Journal of Consulting and Cfimcal i's)<:hology 19%, Vol.64, No.

1,22-31

C~iaht

1996 by the Amerialll PsYCholoBical Association, Jnc.
0022.()()6X/96f$3.00

The Relation of Attachment Status, Psychiatric Classification, and Response to Psychotherapy
University College London

Peter Fonagy

Tavistock Clinic

Tom Leigh

Miriam Steele and Howard Steele
University College London

Roger Kennedy and Gretta Mattoon
The Cassel Hospital

Mary Target and Andrew Gerber
University College London
The relation of patterns of attachment and psychiatric status was studied in 82 non psychotic inpatients and 85 case-matched controls using the Adult Attachment Interview (AAl). AAI transcripts rated (masked to case vs, control status and treatment) were classified using M. Main and R. Goldwyn's (1991) system. Psychiatric patients, diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Memal Disorders (3rd ed., rev.) I and II structured interviews, were more likely to be classified as preoccupied and unresolved with respect to loss or abuse, On Axis I, anxiety was associated with unresolved status, and AAI scales were able to discriminate depression and eating disorder. On Axis II, borderline personality disorder (BPD) was linked to experience of severe trauma and lack of resolution with respect to it. BPD patients were also rated. significantly lower on a scale measuring awareness of mental states. Preliminary outcome results suggest that individuals rated as dismissing on the AAI are more likely to show improvements in psychotherapy.

It is a core assumption of psychoanalytic models and practice that parents respond to their children's behavior and characteristics with expectations that are based on past experiences with their own primary caregiving figures (Fraiberg, Adelson, & Sha· piro, 1975; Freud, 1940). J. Bowlby's ideas, as embodied in attachment theory, were a conduit between psychoanalytic ideas and developmental psychology, using concepts from other disciplines (e.g., ethology, control systems theory, cognitive science; Bowlby, 1973, 1988). Most of Bowlby's ideas were derived from observations of clinical populations, yet until recently there has been surprisingly little work that has applied research methods based on attachment theory to clinical groups and their treatment (Holmes, 1993). These studies were made possible by Main and her colleagues' work on a structured assessment instrument, the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985; Main & Goldwyn, 1991), which provided an indication

Peter Fonagy, Miriam Steele, Howard Steele, Mary Target, and Andrew Gerber; Sub-Department of Clinical Health Psychology, University College London, London, United Kingdom; Tom Leigh, Department of Psychology, Tavistock Clinic, London, United Kingdom; Roger Kennedy and Gretta Mattoon, The Cassel Hospital, London, United Kingdom. Correspondence concerning this article should be addressed. to Peter Fonagy, Sub-Department of Clinical Health Psychology, University College London, Gower Street, London WCIE 6BT, United Kingdom.

of the functioning ofintemal working models. The interview is designed to elicit the individual's account of his or her childhood attachment and separation experiences, together with his or her evaluations of the effects ofthose experiences on present functioning. In the Main and Goldwyn system, there are three major classification categories: free-autonomous ([F) coherent valuing of attachments); dismissive ([Os) idealizing, derogatory, and cut off from attachment experiences); and preoccupied ( [E) passive, angry, and entangled by past relationships) . Dozier (1990) found greater security associated with symptoms of affective rather than thought disorders in a sample of 40 young adults. Security was also associated with more compliance with treatment, less rejection of treatment providers, and greater self-disclosure. Dozier, Stevenson, Lee, and Yelligan ( 1991) demonstrated that psychiatric patients who were rated insecure, using the Q-sort method (Kobak, 1989), were more likely to have family members who were overinvolving in terms of an expressed emotion measure. They also found that preoccupied individuals reported more symptoms and pre morbid competence was associated with secure attachment strategies, The Q-sort method of scoring the AAI, however, has not yet been thoroughly validated. Patrick, Hobson, Castle, Howard, and Maughan ( 1994) administered the AAI and the Parental Bonding Instrument (PBI; Parker, Thupling, & Brown, 1979) to 12 dysthymic and 12 borderline patients, matched for age, educational achievement, and socioeconomic status. They found that the borderline group re22

n = 3). they found that 10 of 12 (88%) of the borderline patients were classified as "fearfully preoccupied by trauma .1). Second. Patients with DSM-BPD had somewhat more (p < . obsessive-compulsive. we wanted to explore whether attachment classification at the beginning of treatment might predict a response to inpatient psychotherapeutic intervention. The hospital has a reputation for accepting "difficult-totreat" patients. avoidant. and 45% (n = 37) had a diagnosis of substance abuse. Participants in the psychiatric group were assessed by a research psychiatrist who was not involved in the treatment of the patient using a standardized diagnostic interview schedule (Axes I and II of the Structured Clinical Interview for the DSM-III-R [Diagnostic and Statistical Manual o/Mental Disorders. Psychotherapy is delivered by psychiatrists.6 and that of the control group was 112.7 (range. depressive. 1987) and Denford (Denford. there has not been a controlled study that examined the relationship between psychiatric nosology based on standardized psychiatric interviews and attachment classification based on the careful scrutiny of transcripts using reliable coders who were trained in the Main and Goldwyn (1991) system. Forty-six percent (n = 38) of the patients had other personality disorders (schizoid. obsessive-compulsive disorder. & Schachter. all of whom had a minimum of2 years postqualification experience. 1990). Registrar General's Classification of Occupations (Registrar General. and the preliminary results of Patrick et a1. and the treatment offered has been described in detail by Rosser (Rosser. and their AAis were more likely to be characterized as confused. cyclothymia. The hospital is organized along therapeutic community principles. Axis V of the DSM-III-R system. respectively.7 (SD = 10. projective identification. The average rating at admission was low. Temple. (1994). n = 11. 0 to 8). n = 2. Rosser.SPECIAL SECTION: ATTACHMENT AND PSYCHIATRIC STATUS 23 ported lower maternal care and higher maternal overprotection on the PBI. Schachter. Seventy-two percent (n = 59) of the sample had a definite Axis II diagnosis. The control group was screened using the abbreviated General Health Questionnaire (GHQ-28.1 (the dilferencewas not significant). schizotypal. The Cassel Hospital is a tertiary care center-all the patients are referred by other psy- .or loss" (Subcategory 3 of the E classification). n = 5. Gunderson. Seventeen percent (n = 14) had an eating disorder diagnosis. and one develq:led a major physical illness. bipolar disorder. 1991. Fifty percent of both samples were of social class I or 11 (professional and managerial occupations) according to the U. 1983). First. chiatrists. identity diffusion. n = 20. On the basis of attachment theory (Bowlby. Fifty-one patients satisfied Kernberg's (1977) structural criteria for borderline personality organization (BPO) . 3rd ed. The GHQ is a screening questionnaire for psychiatric disorder designed for use in community surveys. The psychiatric patients were individually matched on age. 0 to 8). The average number of Axis I diagnoses was 2. Drug treatments are only rarely administered at the hospital. Thirty patients met Gunderson's criteria fOT BPD (Gunderson. We assessed overall adjustment using the Global Assessment of Functioning (GAF) Scale. histrionic. Fonagy & Higgitt. The present study had a threefold aim. Williams. This finding was not predicted beforehand.7 for the total sample). n = 17. Denford. one refused to cooperate. narcissistic. Kind.3 vs. and verbal IQ with 85 normal control participants recruited from an outpatient department of a university teaching hospital. however. which stresses intrapsychic rather than social adaptation. social work. GAFscores ofindividua1s with BPDwere somewhat lower than for the rest of the sample (M = Method Participants Eighty-five consecutively admitted nonpsychotic inpatients at the Cassel Hospital in London participated in the study. This hospital is a national center for the inpatient treatment of severe personality disorder and is organized as a therapeutic community with three wards. n = 3. and a further 27% (n = 22) had antisocial or paranoid personality disorders (antisocial. 1981) based on the Diagnostic Interview for Borderline Patients (D]B) interview. we wanted to examine the hypothesis that individuals with BPD were distinguishable from those with other Axis II diagnoses in terms of reduced capacity to reflect on the mental states of their attachment figures. psychologists. Nursing interventions are based on the model of the working relationship as a therapeutic tool described by Flynn (1993). we wanted to determine whether insecure patterns were more common in a psychiatric than in a nonpsychiatric population. SCID-] and SClD-lI. The average number of Axis II diagnoses was 1. Patients with anxiety disorders were more likely to have an Axis II diagnosis than patients without anxiety disorders. Goldberg. & Austin.R criteria for at least one affective disorder (major depressive disorder. gender. n = 21. and occupational therapy support. passive-aggressive. The mean verbal lQ of the psychiatric group was 114. including splitting. n = 3. Despite these early results.4 (range. Bond. with some overlap). All those participants who met Gunderson-BPD criteria met DSM-BPD and BPO criteria. Gibbon & First. Forty-four percent (n = 36) of the sample met DSM-III-R criteria for BPD (DSM-BPD). Each sample included only 15 men. and all but three with severe anxiety also suffered from depression. phobias. n = 2. 26. Birch. social class. 1973). The average age of both samples was 29 years.BPD. paranoid. Specifically. somatoform or stress disorder. n = 20. Spitzer. n = 4. we wanted to explore the relationships between major groups of Axis I disorders and attachment classification. revised. we hypothesized that specific Axis II disorders may show strong relationships to particular attachment types. dysthymia. and if major diagnostic groups such as depression and anxiety could be distinguished on the basis of internal representations of attachment relationships. on the basis of a clinical model of'borderline personality disorder (BPD. fearful. Sixteen patients had depression alone. American Psychiatric Association. n = 37. or substance abuse had somewhat more Axis I diagnoses than patients without these disorders. Even more striking. 1965). and accurate reality testing. following Dozier's ( 1990) results. most of whom have had unsuccessful psychiatric treatments elsewhere. 1983). Fifty-four percent (n = 44) met criteria for at least one anxiety disorder (generalized anxiety disorder. specifically. 2. as well as their own psychological experiences.05) Axis I diagnoses than other groups (M = 3. 1989. eating disorder. 1987]. as well as nursing. Patients with anxiety disorder. n = 3. Finally. focusing on anxiety. dependent. Kolb. 1989). and social workers (the latter two groups having had psychotherapy training). and participants scoring above the cutpoint for a possible case were excluded from the study. and all who met DSM-BPD also met BPO criteria. and somatic symptoms. we wanted to identify the relative strength of the relationships between Axis I and Axis II disorders and attachment patterns. Fonagy. n = 19). n = 4. They tended to be less socially successful and more likely to have episodic psychotic experiences. and overwhelmed in relation to past experiences with attachment figures. n = 21).. one patient left the hospital without completing the assessment. n = 14. Patients receive individual and group psychoanalytic psychotherapy. Eighty-eight percent (n = 72) of the psychiatric sample met DSMI ll.K. Complete data were only available on 82 of these patients.

In this article. The operationalization is based on the literature on the evolution of metacognitive knowledge (Flavell. Special mention of mental states as in examples representing self or other as thinking and feeling. for example. and yet others in which the participants appear 10 be fearfully preoccupied by traumatic events (Subclassification E3 ). The scale is based on Main's ( 1991 ) seminal chapter on metacognitive monitoring and single versus multiple models of attachment. the interviewer is instructed to elicit specific memories to illustrate the participant's general statements. Kaplan. A research psychiatrist (Tom Leigh) administered the diagnostic instruments and rated the patients on the GAF scale and a psychologist (Gretta Mattoon) administered the psychometric instruments and the AAl and made an independent assessment of adjustment (GAF scale). (b) a four-way comparison of Ds. The transcripts were carefully screened to remove references to the hospital treatment or.). 5. For DSM Axis Iand II diagnoses. Patients were followed up at discharge. Interviews are audiotaped and transcribed. K = 0. E. 3. when both psychometric instruments and the AAI were readministered. loving mother and neglecting father) and state of mind of the interviewee as reflected in the narrative (most importantly. Several categories of experience are probed.g. p < . and F participants-all of whom are not unresolved-and U participants.83. Tager-Flusberg. the E (or preoccupied) category contains interviews that indicate a passi~ stance regarding an iU-defined experience of childhood (Subclassification E I ). Steele. Steele. and 9. 1993). The reliability of the RSF scale after training was high. The use of RSF scale ratings in the present study was guided by past work that showed this scale to be a good predictor of infant-parent attachment security. The interviews were rated by two raters (Miriam Steele and Howard Steele) who were unfamiliar with the sample and who had no access to demographic and psychiatric information. tachment figure or trauma is discussed. E. Unresolved attachment status is indicated by interviews where signs of continuing disorganization appear when the at- 2. Ds. The anticipation of the reaction of another.g. the classification recognizes subtypes ofF. including lapses in monitoring of reasoning and lapses in the monitoring of discourse. = 0. Hesse in 1987 and were retrained in 1994 (although this retraining was too late to be of use in this study). In addition to the three main categories explained earlier. Both raters had been trained in conducting this coding by M.81 and .24 FONAGY ET AL. Cohen's K' = 0. The RSF scale operationalizes the notion of individual differences in adults' metacognitive capacities. regardless of unresolved status. In addition to receiving a Ds. 3. as well as more recent contributions under the heading of "a theory of mind" (see Baron-Cohen. for GAF. there were no significant differences between diagnostic groups on the GAF scale. 23. and (c) a two-way comparison of U and non-U participants.77. For exampie.94..80. & Flavell. and Higgitt ( 1991) devised an additional scale for AA] transcripts to assess the interviewee's capacity to understand mental states and their readiness to contemplate these in a coherent manner.91. illness. average stay was 9. 1985). The Reflective-Sel/FulIClion (RSF) scale. & Main. the raters had not yet been trained in the CC (cannot classify) category of AAI coding.85. such as exhibiting explicit recognition ofthe limited power of wishes. which takes into account the other's perception of the mental state of the selfwould also be rated as reflective. particularly childhood abuse. Raters are required to mark the presence or absence of a reflective stance in relation to self or other and use the frequency of these statements to score the participant on a scale from I to 9. secure classification). some interviews are characterized by an apparent failure to resolve mourning over the loss of an attachment figure. The productmoment correlation between the two raters (Miriam Steele and Heward Steele) reviewing all the transcripts was . Green. rejection.. involved-involving anger toward parent [ or parents 1. AA] interviews are rated on a number of scales concerning experience (e. product-moment correlation = 0. shown by the explicit recognition of the possibility of diverse perspectives on the same event. Definitions and narrative descriptions are provided for Points I. Sensitivity to the characteristics of mental states. The coding system jor the AAI. I( Design and Procedure Patients were assessed within 14 days of admission to hospital by two interviewers independent of the hospital team. Both fathers and mothers who were rated to be high in this capacity were three or four times more likely to have secure chil- . 7. the majority of patients ( over 80% ) were discharged after 6 months to I year.4 months. & Cohen. etc. Appreciation of possibility of change in mental states with implications for corresponding changes in behavior as shown in acknowledgments of the possibility of changing attitudes in the future. Moran.1 years. Special efforts at linking mental states to observed behaviors as illustrated by remarks that people may express different emotions to ones they feel and may intentionally wish to deceive by presenting themselves in self-serving ways.05). and had substantial experience with this instrument. The interrater reliabilities of the aforementioned assessment measures were determined by independent assessment. Sensitivity to the complexity and diversity of mental states as. In previous applications of the system pairs of four raters arrived at correlations between . The scale assesses the clarity of an individual's representation of the mental states of others as well as of their own mental states.8. idealization or derogation of caregivers. E. In each of the areas. experiences of early separation. 4. otherwise. and others that are filled with current anger concerning past experiences (Subclassification E2). The different types of reflective statements are as follows: 1. Additional demographic data were collected from the case notes by the psychologist. and maltreatment. The interrater reliabilities of raters in this study were consistent with values reported in the literature: 85% on major attachment classilication (100% agreement on insecure vs. In an attempt to provide a model ofintergenerational transmission of attachment. The interraterreliabilities of these scales used by the present raters were all in excess of . and between 70% and 80% on subclassification categories (see BakermansKranenberg& van ]Jzendoorn. that wishes may not be fulfilled in reality). losses. 1993). thoughts. 1986). including the general quality of early childcaregiver relationships. mention of previous experience with the interview. for Gunderson-BPD. only the data from the initial AAI are reported in relation to diagnostic information and outcome. for Kernberg's BPO. when all the psychometric measures were readministered. in the case of follow-up interviews. Fonagy. coherence. The classification system permits a number of different ways of contrasting patterns of attachment across groups: (a) a three-way comparison of Ds. or F classification. and F participants. This semistructured interview aims to elicit information concerning an individual's current representation of his or her childhood experiences.90. The maximum duration of stay in the hospital was 1. Measures The AAI (George. or other traumatic events. passivity of thought reflected in unfinished sentences. and once again I year after discharge. and E interviews. At the time of coding. and desires with respect to the real world (e. 5. Main and E.

5.00 1. This contrast remains significant for Gunderson-BPD but not for K. U= unresolved. and psychoticism ( or tough mindedness). The Beck Depression Inventory (BDI) is a 21-item inventory that assesses the severity of a participant's complaints.05. For Axis II. Results Attachment Patterns in Psychiatric and Control Samples There was a highly significant difference between the psychiatric and control groups in the three-way distribution of attachment pattern as well as for the four-way attachment distribution (see Table I). Self-report questionnaires. Again. Underscored numbers represent the four-way attachment distribution. • . 1991. The Eysenck Personality Questionnaire (EPQ) isa 90-item inventory that assesses participants along three major dimensions of personality: extraversion. Steele. p < .9··· 72 44 37 14 18(2) 7@ 6(1) 1(Q) 41@ 29(1) 23m 9(Q) 13W 8m o (g) O{W OUl) 80 4(1) ° ill) 3.1. paranoid ideation. The association of major psychiatric diagnoses and attachment classification are displayed in Tables 1 and 2.3 4. 1994).ernberg BPO. obsessive-compulsive disorder. and on a lie scale (Eysenck & Eysenck. anxiety. Target. Of all the subclassifications. Looking at the data subsequently. Four-group refers to F. we found that 47% of the patients with DSM-BPD were from the E3 subclassification. and psychoticism) and three global indices are calculated from the responses (Derogatis. p < .8* <1.3 2. The significance of this analysis was limited by the smaIl numbers of patients falling into the F not U. nonunderscored numbers exclude unresolved participants. and Ds.and three-way attachment classifications and DSM and Gunderson-BPD diagnoses. but there was a significant association between a diagnosis of anxiety and an unresolved classification (explaining both the two.8 3. & Steele. Two-group refers to non-U groups and U. This is significant when comparing them with patients without BPD diagnosis. N = 36) = Table 1 Axis I Diagnostic Groups and AAI Attachment Classification Attachment Grouping Psychiatric Control Axis Idisorder (not mutually exclusive) Depression Anxiety Substance abuse Eating disorder classification Four-group Os 15m 18(1) U Three-group Two-group )(2 idf= 3) 78. only 15% of whom fell into the E3 subclassification. and D not U categories and by the fact that there were few nondepressed patients.0 3. E = insecure-preoccupied. phobic anxiety. N = 82) = 6. All other personality disorders were combined into a residual category for other personality disorders (n = 38). F = free-autonomous.7 2. symptoms. E. 1975). Furthermore. Spielberger. corrected x2( I.7 8.7 Note. E not U. N '" 82) = 10.0 1. p < . Steele. Ds. Nine symptom dimensions (somatization. and concerns related to his current level of depression (Beck. and U. Steele. 1993).and four-way sis- nificant two tests). neuroticism. For Axis I diagnoses. The two-group chiSQuare was Yates corrected. hostility. .2 1.001. Three-group refers to F. p < . Finally. the smaIl number of patients with antisocial disorder (n = 3) and its comorbidity with antisocial personality disorder (2 out of 3 antisocial participants were also paranoid) led us to combine these patients with those who were diagnosed with paranoid disorder into a single category (n = 22 ).4··· n 82 85 F E 49@ 14(W x2(d/= 3) x2(d/= 2) 53 (1Q) 18~) O@) O® 83. it is our impression that at least 10% of the interviews might have been more appropriately assigned to this category. Fonagy.001.. they were analyzed with respect to attachment classification by comparing those participants in a specific diagnostic grouping with all other psychiatric patients.05. Ds = insecure-dismissive. E. • p < . Because of the high comorbidity of Axis I disorders. depression.4.4* <1. The lack of significant difference among BPD participants between the proportion of E3 participants who are anxious (76%) and the proportion of non-E3 participants who are anxious ( 58%)-x2( I.5 2.SPECIAL SECTION: AITACHMENT AND PSYCHIATRIC STATUS 25 dren than parents whose reflective capacity was poor (Fonagy. a significant association between a diagnosis of anxiety disorder and the E3 subclassification was found. the Spielberger State-Trait Anxiety Inventory (STAI) is a 20-item test of anxiety state (current level of anxiety) and trait (anxiety proneness. 1983). Seventy-five percent of BPD individuals were classified as preoccupied. Four self-report questionnaires were used: The Derogatis ( 1977) Symptom Checklist-90-Revised (SCL90-R) is a 90-item self-report inventory that asks participants to assess psychological symptoms of distress on a 5-point scale based on their experience of each symptom during the previous week. fearful preoccupation with traumatic events (Subclassification E3) emerged as unexpectedly common in the psychiatric group. corrected x2(l. All four questionnaires are widely used and reported to have high internal consistency and test-retest reliabilities.1··· 36. Higgitt. Table 2 shows that there are significant associations between two. 28% in the psychiatric group versus 1% in the control group. All chiSQuare statistics for disorders refer to the distribution of attachment for a particular diagnostic group as compared to the rest of the psychiatric sample. it is important to note that the CC classification was not available at the time of coding and might have served to produce a more meaningful classification of participants. 1977). AAI = Adult Attachment Interview. corrected x2( I.. There were no significant associations between three-way attachment classification and any of the Axis I diagnoses. N = 167) = 22.

2. Three-group refers to F. and U. non underscored numbers exclude unresolved participants. "p<. Ds '" insecure-dismissive.80) = 14. n 23 (n = F 18[2]) 6~) (n = 49 (§]) 12Q) 27(1) 22(1) 32(11 21 (2) E (n= 15 [2]) 50 6(!) Os (n = 62 [0)) U Four-group x. F( 1. E. and Ds.7. Only the threew.p < . 80) = 7. and role reversal in parental relations). corrected X2( 1.p < . High preoccupied-involving angel' with parents was associated. Two-group refers to non-U groups and U. Overall.0.2. Patients with bipolar disorder were more likely to be classified Ds (38% ) than MDD (7% ) or dysthymic patients ( 14%). p < . The mean ratings of interview transcripts on experience and state of mind scales were compared for the psychiatric and control groups (see Table 3). whereas better recall was slightly associated with anxiety.2(d/= 2) <1.2 5. with depression. Participants in the psychiatric group were rated significantly lower on one of the positive experience scales (loving relations with parents) and significantly higher on three of five negative experience scales (rejecting by parents. Scores on the AAl Anger scale were significantly higher for the MDD group (M = 5. neglecting by parents.05.z(d/= 3) 3. Four-group refers to F. Borderline patients were likely to have experienced their parents as less loving (all analyses were controlled for age and GAFatadmission). The two-group chisquare was Yates corrected.0 <1. which is an essential precondition for a rating of unresolved-disorganized. lower ratings on coherence of mind and transcript. dysthymic (n = 21 ). Of the state of mind scales.67. All chisquare statistics for disorders refer to the distribution of attachment for a particular diagnostic group as compared with the rest of the psychiatric sample. and low RSF was associated with eating disorder.5. there were significant differences between DSM BPD and non-BPD patients on two experience scales and the RSF scale. compared with 65% without a BPD diagnosis.0001.01. significantly lower on RSF. regardless of whether one controls for age and GAF on admission of the participants (all the following associations will be reported controlling for age and GAF on admission). We went on to examine the frequency ofU transcripts: unresolved. compared with 61 (78%) in the control group. P < . and major depressive disorder (MDD. n = 30). N = 167) = 55. The psychiatric group also had higher ratings on preoccupiedinvolving anger with both parents. DSM = Diagnostic and Statistical Manual a/Mental Disorders. with any of the diagnostic groups. F( 1. no probable experience scales were associated. Seventy-two individuals (88% ) in the psychiatric sample had experienced loss (death) of an attachment figure. N= 82) = 7. E.9 6.4.and moreneg1ecting. and lower ratings on the RSF scale.21. with a diagnosis of depression. and negatively associated.0 30 51 36 2(1) 10<.zy attachment classification discriminated these three groups.001.0 8. F( 1. E = insecure-preoccupied. a significant relationship was found between diagnosis of BPD and unresolved status (see Table 2).5 Three-group x. compared with 7 (8%) in the control sample reported sexual or severe physical abuse. significantly more of the psychiatric group (76%) received a U classification reflecting disorganization associated with either loss or trauma.2. Attachment Classification by Subtype of Depression We subdivided the 72 depressed patients into three categories: bipolar (including two cyclothymic.7 4.0001. with a diagnosis of eating disorder. Attachment classification Axis II disorder (not mutually exclusive) No Axis IIdisorder BPD (DSM criteria) BPD (Gunderson criteria) BPD (Kemberg criteria) Paranoid-antisocial personality disorder Other personality disorder Note. 80) == 13.6* <1. trauma. n = 21 ).0 1.01.02.p < . Eighty-nine percent of individuals diagnosed with BPD. ns-suggests that the association between E3 and BPD is not solely due to the association between E3 and anxiety. N = 167) == 5. 19% and LO%. or those without an Axis II diagnosis (43% ).8.9" 4. N = 82) = 14. corrected x2(l.0 5.respectively).p < .0 <1.p <: .0· 6. Physical or sexual abuse was significantly more prevalent among those with an anxiety disorder (80% ) than those without (47%). idealization of parents was found to be positively associated.4 2. For Axis IIdisorders. meeting the Main and Goldwyn (1991) criteria for abuse. than patients not receiving a BPD diagnosis. Abuse was more common in those with DSM-BPD (89%) than among those with a paranoid-antisocial (68%). Ds. P < . an "other" (68%) Axis II disorder. x2( I. higher ratings for passivity of thought. corrected x2( 1. U '" unresolved. Patients with MDD were significantly more likely to be secure than either bipolar or dysthymic patients (40% vs. or abuse. For Axis I disorders. p < . For Axis II disorders. were classified as unresolved with respect to loss or trauma. Fifty-three (65%) of the 82 participants in the psychiatric sample. BPD = borderline personality disorder. N = 72) = 14. than did the control group (7%. They were also rated. corrected x2(1. F( 1.p< .2.01.1 <1. see Table 1).26 Table 2 Axis II Diagnostic Groups and AAI FONAGY ET AL.) 8Q) 9(J) 30 o ill) Dill) O(i!) 0(11) OQQ) 6(1) 90 8(J) Oem 22 38 9(1) 5(1) Underscored numbers represent the four-way attachment distribution.0 Two-group x_2(d/= 1) 2. but loss was not specifically characteristic of any of the diagnostic categories. F = free-autonomous. AAI = Adult Attachment Interview. disoriented with respect to loss.9.01. disorganized. 80) = IO.0 <1.2.OS.0) than for . F( 1. 80) = 6.001. 1. unresolved interviews were more common only for those with a diagnosis of anxiety disorder. Among Axis I disorders.

6 (1.1) 6.9 (1.3 (1.7 (1.1 (1. Only 4 of 24 ( 17% ) patients reporting abuse in the high RSF group were diagnosed with BPO. com- group of patients with low RSF than those with high RSF.2)""" 2.6 (1.2) 3.6 (1.0 (1.6) 2.6) 2.6)*** Antisocial-paranoid (n = 22) Other (n = 38) 3.5 (1.6) 2.2 (1.6 (1.8) 4.7 (1.9) 3.9 (1.7) 2.2) 6.5 (1.4(1.9 (1.4 (1.8) 2.1(1.5 (2.8)··· 3. = 4.3) 4. we examined the association between reported physical and sexual abuse.2) 2.9) 1. controlling for age and Global Assessment of Functioning score at admission.1 (1.6 (1.5)*" AAI scale Probable Experience Loving parents Rejecting parents Neglecting parents Role reversal Pressure to achieve Overprotection State of Mind Idealization of parents Derogation of parents Involving anger with parents Poor recall Coherence of mind and transcript Passivity of thought Fear of'loss of child Reflective self No Axis II (n = 23) BPD(DSM) (n = 36) 2.9) 4.0) 2.7(1. •p < .9) 4. Means for Axis I diagnoses are adjusted.9) 1.6) 3.6) 3. Thus RSF.6) 3.2 (1.1) 5.0(1. 2.5 (1.6) 2.8) 5.6) 2.5)·· 6. DSM = Diagnostic and Statistical Manual of Mental Disorders ." 1.6 (2.8) 4.8) 4.001.0) 2.2 (1.3) 4.0 (1.7) 2.8) 3.6) 2.4(1.1 (1.7 (1.9 (1.3) 4.1).9) 1. Asterisks indicate statistically significant differences between control and psychiatric groups (column 2) and between groups diagnosed with a disorder compared with all those in the psychiatric group not diagnosed with that disorder (columns 3-6). .9) 2.0 (1. with BPD.6) 3.9) 1.2) 2.2 (1.6) 5.6) 3.2) 3.0 (1.9 (1.5 (1.0) 2.0(2.8) (mutually exclusive) 3.7(1.1) 6.5 (1.8) 2.9) 1.8) 4.8 (1.7) and dysthymic groups (M = 9.9) 1.5(1.3) 1. whereas 28 of 29 (97%) patients reporting abuse in the low RSF group were diagnosed with BPO.2 (1.9 (1.8(2. and BPD Following the theoretical model linking abuse and RSF to borderline states.5) 6.5).9) 3.9) 1.l).9(1.3) 5.W 5.4 (1.7) 2.05.1) 5. 2.9 (2.7 (1.1(1.0) 3.2) 2.7 (2.2)··· 2.7) 2.6) 2.0) 2.1 (1.p < .9 (1.9) 1.2) 4.2) 2.2 (2.7)· 2.1 (1.6)··· 1.3) 4.9) 1.7). F( 2.9) 1.9 (2.5 (1.5 (1.0)· 3.7 (1.6(1.0) 2.0 (1. in itself.2 (1.0 (2.3) 3.7) 2.1 (1.9) 1.7(1.7 (1.9) 1.9(1.0) 1.8(1.2) 3.5 (1.8 (1.0 (1.2) 3.1 (l.9) 4.6) 5.3 (2.9) 4.5 (L2) 2. and a diagnosis ofBPO in a 2 X 2 X 2 hierarchical log-linear analysis using the score of 3 as a median split for RSF.9) 1.0).3 (1.5 (1.1) 6.SPECIAL SECTION: ATTACHMENT AND PSYCHIATRIC STATUS 27 Table 3 Means (and Standard Deviations) for Adult Attachment Interview (AAI) Scale Scores and Diagnostic Group M (and SD) for diagnostic group Grouping Psychiatric (n = 82) Control (n = 85) Depression (n = 72) Axis I diagnoses (not mutually Anxiety (n = 44) exclusive) AAI scale Probable Experience Loving parents Rejecting parents N eglecting parents Role reversal Pressure to achieve Overprotection State of Mind Idealization of parents Derogation of parents Involving anger with parents Poor recall Coherence of mind and transcript Passivity of thought Fear of loss of child Reflecti ve self Substance abuse (n = 37) Eating disorder (n = 14) 2.1) 5.1 (1.6) 3.4 (2. does not appear to be an independent risk factor for BPD.1(1. ••• p < .6 (1. the bipolar (M = 3.7 (1. Thirty-two of the 53 (60%) cases who reported abuse were independently diagnosed.3 (1.3) 3.0(1.8) 4.9 (2.2 (1.9) 4.5) 2. The likelihood of reported abuse being associated with BPO was greater in the Interaction of Abuse.0 (1.9) J.2) 5.3) 3.8(1.1 (1.5)··· 3.01.2) 2.0 (1.8 (1.6 (1.9) 4. 69) pared with 4 of29 ( 14%) who did not report abuse.9) 1.7)··· 1.2) 2.3 (1.25.7)·· 4.1(1.9) 1.2) 3.3 (1.6 (1.7 (1.3 (O.6)'" 2.7 (1.8) 3.8 (1.0 (1.1 (1.6 (1.6 (0." 3.4 (2.7) 2.8 (1.8) Axis II diagnoses 2.6 (1.2 (2.1 (1.3) 2.3 (1. low and high RSF patients had comparable incidence of BPD (2 of 17 for high RSF VS.6 (1.5) 6.2 (2.2 (1.6) 2.3 (1.1(1.0)· 2. In the nonabused group.9) 2. the three-way interaction in the log- .4 (1.7 (1.8)· 4.9) 4.3) 3.6) 5.7) Note.9 (2. In line with this view. 2 of 12 for low RSF).6) 3. Standard deviations are in parentheses.6(1.3) 4.2 (1.0 (1. RSF scores.3 (2..0 (1.4 (1.3) 4. 2. but is highly predictive ofBPD in the presence of abuse.6) 5.2(1.5) 5.0 (1.2 (1. RSF.0 (1.8 (1.5) 2.7 (1.7(1.4)··· 2.2 (1.2) 2.0(1.p < .0) 2.0) 2.5 (1.7 (2.1) 6.9 (1.8 (1.05.3 (2.7) 2.2) 3.5 (1.3).6) 5.2 (1.9 (1.

p < . Ds = insecure-dismissive.9. 79) '" 4. The association of three-way attachment classification and final GAF score was significant in an analysis of covariance (ANCOVA) controlling for GAF scores at start of treatment.51. p < . MDD. x2(2.28 linear analysis was significant. On the other hand. X2( I. and F. therefore. It may be suggested that narratives of bipolar patients are characterized by derogation associated with a hypomanic or manic state and readily classified as Ds. The significant association between a diagnosis of anxiety and the unresolved classification supports the clinical validity of the unresolved category. The relationship between a diagnosis of eating disorder and a participant's idealization of his or her parents echoes the clinical observation that participants with eating disorders are perfectionists (Slade. Approximately half (n = 40) of the total group showed clinical improvement. particularly in patients with BPD.- osl lSL_. Discussion The present study demonstrated that psychiatric patients' narratives of their childhoods could be readily distinguished from those of normal control participants. whereby attachment classifications contribute to the evolution of specific types of pathology after stressful experiences. January 1995). However. respectively. N 8. Both preoccupied and unresolved classifications appear to be characteristic of this psychiatric sample. and 0. BDI. The proportion of patients who improved was highest in the Ds group (93%) as opposed to that in the E (41 % ) and F (33%) groups. a higher prevalence ofF participants. or any of the psychometric measures used (SCL-90-R. and Revenstorf ( 1984) and modified by Christensen and Mendoza ( 1986). The significant differences between mean AAI scales for the psychiatric and control groups confirmed our expectation that Positive Experience (e. Change in Global Assessment of Functioning (GAF) score between admission and discharge. was significantly predictive of the GAF measure of improvement. explaining the association between depression and lower idealization of parents. 1980. depressed participants have a sadder view of the world and lower expectations of their attachment figures. transcript. 1.g. Alternatively. The observed relationship of attachment classification and depression subtype corresponds to the severity and prognosis of these diagnoses.84. or STAll. Only longitudinal studies that assess MDD patients during nonsymp- . the four-way attachment classification. N = 82) = 14. 1982) whose eating disorder may stem from exaggerated standards that are also applied to parents.001. Follette. The effect sizes for the three groups were 1. 1988). Anxiety indicates the extent to which past traumatic experiences are felt to be in the present. personal communication. It should be pointed out that the control sample yielded fewer participants who were designated as unresolved than is typical even for noncIinical populations (van IJzendoorn & Bakermans-Kranenburg. Anxiety may be an underlying mental state that results in disorganization and prevents an individual from resolving loss or abuse. However. loving. Alternatively.67.28. a causal model may be proposed. ences in AAI classification between control and psychiatric groups. 82) = Changes in Adaptation During Treatment We examined changes in overall adaptation (GAF) between admission and discharge within the psychiatric group. metacognition. E. None of the other potential predictors. Axis I and Axis II diagnoses. in line with the predictions of attachment theory (Bowlby. the direction of causality remains unclear. F{2. and the RSF) scales would be lower and that Negative Experience and State of Mind scales would be higher for the psychiatric group.careful training and interrater reliability testing of the coders in the Main and Goldwyn (1991) system served to focus the coders on manualized AAI criteria and minimized the influence of interview length. for Ds. The study provided overwhelming support for the association of psychiatric disorder with unresolved difficult early relationships.02 (see Figure I). an unresolved experience of loss or abuse may cause present anxiety. We classified patients according to the presence of statistically reliable change as proposed by Jacobson. frequently an episodic disorder. divided according to their major AAI classification at admission.004. The high scores on the AAI Anger scale are consistent with the classical psychoanalytic conception of depression as unresolved anger with the other which is then turned against the self.. EPQ. may be associated with lesser disruption of the personality and. P < . likelihood ratio. The vast majority of the personal histories in the AAls of the psychiatric group are so compelling and beyond the ordinary range of experience that a model based on the social causation of mental disorder becomes intuitively hard to reject. = FONAGY ET AL. nonrejecting parents) and State of Mind (coherence of mind. including U status. E = insecurepreoccupied. It may be argued that the disproportionate length of interviews from the psychiatric group could not be disguised and may have accounted for some of the observed differences between psychiatric and control attachment ratings. Discharge Figure 1.. F = free-autonomous. thus potentially exaggerating the differ- 40 35 GAF 30 25 20 - I-F -E Admission -.09.

and 6year-old children (Fonagy. e. which also characterizes the BPD group (Main & Goldwyn. We cannot be confident that attachment classification is independent of symptomatic presentation and thus can be appropriately considered either a general risk factor or an indicator of a predisposition to particular types of disturbance. Fonagy. It has been proposed (Fonagy. 47%) was significantly greater than would be expected by chance. it did not match the specificity found by Patrick et al. the disproportionate number of BPD participants classified as E3 is notable and may be interpreted as confirming the predominant feature of the E3 group. only 3 were rated as autonomous but not unresolved. It is unfortunate that at the time of the coding of the interviews. 1991. Although the proportion of DSM-BPD patients who were fearfully preoccupied (E3. It is perhaps easier to draw someone's attention to past relationships as determinants of current difficulties when they have previously avoided concerning themselves with such issues than it is to try to cast a well-established set of perceptions about the past into a different. In addition. and (c) significantly higher ratings on the Lack of Resolution of Abuse or Loss scales. It is possible that Ds status represents an extreme interpersonal state and. Ruffins. Our preferred explanation (Fonagy. although further work is needed to test this hypothesis with other and more rigorous methods of evaluating therapeutic change. & Target. It is also possible that the high frequency of reported childhood maltreatment may be an aspect of the dramatic reporting style of BPD individuals or the consequences of therapy-induced suggestion in this particularly susceptible group (Loftus. An alternative way of interpreting the data may be in terms of the relative inaccessibility of preoccupied individuals to psychotherapy. They were identified as a homogenous group of "prototypical borderlines" and did not include depressed patients. The failure to understand mental states becomes a core symptom of their disturbance and accounts for many aspects of the clinical presentation of BPD (Fonagy.g. there are early signs that AAI classification indicates who is most likely to improve in treatment. Main ( 1991 ) discussed "minimizing" and "maximizing" attachment strategies: E adults and anxious-resistant infants display attachment behaviors in the absence of the activation of the attachment behavioral system. & Charman. Nevertheless. It also drastically limits their capacity to come to terms with these abusive experiences later in life and creates a vulnerability to interpersonal stress (Fonagy et al. A concrete (nonsymbolic) manner may be a characteristic of individuals with BPD. this theory can only be tested by a prospective study of the developing mentalizing capacity in children who were the victims of abuse. Concern with memories of abuse may lead to the domination of the participant's narrative by details of events in the individual's past and artifactually reduce the proportion of reflective statements. 1989) that some BPD individuals may be those victims of childhood abuse who coped by refusing to conceive of the contents of their caregiver's mind and thus successfully avoided having to think about their caregiver's wish to harm them. Beeghly and Cicchetti ( 1994) found that a large proportion of children with experience of severe neglect or abuse show a specific deficit in their use of mental state words. BPD patients' interviews were differentiated by a combination of three characteristics: ( a) higher prevalence of abuse and neglect reported in the AAI narratives (consistent with previous findings. The most specific relationship demonstrated in this study was between BPD diagnoses and attachment classification.' thus. we found a significant interaction between reporting of abuse and low RSF in predicting a BPD diagnosis. (b) significantly lower ratings on the RSFscale. We predict that children who respond to abuse by a deficit in capacity to mentalize are more likely to have serious personality disturbances in adulthood. The failure of Kernberg's BPO diagnosis to relate to attachment in the same way as did DSM and Gunderson diagnoses suggests that the specificity of this classification within a psychiatric population is too low. There is independent evidence that mentalizing capacity may be related to the quality of childhood relationships..SPECIAL SECTION: ATTACHMENT AND PSYCHIATRIC STATUS 29 tomatic periods will help discriminate between these two models. Redfern. Our own work has demonstrated a relationship between quality of attachment to mother and belief-desire reasoning in 5. A number of accounts may be offered for this pattern of results. In these patients. Fonagy & Higgitt. This strategy potentially interferes with a productive therapeutic relationship. the coders were not yet trained in the CC category of the AAL This classification may well have helped clarify this and other links between attachment and psychiatric diagnosis.1991). 1990). ( 1994. 1994). there was a tendency for incoherence and passivity of thought to be restricted to narratives concerning loss of abuse. they were less likely to show concurrent Axis I and II disorders. resulting both in their diagnosis of BPD and in their inability to resolve previous trauma. Ultimately. in press). their fear of relationships. The results of the present study are promising but by no means conclusive. Westen. 83%). Nisle.. It is equally possible that participants with BPD are unable to reflect on others' mental states for constitutional reasons. Aspects of the sampling for the two studies may account for this discrepancy. Longitudinal studies are urgently needed to demonstrate the predictive value of adult attachment classi- . & Block. 1989. Finally. 1991) is that individuals with experience of severe maltreatment in childhood who respond to this experience by an inhibition of menta lizing function (Morton & Frith. Although 36% (n = 8) of the participants who fall into the paranoid-antisocial category of Axis II diagnosis were rated as being secure or autonomous. the difference in outcome between the three groups is a regression to the mean effect. Moran. therefore. Ludolph. The 12 BPD patients in the Patrick study were selected from an outpatient psychotherapy department's referrals and were likely to be less severely handicapped than the present group. 1994). 1995) are less likely to resolve this abuse and are more likely to manifest borderline psychopathology. This initially defensive disruption of the capacity to depict feelings and thoughts in themselves and in others becomes a characteristic response to all subsequent intimate relationships. 1993). and probably far less self-serving mold.

Cicchetti & D. Fonagy. S. SCL-90-R: Administration.. H. multiple (incoherent) models of attachment: Findings and directions for future research. J. 5-30. and procedures manual l. London: Hogarth Press. 17. L. & c. Baltimore: Clinical Psychometrics Research. 896-903. and singular ( coherent) vs. Dozier. 137-207). G. L. ( 1973). and Trans. H... ( 1965). W. Development and Psychopathology. A developmental perspective on borderline personality disorder. S. P.J. D. Moran.. Steele. In D. Kobak. S.• rev).30 FONAGY ET AL.. A parental bonding instrument. P... London: Hodder and Stoughton. (1989).471485. Kaplan. P. 231-257. (1986). 47-60. J. & Rosser. 29. Journal o/the American Academy of Child Psychiatry. M. Beck Depression Inventory manual. 74. 94. (1989). R. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment.. & Main. J. TX: The Psychological Corporation. H. ( 1991 ). M. (1995). & Shapiro. J. 56. (1993). Steele.. Loss. & Higgitt. J. Oxford. The standard edition 0/ the complete psychological works 0/ Sigmund Freud (Vol. M.. Understanding other minds: Perspectives from autism. American American manual 0/ mental disorders (3rd Psychiatric Association. D. Moran. Main. Birch. New York: Wiley. Journal ofPsychiatry. In P. ( 1988). H. ( 1940). Holmes. San Antonio. Journal 0/ Child Psychology and Psychiatry. Development of knowledge about the appearance-reality distinction. W. I.. Dozier. Schachter. Berkeley.. J. 194-198). B. L. 72.. N. pp. F. Bulletin o/the Anna Freud Centre. (1991). N. E. & Cohen. Jacobson. Patrick. (1980). Attachment organization and treatment use for adults with serious psychopathological disorders. Revue Intemationale de Psychopathologie. & Flavell. Castle. Metacognitive knowledge. (Eds. Maternal representations of attachment during pregnancy predict the organization of infantmother attachment at one year of age. We hope that the analysis of follow-up AAls and other psychometric tests from this study will answer some of these questions. G. (1979). Personality disorder and the mental representation of early social experience. ITifant Mental Health Journal. Adult Attachment Classification Svstem. R. pp. Handbook 0/ psychiatry (Vol. E. United Kingdom: Oxford University Press. United Kingdom: Cambridge University Press. Hartocollis (Ed. Beeghly. M. Fraiberg. J.. Lee. Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance. Child Development. Baron-Cohen. & Revenstorf.. 357390). Derogatis. London: Her Majesty's Stationery Office.C. Loftus. (1994). S. University of Delaware. & Velligan. Monographs 0/ the Societyfor Research in Child Development. O. Bowlby. 2. & Target.. R. M. Therapeuuc Communities International Journal/or Therapeutuc and Supportive Orga· nizations. 62. 443-445. 87-121). Registrar General. Unpublished document. & Higgitt. Adelson.. Fonagy. Temple. ( 1994). 225-243. 23. Freud. 6. Attachment organization and familial overinvolvement for adults with serious psychopathological disorders. 336-352. 1-18. (1984). Steele. Berkeley. Unpublished manuscript. 3. Aggression and the psychological self. H. Borderline personality disorders: The concept. 125-159. Kind. I.. ( 1994). 127-159)..). American Journal 0/ Psychiatry. New York: Jason Aronson. & Steele. J.. Tupling. In P. P. H.. M. New York: Basic Books. (1991). Stevenson-Hinde. Behavior Therapy. Parkes (Eds.. OC: Author. & Cicchetti. M. Steele. Version 5. G. New York: Routledge-Kegan Paul. L. J. (1993)Apsychometric study of the Adult Attachment Interview: Reliability and discriminant validity. Flavell. 870-879. Bakermans-Kranenburg. F. Green. 5I(Serial No.. & Schachter. (1987). (1975). Follette. Stevenson. and the self system: Emergence of an internal state lexicon in toddlers at high social risk.. A method of assessing change in a single subject: An alteration of the RC index. Eysenck. The Adult Attachment [Privileged communication. /63. H. References (1987). ( 1975). (1985). The patient's pantry: The nature of the nursing task [Special issue]. scoring. A.. S. Rosser. 15. Fonagy. 14. (pp. Ghosts in the nursery: A psychoanalytic approach to the problem of impaired infant-mother relationships. M. ( 1981 ). & Maughan. The repressed memory controversy. N.). M. 12. Interview. P.. J. Main.. Denford. J. 375-388. P. "(1990). Developmental psychiatry comes of age. H. Howard. University of California. M. J. Attachment and loss: Volume 3. Flynn. 1-10. American Psychologist. attachment. Attachment and loss: Volume 2. P. Strachey (Ed. Bowlby. & Eysenck.. Washington. M. Selection and outcome in in-patient psychotherapy.. S. J. J. P. Behavior Therapy.). (1993). 1-68. Tager-Flusberg. Developmental Psychology. Child maltreatment. D. (1977). 1-10. Cohen (Eds. Morton. E. 387-422. the syndrome. Parker. Russel & L. I38.. L..] Unpublished manuscript. D. R. A. J. R. 52. Development and Psychopathol· ogy. L. Causal modeling: A structural approach to developmental psychopathology. & Goldwyn.. Fonagy.. (1994). The AAI itself should be explored as a measure of change. Manua! of the Eysenck Personality Questionnaire. ( 1991 ). ( 1989). Fonagy.227-236. /45. On tolerating mental states: Theory of mind in borderline patients. C (1993). In G. Manual o/Developmental Psychopathology. c... British Journal of Medical Psychology. Fonagy. Bowlby.. Beck. D. & vanUzendoom. P. The attachment interview. (1983). G. ( 1991 ). particularly its correlation with more symptomatic measures and its predictive value for forecasting remission and recurrence.475-489. Diagnostic and statistical ed. Attachment across the lifecycle (pp. metacognitive monitoring. Harris. International Journal 0/ Psycho-Analysis. ( 1991 ).. 305-308. . E.200-216. 14. A. V..430-438. An outline of psychoanalysis. Hersov (Eds. 4. A. British Journal 0/ Medical Psychology.91-115. F.). University of California. The diagnostic interview for borderline patients.. Development and Psychopathology. V. fications for the development of psychopathology. 35. Department of Psychology. S... M. C. M.• Bond. /. The structural diagnosis of borderline personality organization. M. R. R. & Austin. & Mendoza. Classification 0/ occupations.. F. Goldberg. P.). M. Fonagy. Personality disorders in adults predisposing to minor depressive disorders. ( 1"977). (1993). Tom Main and after: His legacy.. George.. (1983). Hobson. 212). (1993). & Target. & Frith. Gunderson. Christensen. Attachment theory: A biological basis for psychotherapy? British Journal o/Psychiatry. R. Higgitt. Kernberg. Thinking about thinking: Some clinical and theoretical considerations in the treatment ofa borderline patient. Denford. Separation anxiety and anger. In J. 13. H.). U. Theory and practice of resilience.. the patient (pp. Kolb. & Brown. 49. Cambridge. (1986). New York: Basic Books. IntemationaIJournalo/Psychoanaiysis. 880893. Steele. A. Development and Psychopathology.. S.

B. W. 55-66... Journal of the Royal SodelY of Medicine.1995 • . Gibbon. British Journal of Clinical Ps}. S. Williams. B. Towards a functional analysis of anorexia nervosa and bulimia nervosa. DC: American Psychiatric Press.J. Palo Alto. 1994 Revision received May 10. 21. P. 31 User's guide for the Structured Clinical Interview for DSM-Ill-R. D. M. & First.1995 Accepted July 21. ical and sexual abuse in adolescent girls with borderline personality disorder. (1990). 80. & Block. C. R. Spitzer. Slade. Manual for the Stale Trait Anxiety Inventory. D.:hology..SPECIAL SECTION: ATTACHMENT AND PSYCHIATRIC STATUS Five-year follow-up patients treated with inpatient psychotherapy at the Cassel Hospital for Nervous Diseases.. ( 1990). Nisle. 167179. D. ( 1983). M. 549-555. B.. Received August 8. J. PhysWashington. Ruffins.. P. L. CA: Consulting Psychologists Press. Ludolph. Spielberger. American Journal of Orthopsychiatry. 60. Westen. (1982).

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