difference. The findings regarding the sex differences in attachment and personality give support to our theoretical introduction based on the theory of [19,20] and the model of Dozier, [23]. Anxious attachment and internalizing PDS were namely indeed more common among women, and avoidant attachment and externalizing PDS more common among men. This might indicate that the sex differences in attachment styles and PDS indeed results from sexspecific attachment experiences in childhood: girls primarily with a same-sex attachment figure, and boys primarily with a cross-sex one, in both cases the mother. Simultaneously, other factors might have contributed to this sex difference as well, such as sex role stereotypes and biological factors [11].

Regarding the relationship between attachment and autonomy, the current findings agree with Bowlby’s initial theory [16,17], which states that secure attachment leads to healthy autonomy. We found specific relations between autonomy-connectedness and attachment. We namely found that anxious attachment was negatively related to self-awareness and capacity of managing new situations, meaning, more specifically, that being anxiously attached contributes to a low awareness of one’s own opinions, wishes, and needs, and the capacity to express these in social interactions; and to low flexibility and inclination to exploration. Secondly, anxious attachment leads to a high sensitivity to others and avoidant attachment contributes to a lower sensitivity to others. Anxiously attached individuals are, contrary to avoidantly attached individuals, more sensitive to the opinions, wishes, and needs of other people; and have a higher capacity and need for intimacy. These findings although crosssectional in nature, add to our insight in how specific insecure attachment schemata may contribute and lead to specific autonomy problems. By taking these specific relations into account in therapies, more targeted and thereby efficient interventions can be given to patients with attachment and autonomy problems.

In the current study our hypothesis regarding the role of autonomy and attachment in internalizing PDS was confirmed. When controlling for sex and the three autonomy scales, we found that anxious and avoidant attachment significantly contributed to internalizing PDS, the other variables in our model did not have significant regression coefficients. Moreover the effect of anxious attachment was significantly larger than that of avoidant attachment, indicating that especially anxiously attached individuals are prone to the development of internalizing PDS. Moreover, when leaving out the attachment scales (anxious and avoidant attachment) from the regression analyses, we found the three autonomy scales did significantly predict internalizing PDS: self-awareness and capacity of managing new situations negatively and sensitivity to others positively. This indicates that being low self-aware, having a low capacity for managing new situations and being highly sensitive to others, make individuals vulnerable to developing internalizing PDS. The results of these analyses however suggest that spurious regression effects were present, since in the first analysis when all variables of our model were taken into account, the autonomy sales did not significantly predict internalizing PDS. In other words the effect of autonomy on internalizing PDS disappeared, when controlling for attachment styles. We conclude that, in line with our theoretical model, the three autonomy components and internalizing PDS all appear to have anxious-and avoidant attachment as a common predictor (maybe even “cause”); and, secondly, that the effect of autonomy on internalizing PDS can be explained by the effects of the more fundamental factors of anxious and avoidant attachment on internalizing PDS. Especially anxious attachment played a significant and large role in internalizing PDS. Treatment of internalizing PDS should therefore not only be targeted at internalizing PDS, but also on underlying anxious attachment schemata. Targeting the underlying sex-specific variables that lead to internalizing PDS might enhance the effect of attachment based psychotherapies such as Attachment Based Therapy [22], Schema Focused Therapy [49] and Mentalization Based Therapy [4] that are aimed at reduction of internalizing PDS. Secondly, targeting autonomy problems in therapy might also be (cost) effective since autonomy also is strongly related to internalizing PDS in a unique way. Autonomy problems might be relatively easier to treat as compared to changing more fundamental insecure attachment schemas through treatment. Autonomy groups are an efficient way to treat autonomy problems. A recent RCT showed that autonomy groups are a cost effective alternative for CBT for anxiety disorders [38]. It might therefore also be a viable transdiagnostic treatment strategy for other internalizing disorders. More research on the effectiveness of autonomy groups for internalizing PDS is needed to investigate if this is indeed the case.

Regarding externalizing psychopathology we found that sex and anxious attachment were significant predictors of externalizing PDS. In line with our theoretical model, men appear to be more prone to externalizing pathology. Contrary to our expectations anxious attachment predicted externalizing pathology. None of the autonomy connectedness scales contributed directly to externalizing personality pathology, neither when leaving out the two attachment style scales from the regression analysis. We conclude that, in the current population, we did not find evidence for our hypothesis concerning the role of avoidant attachment and autonomy in externalizing pathology. These results might be due to the characteristics of our population, which might be more characterized by internalizing than by externalizing characteristics. Further research is needed in a truly externalizing population, to further investigate our theoretical model.

Moreover the effect of sex on internalizing appeared to be mediated by anxious attachment in a positive way and avoidant attachment in a negative way. This might indicate, in line with our theoretical introduction, that women are more prone to internalizing pathology since they are more anxiously attached than men, and that men are less prone to internalizing pathology since they are more avoidantly attached. We did not find any indirect effects for externalizing.

Notwithstanding these positive results, a few limitations must be mentioned. In the current study we solely used self-report measures, which might influence the result by inaccuracies, such as social desirability biases. Future research on this subject might profit from using multiple methods, such as simultaneous use of clinical structured interviews and self-report measures or experimental activation of attachment schemata. Secondly, these results might also be due to third variables not included in the current study. Future experimental and/or longitudinal research in internalizing and externalizing clinical populations will add to our understanding of the relationships between attachment, autonomy and internalizing and externalizing PDS.

Despite these limitations, the results of the present study provide further support for the existence of the two-factor higher structure of internalizing and externalizing in PDS. We therefore advise future researchers to use the higher order categories of internalizing and externalizing as well as anxious and avoidant attachment, in order to enlarge the insight into underlying explanatory variables of common mental disorders among practitioners and researchers, they give a good overall indication of the psychological functioning of patients and they give a valid structural model of psychopathology which could be used in new classification systems, thirdly by using these higher order categories one reduces the high correlations between disorders that show high comorbidity figures in the clinical practice, lastly it promotes the search for the common grounds of disorders that show very high comorbidity patterns. Secondly, the results support our hypotheses about the existence of sex differences in autonomy-connectedness, attachment styles, and internalizing and externalizing PDS. In line with our hypotheses sex-specific attachment experiences in childhood might indeed lead to sex differences in attachment styles and personality psychopathology. Further research using multi measurement methods, or experimental research is needed to further clarify these relationships. We however advise researchers and practitioners to be alert on these common sex differences in autonomy, attachment and PDS, because taking these sex-specific variations into account in treatment interventions might enhance treatment effectiveness. Furthermore, sex-specific treatment interventions targeting these specific sex-related variables should be further developed, like in autonomy-groups, because in the clinical practice there is a lack of such specific treatment interventions. We think that attachment based therapies, such as Schema Focused Therapy, Mentalization Based Therapy, should be further developed and investigated by taking these findings into account. Moreover, sex specific differences in attachment should also be taken into account, since women are more prone to internalizing pathology while they are more anxiously attached and less avoidant attached than men.

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