Relationship Between Attachment Patterns

and Personality Pathology in Adolescents

ORA NAKASH-EISIKOVITS, M.A., LISSA DUTRA, ED.M., AND DREW WESTEN, PH.D.

ABSTRACT
Objective: To explore the relationship between attachment status and personality pathology in a large clinical sample of
adolescents. Method: Two hundred ninety-four randomly selected psychiatrists and psychologists were each asked to
provide data on a patient (aged 14–18 years) in treatment for maladaptive personality patterns. Clinicians completed
several measures including a clinician-report attachment questionnaire, several measures of personality pathology, and
a clinician-report version of the Child Behavior Checklist. Results: In both dimensional and categorical analyses, secure
attachment was negatively correlated with personality pathology and positively correlated with healthy functioning,
whereas disorganized/unresolved attachment was strongly associated with multiple forms of personality pathology.
Anxious/ambivalent attachment tended to be associated with measures of withdrawal, internalization, and introversion.
Avoidant attachment style was not associated with any single form of personality pathology. Conclusion: The marked asso-
ciation between unresolved attachment and more severe psychopathology in adolescents, the lack of construct validity
of avoidant personality disorder in adolescents, and the broader relations among attachment, personality, and psycho-
pathology are discussed. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(9):1111–1123. Key Words: attachment,
personality disorders, adolescent psychopathology, disorganized attachment, clinician-report method.

Attachment theory provides one of the most useful
frameworks for understanding risk and protective factors
in development (Bowlby, 1969, 1973, 1980). Bowlby
suggested that children form mental representations of
relationships based on their interactions with, and adap-
tation to, their care-giving environment. Described as
internal working models, these cognitive/affective repre-
sentations help organize affect and social experience and
shape not only current but future interpersonal relation-
ships (Hamilton, 2000; Lewis et al., 2000; Sroufe et al.,
1983; Waters et al., 2000).
Accepted April 15, 2002.
From the Center for Anxiety and Related Disorders and Department of
Psychology, Boston University. Dr. Westen is now with the Departments of
Psychology and Psychiatry at Emory University, Atlanta.
Preparation of this manuscript was supported in part by NIMH grants
MH59685 and MH60892. The authors acknowledge the assistance of the more
than 300 clinicians who helped refine the SWAP-200-A assessment instrument,
including the 294 clinicians who participated in this study.
Correspondence to Ms. Nakash-Eisikovits or Dr. Westen, Center for Anxiety
and Related Disorders, Department of Psychology, Boston University, 648 Beacon
Street, 4th Floor, Boston, MA 02215; e-mail: oeisiko@bu.edu or dweston@emory.edu.
0890-8567/02/4109–1111䉷2002 by the American Academy of Child and
Adolescent Psychiatry.
DOI: 10.1097/01.CHI.0000020258.43550.BD
Ainsworth was the first to classify infants’ attachment
styles empirically, based on a structured series of separa-
tions and reunions between the infant and caregiver, the
Strange Situation (Ainsworth et al., 1978). Upon reunion,
secure infants seek comforting contact with the caregiver.
These infants learn to rely on the availability and sensi-
tivity of the caregiver if the need arises. Ainsworth and
her colleagues identified three variations of insecure attach-
ment patterns. Avoidant infants are indifferent or ignore
the return of the caregiver after separation. Anxious/
ambivalent infants seek contact with the caregiver but fail
to be soothed by it (Ainsworth et al., 1978). Main and
Solomon (1986) later added a fourth attachment style,
disorganized, characterized by the lack of a coherent pat-
tern of responding to separation and reunion.
The development of the Adult Attachment Interview
(AAI) (C. George et al., unpublished, 1996) made the
assessment of working models in adolescence and adult-
hood possible. The interviewer encourages subjects to
recount their childhood attachment and separation expe-
riences and appraise the influence of those experiences
on their current lives and relationships. A rating based
on the degree to which the narratives appear coherent
and integrated helps classify interviewees as secure/autonomous

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NAKASH-EISIKOVITS ET AL.
(subjects have a coherent and balanced view of attach-
ments), insecure/dismissing (subjects either deny impor-
tance of or idealize attachment figures), or insecure/
preoccupied (subjects remain anxiously enmeshed in past
and present attachments). A fourth classification, unresolved,
is assigned to subjects whose narratives indicate affective
disruption of coherence, dissociation, and lapses in the
ability to monitor their own thoughts and discourse.
From both theoretical and empirical points of view,
one would expect a relationship between attachment orga-
nization and psychopathology, particularly pathology
involving interpersonal functioning and affect regulation.
Bowlby (1973) linked insecure attachment styles to depres-
sion and anxiety. Research has in fact implicated insecure
attachment as a risk factor for the development of child-
hood psychopathology (Lewis et al., 1984; Renken et al.,
1989; Rubin and Lollis, 1988; Sroufe and Egeland, 1989),
and a growing body of research indicates that attachment
provides a diathesis for various forms of psychopathol-
ogy in adulthood (e.g., Dozier, 1990; Dozier et al. 1991;
Muller et al., 2000; Sable, 1995).
Research on the relation between attachment organi-
zation and psychopathology in adolescents is relatively
recent (Allen et al., 1996, 1998; Kobak and Sceery, 1988;
Rice, 1990; Rosenstein and Horowitz, 1996). Allen et al.
(1996) investigated the relationship between severe psy-
chopathology in adolescence (as indicated by a need for
psychiatric hospitalization) and attachment classifications
in young adulthood as assessed by the AAI. Whereas vir-
tually all of the previously hospitalized adolescents were
insecure as young adults, a matched sample of nonhos-
pitalized teenagers followed longitudinally showed a mix-
ture of attachment patterns, with roughly half secure.
Across the sample, adolescents classified as insecure were
more likely to abuse drugs, to be involved in criminal acts,
and to have unresolved trauma histories. Rosenstein and
Horowitz (1996) similarly found a high prevalence of inse-
cure attachment style in adolescent psychiatric inpatients.
Recent research using a variety of attachment mea-
sures has linked the ambivalent/preoccupied classifica-
tion in adolescents to higher levels of internalizing pathology
(Allen et al., 1998), suicidal behavior (Adam et al., 1995),
agoraphobia (de Ruiter and van IJzendoorn, 1992), con-
duct problems (Speltz et al., 1999), anxious and dys-
thymic personality traits (Rosenstein and Horowitz, 1996),
and lower ego resiliency (Kobak and Sceery, 1988).
Numerous recent studies have linked insecure attachment
patterns and eating disorders in preadolescent and ado-
1112
lescent girls (O’Kearney, 1996; Ward et al., 2000). Similarly,
college females with mood or eating disorders are more
likely to be classified as preoccupied (Cole-Detke and
Kobak, 1996; Suldo and Sandberg, 2000).
The unresolved classification is of particular relevance
to psychopathology because it was designed to capture
individuals whose attachment strategies and attempts to
construct coherent working models are overwhelmed (dis-
organized) in the process of experiencing major loss or
trauma and who remain unable to reorganize coherently
(Main and Hesse, 1990). Main and Hesse (1990) hypoth-
esized that this attachment category would be associated
with more severe psychopathology in adolescents, and empir-
ically, adolescents classified as disorganized during infancy
have shown the most marked indices of psychopathology
as assessed by structured interview (Clarson, 1998).
Of particular interest is the relationship between attach-
ment styles and personality disorders (PDs), given that per-
sonality refers to enduring patterns of thought, motivation,
emotion, emotion regulation, impulse regulation, and inter-
personal functioning, and attachment appears to be related
to most of these domains. Using the AAI with an adult
sample, Fonagy (1999; Fonagy et al., 1996, 2000) found
a strong association between borderline personality disor-
der and preoccupied attachment style. Other research with
adults has found a relationship between avoidant and depen-
dent PDs and preoccupied attachment, and between schizoid
PD and dismissing attachment (Livesley, 1987; Livesley
et al., 1990; West et al., 1994).
With respect to adolescent PDs, Rosenstein and Horowitz
(1996) found that adolescents classified as dismissing were
at elevated risk for PDs such as narcissistic and antisocial
PDs (as well as conduct disorder and substance use).
Preoccupied adolescents, in contrast, were more likely to
have a range of PDs, including obsessive-compulsive,
histrionic, borderline, or schizotypal PDs (as well as mood
disorders). Brennan and Shaver (1998) studied a large
nonclinical sample of adolescents and found a substan-
tial association between insecure attachment and self-
reported measures of PDs.
The Present Study
Recent research has thus provided support for a rela-
tionship between insecure attachment patterns and psy-
chopathology, although few studies have focused on PDs,
which are of particular relevance to attachment theory
because they may represent different styles of regulating
closeness and regulating emotion that develop substan-
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2

tially through experiences in attachment relationships.
In this study we examine the relation in adolescence
between attachment and personality pathology broadly
defined, which includes not only the severe disturbances
captured on Axis II of DSM-IV (American Psychiatric
Association, 1994) but also the wider range of personal-
ity problems seen in adolescents (e.g., feelings of inade-
quacy, self-criticism, difficulty regulating anger, emotional
constriction), particularly in adolescents in treatment for
psychological problems (Westen and Chang, 2000).
METHOD
Participants
As part of a broader study of personality pathology in adolescents
(Westen and Chang, 2000; D. Westen et al., unpublished, 2001), we
used practice network methodology to examine the relation between
attachment and personality pathology in adolescents. Practice net-
work designs rely on clinicians (rather than parents or children) as
informants, making use of the training and expertise of clinical observers
while quantifying their judgments using psychometrically reliable and
valid instruments (Westen and Shedler, 1999a, 2000; Wilkinson-Ryan
and Westen, 2000; Zarin et al., 1997). Using clinicians as informants
has a number of advantages. They are experienced observers with sub-
stantially larger, more diverse implicit and explicit normative data-
bases with which to respond to questions about psychopathology than
patients have. They also do not share the biases of patients or their
family members, who are the usual respondents in psychiatric research.
The use of clinicians as informants is likely to be of particular value
in studying children and adolescents, who often lack insight into their
own personality processes, attachment patterns, and so forth, and
whose parents may have difficulty providing accurate descriptions of
their personality or psychopathology (D. Westen et al., unpublished,
2001). Clinicians working with adolescents typically synthesize data
from multiple sources, including the child, parents, school officials,
and other mental health professionals. In this study, as in others using
this design, we asked clinicians to make use of all sources available in
making their assessments.
In a first wave of data collection, we recruited psychologists and
psychiatrists from the membership roster of the American Academy
of Child and Adolescent Psychiatry. Because of a relatively low response
rate (20% response to our initial letter of inquiry), in a second wave
we recruited a random sample of members of the American Psychological
Association, selected by a computer search from among those who
reported treating adolescents and had at least 3 years’ posttraining
practice experience. The response rate of this latter group was sub-
stantially higher (approximately 40%).
Procedure
We sent clinicians an initial letter inquiring about their willingness
to participate in a study of adolescent personality pathology, enclos-
ing a postcard on which they could provide information about the
number of patients in their practices at each of the following ages:
14, 15, 16, 17, and 18. Clinicians who agreed to participate subse-
quently received packets asking them to provide data on a randomly
selected adolescent patient (operationalized as “the last patient you
saw last week before completing this form who meets study criteria”)
currently in treatment for “enduring maladaptive patterns of thought,
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ATTACHMENT AND PERSONALITY DISORDERS
feeling, motivation, or behavior—that is personality.” To obtain an
age-stratified sample, we asked clinicians to select a patient of a par-
ticular age (14, 15, 16, 17, or 18), based on their initial survey responses.
To minimize rater-dependent variance, we asked each clinician to
describe only one patient.
We sent out packets in batches of 50 to 100 divided equally by age.
Based on the number of packets received for each age group, we
adjusted the numbers sent in the next batch by age to try to obtain
roughly equal representation for each age. Clinicians who contributed
data received an honorarium of $25. The packets included a clini-
cian-report version of the Relationship Questionnaire (Bartholomew
and Horowitz, 1991), a clinician-report version of the Child Behavior
Checklist (CBCL) (Achenbach, 1991), multiple measures of person-
ality and personality pathology, and an adolescent version of the
Clinical Data Form (Westen and Shedler, 1999a), which asks for
demographic data on the clinician and patient as well as measures of
adaptive functioning, diagnosis, and developmental and family his-
tory. Here we describe the measures of relevance to the present study.
Measures of Personality and Personality Pathology
To maximize the likelihood of reliable findings, we included multi-
ple measures of personality pathology, broadly defined to include both
PDs and less severe, but nevertheless maladaptive, personality traits and
constellations. Given questions about the applicability of Axis II diag-
noses to adolescents, we included not only measures of current Axis II
disorders but also measures that can be used to derive personality diag-
noses or trait dimensions empirically. Thus we included four measures
of Axis II symptoms using adult Axis II criteria as well as the Shedler-
Westen Assessment Procedure Q-sort for Adolescents (SWAP-200-A).
Axis II Pathology. Clinicians assessed Axis II pathology as defined
by DSM-IV (American Psychiatric Association, 1994) criteria in mul-
tiple ways, both categorical and dimensional. First, we asked clini-
cians to provide primary and secondary Axis II (categorical) diagnoses,
if applicable, as they would in clinical practice. Second, we listed the
Axis II disorders and asked clinicians to rate the extent to which their
patients each met criteria for each disorder (7-point rating scale: 1 =
not at all, 4 = has some features, 7 = fully meets criteria) (Westen and
Shedler, 1999a,b; Widiger and Sanderson, 1995). Third, we presented
clinicians with a checklist of all criteria currently included on Axis II
for all disorders, randomly ordered, and asked them to (a) rate each
criterion as present or absent, as in the current diagnostic system, and
(b) rate the extent to which each item applied using a 1–7 scale. These
checklist data generated two additional dimensional measures of Axis
II pathology (the number of diagnostic criteria for each PD endorsed
as present, and the mean of the 1–7 ratings for each applicable crite-
rion for each diagnosis), as well as categorical diagnoses derived by
summing the number of criteria present and applying DSM-IV deci-
sion rules regarding number of criteria required for diagnosis. Similar
methods have produced robust findings in previous research (Blais
and Norman, 1997; Morey, 1988).
SWAP-200-A Q-Sort for Assessing Adolescent Personality Pathology.
The SWAP-200-A (D. Westen et al., unpublished, 2001) is an instru-
ment for assessing adolescent personality pathology designed for use
by skilled clinical observers based on either longitudinal knowledge
of the patient over the course of treatment or a systematic clinical
interview of the patient and parents. A Q-sort is a set of statements,
each printed on a separate index card. To describe a patient, the clin-
ician sorts (rank-orders) the statements into eight categories based on
their applicability to the patient, from those that are irrelevant or not
descriptive (assigned a value of 0) to those that are highly descriptive
(assigned a value of 7), thereby providing a numeric score ranging
from 0 to 7 for each of 200 personality-descriptive items. Because the
1113
NAKASH-EISIKOVITS ET AL.
standard Q-sort procedure of sorting a specified number of items
(cards) to each category (pile) takes a substantial amount of time to
do, we attempted to maximize response rate in the current study by
foregoing this fixed distribution method and instead using a semi-
constrained rating scale version of the instrument.
In this study, which was designed, among other things, to study
the psychometric properties of the item set as applied to adolescents,
we presented SWAP 200-A items in a 7-point rating scale question-
naire form with a semiconstrained distribution, giving clinicians gen-
eral guidelines on the number of items to be given a rating of 5, 6,
or 7. The SWAP-200A can yield categorical and dimensional PD diag-
noses using current adult diagnoses from the DSM-IV, as well as
dimensional measures of empirically derived PDs, styles, and traits.
The SWAP-200-A was adapted from its adult progenitor, the SWAP-
200 (Westen and Shedler, 1999a). Both the adult and adolescent ver-
sions have shown strong evidence of validity, reliability, and utility in
taxonomic research with adult and adolescent samples (Shedler and
Westen, 1998; Westen and Chang, 2000; Westen and Harnden, 2001;
Westen and Shedler, 1999a,b; D. Westen et al., unpublished, 2001).
Measure of Attachment
To maximize the reliability and validity of our data, we used both cat-
egorical and dimensional measures of attachment. Clinicians completed
a clinician-report version of the Relationship Questionnaire (Bartholomew
and Horowitz, 1991), which is an adaptation of Hazan and Shaver’s
(1987) measure of adult romantic attachment. This measure consists of
four descriptions of prototypical adult attachment patterns that have
been used in studies of adolescents as well. The first three descriptions
were derived by Hazan and Shaver to correspond with the major attach-
ment statuses described in the literature, namely, secure, avoidant (dis-
missing), and anxious (preoccupied). The secure prototype describes a
person for whom becoming emotionally close to others is easy and for
whom mutual dependence is experienced as safe and comfortable. The
avoidant prototype describes a kind of person who is comfortable with-
out close emotional relationships, for whom independence and self-suf-
ficiency are central issues. The anxious prototype describes a pattern of
ambivalence, in which the individual craves emotional intimacy but
often finds others reluctant, unfulfilling, and so forth.
The fourth description, called fearful/avoidant by Bartholomew
and Horowitz, most closely resembles the disorganized (unresolved)
pattern and represents negative internal working models of both self
and others. The prototype describes a person who is drawn to rela-
tionships but has difficulty with trust and safety in relationships. For
purposes of continuity with other studies, we use the term disorganized/
unresolved here to refer to this fourth prototype. As both prior research
(Alexander et al., 1998; Bartholomew and Horowitz, 1991) and our
own findings below suggest, this appears to be a reasonable extrapo-
lation. (The alternative was to develop our own fourth prototype, to
represent disorganized attachment more directly, but we chose instead
to use a measure that had already shown some evidence of validity.)
Relationship Questionnaire ratings show convergent validity with
interview ratings (Bartholomew and Horowitz, 1991; Griffin and
Bartholomew, 1994) and moderately high stability over 8 months
(Scharfe and Bartholomew, 1994).
We presented clinicians with the four vignettes and asked them to
select the prototype that best described their patient, yielding a cate-
gorical assessment of the patient’s attachment status. Similar to the
method used in Bartholomew and Horowitz’s (1991) Relationship
Questionnaire, we then asked clinicians to use a 7-point Likert-type
scale to rate each prototype for the extent to which it described the
patient. These ratings yielded a dimensional assessment of the patient’s
attachment status, offering a more sensitive measure of attachment
1114 J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2
and enabling us to obtain data on differences among subjects within
the same attachment category (Collins and Read, 1990).
Although this measure has the structure of the self-report attach-
ment measures from which it was derived, its design is actually a hybrid
between these approaches and narrative-based approaches using the
AAI. Research on personality characteristics relevant to attachment
(such as affect regulation, representations, and interpersonal func-
tioning in close relationships) shows that when clinicians make judg-
ments of these characteristics, they do so primarily by listening to
patients’ narratives about significant interpersonal events and observ-
ing their behavior with the clinician (Westen, 1997). Clinicians of all
theoretical perspectives report minimal reliance on self-reports to assess
personality processes, and the clinical setting is one in which patients
typically have the opportunity to tell many narratives about many sit-
uations and relationships over time and to form an intimate rela-
tionship with a clinician that mirrors certain aspects of attachment
relationships. Thus we would expect clinicians to make use of such
information in completing our measure of attachment. As described
below, we included validity checks to ensure that this measure was in
fact assessing attachment status.
Child Behavior Checklist
The CBCL/4–18 (Achenbach, 1991) is a parent-report question-
naire designed to assess the behavioral problems and social compe-
tencies of children and adolescents aged 4–18 years. The CBCL is
composed of 118 problem items and 20 competence items grouped
into 11 problem scales (including eight syndrome scales) and four com-
petence scales (although many studies use only the problem scales
because of their focus on psychopathology). The CBCL is widely used
in both clinical and research settings because of its demonstrated reli-
ability and validity, ease of administration and scoring, and applica-
bility to clinical, nonclinical, and cross-cultural samples (Achenbach,
1991; Cohen et al., 1985; DeGroot et al., 1994; Drotar et al., 1995;
Sandberg et al., 1991). In this study, we asked clinicians to complete
the problem scales of a clinician-report adaptation of the CBCL, which
has shown strong evidence of reliability and validity in the assessment
of adolescents (L. Dutra and D. Westen, unpublished, 2001).
Clinical Data Form
The Clinical Data Form (CDF) assesses a range of variables rele-
vant to demographics, diagnosis, and etiology. This measure has been
developed over several years and used in a number of studies (Westen
and Shedler, 2000). It was adapted in this study for an adolescent
sample. The CDF first asks clinicians to provide basic demographic
data on themselves and the patient, including the clinician’s discipline
(psychiatry or psychology), theoretical orientation, years of experi-
ence, employment sites (e.g., private practice, inpatient unit, school),
sex, and race, and the patient’s age, sex, race, socioeconomic status,
family composition, current living situation (e.g., one-parent home,
foster care), and Axis I diagnoses. Following basic demographic and
diagnostic questions, the CDF asks the clinician to rate the patient’s
adaptive functioning, including school functioning (1 = severe con-
duct problems/suspensions, 7 = working to potential); peer func-
tioning (1 = very poor, 7 = very good); history of suicide attempts,
arrests, and hospitalizations; and social support (number of close con-
fidantes in which the patient feels comfortable confiding). From prior
research we have found such ratings to be highly reliable and to cor-
relate strongly with ratings made by independent interviewers
(Westen et al., 1997).
The final section of the CDF assesses aspects of the patient’s devel-
opmental and family history with which clinicians who have worked

with a patient for a minimum of five sessions are likely to be famil-
iar. The adolescent version of the questionnaire assesses a wide range
of variables shown in research in developmental psychopathology to
be of potential relevance to the etiology of personality pathology and
Axis I symptomatology. Developmental history variables include his-
tory of adoption, foster care, and residential placements; quality of
relationship with mother and father; adaptive functioning of mother
and father; attachment history, including significant separations, losses,
and parental divorce; general family instability (including frequency
of geographic moves); general family warmth or hostility; physical
and sexual abuse; and maternal history of sexual abuse. In prior stud-
ies, clinicians’ judgments on such variables have not only predicted
theoretically relevant criterion variables but also tend to reflect rea-
sonable strategies of aggregating data over the course of clinical obser-
vation. For example, when asked to check off reasons for their belief
that a patient had a history of sexual abuse, virtually all clinicians
checked off items indicating state involvement, memories of sexual
abuse prior to treatment, and corroboration from family members or
court records; few indicated that their judgment reflected inferences
from the symptom picture or recovered memories, and cases with bor-
derline reasons for inference tended to receive a rating of “unsure” by
clinicians (Wilkinson-Ryan and Westen, 2000).
The CDF also measures family history of psychiatric disorder, pre-
senting clinicians with a list of diagnoses and psychiatrically related prob-
lems (e.g., psychosis, bipolar disorder, major depression, alcohol abuse,
criminality, suicide) and asking them to indicate presence or absence of
each in first- and second-degree relatives. The form instructs clinicians
only to indicate presence if they are confident in their judgment, and to
indicate absence if they are unsure, to minimize guessing and false pos-
itives. Data from previous studies suggest that this method yields valid
data (D. Westen and J. Shedler, unpublished, 2001), particularly with
large sample sizes, where the unreliability of any given judgment by any
given clinician tends to cancel over subjects. The validity of the data
appears to reflect the fact that clinicians are unlikely to know about spe-
cific symptoms in specific relatives (unless they have met them, which
is frequently the case in treatment of adolescents), but they are very likely
to have heard about a relative who has been in and out of psychiatric
hospitals with delusions or hallucinations, who has spent time in prison,
who has committed suicide, and so forth. Coding “unsure” as “no” and
asking only about relatively obvious syndromes or diagnostic groupings
(e.g., history of anxiety disorders, rather than specific disorders) has the
advantage of preventing speculative diagnosis at a distance.
Statistical Analyses
Validity of Attachment Measure. As a test of the validity of our attach-
ment measure, we correlated attachment status with two sets of cri-
terion variables that should, theoretically, be related to it: data from
the CBCL and a Five Factor Model Adjective Checklist.
Attachment Status and Personality Pathology. Our primary measure
of Axis II pathology was the number of symptoms endorsed by the
clinicians for each disorder from the Axis II checklist. However, to
maximize reliability, we also created a composite measure of Axis II
pathology by transforming dimensional scores obtained from the three
Axis II measures (global ratings, number of Axis II criteria met, and
summed ratings on each criterion for each disorder) to Z scores and
then averaging these scores. We also examined the relationship between
attachment status and Axis II pathology measured by the SWAP-200-
A, which assigns dimensional diagnoses by correlating patients’ observed
profiles with profiles of patients with each PD from a normative sam-
ple (Westen and Shedler, 1999a).
Where possible, we used the Pearson r with dimensional data, dummy-
coding dichotomous variables where appropriate (e.g., coding “pre-
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ATTACHMENT AND PERSONALITY DISORDERS
sent”/ “absent” as 0 and 1). Although we also used analysis of variance
to examine the association between categorical attachment status and
dimensional personality pathology and χ2 tests to examine the associ-
ation between categorical attachment status and categorical personal-
ity pathology, these analyses were largely redundant with dimensional
analyses, which have more useful psychometric properties (less infor-
mation loss, greater power), particularly in variables not previously
shown to be truly taxonic (i.e., that appear instead to be continuously
distributed in the population). Thus we report primarily dimensional
data except where categorical analyses are nonredundant.
Attachment Status and Empirically Derived Adolescent Personality
Pathology Prototypes. Because the applicability of DSM-IV Axis II cat-
egories to adolescents is not as well established as Axis II for adults,
we also examined the association between attachment status and empir-
ically derived personality pathology prototypes that do not require a
priori commitment to adult Axis II categories. In a previous study
(Westen and Chang, 2000), we used the SWAP-200-A data to con-
struct empirically derived adolescent personality prototypes via a
cluster-analytic technique, Q-factor analysis (or simply Q-analysis),
which identifies clusters of patients who share common psychological
features and are distinct from other clusters of patients. Q-analysis can
be understood in relation to conventional factor analysis, which iden-
tifies groups of variables that are highly similar to one another (i.e.,
highly intercorrelated). Q-analysis is computationally the same pro-
cedure, except that it creates groupings of similar people, not variables.
These groupings of people, called Q-factors, represent empirically
derived diagnostic prototypes—that is, aggregated portraits of par-
ticular kinds of people.
Q-factor analysis yielded the following six nonoverlapping adoles-
cent personality prototypes. The psychological health Q-factor identi-
fied a kind of adolescent with numerous psychological strengths. The
items most descriptive of this prototype reflected the positive pres-
ence of psychological strengths and inner resources, including the
capacity to love, find meaning in life experiences, and gain insight
into the self. The antisocial/defiant Q-factor is characterized by fea-
tures commonly associated with antisocial PD as well as with the clin-
ical construct of psychopathy (Cleckly, 1941; Hare, 1998). The
highest-ranked (most defining) items include imperviousness to con-
sequences, impulsivity, hostility, physical aggressiveness, unreliability
and irresponsibility, and lack of remorse, as well as a tendency to be
rebellious and defiant toward authority figures. The emotionally dys-
regulated Q-factor is characterized by features commonly associated
with borderline PD. Such features include a deficiency in the capac-
ity to regulate and modulate affect, as well as a tendency to fear rejec-
tion or abandonment; to be self-critical and feel inadequate; to
catastrophize (e.g., see problems as disastrous or irresolvable); and to
struggle with suicidal feelings. The withdrawn Q-factor is character-
ized by features commonly associated with schizoid PD and, to a lesser
extent, avoidant PD. Such features include a difficulty acknowledg-
ing or expressing emotions, as well as a tendency to be passive, shy,
and unassertive; to be unreliable and irresponsible; to lack social skills;
to be inarticulate; to lack energy; and to be inattentive or easily dis-
tracted. The histrionic Q-factor is characterized by features commonly
associated with histrionic PD as well as some features currently defined
as borderline. The most defining features of this prototype include
the tendency to have unstable and chaotic relationships; to fantasize
about finding ideal and perfect love; to become attached quickly or
intensely; to be suggestible; to be overly sexually provocative; to seek
to be the center of attention; to be overly needy or dependent; and
to express emotions in exaggerated ways. Finally, the narcissistic Q-
factor includes features such as self-importance, grandiosity, and enti-
tlement, as well as the tendency to treat others as audiences to provide
1115
NAKASH-EISIKOVITS ET AL.

admiration; to see the self as logical and rational, uninfluenced by

Problems

–.45**

0.30**
emotion; to be controlling; and to set unrealistically high standards

Total

0.20*

0.06
for the self and be intolerant of one’s own human defects.
Association Between Attachment Status and Family and Developmental
History Variables. Finally, to investigate the antecedents of adolescent

Internal- External-

–.25**
0.16*
attachment status in this clinical sample, we examined the relation-

izing

–0.02

0.09
ship between attachment status and developmental and family history
variables selected a priori. The developmental variables we investigated
included history of separations from primary caregiver, history of sex-

–.32**

0.40**
ual or physical abuse (coded 0, 1, and 2 for no, unsure, and yes, respec-

0.18*
izing

0.07
tively), quality of relationship with each parent (assessed using a 1–7
rating scale, where 1 = poor/conflictual and 7 = positive/loving), and
family stability and warmth (assessed using a 1–7 rating scale, anchored

Correlations Between Dimensional Attachment Status and Child Behavior Checklist Scores (n = 225–288)

Behavior Problems Problems

0.04

0.13
–.10

0.10
by chaotic and stable, and hostile to loving, respectively). The family

Sex
history variables included history of each of the conditions coded on
the Clinical Data Form as present, aggregated across first- and second-
degree relatives (i.e., presence or absence of history in either first- or

0.25**
–.26**
Aggressive Other

0.02

0.07
second-degree relatives), to maximize reliability.

RESULTS

–.28**
0.16*

–0.01

0.11
Child Behavior Checklist Scores
Sample Characteristics

The clinician sample consisted of 294 clinicians.

Attention Delinquent
Clinician-respondents (61.4% psychiatrists, 50.2% male)

Problems Behavior

–.18*

0.05
–0.03
0.11
were on average highly experienced (mean years experi-
ence posttraining: 13.4, SD 9.4). Clinicians’ theoretical
TABLE 1

orientations were varied: 34.8% described themselves as

–.21**
psychodynamic, 11.6% cognitive-behavioral, 6.5% bio-

0.08

0.08

0.15
logical, 3.8% family systems, and 42.7% eclectic. Most
worked in multiple settings: 77.0% private practice, 31.3%
Withdrawn Complaints Depressed Problems Problems
Thought

outpatient clinic, 25.8% hospital, 13.4% school, and

–.20**

0.18*
0.04
0.10
6.5% forensic. Clinicians tended to know the patients
well: median length of treatment prior to completing the
–0.38**

questionnaire was 20 sessions. 0.19**

Social

0.06

0.04

Patients were relatively evenly distributed by gender

(52.9% female) and age (for ages 14, 15, 16, 17, and 18,
Anxious/

0.43**
–0.23**

0.29**

the number of subjects per age was 54, 58, 67, 59, and
–0.03

53, respectively). The majority of the subjects (84.9%)

were white, with most of the remaining subjects being
African American or Hispanic. With respect to socioeco-
Somatic

–0.02

0.11
–0.11

0.11

nomic status, clinicians classified 7.5% as poor, 20.9%

working class, 50.7% middle class, and 20.9% upper class.
Validity of Attachment Measure
0.32**
–0.40**
0.27**

–0.12

To provide a validity check on the attachment measure,

* p ≤ .01; ** p ≤ .001.

we examined the correlations between attachment status

and relevant scores from the CBCL, a widely used, well-
Anxious/Ambi-

validated, and reliable measure of child and adolescent

Disorganized/
Unresolved
Attachment

psychopathology. As seen in Table 1, as expected, secure

Avoidant

valent

attachment status was negatively correlated with almost

Secure
Status

all of the problem scales, whereas anxious/ambivalent

1116 J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2

attachment was strongly associated with the Anxious/
Depressed and Internalizing scales. In addition to the
expected high correlation with the Withdrawn scale, avoidant
attachment was also associated with the Aggressive and
Externalizing scales, suggesting that avoidant attachment
may have multiple meanings in an adolescent clinical sam-
ple, a point to which we return in the discussion. Finally,
as was also expected based on the existing literature of the
four attachment statuses, disorganized/unresolved was pos-
itively correlated with most problem scales (7 scales out
of 13) and had the strongest correlation with the Total
Problems scale. Although these validity data are of course
not definitive, they provide initial corroboration of the
validity of the measure as completed by clinicians rather
than by self-report.
Association Between Attachment Status
and Axis II Pathology
Our primary goal was to examine the relation between
attachment and personality pathology. We report here the
correlations between dimensional attachment status and
dimensional Axis II pathology scores, as measured by the
number of diagnostic criteria for each PD that clinicians
endorsed as present for each patient. As can be seen in
Table 2, secure attachment was negatively correlated with
every PD. Notably, secure attachment tended to be most
strongly negatively correlated with those PDs character-
ized by social withdrawal (e.g., schizoid, schizotypal, and
avoidant PD). Conversely, disorganized/unresolved attach-
ment was positively correlated with every PD, except for
antisocial and histrionic PDs, and was most strongly cor-
related with avoidant and borderline.
Avoidant attachment was most strongly associated with
Axis II cluster A PDs (paranoid, schizoid, and schizotypal),
which are characterized by social withdrawal and non-
TABLE 2
Correlations Between Dimensional Attachment Status and Axis II Dimensional Diagnoses Using Adult Criteria (n = 288–290)
Cluster A
Attachment Schizo-
Status Paranoid Schizoid typal
Secure –0.25** –0.50** –0.40**
Avoidant 0.20** 0.37** 0.28**
Anxious/
Ambivalent 0.14 –0.19** –0.04
Disorganized/
Unresolved 0.37** 0.25** 0.27**
* p ≤ .01; ** p ≤ .001.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2
ATTACHMENT AND PERSONALITY DISORDERS
consensual thinking. Notably, however, avoidant attach-
ment was not associated with avoidant PD, which includes
criteria specifying that the person consciously wishes for
more contact with people but fears and hence avoids it.
Anxious/ambivalent attachment was associated with PDs
characterized by neediness and dependency in relation-
ships, including borderline, histrionic, and dependent PD.
We performed two additional sets of analyses to assess
the robustness of these findings, using two alternative
indicators of Axis II pathology. In the first, we used com-
posite dimensional PD scores, obtained by averaging the
Z scores of our three-dimensional PD measures (see
“Method”). The results were virtually identical with those
displayed in Table 2. For example, secure attachment was
negatively correlated with every PD (r values ranged from
–0.17 to –0.48, df = 287, p < .01–001), except for histri-
onic PD. Disorganized/unresolved attachment was sig-
nificantly correlated with every PD (r values ranged from
0.19 to 0.39, df = 288, p < .001), except for histrionic
and antisocial PDs. In a second set of analyses, we mea-
sured Axis II pathology using the SWAP-200-A Q-sort.
In this assessment method, patients receive scores for each
current Axis II PD based on the correlation or match
between their 200-item profile and composite profiles of
patients with each disorder in a normative sample. Once
again, these analyses yielded similar results, suggesting
that the findings are robust across multiple measures.
As noted earlier, dimensional data tend to outperform
categorical data in PD research (Widiger, 1993). However,
because attachment status and PDs tend to be assessed
categorically in research, in an additional set of analyses
we used χ2 tests to examine the relation between these
variables treated categorically. Thus we used clinicians’
rankings of the four attachment statuses to indicate pri-
mary status (using a ranking of 1 as categorical status) and
Cluster C
Cluster B Obsessive-
Antisocial Borderline Histrionic Narcissistic Avoidant Compulsive Dependent
–0.24** –0.29** –0.14 –0.33** –0.33** –0.21** –0.20**
0.12 –0.05 –0.15* 0.19* 0.12 0.20** –0.12
–0.10 0.20** 0.33** 0.02 0.14 –0.03 0.32**
0.03 0.39** 0.13 0.17* 0.44** 0.28** 0.31**
1117
NAKASH-EISIKOVITS ET AL.
determined presence/absence of each Axis II PD by sum-
ming the number of symptoms endorsed for each PD and
applying DSM-IV decision rules regarding number of cri-
teria required for diagnosis (e.g., the patient must meet
five of nine borderline criteria for a categorical diagnosis
of borderline PD). With the exceptions of schizotypal,
antisocial, and obsessive-compulsive PDs, χ2 analyses
yielded significant differences for all PDs . This makes
sense given that thought disorder, antisocial behavior, and
obsessive-compulsive symptoms do not have obvious equiv-
alents in attachment status. Overall, categorical data pro-
duced a pattern of findings similar to the dimensional
data. For example, among subjects categorized as having
disorganized/unresolved attachment, 49.6% met DSM-
IV diagnostic criteria for avoidant PD, 39.7% met diag-
nostic criteria for borderline PD, and 31.3% met diagnostic
criteria for paranoid PD. Of the subjects categorized with
anxious/ambivalent attachment, 36.5% met criteria for
borderline PD, 30.8% met criteria for histrionic PD, and
23.1% met criteria for dependent PD. Of subjects cate-
gorized as having avoidant attachment, 53.7% met diag-
nostic criteria for schizoid PD.
Association Between Attachment Status and Empirically
Derived Personality Pathology Categories
Because the PD diagnoses in Axis II of DSM-IV were
developed exclusively from adult samples, and research on
their applicability to adolescents is relatively recent and not
yet conclusive (e.g., Johnson et al., 1999; Ludolph et al.,
1990), we investigated the relation between attachment
and personality pathology one more way, using diagnos-
tic prototypes (Q-factors) derived empirically from this
sample (see “Method”). These personality prototypes, unlike
Axis II diagnoses, have the advantages of being (a) empir-
TABLE 3
Correlations Between Dimensional Attachment Status and Personality Pathology Q-Factor Scores
(Empirically Derived Prototypes) (n = 281–282).
Personality Pathology Q-Factor Scores
Attachment Psychological Antisocial/
Status Health Defiant
Secure 0.59** –0.08
Avoidant –0.17* 0.11
Anxious/
Ambivalent 0.11 –0.16*
Disorganized/
Unresolved –0.25** –0.06
* p ≤ .01; ** p ≤ .001.
1118
ically rather than intuitively derived, (b) nonoverlapping
and hence providing nonredundant information, and (c)
derived directly from a large sample of adolescent patients
with personality pathology rather than assumed to match
categories and criteria developed through research and clin-
ical observation with adults. In addition, because clinicians
were unfamiliar with these prototypes (unlike current Axis
II diagnoses), any diagnostic biases that may have produced
artifactual links between attachment status and Axis II
would not be reproduced in these analyses.
As displayed in Table 3, secure attachment was the only
attachment status that was significantly positively corre-
lated with the psychological health Q-factor. Similar to
results obtained from our previous analyses, secure attach-
ment was negatively correlated with most of the other dis-
orders. Disorganized/unresolved attachment was the only
attachment status that was significantly negatively corre-
lated with the psychological health Q-factor. As predicted,
this attachment status was most strongly associated with
the emotionally dysregulated prototype. Similar to the find-
ings using Axis II diagnoses, anxious/ambivalent attach-
ment was strongly correlated with the histrionic Q-factor,
which includes dependent as well as histrionic and bor-
derline features as currently conceptualized using DSM-IV,
and negatively correlated with the avoidant Q-factor. Most
notably, contrary to the findings using DSM-IV avoidant
PD, avoidant attachment was the only attachment style
that was significantly associated with the avoidant-with-
drawn Q-factor. This suggests that the personality pathol-
ogy prototype represented by our empirically derived
avoidant-withdrawn Q-factor may significantly differ from
DSM-IV avoidant PD and may be closer to the construct
of avoidant attachment.
Emotionally Avoidant/
Disregulated Withdrawn Histrionic Narcissistic
–0.24** –0.29** –0.04 –0.34**
–0.07 0.19** –0.25** 0.32**
0.12 –0.22** 0.37** –0.07
0.40** –0.00 0.08 0.15*
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2
 ATTACHMENT AND PERSONALITY DISORDERS

TABLE 4
Correlations Between Dimensional Attachment Status and Developmental History Variables (n = 257–288)
Developmental History Variables
Lengthy
Separation Quality of Quality of
Attachment From Primary Physical Sexual Relationship Relationship Family Family
Status Caretaker Abuse Abuse With Mother With Father Stability Warmth

Secure –0.08 –0.15 –0.07 0.30** 0.33** 0.24** 0.36**

Avoidant 0.08 0.06 –0.11 –0.07 –0.05 –0.01 –0.08
Anxious/
Ambivalent 0.01 –0.10 0.00 0.08 0.07 0.05 0.09
Disorganized/
Unresolved 0.21** 0.17* 0.17* –0.20** –0.30** –0.25** –0.33**

* p < .01; ** p < .001.

Association Between Attachment Status and Family and
Developmental History Variables
In a final set of analyses, we investigated the antecedents
of adolescent attachment by examining the association
between attachment and a set of potentially relevant vari-
ables (family and developmental history) selected a pri-
ori. First, we investigated the association between attachment
status and family history of psychopathology. These analy-
ses yielded no significant correlations. This is notewor-
thy, given that the same variables in the same sample
strongly predict diagnostic variables, such as CBCL and
personality pathology scale scores. Thus in this sample,
attachment status appears unrelated to family history of
psychiatric disorders.
Next we examined the association between attachment
status and each of the psychosocial developmental history
variables presented in Table 4. The results are striking.
Whereas secure attachment was positively correlated with
good maternal and paternal relationships and with fam-
ily stability and warmth, disorganized/unresolved status
was significantly associated with every developmental his-
tory variable (risk factor). Of particular relevance were the
specific associations between disorganized/unresolved
attachment style and (a) history of lengthy separations
from primary caretaker and (b) history of physical and
sexual abuse. Avoidant and anxious/ambivalent attach-
ment styles were not associated with any developmental
history variable.
Because prior research suggests that gender often mod-
erates the relation between child risk factors and later psy-
chopathology (e.g., Block et al., 1991), in an additional set
of analyses we examined the association between attach-
ment and the developmental history variables separately
for males and females. Disorganized/unresolved attach-
ment was associated with physical and sexual abuse for
females only (r = 0.21 and 0.22, respectively, df = 148 and
150, p < .01). Furthermore, disorganized/unresolved attach-
ment was significantly associated with lengthy separation
from primary caregiver and good paternal relationship vari-
ables for males only (r = 0.24, df = 132, p < .01; r = –0.39,
df = 141, p < .001, respectively). These analyses suggest
that for the disorganized/unresolved attachment style, the
association between attachment and developmental expe-
riences may to some extent be gender-specific.
DISCUSSION
The purpose of this study was to examine the relation
between attachment style and personality pathology in a
large clinical sample of adolescents. The results support
the conclusion that attachment patterns are indeed related
to personality pathology in adolescents. Across dimen-
sional and categorical analyses, secure attachment was neg-
atively correlated with adolescent pathology and positively
correlated with healthy functioning, whereas disorga-
nized/unresolved attachment was associated with various
forms of personality pathology. Anxious/ambivalent attach-
ment tended to be associated with measures of withdrawal
and internalizing. Of interest, avoidant attachment style
was associated with a variety of DSM PDs, which reflected
a mixture of internalizing and externalizing pathology.
Attachment status also showed meaningful patterns of
association with developmental experiences, such as sep-
aration from primary caretaker, physical and sexual abuse,
and family stability, but was unrelated to family history
of psychiatric disorders. These findings accord with other
studies showing that environmental influences account

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NAKASH-EISIKOVITS ET AL.
for the majority of variance in attachment status (e.g.,
Brussoni et al., 2000; Finkel et al., 1998).
Two aspects of these findings are particularly note-
worthy. The first regards the meaning of avoidant PD,
and whether the avoidant construct is itself a “coherent
working model.” In recent editions of the DSM the def-
inition of avoidant PD has evolved as a changing blend
of schizoid, depressive, and phobic character traits (Millon
and Martinez, 1995). In the most recent revisions of the
DSM, the construct of avoidant PD has shifted toward
the phobic dimension and away from the view of avoidant
patients as loners. Thus the most recent version of the dis-
order describes a shame-prone, interpersonally insecure
person who worries constantly about being inadequate.
This shift in emphasis links avoidant PD with anxiety
disorders on Axis I, but it has the disadvantage of divorc-
ing the avoidant concept from promising developments
in attachment research that may be highly relevant to the
construct (Dozier and Kobak, 1992; Main et al., 1985;
Pilkonis, 1995). As our data show, avoidant PD no longer
maps onto either the avoidant/dismissive or the anx-
ious/preoccupied attachment style, because the former is
defined by a tendency to avoid intimacy without mani-
fest anxiety about attachment, whereas the latter is char-
acterized by much greater social engagement reflecting
fears of losing the other person. In contrast, when we
examined empirically derived adolescent personality pro-
totypes, avoidant attachment was the only attachment
style associated with the avoidant Q-factor (which is char-
acterized by features commonly associated with schizoid
PD, such as difficulty acknowledging or expressing emo-
tions, as well as a tendency to be passive, shy, and unassertive).
A second issue regards the nature of the disorga-
nized/unresolved status in adolescents with psychopa-
thology. In this study, disorganized/unresolved attachment
was associated with virtually all PDs, particularly the more
severe ones. Although this could be an artifact of our use
of the Bartholomew fearful/avoidant prototype as a proxy
for disorganized attachment, the data are consistent with
the hypothesis that the unresolved attachment category
is associated with more severe psychopathology in ado-
lescents (Clarson, 1998; Main and Hesse, 1990). Of par-
ticular note is the relation between disorganized/unresolved
status and the empirically derived emotionally dysregu-
lated prototype, which describes a type of adolescent who
is overwhelmed by emotion and uses desperate measures
to try to escape it. The unresolved classification thus
appears, in this study as in others, particularly relevant
1120
to psychopathology, as it characterizes individuals whose
attempts to find useful strategies for engaging attachment
figures and to construct coherent working models have
been overwhelmed by separation, loss, or trauma.
Clinical Implications
Our findings bear on the broader relation between attach-
ment status and personality pathology, the boundaries of
each set of constructs, and the clinical relevance and com-
prehensiveness of the two sets of constructs. On the one
hand, the construct of PD as currently defined by the
DSM-IV appears too limited in clinical scope, lacking the
range to address styles of representing relationships and
regulating affect relevant to psychopathology but not severe
enough to warrant a PD diagnosis (Westen and Arkowitz-
Westen, 1998). Thus high-functioning adolescents with
an avoidant status that may include clinically significant
features cannot be diagnosed using the DSM-IV. The same
is true of a subset of anxious/preoccupied adolescents who
are able to form meaningful relationships and function
well at school but whose ways of attaching to others may
nonetheless make them vulnerable to depression or anxi-
ety (and hence to anxious/depressed and internalizing symp-
toms on the CBCL). Thus clinicians working with adolescents
need—and appear—to attend to a broader range of clin-
ically significant personality pathology than recognized on
Axis II of DSM-IV.
On the other hand, the attachment construct has always
borne an important but ambiguous relation to psycho-
pathology, leading in recent years to tremendous enthu-
siasm about attachment research among clinicians but
continued questions about how precisely to use it in clin-
ical practice. The attachment construct as developed by
Bowlby was not designed to describe psychopathology
per se, and in fact cannot account for phenomena such
as impulsivity and aggression in adolescents, which are
not associated with any particular attachment status. For
example, in the present study, antisocial PD was nega-
tively correlated with secure attachment style but was not
associated with any of the insecure attachment patterns.
Bowlby initially recognized the importance of attach-
ment phenomena from clinical observation of children
with attachment pathology (children with a history of
early neglect or loss), but he then expanded the scope of
the theory and construct to include the range of attach-
ment processes seen in the broader population. When
Ainsworth (1967) developed a model of individual dif-
ferences in attachment, interest in the field moved away
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2

from responses to extreme environments to responses to
the “average expectable” environments provided by most
attachment figures. The discovery of disorganized and
unresolved attachment patterns in infants and adults
(Main et al., 1985; Main and Solomon, 1986) has inevitably
led the field back to an integration with research on clin-
ically significant attachment disturbances. It may well be
that the three insecure attachment patterns seen in infants
differentiate into a more varied yet related set of path-
ways in adolescence and adulthood of considerable rele-
vance to PDs, for which disturbances in attachment are
one of the primary features.
At present, attachment constructs call attention to clin-
ically crucial phenomena seen in many adolescents and
adults—ways of representing the self and others in inti-
mate relationships, ways of regulating emotions in close
relationships, and so forth—that are likely to require sub-
stantial time to change over the course of treatment and to
place a priority on using experiences within the therapeu-
tic relationship as a crucible for exploring and altering prob-
lematic patterns. To what extent interventions with the
broader family system, and particularly with the adoles-
cent’s primary attachment figures from childhood, may also
alter adolescent attachment patterns (including ways of rep-
resenting relationships and regulating affects that have pre-
sumably become structuralized over many years of interaction)
is an additional question worthy of empirical attention.
Potential Objections and Limitations
One might raise three primary objections to this study.
First, we measured attachment with a clinician-report
adaptation of a self-report attachment measure. As noted
earlier, this method is probably best described as a hybrid
between narrative and self-report methods, with infer-
ences similar to the former informing clinicians’ ratings
but a format similar to the latter. The strength of the AAI
lies in its ability to transform inferences about the struc-
ture of the subject’s narrative into a description of the
person’s enduring ways of representing and regulating
attachment relationships. Similarly, we relied on clini-
cians as informants, who had an average of 20 sessions
of narratives to “code,” and who, empirically, tend to use
narratives to assess important aspects of personality such
as ways of representing and regulating relationships and
emotion (Westen, 1997). Perhaps most importantly, our
results indicated that our attachment measure, though
imperfect, showed predictable patterns of correlations
with other reliable and valid measures, notably relevant
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ATTACHMENT AND PERSONALITY DISORDERS
scales of the CBCL. Nevertheless, future research on PDs
in adolescents using the AAI is clearly warranted.
Second, the findings reflect data provided by one infor-
mant, the treating clinician. Although multiple infor-
mants would clearly be optimal, several considerations
limit this concern. First, most studies of PDs rely on a
single observer, usually the patient, either through self-
report questionnaires or structured interviews. We believe
the judgments of experts (with an average of more than
14 years’ practice experience, who have known the patient
over an extended period of time) are likely to be at least
as informative as either self-reports or judgments made
in brief interviews, often by lay observers, that sample a
cross-section of verbal behavior on a single day. This is
particularly true given the potential confounds of state
and trait that make assessment of PDs difficult. Nevertheless,
research using multiple data sources, notably studies
including clinician observation, self-report, informant
report, and laboratory tests, is clearly preferable.
Third, the data are correlational and thus cannot address
questions of causality or etiology. In all likelihood, attach-
ment styles in infancy (which themselves are influenced
by heredity, environment, and their interaction) influence
subsequent attachment and personality processes (such as
representations and affect regulation strategies). As children
develop, templates for relatedness, self-understanding, and
affect regulation forged in infancy and early childhood
influence subsequent experiences and choices in ways that
ramify throughout the child’s life, not only in attachment
relationships but also in peer relationships, at school and
work, and so forth. Understanding the links between
attachment and subsequent personality pathology in ado-
lescents and adults will, however, require longitudinal data,
which are now becoming available as infants first assessed
in the Strange Situation are moving into their teens and
twenties, particularly in the high-risk samples.
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