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Adult attachment styles in panic disorder with and

without comorbid adult separation anxiety disorder


Vijaya Manicavasagar, Derrick Silove, Claire Marnane, Renate Wagner

Objective: Attachment theory suggests that anxious attachment styles are associated
with risk to psychiatric disorder, especially anxiety disorders. Separation anxiety would
appear to be a core form of anxiety that is associated with anxious attachment.
Nevertheless, as yet no research has examined the relationship of attachment styles to
adult separation anxiety disorder, a condition that has only recently been fully recognized.
Method: The Attachment Style Questionnaire was used to examine attachment styles
among 83 consecutive anxiety clinic patients diagnosed with panic disorder with
agoraphobia and those re-assigned from that category to adult separation anxiety disorder.
Results: Dimensional associations showed strong correlations with scales measuring
anxious attachment and separation anxiety. Patients assigned to the separation anxiety
group scored significantly higher than those in the panic disorder group on the scales of
Need for Approval and Preoccupation with Relationships.
Conclusions: The findings finally dispel the notion that separation anxiety and anxious
attachment are relevant to panic disorder with agoraphobia, suggesting instead that that
constellation is confined to a separate group, namely that of adult separation anxiety
disorder. Possible implications for treatment are considered.
Key words: adult, object attachment, panic disorder, separation anxiety disorder.

Australian and New Zealand Journal of Psychiatry 2009; 43:167 172

The link between attachment styles and overt


psychiatric symptoms has attracted extensive theoretical attention, particularly in relation to early childVijaya Manicavasagar, Associate Professor, School of Psychiatry,
University of New South Wales; Director, Psychological Services, Black
Dog Institute (Correspondence)
Black Dog Institute, Prince of Wales Hospital Randwick, NSW 2031,
Australia. Email: v.manicavasagar@unsw.edu.au
Derrick Silove, Professor, Psychiatry Research and Teaching Unit,
School of Psychiatry, University of New South Wales; Director, Centre
for Population Mental Health Research, Sydney South West Area
Health Service, Australia
Psychiatry Research and Teaching Unit, Mental Health Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
Claire Marnane, Research Assistant, School of Psychiatry, University of
New South Wales, and Clinic for Anxiety and Traumatic Stress,
Bankstown Hospital, Australia; Renate Wagner, Director, Clinic for
Anxiety and Traumatic Stress, Bankstown Hospital; Conjoint Lecturer,
School of Psychiatry, University of New South Wales, Australia.
Clinic for Anxiety and Traumatic Stress, Bankstown Hospital, Bankstown, New South Wales, Australia
Received 19 February 2008; accepted 20 October 2008.

# 2009 The Royal Australian and New Zealand College of Psychiatrists

hood [1,2]. The recent identification of adult


separation anxiety disorder (ASAD) [35] offers the
potential to examine this association over the course
of later development.
Attachment theory postulates that early parent
child bonds play a major role in the development of
internal working models of close interpersonal relationships, thereby establishing a template for enduring attachment styles [1,6]. Once established,
attachment styles are thought to modulate ongoing
interpersonal interactions and influence expectations
of future relationships. Securely attached adults have
confidence in developing close, intimate relationships
characterized by reciprocal support, care and affection. In contrast, adults with anxious or preoccupied
attachment styles tend to be hypervigilant about
their relationships, being sensitive to loss or threat
of ruptures in relation to close interpersonal
bonds. They seek close proximity to or contact with

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ASAD AND ADULT ATTACHMENT

attachment figures, requiring repeated reassurances


that they will not be abandoned. It is hypothesized
that anxious attachment styles in turn predispose to a
range of anxiety and depressive symptoms, particularly at times of later interpersonal stress [79].
Of all the forms of anxiety, separation anxiety
disorder would seem to be the most likely to be
associated with an anxious attachment style, because
sufferers are by definition highly sensitive to real or
perceived threats to relationships [2,10]. Dysfunctional parenting and hereditary factors appear to play
a role in generating early separation anxiety [11],
recognizing however that the childs anxiety itself
may generate overprotective parenting [12]. As yet,
no studies have examined whether anxious attachment styles represent a risk to separation anxiety
disorder in adulthood.
The status of ASAD has been clarified only
recently [4,5]. The delay in focusing on that category
may have been a consequence of Bowlbys assertion
that agoraphobia represents underlying separation
anxiety in adulthood [1]. In DSM-III the link with
separation anxiety shifted to panic disorder (PD),
with agoraphobia being regarded as a strategy to
avoid panic triggers. Yet, studies attempting to link
early separation anxiety with adult PD with agoraphobia have yielded contradictory results [1315],
with some studies showing specific links and others
suggesting that separation anxiety is a general risk
factor to a range of anxiety disorders [16,17]. But
these former studies did not take into account the
category of ASAD.
The phenomenology of ASAD was described in the
late 1990s [3,4]. Subsequently, an independent research group has identified the same constellation of
symptoms [5]. ASAD symptoms are analogous to
those manifested in childhood separation anxiety
disorder apart from expectable maturational differences (e.g. adults fear leaving home for work while
children may exhibit school refusal). Affected adults
described intense anxiety about separation from key
attachment figures (not only parents, but also spouses
and children), fears that harm might befall those close
to them, and an intense yearning to return home [3].
They report high levels of early separation anxiety,
suggesting that there is a developmental continuity
for this form of anxiety. Specifically, repeated studies
have found substantial correlations between the
Separation Anxiety Symptom Inventory (SASI) [18],
a retrospective self-report measure of juvenile separation anxiety symptoms, and scores on the Adult

Separation Anxiety Questionnaire (ASA-27) [4,12].


Furthermore, approximately two-thirds of adults
diagnosed with ASAD fulfilled criteria for a retrospective diagnosis of juvenile separation anxiety using
DSM-IV criteria [4]. Once ASAD is included as a
subcategory of adult anxiety, any apparent relationship between early separation anxiety and PD or PD
with agoraphobia (PD/PD-AG) disappears [17]. Recently, the National Comorbidity Survey Replication
[19] included a module for ASAD, reporting a
12 month prevalence of 0.9% and a lifetime prevalence of 6.6% [20].
Clinic-based studies have indicated that adults
referred with a presumptive diagnosis of PD/PDAG can often be re-assigned to ASAD after systematic assessment using structured diagnostic measures
[12,19,21,22]. In the majority of cases symptoms of
separation anxiety occurred first, with panic attacks,
when present, being triggered by typical fears of
separation. Also, when panic was present, separation
anxiety symptoms were regarded as having greater
salience to the patient and being most responsible for
ongoing psychosocial disability. A recent clinic-based
study of cognitive behavioural therapy for PD/PDAG has shown that of all the variables assessed, only
two factors predicted treatment outcome. Recovery
was associated with greater severity of panic symptoms at the commencement of therapy; and, in
contrast, the presence of ASAD was a strong
predictor of poor outcome (odds ratio 3.74) [23].
It seems possible that a cognitive behavioural therapy
approach focusing solely on symptoms of panic and
agoraphobia may not have addressed the core
problems associated with separation anxiety and/or
an underlying disturbance in attachment styles.
The aim of the present study, therefore, was to
investigate whether patients initially diagnosed with
PD/PD-AG who also met criteria for ASAD differed
from the remaining group in manifesting insecure
attachment styles.

Methods
Sample
The sample was recruited from a public hospital anxiety clinic in
Sydney, Australia. All patients signed a consent form approved by
the Ethics Committee for the Sydney South West Area Health
Service. The sample consisted of consecutive patients diagnosed
with PD/PD-AG according to the Structured Clinical Interview for
DSM-IV (SCID) [24].

V. MANICAVASAGAR, D. SILOVE, C. MARNANE, R. WAGNER

169

Measures

Separation Anxiety Symptom Inventory

Structured Clinical Interview for DSM-IV

The SASI is a 15-item self-report measure that assesses adults


memories of separation anxiety symptoms experienced up to the
age of 18 years [18]. Items are rated on a 4-point scale similar to
that of the ASA-27, with the square root being calculated for the
aggregated score to normalize the distribution. The measure has a
coherent factorial structure, high internal consistency (Cronbachs
alpha ranging from 0.84 to 0.88) and sound testretest reliability
(intra-class correlations ranging from 0.86 to 0.98) [18].

The SCID is a clinician-administered semi-structured interview


used for diagnosing major Axis I disorders [24]. The measure was
used to assign a current diagnosis of anxiety subtypes (but not
separation anxiety, which is currently not included in the adult
SCID). Studies of earlier versions of the SCID have yielded
adequate testretest reliability indices in patients (ranging from
0.54 to 0.85) [25,26]. Kappa coefficients across disorders have
ranged from 0.43 to 0.67 for clinic samples [26].

Attachment Style Questionnaire


The Attachment Style Questionnaire (ASQ) is a 40-item selfreport questionnaire consisting of five subscales: Confidence,
Discomfort with Closeness, Need for Approval, Preoccupation
with Relationships, and Relationships as Secondary (to achievement) [27]. Items are rated on a 6-point scale from 1 totally
disagree, to 6 totally agree. The subscales correspond to the three
broad domains of attachment styles identified in the literature
[2,10], namely secure, avoidant, and ambivalent. High scores on the
Confidence subscale are thought to reflect a secure attachment
style, while high scores on the other subscales reflect pathological
styles of attachment. Discomfort with Closeness and Relationships
as Secondary correspond to an avoidant (of intimacy) attachment
style while Need for Approval and Preoccupation with Relationships correspond to an anxious (about abandonment) style [27].
Alpha coefficients for the subscales have been satisfactory,
ranging from 0.76 (for Relationships as Secondary) to 0.80 (for
Confidence). Testretest reliabilities for the subscales at a 10 week
interval have ranged from 0.67 (Relationships as Secondary) to
0.78 (Need for Approval) [27]. Normative data drawn from a
sample of healthy volunteers (n64, mean age23.0 years, SD
2.8 years) [28] are presented in Table 1 and are used as an
approximate comparison with the data derived from the anxiety
clinic.

Statistical analysis
SPSS was used to undertake all analyses (SPSS, Chicago, IL,
USA). Clinic patient data were compared with normative data
using a single samples t-test, while the two anxiety subgroups were
compared using independent samples t-tests. The multivariate
analysis applied a stepwise regression to examine the relationship
between the ASQ subscales and a measure of adult separation
anxiety symptoms (ASA-27). A predetermined significance criterion of p 0.01 was used throughout.

Results
Sample characteristics
Eighty-three consecutive outpatients were diagnosed with PD or
PD-AG. Seventy-four per cent (n61) were female, and 51% (n
42) were either married or in cohabiting relationships. The mean
age of the sample was 37.2 years (SD12.7). Fifty-four patients
from this group were also assigned to ASAD using a cut-off of 22
on the ASA-27. Means and standard deviations for the attachment
subscales of the ASQ for the whole sample are provided in Table 1,
showing broad comparisons with normative data provided by
Troisi et al. [28].

Associations of SASI with ASA-27


Adult Separation Anxiety Questionnaire
This scale is a 27-item self-report measure developed to assess
core separation anxiety symptoms [29]. Each item is rated on a
4-point scale where 0 indicates this has never happened and 3
indicates this happens very often. The measure has a coherent
single factor that has been found to account for 45% of variance in
separation anxiety symptoms. Cronbachs alpha was 0.95 and test
retest reliability at 3 weeks was high (0.86) [29]. A receiver
operating characteristic (ROC) analysis comparing an ASA-27derived diagnosis of ASAD with one obtained using a clinicianadministered semi-structured interview yielded a high area under
the curve index (AUC0.9). Using a cut-off score of 22 on the
ASA-27 to assign subjects to the putative category of ASAD
yielded a sensitivity of 81% and a specificity of 84% compared to
diagnoses assigned by clinicians using the structured interview.

The mean SASI and ASA-27 scores for the sample were 3.4
(SD1.5) and 32.3 (SD18.2), respectively. SASI and ASA-27
scores were significantly correlated (r 0.56, p0.001).

Associations of ASA-27 with ASQ


Table 2 shows correlations between the ASA-27 and the ASQ
dimensions. Discomfort with Closeness, Need for Approval and the
Preoccupation with Relationships subscales all yielded significant
associations with the ASA-27.
Stepwise regression analyses were undertaken to test for the
overall predictive power of the ASQ when covariance among
the subscales was taken into account. The ASQ accounted for 31%
of the overall variance of the ASA-27 score. Subscale analysis using
a stepwise regression indicated that the Preoccupation with

170

ASAD AND ADULT ATTACHMENT

Table 1.
ASQ subscales
Confidence
Discomfort with Closeness
Relationships as Secondary
Need for Approval
Preoccupation with
Relationships

ASQ subscale scores

Anxiety patients (n83)


(Mean9SD)
30.896.8
38.498.1
18.795.8
26.597.3
30.897.6

Normative (n64) (SD)


(Mean9SD)
31.794.8
34.196.2
15.694.5
20.695.5
28.897.2

t, df, p
NS
4.8, 82, B0.001
4.8, 82, B0.001
7.3, 82, B0.001
NS

ASQ, Attachment Style Questionnaire.

Relationships subscale accounted for almost all of the variance


(28%) attributable to the ASQ.

Association between attachment styles and ASAD


diagnosis
The sample was then divided into those with PD/PD-AG who
reached threshold for a diagnosis of ASAD (n55) using the
established cut-off of 22 on the ASA-27 and a residual PD/PD-AG
group (n29). (For simplicity we will refer to the comorbid PD/
PD-AG plus ASAD group as ASAD). ASAD patients returned
statistically higher scores than the PD/PD-AG patients on two of
the ASQ subscales: Need for Approval and Preoccupation with
Relationships (Table 3). It is noteworthy that residual PD/PD-AG
patients did not differ statistically from the normative data
reported in Table 1 on any of the attachment style subscales.

Discussion
To our knowledge this study is the first to examine
attachment styles among patients with comorbid PD/
PD-AG and ASAD. The results showed an association between a dimensional index of adult separation
anxiety and particular attachment styles. In addition,
patients with comorbid ASAD showed more aberrant
attachment styles than those with PD/PD-AG alone.
Table 2. Correlations between the ASA-27 and the
ASQ dimensions
ASQ subscales
Confidence
Discomfort with Closeness
Relationships as Secondary
Need for Approval
Preoccupation with Relationships

ASA-27
0.35
0.43**
0.24
0.52**
0.54**

ASA, Adult Separation Anxiety Questionnaire; ASQ, Attachment Style Questionnaire.; **p 0.01.

Moreover, the abnormalities associated with ASAD


were primarily associated with anxious rather than
avoidant attachment styles.
Prior to discussing the possible implications of
these findings, the limitations of the study need to
be considered. The diagnostic status of ASAD
remains provisional despite its recent adoption by
the NCS-R study [19]. The construct, however, seems
to be gaining acceptance [5], with increasing evidence
to support its status as a specific form of adult anxiety
category equivalent to the established childhood
diagnosis of separation anxiety disorder.
Nevertheless, given the low recognition of ASAD in
primary care, patients are not yet referred to anxiety
clinics specifically for that diagnosis. As such, referrals are usually assigned another diagnosis, commonly PD/PD-AG. The present data therefore are
based on persons with comorbid diagnoses of PD/
PD-AG and ASAD. Although our previous data
suggest that when there is comorbidity, separation
anxiety disorder precedes PD [3,21], only communitybased studies can test whether the present results
apply to the majority of ASADs including those who
do not have comorbid disorders [19]. In contrast, by
comparing the data for ASADs against the residual
PD/PD-AG group, we used a stringent design, if
anything weighting the study against finding a
difference.
It is possible that patients with ASAD are predisposed to report adverse attachment styles. It is
noteworthy that they did not return statistically higher
scores on all aberrant attachment dimensions, only on
those associated with anxious attachment. A parsimonious explanation of the results could be that the two
phenomena (ASAD and anxious attachment) simply
reflect different aspects of the same construct, anxiety
about relationships. Yet the analyses suggest otherwise: although there were strong associations between
the two relevant measures, the greater portion of the

V. MANICAVASAGAR, D. SILOVE, C. MARNANE, R. WAGNER

171

Table 3. Mean ASQ subscale scores by diagnosis


ASQ subscales
Confidence
Discomfort
Relationships as Secondary
Need for Approval
Preoccupation with Relationships

ASAD n54 (Mean9SD)


29.797.0
39.598.4
19.896.2
28.497.3
33.196.5

variance remained unexplained, suggesting a high


degree of independence of the two constructs.
Agoraphobia has evolved as a diagnostic construct
over several decades. Bowlby made a specific link
between early separation anxiety and adult agoraphobia, effectively proposing that the latter disorder
was the adult manifestation of persisting separation
anxiety [1]. He implicated overprotective parenting in
the genesis of that developmental pathway. Notably,
however, more recent studies have suggested that
patients with agoraphobia tend to report exposure to
uncaring rather than overprotective parenting [30]. A
later formulation, and one that informed the development of DSM-III and DSM-IV, gave primacy to
PD, thereby assigning agoraphobia largely to the
status of a behavioural reaction aimed at avoiding
situations that triggered panic [31,32]. That nosological shift focused attention on early separation
anxiety as a possible risk factor to PD with or
without agoraphobia. Yet, as indicated, the evolving
body of research failed to provide consistent support
for that putative developmental link [16,17]. Based on
the identification of ASAD and the present data, we
propose a third formulation, that is, a developmental
continuity theory of separation anxiety disorder.
That model suggests that hereditary factors and early
parental overprotectiveness combined to generate
high levels of separation anxiety [11,12]. Most often
symptoms manifest in childhood but the onset can be
in early adulthood. The overlap with PD-AG may
occur for two reasons: acute separation anxiety (e.g.
after a bond rupture) can lead to panic attacks, which
in turn can become self-perpetuating; and/or contemporary operational criteria for agoraphobia overlap with those of ASAD  for example, both groups
may be reluctant to leave the home, but further
inquiry will clarify that the reasons differ across the
two diagnostic categories.
It seems likely that persisting separation anxiety
generates an enduring style of attachment in close
relationships. Fears of abandonment and/or that
harm will befall attachment figures will produce
working models of relationships as being perpetually

PD/PD-AG n29 (Mean9SD)


32.696.2
36.397.2
16.694.3
23.096.0
26.597.7

t, df, p
NS
NS
NS
3.4, 81, B0.01
4.1, 81, B0.001

insecure. As the child grows older, attachment styles


are likely to become entrenched, with exacerbations
of separation anxiety resulting from real or imagined
ruptures to bonds, reinforcing and consolidating
these habitual patterns of response. We note, however, that the developmental pathway linking ASAD
to anxious attachment cannot be elucidated definitively from a cross-sectional study of this kind. It
seems likely that the relationship is complex, involving feedback loops linking insecure bonding experiences with anxious attachment styles and periodic
exacerbations of overt separation anxiety symptoms.
Only longitudinal studies might be able to unravel
these interlinked relationships more clearly.
As yet no standard treatments for ASAD have been
established. It is noteworthy, however, that two
recent studies have indicated that comorbid ASAD
among PD/PD-AG patients is a strong predictor of
poor outcome for cognitive behavioural therapy
[23,33]. Standard cognitive behavioural therapy for
PD/PD-AG does not address the core symptom
problems of ASAD or the underlying anxious attachment styles that may predispose to that condition.
There appears to be some urgency to develop
treatment strategies, whether based on cognitive
behavioural, interpersonal or dynamic psychotherapies that are specifically designed to address these
core issues among patients with ASAD. In addition,
there is room to explore pharmacotherapies that may
be beneficial in addressing ASAD symptoms, with
animal models suggesting that the tricyclics may have
a role [34].

Conclusions
The present study suggests that anxiety patients
with comorbid ASAD-PD/PD-AG have underlying
anxious attachment styles. These enduring patterns of
attachment may be responsible in part for the
substantial disability associated with ASAD [19],
exacerbating the impact on the sufferers interpersonal relationships. As yet, persons with ASAD remain

172

ASAD AND ADULT ATTACHMENT

underdiagnosed and there are no specific treatment


protocols aimed at addressing their core problems at
a symptomatic level [3] or in terms of underlying
attachment styles. There is an urgent need to advance
clinical recognition of this problem and to develop
effective treatment strategies to assist these patients.

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