This article was downloaded by: [Moskow State Univ Bibliote] On: 07 December 2013, At: 08:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Attachment & Human Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rahd20 Attachment style and psychological adjustment in couples Ana Conde a , Bárbara Figueiredo a & Antonia Bifulco b a School of Psychology , University of Minho , Portugal b Kingston University , London, UK Published online: 18 Apr 2011. To cite this article: Ana Conde , Bárbara Figueiredo & Antonia Bifulco (2011) Attachment style and psychological adjustment in couples, Attachment & Human Development, 13:3, 271-291, DOI: 10.1080/14616734.2011.562417 To link to this article: http://dx.doi.org/10.1080/14616734.2011.562417 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms- and-conditions
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This article was downloaded by: [Moskow State Univ Bibliote]On: 07 December 2013, At: 08:44Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Attachment & Human DevelopmentPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rahd20
Attachment style and psychologicaladjustment in couplesAna Conde a , Bárbara Figueiredo a & Antonia Bifulco ba School of Psychology , University of Minho , Portugalb Kingston University , London, UKPublished online: 18 Apr 2011.
To cite this article: Ana Conde , Bárbara Figueiredo & Antonia Bifulco (2011) Attachment styleand psychological adjustment in couples, Attachment & Human Development, 13:3, 271-291, DOI:10.1080/14616734.2011.562417
To link to this article: http://dx.doi.org/10.1080/14616734.2011.562417
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.
This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Attachment style and psychological adjustment in couples
Ana Condea, Barbara Figueiredoa* and Antonia Bifulcob
aSchool of Psychology, University of Minho, Portugal; bKingston University,London, UK
(Received 30 May 2009; final version received 29 June 2010)
The present study addresses the gap in research concerning poor marital supporttogether with insecure attachment style explaining risk for anxiety or depression inbothmembers of a couple expecting a baby. The Attachment Style Interview (ASI)was administered separately to both members of a couple (N ¼ 126) during thesecond trimester of pregnancy together with measures of state-anxiety (STAI-S)and depression (EPDS). These measures were repeated at three monthspostpartum. While insecure attachment style was related to higher anxiety anddepression symptoms in both partners at both time periods, there was an increaseof postnatal depression symptoms in women. Poor partner support contributed toanxiety symptoms only in men. When insecure attachment combinations in bothmembers of the couple were examined, insecure styles increased anxiety anddepression symptoms in both genders antenatally, but postnatal anxiety symptomsonly in women. A combined effect of partner’s support and attachment style ontemporal changes of anxiety symptoms was observed differently for women andmen. It is important to assess attachment style and partner support of bothmembers, as well as the mutual interplay between them, to understand gendereddifferences in psychological adjustment of a couple expecting a baby.
Attachment style is acknowledged as an important factor in the perinatal mentalhealth of mothers (Matthey, Barnett, Ungerer, & Waters, 2000; Morse, Buist, &Durkin, 2000). Insecure Anxious attachment styles are associated with both prenatal(Figueiredo, Bifulco, Pacheco, Costa, & Magarinho, 2006) and postnatal depressionand/or anxiety disorder in women (Kuscu et al., 2008) and with the persistence ofdepression symptoms over the postpartum period (McMahon, Barnett, Kowalenko,& Tennant, 2005). Less is known about the role of insecure attachment in thedevelopment of disorders perinatally in men, although this is now beginning toattract attention (Teixeira, Figueiredo, Conde, Pacheco, & Costa, 2009). Severalresearch studies additionally show that attachment style plays a crucial role inwomen’s marital adaptation when expecting a baby (Findler, Taubman-Ben-Ari, &Jacob, 2007) including difficulties in the couple’s relationship and lack of maritalsupport from the partner are key to successful adaptation after the birth of a baby
(Dennis & Ross, 2006). Lack of support is established as a risk factor for both malesand females (Lutz & Hock, 2002). However, the interplay of attachment style andpoor support as risk factors, by gender and perinatal period on depression or anxietydisorder needs further investigation and clarification. Studying these in bothmembers of a couple having a baby to identify differentiation of such risks is the aimof the study reported here.
The measurement of attachment style perinatally has largely been conductedeither through the use of brief self-report questionnaires (e.g., RelationshipsQuestionnaire; Bartholomew & Horowitz, 1991, or Adult Attachment Question-naire; Simpson, Rholes, & Phillips, 1996) or through intensive interview measuresfocused on childhood experience (e.g., Adult Attachment Interview; George,Kaplan, & Main, 1984). While both approaches have added to the understandingof the impact of attachment style, neither set of measures provides any ongoingcontextual assessment of the partner relationship, wider supportive relationshipsor attitudes around help-seeking, autonomy and trust in relationships. Such infor-mation would illuminate the role of marital support and support-based attachmentstyle in the perinatal period for both members of a couple in relation to affectivedisorder.
The Attachment Style Interview (ASI) is increasingly used as a standardisedresearch interview tool to investigate the role of poor partner relationship and lack ofsocial support along with negative attitudes around Anxious and Avoidant styles inthe onset of major depression (Bifulco, Moran, Ball, & Bernazzani, 2002; Bifulco,Moran, Ball, & Lillie, 2002). However, to date it has not been used with bothpartners in a relationship. The measure has been utilised in perinatal investigation ofdepression cross-culturally in mothers across eight European centres and showedinsecure attachment style related to women’s depression both antenatally andprospectively in the postnatal period with differentiation of type of attachment styleand perinatal period indicated (Bifulco, Figueiredo, Guedeney, Gorman, Hayes,Muzik, et al., 2004). These findings were replicated in an antenatal study in Portugalalso using the ASI to investigate teenage pregnancy and depression in 66 pregnantadolescents and 64 pregnant adult women. Pregnant teenagers were found to benearly three times more likely to have an insecure attachment style, markedly ormoderately Enmeshed, Angry-Dismissive, or Fearful style than the older pregnantwomen. Logistic regression showed Enmeshed style and poor partner supportprovided the best model for depression with age at pregnancy showing nocontribution (Figueiredo et al., 2006). However, no assessment was made of themale partner’s attachment style or symptomatology in contributing to the lack ofpartner support and depression for the young women.
Additional research is required to understand the risks for psychologicaladjustment not only by gender, but in both members of a couple around the birthof a baby, to focus on individual and joint support and attachment needs (Besser,Priel, & Wiznitzer, 2002; Feeney, Alexander, Noller, & Hohaus, 2003). While poorsupport increases risk, good support can protect from disorder in the face ofupheaval and stress (Milgrom et al., 2008; Spoozak, Gotman, Smith, Belanger, &Yonkers, 2009). Although lack of support is established as a risk factor forpsychological adjustment in both males and females (Lutz & Hock, 2002), the addedimpact of underlying insecure attachment style with accompanying anxious-ambivalent or avoidant barriers to help-seeking during periods of crisis or changeare under-researched (Escribe-Aguir, Gonzalez-Galarzo, Barona-Vilar, & Artazcoz,
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2008). Thus understanding the patterning in couples of partner support, and insecureattachment style is important to understanding the potential for risk of psychologicalmaladjustment in both members of a couple during times of stress or change, such aswhen expecting a baby.
Existing research on the postpartum affective experiences of couples shows non-gendered effects with more than a quarter of mothers and fathers reporting elevateddepression symptoms, and these results correlated between partners (Soliday,McCluskey-Fawcett, & O’Brien, 1999). Depression was higher in both genders in thepresence of marital dissatisfaction (Escribe-Aguir et al., 2008) and antenatal moodand partner relationship are significant predictor variables for the postnatal mood ofboth mothers and fathers (Matthey et al., 2000). However the research focus hasbeen largely on subjective accounts of marital satisfaction, rather than moreobjective features of supportive behaviour. A detailed review of couple experienceand attachment style by Mikulincer, Florian, Cowan, and Cowan (2002) shows thatsecure attachment style is associated with a range of factors such as beliefs about thepartner relationship, including satisfaction, high intimacy and positive interactionand communication. Studies of attachment style in the transition to parenthoodshow that self report assessment of Avoidant style is correlated with ongoingnegativity in marriage during pregnancy (Rholes, Simpson, Campbell, & Grich,2001), with Anxious-Ambivalent attachment style associating with women’sperception of lack of support from the partner towards the end of the pregnancywhich in turn predicted a reduction in marital satisfaction in both men and womenpostpartum (Rholes et al., 2001; Simpson, Rholes, Campbell, Tran, & Wilson, 2003).Women with Anxious-Ambivalent attachment style, who perceived less support orgreater anger from their husbands, experienced an increase in depressive symptomspostnatally (Simpson et al., 2003).
Studies of couples using the Adult Attachment Interview (George, Kaplan, &Main, 1984) show declines in positive marital perceptions across a two-yearpostnatal period were found to be greater in insecure husbands and their wives thansecure husbands and their wives (Paley, Cox, Harter, & Margand, 2002). Whenhusbands had insecure styles there was more negative interaction at 24 monthspostpartum, particularly when there was prior indication of negative behaviour.Poorer family interactions at 24 months were predicted by father’s withdrawalprenatally and mother’s withdrawal postnatally (Paley, Cox, Kanoy, Harter,Burchinal, & Margand, 2005).
Volling, Notaro, and Larsen (1998) looked at attachment patterns using the AAI,in association with partner relationships and parenting in 62 married couples with aone-year-old child. In half the couples, both partners were Secure, with coupleshaving Secure-Avoidant combinations emerging as the most common discrepantpattern (30%). In only 7% of couples were both partners Insecure. Where bothpartners were Secure the marital relationships and support networks were better. ASecure wife and Avoidant husband fared better in terms of their relationships, thanwhen the wife had an Insecure style. This implies that gender may relate todifferential risk for psychological adjustment in women and men.
The aim of the study reported here is to both replicate and add to previousfindings of gender effects on anxiety and depression both before and after the birth ofa child. By investigating married couples this will additionally allow for theinvestigation of individual and couple effects of attachment style and support to thetwo disorders prospectively. The study has the following research objectives:
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(1) To examine attachment style individually for women and men and itsassociation with concurrent anxiety and depression symptoms, bothantenatally and prospectively at three months postpartum.
(2) To examine partner support in pregnancy and its association with anxietyand depression symptoms individually for women and men, antenatally andprospectively at three months postpartum.
(3) To test the combined pattern of attachment style of the couple in pregnancyand its association with anxiety and depression symptoms on both gendersantenatally and prospectively at three months postpartum.
(4) To examine the combined effect of partner support and attachment style onanxiety and depression symptoms on both genders antenatally andprospectively at three months postpartum.
Based on previous findings, we hypothesise that women and men adjust differently topregnancy at the first months postpartum, with women exhibiting higher anxiety anddepression symptoms than men. We also hypothesise that both attachment style andpartner’s support appear as important factors for psychological adjustment duringpregnancy and postpartum on both elements of the couple, with insecure attachmentstyle, mainly anxious attachment style, and poor partner’s support being associatedto higher anxiety and depression symptoms.
Method
Sample
The sample consisted of 63 couples (N ¼ 126), recruited consecutively at theantenatal obstetric unit of the Julio Dinis Maternity Hospital, Oporto, Portugal,before 14 weeks gestation. This sample constitutes a low medical-risk series and noselection for psychosocial risk was applied. From the 104 couples who originallyagreed to participate in the study, there was a 39.4% fall-off in cooperation atfollow-up mainly due to the ending of medical proceedings at the hospital, whichresulted in lower cooperation after this point.
There were some demographic differences noted between those participants whostayed in the study and those who dropped out. Those who stayed in the study weresignificantly more likely to be over age 18 (p ¼ .004), employed (p ¼ .003), married(p ¼ .000), already had children (p ¼ .01) and living with their partner (p ¼ .002).However there were no significant differences in terms of educational attainment,overall attachment style classification, support in marital relationship or antenatalanxiety or depression symptoms.
The majority of the participants in the final sample were Portuguese citizens(87.3%) and Caucasian (98.4%), over 18 years (95.2%; range 15–48, female ageM ¼ 28.79, SD ¼ 5.52, and male age M ¼ 30.57, SD ¼ 6.07). Most were eithermarried (73.8%) or cohabiting (19.8%), and living with the partner (92.9%, with[14.3%] or without [78.6%] the extended family), with the mean relationship lengthof 3.86 years (SD ¼ 4.0). Only 1.6% were separated or divorced and 4.8% single.Most were employed (86.5%) in manual occupations (61.5%) and had lower middle-class status. Half of the participants were first time parents (women ¼ 50.8%;men ¼ 49.2%) and pregnancy was reported as planned for 60%. In all cases, bothelements of the couple were the biological parents.
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Measures
Demographic factors
Age, ethnicity, nationality, employment and occupation, marital status, householdarrangements and educational attainment were obtained through a standardisedinterview.
This is an investigator-based interview, whereby the interviewer rates informationcollected face-to-face according to benchmarked thresholds to determine bothbehaviour and attitudes relating to support and attachment style. It is derived from asocial psychological approach to attachment style, which assesses the respondents’ability to form and maintain supportive relationships by questioning about family oforigin, partner and ‘‘very close other’’ relationships, together with attitudes aboutcloseness/distance from others, autonomy and fear/anger in relationships. Inter-raterreliability of the measure is high (Bifulco, Moran, Ball, & Bernazzani, 2002; Bifulcoet al., 2004). A Portuguese translation of the interview and rating (Bifulco et al.,2004) showed good inter-rater reliability (ranging from 0.81 to 1.00 Kw) andrelatively high stability rates with correlations between antenatal and postnatal ASIratings ranging from 0.67 to 0.90. The current use of the instrument was overseen byits original designer (AB) with discussion of difficult ratings to ensure reliability.
A list of ASI scales is provided in the Appendix. The interview takes about 60minutes to administer and is scored from recordings after the interview. The firstsection questions about support networks (family and friends) and the quality ofrelationship within three close relationships (partner and two others named as veryclose). For each relationship, ratings are made on ongoing level of confiding, activeemotional support, quality of interaction, and felt attachment. An overall summaryrating of support is provided for each of the three relationships. Thus ratings of ‘‘1:very good – 3: good average support’’ reflects relationships with a high level ofconfiding evidenced by actual examples of stressful topics discussed and positiveactive emotional response received. Ratings of ‘‘4: inadequate support – 7: poorsupport’’ were rated when confiding and support were low or absent on the basis ofcarefully probed questions. On the basis of both the number and quality of supportiverelationships a rating of poor ‘‘ability to make and maintain relationships’’ forms thebasis for rating the degree of insecurity of attachment style. While the information onpartner support contributes to this overall assessment, it can also stand alone as a riskfactor. Poor partner support is neither a necessary or sufficient condition of poorability to form and maintain relationships, although those with lowest ability to formand maintain relationships will also typically have poor quality of partner support.
The ASI additionally utilises seven attitudinal scales denoting Avoidancecharacteristics (e.g., mistrust, constraints on closeness, high self-reliance, or anger)and Anxious attachment characteristics (e.g., high desire for engagement, fear ofseparation, or fear of rejection). On the basis of these, and in accordance with clearmanualised rating rules, a classification is made of the type of style. This includes twotypes of Anxious attachment style (Enmeshed or Fearful) and two Avoidant styles(Angry-dismissive or Withdrawn), in addition to Secure. While these mostly parallelthose found in other social psychological classifications such as the Relationship
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Questionnaire (Bartholomew & Horowitz, 1991), the additional category of Angry-Dismissive in the ASI is comparable to the Mistrustful style identified in the clinicalversion of the Relationship Questionnaire (Holmes & Lyons-Ruth, 2006). Inaddition to rating the type of style, the degree of insecurity or impairment in relatingstyle was assessed as ‘‘marked’’, ‘‘moderate’’, ‘‘some’’ or ‘‘little/none’’. Previousanalyses have shown a dose-effect of level of insecurity to depression, with only‘‘marked’’ and ‘‘moderate’’ levels of insecure style conferring risk for depressionconcurrently or prospectively (Bifulco, Moran, Ball, & Lillie, 2002; Bifulco et al.,2004). For the present study the Portuguese team was trained in the ASI by theinterview’s author with regular communication on rating maintained. A two-daytraining course was provided at the beginning of the study. All trainees wereprovided with a manual of precedent rating examples to aid reliability. Each teamwas required to send back to the interview’s author ratings for their first fiveinterviews, which were checked, and any difference in rating reported back. Teamswere encouraged to e-mail questions about difficult ratings, to ensure consistency. Inaddition, face-to-face meetings were held with team leaders, when requested, todiscuss ratings. All ratings were made according to manualised benchmarkedexamples with consensus ratings used to enhance reliability (Figueiredo et al., 2006).Satisfactory inter-rater reliability was found with high levels of agreement betweenobservers ranging from 0.81 to 1.00.
The STAI is a self-report questionnaire that consists of two subscales, the stateanxiety subscale and the trait anxiety subscale, each containing 20 items. Only thestate anxiety subscale (STAI-S), which measures anxiety at the point of scoring, wasused in the analyses. The scores in this subscale range from 20 to 80, higher scoresindicating higher state anxiety. This is conceptualised as a transient emotionalcondition of the individual, characterised by subjectively experienced feelings oftension, together with a heightened activity of the autonomous nervous system. TheSTAI has been used in several studies implemented during pregnancy and thepostpartum period, both with women and men (e.g., Teixeira et al., 2009). ThePortuguese version of the measure showed good internal consistency (StateCronbach’s alpha in women ¼ 0.88 and in men ¼ 0.93, respectively) and constructvalidity demonstrated by substantial differences in scores obtained under stressfuland neutral conditions. The recommended cut-off of 45 for high-anxiety is utilised(Biaggio, Natalicio, & Spielberger, 1976).
The EPDS is a self-report questionnaire composed of 10 items in a Likert scale offour points (0–3) to assess depression symptoms. The EPDS Portuguese versionshows good internal consistency (Cronbach’s alpha ¼ 0.85) and test-retestreliability (Spearman Correlation ¼ 0.75) (Figueiredo, Pacheco, & Costa, 2007).The recommended cut-off score of 10 or more was used to define probable clinicallevels both in women and men (Areias, Kumar, Barros, & Figueiredo, 1996). Thisquestionnaire has been used extensively in perinatal studies of women, as well aswith men, both internationally and in Portuguese samples (e.g., Teixeira et al.,2009).
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Procedures
Medical records were consulted to identify all pregnant women up to 14 weeksgestation, excluding those with multiple gestations or with medical and/or obstetriccomplications. Participants’ informed consent was obtained and ethical permissionwas granted from the hospital’s ethics board. Cooperation for the study was requiredboth from the pregnant women initially contacted (N ¼ 123) and their husbands/partners. From the initially contacted couples, 15.4% refused to participate in thestudy. Assessments were undertaken individually with each member of the coupleduring the second trimester of pregnancy and again at three months postpartum.This involved demographic assessment and use of the ASI, as well as the STAI-Ssub-scale of the State-Trait Anxiety Inventory and the EPDS at first contact. Atfollow-up, the questionnaires to assess anxiety and depression symptoms wererepeated.
Statistical analysis
SPSS – 16.0 was used for the statistical analysis. Due to reduced sample size, ASIcategories were combined for all statistical analyses consistent with previousinvestigations: Anxious styles (‘‘marked’’ or ‘‘moderate’’ levels of Enmeshed orFearful styles); Avoidant styles (‘‘marked’’ or ‘‘moderate’’ levels of ‘‘Angry-dismissive’’ or ‘‘Withdrawn’’ styles); Secure styles (included any ‘‘mildly’’ insecureor ‘‘clearly secure’’ attachment style). The presence of either Anxious or Avoidantattachment style was also categorised as ‘‘Insecure Style’’ and compared with Securefor some analyses (see Appendix for summary of scales). Statistical analysis utilisedchi squares (at 5% significance levels), repeated measures ANOVA, and McNemartwo related sample tests. Their application is described in more detail in the resultssection.
Results
Rates of anxiety and depression by gender
In order to determine whether women and men had similar or different rates ofanxiety and depression symptoms during pregnancy and postpartum, frequencies ofEPDS total scores higher or equal than 10 and STAI-S total scores higher or equalthan 45 were calculated. In the overall sample, 12.7% of the participants haddepression at probable clinical levels antenatally reducing to 10.3% at postpartum(McNemar p ¼ .63, N ¼ 126). While there were no significant gender differences,depression was somewhat higher in women than in men both during the pregnancy(14.3% of women and 11.1% of men, ns) and at three months postpartum (14.3% ofwomen and 6.3% of men, ns). Fifteen per cent of the sample had high anxiety levelsin the pregnancy with similar rates at postpartum (13.5%). Again, there was a non-significant trend for higher anxiety in women when compared to men duringpregnancy (19.0% of women and 11.1% of men) and postpartum (19.0% of womenand 7.9% of men). Rates of disorder in both members of the couple were rare (highdepression scores in both elements were 3.2% in pregnancy and 1.6% at postpartum,and high anxiety scores in both elements were 4.8% in pregnancy and 3.2% atpostpartum).
A significant main effect of gender on anxiety and depression symptoms wasfound, with elevated levels in women. Antenatally this effect was significant for
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depression symptoms, F(1, 122) ¼ 5.87, p ¼ .02, but not for anxiety symptoms, F(1,122) ¼ 3.72, p ¼ .06, while postnatally this effect was observed for both anxiety, F(1,120) ¼ 5.45, p ¼ .02, and depression symptoms, F(1, 120) ¼ 13.66, p ¼ .000. Thislatter finding held even after controlling for antenatal psychological symptoms.
Insecure attachment style and anxiety and depression symptoms
To examine attachment style individually antenatally and postnatally, for women andmen, frequencies of individuals presented at each category of attachment style werecalculated with gender differences taken into account. Just over half of individuals inthe sample had Secure attachment style (58.7%), with a non-significant trend, forwomen to be more secure (65%) than men (52.3%). Anxious attachment style wassomewhat more prevalent (23.8%; n ¼ 30) than Avoidant attachment style (17.4%;n ¼ 22) in the series overall. Gender differences were found in rates of Anxious versusAvoidant insecure attachment styles, x2(1, N ¼ 63) ¼ 9.09, p ¼ .004. In women28.5% had an Anxious attachment style and only 6.3% had an Avoidant attachmentstyle. In men 19% had an Anxious attachment style and 28.5% had an Avoidantattachment style. Thus, men were twice as likely to have an insecure Avoidant style,while women were three times more likely to have an insecure Anxious attachmentstyle. Avoidant attachment style was particularly rare in the women (n ¼ 4).
To examine attachment style (Secure versus Insecure) individually antenatally,for women and men, and its association with concurrent anxiety and depressionsymptoms, and the same prospectively at three months postpartum, repeated-measures ANOVA with between-subjects factors (mixed design ANOVA) wasapplied. In this general linear model, points of assessment were included as thewithin-subjects factor with two levels (antenatal and postnatal), STAI-S and EPDStotal scores as measures, and individual’s attachment style (Insecure versus Secure)and gender (women versus men) as the between-subjects factors. These statisticalanalyses were followed by independent MANOVAs to test the proposed aim at eachof the considered time points. STAI-S and EPDS total scores were defined as thedependent variables of the model and individual’s attachment style and gender as thefixed factors. In the analyses at three months postpartum, STAI-S and EPDS totalscores obtained at the second trimester of pregnancy were included as covariates inorder to control for the possible effects of antenatal anxiety and depressionsymptoms when looking at postpartum anxiety and depression symptoms in relationto an individual’s attachment style and gender.
A significant main effect was found for attachment style on anxiety, F(1,122) ¼ 14.20, p ¼ .000, and depression symptoms, F(1, 122) ¼ 17.99, p ¼ .000, withindividuals with insecure attachment style showing higher symptom levels(see Table 1). The MANOVAs showed these effects to be significant, bothantenatally and postnatally. This association held postnatally even after controllingfor antenatal anxiety and depression symptoms.
No significant interaction effect of attachment style and gender was found, eitherfor anxiety, F(1, 122) ¼ .25, p ¼ .62, or for depression symptoms, F(1, 122) ¼ 1.34,p ¼ .25, during pregnancy or at postpartum. Thus the main effect of attachment styleon psychological symptoms was the same for men and women during the wholeperiod.
A main effect of Time on psychological symptoms was found for depressionsymptoms, F(1, 122) ¼ 6.18, p ¼ .01. This did not hold for anxiety symptoms,
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F(1, 122) ¼ .02, p ¼ .90. Only women with an insecure attachment style showed anincrease in depression symptoms in the postpartum. For the remaining sample(secure women and all men) a decrease in depression symptoms was observed frompregnancy to the postpartum (significant interaction Time x Gender in univariatetests; F(1, 122) ¼ 4.99, p ¼ .03) (see Table 1). No significant effects of theinteractions between Time x Attachment style, and Time x Attachment style xGender on psychological symptoms were found.
Anxious versus Avoidant attachment style and anxiety and depression symptoms
Continuing to assess the effect of attachment style individually and antenatally, forwomen and men, on concurrent anxiety and depression symptoms, and prospectivelyat three months postpartum, but now comparing Anxious versus avoidant insecureattachment style repeated-measures ANOVA with between-subjects factors (mixeddesign ANOVA) were again implemented, as previously described for the effects ofSecure versus Insecure individual’s attachment style. These statistical analyses werefollowed by independent MANOVAs to test the proposed aim at each of the timepoints. While multivariate tests found no significant main effect of individual’sattachment style on psychological symptoms over the two time points, univariatetests revealed a significant effect of insecure Anxious attachment style on anxietysymptoms, F(1, 48) ¼ 5.18, p ¼ .03 (see Table 2). Results of the MANOVAs showedthat antenatally, Anxious attachment style was significantly related to both anxietyand depression symptoms. These effects were not found postnatally.
No significant interaction effect between the type of attachment style and genderwas found on psychological symptoms, either antenatally, F(2, 47) ¼ .89, p ¼ .42, orin the postpartum (even after controlling for antenatal psychological symptoms),F(2, 45) ¼ .14, p ¼ .87. This indicated that the main effect of individual’s attachmentstyle on psychological symptoms was similar for women and men, both in pregnancyand postpartum. No significant effect of the interactions Time x Attachment style,and Time x Attachment style x Gender was found.
Partner support and anxiety and depression symptoms
Poor support in the marital relationship was also assessed determining its frequency,both in women and men. A similar rate for pregnant women (23.8%) and theirpartners (25.4%) was found. Most couples had good support rated by both partners(60.3%, 38 pairs), with just under a third of couples (30.2%, 19) having differentsupport ratings among partners. Poor support in both members of the couple wasfound in only 9.5% (six pairs).
To examine partner support in pregnancy and its association with anxiety anddepression symptoms individually for women and men, antenatally and prospec-tively at three months postpartum independent MANOVAs were performed forwomen and men, to analyse differences in anxiety and depression symptoms at thesecond trimester of pregnancy and three months postpartum. At both time points,STAI-S and EPDS total scores, of women and men, were defined as the dependentvariables of the model and support in the marital relationship (poor support versusgood support) as the fixed factor. In the analyses at postpartum, STAI-S and EPDStotal scores obtained in pregnancy were included in the analysis as covariates inorder to control the possible effects of earlier symptoms on later symptoms.
In the overall sample, poor partner support was unrelated to anxiety ordepression symptoms, either in pregnancy or postnatally. Similarly there was nosignificant effect of poor partner support on women’s symptoms antenatally orpostnatally. However, a significant effect of poor partner support was found bothantenatally and postnatally for men’s anxiety symptoms. This held at thepostpartum period after controlling for antenatal symptoms (see Table 3).
Couple’s joint attachment style and anxiety and depression symptoms
To test the combined pattern of attachment style of the couple during pregnancy, thefrequency of the following categories of attachment style organisation in the couple(‘‘Secure-Secure’’, ‘‘Secure-Insecure’’ and ‘‘Insecure-Insecure’’) were calculated. Amarginally significant difference was found in attachment styles at first contactrelated to gender, x2 (1, N ¼ 63) ¼ 3.48, p (2-sided) ¼ .07, p (1-sided) ¼ .06.Women with an insecure attachment style were 1.9 times more likely to have ahusband with an insecure attachment style, while men with an insecure attachmentstyle had a 1.6 times greater likelihood of having a wife with an insecure rather thanwith a Secure attachment style (39.7% of the couple dyads were ‘‘Secure-Secure’’,38.1% ‘‘Secure-Insecure’’ and 22.2% ‘‘Insecure-Insecure’’).
To test the combined pattern of attachment style of the couple during pregnancyand its association with anxiety and depression symptoms on both gendersantenatally and prospectively at three months postpartum, repeated-measuresANOVA with between-subjects factors was implemented similarly for women andmen. Thus, independent repeated-measures ANOVA with between-subjects factorswas used to analyse the prevalence and course of both women and men’s anxiety anddepression symptoms from the antenatal to the postnatal period, focusing on thejoint attachment style of the couple (utilising the couple dyads of ‘‘Secure-Secure’’,‘‘Secure-Insecure’’ and ‘‘Insecure-Insecure’’). In each general linear model, points ofassessment were included as the within-subjects factor with two levels (antenatal andpostnatal), women and men’s STAI-S and EPDS total scores, respectively at eachanalysis, as measures, and joint attachment style in the couple, as the between-subjects factor. Post hoc analyses were undertaken using Scheffe’s test to examinesignificant differences in sub-groups of particular categories of joint attachment stylein the couple. The repeated-measures ANOVA with between-subjects factors wasfollowed by independent MANOVAs to test the proposed aim at both time points.STAI-S and EPDS total scores were defined as the dependent variables of the modeland joint attachment style in the couple as the fixed factor. In the postnatal analysesSTAI-S and EPDS total scores obtained antenatally were included as covariates ascontrols for the possible effects of earlier symptoms on later symptoms.
Impact on women’s symptoms
A significant main effect of couple attachment style was found for women’s anxietyand depression symptoms. Post-hoc analyses using Scheffe’s test found significantdifferences in women’s anxiety symptoms between the ‘‘Insecure-Insecure’’ and‘‘Secure-Secure’’ (p ¼ .001) or ‘‘Secure-Insecure’’ (p ¼ .03) groups. Significantdifferences were also found in women’s depression symptoms between the‘‘Insecure-Insecure’’ and the ‘‘Secure-Secure’’ (p ¼ .004) or the ‘‘Secure-Insecure’’(p ¼ .04) groups. Overall higher anxiety and depression symptoms were found in
women with ‘‘Insecure-Insecure’’ combination of attachment style in the couple, thanin women with ‘‘Secure-Secure’’ or ‘‘Insecure-Secure’’ couple attachment stylecategories (see Table 4). Results of independent MANOVAs implemented for theantenatal and postnatal period revealed the effect of the joint attachment style in thecouple antenatally was significant for depression symptoms, F(2, 60) ¼ 4.34, p ¼ .02,between the ‘‘Insecure-Insecure’’ and the ‘‘Secure-Secure’’ group (p ¼ .02). This fellshort of significance for anxiety symptoms, F(2, 60) ¼ 2.92, p ¼ .06. In contrast, in thepostnatal period this effect was significant for anxiety symptoms, F(2, 58) ¼ 4.90,p ¼ .01, between the ‘‘Insecure-Insecure’’ and the ‘‘Secure-Secure’’ (p ¼ .000) or the‘‘Secure-Insecure’’ (p ¼ .005) groups. This did not hold for depression symptoms, F(2,58) ¼ 1.56, p ¼ .22. There was no significant effect of the interaction between Coupleattachment style x Time, neither for women’ anxiety nor for depression symptoms.
Impact on men’s symptoms
As previously referred, repeated-measures ANOVA with between-subjects factorswas also used to analyse the prevalence and course of men’s anxiety and depressionsymptoms from the antenatal or postnatal period focusing on the joint attachmentstyle in the couple (considering the couple dyads of ‘‘Secure-Secure’’, ‘‘Secure-Insecure’’ and ‘‘Insecure-Insecure’’). A significant main effect of the combinedattachment style pattern in the couple was found for men’s depression symptoms,but not anxiety symptoms. Post-hoc analyses using Sheffe’s test to examine maineffects showed higher depression symptoms in men from ‘‘Insecure-Insecure’’couples than in men with ‘‘Secure-Secure’’ couple attachment style categories(p ¼ .01) (see Table 4). Results of MANOVAs showed that this effect was significantantenatally, F(4, 118) ¼ 2.98, p ¼ .02, but not postnatally, F(4, 114) ¼ 1.15,p ¼ .34. No significant interaction effect of Couple attachment style x Time wasobtained, for men’s anxiety or depression symptoms. Thus, the course ofpsychological symptoms from pregnancy to postpartum was similar in sub-groupsof particular categories of joint attachment style in the couple.
Combined effect of partner support and attachment style on anxiety and depressionsymptoms
Repeated-measures ANOVA with between-subjects factors was used to analyse thecombined effect of partner support and attachment style on anxiety and depressionsymptoms on both genders antenatally and prospectively at three monthspostpartum. In order to explore this effect, the interaction effect of Partner supportx Attachment style x Gender was focused, considering these variables as thebetween-subjects factors of the repeated-measures ANOVA model.
When we considered individual’s attachment style (Secure versus Insecure) andpartner support (poor support versus good support), no significant effects of theinteraction Time x Partner support x Attachment style, F(2, 117) ¼ 1.82, p ¼ .17,Time x Partner support x Attachment style x Gender, F(2, 117) ¼ .02, p ¼ .98,Partner support x Attachment style, F(2, 117) ¼ .22, p ¼ .80, and Partner support xAttachment style x Gender, F(2, 117) ¼ .66, p ¼ .52, were found neither for anxietynor for depression symptoms.
When we took into account the individual’s attachment style (Anxious versusAvoidant) and partner support (poor support versus good support) no significant
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Table
4.
Combined
attachmentstyle
inthecouple
(Insecure
and/orSecure)andanxiety
anddepressionsymptoms,
antenatallyandpostnatallyby
gender.
Couple
attachment
Secure-Secure
a
(n¼
25)
Secure-Insecure
b
(n¼
24)
Insecure-Insecure
c
(n¼
14)
style
(ASI)
Mean(SD)
Mean(SD)
Mean(SD)
p
Women
(1)
STAI–S
Pregnancy
31.76(9.74)
35.25(7.29)
39.00(10.58)
a*c¼
.001
Postpartum
31.48(8.65)
33.83(7.34)
44.14(12.06)
b*c¼
.034
EPDS
Pregnancy
5.00(3.56)
5.96(2.87)
8.43(4.33)
a*c¼
.004
Postpartum
4.64(3.00)
5.54(3.44)
8.78(6.19)
b*c¼
.042
Men
(2)
STAI–S
Pregnancy
29.16(7.71)
34.75(9.96)
32.14(10.88)
n.s.
Postpartum
27.40(7.62)
32.46(7.17)
34.78(12.20)
EPDS
Pregnancy
3.68(3.31)
5.17(3.53)
6.57(4.78)
a*c¼
.012
Postpartum
1.96(2.30)
3.38(2.53)
5.43(6.25)
MANOVA
MAIN
EFFECTS(1)
Attachmentstyle:
Wilks’Lambda¼
.79,F(4,118)¼
3.70;p¼
.01Anxiety
SymptomsF(2,60)¼
7.00,p¼
.002DepressionSymptomsF(2,60)¼
6.10,p¼
.004
Tim
e:
Wilks’Lambda¼
.97,F(2,59)¼
1.00,p¼
.37Anxiety
SymptomsF(1,60)¼
1.06,p¼
.31DepressionSymptomsF(1,60)¼
.08,p¼
.78
Attachmentstyle
xTim
e:
Wilks’Lambda¼
.91,F(4,118)¼
1.45,p¼
.22Anxiety
SymptomsF(2,60)¼
2.76,p¼
.07DepressionSymptomsF(2,60)¼
.21,p¼
.81
MANOVA
MAIN
EFFECTS(2)
Attachmentstyle:
Wilks’Lambda¼
.80,F(4,118)¼
3.40,p¼
.011Anxiety
SymptomsF(2,60)¼
3.27,p¼
.05DepressionSymptomsF(2,60)¼
4.59,p¼
.01
Tim
e:
Wilks’Lambda¼
.76,F(2,59)¼
9.43,p¼
.000Anxiety
SymptomsF(1,60)¼
.19,p¼
.67DepressionSymptomsF(1,60)¼
9.98,p¼
.002
Attachmentstyle
xTim
e:
Wilks’Lambda¼
.92,F(4,118)¼
1.28,p¼
.28Anxiety
SymptomsF(2,60)¼
1.74,p¼
.18DepressionSymptomsF(2,60)¼
.15,p¼
.86
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effects of the interaction Time x Partner support x Attachment style, F (2, 43) ¼ .18,p ¼ .84, Partner support x Attachment style, F(2, 43) ¼ .80, p ¼ .46, and Partnersupport x Attachment style x Gender, F(2, 43) ¼ .56, p ¼ .57, neither for anxiety norfor depression symptoms, were found. However, while no significant effects of theinteraction Time x Partner support x Attachment style x Gender were found fordepression symptoms, F(1, 44) ¼ .63, p ¼ .43, significant effects of this interactionwere observed for anxiety symptoms, with women and men exhibiting differenttemporal changes between pregnancy and postpartum. While women with goodpartner’s support and either with an anxious or an avoidant attachment style,showed an increase in anxiety symptoms from pregnancy to postpartum, mencategorised equally at partner’s support or attachment style showed a decrease.Additionally, when women and men had poor support, while the avoidant womenshowed a decrease in anxiety symptoms, avoidant men showed an increment, theopposite being observed in anxious women and men, respectively.
Discussion
The study examined attachment style and partner support in couples expecting ababy in relation to anxiety and depression symptoms both antenatally andpostnatally. These were examined by gender and by joint attachment style in thecouple. Anxiety was somewhat more common that depression in the sample withhigher rates of both in pregnancy compared to the postpartum period. While thisheld for both genders, mothers had more symptoms overall, consistent with previousstudies (Teixeira et al., 2009).
Secure attachment style (common to over half the sample) was found to havesimilar rates in women and men, but with a gender difference in the type of insecureattachment style. Insecure attachment style related to anxiety and depressionsymptoms in both women and men, both at pregnancy and in the postpartum. Thisis consistent with other studies that show attachment insecurity plays a crucial role ina parent’s psychological adjustment during the transition to parenthood (Findleret al., 2007), both prenatally (e.g., Bifulco et al., 2004; Figueiredo et al., 2006) andpostnatally for anxiety and/or depression (e.g., Kuscu et al., 2008). However, whilemost previous studies focus mainly on women, the present findings show a clear non-gender result, with Insecure attachment style being associated both in women andmen to anxiety and depression symptoms during pregnancy and in the firstpostpartum months. The effect of attachment style in this study showed gendereffects. Women were three times more likely to have Anxious attachment styles(Enmeshed or Fearful) and men twice as likely to have Avoidant styles (Angry-dismissive or Withdrawn). Avoidant styles were very rare in women in this study,which is consistent with other study findings (Bartholomew & Horowitz, 1991;Brennan, Clark, & Shaver, 1998; Mikulincer & Florian, 1995). Anxious styles wererelated to both depression and anxiety, in both genders antenatally, but notpostnatally. Therefore having an Avoidant style may indicate some protectionagainst symptomatology.
There was also a gender effect in the pattern of change of depression symptomsfrom pregnancy to postpartum. Women with an insecure attachment style showed anincrease in depression symptoms from pregnancy to postpartum, while all those withsecure attachment style showed a decrease in depression symptoms postnatally.Thus, attachment style may be responsible for a cross-over effect; with secure
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attachment style functioning as a protective factor for postnatal symptoms as foundin some community samples (e.g., Heron, O’Connor, Evans, Golding, Glover, & theALSPAC Study Team, 2004), but insecure attachment style accounting for higherincidence and persistence of depression symptoms over the postpartum period inothers (McMahon et al., 2005). Poor partner support was a less predictive factor fordisorder in this study than attachment style, and was only associated with higheranxiety symptoms in men at both time points. This is unlike other studies where poorpartner relationship, particularly around dissatisfaction and negative interaction, hasbeen a predictive factor for depression in women (Matthey et al., 2000). Thisdifference in finding may be due to the fact that a more objective assessment ofpartner support was used in this study, less likely to be contaminated by mood, butgiven partner support overall was the same rate in women and men, may indicatesome shifting of women’s support needs to non-partner relationships duringpregnancy to buffer the impact of poorer partner relating. Other research indicatesmen as less likely to have as wide a range of close other relationships as women, sopoor partner support may be associated with more depleted support overall for menin the perinatal period (Wallace & Vaux, 1993). This aspect needs further exploringin future research, so that male-specific vulnerabilities in the postnatal period may bebetter understood and addressed in clinical work with couples.
When attachment style in both members of the couple was analysed, in half ofthe couples both members of the pair had the same attachment style security. Whilemost were both Secure, a small percentage of couples showed an insecure style inboth partners, similar to those found in a US sample (Volling et al., 1998). Theinfluence of insecure attachment in couples over the perinatal period showed somegender differences. When both spouses had an Insecure attachment style, bothwomen and men were more likely to be depressed antenatally but only women hadhigher anxiety symptoms, particularly in the postpartum period. This indicates adifferent patterning of risk for disorder with somewhat higher psychological risk forthe women overall, being more prone to both types of symptoms. This supportsprevious evidence of an association between adult attachment and psychologicalmaladjustment (Marazziti et al., 2007), but also shows the potentially cumulativeeffect of joint insecurity on emotional adjustment, of both women and men, to thechallenging life stage of having a baby.
While there are a number of strengths in this study including the intensiveinterviewing of both women and men, to ascertain the quality of partnerrelationship, support and attachment style individually and in the couple, as wellas the use of a prospective design to investigate symptoms during the pregnancy,there are also a number of study limitations. First, the relatively small number ofcouples means the results need to be treated with caution, with a lack of statisticalpower in some analyses. This was in part due to attrition at follow-up which alsomakes the representativeness of the sample less clear. The reduced numbers meansthere were relatively low rates of certain insecure attachment styles, particularlyavoidant attachment style in women, and this potentially limited the range ofanalyses that could be undertaken and the generalisability of the findings. Thus,repeating the study with larger numbers and in a higher risk sample would serve tofurther test these findings. Second, the use of self-report measures for symptoms waslimiting in terms of the clinical interpretation of findings. There is also the possibilityof symptom-based bias in reporting of symptoms in pregnancy which may confounddescriptions of attachment styles at the first measurement point. However, using a
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contextualised interview tool which requires evidence of behaviour and detaileddescription of attachment attitudes partly circumvents this. Third, no comparativemeasures of support or attachment style were used for equivalence to other studies.
Although the hypothesis initially proposed were mainly confirmed, the centralmessage of present findings alert to the differential impact of attachment style andpartner support on women’s and men’s psychological adjustment during pregnancyand first months postpartum, as well as the independent effect of attachment styleand partner support, as already noted by the theoretical framework. Thus, whileinsecure attachment style was related to higher anxiety and depression symptoms inboth partners at both time points, there was an increase of postnatal depressionsymptoms in women. Poor partner support contributed to anxiety symptoms only inmen. When insecure attachment combinations in both members of the couple wereexamined, insecure styles increased anxiety and depression symptoms in bothgenders antenatally, but postnatal anxiety symptoms only in women. A combinedeffect of partner’s support and attachment style on temporal changes of anxietysymptoms was observed differently for women and men. These main results suggestthe importance of assessing attachment style and partner support of both members,as well as the mutual interplay between them, to understand gendered differences inpsychological adjustment of a couple expecting a baby.
In general, this study provides evidence of adult attachment style shapingindividual and couple psychological adjustment during the pregnancy and birth of achild, in mothers and fathers. Joint insecure style is associated with an increase ofdepression symptoms of both women and men during pregnancy and women’sanxiety symptoms mainly at postpartum. The results indicate the importance ofsystemic approaches to attachment style in couples when perinatal interventions areplanned (e.g., O’Hara, Stuart, Gorman, & Wenzel, 2000). Utilising support andattachment information antenatally could usefully inform interventions to reducepsychological morbidity and improve parental emotional adjustment to thechallenging conditions around pregnancy and birth.
Acknowledgements
We would like to thank the women and men who agreed to participate in the presentstudy. This research was funded under a doctoral grant for Science in Measure IV.3,and co-funded under the 2010 Science and Innovation Operational Program (POCI2010) from Science and Technology Foundation, Government of the PortugueseRepublic (ref. SFRH/BD/13768/2003) and under the 2010 Science and InnovationOperational Program (POCI 2010) of the Community Support Board III, andsupported by the European Community Fund FEDER (POCI/SAU-ESP/56397/2004).
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Appendix
Attachment Style Interview (ASI) scales:
I- Ratings for Partner and two Very Close Support Figures (family or friends)
Evidenced by actual examples of behaviour, with probing about intensity and frequency ofparticular experiences. (Rated 1. Marked, 2. Moderate, 3. Some, 4. Little/none)
(i) Confiding (of emotionally charged topics)(ii) Active Emotional Support (in relation to actual confiding)
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(iii) Positive and Negative Quality of Interaction (evidenced by frequency and intensity ofpositive interactions such as enjoyment, relaxed, or negative such as arguments androws in interaction)
(iv) Felt attachment (feelings of closeness and not being able to live without the other)
Overall summary of support (1–3 high confiding and active emotional support) (4–7 lowconfiding and low active emotional support)
II – Ability to make and maintain relationships
(1–4) based on the range and quality of close supportive relationships including family oforigin, partner and two Very Close Others. (1–2 denotes good ability to make relationshipsand 3–4 poor ability to make relationships)
. Mistrust (suspicion of others motives and behaviours)
. Constraints on closeness (barriers to seeking help and confiding)
. High Self-reliance (the ability to cope and make decisions alone and be in control, withover self-reliance expressed).
. Anger (presence of high negative interaction in close relationships, as well as generalisedfeelings of resentment and hostility differentiated from under self-reliance and from theideal or moderate/average level)
Anxious attitudes
. Fear of rejection (expectation of being let down and hurt by others)
. Desire for company (need to have other people around much of the time. Very highdifferentiated from very low, with moderate/average denoting the ideal position)
. Fear of separation (distress and discomfort and even short separations from close others)
. (Anger – can be present).
IV – Overall attachment styles (Rated 1–13)
Based on ability to make and maintain relationships (the poorer the ability the higher the levelof insecure style) and combination of negative attitudinal scales. Each insecure style rated as‘‘marked’’, ‘‘moderate’’ or ‘‘mild’’:
Anxious styles:
. Enmeshed: Low self-reliance, high desire for company, high fear of separation
. Fearful: High mistrust, high fear of rejection and low anger
Avoidant styles:. Angry-dismissive: High mistrust, high self-reliance and high anger. Withdrawn: High constraints on closeness and high self-reliance (low anger and low fearof rejection)
Secure: Low mistrust, low constraints on closeness, low fear of rejection, low fear ofseparation and low anger, with moderate/average levels of self-reliance and desire forcompany.
