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Journal of Personality Assessment, 93(5), 491–499, 2011

Copyright C Taylor & Francis Group, LLC

ISSN: 0022-3891 print / 1532-7752 online
DOI: 10.1080/00223891.2011.594128

Reliability of Self-Reported Attachment Style in Patients

With Severe Psychopathology
Mental Health Unit, Center of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Rome, Italy
Department of Psychiatry, Catholic University of Rome, Italy
Department of Mental Health, RM-B Local Health Unit, Rome, Italy

Little is known about whether severe psychopathology influences the assessment of self-reported attachment style. Fifty-eight randomly selected
adult psychiatric inpatients completed the Experiences in Close Relationship questionnaire (ECR; Brennan, Clark, & Shaver, 1998) and were
administered the 24-item Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993) and the Hamilton Depression Rating Scale (HDRS; Hamilton,
1960) at both admission and discharge. The Structured Clinical Interview for DSM–IV (SCID–I; First, Spitzer, Gibbon, & Williams, 1996) was
used to establish Axis I diagnoses. The ECR scales showed good internal consistency and absolute stability both in patients with (n = 24) and
without (n = 34) a psychotic disorder. Relative stability was only fair among patients with psychotic disorders but good among patients without
psychotic disorders. Neither higher BPRS or HDRS scores, nor the presence of a psychotic disorder, significantly reduced the retest reliability of
the ECR scales. These findings suggest that self-report measures might provide a reliable assessment of attachment style in patients with severe
psychopathology, except for the most severely impaired patients.

Attachment theory (Bowlby, 1969, 1973, 1980) is a life-span coping strategies, verbal intelligence, social desirability, phys-
developmental theory that has established itself as a fruitful ical attractiveness, and relationship satisfaction (Crowell,
theoretical framework for disciplines as different as develop- Fraley, & Shaver, 1999; Griffin & Bartholomew, 1994; Picardi,
mental psychology, psychoanalysis, psychiatry, cognitive psy- Caroppo, Toni, Bitetti, & Di Maria, 2005). Individuals with
chotherapy, family therapy, personality and social psychology, secure attachment are characterized by relatively low levels of
psychobiology, and psychosomatic medicine. According to at- both attachment-related anxiety and avoidance. They tend to see
tachment theory, humans are born with a disposition to build themselves as valued and worthy of affection, and to see their
and preserve some key intimate relationships that are crucial for partners as trustworthy, reliable, and available to provide support
survival and good health from early childhood to old age. Chil- when needed. Individuals with high attachment-related anxiety
dren rapidly form attachment bonds to their parents and main- tend to be preoccupied with their romantic relationships, to feel
tain them across childhood and into adulthood, and committed unappreciated, and to worry about not being loved enough or be-
romantic relationships emerge in adolescence and gradually be- ing abandoned. Adults with high attachment-related avoidance
come the primary attachment bond for each person. Although tend to experience difficulty trusting or depending on others, to
all humans share this disposition to form intimate bonds, in- be uncomfortable with emotional closeness and intimacy, and
dividuals differ substantially in how they build, maintain, and to hesitate to ask their partner for support.
experience close relationships. The term attachment style refers The current widespread and increasing interest in attachment
to individual differences in emotion regulation and in percep- theory stems from the intriguing findings of a large body
tions of and beliefs about self and significant others (Mikulincer of research carried out in many diverse fields. Parent–child
& Shaver, 2003; Weinfield, Sroufe, Egeland, & Carlson, 1999). interactions and attachment security have been found to be
Two main dimensions, named attachment-related anxiety correlated with a variety of developmental outcomes, such
(about abandonment or insufficient love) and attachment-related as emotional regulation, empathy, social competence, and
avoidance (of intimacy and emotional expression), underlie self-reliance (Allen & Manning, 2007; Attili, 1989; Sroufe,
adult attachment style. Conceptually, they correspond to similar 2005). Attachment insecurity was also found to be associated
dimensions that can be observed in infants in a stressful labora- with increased risk of several physical illnesses (Janković
tory procedure called the Strange Situation (SS), which involves et al., 2009; McWilliams & Bailey, 2010; Mrazek, Casey, &
separations from mother, exposure to an adult stranger, and re- Anderson, 1987; Picardi, Mazzotti, et al., 2005; Picardi,
unions with mother (Ainsworth, Blehar, Waters, & Wall, 1978). Pasquini, Cattaruzza, Gaetano, Baliva, et al., 2003; Picardi,
Attachment-related anxiety and avoidance are related in a theo- Pasquini, Cattaruzza, Gaetano, Melchi, et al., 2003), and a va-
retically consistent way to important constructs such as the Big riety of mental disorders including mood, anxiety, somatoform,
Five factors, temperament, character, self-esteem, self-efficacy, and personality disorders (Bifulco, Moran, Ball, & Bernazzani,
2002; Conradi & de Jonge, 2009; Fossati et al., 2003; Marazziti
et al., 2007; Myhr, Sookman, & Pinard, 2004; Noyes et al., 2003;
Received April 20, 2010; Revised November 22, 2010. Waller, Scheidt, & Hartmann, 2004). Furthermore, research
Address correspondence to Angelo Picardi, Mental Health Unit, Center has uncovered associations between attachment insecurity and
of Epidemiology, Surveillance and Health Promotion, Italian National In- altered autonomic and endocrine reactivity to stress (Ahnert,
stitute of Health, Viale Regina Elena 299, 00161, Rome, Italy; Email: an- Gunnar, Lamb, & Barthel, 2004; Feeney & Kirkpatrick, 1996) and decreased cellular immune function (Picardi et al., 2007).

In recent years, there has been increasing recognition of the respondents’ feelings, thoughts, and behavior not only in
the significance of social cognitive, interpersonal, and affec- attachment relationships such as parent–child relationships and
tive factors in determining vulnerability and outcome in se- committed romantic relationships, but also in other relation-
vere psychiatric disorders (Garety, Kuipers, Fowler, Freeman, & ships such as those with friends, teachers, mentors, or health
Bebbington, 2001). This has led several researchers to assess at- care workers. Although the latter relationships are significant in
tachment security in patients with psychosis. In some studies the patients’ social networks, they are not generally considered
(Dozier, 1990; Dozier, Cue, & Barnett, 1994; Dozier & Lee, to be attachment relationships, as they usually lack one or more
1995; Dozier, Lomax, Tyrrell, & Lee, 2001; Dozier, Stevenson, of the four key features of proximity maintenance, safe haven,
Lee, & Velligan, 1991), the Adult Attachment Interview (AAI; separation distress, and secure base (Hazan & Zeifman, 1999).
Hesse, 1999) was used. In other studies (Mickelson, Kessler, This study was performed on a sample of psychiatric in-
& Shaver, 1997; Mulligan & Lavender, 2010; Ponizovsky, patients with the aim of evaluating whether the reliability of
Nechamkin, & Rosca, 2007; Tait, Birchwood, & Trower, 2004), an established self-report measure of attachment style is in-
a self-report instrument was used to assess attachment security. fluenced by the severity of psychopathology and the presence
Self-report adult attachment measures are easier to adminis- of psychosis. For this purpose, we examined the main aspects
ter than the AAI and might be more amenable to use in clinical of reliability, including internal consistency, absolute stability
practice. Given their focus on conscious thoughts, feelings, and (i.e., the extent to which scores change over time) and rela-
behaviors, the reliability of such measures might nevertheless tive stability (i.e., the extent to which the relative differences
be lower in patients with severe psychopathology who have lim- among individuals remain the same over time). Also, we in-
ited insight into their difficulties. Also, the frequent finding itself vestigated whether greater severity of psychiatric symptoms or
of an association between attachment insecurity and a variety the presence of a psychotic disorder moderates the stability of
of psychiatric disorders raises the possibility that attachment attachment-related anxiety and avoidance. Based on previous
style might include a state component. This would imply that research on self-report assessment in severe mental disorders,
a proportion of the variance in attachment dimensions could be we hypothesized that psychiatric inpatients would be able to
attributable, at least to some degree, to the presence and sever- provide sufficiently reliable judgments of attachment style. We
ity of emotional distress and psychiatric symptoms. Therefore, also expected that the reliability of the assessment would be
the reliability of attachment style measures in patients with se- higher in patients without a diagnosis of psychotic disorder.
vere mental disorders is an important issue for all researchers
interested in the links between attachment and mental health. METHOD
There is a scarcity of studies investigating the extent to which
psychopathology might influence the reliability of self-reported Participants
attachment style. A study of nonclinical respondents (Picardi, This study is part of a larger research project focusing on
Caroppo, et al., 2005) evaluated the stability of attachment di- individual differences and psychopathology. It was performed
mensions by examining their relationship with depressive and in a private psychiatric facility located in Rome and accred-
anxiety symptoms and with short-term changes in these symp- ited by the Italian National Health Service. Adult patients who
toms. In this study, changes in attachment-related anxiety were were consecutively admitted to the inpatient ward over a 3-year
not related to changes in depression or anxiety, and changes enrollment period and clinically determined to be free from
in attachment-related avoidance were modestly correlated with dementia and severe cognitive impairment were invited to par-
changes in depression. ticipate. All patients were given the opportunity to ask further
Almost unexplored is the possible influence of more severe questions about the research project, and those who accepted
psychopathology on self-report assessment of attachment style. were asked to sign a statement of informed consent.
Studies in patients with psychotic disorders that focused on other Two hundred and fifty-three patients admitted during the
constructs suggested that self-rated instruments might have ac- enrollment period met the study inclusion criteria. Fifty-four
ceptable reliability even in severe psychiatric patients. These patients (41 diagnosed with schizophrenia and 13 with
constructs include personality traits (Beauchamp, Lecomte, schizoaffective disorder) had to be excluded as they were either
Lecomte, Leclerc, & Corbière, 2006; Horan, Subotnik, Reise, discharged within a short time (usually to be transferred to a
Ventura, & Nuechterlein, 2005; Kentros et al., 1997), posi- general hospital psychiatric ward) or were judged to be still so
tive psychotic symptoms (Pinto, Gigantesco, Morosini, & La impaired 3 days after admission that they could not be reliably
Pia, 2007), manic symptoms (Altman, Hedeker, Peterson, & assessed. The remaining 199 patients were invited to take part in
Davis, 2001), quality of life (Ritsner, Kurs, Gibel, Ratner, & the project and accepted. Most probably, this high participation
Endicott, 2005; Voruganti, Heslegrave, Awad, & Seeman, 1998), rate resulted from the presentation of the research project as
and therapeutic relationship (Misdrahi, Verdoux, Lançon, & an activity that would provide clinicians with a thorough and
Bayle, 2009). Only one study focused on an attachment mea- comprehensive assessment, which would help in choosing the
sure and reported that attachment-related anxiety and avoidance best treatment for each patient. In this study setting, as well
displayed satisfactory stability over a 1-month period among as in most Italian psychiatric facilities (Santone et al., 2005),
a sample of patients with psychosis (Berry, Barrowclough, & standardized assessment instruments are not routinely used.
Wearden, 2008). However, this study used a newly developed Therefore, patients’ participation was encouraged as they could
patient-oriented questionnaire (Berry, Wearden, Barrowclough, safely receive, at no cost, a comprehensive clinical assessment
& Liversidge, 2006) with items that assess the constructs of with state-of-the-art diagnostic and symptom rating instruments
anxiety and avoidance but do not refer specifically to romantic that otherwise would not have been performed. The results of the
relationships, as patients are asked to think about how they relate interviews and psychopathology rating scales were actually
to key people in their life in general. Therefore, it might assess used in treatment planning, whereas the research instruments,

such as the attachment measure, were not scored before study TABLE 1.—Demographic and clinical characteristics of participants.
Dependent Variable N % M SD
Within 3 days of admission, the participants were admin-
istered a battery of self-report measures, including the Expe- Sex
riences in Close Relationships questionnaire (ECR; Brennan, Male 25 43.1
Clark, & Shaver, 1998), and several clinician-rated instruments, Female 33 56.9
including the Structured Clinical Interview for DSM–IV Axis I Age 43.0 12.4
Marital status
(SCID–I; First, Spitzer, Gibbon, & Williams, 1996), the 24-item Single 32 55.2
Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993), and Married or living with a partner 16 27.6
the 17-item version of the Hamilton Depression Rating Scale Separated or divorced 9 15.5
(HDRS; Hamilton, 1960). Widowed 1 1.7
At admission, nearly four fifths of patients (n = 156, 78%) Primary school or lower 12 20.7
returned a completed ECR. They did not significantly differ Junior high school 15 25.9
(all p > .10) from those who did not on gender (r = .01), age Senior high school 27 46.6
(Cohen’s d = 0.14), education (r = .08), presence of a psychotic University degree 4 6.9
disorder (r = .10), mean BPRS score (Cohen’s d = 0.27), and Primary Axis I diagnosis (SCID–I)
Substance use disorders 5 8.6
mean HDRS score (Cohen’s d = 0.04). This study focuses on Anxiety disorders 2 3.4
a random sample of 58 patients who were selected to complete Bipolar disorders 16 27.6
the ECR again during the 2-day period preceding discharge. Major depressive disorder 9 15.5
The mean of the retest interval was 55 days (range = 15–152, Other mood disorders 3 5.2
Schizophrenia 7 12.1
SD = 33). The use of a random sample was dictated by feasibility Schizoaffective disorder 3 5.2
issues, as the assessment at discharge included the administra- Schizophreniform disorder 1 1.7
tion of all clinician-completed rating scales used in the research Delusional disorder 1 1.7
project and there were not enough resources to perform a Psychotic disorder not otherwise specified 3 5.2
second assessment on all patients. The demographic and clinical Other disorders 2 3.4
No current Axis I diagnosis 6 10.3
characteristics of study participants are summarized in Table 1. Presence of Axis I comorbidity 17 29.3
They did not differ (all p > .70) from the 98 patients who Presence of a psychotic disorder 24 41.4
completed the ECR only at admission on gender (r = .04), ECR Anxiety score at admission 86.8 20.4
age (Cohen’s d = 0.05), education (r = .02), presence of a ECR Avoidance score at admission 53.9 21.9
BPRS total score at admission 43.2 11.3
psychotic disorder (r = .04), mean BPRS score (Cohen’s d HDRS total score at admission 13.9 7.5
= 0.11), and mean HDRS score (Cohen’s d = 0.02). Most
participants (n = 53) were rated on the BPRS and HDRS Note. SCID–I = Structured Clinical Interview for DSM–IV; ECR = Experiences in
at admission, and 49 and 51 participants, respectively, were Close Relationships questionnaire; BPRS = Brief Psychiatric Rating Scale; HDRS =
Hamilton Depression Rating Scale.
administered the BPRS and HDRS before discharge.
From admission to discharge, significant (p < .001) decreases
in mean BPRS scores from 43.1 (SD = 11.3) to 37.0 (SD = 9.4)
and in mean HDRS scores from 13.7 (SD = 7.6) to 9.2 (SD = ual of Mental Disorders (4th ed. [DSM–IV]; American Psy-
6.1) were observed (Cohen’s d = 0.66 and 0.78, respectively). chiatric Association, 1994) diagnoses. Several studies showed
its superior validity over standard clinical interviews at intake
episode (Fennig, Naisberg-Fennig, Craig, Tanenberg-Karant, &
Measures Bromet, 1996; Ramirez Basco et al., 2000). The SCID–I be-
The ECR (Brennan et al., 1998) is a self-report instrument gins with an overview of the patient’s presenting complaints
consisting of 36 items, each scored on a 7-point scale. The in- and history. Then, the interviewer proceeds through several re-
strument provides scores on two dimensions, named Anxiety quired diagnostic modules until the interview is complete. The
and Avoidance. Each scale consists of 18 items, some of which instrument incorporates a categorical system for the rating of
are reverse-keyed, and is scored by summing the scores for symptoms and diagnostic criteria, and algorithms that guide the
all the items constituting the scale. Scores on each ECR scale interviewer through the diagnostic process. When the interview
can range from 18 to 126, with higher scores indicating greater is completed, lifetime and current Axis I diagnoses are recorded
insecurity with respect to the attachment dimension being mea- on a summary score sheet. We used the Italian version of the in-
sured. Individuals scoring high on the Anxiety scale tend to be strument (Mazzi, Morosini, de Girolamo, Lussetti, & Guaraldi,
preoccupied with their romantic relationships, to worry about 2000). In this study, the interviewers based their ratings on all
being abandoned, to desire a high level of closeness to their sources of information available, including not only patients’
partner, and to ask the partner for more feeling and commit- answers and clinical observation, but also referral notes, medi-
ment. Individuals scoring high on the Avoidance scale tend to cal records, and reports of significant others.
avoid emotional closeness and intimacy, to feel uncomfortable The 24-item version of the BPRS (Ventura et al., 1993) is an
opening up to or depending on their partner, and to be reluctant expanded standardized version of the 18-item BPRS (Overall,
to ask their partner for comfort, advice, or help. We used the 1972) with defined scale points and probe questions. It is a
validated Italian version of the instrument (Picardi et al., 2002). clinician-rated instrument consisting of 24 items, scored on a
The SCID–I (First et al., 1996) is a clinician-administered 7-point severity scale, that assess symptoms such as somatic
interview that covers most Axis I disorders and is regarded concern, anxiety, depression, suicidality, guilt, hostility,
as the standard for making Diagnostic and Statistical Man- elevated mood, grandiosity, suspiciousness, hallucinations,

unusual thought content, bizarre behavior, self-neglect, disori- The correlation between the two ECR scales was low (r =
entation, conceptual disorganization, blunted affect, emotional .27 and r = .20 at admission and discharge, respectively). ECR
withdrawal, motor retardation, tension, uncooperativeness, Anxiety score at admission was not significantly correlated with
excitement, distractibility, motor hyperactivity, mannerisms, BPRS total score (r = .14) and showed a significant correlation
and posturing. We used an Italian version of the instrument with only a few BPRS items, namely Anxiety (ρ = 0.33, p <
(Morosini & Casacchia, 1995) that has high reliability (Ron- .05), Depression (ρ = 0.39, p < .01), and Grandiosity (ρ =
cone et al., 1999). We used the 0–6 item response format, –0.30, p < .05). ECR Avoidance score at admission was not
which gives a total score ranging from 0 to 144. Higher scores significantly correlated either with BPRS total score (r = .04)
indicate greater severity of psychiatric symptoms. To complete or with any BPRS item score. Also, ECR Anxiety and Avoid-
the scale, the raters used all sources of information available, ance scores at admission were not significantly correlated with
mainly patient interviews, observations, and clinical charts. HDRS score at admission (r = .20 and r = .10, respectively).
The HDRS (Hamilton, 1960) is probably the most commonly Furthermore, ECR Anxiety scores at either admission or dis-
used clinician-administered rating scale to measure the severity charge were not significantly correlated with age (r = –.10 and
of depressive symptoms. It consists of 17 items, each of which is r = .05, respectively), gender (ρ = .10 and ρ = .12, respec-
rated on either a 5-point (0–4) or a 3-point (0–2) scale. The scale tively), and education (r = –.01 and r = .12, respectively). Sim-
covers a wide variety of symptoms, such as depressed mood, loss ilarly, ECR Avoidance scores at either admission or discharge
of interest in work and activities, retardation, feelings of guilt, were not significantly correlated with age (r = –.07 and r =
loss of insight, psychic anxiety, agitation, insomnia, somatic –.12, respectively), gender (ρ = .12 and ρ = .03, respectively),
anxiety, hypochondriasis, general somatic symptoms, gastroin- and education (r = –.05 and r = –.03, respectively).
testinal symptoms, and weight loss. Scores on the HDRS can Then, the reliability of the ECR scales was examined. To
range from 0 to 52, with higher scores indicating greater sever- assess internal consistency, we calculated coefficient alpha for
ity of depression. We used an Italian version of the instrument ECR scores both at admission, when symptoms were most se-
(Cassano, Conti, & Levine, 1999) for which there is consider- vere, and at discharge, when the majority of patients displayed
able experience in research and clinical practice. The scale was less severe symptoms. To examine absolute stability, we com-
scored based on all sources of information available, mainly pared mean ECR scores on the first and second administration
patient interviews, observations, and clinical charts. with the paired t test. To examine relative stability, we calcu-
The SCID–I, the BPRS, and the HDRS were administered by lated the intraclass correlation coefficient (ICC) between ECR
three experienced raters (a psychiatrist, a clinical psychologist, scores on the first and second administration. All of these anal-
and a senior resident in psychiatry) who received specific train- yses were performed separately for patients with and without a
ing in administering and scoring the instruments prior to the psychotic disorder.
study. The interrater reliability was assessed on three occasions For both ECR scales, the internal consistency was good (co-
during the study period using conjoint interviews of psychiatric efficient α > 0.75) in both patient groups at admission as well
patients in which one rater interviewed the patient and the other as at discharge (Table 2). The alpha values were similar in de-
raters listened to the interview and did not ask clarifying ques- mographic subgroups of age (≤40 vs. >40), gender, marital
tions. Overall, the reliability of the SCID–I as measured by the status (married or living with a stable partner vs. unmarried,
kappa coefficient ranged from .75 to .91 for the more common separated, divorced, or widowed), and education (junior high
diagnoses (psychotic, mood, anxiety, and substance use disor- school or lower vs. senior high school or higher).
ders). The mean interrater reliability of the BPRS and HDRS as The absolute stability of the ECR scales was also good, as
measured by intraclass correlation was found to be .81 and .85, the change in scores over time was nonsignificant in both pa-
respectively. tient groups, with negligible to small effect sizes. Patients with
a diagnosis of psychotic disorder showed greater changes (see
Table 2), and we observed a different direction of change in ECR
scores among psychotic and nonpsychotic patients. A repeated-
RESULTS measures analysis of variance (ANOVA) with presence of a
The mean scores on both ECR scales (Table 1), particularly psychotic disorder as between-subject factor and time of assess-
the Anxiety scale, were relatively high as compared with those ment as within-subjects factor revealed a significant, F(1, 56) =
observed in previous studies using the same Italian version on 4.48, η2 = 0.07, and a nearly significant, F(1, 56) = 3.67, η2 =
nonclinical respondents, either undergraduate and graduate stu- 0.06, Group × Time interaction for the Avoidance and Anxiety
dents (Cohen’s d = 0.83 for Anxiety and 0.36 for Avoidance; scale, respectively.
Picardi, Caroppo, et al., 2005) or nurses (Cohen’s d = 1.06 for The relative stability was high (ICC > .80) for both ECR
Anxiety and 0.65 for Avoidance; Picardi et al., 2007). The small scales among patients without a psychotic disorder, whereas it
size of the most common diagnostic groups (schizophrenia and was lower (ICC = .45–.46), although still statistically signifi-
other nonaffective psychoses, bipolar disorder, unipolar depres- cant (p < .01), among patients with a psychotic disorder (see
sion, substance use disorders) prevented formal statistical test- Table 2). The ICC values did not greatly differ by education
ing of differences in mean ECR scores. Only small to moderate subgroup, whereas they were lower in the male, younger, and
differences between groups were observed in attachment-related nonmarried subgroups. This finding is likely to be ascribed to
anxiety, with mean scores ranging from 79.4 to 89.9, whereas the much greater proportion of psychotic patients in the latter
more pronounced differences were observed in attachment- three demographic subgroups.
related avoidance, with patients with substance use disorders Finally, moderated regression analysis was used to exam-
showing the lowest (31.6) and patients with nonaffective psy- ine whether greater severity of symptoms or the presence of a
choses having the highest (61.3) mean scores. psychotic disorder moderate the stability of attachment-related

TABLE 2.—Reliability of ECR scales by presence of a diagnosis of psychotic (49–73), two of whom had low education (primary school or ju-
disorder. nior high school), were identified and excluded from this model.
Anxiety Avoidance
The second model (Table 4) included ECR Avoidance and BPRS
No No
scores. No outliers were found. In both models, the only predic-
Diagnosis Diagnosis Diagnosis Diagnosis tor of ECR Anxiety and Avoidance score at discharge was the
of Psychotic of Psychotic of Psychotic of Psychotic corresponding ECR score at admission, and no interaction effect
Disorder Disorder Disorder Disorder was found. These findings suggest that greater overall severity
of psychiatric symptoms does not affect the retest reliability of
Internal consistency the ECR.
Coefficient alpha 0.93 0.77 0.89 0.85
(admission) The third model (Table 3) included ECR Anxiety and the
Coefficient alpha 0.91 0.89 0.91 0.84 presence of a psychotic disorder. No outliers were found. Both
(discharge) ECR Anxiety score at admission and the presence of a psy-
Relative stability chotic disorder predicted ECR score at discharge. There was
ICC (95% CI) 0.83∗∗ 0.45∗ 0.84∗∗ 0.46∗
(0.70–0.91) (0.08–0.71) (0.71–0.92) (0.10–0.72)
also a trend toward an interaction between predictors (p = .07).
Absolute stability The fourth model (Table 4) included ECR Avoidance and the
Mean (SD) score 87.0 (21.9) 86.5 (18.6) 51.1 (25.4) 57.9 (15.2) presence of a psychotic disorder. No outliers were found. Only
at admission ECR Avoidance score at admission predicted ECR score at dis-
Mean (SD) score 88.8 (22.4) 80.3 (19.0) 54.0 (23.1) 52.1 (19.5) charge, and the presence of a psychotic disorder fell short of
at discharge
Cohen’s d 0.14 –0.32 0.22 –0.33 statistical significance (p = .08). No interaction between pre-
dictors was detected. These findings suggest that the presence
Note. ICC = intraclass correlation coefficient (between scores at admission and dis- of a psychotic disorder might slightly reduce the reliability of
charge); CI = confidence intervals.

p ≤ .01. ∗∗ p ≤ .001.
the ECR Anxiety scale, but not of the Avoidance scale.
The fifth model (Table 3) included ECR Anxiety and HDRS
scores. Two outlier cases, both of whom had a low level of
anxiety and avoidance. Six separate regression models were education (primary school or junior high school), were identi-
built. They tested the hypotheses that greater overall severity of fied and excluded from this model. The sixth model (Table 4)
psychiatric symptoms as measured by the BPRS, or the pres- included ECR Avoidance and HDRS scores. No outliers were
ence of a psychotic disorder, or higher levels of depression as found. In both models, the only predictor of ECR Anxiety and
measured by the HDRS, reduces the retest reliability of the ECR Avoidance score at discharge was the corresponding ECR score
scales. In each model, the dependent variable was either the ECR at admission, and no interaction effect was found. These find-
Anxiety or Avoidance score at discharge. In the first block, the ings suggest that higher severity of depressive symptoms does
corresponding ECR score at admission and either the BPRS or not affect the retest reliability of the ECR.
HDRS total score at admission or the presence of a psychotic
disorder were centered and entered as predictors. In the second DISCUSSION
block, the product interaction of the two centered predictors Currently, the ECR questionnaire is one of the most estab-
was entered. Prior to each regression analysis, Mahalanobis dis- lished instruments to measure adult attachment style. It has been
tance was computed to screen for multivariate outliers using a used extensively by researchers in several countries to investi-
conservative criterion of p < .001. gate links between attachment insecurity and a variety of corre-
The first model (Table 3) included ECR Anxiety and BPRS lates including genetic polymorphisms related to emotions and
scores. Three outlier cases with high BPRS scores at admission social behavior (Gillath, Shaver, Baek, & Chun, 2008), immune

TABLE 3.—Summary of hierarchical regression analyses with ECR Anxiety score at discharge as dependent variable, and ECR Anxiety at admission and either
BPRS scores at admission, presence of a psychotic disorder, or HDRS scores at admission as independent variables (n = 53, 58, and 53, respectively).

ECR ECR Anxiety × ECR

ECR Anxiety × ECR Psychotic Psychotic ECR Anxiety ×
Anxiety BPRS BPRS Anxiety Disordera Disorder Anxiety HDRS HDRS

Model 1
B 0.76 –0.04 0.73 –8.22 0.60 0.33
SE B 0.09 0.17 0.10 3.99 0.11 0.30
β .80∗∗ –.03 .70∗∗ –.19∗ .63∗∗ .12
R2 .63 .52 .44
F for change in R2 39.58∗∗ 30.41∗∗ 19.20∗∗
Model 2
B 0.80 –0.07 0.001 0.70 –8.27 –0.38 0.62 0.34 0.002
SE B 0.10 0.17 0.01 0.10 3.91 0.20 0.11 0.30 0.02
β .84∗∗ –.04 .11 .67∗∗ –.19∗ –.17 .65∗∗ .12 .15
R2 .64 .55 .46
F for change in R2 1.29 3.52 1.84

Note. ECR = Experiences in Close Relationships questionnaire; BPRS = Brief Psychiatric Rating Scale; HDRS = Hamilton Depression Rating Scale.
No = 0, yes = 1.

p < .05. ∗ ∗ p < .001.

TABLE 4.—Summary of hierarchical regression analyses with ECR avoidance score at discharge as dependent variable, and ECR avoidance at admission and either
BPRS scores at admission, presence of a psychotic disorder, or HDRS scores at admission as independent variables (n = 53, 58, and 53, respectively).

ECR Avoidance × ECR
ECR Avoidance ECR Psychotic Psychotic ECR Avoidance
Avoidance BPRS × BPRS Avoidance Disordera Disorder Avoidance HDRS × HDRS

Model 1
B 0.74 0.28 0.74 –7.02 0.71 0.29
SE B 0.09 0.17 0.09 3.94 0.09 0.28
β .75∗ .14 .75∗ –.16 .72∗ .10
R2 .590 .559 .55
F for change in R2 36.05∗ 34.79∗ 30.57∗
Model 2
B 0.74 0.26 –0.0002 0.71 –6.65 –0.14 0.68 0.22 0.002
SE B 0.10 0.19 0.01 0.10 4.00 0.22 0.10 0.28 0.01
β .74∗ .14 –.02 .72∗ –.15 –.06 .69∗ .08 –.12
R2 .591 .562 .56
F for change in R2 0.03 0.40 1.53

Note. ECR = Experiences in Close Relationships questionnaire; BPRS = Brief Psychiatric Rating Scale; HDRS = Hamilton Depression Rating Scale.
No = 0, yes = 1.

p < .001.

function (Picardi et al., 2007), brain activity (Gillath, Bunge, 1987), whereas the other (Berry et al., 2008) used a newly de-
Shaver, Wendelken, & Mikulincer, 2005) and structure (Quirin, veloped patient-oriented questionnaire (Berry et al., 2006) not
Gillath, Pruessner, & Eggert, 2010), anxiety sensitivity (Weems, focusing specifically on romantic relationships.
Berman, Silverman, & Rodriguez, 2002), and vulnerability to For both attachment-related anxiety and avoidance, the inter-
physical (Jancović et al., 2009; Picardi, Mazzotti, et al., 2005b; nal consistency was high in nonpsychotic patients and in patients
Picardi, Pasquini, Cattaruzza, Gaetano, Baliva, et al., 2003; with a diagnosis of psychosis. The former showed coefficient al-
Picardi, Pasquini, Cattaruzza, Gaetano, Melchi, et al., 2003) pha values as good as those obtained in nonclinical respondents
and mental (Marazziti et al., 2007) health problems. Its popular- (Brennan et al., 1998; Picardi et al., 2002), whereas the latter dis-
ity has led to the development of several versions, including a played only slightly lower values of alpha. Of note, there were
revised (Sibley, Fischer, & Liu, 2005), shortened (Wei, Russell, only small differences in internal consistency between admis-
Mallinckrodt, & Vogel, 2007), and modified (Lo et al., 2009) sion and discharge, when most patients experienced a substantial
form. decrease in symptom severity. Furthermore, both at admission
Little is known, however, regarding the use of the ECR ques- and at discharge, the degree of intercorrelation between Anx-
tionnaire and similar instruments in individuals with severe psy- iety and Avoidance scores was low and of similar magnitude
chopathology, and conceptual concerns might be raised about to that observed in individuals free from psychiatric morbidity.
using a self-report instrument with individuals who could have In a recent meta-analysis of studies using the ECR, the average
limited or impaired introspection, such as psychiatric inpatients. correlation between anxiety and avoidance was .15 (Finnegan
If attachment theory is to inform and advance our understand- & Cameron, 2009). Overall, these findings suggest that patients
ing of severe psychiatric disorders (Berry, Barrowclough, & answered questions consistently on both ECR scales.
Wearden, 2007), it is important to demonstrate that measures of In nonpsychotic patients, the absolute stability of attachment-
attachment styles are not confounded by the presence of severe related anxiety and avoidance was high. In these patients, the
psychopathology. mean change in ECR scores between admission and discharge
At admission, attachment-related anxiety and avoidance did after an average of about 2 months was negligible to small
not significantly correlate with BPRS and HDRS scores and dis- and was comparable to the change observed over a 1-month
played modest correlations with a few BPRS items. This finding period among nonclinical participants (Cohen’s d = 0.10 and
is consistent with the low (6% or less) proportion of variance 0.04 for Anxiety and Avoidance, respectively; Picardi, Caroppo,
in ECR scores that was found to be independently explained by et al., 2005). In a previous study, Berry et al. (2008) did not
measures of depression and anxiety among nonclinical partici- observe significant differences between baseline and 1-month
pants (Picardi, Caroppo, et al., 2005). Although two recent stud- follow-up attachment style scores in a sample of 33 patients with
ies of patients with psychosis reported an association between psychosis. In our study, the absolute stability of ECR scales in
positive psychotic symptoms and attachment-related avoidance patients with a psychotic disorder was moderate. They showed
(Berry et al., 2008; Ponizovsky et al., 2007) or anxiety (Poni- a greater degree of change in both ECR scales, and the findings
zovsky et al., 2007), they cannot be directly compared with ours of a repeated-measures ANOVA suggested that the presence of
because of differences in the study population and assessment. a psychotic disorder affects the absolute stability of ECR scales,
These studies included only patients with schizophrenia and although the effect sizes were relatively small.
they both used the Positive and Negative Syndrome Scale (Kay, The relative stability of attachment-related anxiety and
Fiszbein, & Opler, 1987) to assess psychopathology. To mea- avoidance was high among nonpsychotic patients, who showed
sure attachment style, one study (Ponizovsky et al., 2007) used ICC values slightly higher than those obtained in nonclinical
Hazan and Shaver’s three-category measure (Hazan & Shaver, participants (ICC = .82 and .79 for Anxiety and Avoidance,

respectively; Picardi, Caroppo, et al., 2005). The relative Altman, E., Hedeker, D., Peterson, J. L., & Davis, J. M. (2001). A comparative
stability was only fair among patients with a psychotic disorder. evaluation of three self-rating scales for acute mania. Biological Psychiatry,
A recent study of patients diagnosed with psychosis reported 50, 468–471.
higher levels of relative stability of scores (Berry et al., 2008). American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
However, its findings cannot be directly compared with ours
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due to differences in the focus of the assessment (experiences in tween home relationships and behaviour problems in preschool. In B. H.
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relative stability of ECR scores over a 2-month interval on profiles? Schizophrenia Research, 85, 162–167.
average is quite satisfactory from a psychometric perspective. Berry, K., Barrowclough, C., & Wearden, A. (2007). A review of the role of adult
Further support for the reliability of the ECR in patients with attachment style in psychosis: Unexplored issues and questions for further
severe mental disorders was also provided by the results of the research. Clinical Psychology Review, 27, 458–475.
Berry, K., Barrowclough, C., & Wearden, A. (2008). Attachment theory: A
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of psychiatric symptoms nor the presence of a psychotic dis- psychosis. Behaviour Research and Therapy, 46, 1275–1282.
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The authors are grateful to Dr. John Kurtz for his thoughtful Dozier, M., & Lee, S. (1995). Discrepancies between self- and other- report
and detailed comments and his very helpful suggestions. They of psychiatric symptomatology: Effects of dismissing attachment strategies.
also thank two anonymous reviewers for their constructive crit- Development and Psychopathology, 7, 217–226.
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