Attachment insecurity and obsessive–compulsive personality disorder among inpatients with serious mental illness

Journal of Affective Disorders 174 (2015) 411–415

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Attachment insecurity and obsessive–compulsive personality disorder among inpatients with serious mental illness Anika Wiltgen a, Herman Adler a, Ryan Smith a, Katrina Rufino a,b, Christopher Frazier a, Christopher Shepard a, Kirk Booker a, Diedra Simmons a, Leah Richardson a, Jon G. Allen a,c, J. Christopher Fowler a,c,n a

Menninger Clinic 12301 Main St Houston TX 77035, USA University of Houston, Downtown 1 Main St, Houston, TX 77002, USA c Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA b

art ic l e i nf o

a b s t r a c t

Article history: Received 26 November 2014 Accepted 4 December 2014 Available online 13 December 2014

Background: Obsessive–compulsive personality disorder (OCPD) is characterized by traits such as extreme rigidity, perfectionism, and controlling behavior, all of which have a negative impact on interpersonal functioning. Attachment theory provides a useful framework to elucidate the interpersonal dysfunction characteristic of OCPD; yet, there is a dearth of attachment research on OCPD in the context of severe mental illness. Methods: Attachment security and personality disorders were assessed in adult inpatients with severe mental illness. Propensity Score Matching (PSM) was used to match OCPD and control subjects on age, gender, number of psychiatric disorders, and number of criteria endorsed for borderline personality disorder. Results: Consistent with hypotheses, the OCPD group (n ¼61) showed greater attachment avoidance than controls (n ¼ 61), and the avoidance was manifested in a predominance of the most insecure attachment style, fearful attachment. Correlations between attachment anxiety/avoidance with specific OCPD diagnostic criteria revealed that attachment avoidance was correlated with four of eight OCPD criteria across the full sample. Within the subset of OCPD patients, attachment avoidance was significantly correlated with OCPD criterion 3 (is excessively devoted to work and productivity to the exclusion of leisure activities and friendships). Limitations: The use of self-report measure of attachment and the high burden of illness in the SMI population may not generalize to interview based assessment or outpatients, respectively. Conclusions: Findings attest to the severity of impairment in interpersonal functioning and attachment avoidance, in particular, is characteristic of OCPD patients. These results suggest that viable treatment targets include interpersonal functioning along with more classical features of OCPD such as perfectionism and obsessiveness in task performance. & 2014 Elsevier B.V. All rights reserved.

Keywords: OCPD Attachment insecurity Fearful attachment style

1. Introduction The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) general diagnostic features of obsessive–compulsive personality disorder (OCPD) are characterized by “A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency…” (American Psychiatric Association, 2013, p. 676). The lifetime prevalence rates for OCPD vary widely from study to study (from 2.1% to

n Corresponding author at: Menninger Clinic 12301 Main St Houston TX 77035. Tel.: þ 1 713 275 5508. E-mail address: [email protected] (J.C. Fowler).

http://dx.doi.org/10.1016/j.jad.2014.12.011 0165-0327/& 2014 Elsevier B.V. All rights reserved.

7.9%). As Skodol et al. (2011) summarize, OCPD is among the most common personality disorders in clinical populations, and its core features are rigidity and perfectionism. Moreover, although the overall impairment associated with OCPD is relatively low (e.g., compared with borderline or schizotypal personality disorder), patients with OCPD typically showed moderate to severe impairment in at least one area of functioning, typically in the interpersonal domain. This finding is consistent with the fact that at least two diagnostic criteria point to impairment in interpersonal functioning: Criterion 3 (is excessively devoted to work and productivity to the exclusion of leisure activities and friendships [not accounted for by obvious economic necessity]); and Criterion 6 (is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things). Indeed, the struggle these individuals have understanding and valuing the

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perspectives of others, combined with a need for control in relationships, leads many to avoid intimacy altogether (Skodol, 2014). Furthermore, although persons with OCPD have trouble expressing positive emotions such as love, they are quick to express negative emotions such as anger and exasperation—this emotional imbalance keeps others at arms' length (Villemarette-Pittman et al., 2004). These interpersonal problems have clear implications for treatment: notwithstanding their compulsively compliant efforts to be good patients, their rigidity and need for control impedes these patients' ability to develop a therapeutic alliance (Bender, 2014). Given its clinical significance, impaired interpersonal functioning in OCPD merits further exploration. Attachment theory and research offers a promising direction for such exploration, given the extensive research literature on the impact of adult attachment patterns on interpersonal functioning (Mikulincer and Shaver, 2007). Yet the research literature on adult attachment is complicated by virtue of two competing measurement traditions (Roisman et al., 2007), each employing somewhat different terminology for the various patterns of secure and insecure attachment. The clinical tradition employs the Adult Attachment Interview (AAI) to classify participants into four categories: secure-autonomous, dismissing, preoccupied, and disorganized/unresolved with respect to trauma and loss (Hesse, 2008). In short, secure attachment is characterized by confidence in the availability and responsiveness of the attachment figure in times of distress; preoccupied attachment is evident in ambivalence, wherein a strong desire for closeness is coupled with a fear of rejection or abandonment; dismissing attachment entails self-reliance in the sense of managing distress on one's own; and disorganized attachment is evidenced by the lack of a consistent strategy for managing attachment relationships, leaving the individual unable either to be self-reliant or to rely on others in times of distress. In contrast to the clinical tradition, the social psychology literature uses self-report measures and a dimensional approach such as that developed by Bartholomew and Horowitz (1991) to measure degrees of attachment anxiety and avoidance. These dimensional scores can be mapped on to the fourfold classification of attachment “styles” (with some modification in language) as follows: secure (secure-autonomous) attachment entails low levels of avoidance and anxiety; avoidant (dismissing) attachment entails high levels of avoidance and low levels of anxiety; ambivalent (preoccupied) attachment entails low levels of avoidance and high levels of anxiety; and fearful (disorganized) attachment entails high levels of avoidance and anxiety (Bartholomew and Horowitz, 1991). Insecure attachment styles are associated with interpersonal dysfunction in general (Brennan and Shaver, 1998; Choi-Kain et al., 2009) and with personality disorders more specifically (Adshead and Sarkar, 2012; Lorenzini and Fonagy, 2013), wherein cluster B personality disorders (i.e., antisocial, borderline, and narcissistic) are especially prominent (Bender et al., 2001; Brennan and Shaver, 1998). By contrast, secure attachment is rarely associated with personality disorders, and has been proposed as a protective factor in the emergence of personality disorders in adolescents (Westen et al., 2006). Most specifically, reviewing 13 studies, Agrawal et al. (2004) found borderline personality disorder (BPD) to be associated with preoccupied and disorganized (fearful) attachment. Similarly, Westen et al. (2006) found individuals diagnosed with BPD to be classified as preoccupied or disorganized. In contrast, individuals with schizoid personality disorder are likely to be dismissing, whereas those with dependent personality are more likely to be preoccupied (West et al., 1994; Meyer et al., 2001). Although many studies have explored the relationship between attachment security and personality disorders, few have focused on OCPD. Lenzenweger and Clarkin (2005) suggested that insecure attachment in individuals with OCPD develops in relation to firm parenting styles wherein love and caretaking is dependent upon the child's performance. Two studies have yielded inconclusive

results. Brennan and Shaver's (1998) study of college students revealed those with OCPD to have either secure or fearful attachment, while Aaronson et al. (2006) found indications of greater attachment insecurity in patients with BPD than OCPD; they did not characterize specifically the nature or extent of attachment security in the OCPD group. Few studies have examined patterns of attachment among psychiatric inpatients with serious mental illness, and none have examined the patterns of attachment among seriously mentally ill patients diagnosed with OCPD. The current case-control study explored this gap in the literature by assessing the core attachment dimensions and specific attachment styles in a cohort of psychiatric inpatients with and without OCPD. Owing to the interpersonal distancing that is characteristic of OCPD, the authors hypothesized: 1. OCPD group would manifest greater attachment avoidance than the control group, and 2. OCPD group would evidence greater prevalence of attachment styles characterized by high levels of avoidance, that is, avoidant (dismissing) or fearful (disorganized). Secondary exploratory analyses examined the relationships between attachment anxiety/avoidance and specific OCPD criteria scores for the entire sample as well as for the OCPD subsample.

2. Methods 2.1. Participants The initial sample consisted of 910 consecutively admitted inpatient adults (427 males and 483 females) from January 2010 to October 2013. All patients were engaged in a six to eight week intensive multimodal treatment. Descriptions of the setting, treatment, and extant measures are available in detail elsewhere (Allen et al., 2009). Patients were included in the study regardless of symptom severity or co-morbid diagnoses. The majority were Caucasian (90.8%), with small percentages identifying as multiracial (5.8%), Asian (1.8%), Black/African American (1.2%), and American Indian (.4%). Average age at admission was 36.4 years (SD ¼14.8). Educational level was comparable to national census data with 90% attaining a high school diploma and 30% with a bachelor degree (United States Census Bureau, 2011). 2.2. Treatment setting and procedures Typical lengths of stay in the hospital range from four to eight weeks. Treatment included medication management, individual and group psychotherapy, psychoeducation, and social activities in the context of a therapeutic milieu. Psychoeducational groups included mentalizing (Allen et al., 2012; Groat and Allen, 2011) and Dialectical Behavior Therapy (Linehan, 1993) with specialized groups for substance abuse and eating disorders. Data were collected as part of the hospital's Adult Outcomes Project, described in detail elsewhere (Allen et al., 2009). All participants were assessed using validated measures within 72 h of admission. This project was a clinical outcomes project, conducted with all patients. Use of the project's data was approved by Baylor College of Medicine's Institutional Review Board. 2.3. Measures Demographic variables and history of psychiatric service usage were assessed using a standardized patient information survey (Fowler et al., 2013). Psychiatric disorders including personality disorder diagnoses were assessed using the research versions of the Structured Clinical Interview for DSM-IV Disorders (SCID-I/II). The SCID-I (First et al., 1997) and SCID II (First et al., 2002) were administered by master's level researchers after reviewing pertinent

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psychiatric and psychosocial evaluations as well as consulting with the attending psychiatrist. Criteria were coded as absent (0) or present (1) with no skip-outs for eight criteria of OCPD: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost, 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met), 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity), 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification), 5. Is unable to discard wornout or worthless objects even when they have no sentimental value, 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things, 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes, and 8. Shows rigidity and stubbornness. The Relationship Questionnaire (RQ) (Bartholomew and Horowitz, 1991) is a prototype measure derived by crossing two theoretical dimensions of attachment representations: attachment anxiety (positive/negative) and attachment avoidance (positive/negative). Respondents rate the prototype that most accurately reflects the individual's attachment style and then rate each prototype (secure, dismissing, preoccupied, and fearful) on a 7-point scale regarding the extent to which each description corresponds to their general relationship style. Total scores are derived by the following formulas: Attachment Anxiety¼(Secureþ Dismissing) (PreoccupiedþFearful); Attachment Avoidance¼(SecureþPreoccupied) (DismissingþFearful). Scores on each dimension of the RQ range from  12 to þ12; scores in the negative range indicate insecurity, whereas scores in the positive range indicate greater security (i.e., low levels of anxiety and avoidance). Securely attached individuals exhibit positive anxiety and avoidance scores and are thus characterized by a sense of trust and comfort in being interdependent on others. Preoccupied individuals have heightened attachment anxiety (negative scores) yet positive scores on attachment avoidance; thus they desire closeness, but at the same time fear rejection or disapproval. Conversely, dismissing individuals evidence a low levels of attachment anxiety (positive scores) yet heightened attachment avoidance (negative scores); accordingly, they are self-reliant and undervalue the importance of relationships. Lastly, those with a fearful attachment style evidence heightened attachment anxiety (negative scores) and attachment avoidance (negative scores), such that their profound distrust precludes them from developing stable, close relationships. 2.4. Data analysis Analyses were conducted using SPSS for windows, version 21 (IBM). The current study utilized Propensity Score Matching (PSM) that matched individual subjects from different groups (such as case, control or active treatment arms and wait-list controls) based on a propensity score, or balancing score, such that the distribution of identified baseline confounds are similar among both groups (Austin, 2011; Rosenbaum and Rubin, 1983) and group differences can be directly compared, increasing the probability that results are due to primary dependent variables (in this case the presence/absence of OCPD) rather than baseline confounds (Austin, 2011). Propensity score matching is popular in traditional medical research (Stürmer et al., 2006) and has recently gained popularity among psychiatric (Hansen and Bowers, 2008) and psychotherapy treatment outcome research (Bartak et al., 2010; Barth et al., 2007; Ye and Kaskutas, 2009). Analysis of variance models were conducted to assess differences in attachment anxiety and avoidance as well as burden of illness markers. Pearson correlations (a special form of point-biserial correlation

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Table 1 Attachment prototypes in OCPD.

Att. anxiety Att. avoidance Secure Ambivalent Fearful Detached

OCPD Mean SD

Controls Mean SD

F

p

Cohen's d

 2.59  2.82 2.49 3.39 5.20 3.51

 2.13  .23 3.10 3.72 4.28 2.77

.36 9.04 3.73 .76 6.56 4.31

.55 .01 .06 .39 .01 .04

.01 .54 .35 .16 .46 .38

(4.39) (4.99) (1.60) (2.19) (1.93) (2.06)

(3.99) (4.51) (1.86) (1.98) (2.03) (1.86)

Table 2 Comparison of clinical diagnoses by OCPD and control groups. AXIS I spectrum disorder

χ2

p

Psychotic spectrum Major depressive disorder spectrum SUD spectrum Anxiety spectrum

2.140 2.380 2.702 .374

.143 .123 .100 .541

appropriate for binary and interval data) were computed to assess associations among attachment dimensions and eight OCPD criteria.

3. Results Propensity score matching was used to match the OCPD and nonOCPD groups for age, gender, total Axis I and II disorders, and total BPD criteria.1 Of the initial 910 cases, 61 OCPD cases were matched with 61 inpatients without OCPD. To test the hypothesis that patients with OCPD would have higher levels of attachment avoidance, a oneway analysis of variance (ANOVA) was conducted. Patients with OCPD manifested greater attachment avoidance (M¼ 2.82, SD¼4.99) than patients without OCPD (M¼  .23, SD¼4.51). Consistent with the hypotheses, results revealed significant differences in attachment avoidance (F[1,121]¼ 9.04, po.01; Cohen's d¼ .54). Case and control groups did not differ on attachment anxiety (F[1,121]¼.36, po.55). To test the hypothesis that patients with OCPD would differ from non-OCPD patients with regard to the avoidant and fearful attachment styles, a one-way ANOVA was conducted. Patients with OCPD (Table 1) rated themselves as higher on the fearful attachment item (M¼ 5.20, SD¼1.93) compared to patients without OCPD (M¼4.28, SD¼ 2.03). Once Bonferroni corrections were taken into account, only the differences for fearful attachment style reached a level of significance (F[1,121]¼6.56, po.01; Cohen's d¼.46). The remainder of the attachment styles failed to reach significance: secure (F[1,121]¼3.73, p¼ ns), ambivalent (F[1,121]¼.76, p¼ns), and avoidant (F[1,121]¼ 4.31, p¼ns). Post-hoc analyses revealed that patients with OCPD had more extensive psychiatric contacts with providers (M¼3.74, SD ¼3.18) than patients without OCPD (M ¼2.28, SD ¼1.57) and this difference was statistically significant (F[1,121] ¼10.30, po .01; Cohen's d¼ .58). Pearson chi-square analyses were conducted to determine if there were any interactions between Axis I spectrum disorders and OCPD status. As indicated in Table 2, the percentages of patients with OCPD and Axis I diagnoses did not vary significantly on the psychotic disorder, major depressive disorder, substance use disorder, or the anxiety disorder spectra. 1 BPD total criteria were included after the first PSM model identified high comorbidity of BPD in a subset of the OCPD group.

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For the complete sample Pearson correlations revealed significant association between attachment avoidance and Criterion 3 (r ¼  .38, p o.0001), Criterion 6 (r ¼ .25, po .006), and Criterion 8 (r ¼ .27, p o.002). For the OCPD group attachment avoidance was significantly correlated with Criterion 3 (r ¼ .38, p o.002); yet, no significant correlations were observed between attachment dimensions and OCPD criteria for the non-OCPD control group.

therapy, cognitive therapy, and psychodynamic psychotherapy have been shown, in small samples, to be moderately helpful in treatment of the rigid and perfectionistic thoughts, assumptions, and behaviors characteristic of patients with OCPD (Strauss et al., 2006; McMain and Alberta, 2007; Enero et al., 2013). The present findings suggest that additional attention to attachment insecurity (specifically attachment avoidance) in an attachment-informed approach to psychotherapy (Allen, 2013; Obegi and Berant, 2009; Slade, 2008) might be integrated into cognitive-behavioral strategies for ameliorating the more conspicuous symptoms of OCPD.

4. Discussion Patients with OCPD pose significant treatment challenges (Skodol et al., 2011): although their impairment is less severe than those with BPD, they have high levels of utilization of mental health treatment and primary care, and their personality disturbance has an adverse impact on the course of comorbid anxiety and depressive disorders. The attachment disturbance observed in the present study is consistent with Skodol and colleagues' conclusion: “The disconnect between the low levels of impairment in patients with OCPD in the community and the more substantial clinical costs may be due to the inclusion of a larger number of less severe or even adaptive cases of OCPD in a general population sample compared to the more severe and dysfunctional cases who seek treatment” (p. 146). Working with patients with OCPD poses specific challenges because these individuals tend to be burdened by self-schemas of self-imposed, unrelenting standards that tend to subvert the importance of interpersonal relationships (Jovev and Jackson, 2004). This assertion is consistent with our findings not only that OCPD is associated with high scores on the attachment avoidance dimension but also that their most common attachment style was fearful, the most problematic of the four attachment styles and one marked by significant fear of sustained engagement. The fact that our sample consisted of patients with severe mental illness is consistent with their highly impaired interpersonal functioning. The finding that attachment avoidance was correlated with Criteria 3 (is excessively devoted to work and productivity to the exclusion of leisure activities and friendships [not accounted for by obvious economic necessity]) provides a degree of specificity to the link between attachment dimensions and the relational component of this criterion. In light of the fact that obsessive–compulsive was estimated as the second most prevalent personality disorders in adult (Torgersen et al., 2001) and child (Crawford et al., 2005) community samples, the research literature is sparse. While one of the first studies to assess attachment security/insecurity in a relatively large sample of OCPD inpatients with SMI, several limitations of the current study bear mention. First, the use of self-report measure of attachment may appear problematic in that some inpatients with SMI may lack the necessary insight into their approach to relationships and attachments to accurately reflect reality. Second, while PSM allows for relatively granular matching on potential confound variables, the set of variables included in the PSM were far from exhaustive and we cannot be certain that inclusion of other variables may result in different control group selection. Last, the high degree of illness burden in the SMI population may not generalize well to less severe outpatient settings; however, the results do address a growing demand for research on serious mental illness associated with an increasing awareness of its prevalence, cost, and burden (Druss and Bornemann, 2010; World Health Organization, 2004). In light of these limitations, this study has implications for treating individuals with OCPD. Previous authors have emphasized the difficulty in treating individuals with OCPD owing to their need for control and the potential for power struggles between patient and therapist (Pretzer and Hampl, 1994; Bender, 2014). Traditional treatment approaches, such as cognitive-behavioral

Role of funding source Research is supported by The Menninger Foundation. The study sponsors were not involved in any aspect of the research activities and did not approve the specific protocol or manuscript. Thus, the authors were independent from study sponsors in the context of the research.

Conflict of interest Authors report no conflict of interest.

Acknowledgments We thank the individuals who participated in this study. We also thank Laurie Wallin, Fred Lauckner, Steve Herrera, and Tina Holmes for support in data collection and processing.

References Aaronson, C.J., Bender, D.S., Skodol, A.E., Gunderson, J.G., 2006. Comparison of attachment styles in borderline personality disorder and obsessive–compulsive personality disorder. Psychiatr. Q. 77 (1), 69–80. Adshead, G., Sarkar, J., 2012. The nature of personality disorder. Adv. Psychiatr. Treat. 18, 162–172. Agrawal, H.R., Gunderson, J., Holmes, B.M., Lyons-Ruth, K., 2004. Attachment studies with borderline patients: a review. Harvard Rev. Psychiatry 12 (2), 94–104. Allen, J.G., 2013. Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. American Psychiatric Publishing, Arlington, VA. Allen, J.G., Frueh, B.C., Ellis, T.E., Latini, D.M., Mahoney, J.S., Oldham, J.M., Wallin, L., 2009. Integrating outcomes assessment and research into clinical care in inpatient adult psychiatric treatment. Bull. Menninger Clin. 73 (4), 259–295. Allen, J.G., O’Malley, F., Freeman, C., Bateman, A.W., 2012. Brief treatment. In: Fonagy, P., Bateman, A.W. (Eds.), Handbook of Mentalizing in Mental Health Practice. American Psychiatric Publishing, Washington, DC, pp. 159–196. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Publishing, Washington, DC. Austin, P.C., 2011. Comparing paired vs non-paired statistical methods of analyses when making inferences about absolute risk reductions in propensity-score matched samples. Statistics in Medicine 30 (11), 1292–1301. Bartak, A., Spreeuwenberg, M.D., Andrea, H., Holleman, L., Rijnierse, P., Rossum, B.V., Emmelkamp, P.M., 2010. Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study. Psychother. Psychosom. 79 (1), 20–30. Barth, R.P., Greeson, J.K., Guo, S., Green, R.L., Hurley, S., Sisson, J., 2007. Outcomes for youth receiving intensive in-home therapy or residential care: a comparison using propensity scores. Am. J. Orthopsychiatry 77 (4), 497–505. Bartholomew, K., Horowitz, L.M., 1991. Attachment styles among young adults: a test of a four-category model. J. Pers. Soc. Psychol. 61 (2), 226–244. Bender, D.S., 2014. Therapeutic alliance. In: Oldham, J.M., Skodol, A.E., Bender, D.S. (Eds.), Textbook of Personality Disorders. American Psychiatric Publishing, Washington, D.C., pp. 189–216. Bender, D.S., Dolan, R.T., Skodol, A.E., Sanislow, C.A., Dyck, I.R., McGlashan, T.H., Gunderson, J.G., 2001. Treatment utilization by patients with personality disorders. Am. J. Psychiatry 158 (2), 295–302. Brennan, K.A., Shaver, P.R., 1998. Attachment styles and personality disorders: their connections to each other and to parental divorce, parental death, and perceptions. J. Pers. 66 (5), 835–878. Choi-Kain, L.W., Fitzmaurice, G.M., Zanarini, M.C., Laverdiere, O., Gunderson, J.G., 2009. The relationship between self-reported attachment styles, interpersonal dysfunction, and borderline personality disorder. J. Nerv. Ment. Dis. 197 (11), 816–821. Crawford, T.N., Cohen, P., Johnson, J.G., Kasen, S., First, M.B., Gordon, K., Brook, J.S., 2005. Self-reported personality disorder in the children in the community sample: convergent and prospective validity in late adolescence and adulthood. J. Pers. Disord. 19 (1), 30–52.

A. Wiltgen et al. / Journal of Affective Disorders 174 (2015) 411–415

Druss, B.G., Bornemann, T.H., 2010. Improving health and health care for persons with serious mental illness: the window for US federal policy change. J. Am. Med. Assoc. 303 (19), 1972–1973. Enero, C., Soler, A., Ramos, I., Cardona, S., Gullamat, R., Valles, V., 2013. Distress level and treatment outcome in obsessive–compulsive personality disorder (OCPD). Eur. Psychiatry 28 (1), 1. First, M.B., Gibbon, M., Spitzer, R.L., Williams, J.B., Benjamin, L.S., 1997. Structured Clinical Interview for DSM-IV Axis II Personality Disorders, (SCID-II). American Psychiatric Press, Washington, D.C.. First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B., 2002. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen (SCID-I/P W/ PSY SCREEN). Biometrics Research, New York State Psychiatric Institute, New York. Fowler, J.C., Allen, J.G., Oldham, J.M., Frueh, B.C., 2013. Exposure to interpersonal trauma, attachment insecurity, and depression severity. J. Affect. Disord. 149 (1–3), 313–318. Groat, M., Allen, J.G., 2011. Promoting mentalizing in experiential psychoeducational groups: from agency and authority to authorship. Bull. Menninger Clin. 75 (4), 315–343. Hansen, B.B., Bowers, J., 2008. Covariate balance in simple, stratified and clustered comparative studies. Stat. Sci. 23 (2), 219–236. Hesse, E., 2008. The adult attachment interview: protocol, method of analysis, and empirical studies. In: Cassidy, J., Shaver, P.R. (Eds.), Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd ed. Guilford Press, New York, NY, pp. 552–598. Jovev, M., Jackson, H.J., 2004. Early maladaptive schemas in personality disordered individuals. J. Pers. Disord. 18 (5), 467–478. Lenzenweger, M.F., Clarkin, J.F., 2005. The personality disorders: history, classification, and research issues. In: Lenzenweger, M.F., Clarkin, J.F. (Eds.), Major Theories of Personality Disorder, 2nd ed. Guilford Press, New York, NY. Linehan, M.M., 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press, New York, NY. Lorenzini, N., Fonagy, P., 2013. Attachment and personality disorders: a short review. FOCUS: J. Lifelong Learn. Psychiatry 11 (2), 155–166. McMain, S., Alberta, P.E., 2007. Advances in psychotherapy of personality disorders: a research update. Curr. Psychiatry Rep. 9 (1), 46–52. Meyer, B., Pilkonis, P.A., Heape, C.L., Egan, M., Proietti, J.M., 2001. Attachment styles and personality disorders as predictors of symptom course. J. Pers. Disord. 15 (5), 371–389. Mikulincer, M., Shaver, P.R., 2007. Attachment in Adulthood: Structure, Dynamics, and Change. Guilford Press, New York, NY. Obegi, J.H., Berant, E., 2009. Introduction. In: Obegi, J.H., Berant, E. (Eds.), Attachment Theory and Research in Clinical Work With Adults. Guilford Press, New York, pp. 1–14. Pretzer, J., Hampl, S., 1994. Cognitive behavioral treatment of obsessive compulsive personality disorder. Clin. Psychol. Psychother. 1 (5), 298–307.

415

Roisman, G.I., Holland, A., Fortuna, K., Fraley, R.C., Clausell, E., Clarke, A., 2007. The adult attachment interview and self-reports of attachment style: an empirical rapproachement. J. Pers. Soc. Psychol. 92 (4), 678–697. Rosenbaum, P.R., Rubin, D.B., 1983. The central role of the propensity score in observational studies for causal effects. Biometrika 70 (1), 41–55. Skodol, A.E., Clark, L.A., Bender, D.S., Krueger, R.F., Morey, L.C., Verheul, R., Oldham, J.M., 2011. Proposed changes in personality and personality disorder assessment and diagnosis for DSM-5 part I: description and rationale. Pers. Disord.: Theory Res. Treat. 2 (1), 4–22. Skodol, A.E., 2014. Manifestations, sociodemographics, and functional impairment. In: Oldham, J.M., Skodol, A.E., Bender, D.S. (Eds.), Textbook of Personality Disorders. American Psychiatric Publishing, Washington, DC, pp. 131–164. Slade, A., 2008. The implications of attachment theory and research for adult psychotherapy: research and clinical perspectives. In: Cassidy, J., Shaver, P.R. (Eds.), Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd ed. Guilford Press, New York, NY, pp. 762–782. Strauss, J.L., Hayes, A.M., Johnson, S.L., Newman, C.F., Brown, G.K., Barber, J.P., Beck, A.T., 2006. Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive–compulsive personality disorder. J. Consul. Clin. Psychol. 74 (2), 337–345. Stürmer, T., Joshi, M., Glynn, R.J., Avorn, J., Rothman, K.J., Schneeweiss, S., 2006. A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods. J. Clin. Epidemiol. 59 (5), 437–447. Torgersen, S., Kringlen, E., Cramer, V., 2001. The prevalence of personality disorders in a community sample. Arch. Gener. Psychiatry 58 (6), 590–596. United States Census Bureau, 2011. Household demographics [data file]. Retrieved from 〈http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=AHS_2011_C08AO&prodType=table〉. Villemarette-Pittman, N.R., Stanford, M.S., Greve, K.W., Houston, R.J., Mathias, C.W., 2004. Obsessive–compulsive personality disorder and behavioral disinhibition. J. Psychol.: Interdiscip. Appl. 138 (1), 5–22. West, M., Rose, M.S., Sheldon-Keller, A., 1994. Assessment of patterns of insecure attachment in adults and application to dependent and schizoid personality disorders. J. Pers. Disord. 8 (3), 249–256. Westen, D., Nakash, O., Thomas, C., Bradley, R., 2006. Clinical assessment of attachment patterns and personality disorder in adolescents and adults. J. Consult. Clin. Psychol. 74 (6), 1065–1085. World Health Organization, 2004. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. J. Am. Med. Assoc., 291; , pp. 2581–2590. Ye, Y., Kaskutas, L.A., 2009. Using propensity scores to adjust for selection bias when assessment the effectiveness of Alcoholics Anonymous in observational studies. Drug Alcohol Depend. 104 (1–2), 56–64.