Psychological Medicine, 2003, 33, 10991110.

f 2003 Cambridge University Press

DOI : 10.1017/S0033291703008237 Printed in the United Kingdom

The Vulnerable Attachment Style Questionnaire

(VASQ): an interview-based measure of attachment
styles that predict depressive disorder
A. B I F U L C O,1 J. M A H O N, J. - H. K W O N, P. M. M O R A N

AND

C. J A C O B S

From the Lifespan Research Group, Royal Holloway, University of London

ABSTRACT
Background. The Vulnerable Attachment Style Questionnaire (VASQ) was developed to provide
a brief self-report tool to assess adult attachment style in relation to depression and validated
against an existing investigator-based interview (Attachment Style Interview ASI). This paper
describes the development and scoring of the VASQ and its relationship to poor support and major
depression.
Method. Items for the VASQ reected behaviours, emotions and attitudes relating to attachment
relationship style, drawn directly from the ASI. The VASQ was validated against the ASI for 262
community-based subjects. Testretest was determined on 38 subjects.
Results. Factor analysis derived two factors, labelled insecurity and proximity-seeking. The
VASQ insecurity dimension had highest mean scores for those with interview-based Angrydismissive and Fearful styles and was signicantly correlated with degree of interview-based insecurity. The proximity-seeking VASQ scores had highest mean for those with Enmeshed interview
attachment style and was uncorrelated with ASI insecurity. VASQ scores were highly correlated
with a well-known self-report measure of insecure attachment (Relationship Questionnaire) and
textretest reliability of the VASQ was satisfactory. The total VASQ score and the insecurity subscale proved highly related to poor support and to depressive disorder. This was not the case for
the proximity-seeking subscale.
Conclusion. The VASQ is a brief self-report measure that distinguishes individuals with attachment
styles vulnerable for depressive disorder. The use of the measure for screening in research and
clinical contexts is discussed.

INTRODUCTION
There is increasing evidence that attachment
factors make a major contribution to mental illhealth (George & West, 1999). Investigation of
the links between attachment and psychopathology, however, has been hampered by the lack
of appropriate measures for the predictive
potential of disordered attachment. This paper
presents a self-report measure of vulnerable attachment style whose main purpose is to predict
1
Address for correspondence : Dr A. Bifulco, Lifespan Research
Group, Royal Holloway, University of London, 11 Bedford Square,
London WC1B 3RA.

psychopathology in the form of major depression. The methods for developing the questionnaire and assessing its reliability and validity
are described.
Although in recent years, self-report measures
of adult attachment have proliferated (Hazan &
Shaver, 1987; West et al. 1987 ; Bartholomew &
Horowitz, 1991 ; Feeney et al. 1994) these have
largely been designed to assess individual differences in attachment, mainly as expressed in
romantic relationships. There have been parallel
variations in the interpretation of the construct
of attachment (Stein et al. 1998). These have
largely dichotomized into those invoking

1099

1100

A. Bifulco and others

attachment as a relating style that is reected

in the quality of adult relationships, and those
invoking attachment as a state of mind that is
reected in defensive strategy assessed by discourse coherence (Crowell et al. 1999). The
latter is exemplied by the Adult Attachment
Interview (George et al. 1984), which typically
shows only a modest association with social
construct approaches and is unrelated to assessments of adult relationships and support or
depression (Dozier et al. 1999; Waters et al.
2002). This modest level of overlap is argued as
non-surprising by researchers in the eld, given
that socially constructed adult attachment styles
only purport to be conceptual parallels to the
attachment behaviours in the child development
eld, whereas states of mind approaches are
actually used to predict infant attachment in
the next generation (Bernier & Dozier, 2002). It
is the social construct that is the focus of the
present report and measure.
Existing self-report attachment style measures
have a number of disadvantages in being used
to predict poor relationships and psychopathology. First, they have largely been validated on
young age groups such as college samples, for
whom parental relationships are likely still to be
central and who may not have had a full range
of adult attachment relationships (Hazan &
Shaver, 1987; Bartholomew & Horowitz, 1991).
These measures may therefore not be appropriate for a wider age range. Secondly, most
attachment measures have not been designed
for use in high-risk series where relationship
diculties involving conict or isolation may
be prominent and more serious attachment
diculties likely to be evidenced. Thirdly, the
diverse number of measures fail to agree on
attachment classication and the number and
denition of insecure styles. The measures also
variously use dimensional and categorical
measurement approaches that lead to problems
in comparability. Few have been validated
against interview measures, although exceptions
include the work of Bartholomew & Horowitz
(1991).
Opinion on whether attachment is best conceptualized as typological or dimensional is
divided (Fraley et al. 1998). They argue that
Ultimately, only the dimensional scores matter
( since) the types are not real in any case,
and their use can be justied only on the

grounds of convenience (p. 50). However, for

certain purposes, such as in the clinical context
where the task of identifying people who are at
greater risk of psychopathology and its recurrence, the development of a typology is useful
in dierentiating categories of individuals who
need treatment. Thus, such typologies may have
clinical relevance (for example in dierentiating
those angry-avoidant, those anxiously-avoidant
and those exhibiting psychological blockages
in attachment behaviour) but these may not be
well dierentiated by dimensional self-report
approaches.
Measurement of attachment has only recently been used to investigate psychopathology
(Hammen et al. 1995 ; Shapiro & Levendosky,
1999 ; Gerlsma & Luteijn, 2000) even though it
has long been a concern of attachment theory
(Bowlby, 1977). Studies of attachment and
psychopathology, which look at relating-style
in particular, have been limited. Although associations between insecure attachment and
psychiatric disorder have been found, there is
little consistency across types of insecure style
and type of disorder (Murphy & Bates, 1997;
McCarthy, 1999; Gerlsma & Luteijn, 2000). In
a large, nationally representative US study, attachment style was assessed by one of the early
prole-based relating-style questionnaires,
designed by Hazan & Shaver. This was used,
together with clinical interviews of psychopathology (major depression, anxiety disorders,
substance abuse and antisocial disorders)
(Mickelson et al. 1997). Psychopathology was
negatively related to secure classication and
positively related to both types of insecure classications (anxious/ambivalent and avoidant).
There was no dierentiation of attachment style
with type of disorder.
The reliability and validity of the self-report
scales assessing attachment style have recently
been tested with meta-analyses undertaken on
their agreement. Despite consistent two factor
solutions, these have been open to dierent
interpretations. Thus, Brennan and colleagues
analysed the contents of 19 dierent attachment
measures focused on romantic relationships
and found that they all reliably tapped into the
same two orthogonal dimensions, labelled as
Avoidance and Anxiety (Brennan et al. 1998).
Examples of items in the former include I prefer not to show a partner how I feel deep down

The Vulnerable Attachment Style Questionnaire

or I feel comfortable depending on romantic

partners (reversed) and the latter include I do
not often worry about being abandoned (reversed) or I need a lot of reassurance I am loved
by my partner . A more recent investigation of
the relationships between ve attachment questionnaires examined their comparability using
both categorical and dimensional approaches
to determine underlying constructs and found
greatest agreement for the Secure versus any
Insecure classication (Stein et al. 2002). The
study further investigated the relationship to
self-report of psychiatric symptomatology and
found secure versus insecure overall classication proved a better discriminator than any
of the insecure subtypes. The authors nd evidence for two orthogonal dimensions separating
security of attachment from what they term
the attachment strategy for coping with interpersonal diculties. The authors conclude
that the relatively weak relationships found
among attachment measures may actually result from a misconception that the preoccupied
and dismissing styles categorized by these
measures reect distinct styles. Instead they
argue that these are variants of underlying
attachment insecurity inuenced by attachment
strategy employed for coping with interpersonal problems.
This latter nding is important for instruments used to predict psychopathology. A
measure which could be used to discriminate
between those who are at high and low risk for
disorder may need to be keyed into a measurement of severity of insecure attachment, rather
than just style of attachment, since description
of attachment style on it own is usually not
sucient for obtaining a reliable identication
of those who are at risk for disorder (Bifulco
et al. 2002 a). These methodological arguments
indicate that a measure is required, designed
specically for prediction of the more disordered attachment for clinical and research
purposes. Such a measure would ideally be
tested on community rather than collegiate or
patient samples with sucient coverage of highrisk individuals to ascertain its relationship with
the psychosocial depressive risks and disorder
and be validated against a standardized interview measure that predicts depressive disorder.
The VASQ reported on here, is based on
an investigator-based interview measure. The

1101

Attachment Style Interview (ASI) was developed to examine the degree of which insecure
attachment styles were dysfunctional (highly
insecure or non-standard) and related to depression (Bifulco et al. 2002 a, b). The interview
questions not only about behaviour in specic
close relationships (with partner and support
gures, both kin and non-kin), but also about
more general attitudes to close others. Highly
insecure levels of Enmeshed, Fearful and
Angry-dismissive styles all related to depressive
disorder, even when tested prospectively. Little
dierentiation between style was found in
terms of depression, although Withdrawn style
(avoidant but free of either fear or hostility)
showed little association. However, the degree
to which the styles were insecure was highly
related to onset of depression. There was also
evidence of such styles relating to chronicity of
disorder. When the presence of highly insecure
styles was examined in relation to recovery from
chronic depressive disorder in a Befriending
intervention (Harris et al. 1999), those either
clearly secure or mildly insecure at rst contact
predicted remission. This together with positive
event experiences and the befriending intervention provided the best model for remission.
The authors conclude that assessing highly insecure attachment style in the clinical context
could benecially inuence choice of therapeutic
intervention. These ndings converge to indicate that the insecurity of attachment itself is
of paramount importance in predicting psychopathology.
The VASQ was developed out of this clinical
need to have a measure to assess the degree of
attachment insecurity and yet relate substantially to a well-validated interview measure. The
VASQ items were directly chosen from the
interview to establish content validity vis-a`-vis
the interview. The relationship between the
VASQ and outcome was then tested to see if
it was similar to the interview. This method is
similar to the one used to develop other selfreport instruments such as the Working Alliance
Inventory (Horvarth, 1994) and has been used
for clinical screening questionnaires where
guidelines of specic interview-based diagnostic
criteria are imposed (Wittchen & Boyer, 1998).
However, unlike the interview the questionnaire
utilized a dimensional approach. This is argued
to involve less self-report bias and is amenable

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A. Bifulco and others

to a greater range of statistical analyses (Shaver

& Mikulincer, 2002).
The aim of the present report is to describe
the development of the VASQ, specically : (i)
to develop a scoring system for the VASQ and to
show its reliability through internal consistency
and testretest ; (ii) to assess criterion validity
of the VASQ in terms of its association with
the ASI interview and with another self-report
attachment measure (RQ) ; and, (iii) to assess
construct validity of the VASQ in terms of its
association with poor support and depression.
METHOD
The sample
The questionnaire was tested on a intergenerational community series of mothers and their
adult ospring conducted in 199599. The
sample comprised 149 mid-life women, twothirds of whom were selected for psychosocial
risk factors for depression when originally
studied in the early 1990s. These were followed
up for the present study an average of 3 years
later. The women were originally selected
through questionnaire screening of those
registered with GP practices in North London.
Selection procedures, compliance rates, and
other sample details are described elsewhere
(Bifulco et al. 1997, 1998). In addition, 127
family members of the rst group from two
dierent generations were included in this
analysis, a younger group of 71 ospring aged
1625 and an older group of 56 older mothers
aged 5075. The average age of the nal series
at interview was 40.39 (S.D. 16.34). Two-thirds
were middle-class as determined by main family
earners occupation, just under half (47 %) were
married or cohabiting and 68% were parents.
Ninety per cent of the series were female with all
of the 30 males in the young age group.
Thirty-three individuals failed to complete
the VASQ fully and had at least one missing
questionnaire value. These were excluded from
the particular analysis involved which results
in some variation in total numbers quoted.
Testretest series
The testretest reliability of the VASQ was
obtained by one-quarter of the respondents
from the midlife series completing a second

VASQ approximately 6 months after the rst

one. The 6-month time interval was chosen as
optimal because a longer period might have
led to confounds due to possible change in supportive context and a briefer period might have
resulted in initial responses being remembered.
Measures
Measurement was both by semi-structured
interview and by self-report questionnaire of
attachment, support and major depression.
Vulnerable Attachment Styles Questionnaire
(VASQ)
From a pool of 31 questions concerning vulnerable attachment styles drawn directly from
the ASI, eight items were found to be redundant
in terms of extensive overlap leaving 23 items
for the nal VASQ questionnaire scoring. These
were extensively respondent- and expert-tested
in an interactive interview context. Questionnaire items were written as self-statements with
a ve-point Likert response scale. Response options ranged from strongly agree to strongly
disagree. The centre point was unsure . In
order to minimize state eects, respondents were
asked to complete items as they felt generally
rather than currently. Instructions to the respondent were broad: Below are a number of
statements concerning the way people feel
about themselves in relation to others. Indicate
whether you agree or disagree with the description as it applies to you by circling a number
from 1 to 5. There are no right or wrong
answers . (See Appendix 1.)
Attachment Style Interview (ASI )
(Bifulco et al. 2002 a)
An investigator-based interview assessed respondents attachment styles on the basis of
their ability to make and maintain supportive
relationships along with attitudes about closeness/distance from others and fear/anger in
relationships. The in-depth interview is taken
to be the gold-standard for determining attachment style in this study. Interviewer judgements are informed by full training and checked
by consensus panels and reliability of ratings is
high, for example 0.80 (KW) agreement between
independent raters for the overall attachment
scale and average of 0.75 (KW) for subscales.

The Vulnerable Attachment Style Questionnaire

The ASI utilizes seven attitudinal scales

which together with a behavioural assessment
of ability to make and maintain relationships
based on presence of close supportive relationships, allow for a classication of the type of
insecure attachment (Enmeshed, Fearful, Angrydismissive, Withdrawn and Clearly Secure/
Standard) and the degree to which attachment
styles are markedly, moderately, mildly or
not insecure. Vulnerable attachment styles
were those judged marked-moderately insecure
and Enmeshed, Fearful or Angry-dismissive.
These were the most highly related to depressive
disorder and psychosocial risk factors in prior
analyses.
Support (OConnor & Brown, 1984)
An assessment of support was made as part
of the ASI assessment, involving quality of relationship with partner and up to two other
adults named as very close . Poor support
was an index based on poor conding in partner
(rated 3 or 4 on a four-point scale) or lack of a
close condant seen at least monthly, consistent
with prior analyses (Brown et al. 1986).

1103

used for a preliminary description of inter-item

agreement, using principal components for
factor extraction and varimax for rotation. Chisquares and odds ratios were used to evaluate
the criterion validity of VASQ. ANOVA was
used for group comparison of questionnaire
subscales and interview-based attachment styles.
Logistic regression was utilized to examine
whether VASQ or RQ best modelled depressive
disorder.
RESULTS
The sample
A third of the series (88/262) had a highly insecure attachment style as assessed by the ASI
and 40% (113/284) judged to have poor support
in terms of either lacking close condants
or poor partner relationship. Twenty per cent
(52/262) of the series had major depression
in the year before interview contact, with 32 %
(84/262) having a lifetime history of chronic or
recurrent disorder.

Structured Clinical Interview for DSM

diagnoses (SCID) (First et al. 1996)
Major depression in the 12 months before interview was assessed using the SCID, utilizing
DSM-IV criteria. Lifetime episodes of depression were also questioned about in detail.
An index of chronic (any episode lasting
12-months or more) or recurrent (two or more
episodes) of major depression was devised.

VASQ scoring
Items
Factor analysis was undertaken on all 23 items
and a two factor solution derived. One item
poorly loaded on either factor was excluded. Of
the remainder, 12 items proved to be loaded
on the rst factor and ten on the second factor
(see Appendix 1). Items loaded on the rst
factor represented a range of feelings and attitudes relating to discomfort with, or barriers
to, closeness with others, including inability to
trust and hurt or anger at being let down (e.g.
I nd it hard to trust others , people let me
down a lot , I feel people are against me , I feel
uneasy when others conde in me ). This dimension was labelled as insecurity . The second
factor comprised items representing otherdependence or approach behaviour (e.g. I miss
the company of others when Im alone, Its
important to have people around me , I get
anxious when people close to me are away ).
This second factor was labelled proximityseeking .

Statistical analysis
Statistical analyses were conducted within
SPSS-10, with alpha scores and factor analysis

Reliability of subscales
Cronbachs alpha for the 12 insecurity scale
items was 0.82 and for the 10 proximity-seeking

Relationship Questionnaire (RQ)

(Bartholomew & Horowitz, 1991)
A self-report attachment scale, the RQ, was
chosen for concurrent validation of the VASQ.
This measure is based on four brief relationship
proles describing Secure (A), Fearful (B)
Preoccupied/enmeshed (C) or Dismissive
(D), attachment styles. The subject rates the
degree (on seven points) to which each of these
styles applies to her/him and then chooses
one style as representing her/his overall attachment style.

1104

Table 1.

A. Bifulco and others

Group dierences among ASI attachment styles on the VASQ scales in order of highest
mean scores
ASI

VASQ Total
vulnerable

Fearful

Enmeshed

AngryDismissive

Withdrawn

Clearly secure/
Standard

Mean (S.D.)

60.90 (9.21)

59.30 (9.56)

58.87 (9.94)

55.74 (8.23)

54.47 (8.13)

df(4, 242) 5.31

AngryDismissive

Fearful

Enmeshed

Withdrawn

Clearly secure/
Standard

Mean (S.D.)

34.12 (7.75)

33.84 (8.01)

30.39 (6.84)

29.02 (6.04)

27.23 (5.58)

df(4, 256) 11.21

VASQ Proximity-seeking

Enmeshed

Fearful

Clearly secure/
Standard

Withdrawn

AngryDismissive

Mean (S.D.)

28.91 (5.95)

27.89 (5.95)

27.25 (5.19)

25.96 (4.79)

25.58 (6.01)

df(4, 248) 2.55

VASQ Insecurity

Each attachment category consists of marked, moderate and somewhat fearful.

Number of cases in each ANOVA analysis varies slightly because of missing cases (Fearful N=6063, Dismissive N=3133, Enmeshed
N=33, Avoidant N=5358, Standard N=7074).
Hierarchy of secure style is shown in bold type.

items was 0.67. The testretest reliability was

0.73 (Pearsons r, P<0.001) for the insecurity
scale and 0.65 (P<0.0001) for the proximityseeking scale. Correlation for the total score at
retest was 0.65 (P<0.0001).
VASQ and ASI
Type of attachment style
The VASQ scores were examined in relation to
the ASI attachment styles. The mean VASQ
score on each of the two questionnaire subscales (insecure and proximity-seeking) together
with the total score, was compared with each
ASI style category using ANOVA. Table 1
shows signicant relationships with the VASQ
total score having the highest mean score for
those judged Fearful at interview, followed
by those Enmeshed, with lowest means for
Withdrawn and Clearly Standard/Secure (see
Table 1, row 1). For the VASQ insecurity
subscale the highest means were for Angrydismissive style followed by Fearful, with lowest
for Withdrawn and Clearly Standard/Secure
(see Table 1 row 2). However, a dierent pattern
was shown for the VASQ proximity-seeking
subscale with the highest means in the Enmeshed
group, followed by Fearful and lowest for
Withdrawn and Angry-dismissive. Here Clearly
Secure/Standard occupied a middle position.

Attachment insecurity
The questionnaire subscales were examined in
relation to the ASI degree of insecurity. Signicant association was found for the VASQ insecurity dimension (r=0.36, P<0.0001) and for
the total scale (r=0.27, P<0.001). However,
there was no relationship with the proximityseeking scale (r=x0.12, NS). The sensitivity
and specicity of VASQ insecurity and ASI
degree of insecurity (marked/moderate v.
mild/none) proved to be 70% (82/117) and 67 %
(96/144) respectively.
Vulnerable attachment styles
Median scores on the two VASQ subscales were
used as cut-o points (>30 for the insecurity
scale, >27 for the proximity-seeking scale) for
examining VASQ in relation to the vulnerable
attachment categories of the ASI. These included Fearful, Angry-dismissive or Enmeshed
styles at marked/moderate levels of insecurity.
As can be seen in the Table 2, high scorers on
the VASQ insecurity scale were most discriminated in the Fearful and Angry-dismissive
ASI subtypes. In contrast, high scorers on the
VASQ proximity-seeking scale were most highly
dierentiated in the Enmeshed interview subtype. The total VASQ score (median cut-o
>57) discriminated all the vulnerable ASI styles

1105

The Vulnerable Attachment Style Questionnaire

Table 2.

High and low scorers on the VASQ and ASI attachment styles
ASI
Marked/moderate insecure

VASQ*

Fearful
% (N )

Insecurity
High >30
Low f29

74 (34)
26 (12)

Proximity-seeking
High o27
Low <26

51 (23)
49 (22)

Vulnerable (Total score)

High o57
Low <56

70 (30)
30 (13)

AngryDismissive
% (N )

Secure/mild insecure
Enmeshed
% (N )

Mildly insecure#
% (N )

Clearly secure
% (N )

84 (21)
16 (4)

37 (37)
63 (63)

23 (17)
76 (57)

50 (13)
50 (13)

41 (39)
49 (56)

49 (35)
51 (36)

63 (15)
37 (9)

38 (36)
62 (58)

26 (18)
74 (52)

53 (9)
47 (8)
x2 (df=4)=48.42, P<0.001
76 (13)
24 (4)
x2 (df=4)=7.60, P>0.10$
65 (11)
35 (6)
x2 (df=4)=28.58, P<0.001

* Missing values on any VASQ item involved exclusions : 262 individuals had complete VASQ items for the insecurity scale, 254 for
proximity-seeking scale and 248 on both scales.
# ASI rating of mild insecure includes the non-vulnerable categories of mildly enmeshed, angrydismissive or fearful and any withdrawn
attachment.
$ Enmeshed versus remaining categories : x2=5.76, df=1, P<0.025.
Boldtype indicates the styles most highly related to the VASQ index on the left of the table.

(Fearful, Angry-dismissive and Enmeshed) most

eectively.
In order to explore whether more precise
mapping of the VASQ against the ASI insecure
styles could be obtained (i.e. those highly
insecure and Fearful, Angry-dismissive or
Enmeshed), combinations of those with high and
low VASQ scores on either scale were examined.
For those with high VASQ insecurity and high
proximity-seeking scores, 53 % (9/17) had insecure Enmeshed interview style compared with
23 % (53/233) of other categories combined
(P<0.01). When those with high VASQ insecurity and low proximity-seeking were
identied these accounted for 49% (33/67) of
interview insecure Fearful/Dismissive categories
compared with 28% of remaining categories
(P<0.005). Finally, when those with low VASQ
insecurity and any proximity-seeking score
were examined, these reected 53 % (88/166)
of those rated Secure on the ASI compared
with 17 % (14/82) of remaining categories
(P<0.0001). This indicated a moderate degree
of overlap of the VASQ with specic interviewbased attachment categories, but with highest
overlap for those secure on either measure. This
is because the discriminatory function of the

VASQ insecurity scale alone against the ASI is

particularly high.
VASQ and support
Scores on the two VASQ subscales and total
score were examined in relation to interviewassessed poor support. Signicant correlations
were obtained with interview assessments of
VASQ insecurity scale (r=0.33, P<0.0001)
and VASQ total score (r=0.31, P<0.0001) and
poor partner support. No signicant association
was found with VASQ proximity-seeking scores
and partner support (r=0.15, NS). Poor support from others labelled as very close was
similarly signicantly associated with the insecurity score (r=0.19, P<0.001) and the total
score (r=0.15, P<0.01) but not with the proximity seeking score (r=0.002, NS). An overall
index of poor support from either partner or
close other showed correlations of r=0.26 with
VASQ insecurity score (P<0.001) and 0.21
(P<0.001) with the total score, but r=0.19 with
the proximity-seeking score (NS).
ASQ and RQ
The criterion validity of VASQ was examined in
terms of its association with the self-report

1106

A. Bifulco and others

Table 3.

VASQ scores and depression

Depression

VASQ scale
Insecurity
High (Scale 1>30)
Low (Scale 1f29)
Proximity-seeking
High (Scale 2>27)
Low (Scale 2f26)
Total scale
High (Total >57)
Low (Total f56)

12-month
% (N )

Chronic/recurrent
% (N )

29 (34/118)
13 (18/144)
OR=2.82, P<0.001

41 (48/118)
25 (36/144)
OR=2.05, P<0.007

23 (28/123)
18 (23/131)
OR=1.39, NS

32 (39/123)
33 (43/131)
OR=0.96, NS

31 (34/110)
13 (17/138)
OR=3.17, P<0.001

41 (45/110)
25 (35/138)
OR=2.05, P<0.009

Table 4. Logistic regression : attachment questionnaire assessments and 12-month depression

RQ (Style A v. B/C/D)
VASQ Total

Wald

df

0.43
0.05

1.22
6.57

1
1

NS
0.01

Best predictor of depression is the VASQ total score.

questionnaire measure of attachment, the RQ.

A high level of association was found between
these two measures: the seven-point insecure
RQ score and the VASQ insecurity score
was correlated at r=0.53 (P<0.001) and the
VASQ total score at r=0.43 (P<0.01). The
VASQ proximity-seeking score was signicantly
correlated with the RQ preoccupied subtype
(r=0.33, P<0.01) and negatively with the RQ
dismissive subtype (r=x0.14, P<0.05).
VASQ and depression
The criterion validity of the VASQ was
examined in relation to major depression. High
VASQ insecurity scores and total scores were
associated with higher rates of depression in the
12 months before contact as seen in Table 3.
Odds ratios of 2.82 (P<0.001) and 3.17 (P<
0.001) were obtained for VASQ insecure and
total score respectively. When lifetime chronic
or recurrent depression was examined the
respective odds ratios were both 2.05 (P<
0.007) (see Table 3 nal column). The VASQ

proximity-seeking scale was not signicantly

associated with depression.
In order to examine possible bias from depression concurrent with VASQ completion,
results were re-examined once the 27 subjects
with concurrent depression were excluded. The
association remained, but fell just short of statistical signicance at the 5% level : 50% (30/60)
of high total scorers having recurrent/chronic
lifetime depression compared with 37 % (59/161)
without (P<0.07).
When the VASQ total score and the RQ secure versus insecure styles were both examined
in relation to 12-month depression, logistic regression conrmed that the VASQ score alone
provided the best model (see Table 4).
DISCUSSION
The VASQ, is a brief self-report tool measuring
behaviours, feelings and attitudes toward attachment, which is potentially useful for the
prediction of disorder in community populations, yielding results similar to intensive interview methods. It has been shown to have
good reliability and validity in discriminating
those with insecure and proximity-seeking
styles. The questionnaire identies a total score,
in addition to two separate scales labelled as
insecurity and proximity-seeking . Both total
score and the insecurity score were related to
disorder, to poor support and to the interview assessment of marked insecurity. The

The Vulnerable Attachment Style Questionnaire

proximity-seeking scale shows a high relationship with Enmeshed interview-based styles. The
VASQ was shown to have high concurrent
validity with another self-report measure of attachment, the RQ, with the proximity-seeking
VASQ score positive related to the RQ preoccupied category and negatively to the dismissive category. While the proximity-seeking VASQ
scale did not relate either to poor support or to
depression, there was some evidence that those
with both high insecurity and high proximity
scores more closely modelled the interview-based
insecure Enmeshed style.
There has been much debate on the dimensions into which self-report attachment measures
tap. Most self-report instruments and their
meta-analyses derive two factors usually identied as Anxious and Avoidant attachment dimensions (Brennan et al. 1998). Items indicate
that these reect those individuals with high
needs for company and dependence and anxiety
associated with separation, versus those with
high needs for independence and distance. In
Brennans scheme those labelled as secure thus
entail those with low scores on both dimensions.
However, Stein and colleagues conceptualization of two dimensions similarly derived from
a meta-analysis, identify one dimension as insecurity (from secure to fearful) and the second
orthogonal factor as strategy for coping (Stein
et al. 2002). This second conceptualization is
close to the one proposed in this analysis. In
the VASQ the dimension labelled as insecure
reects items indicating blockages to intimacy
and closeness. However, unlike Steins classication items imply that this not only involves
blockages or intimacy-constraints due to fearfulness (of being hurt or let down) but also due
to hostility (feeling people are against one and
anger that others have not done enough for
one). Both elements, as seen from the interview
counterparts, could be argued to involve ambivalence and defensiveness those fearful often
desire closeness but inhibit dependency needs
through fear, those angry-dismissive mask dependency needs through avowed self-reliance.
The scheme proposed here views types of attachment styles varying in approach/avoidance
behaviour as vulnerable only when levels of
such insecurity are high.
Although this throws some light on elements
that make up insecurity, it nevertheless begs

1107

a number of other questions in terms of its

relationship with psychopathology, for instance
the overlap with chronic symptomatology or
neuroticism. Debate about the nature of support and its relationship to aective disorder
in the 1980s by Henderson & Brown (1988)
revolved around whether the perception of
support was more potent in relating to aective
disorder than evidence of poor support per se.
The former was argued by Henderson to be
the more important factor for psychopathology,
itself seen as the product of low level chronic
symptomatology or neuroticism (Henderson,
1998). Analysis of the ASI has shown vulnerable
attachment styles involving both poor support
across a range of relationships and insecure
attitudes to attachment providing best model
for depressive disorder suggesting input both
from social environment and psychological factors, common to other potent sources of vulnerability (Brown et al. 1990).
It is not possible to surmise from this analysis
the overlap of the VASQ insecurity score and
neuroticism, and controls for concurrent depression were somewhat inconclusive given the
retrospective nature of the depression analysis
and the large overlap between those with current
depression and lifetime recurrent disorder. The
analysis ideally needs repeating prospectively
prior to disorder onset when contamination of
measure and symptoms can be discounted.
Similar analysis of the ASI shows insecurity of
attachment was indeed distinct from chronic
depressive symptomatology (Bifulco et al.
2002a). Given the VASQ insecurity items clearly
relate to independently gauged behavioural assessments of poor support this lends some credence to their reection of actual problematical
social contexts in addition to attitudinal barriers
to support-eliciting. Attachment style aims to
understand representations of self in relation to
others, specically issues around trust of others
(Harris, 2002), and does not purport to cover
all aspects of vulnerable functioning (Bernier
& Dozier, 2002). The complex behaviours and
situations reected in attachment diculties
can clearly encompass both impoverished supportive context and attachment-barriers as well
as other indicators of poor functioning encompassing suppression of negative emotions,
hypervigilance and rumination impeding coping
ability (Shaver & Mikulincer, 2002).

1108

A. Bifulco and others

The proximity-seeking VASQ scale is easier

to conceptualize in terms of a high score denoting approach behaviour displaying need for
company and anxiety about separation and low
scoring denoting greater distance in relating.
Neither pole of the scale seems to indicate
susceptibility to psychopathology, and may well
reect individual, and possibly temperamental,
dierences in inter-personal style. Apart from a
function in rening the insecurity scale in terms
of insecure approach versus avoidant behaviour
indicated in this analysis, its further role in discriminating between attachment styles in terms
of relationship patterns and perceptions of support needs further investigation in more varied
samples.
There are also issues around the preference of
measurement approach for attachment style.
There is debate about whether attachment style
is better assessed with self-report or interview
methods (Crowell et al. 1999). Although persuasive arguments have been made for interview
investigation of situational characteristics including support in order to accurately encompass
context and guard against subjective bias
(Brown, 1991), such considerations could be
argued to apply less to subjective states and
attitudinal material. Recently, Shaver and
Mikulincer have strongly argued for the use of
self-report measures of attachment style, citing
empirical evidence of their association with
separately assessed attachment behaviours and
physiological responses and provoking renewed
debate about assessment (Shaver & Mikulincer,
2002). The VASQ oers an alternative form
of assessment to the ASI against which it is
validated in this report. It relates well to other
self-report measures and performs somewhat
better in relation to prediction of depressive disorder. It is highly associated with aspects of the
ASI interview and, as a dimensional measure, it
can provide a more subtle estimate of the level
of insecurity an individual has in relating to
others. However, it is not ideally suited to evaluating categories of attachment style, neither can
it reect personal context relevant for clinical
judgements and therefore eectively represents
an alternative form of attachment assessment
rather than a mirror of the interview measure.
Perhaps there is a need to use both investigatorbased and self-report measures of a phenomenon
as varied and complex as attachment style to try

to triangulate on an accurate reection of the

phenomenon, capitalizing on both investigatorbased and self-report judgements and on dimensional and categorical approaches (Bifulco,
2002).
Often the choice of research measure is made
on pragmatic grounds depending upon the
purpose and economic resources of the study.
For large-scale surveys or brief screening prior
to more intensive measurement, self-report
scales are clearly crucial. However, for intensive
investigation of contextual assessments of attachment as related to ongoing relationships
and interpersonal stressors, and for clinical assessments, interviews clearly have advantages.
Given the VASQ is a self-report measure
complementing an interview assessment of vulnerable attachment style, the two can be used
appropriately according to the demands of a
particular study. Thus, while the ASI has the
advantage of dierentiating various styles of
attachment and incorporating objective assessment of support context, the VASQ is a much
briefer measure, more economical to use for a
larger scale series which appears to discriminate
high-risk individuals equally well.
Further tests of the VASQs prospective
utility remain. The ASI has been shown to relate prospectively to new onset of depression,
whereas the VASQ has not been put through
this test as yet. This study is also limited by
the relatively modest numbers of subjects particularly in the retest analysis. Furthermore, this
analysis only considered one type of disorder
(major depression), and so did not test the full
range of outcomes that might be predicted by
the VASQ.
As well as introducing a new self-report
assessment and a novel scoring method which
can benet both researchers and clinicians, the
testing of VASQ lends support to an emerging
model of attachment style and disorder. This
model, developed on intensively interviewed
series, traces a line through childhood adversity
to adult problems with support and self-esteem
with attachment style as a linking factor in vulnerability for psychiatric disorder. It is hoped
that further use and testing of the VASQ will
increase understanding of the links between
vulnerable attachment and psychiatric disorder
in a wider range of studies than is possible with
its interview counterpart.

1109

The Vulnerable Attachment Style Questionnaire

APPENDIX 1
VASQ items showing two factor solution and scoring procedure
Factor 1
Insecure
1. I take my time getting to know people.
2. I rely on others to help me make decisions.
3. People let me down a lot.
4. I miss the company of others when I am alone.
5. Its best not to get too emotionally close to other people.
6. I worry a lot if people I live with arrive back later
than expected.
7. I usually rely on advice from others when I ve got
a problem.
8. I feel uncomfortable when people get too close to me.
9. People close to me often get on my nerves.
10. I feel people are against me.
11. I worry about things happening to close family and friends.
12. I often get into arguments.
13. I am clingy with others.
14. I look forward to spending time on my own. (R)
15. I like making decisions on my own. (R)
16. I get anxious when people close to me are away.
17. I feel uneasy when others conde in me.
18. I nd it hard to trust others.
19. Having people around me can be a nuisance.
20. I feel people haven t done enough for me.
21. Its important to have people around me.
22. I nd it dicult to conde in people.
Eigen value

0.39
0.60
0.60

Factor 2
Proximity-seeking
0.47
0.72
0.35
0.55

0.62
0.57
0.62
0.36

0.34
0.66
0.64
0.53
0.62
4.14

0.33
0.48
x0.43
x0.42
0.45

0.61
2.65

Rated : 5, strongly agree; 4, agree; 3, unsure ; 2, disagree ; or 1, strongly disagree.

Factor analysis : Extraction Method ; Principal Component Analysis.
Rotation Method : Varimax with Kaiser Normalization. Rotation converged in three iterations.
R, reversed scoring (items 14 and 15).
Scoring : Scale 1 items insecurity (1, 3, 5, 8, 9, 10, 12, 17, 18, 19, 20, 22) summed; Scale 2 items proximityseeking (2, 4, 6, 7, 11, 13, 14, 15, 16, 21) summed ; Total score=sum of all items.
f A. Bifulco, Royal Holloway, University of London, 1995.
The research was supported by the Medical Research
Council (programme grant G9827201). Professor
Kwon was released on sabbatical from Korea University, South Korea to work in the team and conduct
analyses. We acknowledge the contribution of Professor George Brown and Tirril Harris to the research
programme. We would like to thank Rebecca Baines,
Amanda Bunn, Lucy Reader, Joanne Cavagin, Lisa
Steinberg, Kate Benaim and Katherine Stanford for
data collection. Thanks are also due to Dr Soumitra
Pathare for checking reliability of psychiatric ratings
and to Laurence Letchford for computer analysis.
Finally, we are grateful to the Islington families who
generously and patiently, participated in this research
over the two waves of study.

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