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Attachment style and psychological

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Ana Conde , Brbara Figueiredo & Antonia Bifulco
a
School of Psychology , University of Minho , Portugal
b
Kingston University , London, UK
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 Attachment & Human Development
Vol. 13, No. 3, May 2011, 271291

Attachment style and psychological adjustment in couples

Ana Condea, Barbara Figueiredoa* and Antonia Bifulcob
a
School of Psychology, University of Minho, Portugal; bKingston University,
London, UK
(Received 30 May 2009; nal version received 29 June 2010)
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The present study addresses the gap in research concerning poor marital support
together with insecure attachment style explaining risk for anxiety or depression in
both members of a couple expecting a baby. The Attachment Style Interview (ASI)
was administered separately to both members of a couple (N 126) during the
second trimester of pregnancy together with measures of state-anxiety (STAI-S)
and depression (EPDS). These measures were repeated at three months
postpartum. While insecure attachment style was related to higher anxiety and
depression symptoms in both partners at both time periods, there was an increase
of postnatal depression symptoms in women. Poor partner support contributed to
anxiety symptoms only in men. When insecure attachment combinations in both
members of the couple were examined, insecure styles increased anxiety and
depression symptoms in both genders antenatally, but postnatal anxiety symptoms
only in women. A combined eect of partners support and attachment style on
temporal changes of anxiety symptoms was observed dierently for women and
men. It is important to assess attachment style and partner support of both
members, as well as the mutual interplay between them, to understand gendered
dierences in psychological adjustment of a couple expecting a baby.
Keywords: attachment style; depression; anxiety; couples; childbirth

Introduction
Attachment style is acknowledged as an important factor in the perinatal mental
health of mothers (Matthey, Barnett, Ungerer, & Waters, 2000; Morse, Buist, &
Durkin, 2000). Insecure Anxious attachment styles are associated with both prenatal
(Figueiredo, Bifulco, Pacheco, Costa, & Magarinho, 2006) and postnatal depression
and/or anxiety disorder in women (Kuscu et al., 2008) and with the persistence of
depression symptoms over the postpartum period (McMahon, Barnett, Kowalenko,
& Tennant, 2005). Less is known about the role of insecure attachment in the
development of disorders perinatally in men, although this is now beginning to
attract attention (Teixeira, Figueiredo, Conde, Pacheco, & Costa, 2009). Several
research studies additionally show that attachment style plays a crucial role in
womens marital adaptation when expecting a baby (Findler, Taubman-Ben-Ari, &
Jacob, 2007) including diculties in the couples relationship and lack of marital
support from the partner are key to successful adaptation after the birth of a baby

*Corresponding author. Email: bb@psi.uminho.pt

ISSN 1461-6734 print/ISSN 1469-2988 online

2011 Taylor & Francis
DOI: 10.1080/14616734.2011.562417
http://www.informaworld.com
 272 A. Conde et al.

(Dennis & Ross, 2006). Lack of support is established as a risk factor for both males
and females (Lutz & Hock, 2002). However, the interplay of attachment style and
poor support as risk factors, by gender and perinatal period on depression or anxiety
disorder needs further investigation and clarication. Studying these in both
members of a couple having a baby to identify dierentiation of such risks is the aim
of the study reported here.
The measurement of attachment style perinatally has largely been conducted
either through the use of brief self-report questionnaires (e.g., Relationships
Questionnaire; Bartholomew & Horowitz, 1991, or Adult Attachment Question-
naire; Simpson, Rholes, & Phillips, 1996) or through intensive interview measures
focused on childhood experience (e.g., Adult Attachment Interview; George,
Kaplan, & Main, 1984). While both approaches have added to the understanding
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of the impact of attachment style, neither set of measures provides any ongoing
contextual assessment of the partner relationship, wider supportive relationships
or attitudes around help-seeking, autonomy and trust in relationships. Such infor-
mation would illuminate the role of marital support and support-based attachment
style in the perinatal period for both members of a couple in relation to aective
disorder.
The Attachment Style Interview (ASI) is increasingly used as a standardised
research interview tool to investigate the role of poor partner relationship and lack of
social support along with negative attitudes around Anxious and Avoidant styles in
the onset of major depression (Bifulco, Moran, Ball, & Bernazzani, 2002; Bifulco,
Moran, Ball, & Lillie, 2002). However, to date it has not been used with both
partners in a relationship. The measure has been utilised in perinatal investigation of
depression cross-culturally in mothers across eight European centres and showed
insecure attachment style related to womens depression both antenatally and
prospectively in the postnatal period with dierentiation of type of attachment style
and perinatal period indicated (Bifulco, Figueiredo, Guedeney, Gorman, Hayes,
Muzik, et al., 2004). These ndings were replicated in an antenatal study in Portugal
also using the ASI to investigate teenage pregnancy and depression in 66 pregnant
adolescents and 64 pregnant adult women. Pregnant teenagers were found to be
nearly three times more likely to have an insecure attachment style, markedly or
moderately Enmeshed, Angry-Dismissive, or Fearful style than the older pregnant
women. Logistic regression showed Enmeshed style and poor partner support
provided the best model for depression with age at pregnancy showing no
contribution (Figueiredo et al., 2006). However, no assessment was made of the
male partners attachment style or symptomatology in contributing to the lack of
partner support and depression for the young women.
Additional research is required to understand the risks for psychological
adjustment not only by gender, but in both members of a couple around the birth
of a baby, to focus on individual and joint support and attachment needs (Besser,
Priel, & Wiznitzer, 2002; Feeney, Alexander, Noller, & Hohaus, 2003). While poor
support increases risk, good support can protect from disorder in the face of
upheaval and stress (Milgrom et al., 2008; Spoozak, Gotman, Smith, Belanger, &
Yonkers, 2009). Although lack of support is established as a risk factor for
psychological adjustment in both males and females (Lutz & Hock, 2002), the added
impact of underlying insecure attachment style with accompanying anxious-
ambivalent or avoidant barriers to help-seeking during periods of crisis or change
are under-researched (Escribe`-Aguir, Gonzalez-Galarzo, Barona-Vilar, & Artazcoz,
 Attachment & Human Development 273

2008). Thus understanding the patterning in couples of partner support, and insecure
attachment style is important to understanding the potential for risk of psychological
maladjustment in both members of a couple during times of stress or change, such as
when expecting a baby.
Existing research on the postpartum aective experiences of couples shows non-
gendered eects with more than a quarter of mothers and fathers reporting elevated
depression symptoms, and these results correlated between partners (Soliday,
McCluskey-Fawcett, & OBrien, 1999). Depression was higher in both genders in the
presence of marital dissatisfaction (Escribe`-Aguir et al., 2008) and antenatal mood
and partner relationship are signicant predictor variables for the postnatal mood of
both mothers and fathers (Matthey et al., 2000). However the research focus has
been largely on subjective accounts of marital satisfaction, rather than more
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objective features of supportive behaviour. A detailed review of couple experience

and attachment style by Mikulincer, Florian, Cowan, and Cowan (2002) shows that
secure attachment style is associated with a range of factors such as beliefs about the
partner relationship, including satisfaction, high intimacy and positive interaction
and communication. Studies of attachment style in the transition to parenthood
show that self report assessment of Avoidant style is correlated with ongoing
negativity in marriage during pregnancy (Rholes, Simpson, Campbell, & Grich,
2001), with Anxious-Ambivalent attachment style associating with womens
perception of lack of support from the partner towards the end of the pregnancy
which in turn predicted a reduction in marital satisfaction in both men and women
postpartum (Rholes et al., 2001; Simpson, Rholes, Campbell, Tran, & Wilson, 2003).
Women with Anxious-Ambivalent attachment style, who perceived less support or
greater anger from their husbands, experienced an increase in depressive symptoms
postnatally (Simpson et al., 2003).
Studies of couples using the Adult Attachment Interview (George, Kaplan, &
Main, 1984) show declines in positive marital perceptions across a two-year
postnatal period were found to be greater in insecure husbands and their wives than
secure husbands and their wives (Paley, Cox, Harter, & Margand, 2002). When
husbands had insecure styles there was more negative interaction at 24 months
postpartum, particularly when there was prior indication of negative behaviour.
Poorer family interactions at 24 months were predicted by fathers withdrawal
prenatally and mothers withdrawal postnatally (Paley, Cox, Kanoy, Harter,
Burchinal, & Margand, 2005).
Volling, Notaro, and Larsen (1998) looked at attachment patterns using the AAI,
in association with partner relationships and parenting in 62 married couples with a
one-year-old child. In half the couples, both partners were Secure, with couples
having Secure-Avoidant combinations emerging as the most common discrepant
pattern (30%). In only 7% of couples were both partners Insecure. Where both
partners were Secure the marital relationships and support networks were better. A
Secure wife and Avoidant husband fared better in terms of their relationships, than
when the wife had an Insecure style. This implies that gender may relate to
dierential risk for psychological adjustment in women and men.
The aim of the study reported here is to both replicate and add to previous
ndings of gender eects on anxiety and depression both before and after the birth of
a child. By investigating married couples this will additionally allow for the
investigation of individual and couple eects of attachment style and support to the
two disorders prospectively. The study has the following research objectives:
 274 A. Conde et al.

(1) To examine attachment style individually for women and men and its
association with concurrent anxiety and depression symptoms, both
antenatally and prospectively at three months postpartum.
(2) To examine partner support in pregnancy and its association with anxiety
and depression symptoms individually for women and men, antenatally and
prospectively at three months postpartum.
(3) To test the combined pattern of attachment style of the couple in pregnancy
and its association with anxiety and depression symptoms on both genders
antenatally and prospectively at three months postpartum.
(4) To examine the combined eect of partner support and attachment style on
anxiety and depression symptoms on both genders antenatally and
prospectively at three months postpartum.
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Based on previous ndings, we hypothesise that women and men adjust dierently to
pregnancy at the rst months postpartum, with women exhibiting higher anxiety and
depression symptoms than men. We also hypothesise that both attachment style and
partners support appear as important factors for psychological adjustment during
pregnancy and postpartum on both elements of the couple, with insecure attachment
style, mainly anxious attachment style, and poor partners support being associated
to higher anxiety and depression symptoms.

Method
Sample
The sample consisted of 63 couples (N 126), recruited consecutively at the
antenatal obstetric unit of the Julio Dinis Maternity Hospital, Oporto, Portugal,
before 14 weeks gestation. This sample constitutes a low medical-risk series and no
selection for psychosocial risk was applied. From the 104 couples who originally
agreed to participate in the study, there was a 39.4% fall-o in cooperation at
follow-up mainly due to the ending of medical proceedings at the hospital, which
resulted in lower cooperation after this point.
There were some demographic dierences noted between those participants who
stayed in the study and those who dropped out. Those who stayed in the study were
signicantly more likely to be over age 18 (p .004), employed (p .003), married
(p .000), already had children (p .01) and living with their partner (p .002).
However there were no signicant dierences in terms of educational attainment,
overall attachment style classication, support in marital relationship or antenatal
anxiety or depression symptoms.
The majority of the participants in the nal sample were Portuguese citizens
(87.3%) and Caucasian (98.4%), over 18 years (95.2%; range 1548, female age
M 28.79, SD 5.52, and male age M 30.57, SD 6.07). Most were either
married (73.8%) or cohabiting (19.8%), and living with the partner (92.9%, with
[14.3%] or without [78.6%] the extended family), with the mean relationship length
of 3.86 years (SD 4.0). Only 1.6% were separated or divorced and 4.8% single.
Most were employed (86.5%) in manual occupations (61.5%) and had lower middle-
class status. Half of the participants were rst time parents (women 50.8%;
men 49.2%) and pregnancy was reported as planned for 60%. In all cases, both
elements of the couple were the biological parents.
 Attachment & Human Development 275

Measures
Demographic factors
Age, ethnicity, nationality, employment and occupation, marital status, household
arrangements and educational attainment were obtained through a standardised
interview.

Attachment Style Interview (ASI; Bifulco, Moran, Ball, & Bernazzani, 2002)
This is an investigator-based interview, whereby the interviewer rates information
collected face-to-face according to benchmarked thresholds to determine both
behaviour and attitudes relating to support and attachment style. It is derived from a
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social psychological approach to attachment style, which assesses the respondents

ability to form and maintain supportive relationships by questioning about family of
origin, partner and very close other relationships, together with attitudes about
closeness/distance from others, autonomy and fear/anger in relationships. Inter-rater
reliability of the measure is high (Bifulco, Moran, Ball, & Bernazzani, 2002; Bifulco
et al., 2004). A Portuguese translation of the interview and rating (Bifulco et al.,
2004) showed good inter-rater reliability (ranging from 0.81 to 1.00 Kw) and
relatively high stability rates with correlations between antenatal and postnatal ASI
ratings ranging from 0.67 to 0.90. The current use of the instrument was overseen by
its original designer (AB) with discussion of dicult ratings to ensure reliability.
A list of ASI scales is provided in the Appendix. The interview takes about 60
minutes to administer and is scored from recordings after the interview. The rst
section questions about support networks (family and friends) and the quality of
relationship within three close relationships (partner and two others named as very
close). For each relationship, ratings are made on ongoing level of conding, active
emotional support, quality of interaction, and felt attachment. An overall summary
rating of support is provided for each of the three relationships. Thus ratings of 1:
very good 3: good average support reects relationships with a high level of
conding evidenced by actual examples of stressful topics discussed and positive
active emotional response received. Ratings of 4: inadequate support 7: poor
support were rated when conding and support were low or absent on the basis of
carefully probed questions. On the basis of both the number and quality of supportive
relationships a rating of poor ability to make and maintain relationships forms the
basis for rating the degree of insecurity of attachment style. While the information on
partner support contributes to this overall assessment, it can also stand alone as a risk
factor. Poor partner support is neither a necessary or sucient condition of poor
ability to form and maintain relationships, although those with lowest ability to form
and maintain relationships will also typically have poor quality of partner support.
The ASI additionally utilises seven attitudinal scales denoting Avoidance
characteristics (e.g., mistrust, constraints on closeness, high self-reliance, or anger)
and Anxious attachment characteristics (e.g., high desire for engagement, fear of
separation, or fear of rejection). On the basis of these, and in accordance with clear
manualised rating rules, a classication is made of the type of style. This includes two
types of Anxious attachment style (Enmeshed or Fearful) and two Avoidant styles
(Angry-dismissive or Withdrawn), in addition to Secure. While these mostly parallel
those found in other social psychological classications such as the Relationship
 276 A. Conde et al.

Questionnaire (Bartholomew & Horowitz, 1991), the additional category of Angry-

Dismissive in the ASI is comparable to the Mistrustful style identied in the clinical
version of the Relationship Questionnaire (Holmes & Lyons-Ruth, 2006). In
addition to rating the type of style, the degree of insecurity or impairment in relating
style was assessed as marked, moderate, some or little/none. Previous
analyses have shown a dose-eect of level of insecurity to depression, with only
marked and moderate levels of insecure style conferring risk for depression
concurrently or prospectively (Bifulco, Moran, Ball, & Lillie, 2002; Bifulco et al.,
2004). For the present study the Portuguese team was trained in the ASI by the
interviews author with regular communication on rating maintained. A two-day
training course was provided at the beginning of the study. All trainees were
provided with a manual of precedent rating examples to aid reliability. Each team
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was required to send back to the interviews author ratings for their rst ve
interviews, which were checked, and any dierence in rating reported back. Teams
were encouraged to e-mail questions about dicult ratings, to ensure consistency. In
addition, face-to-face meetings were held with team leaders, when requested, to
discuss ratings. All ratings were made according to manualised benchmarked
examples with consensus ratings used to enhance reliability (Figueiredo et al., 2006).
Satisfactory inter-rater reliability was found with high levels of agreement between
observers ranging from 0.81 to 1.00.

State-Trait Anxiety Inventory (STAI; Spielberger, 1983)

The STAI is a self-report questionnaire that consists of two subscales, the state
anxiety subscale and the trait anxiety subscale, each containing 20 items. Only the
state anxiety subscale (STAI-S), which measures anxiety at the point of scoring, was
used in the analyses. The scores in this subscale range from 20 to 80, higher scores
indicating higher state anxiety. This is conceptualised as a transient emotional
condition of the individual, characterised by subjectively experienced feelings of
tension, together with a heightened activity of the autonomous nervous system. The
STAI has been used in several studies implemented during pregnancy and the
postpartum period, both with women and men (e.g., Teixeira et al., 2009). The
Portuguese version of the measure showed good internal consistency (State
Cronbachs alpha in women 0.88 and in men 0.93, respectively) and construct
validity demonstrated by substantial dierences in scores obtained under stressful
and neutral conditions. The recommended cut-o of 45 for high-anxiety is utilised
(Biaggio, Natalicio, & Spielberger, 1976).

Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987)
The EPDS is a self-report questionnaire composed of 10 items in a Likert scale of
four points (03) to assess depression symptoms. The EPDS Portuguese version
shows good internal consistency (Cronbachs alpha 0.85) and test-retest
reliability (Spearman Correlation 0.75) (Figueiredo, Pacheco, & Costa, 2007).
The recommended cut-o score of 10 or more was used to dene probable clinical
levels both in women and men (Areias, Kumar, Barros, & Figueiredo, 1996). This
questionnaire has been used extensively in perinatal studies of women, as well as
with men, both internationally and in Portuguese samples (e.g., Teixeira et al.,
2009).
 Attachment & Human Development 277

Procedures
Medical records were consulted to identify all pregnant women up to 14 weeks
gestation, excluding those with multiple gestations or with medical and/or obstetric
complications. Participants informed consent was obtained and ethical permission
was granted from the hospitals ethics board. Cooperation for the study was required
both from the pregnant women initially contacted (N 123) and their husbands/
partners. From the initially contacted couples, 15.4% refused to participate in the
study. Assessments were undertaken individually with each member of the couple
during the second trimester of pregnancy and again at three months postpartum.
This involved demographic assessment and use of the ASI, as well as the STAI-S
sub-scale of the State-Trait Anxiety Inventory and the EPDS at rst contact. At
follow-up, the questionnaires to assess anxiety and depression symptoms were
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repeated.

Statistical analysis
SPSS 16.0 was used for the statistical analysis. Due to reduced sample size, ASI
categories were combined for all statistical analyses consistent with previous
investigations: Anxious styles (marked or moderate levels of Enmeshed or
Fearful styles); Avoidant styles (marked or moderate levels of Angry-
dismissive or Withdrawn styles); Secure styles (included any mildly insecure
or clearly secure attachment style). The presence of either Anxious or Avoidant
attachment style was also categorised as Insecure Style and compared with Secure
for some analyses (see Appendix for summary of scales). Statistical analysis utilised
chi squares (at 5% signicance levels), repeated measures ANOVA, and McNemar
two related sample tests. Their application is described in more detail in the results
section.

Results
Rates of anxiety and depression by gender
In order to determine whether women and men had similar or dierent rates of
anxiety and depression symptoms during pregnancy and postpartum, frequencies of
EPDS total scores higher or equal than 10 and STAI-S total scores higher or equal
than 45 were calculated. In the overall sample, 12.7% of the participants had
depression at probable clinical levels antenatally reducing to 10.3% at postpartum
(McNemar p .63, N 126). While there were no signicant gender dierences,
depression was somewhat higher in women than in men both during the pregnancy
(14.3% of women and 11.1% of men, ns) and at three months postpartum (14.3% of
women and 6.3% of men, ns). Fifteen per cent of the sample had high anxiety levels
in the pregnancy with similar rates at postpartum (13.5%). Again, there was a non-
signicant trend for higher anxiety in women when compared to men during
pregnancy (19.0% of women and 11.1% of men) and postpartum (19.0% of women
and 7.9% of men). Rates of disorder in both members of the couple were rare (high
depression scores in both elements were 3.2% in pregnancy and 1.6% at postpartum,
and high anxiety scores in both elements were 4.8% in pregnancy and 3.2% at
postpartum).
A signicant main eect of gender on anxiety and depression symptoms was
found, with elevated levels in women. Antenatally this eect was signicant for
 278 A. Conde et al.

depression symptoms, F(1, 122) 5.87, p .02, but not for anxiety symptoms, F(1,
122) 3.72, p .06, while postnatally this eect was observed for both anxiety, F(1,
120) 5.45, p .02, and depression symptoms, F(1, 120) 13.66, p .000. This
latter nding held even after controlling for antenatal psychological symptoms.

Insecure attachment style and anxiety and depression symptoms

To examine attachment style individually antenatally and postnatally, for women and
men, frequencies of individuals presented at each category of attachment style were
calculated with gender dierences taken into account. Just over half of individuals in
the sample had Secure attachment style (58.7%), with a non-signicant trend, for
women to be more secure (65%) than men (52.3%). Anxious attachment style was
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somewhat more prevalent (23.8%; n 30) than Avoidant attachment style (17.4%;
n 22) in the series overall. Gender dierences were found in rates of Anxious versus
Avoidant insecure attachment styles, x2(1, N 63) 9.09, p .004. In women
28.5% had an Anxious attachment style and only 6.3% had an Avoidant attachment
style. In men 19% had an Anxious attachment style and 28.5% had an Avoidant
attachment style. Thus, men were twice as likely to have an insecure Avoidant style,
while women were three times more likely to have an insecure Anxious attachment
style. Avoidant attachment style was particularly rare in the women (n 4).
To examine attachment style (Secure versus Insecure) individually antenatally,
for women and men, and its association with concurrent anxiety and depression
symptoms, and the same prospectively at three months postpartum, repeated-
measures ANOVA with between-subjects factors (mixed design ANOVA) was
applied. In this general linear model, points of assessment were included as the
within-subjects factor with two levels (antenatal and postnatal), STAI-S and EPDS
total scores as measures, and individuals attachment style (Insecure versus Secure)
and gender (women versus men) as the between-subjects factors. These statistical
analyses were followed by independent MANOVAs to test the proposed aim at each
of the considered time points. STAI-S and EPDS total scores were dened as the
dependent variables of the model and individuals attachment style and gender as the
xed factors. In the analyses at three months postpartum, STAI-S and EPDS total
scores obtained at the second trimester of pregnancy were included as covariates in
order to control for the possible eects of antenatal anxiety and depression
symptoms when looking at postpartum anxiety and depression symptoms in relation
to an individuals attachment style and gender.
A signicant main eect was found for attachment style on anxiety, F(1,
122) 14.20, p .000, and depression symptoms, F(1, 122) 17.99, p .000, with
individuals with insecure attachment style showing higher symptom levels
(see Table 1). The MANOVAs showed these eects to be signicant, both
antenatally and postnatally. This association held postnatally even after controlling
for antenatal anxiety and depression symptoms.
No signicant interaction eect of attachment style and gender was found, either
for anxiety, F(1, 122) .25, p .62, or for depression symptoms, F(1, 122) 1.34,
p .25, during pregnancy or at postpartum. Thus the main eect of attachment style
on psychological symptoms was the same for men and women during the whole
period.
A main eect of Time on psychological symptoms was found for depression
symptoms, F(1, 122) 6.18, p .01. This did not hold for anxiety symptoms,
 Attachment & Human Development 279

F(1, 122) .02, p .90. Only women with an insecure attachment style showed an
increase in depression symptoms in the postpartum. For the remaining sample
(secure women and all men) a decrease in depression symptoms was observed from
pregnancy to the postpartum (signicant interaction Time x Gender in univariate
tests; F(1, 122) 4.99, p .03) (see Table 1). No signicant eects of the
interactions between Time x Attachment style, and Time x Attachment style x
Gender on psychological symptoms were found.

Anxious versus Avoidant attachment style and anxiety and depression symptoms
Continuing to assess the eect of attachment style individually and antenatally, for
women and men, on concurrent anxiety and depression symptoms, and prospectively
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at three months postpartum, but now comparing Anxious versus avoidant insecure
attachment style repeated-measures ANOVA with between-subjects factors (mixed
design ANOVA) were again implemented, as previously described for the eects of
Secure versus Insecure individuals attachment style. These statistical analyses were
followed by independent MANOVAs to test the proposed aim at each of the time
points. While multivariate tests found no signicant main eect of individuals
attachment style on psychological symptoms over the two time points, univariate
tests revealed a signicant eect of insecure Anxious attachment style on anxiety
symptoms, F(1, 48) 5.18, p .03 (see Table 2). Results of the MANOVAs showed
that antenatally, Anxious attachment style was signicantly related to both anxiety
and depression symptoms. These eects were not found postnatally.
No signicant interaction eect between the type of attachment style and gender
was found on psychological symptoms, either antenatally, F(2, 47) .89, p .42, or
in the postpartum (even after controlling for antenatal psychological symptoms),
F(2, 45) .14, p .87. This indicated that the main eect of individuals attachment
style on psychological symptoms was similar for women and men, both in pregnancy
and postpartum. No signicant eect of the interactions Time x Attachment style,
and Time x Attachment style x Gender was found.

Partner support and anxiety and depression symptoms

Poor support in the marital relationship was also assessed determining its frequency,
both in women and men. A similar rate for pregnant women (23.8%) and their
partners (25.4%) was found. Most couples had good support rated by both partners
(60.3%, 38 pairs), with just under a third of couples (30.2%, 19) having dierent
support ratings among partners. Poor support in both members of the couple was
found in only 9.5% (six pairs).
To examine partner support in pregnancy and its association with anxiety and
depression symptoms individually for women and men, antenatally and prospec-
tively at three months postpartum independent MANOVAs were performed for
women and men, to analyse dierences in anxiety and depression symptoms at the
second trimester of pregnancy and three months postpartum. At both time points,
STAI-S and EPDS total scores, of women and men, were dened as the dependent
variables of the model and support in the marital relationship (poor support versus
good support) as the xed factor. In the analyses at postpartum, STAI-S and EPDS
total scores obtained in pregnancy were included in the analysis as covariates in
order to control the possible eects of earlier symptoms on later symptoms.
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280

Table 1. Insecure* versus Secure attachment style and anxiety and depression symptoms antenatally and postnatally, by gender.

Women (N 63) Men (N 63) Total (N 126)

Insecure Secure Insecure Secure Insecure Secure
Individual (n 22) (n 41) (n 30) (n 33) (n 52) (n 74)
attachment
style (ASI) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
STAIS Pregnancy 37.41 (8.90) 33.24 (9.38) 34.20 (10.06) 29.91 (8.68) 35.56 (9.63) 31.76 (9.17)
Postpartum 40.73 (11.27) 3.22 (8.26) 33.80 (9.97) 28.39 (7.38) 36.73 (10.99) 30.51 (8.06)
EPDS Pregnancy 7.91 (3.75) 5.17 (3.32) 5.77 (3.86) 4.09 (3.74) 6.67 (3.93) 4.69 (3.53)
Postpartum 8.27 (5.07) 4.63 (3.22) 4.30 (4.79) 2.33 (2.27) 5.98 (5.25) 3.61 (3.05)

*Marked or moderate level of insecure style versus mildly insecure or clearly secure style.
MANOVA MAIN EFFECTS
Attachment style: Gender:
A. Conde et al.

Wilks Lambda .86, F(2,121) 9.51, p .000
Pregnancy
Wilks Lambda .92, F(2,121) 5.49, p .005
Postpartum
Wilks Lambda .93, F(2,119) 4.65, p .011
Wilks Lambda .88, F(2,121) 8.02, p .001
Pregnancy
Anxiety symptoms F(1,122) 3.72, p .06
Depression symptoms F(1,122) 5.87, p .02
Postpartum
Anxiety symptoms F(1,120) 5.45, p .02
Depression symptoms F(1,120) 13.66, p .000
Time:
Wilks Lambda .92, F(2,121) 5.52, p .005

Interaction eects all non signicant

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Table 2. Insecure Anxious* versus Avoidant attachment style and anxiety and depression symptoms antenatally and postnatally, by gender.

Women (N 22) Men (N 30) Total (N 52)

Individual Anxious (n 18) Avoidant (n 4) Anxious (n 12) Avoidant (n 18) Anxious (n 30) Avoidant (n 22)
Attachment
Style (ASI) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
STAIS Pregnancy 39.50 (8.24) 28.00 (5.10) 37.00 (10.92) 32.33 (9.28) 38.50 (9.31) 31.54 (8.74)
Postpartum 42.44 (11.56) 33.00 (5.94) 34.33 (7.13) 33.44 (11.68) 39.20 (10.67) 33.36 (10.75)
EPDS Pregnancy 8.67 (3.66) 4.50 (1.91) 6.33 (3.20) 5.39 (4.30) 7.73 (3.62) 5.23 (3.95)
Postpartum 8.83 (5.30) 5.75 (3.20) 3.83 (2.82) 4.61 (5.80) 6.83 (5.07) 4.82 (5.38)

*Anxious styles either Enmeshed or Fearful style at marked or moderate insecurity levels. Avoidant styles either Angry-dismissive or Withdrawn style at marked
or moderate insecurity levels.
MANOVA MAIN EFFECTS
Attachment style: Gender:
Wilks Lambda .90, F(2,47) 2.61, p .08 Wilks Lambda .94, F(2,47) 1.46, p .24
Pregnancy Pregnancy
Anxiety symptoms F(1,48) 7.04, p .01 Wilks Lambda .98, F(2,47) .56, p .57
Attachment & Human Development

Depression symptoms F(1,48) 4.24, p .04 Postpartum

Postpartum Wilks Lambda .94, F(2,45) 1.53, p .23
Anxiety symptoms F(1,46) .05, p .83 Time:
Depression symptoms F(1,46) .22, p .64 Wilks Lambda .91, F(2,47) 2.35, p .11

Interaction eects all non signicant

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 282 A. Conde et al.

In the overall sample, poor partner support was unrelated to anxiety or

depression symptoms, either in pregnancy or postnatally. Similarly there was no
signicant eect of poor partner support on womens symptoms antenatally or
postnatally. However, a signicant eect of poor partner support was found both
antenatally and postnatally for mens anxiety symptoms. This held at the
postpartum period after controlling for antenatal symptoms (see Table 3).

Couples joint attachment style and anxiety and depression symptoms

To test the combined pattern of attachment style of the couple during pregnancy, the
frequency of the following categories of attachment style organisation in the couple
(Secure-Secure, Secure-Insecure and Insecure-Insecure) were calculated. A
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marginally signicant dierence was found in attachment styles at rst contact

related to gender, x2 (1, N 63) 3.48, p (2-sided) .07, p (1-sided) .06.
Women with an insecure attachment style were 1.9 times more likely to have a
husband with an insecure attachment style, while men with an insecure attachment
style had a 1.6 times greater likelihood of having a wife with an insecure rather than
with a Secure attachment style (39.7% of the couple dyads were Secure-Secure,
38.1% Secure-Insecure and 22.2% Insecure-Insecure).
To test the combined pattern of attachment style of the couple during pregnancy
and its association with anxiety and depression symptoms on both genders
antenatally and prospectively at three months postpartum, repeated-measures
ANOVA with between-subjects factors was implemented similarly for women and
men. Thus, independent repeated-measures ANOVA with between-subjects factors
was used to analyse the prevalence and course of both women and mens anxiety and
depression symptoms from the antenatal to the postnatal period, focusing on the
joint attachment style of the couple (utilising the couple dyads of Secure-Secure,
Secure-Insecure and Insecure-Insecure). In each general linear model, points of
assessment were included as the within-subjects factor with two levels (antenatal and
postnatal), women and mens STAI-S and EPDS total scores, respectively at each
analysis, as measures, and joint attachment style in the couple, as the between-
subjects factor. Post hoc analyses were undertaken using Schees test to examine
signicant dierences in sub-groups of particular categories of joint attachment style
in the couple. The repeated-measures ANOVA with between-subjects factors was
followed by independent MANOVAs to test the proposed aim at both time points.
STAI-S and EPDS total scores were dened as the dependent variables of the model
and joint attachment style in the couple as the xed factor. In the postnatal analyses
STAI-S and EPDS total scores obtained antenatally were included as covariates as
controls for the possible eects of earlier symptoms on later symptoms.

Impact on womens symptoms

A signicant main eect of couple attachment style was found for womens anxiety
and depression symptoms. Post-hoc analyses using Schees test found signicant
dierences in womens anxiety symptoms between the Insecure-Insecure and
Secure-Secure (p .001) or Secure-Insecure (p .03) groups. Signicant
dierences were also found in womens depression symptoms between the
Insecure-Insecure and the Secure-Secure (p .004) or the Secure-Insecure
(p .04) groups. Overall higher anxiety and depression symptoms were found in
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Table 3. Partner support* and anxiety and depression symptoms, antenatally and postnatally, by gender.
Women (N 63) Men (N 63) Total (N 126)
Poor Good Poor Good Poor Good
support support support support support support
Support (n 15) (n 48) (n 16) (n 47) (n 31) (n 95)
from
partner (ASI) Mean (SD) Mean (SD) Statistics Mean (SD) Mean (SD) Statistics Mean (SD) Mean (SD) Statistics

STAIS Pregnancy 35.73 (7.65) 34.38 (9.89) F(1,61) .24 36.56 (10.29) 30.38 (8.83) F(1,61) 5.37 36.16 (8.97) 32.40 (9.54) F(1,124) 3.74
p .63 p .02 p .60
Postpartum 35.07 (9.40) 35.23 (10.52) F(1,59) .22 36.94 (7.68) 28.94 (8.64) F(1,59) 5.39 36.16 (8.97) 32.40 (9.54) F(1,122) .99
p .64 p .02 p .32
EPDS Pregnancy 6.47 (2.97) 6.02 (3.90) F(1,61) .16 6.19 (4.28) 4.45 (3.66) F(1,61) 2.48 6.32 (3.64) 5.24 (3.85) F(1,124) 1.89
p .69 p .12 p .17
Postpartum 5.47 (3.36) 6.04 (4.58) F(1,59) .65 5.00 (3.74) 2.68 (3.66) F(1,59) 2.93 5.22 (3.51) 4.38 (4.46) F(1,122) .09
p .42 p .09 p .76
Attachment & Human Development

High support 1: very good 3 good average support.

Poor support 4: inadequate support 7 poor support.
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women with Insecure-Insecure combination of attachment style in the couple, than

in women with Secure-Secure or Insecure-Secure couple attachment style
categories (see Table 4). Results of independent MANOVAs implemented for the
antenatal and postnatal period revealed the eect of the joint attachment style in the
couple antenatally was signicant for depression symptoms, F(2, 60) 4.34, p .02,
between the Insecure-Insecure and the Secure-Secure group (p .02). This fell
short of signicance for anxiety symptoms, F(2, 60) 2.92, p .06. In contrast, in the
postnatal period this eect was signicant for anxiety symptoms, F(2, 58) 4.90,
p .01, between the Insecure-Insecure and the Secure-Secure (p .000) or the
Secure-Insecure (p .005) groups. This did not hold for depression symptoms, F(2,
58) 1.56, p .22. There was no signicant eect of the interaction between Couple
attachment style x Time, neither for women anxiety nor for depression symptoms.
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Impact on mens symptoms

As previously referred, repeated-measures ANOVA with between-subjects factors
was also used to analyse the prevalence and course of mens anxiety and depression
symptoms from the antenatal or postnatal period focusing on the joint attachment
style in the couple (considering the couple dyads of Secure-Secure, Secure-
Insecure and Insecure-Insecure). A signicant main eect of the combined
attachment style pattern in the couple was found for mens depression symptoms,
but not anxiety symptoms. Post-hoc analyses using Shees test to examine main
eects showed higher depression symptoms in men from Insecure-Insecure
couples than in men with Secure-Secure couple attachment style categories
(p .01) (see Table 4). Results of MANOVAs showed that this eect was signicant
antenatally, F(4, 118) 2.98, p .02, but not postnatally, F(4, 114) 1.15,
p .34. No signicant interaction eect of Couple attachment style x Time was
obtained, for mens anxiety or depression symptoms. Thus, the course of
psychological symptoms from pregnancy to postpartum was similar in sub-groups
of particular categories of joint attachment style in the couple.

Combined eect of partner support and attachment style on anxiety and depression
symptoms
Repeated-measures ANOVA with between-subjects factors was used to analyse the
combined eect of partner support and attachment style on anxiety and depression
symptoms on both genders antenatally and prospectively at three months
postpartum. In order to explore this eect, the interaction eect of Partner support
x Attachment style x Gender was focused, considering these variables as the
between-subjects factors of the repeated-measures ANOVA model.
When we considered individuals attachment style (Secure versus Insecure) and
partner support (poor support versus good support), no signicant eects of the
interaction Time x Partner support x Attachment style, F(2, 117) 1.82, p .17,
Time x Partner support x Attachment style x Gender, F(2, 117) .02, p .98,
Partner support x Attachment style, F(2, 117) .22, p .80, and Partner support x
Attachment style x Gender, F(2, 117) .66, p .52, were found neither for anxiety
nor for depression symptoms.
When we took into account the individuals attachment style (Anxious versus
Avoidant) and partner support (poor support versus good support) no signicant
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Table 4. Combined attachment style in the couple (Insecure and/or Secure) and anxiety and depression symptoms, antenatally and postnatally by
gender.

Secure-Securea Secure-Insecureb Insecure-Insecurec

(n 25) (n 24) (n 14)
Couple attachment
style (ASI) Mean (SD) Mean (SD) Mean (SD) p
Women (1) STAIS Pregnancy 31.76 (9.74) 35.25 (7.29) 39.00 (10.58) a*c .001
Postpartum 31.48 (8.65) 33.83 (7.34) 44.14 (12.06) b*c .034
EPDS Pregnancy 5.00 (3.56) 5.96 (2.87) 8.43 (4.33) a*c .004
Postpartum 4.64 (3.00) 5.54 (3.44) 8.78 (6.19) b*c .042
Men (2) STAIS Pregnancy 29.16 (7.71) 34.75 (9.96) 32.14 (10.88) n.s.
Postpartum 27.40 (7.62) 32.46 (7.17) 34.78 (12.20)
EPDS Pregnancy 3.68 (3.31) 5.17 (3.53) 6.57 (4.78) a*c .012
Postpartum 1.96 (2.30) 3.38 (2.53) 5.43 (6.25)

MANOVA MAIN EFFECTS (1)

Attachment style:
Wilks Lambda .79, F(4,118) 3.70; p .01 Anxiety Symptoms F(2,60) 7.00, p .002 Depression Symptoms F(2,60) 6.10, p .004
Time:
Wilks Lambda .97, F(2,59) 1.00, p .37 Anxiety Symptoms F(1,60) 1.06, p .31 Depression Symptoms F(1,60) .08, p .78
Attachment & Human Development

Attachment style x Time:

Wilks Lambda .91, F(4,118) 1.45, p .22 Anxiety Symptoms F(2,60) 2.76, p .07 Depression Symptoms F(2,60) .21, p .81

MANOVA MAIN EFFECTS (2)

Attachment style:
Wilks Lambda .80, F(4,118) 3.40, p .011 Anxiety Symptoms F(2,60) 3.27, p .05 Depression Symptoms F(2,60) 4.59, p .01
Time:
Wilks Lambda .76, F(2,59) 9.43, p .000 Anxiety Symptoms F(1,60) .19, p .67 Depression Symptoms F(1,60) 9.98, p .002
Attachment style x Time:
Wilks Lambda .92, F(4,118) 1.28, p .28 Anxiety Symptoms F(2,60) 1.74, p .18 Depression Symptoms F(2,60) .15, p .86
285
 286 A. Conde et al.

eects of the interaction Time x Partner support x Attachment style, F (2, 43) .18,
p .84, Partner support x Attachment style, F(2, 43) .80, p .46, and Partner
support x Attachment style x Gender, F(2, 43) .56, p .57, neither for anxiety nor
for depression symptoms, were found. However, while no signicant eects of the
interaction Time x Partner support x Attachment style x Gender were found for
depression symptoms, F(1, 44) .63, p .43, signicant eects of this interaction
were observed for anxiety symptoms, with women and men exhibiting dierent
temporal changes between pregnancy and postpartum. While women with good
partners support and either with an anxious or an avoidant attachment style,
showed an increase in anxiety symptoms from pregnancy to postpartum, men
categorised equally at partners support or attachment style showed a decrease.
Additionally, when women and men had poor support, while the avoidant women
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showed a decrease in anxiety symptoms, avoidant men showed an increment, the

opposite being observed in anxious women and men, respectively.

Discussion
The study examined attachment style and partner support in couples expecting a
baby in relation to anxiety and depression symptoms both antenatally and
postnatally. These were examined by gender and by joint attachment style in the
couple. Anxiety was somewhat more common that depression in the sample with
higher rates of both in pregnancy compared to the postpartum period. While this
held for both genders, mothers had more symptoms overall, consistent with previous
studies (Teixeira et al., 2009).
Secure attachment style (common to over half the sample) was found to have
similar rates in women and men, but with a gender dierence in the type of insecure
attachment style. Insecure attachment style related to anxiety and depression
symptoms in both women and men, both at pregnancy and in the postpartum. This
is consistent with other studies that show attachment insecurity plays a crucial role in
a parents psychological adjustment during the transition to parenthood (Findler
et al., 2007), both prenatally (e.g., Bifulco et al., 2004; Figueiredo et al., 2006) and
postnatally for anxiety and/or depression (e.g., Kuscu et al., 2008). However, while
most previous studies focus mainly on women, the present ndings show a clear non-
gender result, with Insecure attachment style being associated both in women and
men to anxiety and depression symptoms during pregnancy and in the rst
postpartum months. The eect of attachment style in this study showed gender
eects. Women were three times more likely to have Anxious attachment styles
(Enmeshed or Fearful) and men twice as likely to have Avoidant styles (Angry-
dismissive or Withdrawn). Avoidant styles were very rare in women in this study,
which is consistent with other study ndings (Bartholomew & Horowitz, 1991;
Brennan, Clark, & Shaver, 1998; Mikulincer & Florian, 1995). Anxious styles were
related to both depression and anxiety, in both genders antenatally, but not
postnatally. Therefore having an Avoidant style may indicate some protection
against symptomatology.
There was also a gender eect in the pattern of change of depression symptoms
from pregnancy to postpartum. Women with an insecure attachment style showed an
increase in depression symptoms from pregnancy to postpartum, while all those with
secure attachment style showed a decrease in depression symptoms postnatally.
Thus, attachment style may be responsible for a cross-over eect; with secure
 Attachment & Human Development 287

attachment style functioning as a protective factor for postnatal symptoms as found

in some community samples (e.g., Heron, OConnor, Evans, Golding, Glover, & the
ALSPAC Study Team, 2004), but insecure attachment style accounting for higher
incidence and persistence of depression symptoms over the postpartum period in
others (McMahon et al., 2005). Poor partner support was a less predictive factor for
disorder in this study than attachment style, and was only associated with higher
anxiety symptoms in men at both time points. This is unlike other studies where poor
partner relationship, particularly around dissatisfaction and negative interaction, has
been a predictive factor for depression in women (Matthey et al., 2000). This
dierence in nding may be due to the fact that a more objective assessment of
partner support was used in this study, less likely to be contaminated by mood, but
given partner support overall was the same rate in women and men, may indicate
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some shifting of womens support needs to non-partner relationships during

pregnancy to buer the impact of poorer partner relating. Other research indicates
men as less likely to have as wide a range of close other relationships as women, so
poor partner support may be associated with more depleted support overall for men
in the perinatal period (Wallace & Vaux, 1993). This aspect needs further exploring
in future research, so that male-specic vulnerabilities in the postnatal period may be
better understood and addressed in clinical work with couples.
When attachment style in both members of the couple was analysed, in half of
the couples both members of the pair had the same attachment style security. While
most were both Secure, a small percentage of couples showed an insecure style in
both partners, similar to those found in a US sample (Volling et al., 1998). The
inuence of insecure attachment in couples over the perinatal period showed some
gender dierences. When both spouses had an Insecure attachment style, both
women and men were more likely to be depressed antenatally but only women had
higher anxiety symptoms, particularly in the postpartum period. This indicates a
dierent patterning of risk for disorder with somewhat higher psychological risk for
the women overall, being more prone to both types of symptoms. This supports
previous evidence of an association between adult attachment and psychological
maladjustment (Marazziti et al., 2007), but also shows the potentially cumulative
eect of joint insecurity on emotional adjustment, of both women and men, to the
challenging life stage of having a baby.
While there are a number of strengths in this study including the intensive
interviewing of both women and men, to ascertain the quality of partner
relationship, support and attachment style individually and in the couple, as well
as the use of a prospective design to investigate symptoms during the pregnancy,
there are also a number of study limitations. First, the relatively small number of
couples means the results need to be treated with caution, with a lack of statistical
power in some analyses. This was in part due to attrition at follow-up which also
makes the representativeness of the sample less clear. The reduced numbers means
there were relatively low rates of certain insecure attachment styles, particularly
avoidant attachment style in women, and this potentially limited the range of
analyses that could be undertaken and the generalisability of the ndings. Thus,
repeating the study with larger numbers and in a higher risk sample would serve to
further test these ndings. Second, the use of self-report measures for symptoms was
limiting in terms of the clinical interpretation of ndings. There is also the possibility
of symptom-based bias in reporting of symptoms in pregnancy which may confound
descriptions of attachment styles at the rst measurement point. However, using a
 288 A. Conde et al.

contextualised interview tool which requires evidence of behaviour and detailed

description of attachment attitudes partly circumvents this. Third, no comparative
measures of support or attachment style were used for equivalence to other studies.
Although the hypothesis initially proposed were mainly conrmed, the central
message of present ndings alert to the dierential impact of attachment style and
partner support on womens and mens psychological adjustment during pregnancy
and rst months postpartum, as well as the independent eect of attachment style
and partner support, as already noted by the theoretical framework. Thus, while
insecure attachment style was related to higher anxiety and depression symptoms in
both partners at both time points, there was an increase of postnatal depression
symptoms in women. Poor partner support contributed to anxiety symptoms only in
men. When insecure attachment combinations in both members of the couple were
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examined, insecure styles increased anxiety and depression symptoms in both

genders antenatally, but postnatal anxiety symptoms only in women. A combined
eect of partners support and attachment style on temporal changes of anxiety
symptoms was observed dierently for women and men. These main results suggest
the importance of assessing attachment style and partner support of both members,
as well as the mutual interplay between them, to understand gendered dierences in
psychological adjustment of a couple expecting a baby.
In general, this study provides evidence of adult attachment style shaping
individual and couple psychological adjustment during the pregnancy and birth of a
child, in mothers and fathers. Joint insecure style is associated with an increase of
depression symptoms of both women and men during pregnancy and womens
anxiety symptoms mainly at postpartum. The results indicate the importance of
systemic approaches to attachment style in couples when perinatal interventions are
planned (e.g., OHara, Stuart, Gorman, & Wenzel, 2000). Utilising support and
attachment information antenatally could usefully inform interventions to reduce
psychological morbidity and improve parental emotional adjustment to the
challenging conditions around pregnancy and birth.

Acknowledgements
We would like to thank the women and men who agreed to participate in the present
study. This research was funded under a doctoral grant for Science in Measure IV.3,
and co-funded under the 2010 Science and Innovation Operational Program (POCI
2010) from Science and Technology Foundation, Government of the Portuguese
Republic (ref. SFRH/BD/13768/2003) and under the 2010 Science and Innovation
Operational Program (POCI 2010) of the Community Support Board III, and
supported by the European Community Fund FEDER (POCI/SAU-ESP/56397/
2004).

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Appendix
Attachment Style Interview (ASI) scales:
I- Ratings for Partner and two Very Close Support Figures (family or friends)
Evidenced by actual examples of behaviour, with probing about intensity and frequency of
particular experiences. (Rated 1. Marked, 2. Moderate, 3. Some, 4. Little/none)
(i) Conding (of emotionally charged topics)
(ii) Active Emotional Support (in relation to actual conding)
 Attachment & Human Development 291

(iii) Positive and Negative Quality of Interaction (evidenced by frequency and intensity of
positive interactions such as enjoyment, relaxed, or negative such as arguments and
rows in interaction)
(iv) Felt attachment (feelings of closeness and not being able to live without the other)

Overall summary of support (13 high conding and active emotional support) (47 low
conding and low active emotional support)

II Ability to make and maintain relationships

(14) based on the range and quality of close supportive relationships including family of
origin, partner and two Very Close Others. (12 denotes good ability to make relationships
and 34 poor ability to make relationships)
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III Attachment attitudinal scales

(Each rated 1. Marked, 2. Moderate, 3.Some, 4. Little/none)

Avoidant attitudes
. Mistrust (suspicion of others motives and behaviours)
. Constraints on closeness (barriers to seeking help and conding)
. High Self-reliance (the ability to cope and make decisions alone and be in control, with
over self-reliance expressed).
. Anger (presence of high negative interaction in close relationships, as well as generalised
feelings of resentment and hostility dierentiated from under self-reliance and from the
ideal or moderate/average level)

Anxious attitudes
. Fear of rejection (expectation of being let down and hurt by others)
. Desire for company (need to have other people around much of the time. Very high
dierentiated from very low, with moderate/average denoting the ideal position)
. Fear of separation (distress and discomfort and even short separations from close others)
. (Anger can be present).

IV Overall attachment styles (Rated 113)

Based on ability to make and maintain relationships (the poorer the ability the higher the level
of insecure style) and combination of negative attitudinal scales. Each insecure style rated as
marked, moderate or mild:

Anxious styles:
. Enmeshed: Low self-reliance, high desire for company, high fear of separation
. Fearful: High mistrust, high fear of rejection and low anger

Avoidant styles:
. Angry-dismissive: High mistrust, high self-reliance and high anger
. Withdrawn: High constraints on closeness and high self-reliance (low anger and low fear
of rejection)
Secure: Low mistrust, low constraints on closeness, low fear of rejection, low fear of
separation and low anger, with moderate/average levels of self-reliance and desire for
company.

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