Attachment style and depression in
adults: Using a lifespan model
Antonia Bifulco
Professor of Lifespan Psychology & Social Science
Kingston University
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BPS Conference April 2013
An Attachment approach
(Bowlby, 1969-80 Attachment and Loss trilogy)
 Attachment theory is a lifespan approach - childhood experience
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to adult relationships and disorder.
Attachment style is determined by internal working models ‘guidance’ system for relationships based on memories of past
interactions and expectations of future ones.
Distortion occurs through parental rejection (eg physical abuse),
helplessness (eg neglect) or absence (eg separation).
Internal working models determine the type of attachment style in
adulthood: those Anxious or Avoidant or Disorganised versus
Secure.
As yet there is no consensus about which childhood experiences
relate to which style, although all relate to Insecure style in
general.
BPS Conference April 2013
08/04/2015
Attachment style assessment is a
powerful tool for psychologists
 Attachment style is shown to relate to emotional & behavioural
disorder (Dozier et al 1999) as part of a bio-psychosocial
developmental model (Perry et al 1995).
 However, its wider use, particularly in clinical practice, has been
hampered by measures which are too superficial (eg RQ,
Bartholomew & Horowitz, 1991) or too intensive (AAI,George,
Kaplan, Main 1994) and by inconsistency of style definition.
 We introduce the Attachment Style Interview as a user-friendly
measure to progress research and practice.
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BPS Conference April 2013
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Psychosocial model of attachment
style and disorder
Social factors
Mediating effect
Neglect or
Abuse <17
Insecure
Attachment
Style in adults
Major
Depression
or anxiety
onset
Psychological factors
Biological factors
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BPS Conference April 2013
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Intensive study of London women
Study aims
Insecure attachment style will relate to emotional disorder in
women
2. Childhood neglect/abuse will relate to insecure attachment
style.
3. Insecure style will act as a mediator
4. There will be some specific associations for different
attachment styles.
1.
Procedure
 303 London women selected by screening questionnaire from
GP lists for high psychosocial risk for depression. Contacted for
lengthy face-to-face interview on
 childhood experience (CECA)
 attachment style (ASI)
 Major Depression and Anxiety disorder. (SCID)
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 154 followed-up 3 years later for onset of depression or08/04/2015
anxiety.
Measures - Attachment Style Interview (ASI)
 A measure of attachment style in relation to on-going poor supportive
contexts.
 Three close supportive relationships (partner and Very Close other)
questioned about in detail. If one or fewer supportive relationships
then poor ability to relate and insecure style rated.
 Attitudes towards closeness, trust and autonomy questioned around
 Anxious attitudes (fear of rejection, fear of separation, desire for
company)
 Avoidant attitudes (mistrust, constraints on closeness, high selfreliance, anger)
 Overall attachment styles derived – 4 insecure and Secure.
 All insecure styles rated as ‘marked’, ‘moderate’ or ‘mild’ level of
insecurity or dysfunction.
 Good inter-rater reliability (Kappa=0.80 correlation London study; Kappa=0.70
EU study)
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Bifulco, Moran, Ball & Bernazzani (2002)Adult Attachment Style: Its Relationship to clinical 6
4/8/2015
depression, SPPE 37; 50-59
Attachment style classification (ASI)
Dual/disorganised
Combined insecure style ratings, usually Anxious & Avoidant
Anxious styles
 Enmeshed (low self-reliance, fear of separation, high
need for company).
 Fearful (mistrust, constraints on closeness; fear rejection)
Avoidant styles
 Angry-dismissive (mistrust; self-reliance, anger)
 Withdrawn (constraints on closeness; self-reliance)
Secure
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Cartoons are used in a child version being piloted
4/8/2015
Attachment styles relate to survival
strategies of fight, flight, cling and hide
Enmeshed styles ‘cling
Fearful styles ‘run’
Withdrawn styles ‘hide’
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Angry-dismissive
BPS Conference Aprilstyles
2013
fight
Secure styles 08/04/2015
seek help
Measures - Clinical, SCID for DSM-IV
 Interview to determine both
number and severity of symptoms
over the prior 12 months and at
follow-up.
Depression
 Depressed mood/loss of interest
and four or more key symptoms
categorised as cases, together with
significant distress/impairment.
 Minimum length of episode 4
weeks. The average length proved
to be 4 months. Half lasted 12
months or more.
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Anxiety disorders
 Generalised Anxiety Disorder
 Social Phobia
 Panic/Agoraphobia
Rates of Disorder
 35% MDD in year before
interview 1
 36% MDD and 40% anxiety
at follow-up interview 2:
 20% GAD, 10% social
phobia, 12%
panic/agoraphobia 08/04/2015
Childhood Experience of Care and
Abuse (CECA)
 Interview to determine type and severity of childhood neglect
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and abuse experiences before age 17.
Factual focus to aid reliability. Probes for timing, sequence and
details of experiences.
Lack of care (neglect, antipathy & role reversal)
Abuse (physical, psychological & sexual).
All experiences rated marked, moderate, mild or none.
Marked/ moderate termed ‘severe’.
Index of severe neglect, physical abuse & sexual abuse derived,
55% of women scored on index.
Good inter-rater reliability (above .70). Good validity
determined by sibling accounts
Bifulco A & Moran P (1998) Wednesday’s Child. Research into women’s experience of neglect and abuse in
childhood, and adult depression. Routledge, London
Finding 1 – Attachment style &
Depression(N=303, interview 1)
% major depression in 12 months
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Insecure
attachment
Odds
-ratio
Wald
df
P<
Highly
Enmeshed
5.83
10.65
1
0.001
Highly Fearful
3.64
8.72
1
0.003
Highly Angrydismissive
5.01
11.80
1
0.0006
Highly
Withdrawn
2.02
1.54
1
NS
Mildly insecure
1.22
0.30
style Goodness of fit 78.3%
1
NS
Controls made for depression at point of interview
Childhood adversity, attachment style and
depression
Childhood adversity index was double in women with insecure style: 58%
vs 29%. p<.001
Neglect or
Abuse <17
.28
.32
Highly insecure
Attachment
Style*
Major
Depression
*Withdrawn style excluded
M –Insecure attachment
style*
Mediation shown
a= 4.53
p<.0001
X
Neglect/
Abuse<17
b=2.30
p<.00001
c= 1.77,
NS
Y
MDD at follow-up
Attachment style and depression – specificity
(Loglinear analysis)
Highly Enmeshed
ns
.19
Neglect or
Abuse <17
ns
.23
Highly Fearful
.28
Highly Angrydismissive
.26
.19
Major
Depression
ns
Highly Withdrawn
Mediation confirmed for Fearful and Angry-dismissive style
Finding 2: Type of attachment style and
anxiety disorder in follow-up (N=154)
Attachment style
interview 1
Anxiety GAD
disorder
Social
Phobia
Panic/
Agora
Enmeshed
NS
NS
NS
NS
Fearful
0.16*
NS
0.21**
NS
Angry-dismissive
0.17**
0.18*
NS
NS
Withdrawn
NS
NS
NS
NS
*p< .01, ** ,001, ***.0001
Mediating role of attachment styleCase Anxiety
Interview 1--------------------Interview 2
Neglect or
Abuse in
childhood
.33
Highly insecure
Attachment
Style*
.33
Case Anxiety
Follow-up
*Withdrawn style excluded
M – Insecure attachment
style
Mediation confirmed
a= 4.53
p<.0001
X
Neglect/
Abuse<17
b=3.28
p<.00001
c= 1.367,
NS
Y
Case Anxiety
F-u
Specificity - childhood experience and attachment
CECA
style
ASI styles
Lack of Care
Antipathy
.15*
Enmeshed
Neglect
.12*
.20**
Role reversal
.19**
Fearful
.14*
Physical
.12* Angry-dismissive
.14*
.17*
Psychological
Sexual
* p<.05, ** p<.01
Abuse
Withdrawn
Childhood experiences and style –
regression analyses
ASI
CECA
Severe Lack of care
(Antipathy or Neglect
Or Role Reversal
Severe Abuse
(Physical, Sexual or
Psychological)
OR=4.19*
OR=4.51*
Anxious style
(Enmeshed or
Fearful)
Angry-Dismissive
style
OR= significant odds ratios taken from binary logistic
regression analyses. *p<.05
Bifulco & Thomas (2012) Understanding adult attachment in family relationships:
Research, Assessment, Intervention. Routledge, London.
Implications
 Insecure attachment style mediates the relationship between early
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adverse experience and adult major depression and anxiety. Some
specificity of style to experience and disorder is shown.
Early intervention in childhood to protect against neglect/abuse
or in early adulthood to ameliorate attachment style can reduce
disorder in adult life.
Improving the quality of adult relationships and support can
reduce attachment insecurity.
Clinical psychologists, CAMHS and perinatal psychologists can
benefit from assessing attachment style in clients or their parents.
The ASI as a research-based assessment tool is available for
practice contexts to utilise this evidence-base in child and family
social services and psychological services to aid best practice.
4/8/2015
Thank you for your attention
antonia.bifulco@kingston.ac.uk
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BPS Conference April 2013
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