Social anxiety as a potential mediator of the association between attachment and depression

Author’s Accepted Manuscript Social Anxiety as a Potential Mediator of the Association between Attachment and Depression Susanne Manes, Steffi Nodop, Uwe Altmann, Romina Gawlytta, Ulrike Dinger, Wibke Dymel, Johannes C. Ehrenthal, Peter Joraschky, Björn Nolting, Katja Petrowski, Viktoria Ritter, Henning Schauenburg, Ulrich Stangier, Ulrike Willutzki, Bernhard Strauss

PII: DOI: Reference:

www.elsevier.com/locate/jad

S0165-0327(16)30301-9 http://dx.doi.org/10.1016/j.jad.2016.06.060 JAD8358

To appear in: Journal of Affective Disorders Received date: 23 February 2016 Accepted date: 26 June 2016 Cite this article as: Susanne Manes, Steffi Nodop, Uwe Altmann, Romina Gawlytta, Ulrike Dinger, Wibke Dymel, Johannes C. Ehrenthal, Peter Joraschky, Björn Nolting, Katja Petrowski, Viktoria Ritter, Henning Schauenburg, Ulrich Stangier, Ulrike Willutzki and Bernhard Strauss, Social Anxiety as a Potential Mediator of the Association between Attachment and Depression, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2016.06.060 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Social Anxiety as a Potential Mediator of the Association between Attachment and Depression

Susanne Manes1, Steffi Nodop1, Uwe Altmann1, Romina Gawlytta1, Ulrike Dinger2, Wibke Dymel3, Johannes C. Ehrenthal2, Peter Joraschky5, Björn Nolting4, Katja Petrowski5, Viktoria Ritter6, Henning Schauenburg2, Ulrich Stangier6, Ulrike Willutzki7, Bernhard Strauss1

1 Jena University Hospital, Institute of Psychosocial Medicine and Psychotherapy, Germany 2 University Hospital Heidelberg, Department of General Internal Medicine and Psychosomatics, Germany 3 Private Practice, Essen, Germany 4 Hospital for Psychosomatic Medicine and Psychotherapy, Klinikum Esslingen, Germany 5 University Hospital Dresden, Department of Psychosomatic Medicine and Psychotherapy, Germany 6 University of Frankfurt, Department of Psychology, Germany 7 University of Witten-Herdecke, Department of Psychology and Psychotherapy, Germany

Correspondence concerning this article should be addressed to Bernhard Strauss, University Hospital Jena, Institute of Psychosocial Medicine and Psychotherapy, Stoystrasse 3, D 07740 Jena, Germany; [email protected]. Funding: This project was supported by a grant from the German Federal Ministry of Education and Research (BMBF), FKZ 01GV0607.

1

Abstract Objective: The study represents a conceptual replication of the study by Eng, Heimberg, Hart, Schneier, and Liebowitz (2001) in a sample of adult patients diagnosed with social anxiety disorder as primary diagnosis. Methods: Two different attachment questionnaires (Bielefeld Questionnaire of Client Expectations (BQCE) and Experiences in Close Relationships, ECR-RD)) were applied to examine whether the effect of attachment on depression (measured by the BDI) is mediated by social anxiety (measured by the LSAS) in a cross-sectional study. Results: The data confirms such a mediation. The effect of attachment measured with the BQCE on depression was completely mediated, whereas the effet of both scales of the ECR-RD (attachment related avoidance and anxiety) on depression was only partially mediated by social anxiety disorder. Conclusion: The study supports the association of attachment,social anxiety, and depressive symptoms and the need to consider different perspectives on attachment.

Key words: Social anxiety, attachment, depression, mediation, adult attachment, Bielefeld Questionnaire of Client Expectations, Experiences in Close Relationships

word count (main text): 2404

Attachment has been intensively used as a framework to explain the development of various psychopathologies (Bowlby, 1977; Dozier, Stovall, & Albus, 1999; Mickelson, Kessler, & Shaver, 1997). Among others, depression has been related to negative caregiving experiences and insecure attachment patterns with negative expectations on the reliability of others 2

and the loveableness of oneself. Various studies provide evidence for the relationship between depression and insecure attachment (Aderka, Weisman, Shahar, & Gilboa-Schechtman, 2009; Bakermans-Kranenburg & van Ijzendoorn, 2009; Bifulco, Moran, Ball, & Bernazzani, 2002; Dozier et al., 1999; Fonagy et al., 1996; Mickelson et al., 1997; Morley & Moran, 2011) and some even showed that attachment was able to predict future depression (Bifulco et al., 2006; Hammen et al., 1995). In a seminal study, Eng, Heimberg, Hart, Schneier, and Liebowitz (2001) suggested that the connection between attachment and depression is mediated by social anxiety (SA). First, they argue that insecure attachment and SA are strongly intertwined, i.e., insecure attachment with its negative expectations about oneself and/or others and the futile strategies to fulfill attachment related needs impairs social functioning and nurtures social avoidance and anxiety in social interactions. Indeed, there are various studies showing that socially anxious patients predominantely exhibit an insecure attachment style (Eng et al., 2001; Mickelson et al., 1997; Manes et al., 2016) and are more often insecurely attached than normal controls (Cunha, Soares, & Gouveia, 2008; Eng et al., 2001; Mickelson et al., 1997). Moreover, insecure attachment is associated with stronger symptom severity of SA (Bar-Haim, Dan, Eshel, & Sagi-Schwartz, 2007; Eng et al., 2001; Manes et al., 2016; Van Buren & Cooley, 2002). SA in turn is strongly linked to depressive symptoms. There is a high comorbidity between SA and depression with more than one third of the socially anxious patients also suffering from depression (Kessler, Stang, Wittchen, Stein, & Walters, 1999; Stein & Kean, 2000). Moreover, the onset of SA precedes the onset of depression in most of the cases (Kessler et al., 1999; Chartier, Walker, & Stein, 2003). SA contributes to depression by increasing the sensitivity for social rejection and criticism, thus, making socially anxious individuals more prone to negative social experiences and subsequent social withdrawal (Blatt & Zuroff, 1992;

3

Lewinsohn, 1974). Additionally, SA goes along with strong self-criticism and negative cognitions about oneself which also might enhance the vulnerability to depression. In sum, it is assumed that insecure attachment predisposes for SA which in turn leads to depressive symptoms. In line with this assumption, Eng et al. (2001) found that the effect of attachment measured with the Revised Adult Attachment Scale (Collins, 1996) on depression was partially mediated by SA. However, this influential and often cited study has not yet been replicated in a patient sample which we believed to be necessary given the importance of the finding. Accordingly, we aimed to conceptually replicate the mediation finding of Eng et al. (2001) in an adult patient sample which was recruited within a large multicenter RCT in Germany, the Social Phobia Psychotherapy Network (SOPHO-NET, see Leichsenring et al., 2008, 2013, 2014). To assess attachment, we chose two different measures: the Bielefeld Questionnaire of Client Expectations (BQCE, Höger, 1999; Pollak, Wiegand-Grefe, & Höger, 2008) and the German version of the revised Experiences in Close Relationships questionnaire (Ehrenthal, Dinger, Lamla, Funken, & Schauenburg, 2009). Both questionnaires refer to adult attachment but focus on different relationships. The BQCE concentrates on expectations and cognitions towards a psychotherapist and the ECR-RD refers to romantic partnerships. Both relationships are highly relevant and potentially problematic for patients suffering from SA. To measure depression, we selected the BDI (Beck Depression Inventory, Beck, Ward, & Mendelson, 1961) and to asses SA the Liebowitz Social Anxiety Scale (LSAS, Liebowitz, 1987) was applied.

Method Study Background and Participants

4

The study is based on a subsample of 194 patients diagnosed with SAD (52.6% male, mean age 34.6 years) recruited in a large multicenter RCT (SOPHO-NET, see Leichsenring et al., 2008, 2013, 2014 for design and results). Sample characteristics are depicted in Table 1. Inclusion criteria for the study were SA as current primary diagnosis (DSM-IV-R; American Psychiatric Association, 2000) and a global rating on the LSAS above 30 at the screening (Liebowitz, 1987; Mennin et al., 2002). Further inclusion and exclusion criteria are described in detail elsewhere (Leichsenring et al., 2013). Of 251 eligible patients in three participating study centers, 194 agreed to participate in a second study and filled out the BQCE, ECR-RD, BDI, and LSAS. Mostly due to reasons of time not all participants ended up filling out every measure (BQCE: n=173, ECR-RD: n=172, BDI: n=189, LSAS: n=187). Measures Bielefeld Questionnaire of Client Expectations (BQCE). The BQCE (Höger, 1999; Pollak et al., 2008) was used to assess attachment-related cognitions and expectations towards psychotherapists on 33 five point Likert scaled items along 3 subscales (openness in close relationships, need for closeness, problems with self-acceptance) with sufficiently high Cronbach’s alpha from .81 to .87. Based on cluster and discriminant analysis, patients were categorized as secure (combining the clusters secure and avoidant-cooperative) or insecure (combining the remaining avoidant and ambivalent clusters). Experiences in Close Relationships (ECR-Revised, German Version). The German ECR-RD (Ehrenthal et al., 2009) measures self-reported adult romantic attachment with 36 items on a 7 point Likert scale. The dimensional questionnaire results in a score for attachment-related anxiety and avoidance (Brennan, Clark, & Shaver, 1998; Fraley, Waller, & Brennan, 2000). Both scales showed sufficiently high internal consistency with Cronbach’s alpha of .92 and .93, respectively. Liebowitz Social Anxiety Scale (LSAS). SA was assessed by a trained clinician with the LSAS (Liebowitz, 1987) measuring the amount of anxiety in social and performance situ5

ations with 24 items on 4 point scales. The LSAS total score showed high internal consistency (=.93). Beck Depression Inventory (BDI). The severity of depression was assessed with the BDI on 21 items on a 4-point Likert scale (Beck et al., 1961). In the current study, high internal consistency (=.89) was found.

Results We performed a regression-based mediation analysis according to Preacher and Hayes (2008) for all three measures of attachment (i.e., BQCE attachment security, ECR-RD anxiety and avoidance) Attachment served as predictor, the BDI score served as criterion, and the LSAS score as mediator in this analysis (see Figure 1). Testing the effect of the predictor on the mediator (a-path) revealed that attachment security was associated with less SAD for both the BQCE, b = -17.63, t(169) = -3.95, p < .001, the ECR-RD avoidance scale, b = -4.95, t(169) = -3.00, p = .003, as well as anxiety scale, b = -5.96, t(169) = -4.26, p < .001. Stronger SAD was related to stronger depression (b-path), b = .18, t(185) = 6.96, p < .001. Regarding the direct effect of the predictor on the criterion (c-path), attachment was linked to depression, BQCE: b = -4.99, t(171) = -2.84, p = .005; ECR-RD avoidance: b = -2.42, t(170) = -3.93, p < .001; ECR-RD anxiety: b = -2.79, t(170) = -5.39, p < .001. Critical for the test on mediation is a significant indirect path which was tested via bootstrapped confidence intervals (Preacher & Hayes, 2008), indicating a substantial reduction of the c-path when the mediator is included. For the ECR-RD, the effect of attachment on depression was partially mediated by SAD (bias corrected and accelerated 95% CI for avoidance [-1.49,-.28] and anxiety [-1.50,-.44]), i.e. the c’-path still remained significant after including the mediator (avoidance: b = -1.63, t(168) = 2.87, p = .005; anxiety: b = -1.88, t(168) = -3.77, p = .002). For the BQCE, there was a complete mediation (bias corrected and accelerated 95% CI [-4.83,-1.29]) with a nonsignificant c-path after including the mediator, b = -2.39, t(168) = -1.41, p = .16. 6

Discussion In the present study, the relationship between attachment, SA, and depression was examined in a homogenous sample of socially anxious patients from a multicenter study. It was hypothesized that the effect of attachment on depressive symptoms would be mediated by SA. In other words, it was assumed that insecure attachment would enhance socially anxious symptoms which would increase depression within a sample of persons with social anxiety disorder. That is, the effect of attachment on depression should be substantially reduced when including SA in the mediation model. Our data support this assumption and thus replicate findings by Eng and colleagues (2001). Insecure attachment is linked to socially anxious cognitions and avoidance of social interactions. This may prevent positive and rewarding social experiences, which is a major factor for the development and maintenance of depression (Blatt & Zuroff, 1992; Lewinsohn, 1974). Specifically, we found that the effect of attachment operationalized with the BQCE, a questionnaire measuring attachment related cognitions related to the person of the therapist, on depression was completely mediated by SA. That is, the strong effect of attachment related cognitions on depression can be completely explained by the severity of SA symptoms. When assessing attachment using the avoidance and anxiety scales of the ECR-RD, the effect of attachment on depression was only partially mediated. Such a partial mediation was also evident in the seminal study of Eng et al. (2001) as well as in a study with a non-clinical sample (Aderka et al., 2009). This means that the influence of attachment related anxiety and avoidance in intimate relationship on depression is substantially reduced when including SA in the model. Thus, when socially anxious feelings, cognitions, and behavioral patterns are taken into account, the effect of attachment on depression is reduced. Importantly, attachment in romantic relationships is still to some degree able to account for depressive symptoms above SA. Thus, attachment related anxiety of losing somebody or not being good enough for the 7

partner and avoidance of getting to close to the partner constitute a qualitatively different feature that not only relates to social phobic symptoms but also depression. For instance, the negative cognitions about oneself and others which are characteristic of an insecure attachment style might impair social interactions, but also directly contribute to the negative cognitive style of depression (Beck, 1963). Additionally, attachment style has been associated with specific partner selections and constellations which might contribute to depression beyond social anxiety (Carnelley, Pietromonaco, & Jaffe, 1994). This aspect of attachment might be especially represented by the ECR-RD and might explain why the effect of the ECR-RD is only partially mediated by social anxiety. Regarding the BQCE, there seems to be more common variance with social anxiety and thus the effect is completely mediated. A potential explanation might be found in the design of our study where the BQCE was assessed before the first therapeutic contact. Thus, the BQCE refers to a future relationship to a still unknown therapist. This is not the case for the ECR-RD which also refers to current or past relationships. The upcoming first contact to a professional therapist might trigger fear of failure and rejection among the patients which will be captured by the BQCE and which are also typical for social anxiety. The BQCE more than the ECR-RD represents fearful expectations towards an unknown social situation and interaction partner and thus shares more common variance with social anxiety. Moreover, the BQCE addresses readiness for self-disclosure, fear of rejection, and need for care which largely correspond to the expectations and need of socially anxious individuals. Consequently, the effect of the BQCE can be completely mediated by social anxiety. The relationship specific components of the ECR-RD, however, are able to account for depression beyond social anxiety. In general, the results suggest a differential assessment of attachment using several perspectives (such as the romantic partner or the therapist as an attachment figure), since one can expect that different measures of attachment share only a limited amount of variance (Stein et al., 2002).

8

Even though this study successfully replicated the findings of Eng et al. (2001) as intended, some limitations have to be mentioned. First, this study - similar to the one by Eng et al. (2001) - is not able to draw causal conclusions due to its cross-sectional design. To draw conclusions on causes, ideally experimental studies should be made which is neither possible nor ethically suitable regarding this question. Alternatively, future studies should apply longitudinal designs that investigate in one sample whether an early insecure attachment precedes social anxiety which then predicts the onset of depression above the impact of early attachment. Up to now, there is only preliminary evidence in the literature that suggests such a causal link between attachment, SA, and depression. There are studies showing that an insecure attachment style is predictive of future socially anxious symptoms among children (Bifulco et al., 2006; Lee & Hankin, 2009). Additionally, studies in the field of SA have shown that this disorder often precedes upcoming depressive symptoms (Kessler et al., 1999; Chartier et al., 2003) which points to a relationship as described in the present study. However, as argued above, studies like this are not sufficient to finally draw causal conclusions and further research is needed to shed light on the causal relations. A second critical point of the study might be that no other factors have been included in the mediational model. Since this study primarily aimed at testing and replicating the findings of Eng et al. (2001) in a homogenous sample of socially anxious patients, the inclusion of other variables was beyond the scope of the present study. However, one might think about additional pathways and mediating factors extending the model of Eng et al. (2001). For instance, social rank has been suggested as an antecedent of SA (Aderka et al., 2009) that is also associated with attachment. Other studies point to the mediating role of dysfunctional attitudes and low self- esteem (Roberts, Gotlib, & Kassel, 1996) which might be included as additional mediators into the model. Moreover, the present study was restricted to socially anxious patients as was the original study by Eng et al. (2001). Future studies could increase the

9

range of social anxiety and depression by including patients with the primary diagnosis of depression. In conclusion, the present study replicates that the effect of attachment on depression is mediated by SA. Depending on the measure of attachment, this effect was completely or partially mediated. This indicates that on the one hand SA is associated with insecure attachment style and depression and mediates their interrelation. On the other hand this study shows that attachment is linked to depression even beyond SA and has to be considered as an important aspect of psychopathology.

References Aderka, I. M., Weisman, O., Shahar, G., & Gilboa-Schechtman, E. (2009). The roles of the social rank and attachment systems in social anxiety. Personality and Individual Differences, 47(4), 284-288. doi:10.1016/j.paid.2009.03.014 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349. Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007). Predicting children's anxiety from early attachment relationships. Journal of Anxiety Disorders, 21(8), 1061-1068. doi:10.1016/j.janxdis.2006.10.013 Bakermans-Kranenburg, M. J. & van Ijzendoorn, M. H. (2009). The first 10,000 Adult Attachment Interviews: distributions of adult attachment representations in clinical and non-clinical groups. Attachment and Human Development, 11 (3), 223-263. doi: 10.1080/14616730902814762. Beck, A. T. (1963). Thinking and depression: I. Idiosyncratic content and cognitive distortions.

Archives

of

General

Psychiatry,

9(4),

324-333.

doi:10.1001/archpsyc.1963.01720160014002 10

Beck, A. T., Ward, C., & Mendelson, M. (1961). An inventory for measuring depression. (BDI). Archives of General Psychiatry, 4(6), 561-571. Bifulco, A., Kwon, J., Jacobs, C., Moran, P. M., Bunn, A., & Beer, N. (2006). Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety. Social Psychiatry and Psychiatric Epidemiology, 41(10), 796-805. doi: 10.1007/s00127-006-0101-z Bifulco, A., Moran, P. M., Ball, C., & Bernazzani, O. (2002). Adult attachment style. I: Its relationship to clinical depression. Social Psychiatry and Psychiatric Epidemiology, 37(2), 50-59. doi:10.1007/s127-002-8215-0 Blatt, S. J., & Zuroff, D. C. (1992). Interpersonal relatedness and self-definition: Two prototypes

for

depression.

Clinical

Psychology

Review,

12(5),

527-562.

doi:10.1016/0272-7358(92)90070-O Bowlby, J. (1977). The making and breaking of affectional bonds: I. Aetiology and psychopathology in the light of attachment theory. The British Journal of Psychiatry, 130201-210. doi:10.1192/bjp.130.3.201 Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. Attachment theory and close relationships, 4676. Carnelley, K. B., Pietromonaco, P. R., & Jaffe, K. (1994). Depression, working models of others, and relationship functioning. Journal of Personality and Social Psychology, 66(1), 127-140. doi:10.1037/0022-3514.66.1.127 Chartier, M. J., Walker, J. R., & Stein, M. B. (2003). Considering comorbidity in social phobia. Social Psychiatry and Psychiatric Epidemiology, 38(12), 728-734. doi:10.1007/s00127-003-0720-6

11

Collins, N. L. (1996). Working models of attachment: Implications for explanation, emotion, and behavior. Journal of Personality and Social Psychology, 71(4), 810-832. doi:10.1037/0022-3514.71.4.810 Cunha, M., Soares, I., & Gouveia, J. P. (2008). The role of individual temperament, family and peers in social anxiety disorder: A controlled study. International Journal of Clinical and Health Psychology, 8(3), 631-655. Dozier, M., Stovall, K. C., Albus, K. E. (1999) Attachment and psychopathology in adulthood. In: J. Cassidy, P.R. Shaver (eds.) Handbook of attachment: theory, research, and clinical applications (pp 497–519). New York, NY, USA: The Guilford Press. Ehrenthal, J. C., Dinger, U., Lamla, A., Funken, B., & Schauenburg, H. (2009). Evaluation der deutschsprachigen Version des Bindungsfragebogens “Experiences in Close Relationships–Revised”(ECR-RD).

Ppmp:

Psychotherapie

Psychosomatik

Medizinische Psychologie, 59(6), 315-323. doi: 10.1055/s−2008−1067425 Eng, W., Heimberg, R. G., Hart, T. A., Schneier, F. R., & Liebowitz, M. R. (2001). Attachment in individuals with social anxiety disorder: the relationship among adult attachment styles, social anxiety, and depression. Emotion, 1(4), 365-380. doi: 10.1037/1528-3542.1.4.365 Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., & ... Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64(1), 22-31. doi:10.1037/0022-006X.64.1.22 Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item response theory analysis of self-report measures of adult attachment. Journal of Personality and Social Psychology, 78(2), 350. doi: 10.1037/0022-3514.78.2.350

12

Hammen, C. L., Burge, D., Daley, S. E., Davila, J., Paley, B., & Rudolph, K. D. (1995). Interpersonal attachment cognitions and prediction of symptomatic responses to interpersonal

stress.

Journal

of

Abnormal

Psychology,

104(3),

436-443.

doi:10.1037/0021-843X.104.3.436 Höger, D. (1999). Der Bielefelder Fragebogen zu Klientenerwartungen (BFKE). Psychotherapeut, 44(3), 159-166. doi: 10.1007/s002780050161 Kessler, R. C., Stang, P., Wittchen, H. U., Stein, M., Walters, E. E. (1999). Lifetime comorbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychological Medicine, 29(3), 555–567. Lee, A., & Hankin, B. L. (2009). Insecure attachment, dysfunctional attitudes, and low selfesteem predicting prospective symptoms of depression and anxiety during adolescence. Journal of Clinical Child and Adolescent Psychology, 38(2), 219-231. doi:10.1080/15374410802698396 Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., . . . Leibing, E. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, 171(10), 10741082. doi: 10.1176/appi.ajp.2014.13111514 Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., . . . Leibing, E. (2013). Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. American Journal of Psychiatry, 170(7), 759-767. doi: 10.1176/appi.ajp.2013.12081125 Leichsenring, F., Hoyer, J., Beutel, M., Herpertz, S., Hiller, W., Irle, E., & ... Leibing, E. (2008). The social phobia psychotherapy research network: The first multicenter randomized controlled trial of psychotherapy for social phobia: Rationale, methods and patient characteristics. Psychotherapy and Psychosomatics, 78(1), 35-41. doi:10.1159/000162299 13

Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. J. Friedman, M. M. Katz, R. J. Friedman, M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research Oxford, England: John Wiley & Sons. Liebowitz, M. R. (1987). Social phobia. Modern Problems of Pharmacopsychiatry, 22, 141173. doi:10.1159/000414022 Mennin, D. S., Fresco, D. M., Heimberg, R. G., Schneier, F. R., Davies, S. O., & Liebowitz, M. R. (2002). Screening for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale. Journal of Anxiety Disorders, 16(6), 661-673. doi:10.1016/S0887-6185(02)00134-2 Mickelson, K. D., Kessler, R. C., & Shaver, P. R. (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology, 73(5), 10921106. doi: 10.1037/0022-3514.73.5.1092 Morley TE, Moran G (2011) The origins of cognitive vulnerability in early childhood: mechanisms linking early attachment to later depression. Clin Psychol Rev 31(7):1071-82. doi: 10.1016/j.cpr.2011.06.006. Pollak, E., Wiegand-Grefe, S., & Höger, D. (2008). The Bielefeld attachment questionnaires: Overview and empirical results of an alternative approach to assess attachment. Psychotherapy Research, 18(2), 179-190. doi: 10.1080/10503300701376365 Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891. doi: 10.3758/BRM.40.3.879 Roberts, J. E., Gotlib, I. H., & Kassel, J. D. (1996). Adult attachment security and symptoms of depression: The mediating roles of dysfunctional attitudes and low self-esteem. Journal of Personality and Social Psychology, 70(2), 310-320. doi:10.1037/00223514.70.2.310

14

Manes, S., Nodop, S., Altmann, U., Gawlytta, R., Dinger, U., Dymel, W., … Strauss, B. (2016) Attachment in Adult Patients with Social Anxiety Disorder. Manuscript submitted for publication. Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia: Epidemiologic findings. The American Journal of Psychiatry, 157(10), 1606-1613. doi:10.1176/appi.ajp.157.10.1606 Stein, H., Koontz, A. D., Fonagy, P., Allen, J. G., Fultz, J., Brethour, J. J., & ... Evans, R. B. (2002). Adult attachment: What are the underlying dimensions?. Psychology and Psychotherapy:

Theory,

Research

and

Practice,

75(1),

77-91.

doi:10.1348/147608302169562 Van Buren, A., & Cooley, E. L. (2002). Attachment styles, view of self and negative affect. North American Journal of Psychology, 4(3), 417-430.

15

social anxiety -17.63***

attachm ent (BQCE)

social anxiety .18***

-2.39 (-4.99**)

depressi on

-5.96***

attachm ent anxiety (ECR-RD)

social anxiety .18***

-1.88** (-2.79***)

depressi on

-4.95***

attachme nt avoidance (ECR-RD)

.18***

-1.63** (-2.42***)

depressi on

Note: *** p < .001, ** p < .01. Fig. 1. Results of the regression analyses for mediation with unstandardized regression coefficients. Total effects in parentheses.

16

Table 1. Sociodemographic characteristics of the sample. Number (total N=194)

Valid Percent

Marital status single

132

71.1

married

35

20.2

separated/divorced

14

8.1

widowed

1

0.6

54

32.7

living alone

57

32.9

living with partner

72

41.6

living with parents/ relatives

29

16.8

other

15

8.7

no degree

1

0.6

8th/10th grade

56

32.6

high school

115

66.9

no professional training

44

25.9

professional school/ training

78

45.9

any college/ PhD

48

28.2

Having children Living situation

Education (school)

Education (professional)

Funding: This project was supported by a grant from the German Federal Ministry of Education and Research (BMBF), FKZ 01GV0607.

Conflicts of interest: none

17

Highlights Social anxiety mediates the effect of attachment on depression. The study succesfully conceptually replicated the study by Eng et al. (2001). Attachment was assessed by the BQCE and ECR-RD.

18