© 2007 Springer Publishing Company 577
Violence and Victims, Volume 22, Number 5, 2007
Family Environment and Adult
Attachment as Predictors of
Psychopathology and Personality
Dysfunction Among Inpatient
Shelley A. Riggs, PhD
University of North Texas
Gayla Sahl, PhD
Ellen Greenwald, MA
Heather Atkison, MA
Adrienne Paulson, MA
Texas Woman’s University
Colin A. Ross, MD
Timberlawn Psychiatric Hospital
The current study explored the role of early family environment and adult attachment style
in explaining long-term outcomes among child abuse survivors. Adult patients (N = 80)
in a trauma treatment program were assessed for clinical diagnosis and administered a
multiscale questionnaire. Hierarchical regression analyses were significant for dissociative
identity disorder (DID), substance abuse, anxiety disorder, posttraumatic stress, somatiza-
tion, and six personality disorder dimensions. Adult attachment styles were significant
predictors of most outcome variables. Of particular note was the strong contribution
of attachment avoidance to DID. Five family environment scales (Independence, Orga-
nization, Control, Conflict, Expressiveness) also contributed to various psychopathologi-
cal outcomes. Evidence emerged supporting a mediating role for attachment style in the
link between family independence and five personality disorder dimensions.
Keywords: child abuse; family environment; attachment style; psychopathology
dysfunction. Yet, not all abuse survivors suffer negative consequences, and those who do
demonstrate a broad variety of clinical symptoms and personality disturbance. Significant
heterogeneity within this population suggests that other factors, such as abuse characteristics
and pathogenic early home environments, contribute to diverse developmental trajectories
large body of evidence consistently indicates that adult survivors of physical,
sexual, or psychological abuse in childhood are more likely than adults without
a history of abuse to experience a wide range of psychological and personality
578 Riggs et al.
following abuse experiences. The research of Alexander and her colleagues (1992, 1993;
Alexander et al., 1998; Anderson & Alexander, 1996) suggests that adult attachment style
may mediate the association of child abuse with later distress, thus accounting for some of
the variability in outcomes. The current study extends past research to an inpatient popula-
tion and is the first to explore the combined contributions of early family characteristics
and adult attachment style to specific clinical syndromes and personality disturbance.
CHILDHOOD ABUSE, FAMILY BACKGROUND,
AND ADULT OUTCOMES
A variety of negative long-term consequences of child abuse have been reported, including
low self-esteem, interpersonal problems, and increased rates of depression, anxiety, sub -
stance abuse, somatization, and personality disorders (Jumper, 1995; Molnar, Buka, & Kessler,
2001; Mullen, Martin, Anderson, Romans, & Herbison, 1996; Polusny & Follette, 1995).
Although mixed, there is growing evidence that different types of abuse are associated
with specific symptomatology (Briere & Runtz, 1990; Engels, Moisan, & Harris, 1994;
Molnar et al., 2001). Moreover, compared to single forms of abuse, compound trauma
involving both sexual and physical abuse is specifically associated with depression, dis-
ordered eating, dissociation, posttraumatic stress symptoms, and psychiatric comorbidity
(Krupnick et al., 2004; see Higgins & McCabe, 2001, for review).
Because protection is the primary biological and evolutionary function of family care-
givers, childhood abuse may be especially traumatic when it occurs within the context
of family attachment relationships (Allen, 2001; Bowlby, 1980). However, while some
studies support the expectation that a closer family relationship to the perpetrator is asso-
ciated with increased levels of maladjustment and symptomatology, other studies report
no differences in outcome between survivors of intrafamilial or extrafamilial abuse (see
Tyler, 2002, for review). The literature also indicates that parental psychopathology and
parental substance abuse are associated with increased risk for later psychological dif-
ficulties (Benedict & Zautra, 1993; Trull, 2001; Yama, Tovey, Fogas, & Morris, 1995).
These parental problems, in turn, increase the risk of dysfunctional family environments
(Ellis & Zucker, 1997; Mullen et al., 1996) and may influence outcomes indirectly through
associations with disturbed parent–child interactions and increased levels of conflict and
disorganization within the family (Cummings & Davies, 1994; Rutter & Quinton, 1984).
Families with a history of physical or sexual abuse are generally characterized as less
supportive, less organized, and more isolated. They may also demonstrate low levels of
independence and high levels of control (Justice & Calvert, 1990; Moos & Moos, 2002).
Low family cohesion and high conflict and/or control has been linked to depression, anxi-
ety, and posttraumatic stress symptoms in college and community samples of child abuse
survivors (Kamsner & McCabe, 2000; Myerson, Long, Miranda, & Marx, 2002; Yama,
Tovey, & Fogas, 1993). In samples unselected for child abuse, dependent personality
disorder was related to high levels of family control and low levels of expressiveness and
independence; histrionic personality disorder was associated with low cohesion and high
control (Baker, Capron, & Azorlosa, 1996; Head, Baker, & Williamson, 1991). High fam-
ily conflict and disorganization may characterize the early family experiences of patients
diagnosed with borderline personality disorder (Ludolph et al., 1990). Some researchers
have suggested that family background factors are better predictors of psychological out-
comes than abuse-specific variables (Higgins & McCabe, 2003; Mullen et al., 1996; Nash,
Family, Attachment, and Psychopathology 579
Hulsey, Sexton, Harralson, & Lambert, 1993); however, other research indicates no strong
pattern of associations (Harter & Vanecek, 2000; Polusny & Follette, 1995). More research
is needed to clarify the role of family environment in the development of specific Axis I
and II disorders among adults with histories of childhood abuse.
Although scarce, evidence is emerging to support theoretical links between adult attachment
security and healthy early family environments (Diehl, Elnick, Bourbeau, & Labouvie-Vief,
1998; Mikulincer & Florian, 1999; Pfaller, Kiselica, & Gerstein, 1998). Adult romantic
attachment style is presumed to be an outgrowth of early attachment organization, and
research has shown that adult attachment insecurity is related to memories of unavailable and
nonsupportive parenting (Brennan & Shaver, 1998; Mickelson, Kessler, & Shaver, 1997).
Researchers have described adult romantic attachment as comprising two polar dimensions
of anxiety and avoidance (Brennan, Clark, & Shaver, 1998), which form four quadrants or
categories of attachment. According to Bartholomew and Horowitz (1991), secure individu-
als show a balance between a healthy connection to others and self-reliance; they tend to
have a positive self-image (low anxiety) and demonstrate trust and open communication in
relationships (low avoidance). In contrast, preoccupied adults question their self-worth and
fear abandonment (high anxiety), whereas dismissing–avoidant adults distrust others and
minimize or shun interpersonal intimacy (high avoidance). Fearful–avoidant adults experi-
ence high levels of both attachment anxiety and avoidance, which may contribute to ongo-
ing struggles regarding approach/avoidance behaviors in personal relationships (Simpson &
Rholes, 2002), a conflict frequently observed in clinical work with abuse survivors.
Insecure models of attachment, while not synonymous with psychopathology, create
a risk for the development of psychological problems. Preoccupied adult attachment style
is characterized by hyperactivating strategies of coping and emotional regulation (Miku-
lincer & Shaver, 2003) and has been linked to low self-control and tolerance, interpersonal
dependence/reliance, as well as histrionic, dependent, and borderline personality traits
(Allen, Coyne, & Huntoon, 1998; Brennan & Shaver, 1998; Diehl et al., 1998; Onishi,
Gjerde, & Block, 2001). In contrast, dismissing–avoidant attachment is characterized by
deactivating strategies (Mikulincer & Shaver, 2003) and in nonclinical samples has been
associated with substance abuse, somatization, and repressive tendencies (Mickelson
et al., 1997; Mikulincer, Florian, & Weller, 1993; Onishi et al., 2001), with possible links
suggested to dissociation and narcissistic, schizoid, antisocial, paranoid, and obsessive–
compulsive personality traits (e.g., Blatt & Levy, 2003). Findings in nonclinical samples
also have documented significant relationships between fearful–avoidant attachment and
depression, somatic anxiety, substance abuse, dissociation, and paranoid, schizoid, schizo-
typal, avoidant, self-defeating, borderline, narcissistic, and obsessive–compulsive person-
ality traits (Anderson & Alexander, 1996; Brennan & Shaver, 1998; Brennan, Shaver, &
Tobey, 1991). Among inpatients, Allen et al. (1998) reported that high attachment anxiety
and an inability to depend (i.e., fearful avoidance) were related to paranoid, schizotypal,
and borderline personality.
Recently, researchers have become interested in the role of the attachment system in
long-term outcomes of abuse survivors. Retrospective reports of maltreatment in childhood
are linked to insecure romantic attachment among undergraduates (Gauthier, Stollak,
Messe, & Aronoff, 1996; Roche, Runtz, & Hunter, 1999; Styron & Janoff-Bulman, 1997).
580 Riggs et al.
For example, Roche et al. (1999) reported that a negative model of other/attachment
avoidance was related to depression and trauma symptomatology (e.g., defensive avoid-
ance, dissociation). Negative view of self/attachment anxiety has been linked to symptoms
of depression, anxiety, and traumatic stress in college and community samples (Muller,
Lemieux, & Sicoli, 2001; Roche et al.). Among female incest victims, preoccupied attach-
ment was associated with dependent personality traits, whereas fearful–avoidant attach ment
was associated with borderline and avoidant personality traits (Alexander, 1993; Alexander
et al., 1998). Anderson and Alexander (1996) reported that fearful–avoidant attachment
was related to high levels of dissociation and was much more likely to characterize a small
subsample (n = 8) of women identified as having dissociative identity disorder (DID).
Moreover, several researchers have reported recently that internal models of attachment
can both mediate and moderate the impact of childhood abuse and long-term psychologi-
cal outcomes, including dissociation, depression, and traumatic stress (Roche et al., 1999;
Shapiro & Levendosky, 1999; Wekerle & Wolfe, 1998).
THE CURRENT STUDY
Although family systems and attachment theories clearly share similar concepts regarding
development (Hill, Fonagy, Safier, & Sargent, 2003; Marvin & Stewart, 1990), little effort
has been made to integrate these two bodies of literature, and systematic research explor-
ing the interrelationships among family and attachment constructs is lacking. Further, the
bulk of studies examining either of these constructs in relation to psychological outcomes
among abuse survivors have used college or community samples (e.g., Anderson & Al-
exander, 1996; Muller et al., 2001; Roche et al., 1999), with rare exceptions using outpa-
tient clinical samples (Gold, Hyman, & Andres-Hyman, 2004; Nash et al., 1993). However,
college samples, and to a lesser extent community samples, generally show small effect
sizes for the long-term consequences of child abuse and tend to report shorter, less violent,
and less invasive abuse experiences than survivors in clinical samples (Jumper, 1995). The
current study used a geographically diverse sample of inpatients admitted to a specialized
treatment program for survivors of severe trauma. Because the sample was characterized
by a wide range of Axis I and Axis II psychopathology, it was possible to explore the
relative contributions of family environment and adult attachment style in the prediction
of specific types of disorders and personality dysfunction, beyond what is accounted for
by multitype abuse, parental psychopathology, and parental substance abuse. Notably, due
to the nature of the trauma program, a high number of participants were diagnosed with
DID, which offered a unique opportunity to study a disorder thought to originate in the
context of extreme child abuse but rarely seen in practice. A second goal of the study was
to address the suggestion that adult romantic attachment style mediates the association
between early family experiences and later outcomes among child abuse survivors.
Six family environment qualities were examined: five identified by Reichertz and
Frankel (1990) as characteristic of conflicted families (i.e., high conflict and high control, as
well as low cohesion, expressiveness, and independence), and a sixth scale (low organiza-
tion) reported to be associated with a history of child sexual abuse (Moos & Moos, 2002).
Although research examining early family environment and adult romantic attachment in
relation to specific psychological disorders among trauma survivors is relatively scarce,
based on the existing theory and literature previously reviewed, two general hypotheses
were tested. First, we expected family environment and adult attachment style to explain
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Acknowledgments. This project was partially funded by the Department of Psychology and Phi-
losophy at Texas Woman’s University and the Ross Institute. We are grateful to the staff and patients
of the Timberlawn Psychiatric Hospital Trauma Program for their time.
Correspondence regarding this article should be directed to Shelley A. Riggs, PhD, University of North
Texas, Department of Psychology, P.O. Box 311280, Denton, TX 76203–1280. E-mail: email@example.com