Attachment styles as determinants of depression in adult patients with psychiatric disorders

Corresponding Author:

Zainab Khan
Institute of Clinical Psychology
University of Karachi, Pakistan
E-mail: znb.khan333@gmail.com

Abstract

Objective: To find out the predictive relationship between adult attachment styles and depression in patients diagnosed with Schizophrenia, Obsessive-Compulsive Disorder (OCD), and Substance-Related and Addictive Disorders.

Methodology: A total of 130 patients (100 males 30 females) with an age range of 18-55 years, among which 49 were diagnosed with Schizophrenia, 30 with OCD, and 51 with Substance-Related and Addictive Disorders. The sample was recruited from Outpatient Departments (OPDs) of psychiatry of government and private hospitals through purposive sampling technique. The hypothesis for this study was “Depression would be predicted from Adult Insecure Attachment Styles in-patients with Schizophrenia, OCD and with Substance-Related and Addictive Disorders.” Urdu versions of Revised Adult Attachment Style (RAAS) were used to assess adult attachment styles, and Patient Health Questionnaires (PHQ-9), used to assess depression, along with that a demographic form was employed.

Results: Simple linear regression was calculated by using SPSS (22-version). Data analysis suggests 12.6% of the variance in depressive symptoms was explained by insecure attachment style (R2=0.126, F (1)=5.177, p ≤ 0.002).

Conclusion: These findings support a direct predictive relationship between insecure attachment style in adult patients with schizophrenia, OCD, and Substance-Related and Addictive Disorders. In conclusion, attachment anxiety and attachment-related avoidance link to depression in our South Asian culture. These findings are impactful especially when it comes to diagnosis, treatment planning, and interventions in a clinical population.

Keywords

insecure attachment styles, depression

Introduction

■ Insecure attachment leads to depression

Attachment-related research has recently started focusing on the role of insecure attachment in the development and maintenance of different psychiatric disorders [1] especially depression [2,3]. A growing body of western literature suggests the relationship between adult attachment styles and depression [4-6]. These studies have never claimed of establishing a causal relationship between insecure attachment and depression.

■ Attachment related anxiety and avoidance and their association with depression

Secure attachment has been studied in the context of all developmental phases like during childhood, adolescents, and adulthood, and attachment-related security is found to be associated with greater wellbeing in adulthood [7] however, attachment-related anxiety and attachment-related avoidance has been associated with higher levels of stress, anxiety and worrying [8].

Attachment theory provides meaningful insight into the underlying mechanisms involved in affect regulation, proper interpersonal skills, and depression [9]; that being the case psychosocial theories for mood disorders specifically depression resembles attachment theory [10]; like the stress model for depression that has highlighted neglect and or any form of abuse in childhood, lack or absence of supportive structures and poor self-esteem as high-risk elements for developing depression [11].

■ Attachment and depression

The attachment has been studied in patients with a primary diagnosis of depression however we also see studies on samples extracted from a pool of patients with schizophrenia [12- 15], OCD [16] and Substance-Related and Addictive Disorders as a primary diagnosis but they also develop depression along the course of their illness. So the relevance of attachment and depression to these psychiatric vulnerabilities seems plausible. Does this study attempt to understand whether the presence of insecure attachment can lead to depression in these patients? For this study patients with schizophrenia, OCD, and Substance-Related and Addictive Disorders were chosen, because existing literature also shows that depression has been predicted in patients with a primary diagnosis of schizophrenia, OCD, and Substance-Related And Addictive Disorders.

For example, in multiple studies conducted on patients diagnosed with schizophrenia, the role of attachment styles and attachment-related anxiety/avoidance has been assessed to see whether attachment-related insecurities predict depression or not? In a sample of patients with schizophrenia, hopelessness was predicted by an avoidant form of attachment while low selfesteem was predicted by attachment-related anxiety [17]. Similarly, attachment anxiety and attachment avoidance predicted depression and anxiety in a study by Lee, and Hankin, [18] however, attachment was found more associated with internalizing symptoms of depression. Likewise in a study by Bryers [19], patients on the schizophrenia spectrum were found insecurely attached and that also predicted depression.

A person that cannot develop positive Interworking Models (IWMS) for self and/or for others because of childhood abuse/neglect, poor support then he might have difficulty forming, establishing, and sustaining relationships. These experiences of rejection, isolation, abuse, and neglect are very painful. Such a person would be more susceptible to a low sense of worth and self-worth is supposed to be a major asset for human growth.

Since depression is a highly comorbid condition in other psychopathologies the role of insecure attachment in the development of dysfunctional relationships and negative self IWM increases the vulnerability of a person to develop depression pre or post to developing schizophrenia, OCD, and Substance-Related and Addictive Disorders. Insecure attachment is one of the most pervasive factors for the development of depression in different psychopathologies.

Taking literature into account, in this study association of insecure attachment styles with depression will be studied. Association of insecure attachments in adulthood with schizophrenia, obsessive-compulsive disorder, and Substance-Related and Addictive Disorders will be explored. Furthermore, the most important question which the researcher wants to answer is to understand the role of insecure attachments in the development and maintenance of depression in patients diagnosed with schizophrenia, obsessive-compulsive disorder, and Substance-Related and Addictive Disorders.

Methodology

■ Sample

In this study 130 patients (Males N=100, and Females N=30, M age=30.76 years, SD=8.76, range18-55) were included. Patients having 3 distinct diagnostic categories were recruited through purposive sampling. Patients with schizophrenia and OCD diagnosis were approached in 3 different centers of a private welfare psychiatric hospital along with another government psychiatric hospital through psychiatric referral while patients in the Substance-Related and Addictive Disorders group were approached in welfare trust rehabilitation vicinity, who were under treatment and institutionalized. Patients in the Schizophrenia group included outpatients (N=49, M age=32 years, SD=9.24, range18-55); in the Substance-Related and Addictive Disorders group in-patients were included (N=51, M age=28.8 years, SD=7.705, range 18-55) while in the OCD group outpatients were included (N=30, M age=31.8667 years, SD=9.287, range18-55). All the patients were already diagnosed and under treatment and were included in the study after having semistructured clinical interviews (Case History Sheet of Institute of Clinical Psychology) and meeting diagnostic criteria of DSM-V (APA, 2013) to confirm the diagnoses.

■ Measures

Case History Sheet of Institute of Clinical Psychology: It is a semi-structured interview form designed by the Institute of Clinical Psychology (ICP), University of Karachi, and is used with patients visiting the Out-Patient Department (OPD). With this qualitative instrument, a tentative diagnosis is made based on DSM-V (APA, 2013) criteria set of symptoms that clinicians observe in the interviewed information covering patients basic demographic information, presenting complaints, history of onset of symptoms and course of illness, medical, educational, professional history of the patient, social and interpersonal relationship history with family, friends, and colleagues, martial and sexual history details are recorded and mental health status is examined. The interview process usually takes 30 to 40 minutes varying from case to case.

Revised Adult Attachment Scale-Close Relationships Version: Revised Adult Attachment Scale is back-translated for use in this study. RAAS is a widely used reliable and valid tool. It is 18 items, 5 points Likert scale with 1=Not at all characteristic of me and 5= characteristic of me. Item 2,7,8,13,16,17 and 18 are reverse scored (as 1=5, 2=4, 3=3, 4=2, 5=1). It creates scores for three subscales (each having 6 items) that are Close, Depends, and Anxiety subscales so that scores for continuous attachment dimensions regarding attachmentrelated anxiety and attachment-related avoidance can be created. The Close subscale (0.85 Cronbach’s alpha coefficient value) measures a person’s level of comfort with closeness and intimacy in relationships significant to him. Close Subscale score is obtained by calculating mean (of item AT1, AT6, AT8R, AT12, AT13R, AT17R). The Depend subscale (with 0.88 Cronbach’s alpha coefficient value) shows how one feels to depend on others’ availability when they are needed and a score is obtained after calculating the mean (of items AT2R, AT5, AT7R, AT14, AT16R, AT18R). The anxiety subscale (with 0.83 Cronbach’s alpha coefficient value) is also a 6 item subscale like the other two subscales however it measures one’s anticipatory anxiety regarding being loved or susceptibility towards rejection and abandoning experiences in a close relationship. The score is obtained by calculating the mean (of item AT3, AT4, AT9, AT10, AT11, AT15).

Furthermore, RAAS can also yield into four different attachment styles (secure, preoccupied, fearful & dismissing) along continuous dimensions of attachment as recommended by Bartholomew. As per the author’s recommendations, this procedure has got some loopholes it and this procedure must be adopted with caution as there is a high chance of losing important data so using continuous dimensions along with style is the more suitable procedure which is utilized in the current study. So the SPSS commands are supposed to create four distinct styles regarding cut-off scores or midpoint of the calculated mean on a particular attachment subscale. For example, a person with a secure attachment style is supposed to score high or above midpoint on the combined close Dependent mean (i.e. 5 point scale) and low on anxiety dimension. This means that people falling just on the midpoint will be excluded from the data and in our study, 13% of the population falls just at the midpoint, hence in the analysis of attachment styles, they are not included. Following the procedure yielded given below styles.

Applying this procedure we can have following 4 attachment styles:

(CLOSDEP GT 3) AND (ANXIETY LT 3) STYLE = 1.

(CLOSDEP GT 3) AND (ANXIETY GT 3) STYLE = 2.

(CLOSDEP LT 3) AND (ANXIETY LT 3) STYLE = 3.

(CLOSDEP LT 3) AND (ANXIETY GT 3) STYLE = 4.

After back translating RAAS into Urdu The close, Depend, and Anxiety subscales yielded internal consistencies with Cronbach’s alpha coefficient values of 0.638, 0.657, and 0.642 respectively.

The Patient Health Questionnaire depression scale (PHQ-9) Urdu Translation: PHQ-9 is a self-administered brief inventory to screen and diagnose depression. For the current study, PHQ-9 has been back-translated into Urdu and it is found to be internally consistent with Cronbach’s alpha coefficient values of 0.78.

■ Procedure

Already diagnosed patients with Schizophrenia, Substance-Related and Addictive Disorders, and OCD were approached in OPD sittings in different psychiatric setups, after consent for participation in the study, they were asked to read and sign the informed consent. Questionnaires were administered individually. Each patient participating in the study was first interviewed by the researcher using ICP semi-structured interview form and then demographic form, PHQ-9, and RAAS were administered. After filling out all the forms and questionnaires they were debriefed by the examiner about the purpose of the study. Confidentiality of the patient was made sure at each step of the study and all the ethical rules were well-enforced after approving the study from the ethical board review committee and taking permission for collecting data from the concerned authorities.

■ Statistical analysis

All the statistics involving descriptive and inferential statistics were performed using SPSS- 22. Mean Median and Standard deviations were performed for Descriptive statistics while to study the predictive relationship between insecure attachment and depression, linear Regression Analysis was performed. For this study, insecure attachment styles including secure, preoccupied, dismissive, and fearful were studied as independent variables, and attachment was also studied on a dimensional level that is attachment anxiety and attachment avoidance as the independent variable while depression was studied as the dependent variable to see if any form of insecure attachment is responsible for any variance in depressive scores, using regression analysis.

Results

This chapter is focused on the statistical analysis of the obtained research data. The statistical package of social sciences (SPSS, version 22.0) has been used for this purpose and the data is analyzed with a significance level of 0.05. Descriptive statistics and linear regression is mainly utilized for assessing the major four hypotheses TABLE 1 and TABLE 2.

TABLE 1. Summary of Demographic Characteristics of Overall Sample.

TABLE 2. Prevalence of Attachment styles in patients.

■ Demographic characteristics of the sample

Depression is expected to be prevalent among patients diagnosed with obsessive-compulsive disorder, schizophrenia and substance use, and related disorders TABLE 3.

TABLE 3. Prevalence of Depression in patients.

Hypothesis

The following tables show the outcome of linear regression analysis investigating the hypothesis of the study i.e. “Insecure Attachment styles would predict depression in patients diagnosed with the obsessive compulsive disorder, schizophrenia and substance use and related disorders TABLE 4. That is patients with any insecure type of attachment style (i.e. Preoccupied, dismissive and fearful) would have increased depression”. The findings of the first hypothesis are illustrated in TABLE 5. As anticipated, the findings show that insecure attachment style significantly predicts (R2=0.126, F (1)=5.177, p=<0.002), depression among patients with obsessive-compulsive disorder, schizophrenia, and substance use disorder.

TABLE 4. Summary of Linear Regression analysis of Insecure Attachment Style as a predictor of depression in overall sample.

TABLE 5. Summary of Coefficients of Insecure Attachment style as a predictor of depression in overall sample.

Discussion

Attachment theory suggests that proximity contributes as an emotional resource in situations of loss or illness, serving as a stress regulator. Studies also show that an insecure attachment style leads to anxious and avoidant relationships with a prominent difficulty in interpersonal relationships. Review of western literature and theory Bowlby [20] also reflects the strong relationship between failure in internalizing secure attachment styles and pathological forms of mourning, grieving, and depression. The real or perceived unavailability and lack of validation by an attachment figure easily become distressing and a debilitating experience.

The present study is summarized and thoroughly discussed here, with the help of empirical research evidence in the area of Adult Attachment and Depression. The observed findings communicate the impact of attachment styles on Depression. Moreover, the interrelation of adult attachment styles with the development of depression was yet to be explored in the Pakistani cultural context, therefore the present study aims to evaluate Attachment styles as a determinant of depression in patients diagnosed with Schizophrenia, Substance-Related, and Addictive Disorders, and OCD.

Many studies suggest strong predictive relationships between clinical depression and schizophrenia [21-24], Substance-Related and Addictive Disorders [25,26] and OCD [27-30].

So one major aim of this study was to study the prevalence of depression in patients who are diagnosed with schizophrenia, Substance-Related And Addictive Disorders, and OCD, and our findings suggest that 10 % of the total population was found to be mildly depressed, 21.5% were moderately depressed, 26.2% were moderately severely depressed and 42.2% (TABLE 3) were found to be severely depressed as per phq-9 categorization of depression.

Therefore, the prime objective of this study was to observe depression prevalence in our sample that are patients already diagnosed with schizophrenia, Substance-Related and Addictive Disorders, and OCD. Findings suggest that 10% of the total population has shown to be mildly depressed, 21.5% moderately depressed, 26.2% moderately severe depressed and 42.2% (TABLE 3) were found to be severely depressed as per phq-9 categorization of depression. These findings are consistent with existing literature.

Furthermore, another major objective of this study was to explore attachment styles and associated attachment dimensions in psychiatric patients with a presumption of their insecure attachment styles. Literature suggests that insecure attachment predicts and possibly leads to psychopathologies in adulthood [31,32]. The findings of this study are confirming our prediction regarding the presence of insecure attachment in patients with a diagnosis of schizophrenia, OCD and Substance-Related and Addictive Disorders for example secure attachment style was present in 33.8% of the total sample while the rest of the 66.2% of the sample was having insecure attachment styles. Among the patients having insecure attachment styles, 19.2% were having preoccupied, 19.2% with dismissive, and 17.7% having fearful attachment styles (TABLE 3) which shows that sample of this study was found to be significantly insecure in close relationships.

Attachment Styles predicts depression

This study hypothesis proposes the prediction of depression in patients diagnosed with the obsessive compulsive disorder, schizophrenia, and substance-use-related disorders. Specifically with the patients, conforming to the insecure type of attachment style (i.e. Preoccupied, Dismissive, and Fearful). The findings are illustrated in TABLE 4 and TABLE 5. As expected, 12.6% of the variance in depressive scores (R2=0.126, F (1)=5.177, p=<0.002) is significantly explained by insecure attachment styles in our sample.

Given findings agree with former studies which revealed an association of attachment styles with depression [33-35]. For example, depression in adulthood was found to be associated with unresolved (fearful) and preoccupied attachment styles in a meta-analysis of 55 samples (N=4386) [36]. Another study on clinical depression in a community-based high-risk sample of women confirms the presence of all forms of insecure attachment styles including preoccupied, dismissive, and fearful [37].

According to the previous studies, the preoccupied and fearful style of attachment are products of poor self-image which ensues high attachment anxiety and attachment-related avoidance. This intern makes it harder for people to get close to others or depend on others when it comes to building and maintaining relationships. So a person’s low expectations from himself, make them anticipate about responsiveness and emotionally unavailability of others in close relationships, which further adds up to vulnerability towards the development of low self-esteem and depression. This concludes that any form of insecure attachment can lead to serious psychological symptoms specifically depression in adulthood due to their unavoidable and negative impacts [34,38,39].

It is well established in the research that a poor model for self is associated with self-critical attitude, and an individual’s self-criticism on a higher scale is expected to cause low dependency dimensions including increased depressive symptoms, reportedly. Therefore, rather than reaching out for support or help when in need, these individuals strive for selfsufficiency because they think of themselves as unworthy of love or support and assume others to be genuinely uninterested which makes them vulnerable to developing depression. Several types of research indicate low perceived social support associated with depression [40].

Furthermore, poor social functioning in dismissively and fearfully attached individuals is reflective of their poor model of others, so they are unable to activate their social environment, especially in stressful situations which otherwise help securely attached individuals in proximity seeking and affect regulation. According to Besser, et al. [41] lack of mutually satisfying and secure perception of interpersonal relationships with poor affect regulation and inculcating loneliness is interconnected with a strong perception of anticipated unsupportiveness.

Conclusion

Attachment in psychiatric patients has rarely been studied in the Pakistani population and that too in the adult population, this is why this study is a noteworthy initiative in this regard. This study was designed to study the predictive relationship of attachment styles with depression, findings of the study confirm the prevalence of insecure attachment styles and depression and their predictive relationship in our sample that was based on adult patients with a diagnosis of schizophrenia, Substance-Related and Addictive Disorders.

References

1. Ward MJ, Lee SS, Polan HJ. Attachment and psychopathology in a community sample. Attach Hum Dev. 8, 327-340 (2006).
2. Stovall-McClough KC, Dozier M. Attachment states of mind and psychopathology in adulthood. Handbook Attach: The, Res, Clin App. 3, 715-738 (2016).
3. Gerlsma C, Luteijn F. Attachment style in the context of clinical and health psychology: a proposal for the assessment of valence, incongruence, and accessibility of attachment representations in various working models. Br J Med Psychol. 73, 15-34 (2000).
4. Bifulco A, Moran PM, Ball C, et al. Adult attachment style II: Its relationship to psychosocial depressive-vulnerability. Soc Psychiatry Psychiatr Epidemiol. 37, 60-67 (2002).
5. Cooley EL, Garcia AL. Attachment style differences and depression in African American and European American college women: Normative adaptations. J Multicul Couns Dev. 40, 216-226 (2012).
6. Eng W, Heimberg RG, Hart TA, et al. Attachment in individuals with social anxiety disorder: The relationship among adult attachment styles, social anxiety, and depression. Emotion.1, 365-380 (2001).
7. Dozier M, Stovall KC, Albus KE. Attachment and psychopathology in adulthood. In J Cassidy, PR Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications. 497-519 (2008).
8. Wright CJ, Clark GI, Rock AJ, et al. Intolerance of uncertainty mediates the relationship between adult attachment and worry. Person Indiv Differ. 112, 97-102 (2017).
9. Sroufe LA. Attachment and development: A prospective, longitudinal study from birth to adulthood. Attach Hum Dev. 7, 349-367 (2005).
10. Brown GW, Bifulco A, Veiel HOF, et al. Self-esteem and depression. Soc Psychiatry Psychiatr epidemiol. 25, 225-234 (1990).
11. Bifulco A, Kwon J, Jacobs C, et al. Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety. Soc Psychiatry Psychiatr Epidemiol. 41, 796-805 (2006).
12. Berry K, Barrowclough C, Wearden A. Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis. Behav Res Ther. 46, 1275-1282 (2008).
13. MacBeth A, Gumley A, Schwannauer M, et al. Attachment states of mind, mentalization, and their correlates in a first episode psychosis sample. Psychol Psychother. 84, 42-57 (2011).
14. Sitko K, Bentall RP, Shevlin M, et al. Associations between specific psychotic symptoms and specific childhood adversities are mediated by attachment styles: an analysis of the National Comorbidity Survey. Psychiatry Res. 217, 202-209 (2014).
15. Wickham S, Sitko K, Bentall RP. Insecure attachment is associated with paranoia but not hallucinations in psychotic patients: the mediating role of negative self-esteem. Psychol Med. 45, 1495-1507 (2015).
16. Myhr G, Sookman D, Pinard G. Attachment security and parental bonding in adults with obsessive‐compulsive disorder: a comparison with depressed out‐patients and healthy controls. Acta Psychiatrica Scandinavica. 109, 447-456 (2004).
17. Ringer JM, Buchanan EE, Olesek K, et al. Anxious and avoidant attachment styles and indicators of recovery in schizophrenia: Associations with self‐esteem and hope. Psychol Psychother. 87, 209-221 (2014).
18. Lee A, Hankin BL. Insecure attachment, dysfunctional attitudes, and low self-esteem predicting prospective symptoms of depression and anxiety during adolescence. J Clin Child Adolesc Psychol. 38, 219-231 (2009).
19. Bryers CM. Role of adult attachment style in psychosis: a research portfolio. Psychology. (2013).
20. Bowlby J. Attachment and loss: Vol. 3. Loss: Sadness and depression. New York: Basic Books. (1980).
21. Hafner H, Ander Heiden W. Schizophrenia and depression-challenging the paradigm of two separate diseases. Handbook Schizophrenia Spectrum Dis. 2, 389-402 (2011).
22. Ivarsson T, Saavedra F, Granqvist P, et al. Traumatic and adverse attachment childhood experiences are not characteristic of OCD but of depression in adolescents. Child Psychiatry Hum Dev. 47, 270-280 (2016).
23. Siris SG, Addington D, Azorin JM, et al. Depression in schizophrenia: recognition and management in the USA. Schizophrenia Res. 47, 185-197 (2001).
24. Upthegrove R, Birchwood M, Ross K, et al. The evolution of depression and suicidality in first episode psychosis. Acta Psychiatr Scand. 122, 211-218 (2010).
25. Green KM, Zebrak KA, Fothergill KE, et al. Childhood and adolescent risk factors for comorbid depression and substance use disorders in adulthood. Addict Behav. 37, 1240-1247 (2012).
26. Toftdahl NG, Nordentoft M, Hjorthoj C. Prevalence of substance use disorders in psychiatric patients: a nationwide Danish population-based study. Soc Psychiatry Psychiatr Epidemiol. 51, 129-140 (2016).
27. Baer L, Trivedi MH, Huz I, et al. Prevalence and impact of obsessive-compulsive symptoms in depression: a STAR* D report. J Clin Psychiatry. 76, 1668-1674 (2015).
28. Moore KA, Howell J. Yes: The symptoms of OCD and Depression are discrete and not exclusively negative affectivity. Front Psychol. 8, 753 (2017).
29. Osland S, Arnold PD, Pringsheim T. The prevalence of diagnosed obsessive compulsive disorder and associated comorbidities: A population-based Canadian study. Psychiatry Res. 268, 137-142 (2018).
30. Tibi L, Van Oppen P, van Balkom AJLM, et al. The long-term association of OCD and depression and its moderators: A four-year follow up study in a large clinical sample. Eur Psychiatry. 44, 76-82 (2017).
31. Dozier M, Stevenson AL, Lee SW, et al. Attachment organization and familial over involvement for adults with serious psychopathological disorders. Develop Psychopathol. 3, 475-489 (1991).
32. McMahon C, Barnett B, Kowalenko N, et al. Psychological factors associated with persistent postnatal depression: past and current relationships, defence styles and the mediating role of insecure attachment style. J Affective Dis. 84, 15-24 (2005).
33. DeVito CC. The link between insecure attachment and depression: Two potential pathways. Masters Theses. (2014).
34. Roberts JE, Gotlib IH, Kassel JD. Adult attachment security and symptoms of depression: The mediating roles of dysfunctional attitudes and low self-esteem. J Pers Soc Psychol. 70, 310-320 (1996).
35. Scott RL, Cordova JV. The influence of adult attachment styles on the association between marital adjustment and depressive symptoms. J Fam Psychol. 16, 199-208 (2002).
36. Dagan O, Facompre CR, Bernard K. Adult attachment representations and depressive symptoms: A meta-analysis. J Affect Disord. 236, 274-290 (2018).
37. Bifulco A, Moran PM, Ball C, et al. Adult attachment style I: Its relationship to clinical depression. Soc Psychiatry Psychiatr Epidemiol. 37, 50-59 (2002).
38. Bifulco A, Kwon J, Jacobs C, et al. Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety. Soc Psychiatry Psychiatr Epidemiol. 41, 796-805 (2006).
39. Butler AC, Hokanson JE, Flynn HA. A comparison of self-esteem lability and low trait self-esteem as vulnerability factors for depression. Journal of Personality and Social Psychology, 66(1), 166-177 (1994).
40. Besser A, Priel B. A multisource approach to self-critical vulnerability to depression: The moderating role of attachment. J Pers. 71, 515-555 (2003).
41. Besser A, Priel B, Wiznitzer A. Childbearing depressive symptomatology in high-risk pregnancies: The roles of working models and perceived spouse support. Pers Relation. 9, 395-413 (2002).